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
ss. 409.9128
409.901, F.S.
641.513, F.S.
CC-V.H.7.d
19. Emergency Services in
a Non-contracted
Hospital
42 CFR 438.114(b)
CC-V.H.7.i
permitted by applicable law, by other
appropriate personnel under the supervision of a
hospital physician.
The physician, or the appropriate personnel,
indicates on the enrollee's chart the results of all
screenings, examinations and evaluations; and
the health plan covers all screenings,
evaluations and examinations that are
reasonably calculated to assist the provider in
arriving at the determination as to whether the
enrollee's condition is an emergency medical
condition.
The health plan covers any medically necessary
duration of stay in a non-contracted facility,
which results from a medical emergency, until
such time as the health plan can safely transport
the enrollee to a participating facility.
The health plan may transfer the enrollee, in
accordance with state and federal law, to a
participating hospital that has the service
capability to treat the enrollee's emergency
medical condition; and the attending emergency
physician, or the provider actually treating the
enrollee, is responsible for determining when
the enrollee is sufficiently stabilized for transfer
discharge, and that determination is binding on
the entities identified as responsible for
coverage and payment.
DOCUMENTS
REVIEWED
State of Florida Compliance Monitoring_Standard_XIV_F3_07_11
Yes
No
Met
Partially Met
Not Met
Page 7
FINDINGS