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
CC-V.H.10.a.6
CC-V.H.10.b.2
37. Outpatient Services
or 2 candidate for a heart or lung transplant, or
with a Model End State Liver Disease
(MELD) score of 11-25 for a liver transplant,
the health plan submits a copy of the UNOS to
BMHC requesting disenrollment for the
member. The recipient cannot re-enroll with
the health plan until at least 1 year post
transplant. The re-enrollment is not automatic.
(See Summary of Responsibility Table Section
5.H.10.a.6)
Outpatient hospital services:
• Consist of medically necessary
preventive, diagnostic, therapeutic or
palliative care under the direction of a
physician or dentist at a licensed acute
care hospital.
• Include medically necessary
emergency room services, dressings,
splints, oxygen and physician-ordered
services and supplies for the clinical
treatment of a specific diagnosis or
treatment.
• Include emergency services and care
without any specified dollar
limitations.
• Include a procedure for the
authorization of dental care and
associated ancillary medical services
provided in an outpatient hospital
setting if that care meets the following
requirements:
Is provided under the direction of
DOCUMENTS
REVIEWED
FINDINGS
State of Florida Compliance Monitoring_Standard_XIV_F3_07_11
Yes
No
N/A
Met
Partially Met
Not Met
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