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

Standard XII: Administration and Management
CONTRACT
SECTION
25. Claims
Submitted by
Out-of-Network
Providers
CC-X.C.6
26. Aging Claims
Summary
CC-X.C.7
27. Encounter Data
Collection
CC-X.D.1
28. Encounter Data
Submission
CC-X.D.1
29. Revising
Encounter Data
Standards
CC-X.D.1
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
The health plan does not deny claims submitted
by an out-of-network provider, including
provision of emergency services and care, solely
based on the period between the date of service
and the date of clean claim submission, unless
the period exceeds 365 days.
Each quarter the health plan submits an aging
claims summary.
Encounter data collection and submission is
required for all capitated health plans for all
health care services rendered to their enrollees
(services for which the health plan is reimbursed
by the Agency on a capitated basis) and from all
fee-for-service PSNs for all capitated services.
The health plan submits encounter data that
meets established Agency data quality standards
to ensure receipt of complete and accurate data
for program administration.
The Agency will revise and amend the encounter
data standards with 90 calendar days advance
notice to the health plan to ensure continuous
quality improvement.
The health plan makes changes or corrections to
any systems, processes, or data transmission
formats as needed to comply with Agency data
quality standards as originally defined or
subsequently amended.
Yes
No
Yes
No
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Met
Partially Met
Not Met
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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