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

Standard XII: Administration and Management
CONTRACT
SECTION
30. Submitting
Historical
Encounters
CC-X.D.3.a
31. Submitting
Ongoing
Encounters
CC-X.D.3.b
32. Encounters
Failing EDI
CC-X.D.3.c
33. Automated and
Integrated
Encounter Data
Systems
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
The health plan submits the historical encounters
for all typical and atypical services with health
plan paid dates of January 1, 2007 for Reform
populations, and July 1, 2008 for non-Reform
populations, up to the submission start date.
The health plan retains submitted historical
encounter data for a period not less than 5 years.
The health plan submits encounters for all typical
and atypical services with health plan paid dates
on or after the submission start date on an
ongoing basis within 60 calendar days following
the end of the month in which the health plan
paid the claims for services.
For all encounters submitted after the submission
start date, including historical and ongoing
claims, if the Agency or its fiscal agent notifies
the health plan of encounters facility X112
electronic data interface (EDI) compliance edits
or FMMIS threshold and repairable compliance
edits, the health plan remediates all such
encounters within 60 calendar days after such
notice.
All health plan encounters are submitted to the
Agency in the standard HIPAA transaction
formats: the ANSI X12N 837 transaction formats
for P, Professional; I, Institutional, and D,
Dental; and for pharmacy services in the
National Council for Prescription Drug Program
(NCPDP) format.
Health plan paid amounts are provided for non-
Yes
No
N/A
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
DOCUMENTS
REVIEWED
FINDINGS
State of Florida Compliance Monitoring_Standard_XII_F2_07_11
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