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

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Agency For Health Care Administration Managed Care Organizations Appeals File Review Tool 8 9 10 11 12 13 14 15 Complete this section for all Appeals File # Case ID # Written Notice Written Notice Written Notice Includes Results Includes Includes How to and Date of Enrollee’s Right Request a Fair Resolution to a Fair Hearing Hearing Written Notice Includes SAP and BAP Information Written Notice Written Notice Written Notice Includes Includes Includes How to Enrollee Liability Enrollee’s Request a for Cost of Right to Continuance of Continued Continuance Benefits Benefits if Plan’s of Benefits Action Upheld Benefits Continued if Applicable 28 Y N Y N Y N Y N Y N Y N Y N Y N N/A 29 Y N Y N Y N Y N Y N Y N Y N Y N N/A 30 Y N Y N Y N Y N Y N Y N Y N Y N N/A # Applicable Files # Compliant Files Percent Compliant Managed Care Organizations Page 4 Appeals File Review Tool F1_03_10 Florida Medicaid
File # Case ID # Agency For Health Care Administration Managed Care Organizations Appeals File Review Tool 16 17 18 19 20 21 22 23 24 Complete this Section for Standard Appeals Complete this Section for Expedited Appeals Date of Written Resolution Notification # of Days to Resolve Extension Notification Sent Resolved w/in 45 Days of Receipt or w/in 14 Days of Date of Extension Date of Written Resolution Notification # of Extension Days to Notification Sent Resolve Reasonable Effort Oral Notice Written Resolution Notice w/in 72 Hours or w/in 14 Days of Date of Extension 1 Y N N/A Y N Y N N/A Y N Y N 2 Y N N/A Y N Y N N/A Y N Y N 3 Y N N/A Y N Y N N/A Y N Y N 4 Y N N/A Y N Y N N/A Y N Y N 5 Y N N/A Y N Y N N/A Y N Y N 6 Y N N/A Y N Y N N/A Y N Y N 7 Y N N/A Y N Y N N/A Y N Y N 8 Y N N/A Y N Y N N/A Y N Y N 9 Y N N/A Y N Y N N/A Y N Y N 10 Y N N/A Y N Y N N/A Y N Y N 11 Y N N/A Y N Y N N/A Y N Y N 12 Y N N/A Y N Y N N/A Y N Y N 13 Y N N/A Y N Y N N/A Y N Y N 14 Y N N/A Y N Y N N/A Y N Y N 15 Y N N/A Y N Y N N/A Y N Y N 16 Y N N/A Y N Y N N/A Y N Y N 17 Y N N/A Y N Y N N/A Y N Y N 18 Y N N/A Y N Y N N/A Y N Y N 19 Y N N/A Y N Y N N/A Y N Y N 20 Y N N/A Y N Y N N/A Y N Y N 21 Y N N/A Y N Y N N/A Y N Y N 22 Y N N/A Y N Y N N/A Y N Y N 23 Y N N/A Y N Y N N/A Y N Y N 24 Y N N/A Y N Y N N/A Y N Y N 25 Y N N/A Y N Y N N/A Y N Y N 26 Y N N/A Y N Y N N/A Y N Y N Managed Care Organizations Page 5 Appeals File Review Tool F1_03_10 Florida Medicaid
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Attachment I Special Term and Condi
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Attachment II Special Term and Cond
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RICK SCOTT GOVERNOR 272 7 Mah an Dr
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• Encounter data • Systems issu
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Appendix A How to Become a Florida
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How to Become a Florida Medicaid He
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Appendix B MCO Application Checklis
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4 5 6 7 8 9 10 Service Level(s) are
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19 b. Total number of employees; AP
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APPLICATION ITEM 25 3. In the past
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32 33 34 35 36 APPLICATION ITEM 10.
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APPLICATION ITEM C. Criminal Backgr
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APPLICATION ITEM 43 13. For medical
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46 47 APPLICATION ITEM 16. Indicate
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49 APPLICATION ITEM 19. Describe in
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51 52 53 54 55 56 APPLICATION ITEM
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Attachment III Special Term and Con
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RICK SCOTT GOVERNOR Regulatory Auth
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e. Complete a credentialing review
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RICK SCOTT GOVERNOR Regulatory Auth
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Compliance Monitoring Tool with Spe
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Standard I: Care Management/Continu
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Results for Standard I Care Managem
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Standarrd II: Utilizatio on Managem
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Standard III: Eligibility, Enrollme
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Standard IV: Enrollee Services & En
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Results for Standard IV Enrollee Se
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Standard V: Provider Credentialing
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Standard VI: Provider Services CONT
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Standard VI: Provider Services CC-
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Standard VI: Provider Services CONT
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Standard VII: Provider Contracting
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AGENCY FOR HEALTHCARE ADMINISTRATIO
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Standard VIII: Quality Improvement
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Results for Standard IX Medical Rec
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Standard X: Access and Availability
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Results for Standard X Access and A
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Standard XI: Grievances and Appeals
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Standard XII: Administration and Ma
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Results for Standard XII Administra
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Standard XIII: Community Outreach C
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Page 203 and 204: Results for Standard XIII Community
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Vendor Name: Review Period: Date of
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Agency For Health Care Administrati
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Medical Loss Ratio The following dr
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RICK SCOTT GOVERNOR Better Health C
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Plan Name: AGENCY FOR HEALTH CARE A
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DRAFT ATTESTATION OF 201_ QUARTER E
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Draft MLR Reporting Schedule Health
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RICK SCOTT GOVERNOR PLAN TYPES: Bet
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Attachment V Special Term and Condi
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RICK SCOTT GOVERNOR Mission to Ensu
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• Obtaining data from the health
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RICK SCOTT GOVERNOR Mission to Ensu
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Attachment VI Special Term and Cond
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RICK SCOTT GOVERNOR Better Health C
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