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
17. Mailing Notices:
Termination,
Suspension, or
Reduction of
Authorized Services
42 CFR 431.213-214
CC-IX.C.2.a
18. Mailing Notices:
Termination/
Suspension/
Reduction of
Authorized Services
42 CFR 431.213-214
CC-IX.C.2.b
19. Mailing Notices:
Deny/Limit Services
42 CFR 431.213-214
CC-IX.C.2.c
20. Mailing Notices:
Extending the
Timeframe
The health plan mails the notice as
follows:
For termination, suspension, or
reduction of previously authorized
Medicaid-covered services no later
thatn 10 calendars before the action is
to take effect.
The health plan mails the notice as
follows:
For denial of payment, at the time of
any action affecting the claim.
The health plan mails the notice as
follows:
For standard service authorization
decisions that deny or limit services no
more than 14 calendar days following
the request for service or within 3
business days following an expedited
service request.
If the health plan extends the
timeframe for a service authorization
decision, in which case it:
a. Notifies the enrollee of the reason
for extending the timeframe and
advises the enrollee of the right to
file a grievance if the enrollee
disagrees with the extension of
Yes
No
Yes
No
Yes
No
a. Yes
No
b. Yes
No
c. 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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