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

Vendor Name:
Review Period:
Date of Review:
Reviewer:
Participating Vendor Staff Member:
1
Agency For Health Care Administration
Managed Care Organizations
Child Health Check-Up Review Tool
REQUIREMENTS FOR CHILD HEALTH CHECK-UP
Required Components File #1 File #2 File #3 File #4 File #5
Comprehensive health and developmental history including
a. Past medical history
Y N Y N Y N Y N Y N
b. Developmental history Y N Y N Y N Y N Y N
c. Behavioral health status Y N Y N Y N Y N Y N
2 Nutritional assessment Y N Y N Y N Y N Y N
3 Developmental assessment Y N Y N Y N Y N Y N
4 Comprehensive unclothed physical examination Y N Y N Y N Y N Y N
5 Dental screening Y N Y N Y N Y N Y N
a. Dental referral, when required Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A
6 Laboratory Tests Y N Y N Y N Y N Y N
a. Blood lead testing, when required Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A
7 Sensory screening: Vision Y N Y N Y N Y N Y N
a. Sensory screening included objective vision test, when
required
Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A
8 Sensory screening: Hearing Y N Y N Y N Y N Y N
a. Sensory screening included objective hearing test, when
required
Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A
Managed Care Organizations Page 1
Child Health Check-Up Review Tool F1_03_10
Florida Medicaid