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
CC-IX.E.4.a-b
31. Resolution and
Notification:
Disenrollment
CC-IX.E.5
32. Resolution and
Notification: Notice
of Disposition
CC-IX.E.6
33. Resolution and
Notification: Contents
of Notice of Results
CC-IX.E.7.a-b
interest.
b. If the timeframe is extended other
than at the enrollee’s request, the
health plan must notify the enrollee
within 5 business days of the
determination, in writing, of the
reason for the delay.
The health plan completes the
grievance process in time to
accommodate an enrollee’s
disenrollment effective date, which can
be no later than the first day of the
second month after the filing of a
request for disenrollment.
The health plan provides written notice
of disposition of an appeal. In the case
of an expedited appeal, the health plan
also provides oral notice by close of
business the day of disposition.
The written notice of resolution
includes:
a. The results of the resolution
process and the date it was
completed.
b. If not decided in the enrollee’s
favor, information on the right to
request a Medicaid Fair Hearing
and how to do so; the right to
request to receive benefits while
the hearing is pending, and how to
make the request.
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
DOCUMENTS
REVIEWED
FINDINGS
State of Florida Compliance Monitoring_Standard_XI_F2_07_11
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