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.D.4.a-d
27. Resolution and
Notification
CC-IX.E.1
28. Resolution and
Notification: Notice
of Results
CC-IX.E.2
29. Resolution and
Notification: Notice
of Results of an
Appeal
CC-IX.E.3
30. Resolution and
Notification:
Extensions
the process.
d. Considers as parties to the appeal
the enrollee or an authorized
representative or, if the enrollee is
deceased, the legal representative
of the estate.
The health plan follows Agency
guidelines in resolving grievances and
appeals as expeditiously as possible,
observing required timeframes and
taking into account the enrollee’s
health condition.
A grievance must be reviewed and
notice of results sent to the enrollee no
later than 90 calendar days from the
date the health plan receives it.
An appeal must be heard and notice of
results sent to the enrollee no later than
45 calendar days from the date the
health plan receives it.
The timeframe for a grievance or
appeal may be extended up to 14
calendar days if:
a. The enrollee asks for an extension,
or the health plan documents that
additional information is needed
and the delay is in the enrollee’s
Yes
No
Yes
No
Yes
No
a. Yes
No
b. 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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