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.11.a
CC-V.H.11.b.1-2
38. CAPITATED PLANS:
Providing Ancillary
Hospital Services
CC-V.H.12.a.1
39. Emergency Ancillary
Hospital Services
CC-V.H.12.a.2
CC-V.H.12.b
a dentist at a licensed hospital.
Although not usually considered
medically necessary, is
considered medically necessary
to the extent that the outpatient
hospital services must be
provided in a hospital due to the
enrollee’s disability, behavioral
health condition or abnormal
behavior due to emotional
instability or a developmental
disability.
When the capitated health plan or its
authorized physician authorizes ancillary
hospital services (either inpatient or
outpatient), the health plan reimburses the
provider of the service at the Medicaid line
item rate, unless the health plan and the
hospital have negotiated another
reimbursement rate.
The health plan authorizes payment for nonnetwork
physicians for emergency ancillary
services provided in a hospital setting.
If the health plan covers dental services, as
specified in Attachment I, it has a procedure
for the authorization of medically necessary
dental care and associated ancillary services
provided in licensed ambulatory surgical
center settings if that care is provided under
the direction of a dentist as described in the
State Plan.
DOCUMENTS
REVIEWED
FINDINGS
State of Florida Compliance Monitoring_Standard_XIV_F3_07_11
Yes
No
N/A
Yes
No
Met
Partially Met
Not Met
Met
Partially Met
Not Met
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