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

Standard XII: Administration and Management
CONTRACT
SECTION
21. CAPITATED:
Claims
Submitted
Nonelectronically
Exhibit 10
22. CAPITATED:
Payment for
Services
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
For all non-electronically submitted claims for
capitated services, the health plan:
a. Within fifteen (15) calendar days after
receipt of the claim, provides
acknowledgment of receipt of the claim to
the provider or designee or provides the
provider or designee with electronic access
to the status of a submitted claim.
b Within forty (40) calendar days after receipt
of the claim, pays the claim or notifies the
provider or designee that the claim is denied
or contested. The notification to the provider
of a contested claim includes an itemized
list of additional information or documents
necessary to process the claim.
c. Pays or denies the claim within one hundred
and twenty (120) calendar days after receipt
of the claim. Failure to pay or deny the claim
within one hundred and forty (140) calendar
days after receipt of the claim creates an
uncontestable obligation for the health plan
to pay the claim.
The health plan reimburses providers for the
delivery of authorized services as described in s.
641.3155, F.S., including, but not limited to:
a. The provider must mail or electronically
transfer (submit) the claim to the health plan
within six (6) months after:
i. The date of service or discharge from
an inpatient setting.
a. Yes
No
N/A
b. Yes
No
N/A
c. Yes
No
N/A
a. Yes
No
N/A
b. Yes
No
N/A
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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