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
15. Types of Issues:
Appeal
CC-IX.B.4
16. Written Notice of
Action
CC-IX.C.1.a-g
An appeal is a request for review of an
action.
The health plan provides the enrollee
with a written notice of action that
includes the following:
a. The action the health plan or its
contractor has taken or intends to
take.
b. The reason for the action.
c. The enrollee or provider’s right to
file an appeal with the health plan.
d. The enrollee’s right to request a
Medicaid Fair Hearing.
e. The procedures for exercising the
rights specified in the notice.
f. The circumstances under which
expedited resolution is available
and how to request it.
g. The enrollee’s right to have
benefits continued pending
resolution of an appeal, how to
request a continuation of benefits,
and the circumstances in which the
enrollee must have to pay the cost
of those benefits.
Yes
No
a. Yes
No
b. Yes
No
c. Yes
No
d. Yes
No
e. Yes
No
f. Yes
No
g. Yes
No
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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