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

Standard XIV: Covered Services
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT SECTION CONTRACT REQUIREMENT COMPLIANT SCORING
s. 743.064, F.S.
CC-V.H.7.a
16. Emergency Services
CC-V.H.7.b
17. Trauma Services
ss. 395.1041
ss. 395.4045
401.45, F.S.
CC-V.H.7.c
18. Screenings for
Emergency Treatment
emergency services and care received at a
hospital due to lack of parental consent.
b. In addition, the health plan does not deny
payment for treatment obtained when a
representative of the health plan instructs
the enrollee to seek emergency services and
care.
The health plan does not:
Require prior authorization for an enrollee to
receive pre-hospital transport or treatment for
emergency services and care; specify or imply
that emergency services and care are covered by
the health plan only if secured within a certain
period of time; use terms such as "life
threatening" or "bona fide" to qualify the kind
of emergency that is covered; nor does the plan
deny payment based on a failure by the enrollee
or the hospital to notify the health plan before,
or within a certain period of time after,
emergency services and care were given.
The health plan provides pre-hospital and
hospital-based trauma services and emergency
services and care to enrollees.
When an enrollee presents at a hospital seeking
emergency services and care, the determination
that an emergency medical condition exists will
be made, for the purposes of treatment, by a
physician of the hospital or, to the extent
DOCUMENTS
REVIEWED
State of Florida Compliance Monitoring_Standard_XIV_F3_07_11
Yes
No
Yes
No
Yes
No
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Page 6
FINDINGS