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

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Standard XIV: Covered Services AGENCY FOR HEALTHCARE ADMINISTRATION MANAGED CARE ORGANIZATIONS Compliance Monitoring Tool with Specific Contract Standards CONTRACT SECTION CONTRACT REQUIREMENT COMPLIANT SCORING 65C-29.008, FAC. CC-V.H.18.a-c 43. Covered Therapy Services CC-V.H.19 time frames, approves the out-ofnetwork claim and forwards it to the Agency and/or its fiscal agent. • Approves the claims and forwards them to the Agency and/or the fiscal agent for all CHCUP screenings for children/ adolescents whose enrollment and Medicaid eligibility are undetermined at the time of entry into the care and custody of DCF, and who are later determined to be enrollees at the time the examinations took place. Medicaid therapy services are physical, speech-language (including augmentative and alternative communication systems), occupational and respiratory therapies. a. The health plan covers therapy services consistent with the Medicaid Therapy Services Coverage and Limitations Handbook requirements; therapy services are limited to children/adolescents under age 21; and the provision of school-based therapy services to an enrollee does not replace, substitute or fulfill a service prescription or doctors’ orders for therapy services covered by the health plan. . b. Adults are covered for physical and respiratory therapy services under the outpatient hospital services program. DOCUMENTS REVIEWED FINDINGS State of Florida Compliance Monitoring_Standard_XIV_F3_07_11 a. Yes No b. Yes No Met Partially Met Not Met Page 27
Standard XIV: Covered Services AGENCY FOR HEALTHCARE ADMINISTRATION MANAGED CARE ORGANIZATIONS Compliance Monitoring Tool with Specific Contract Standards CONTRACT SECTION CONTRACT REQUIREMENT COMPLIANT SCORING 44. Referrals for Additional Services CC-V.H.19.a-c 45. CMSSP ONLY: Prescribed Pediatric Extended Care (PPEC) Services s. 400.901-.917, F.S., Chapters 59A-13 and 59G-4.260, FAC Exhibit 5 The health plan: Results for Standard XIV Covered Services Score # Elements Met Partially Met Not Met Not Applicable Total # Elements Total # Applicable Elements Percent of Elements Met • Refers enrollees to appropriate providers for further assessment and treatment of conditions. • Offers enrollees scheduling assistance in making treatment appointments and arranging transportation. • Provides for care management in order to follow the enrollee’s progress from screening through the course of treatment. PPEC services are provided at licensed nonresidential facilities that serve three (3) or more children under the age of 21 who require medically necessary short- or long-term medical care due to medically complex conditions. Such services are designed to meet the child’s physiological, developmental, nutritional, and social needs. DOCUMENTS REVIEWED FINDINGS 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 28
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Attachment I Special Term and Condi
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Attachment II Special Term and Cond
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RICK SCOTT GOVERNOR 272 7 Mah an Dr
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• Encounter data • Systems issu
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Appendix A How to Become a Florida
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How to Become a Florida Medicaid He
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Appendix B MCO Application Checklis
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4 5 6 7 8 9 10 Service Level(s) are
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19 b. Total number of employees; AP
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APPLICATION ITEM 25 3. In the past
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32 33 34 35 36 APPLICATION ITEM 10.
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APPLICATION ITEM C. Criminal Backgr
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APPLICATION ITEM 43 13. For medical
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46 47 APPLICATION ITEM 16. Indicate
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49 APPLICATION ITEM 19. Describe in
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51 52 53 54 55 56 APPLICATION ITEM
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Attachment III Special Term and Con
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RICK SCOTT GOVERNOR Regulatory Auth
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e. Complete a credentialing review
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RICK SCOTT GOVERNOR Regulatory Auth
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Compliance Monitoring Tool with Spe
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Standard I: Care Management/Continu
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Results for Standard I Care Managem
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Standarrd II: Utilizatio on Managem
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Standard III: Eligibility, Enrollme
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Standard IV: Enrollee Services & En
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Results for Standard IV Enrollee Se
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Standard V: Provider Credentialing
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Standard VI: Provider Services CONT
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Standard VI: Provider Services CC-
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Standard VI: Provider Services CONT
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Standard VII: Provider Contracting
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AGENCY FOR HEALTHCARE ADMINISTRATIO
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Standard VIII: Quality Improvement
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Results for Standard IX Medical Rec
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Standard X: Access and Availability
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Results for Standard X Access and A
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Standard XI: Grievances and Appeals
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Standard XII: Administration and Ma
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Agency For Health Care Administrati
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5. 6. 7. 8. 9. local WIC office to
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14 Agency For Health Care Administr
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Vendor Name: Review Period: Date of
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8 providers Agency For Health Care
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Medical Loss Ratio The following dr
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RICK SCOTT GOVERNOR Better Health C
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Plan Name: AGENCY FOR HEALTH CARE A
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DRAFT ATTESTATION OF 201_ QUARTER E
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Draft MLR Reporting Schedule Health
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RICK SCOTT GOVERNOR PLAN TYPES: Bet
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Attachment V Special Term and Condi
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RICK SCOTT GOVERNOR Mission to Ensu
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• Obtaining data from the health
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RICK SCOTT GOVERNOR Mission to Ensu
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Attachment VI Special Term and Cond
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RICK SCOTT GOVERNOR Better Health C
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Letter to CMS - Medicaid Managed Care Policies - Agency for ...

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