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
20. Post-stabilization Care
42 CFR 438.114 42
CFR 422.113(c)
CC-V.H.7.k
21. Payment of Emergency
Claims to Nonparticipating
Providers
CC-V.H.7.l
The health plan covers post-stabilization care
services without authorization, regardless of
whether the enrollee obtains a service within or
outside the health plan's network for the
following situations:
Post-stabilization care services that were preapproved
by the health plan; post-stabilization
care services that were not pre-approved by the
health plan because the health plan did not
respond to the treating provider's request for
pre-approval within one (1) hour after the
treating provider sent the request; the treating
provider could not contact the health plan for
pre-approval; and those post-stabilization care
services that a treating physician viewed as
medically necessary after stabilizing an
emergency medical condition are nonemergency
services. The health plan can choose
not to cover them if they are provided by a nonparticipating
provider, except in those
circumstances detailed above.
The health plan does not deny claims for the
provision of emergency services and care
submitted by a nonparticipating provider solely
based on the period between the date of service
and the date of clean claim submission, unless
that period exceeds three-hundred and sixty-five
(365) days.
DOCUMENTS
REVIEWED
State of Florida Compliance Monitoring_Standard_XIV_F3_07_11
Yes
No
Yes
No
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Page 8
FINDINGS