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

APPLICATION ITEM
29 7. Provide a minimum of three separate and verifiable
references. The references listed must be for work similar in
nature to that specified in the application. Do not include
confidential references, and do not list the Agency as a client
reference. Do not list the same client for more than one
reference. In the event that the applicant changed names since
performing work for a listed reference, provide the name under
which the applicant operated in performing the work. References
should be available to be contacted during normal working hours.
30 8. Have there been, or are there any legal actions, taken or
pending, against the applicant or any of its predecessors in the
past five years? If yes, give a brief explanation and the status of
each action. A legal action is defined as an action taken by a
government agency (such as the Centers for Medicare and
Medicaid Services, the Office of Insurance Regulation or the
Agency for Health Care Administration) which would have
resulted in that government agency’s office of General Counsel
issuing a legal order resulting in a monetary or non-monetary
penalty. (See Section XVI, K., Legal Action Notification,
Attachment II, of the model Contract.)
31 9. Have any of the applicant’s agents or managing employees
been convicted of a felony of criminal offense related to the
person’s involvement in any federally-funded health care
program or been convicted of fraud, income tax evasion, or
obstruction of justice? If yes, provide the names, positions and
contact information of each one.
B. Ownership and Control Interest
Agency for Health Care Administration
Internal Working Document
MCO APPLICATION REVIEW CHECKLIST FOR Phase I
INSTRUCTIONS (if applicable)
Conduct three separate reference checks
using the Corporate Reference
Questionnaire form located on the Agency
shared drive in the MCO Application – New
Process Development 2011 folder. The
reference contact person may fax or email in
pdf format the completed form.
Attempt to contact each selected reference
by telephone up to four times. If the contact
person cannot be reached after four
attempts, request an alternate reference.
Allow five business days for submission of
references.
RED FLAG: If applicant reports such legal actions,
discuss with administrators.
RED FLAG: If yes, applicant is deficient until
person is removed. Alert administrators.
LOCATION IN
APPLICATION
(Binder, Tab & Page #)
Date Deficiencies
identified/Date
Deficiencies resolved
Revisions as of 1/23/2012 Page 7 of 19
INITIALS &
DATE
COMPLETED