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

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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 V: Provider Credentialing and Recredentialing CONTRACT SECTION CONTRACT REQUIREMENT COMPLIANT SCORING 1. Credentialing and Recredentialing Criteria CC-VII.H.2 2. Credentialing Policies and Procedures CC-VII.H.4.a-f The health plan establishes and verifies credentialing and recredentialing criteria for all professional providers. The health plan’s credentialing and recredentialing policies and procedures are written and include the following: a. Formal delegations and approvals of the credentialing process, a designated credentialing committee, and identification of providers who fall under its scope of authority. b. A process which provides for the verification of the credentialing and recredentialing criteria. c. Approval of new providers and imposition of sanctions, termination, suspension, and restrictions on existing providers. d. Identification of quality deficiencies which result in the health plan’s restriction, suspension, termination, or sanctioning of a provider. 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_V_F3_07_11 Page 1
Standard V: Provider Credentialing and Recredentialing AGENCY FOR HEALTHCARE ADMINISTRATION MANAGED CARE ORGANIZATIONS Compliance Monitoring Tool with Specific Contract Standards CONTRACT SECTION CONTRACT REQUIREMENT COMPLIANT SCORING 3. Appeal Procedures for Providers CC-VII.H.7 The health plan develops and implements an appeal procedure for providers against whom the health plan has imposed sanctions, restrictions, suspensions and/or terminations. Results for Standard V Credentialing and Recredentialing Score # Elements Met Partially Met Not Met Not Applicable Total # Elements Total # Applicable Elements Percent of Elements Met Yes No Met Partially Met Not Met DOCUMENTS REVIEWED FINDINGS State of Florida Compliance Monitoring_Standard_V_F3_07_11 Page 2
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Attachment I Special Term and Condi
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Attachment II Special Term and Cond
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RICK SCOTT GOVERNOR 272 7 Mah an Dr
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• Encounter data • Systems issu
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Appendix A How to Become a Florida
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How to Become a Florida Medicaid He
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Appendix B MCO Application Checklis
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4 5 6 7 8 9 10 Service Level(s) are
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19 b. Total number of employees; AP
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APPLICATION ITEM 25 3. In the past
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32 33 34 35 36 APPLICATION ITEM 10.
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APPLICATION ITEM C. Criminal Backgr
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APPLICATION ITEM 43 13. For medical
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46 47 APPLICATION ITEM 16. Indicate
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49 APPLICATION ITEM 19. Describe in
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51 52 53 54 55 56 APPLICATION ITEM
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Attachment III Special Term and Con
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RICK SCOTT GOVERNOR Regulatory Auth
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e. Complete a credentialing review
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RICK SCOTT GOVERNOR Regulatory Auth
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Compliance Monitoring Tool with Spe
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Standard I: Care Management/Continu
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Results for Standard I Care Managem
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Page 103: Results for Standard IV Enrollee Se
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Page 109 and 110: Standard VI: Provider Services CC-
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Page 113 and 114: Standard VII: Provider Contracting
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Page 129 and 130: Results for Standard IX Medical Rec
Page 131 and 132: Standard X: Access and Availability
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Page 147 and 148: Standard XI: Grievances and Appeals
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Standard XI: Grievances and Appeals
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AGENCY FOR HEALTHCARE ADMINISTRATIO
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Standard XII: Administration and Ma
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AGENCY FOR HEALTHCARE ADMINISTRATIO
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Results for Standard XII Administra
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Standard XIII: Community Outreach C
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Results for Standard XIII Community
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Standard XIV: Covered Services AGEN
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Standard XV: Immunizations, Pregnan
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Vendor Name: Review Period: Date of
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Agency For Health Care Administrati
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File # Case ID # Agency For Health
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File # Case ID # 1 2 3 4 5 6 7 8 9
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13 14 15 Agency For Health Care Adm
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f. Posting of the Agency Summary of
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Name: Review Period: Date of Review
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5. 6. 7. 8. 9. local WIC office to
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14 Agency For Health Care Administr
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8 providers Agency For Health Care
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Medical Loss Ratio The following dr
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RICK SCOTT GOVERNOR Better Health C
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Plan Name: AGENCY FOR HEALTH CARE A
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DRAFT ATTESTATION OF 201_ QUARTER E
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Draft MLR Reporting Schedule Health
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RICK SCOTT GOVERNOR PLAN TYPES: Bet
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Attachment V Special Term and Condi
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RICK SCOTT GOVERNOR Mission to Ensu
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• Obtaining data from the health
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RICK SCOTT GOVERNOR Mission to Ensu
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Attachment VI Special Term and Cond
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RICK SCOTT GOVERNOR Better Health C
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Letter to CMS - Medicaid Managed Care Policies - Agency for ...

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