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

Standard IV: Enrollee Services & Enrollee Rights
CONTRACT
SECTION
48. Training of Help
Line Staff
CC- IV.A.11.e
49. Help Line
Performance
Standards
CC- IV.A.11.f
50. Automated
Answering
System
CC- IV.A.11.g
51. Instructions on
Automated System
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
The telephone help line staff is trained
to respond to enrollee questions in all
areas, including but not limited to,
covered services, provider network, and
transportation.
The health plan develops performance
standards and monitors telephone help
line performance by recording calls and
employing other monitoring activities.
Such standards are approved by BMHC
before the health plan begins operation.
Performance standards include:
a. All calls are answered within 4 rings
(these calls may be placed in a
queue).
b. Wait time in the queue does not
exceed 3 minutes.
c. Blocked call rate does not exceed
1%.
d. Rate of abandoned calls does not
exceed 5%.
The health plan has an automated system
available between the hours of 7:00 p.m.
and 8:00 a.m. in the enrollee’s time zone,
Monday through Friday and at all hours
on weekends and holidays.
The automated system provides callers
with clear instructions on what to do in
the case of an emergency and includes a
voice mailbox for callers to leave
Yes
No
a. Yes
No
b. Yes
No
c. Yes
No
d. Yes
No
Yes
No
Yes
No
Met
Partially Met
Not Met
Met
Partially Met
Not Met
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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