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. H.2.a-d
49. Recovering the Cost
of Services
CC-IX. H.3
50. Reversal of Health
Plan’s Action
CC-IX. H.4
a. The enrollee withdraws the appeal.
b. Ten business days pass after the
health plan sends the enrollee the
notice of resolution of the appeal
against the enrollee, unless the
enrollee within those 10 days has
requested a Medicaid Fair Hearing
with continuation of benefits.
c. The Medicaid Fair Hearing office
issues a hearing decision adverse to
the enrollee.
d. The time period or service limits of
a previously authorized service
have been met.
If the final resolution of the appeal is
adverse to the enrollee and the health
plan’s action is upheld, the health plan
may recover the cost of services
furnished to the enrollee while the
appeal was pending to the extent they
were furnished solely because of the
continuation of benefits requirement.
If the Medicaid Fair Hearing officer
reverses the health plan’s action and
services were not furnished while the
appeal was pending, the health plan
must authorize or provide the disputed
services promptly.
d. Yes
No
Yes
No
Yes
No
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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