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

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APPLICATION ITEM
The hard copy may be double-sided as long as the applicant
does not include more than one policy/item response on a page.
The application narrative responses must be organized in the
same order as the application items/questions. For example,
narrative response labeled #1 should answer application item 1,
which requests a description of the applicant’s legal history.
Application accepted for review. (Cursory/content review
complete)
PHASE I CONCURRENT REVIEW Days 3-10
Agency for Health Care Administration
Internal Working Document
MCO APPLICATION REVIEW CHECKLIST FOR Phase I
INSTRUCTIONS (if applicable)
Review above submission items and confirm
responses to each applicable question.
LOCATION IN
APPLICATION
(Binder, Tab & Page #)
I. ORGANIZATIONAL INFORMATION - If inconsistencies or unusual organizational structure exist, alert and discuss with Agency Administrator.
A. Legal Background and Experience
14 1. In chronological order, describe the applicant’s legal history.
Include size and resources of all predecessor business entities,
parent corporations, holding companies, subsidiaries, mergers,
reorganizations and changes of ownership. Be specific as to
dates and parties involved. Background details for each shall
include, but not be limited to, the following information:
Review response against A.1.b., B.10.e. and D.14.
response for consistency and any unusual
organizational structure. If inconsistencies or
unusual organizational structure exist, alert and
discuss with administrators.
15 a. Dates of operation; If applicant has existed as a corporate entity,
16 b. Type of business organization (public company, partnership,
subsidiary, etc); and
17 c. Primary business
18 2. For this applicant, provide the following:
a. Number of FTEs engaged in activities relevant to this
application;
response should include dates of operation
for each entity.
Make note of any partnerships or affiliations
with other health plans or entities.
Review against D.14. of the application.
If unusual organizational structure exists,
discuss with administrator.
Review against X.A.163 Staffing and C.12. Criminal
Background Screening for consistency.
Date Deficiencies
identified/Date
Deficiencies resolved
Revisions as of 1/23/2012 Page 3 of 19
N/A
INITIALS &
DATE
COMPLETED