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

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Standard XI: Grievances and Appeals AGENCY FOR HEALTHCARE ADMINISTRATION MANAGED CARE ORGANIZATIONS Compliance Monitoring Tool with Specific Contract Standards CONTRACT SECTION CONTRACT REQUIREMENT COMPLIANT SCORING 51. Reversal of Health Plan’s Action: Paying for Services CC-IX. H.5 If the Medicaid Fair Hearing officer reverses the health plan’s action and the enrollee received the disputed services while the appeal was pending, the health plan must pay for those services in accordance with this contract. Results for Standard XI Grievances and Appeals 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_XI_F2_07_11 Page 15
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 XII: Administration and Management CONTRACT SECTION CONTRACT REQUIREMENT COMPLIANT SCORING 1. Accuracy of The health plan verifies that information it Yes Met Information submits to the Agency or its agents is accurate. No Partially Met Not Met CC-II.D.2 2. Submitting Documents to the BMHC CC-II.D.3-4 3. Prior Approval of Documents and Notification to Enrollees CC-II.D.4.a-b 4. Website Documents CC-II.D.6 The health plan submits all policies and procedures, model provider agreements and amendments, all subcontracts (including behavioral health, if applicable), and all other materials related to this Contract to the Bureau of Managed Health Care (BMHC) for approval before implementation. To obtain BMHC approval: a. The health plan provides written materials to BMHC at least forty-five (45) calendar days before the effective date of the change. b. The health plan provides written notice of such changes affecting enrollees to those enrollees at least thirty (30) calendar days before the effective date of change. The health plan makes enrollee materials, including the preferred drug list, provider directory and enrollee handbook(s), available online at the health plan’s website without requiring enrollee log-in. Yes No a. Yes No b. Yes No Yes No Met Partially Met Not Met Met Partially Met Not Met Met Partially Met Not Met DOCUMENTS REVIEWED FINDINGS State of Florida Compliance Monitoring_Standard_XII_F2_07_11 Page 1
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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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Standarrd II: Utilizatio on Managem
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Standard III: Eligibility, Enrollme
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Standard IV: Enrollee Services & En
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Results for Standard IV Enrollee Se
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Standard V: Provider Credentialing
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Standard VI: Provider Services CONT
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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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