Ann Griev Report HMO by 6195nl1

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									                        HMO/PHC ANNUAL GRIEVANCE REPORTING
                             FISCAL YEAR ENDING JUNE 30


                                                  GRIEVANCE STATUS/RESOLUTION
                                 Total Number     To Formal       Resolved in
                                 of Grievances    Grievance        favor of     Unresolved to
   GRIEVANCE CATEGORIES          (By Category)     Process        Subscriber        SAP
Balance Billing
Enrollment/Disenrollment
Excluded Benefit
Experimental/Investigational
Formulary
Medical Necessity
Non-authorized for Service
Out-of-Network
Pre-existing condition
Quality of Care
Other




Total Number of Grievances                   0                0             0              0


HMO/PHC NAME:

Prepared by:

Date Prepared:



Instructions: Complete shaded areas and submit by August 15

Submit via e-mail to:           carol.greenwood@ahca.myflorida.com

Direct questions to:            Carol Greenwood -- (850) 412-4319


BMHC 05/11

								
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