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

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APPLICATION ITEM
Agency for Health Care Administration
Internal Working Document
MCO APPLICATION REVIEW CHECKLIST FOR Phase I
INSTRUCTIONS (if applicable)
PHASE I CONTENT REVIEW Days 1-2 Complete concurrently with “workplan for health plan application review”
LOCATION IN
APPLICATION
(Binder, Tab & Page #)
BASIC INFORMATION – See Basic Information Page of Application. If items are missing, alert and discuss with Agency Administrator
Primary contact information is complete
Type of health plan is indicated
Target population(s) are indicated
(Check each population requested)
List primary contact person as well as location in the
application. Mailing address must be street address,
not P.O. Box.
☐Provider Service Network – Fee-for-service
☐Provider Service Network – Capitated
☐Health Maintenance Organization
Check appropriate box
☐Temporary Assistance for Needy Families (TANF)
☐Supplemental Security Income (SSI)
NOTE: In non-Reform counties, a health plan
must cover both populations.
Check appropriate box(es)
Date Deficiencies
identified/Date
Deficiencies resolved
Revisions as of 1/23/2012 Page 1 of 19
INITIALS &
DATE
COMPLETED