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
42 CFR 431.213-214
CC-IX.C.2.d
21. Mailing Notices: No
Decision in the
Timeframe
42 CFR 431.213-214
CC-IX.C.2.e
22. Mailing Notices-
Standard Service
Authorization
42 CFR 431.213-214
CC-IX.C.2.f
23. Filing Grievances and
Appeals: Time Limit
42 CFR 431.213-214
CC-IX.D.1
time.
b. Issues and carries out its
determination as expeditiously as
possible and no later than the date
the extension expires.
c. Sends notice of the extension to the
enrollee within 5 business days of
determining the need for an
extension.
The health plan mails the notice as
follows:
For service authorization decisions not
reached within required timeframes, on
the date the timeframes expire. Such
failures constitute a denial and are,
therefore, an adverse action.
The health plan mails the notice as
follows:
For expedited service authorization
decisions within the timeframes
specified.
A grievance may be filed orally or in
writing within one year of the
occurrence.
Yes
No
Yes
No
Yes
No
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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