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

Standard VIII: Quality Improvement Program
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT SECTION CONTRACT REQUIREMENT COMPLIANT SCORING
CC-VIII.A.2.b.5-10
23. Committee Minutes
CC-VIII.A.2.c
24. Peer Review Process
and departments within the health
plan as well as stakeholders,
including how this communication is
documented for the Agency review.
f. The process to direct and analyze
periodic reviews of enrollees’ service
utilization patterns.
The health plan maintains:
a. Minutes of all committee and subcommittee
meetings and makes the
minutes available upon Agency
request.
b. Minutes demonstrate resolution of
items brought forward to the next
meeting.
The health plan has a peer review
process that:
a. Reviews a provider's practice
methods and patterns,
morbidity/mortality rates, and all
grievances filed against the provider
relating to medical treatment.
b. Evaluates the appropriateness of care
rendered by providers.
c. Implements corrective action(s) when
the health plan deems it necessary to
do so.
d. Develops policy recommendations to
maintain or enhance the quality of
a. Yes
No
b. Yes
No
a. Yes
No
b. Yes
No
c. Yes
No
d. Yes
No
e. Yes
No
Met
Partially Met
Not Met
Met
Partially Met
Not Met
DOCUMENTS
REVIEWED
State of Florida Compliance Monitoring_Standard_VIII_F2_07_11
Page 6
FINDINGS