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
36. Track and Trending CCP
Issues
42 CFR 438.206
CC-VIII.A.4.c.
37.Clinical Practice
Guidelines (CPGs)
42 CFR 438.236(b)
QAIS V.A.1.
CC-VIII.B.3
The health plan tracks and trends any
issues identified and implements
interventions to improve the provision of
services.
The health plan adopted clinical practice
guidelines that:
a. Are based on valid and reliable
clinical evidence or a consensus of
health care professionals in a
particular field.
b. Consider the needs of enrollees.
c. Are adopted in consultation with
contracting health care professionals.
d. Are reviewed and updated
periodically as appropriate
e. Are distributed to all affected
providers.
f. Are distributed to enrollees and
potential enrollees upon request.
g. There is evidence that, at a
minimum, the following areas are
consistent with the guidelines:
i. UM decisions
ii. Enrollee education
iii. Coverage of services
Yes
No
a. Yes
No
b. Yes
No
c. Yes
No
d. Yes
No
e. Yes
No
f. Yes
No
g. Yes
No
Met
Partially Met
Not Met
Met
Partially Met
Not Met
DOCUMENTS
REVIEWED
FINDINGS
State of Florida Compliance Monitoring_Standard_VIII_F2_07_11
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