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
24. Filing Grievances and
Appeals: Orally or in
Writing
42 CFR 431.213-214
CC-IX.D.2
25. Filing Grievances and
Appeals: Reasonable
Assistance to
Enrollees
42 CFR 431.213-214
CC-IX.D.3
26. Filing Grievances and
Appeals: Procedures
A grievance may be filed orally or in
writing within 30 calendar days of the
enrollee’s receipt of the notice of
action and, except when expedited
resolution is required, must be
followed with a written notice within
10 calendar days of the oral filing. The
date of oral notice constitutes the date
of receipt.
The health plan provides any
reasonable help to the enrollee in
completing forms and following the
procedures for filing a grievance or
appeal or requesting a Medicaid Fair
Hearing. This includes interpreter
services, toll-free calling, and
TTY/TTD capability.
The health plan handles grievances and
appeals as follows:
a. Provides the enrollee a reasonable
opportunity to present evidence
and allegations of fact or law in
person as well as in writing.
b. Ensures the enrollee understands
any time limits that may apply.
c. Provides opportunity before and
during the process for the enrollee
or an authorized representative to
examine the case file, including
medical records, and any other
material to be considered during
Yes
No
Yes
No
a. Yes
No
b. Yes
No
c. Yes
No
d. 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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