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

Vendor Name:
Review Period:
Date of Review:
Reviewer:
Date Report Received from Plan:
Agency For Health Care Administration
Managed Care Organizations
Hernandez Settlement Agreement Report Checklist
Hernandez Settlement Agreement Report
Item Number Standard Answer to Standard Comments
1
The HSA Report contains:
Total number of participating pharmacy locations surveyed are entered
on the form
Y N
Enter number of pharmacies: ____________
2 Process used to select the pharmacies is explained Y N
3
HSA areas surveyed are listed
Enter counties surveyed: __________________________________
4 HSA delinquencies are noted on the form
5
If the prior question was answered YES, check the area where the HSA
delinquencies are noted on the report.
If delinquencies were found, the number of delinquencies needs to be
completed to meet the element
6 a. Rejection signs posted
7 b. Printed computer screen rejection distributed to recipient
8 c. Pamphlet distributed to recipient
Managed Care Organizations Page 1
HSA Report Audit Tool F1_03_10
Florida Medicaid
Y N
Y N
If NO, none of the answers for
6-15 should be checked
If checked, enter number of
delinquencies _____
If checked, enter number of
delinquencies _____
If checked, enter number of
delinquencies _____