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Letter to CMS - Medicaid Managed Care Policies - Agency for ...

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Vendor Name:<br />

Review Period:<br />

Date of Review:<br />

Reviewer:<br />

Participating Vendor Staff Member:<br />

File #<br />

Case<br />

ID #<br />

<strong>Agency</strong> For Health <strong>Care</strong> Administration<br />

<strong>Managed</strong> <strong>Care</strong> Organizations<br />

Appeals File Review Tool<br />

1 2 3 4 5 6 7<br />

Date Appeal<br />

Received<br />

Standard or<br />

Expedited<br />

Appeal<br />

Acknowledged<br />

in Writing<br />

Assistance<br />

Given, if<br />

Requested<br />

(List type of<br />

assistance in<br />

comments)<br />

Enrollee Given<br />

Chance <strong>to</strong><br />

Present<br />

Evidence<br />

Decision Maker<br />

Involved in<br />

Initial<br />

Determination*<br />

Decision Maker<br />

Has Appropriate<br />

Clinical<br />

Expertise<br />

1 S E Y N N/A Y N N/A Y N Y N Y N<br />

2 S E Y N N/A Y N N/A Y N Y N Y N<br />

3 S E Y N N/A Y N N/A Y N Y N Y N<br />

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20 S E Y N N/A Y N N/A Y N Y N Y N<br />

21 S E Y N N/A Y N N/A Y N Y N Y N<br />

<strong>Managed</strong> <strong>Care</strong> Organizations Page 1<br />

Appeals File Review Tool F1_03_10<br />

Florida <strong>Medicaid</strong>

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