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

File #
Case
ID #
Agency For Health Care Administration
Managed Care Organizations
Grievance File Review Tool
1 2 3 4 5 6 7
Date
Grievance
Received
Standard or
Expedited
Grievance
Acknowledged
in Writing
Assistance
Given if
Requested
(List type of
assistance in
comments)
Enrollee Given
Chance to
Present
Evidence
Decision Maker
Involved in
Initial
Determination*
Decision Maker
Had Appropriate
Clinical Expertise
20 S E Y N N/A Y N N/A Y N Y N Y N
21 S E Y N N/A Y N N/A Y N Y N Y N
22 S E Y N N/A Y N N/A Y N Y N Y N
23 S E Y N N/A Y N N/A Y N Y N Y N
24 S E Y N N/A Y N N/A Y N Y N Y N
25 S E Y N N/A Y N N/A Y N Y N Y N
26 S E Y N N/A Y N N/A Y N Y N Y N
27 S E Y N N/A Y N N/A Y N Y N Y N
28 S E Y N N/A Y N N/A Y N Y N Y N
29 S E Y N N/A Y N N/A Y N Y N Y N
30 S E Y N N/A Y N N/A Y N Y N Y N
# Applicable Files
# Compliant Files
Percent Compliant
* The compliant answer is “No” for element 6
Managed Care Organizations Page 2
Grievance File Review Tool F1_03_10
Florida Medicaid