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

Name:
Review Period:
Date of Review:
Reviewer:
Participating Staff Member:
HEALTH PLAN NAME
Denials Record Review Tool
1 2 3 4 5 6 7 8 9 10 11
Complete if Standard/Expedited Authorization
Decision
Date of
Initial
Request
Date
Notice
Sent
Number
of Days
for
Decision
Complete for Termination,
Suspension, or Reduction of
Previously Authorized
Services
Date
Notice
Sent
Notice
Includes
Reasons
Member
Notice Sent per
Notice Sent per
File # ID
Requirement?
Requirement?
1 Y N N/A Y N N/A Y N Y N
2 Y N N/A Y N N/A Y N Y N
3 Y N N/A Y N N/A Y N Y N
4 Y N N/A Y N N/A Y N Y N
5 Y N N/A Y N N/A Y N Y N
6 Y N N/A Y N N/A Y N Y N
7 Y N N/A Y N N/A Y N Y N
8 Y N N/A Y N N/A Y N Y N
9 Y N N/A Y N N/A Y N Y N
10 Y N N/A Y N N/A Y N Y N
11 Y N N/A Y N N/A Y N Y N
12 Y N N/A Y N N/A Y N Y N
13 Y N N/A Y N N/A Y N Y N
14 Y N N/A Y N N/A Y N Y N
15 Y N N/A Y N N/A Y N Y N
# Applicable
Elements
# Compliant
Elements
Percent
Compliant
Complete for All Denials
Decision
Made by
Qualified
Clinician Comments
Total # Applicable
Elements
Total # Compliant
Elements
Total Percent
Compliant
Denials_File_Review_Tool_F1_03_10.docx