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

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N/A 11. The file contains a current curriculum vitae with at least 5 years of work history for providers in initial credentialing. 12. Gaps in work history of greater than 6 months are explained for providers in initial credentialing. 13. In a PCP’s file, there is evidence of hospital privileges in good standing at the hospital designated as the primary admitting facility by the PCP, or there is evidence of an arrangement with another PCP for hospital coverage. 14. There is an attestation that the total active patient load for all populations and all plans is no more than 3,000 patients per PCP. An active patient is one that is seen by the physician a minimum of 3 times per year. 15. There is evidence of the physician’s disclosure related to ownership and management and business transactions. 16. For PCPs, there is evidence of the results from an office site visit . 17. The site visit includes an assessment of: a. Physical accessibility for persons with disabilities b. Adequate space, supplies, proper sanitation, smoke-free facilities c. Evidence of proper fire and safety procedures d. Medical record keeping practices e. Posting of the Agency’s statewide consumer call center telephone number including the hours of operation in the waiting room/ reception area Agency For Health Care Administration Managed Care Organizations Physician Credentialing and Recredentialing File Review Tool Managed Care Organizations Page 3 Phys Credentialing and Recredentialing File Review Tool F2_07_11 Florida Medicaid Y N N/A Y N N/A Y N N/A Y N N/A Y N Y N N/A a. Y N N/A b. Y N N/A c. Y N N/A d. Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Y N N/A a. Y N N/A b. Y N N/A c. Y N N/A d .Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Y N N/A a. Y N N/A b. Y N N/A c. Y N N/A d. Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Y N N/A a. Y N N/A b. Y N N/A c. Y N N/A d. Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Y N N/A a. Y N N/A b. Y N N/A c. Y N N/A d. Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Y N N/A a. Y N N/A b. Y N N/A c. Y N N/A d. Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Y N N/A a. Y N N/A b. Y N N/A c. Y N N/A d. Y N
f. Posting of the Agency Summary of Florida’s Patient’s Bill of Rights and Responsibilities g. The availability of a copy of the Florid a Patient’s Bill of Rights and Responsibilities for enrollee’s who request a copy of the document. 18. Verification occurs within 180 days of receipt of credentialing/recredentialing application. 19. There is a signed and dated attestation statement concerning the correctness and completeness of the application. 20. The attestation statement includes: a. Physical or mental problems that may impact the ability to provide mental health care; b. History of chemical dependency/substance abuse. c. History of loss of license and/or felony convictions. d. History of loss or restriction of privileges or disciplinary actions. 21. There is evidence that a Medical Director or other qualified individual reviews and approves “clean” credentialing/recredentialing files. Agency For Health Care Administration Managed Care Organizations Physician Credentialing and Recredentialing File Review Tool 22. There is evidence that a peer review body reviews and approves/disapproves files not Y Y Y Y Y Y Y Managed Care Organizations Page 4 Phys Credentialing and Recredentialing File Review Tool F2_07_11 Florida Medicaid N/A e. Y N N/A f. Y N N/A g. Y N N/A Y N Y N a. Y N b. Y N c. Y N d. Y N Y N N/A N/A e. Y N N/A f. Y N N/A g. Y N N/A Y N Y N a. Y N b. Y N c. Y N d. Y N Y N N/A N/A e. Y N N/A f. Y N N/A g. Y N N/A Y N Y N a. Y N b. Y N c. Y N d. Y N Y N N/A N/A e. Y N N/A f. Y N N/A g. Y N N/A Y N Y N a. Y N b. Y N c. Y N d. Y N Y N N/A N/A e. Y N N/A f. Y N N/A g. Y N N/A Y N Y N a. Y N b. Y N c. Y N d. Y N Y N N/A N/A e. Y N N/A f. Y N N/A g. Y N N/A Y N Y N a. Y N b. Y N c. Y N d. Y N Y N N/A N/A e. Y N N/A f. Y N N/A g. Y N N/A Y N Y N a. Y N b. Y N c. Y N d. Y N Y N N/A
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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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Results for Standard XII Administra
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Standard XIII: Community Outreach C
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Results for Standard XIII Community
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Standard XIV: Covered Services AGEN
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Page 213 and 214: Standard XIV: Covered Services AGEN
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Agency For Health Care Administrati
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Vendor Name: Review Period: Date of
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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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