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

Standard XII: Administration and Management
CONTRACT
SECTION
14. Staffing the
Health Plan
CC-X.B.1
15. Performance
Metrics
CC-X.C.1
16. Electronic
Transmissions
CC-X.C.2.3
17. Federal and State
Requirements for
Processing
Claims
42CFR 447.45
42 CFR 447.46
Chapter 641,F.S.
CC-X.C.4
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
The health plan educates its staff about its
policies and procedures and all applicable
provisions of the Contract, including advance
directives, and situations in which advance
directives may be of benefit to enrollees.
The health plan has performance metrics,
including those for quality, accuracy and
timeliness, and include a process for
measurement and monitoring, and for the
development and implementation of
interventions for improvement in regards to
claims processing and claims payment.
The health plan keeps documentation of the
above and has the documentation available for
Agency review.
The health plan is able to accept electronicallytransmitted
claims from providers in HIPAAcompliant
formats.
The health plan uses electronic transmission of
claims, HIPAA-compliant transactions, notices,
documents, forms, and payments to the greatest
extent possible by the health plan.
The health plan ensures that claims are processed
and comply with the federal and state
requirements, which is more stringent.
Yes
No
Yes
No
Yes
No
Yes
No
Met
Partially Met
Not Met
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
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