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
46. Continuation of
Benefits
CC-IX. H.1.a.1-2
47. Continuation of
Benefits
CC-IX. H.1.b-e
48. Continuation or
Reinstatement of
Benefits
The health plan continues the
enrollee’s benefits if the enrollee or the
enrollee’s authorized representative
files an appeal with the health plan
regarding the health plan’s decision:
a. Within 10 business days after the
notice of the adverse action is
mailed.
b. Within 10 business days after the
intended effective date of the
action, whichever is later.
The health plan continues the
enrollee’s benefits if:
a. The appeal involves the
termination, suspension, or
reduction of a previously
authorized course of treatment.
b. The services were ordered by an
authorized provider.
c. The original period covered by the
original authorization has not
expired.
d. The enrollee requests an extension
of benefits.
If, at the enrollee’s request, the health
plan continues or reinstates the
benefits while the appeal is pending,
benefits must continue until one of the
following occurs:
a. Yes
No
b. Yes
No
a. Yes
No
b. Yes
No
c. Yes
No
d. Yes
No
a. Yes
No
b. Yes
No
c. 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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