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

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Agency For Health Care Administration
Managed Care Organizations
Case Management/Continuity of Care Review Tool
REQUIREMENTS FOR CASE MANAGEMENT/CONTINUITY OF CARE
Requirement File #1 File #2 File #3 File #4 File #5
Following diagnosis: Behavioral health, HIV-related, disease
management, pregnancy or developmental/Specialty Healthcare
Needs
Evidence of communication/coordination between case management
PCP and patient/facility
Evidence of member receiving appropriate DME, supplies and
services for diagnosis
Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A
Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A
Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A
16 Evidence of appropriate referrals scheduled and received Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A
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Evidence of appropriate out-of-plan referrals scheduled and received,
if applicable
Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A
18 Case coordinator identified all special needs of the member Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A
19 Evidence of timeliness of coordinated care Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A
20 Evidence of follow up is documented Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A
21 Non-compliance of member was identified and addressed Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A
22 Linguistic/cultural barriers identified and addressed Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A
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Other barriers to health care provision for members were identified
and addressed
Monitoring of enrollees with ongoing medical conditions and
coordination of services for high utilizers to address the following,
ensuring the enrollee has adequate support at home, assisting
enrollees who are unable to access necessary care due to their
medical or emotional conditions or who do not have adequate
community resources to comply with their care, and assisting the
enrollee in developing community resources to manage a medical
condition.
Total # Applicable Elements
Total # Compliant Elements
Total Percent Compliant
Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A
Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A
Managed Care Organizations Page 2
Case Management/Continuity of Care Review Tool F1_03_10
Florida Medicaid