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

Vendor Name:
Review Period:
Date of Review:
Reviewer:
Date Log Received from Plan:
Agency For Health Care Administration
Managed Care Organizations
Hernandez Settlement Agreement Log Checklist
Hernandez Settlement Agreement Log
Item Number Standard
Found on the
Log
Found on the
Log
Found on the
Log
Found on the
Log
The HSA Log contains: Q1 Q2 Q3 Q4
1 The enrollee’s name Y N Y N Y N
2 The enrollee’s address Y N Y N Y N
3 The enrollee’s telephone number Y N Y N Y N
4 The reason for the denial Y N N/A Y N/A Y N/A
5 The reason for the delay
Y N N/A
Comments
Managed Care Organizations Page 1
HSA Log Audit Tool F1_03_10
Florida Medicaid
Y N/A
Y N/A
Y N
Y N
Y N
Y N/A
Y N/A
6 The termination of the prescription Y N N/A Y N/A Y N/A Y N/A
7 Name of pharmacy listed on the log Y N Y N Y N Y N
8 Store number of pharmacy listed on log Y N N/A Y N N/A Y N N/A Y N N/A
9 The date of the call Y N Y N Y N Y N