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
22. CAPITATED PLANS:
Payment of Emergency
Services
CC-V.H.7.m
23. Out of Plan Non-
Emergency Services
CC-V.H.8
24. Using Non-
Participating Providers
For capitated health plans, reimbursement for
services provided to an enrollee under this
section by a non-participating provider is the
lesser of:
The non-participating provider's charges; the
usual and customary provider charges for
similar services in the community where the
services were provided; the amount mutually
agreed to by the health plan and the nonparticipating
provider within sixty (60) calendar
days after the non-participating provider
submits a claim; and the Florida Medicaid
reimbursement rate established for the hospital
or provider.
The health plan provides timely approval or
denial of authorization of out-of-network use
through the assignment of a prior authorization
number, which refers to and documents the
approval.
The health plan does not require paper
authorization as a condition of receiving
treatment if the health plan has an automated
authorization system; and written follow-up
documentation of the approval is provided to the
out-of-network provider within one (1) business
day from the request for approval.
Unless otherwise specified in this Contract,
where an enrollee uses non-emergency services
available under the health plan from a nonparticipating
provider, the health plan is not
DOCUMENTS
REVIEWED
State of Florida Compliance Monitoring_Standard_XIV_F3_07_11
Yes
No
N/A
Yes
No
Yes
No
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
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FINDINGS