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

AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
Standard XII: Administration and Management
CONTRACT
SECTION
CC-X.D.4.a
CONTRACT REQUIREMENT
capitated network providers.
COMPLIANT SCORING
34. Submitting The health plan collects and submits, to the Yes
Met
Service-level
Encounter Data
Agency’s fiscal agent, enrollee service-level
encounter data for all covered services.
No
N/A
Partially Met
Not Met
CC-X.D.b
35. Converting Paper
Claims to
Encounter Data
CC-X.D.c
36. Complete and
Accurate
Encounters
CC-X.D.4.d.1-3
The health plan is responsible for errors or
noncompliance resulting from their own actions
or the actions of an agent authorized to act on
their behalf.
The health plan converts all information that
enters its claims system via hard copy paper
claims or other proprietary formats to encounter
data to be submitted in the appropriate HIPAA-
compliant formats.
The health plan provides complete and accurate
encounters to the Agency. The health plan
implements review procedures to validate
encounter data submitted by providers.
a. Complete: Submitting at least 95% of the
covered services provided by health plan
providers and non-participating providers.
b. Accurate (X12): Ninety-five percent of the
records in a health plan’s encounter batch
submission pass X12 EDI compliance edits
and the FMMIS threshold and repairable
compliance edits.
c. Accurate (NCPDP): Ninety-five percent of
the records in a health plan’s encounter batch
submission pass NCPDP compliance edits
and the pharmacy benefits system threshold
and repairable compliance edits.
Yes
No
N/A
a. Yes
No
N/A
b. Yes
No
N/A
c. 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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