Letter to CMS - Medicaid Managed Care Policies - Agency for ...

Standard XI: Grievances and Appeals
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT SECTION CONTRACT REQUIREMENT COMPLIANT SCORING
CC-IX.A.10.a-c
11. Transportation
Services
CC-IX.A.11
12. Types of Issues:
Complaints
CC-IX.B.1
13. Types of Issues:
Grievance
CC-IX.B.2
14. Types of Issues:
Action
CC-IX.B.3
a. An appeal of a denial that is based
on lack of medical necessity.
b. A grievance regarding the denial
of an expedited resolution of an
appeal.
c. A grievance or appeal that
involves clinical issues.
A health plan that covers
transportation services through a
subcontractor ensures that the
subcontractor meets the complaint and
grievance system requirements for
problems related to transportation
services.
A complaint is the lowest level of
challenge and provides the health plan
an opportunity to resolve a problem
without the complaint becoming a
formal grievance.
Complaints must be resolved by close
of business the day following receipt
or be moved into the grievance system.
A grievance expresses dissatisfaction
about any matter other than an action
by the health plan.
An action is any denial, limitation,
reduction, suspension, or termination
of services; denial of payment; or
failure to act in a timely manner.
No
Yes
No
N/A
Yes
No
Yes
No
Yes
No
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
DOCUMENTS
REVIEWED
FINDINGS
State of Florida Compliance Monitoring_Standard_XI_F2_07_11
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