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.d.1-5
25. Peer Review Committee
CC-VIII.A.2.d.6-8
care provided to enrollees.
e. Conducts reviews that include the
appropriateness of diagnosis and
subsequent treatment, maintenance
of a provider's medical records,
adherence to standards generally
accepted by a provider's peers and
the process and outcome of a
provider's care.
The health plan’s peer review process:
a. Appoints a peer review committee, as
a sub-committee to the QI program
committee, to review provider
performance when appropriate. The
medical director or a designee chairs
the peer review committee. Its
membership is drawn from the
provider network and includes peers
of the provider being reviewed.
b. Receives and reviews all written and
oral allegations of inappropriate or
aberrant service by a provider.
c. Educates enrollees and health plan
staff about the peer review process,
so that enrollees and the health plan
staff can notify the peer review
authority of situations or problems
relating to providers.
a. Yes
No
b. Yes
No
c. Yes
No
Met
Partially Met
Not Met
DOCUMENTS
REVIEWED
State of Florida Compliance Monitoring_Standard_VIII_F2_07_11
Page 7
FINDINGS