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
Exhibit 5
25. Out-of-Network
Emergency Services
s. 409.912, F. S.,
Exhibit 5 H. 8. c
26. Paying Nonparticipating
Providers
s. 641.3155, F. S.
Exhibit 5
liable for the cost of such services unless the
health plan referred the enrollee to the nonparticipating
provider or authorized the out-of-
network service.
In accordance with s. 409.912, F. S., the health
plan reimburses any hospital or physician that is
outside the health plan’s authorized service area
for health-plan-authorized services at a rate
negotiated with the hospital or physician or
according to the lesser of the following:
The usual and customary charge made to the
general public by the hospital or provider; and
the FL Medicaid reimbursement rate established
for the hospital or provider.
Reference: 641.3155 Prompt payment of claims.--
The health plan reimburses all out-of-network
providers as described in s. 641.3155, F. S.
DOCUMENTS
REVIEWED
State of Florida Compliance Monitoring_Standard_XIV_F3_07_11
Yes
No
Yes
No
N/A
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Page 10
FINDINGS
(1) As used in this section, the term "claim" for a noninstitutional provider means a paper or electronic billing instrument submitted to the health maintenance
organization's designated location that consists of the HCFA 1500 data set, or its successor, that has all mandatory entries for a physician licensed under chapter
458, chapter 459, chapter 460, chapter 461, or chapter 463, or psychologists licensed under chapter 490 or any appropriate billing instrument that has all mandatory
entries for any other noninstitutional provider. For institutional providers, "claim" means a paper or electronic billing instrument submitted to the health
maintenance organization's designated location that consists of the UB-92 data set or its successor with entries stated as mandatory by the National Uniform Billing
Committee.
(2) All claims for payment or overpayment, whether electronic or nonelectronic:
(a) Are considered received on the date the claim is received by the organization at its designated claims-receipt location or the date a claim for overpayment is received by