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

AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
MCO Health Plan: Contract Number:
Contract Manager: Date(s) of Monitoring:
Standard IV: Enrollee Services & Enrollee Rights
CONTRACT SECTION CONTRACT REQUIREMENT COMPLIANT SCORING
1. Enrollee
Information
CC-IV.A.1.a
2. Capability to
Answer Enrollee
Inquiries
CC-IV.A.1.b
The health plan notifies enrollees of the
following:
a. Enrollee rights and responsibilities.
b. The role of the PCP.
c. How to obtain care.
d. What to do in an emergency or
urgent medical situation.
e. How to pursue a complaint,
grievance, appeal, or Medicaid Fair
Hearing.
f. How to report suspected fraud and
abuse.
g. The procedures for obtaining
behavioral health services.
h. The health plan telephone numbers
to use to obtain services.
The health plan has the capability to
answer enrollee inquiries with:
a. Written material.
b. Telephone.
c. Electronic transmission.
d. Face-to-face communication.
a. Yes
No
b. Yes
No
c. Yes
No
d. Yes
No
e. Yes
No
f. Yes
No
g. Yes
No
h. Yes
No
a. Yes
No
b. Yes
No
c. Yes
No
d. Yes
No
Met
Partially Met
Not Met
Met
Partially Met
Not Met
DOCUMENTS
REVIEWED
FINDINGS
State of Florida Compliance Monitoring_Standard_IV_F2_07_11
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