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

Standard XII: Administration and Management
Exhibit 10
CONTRACT
SECTION
23. CAPITATED:
Reimbursing
Providers Out of
Service Area
Exhibit 10
24. Resolution of
Claim
Complaints by
Providers
s. 641.3155 F.S.
CC-X.C.5
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
ii. The date that the provider was
furnished with the correct name and
address of the health plan.
b. When the health plan is the secondary payer,
the provider must submit the claim to the
health plan within ninety (90) calendar days
after the final determination of the primary
payer.
In accordance with s. 409.912, F.S., the health
plan reimburses any hospital or physician that is
outside the health plan’s authorized geographic
service area for health plan authorized services
provided by the hospital or physician to
enrollees:
a. At a rate negotiated with the hospital or
physician.
b. The lesser of the following:
i. The usual and customary charge made
to the general public by the hospital or
physician.
ii. The Florida Medicaid reimbursement
rate established for the hospital or
physician.
The health plan has a process for handling and
addressing the resolution of provider complaints
concerning claims issues.
a. Yes
No
N/A
b. Yes
No
N/A
Yes
No
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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