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
36. Resolution and
Notification: Contents
of Notice of Results
CC-IX.E.7.d
37. Expedited Appeals
CC-IX.F.1
38. Expedited Appeal
Resolution Time
Frame
CC-IX.F.2
39. Punitive Action
CC-IX.F.3
40. Denying an
Expedited Appeal
CC-IX.F.4
The written notice of resolution
includes:
That the enrollee may have to pay for
the cost of those benefits if the
Medicaid Fair Hearing upholds the
health plan’s action.
The health plan has an expedited
review process for appeals for use
when taking the time for a standard
resolution could seriously jeopardize
the enrollee’s life or health or ability to
attain, maintain, or regain maximum
function.
The health plan resolves each
expedited appeal and provides notice
to the enrollee, as quickly as the
enrollee’s health condition requires,
within state-established time frames
not to exceed seventy-two (72) hours
after the health plan receives the
appeal request, whether the appeal was
made orally or in writing.
The health plan ensures that punitive
action is not taken against a provider
who requests or supports a request for
an expedited appeal.
If the health plan denies the request for
expedited appeal, it immediately
transfers the appeal to the timeframe
for standard resolution and so notifies
the enrollee.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Met
Partially Met
Not Met
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
Page 11