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

Agency For Health Care Administration
Managed Care Organizations
Appeals File Review Tool
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Complete this section for Standard Appeals Complete this Section for Expedited Appeals
Written
Written
File # Case ID #
Date of
Written
Resolution
Notification
Resolution
# of
Notice w/in 45
Extension
Days to
Days of Receipt
Notification Sent
Resolve
or w/in 14 Days
of Date of
Extension
Date of
Written
Resolution
Notification
Resolution
# of
Reasonable Notice w/in 72
Extension
Days to
Effort Oral Notice Hours or w/in 14
Notification Sent
Resolve
Days of Date of
Extension
27 Y N N/A Y N Y N N/A Y N Y N
28 Y N N/A Y N Y N N/A Y N Y N
29 Y N N/A Y N Y N N/A Y N Y N
30 Y N N/A Y N Y N N/A Y N Y N
# Applicable Elements
# Compliant Elements
Percent Compliant
Total # Applicable Elements
Total # Compliant Elements
Total Percent Compliant
Managed Care Organizations Page 6
Appeals File Review Tool F1_03_10
Florida Medicaid