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

Agency For Health Care Administration
Managed Care Organizations
Hernandez Settlement Agreement Report Checklist
Hernandez Settlement Agreement Report
Item Number Standard Answer to Standard Comments
The HSA Report contains:
9 d. Ombudsman available
10 e. Toll-free number & voicemail
11 f. Two-way fax available __________
12 g. E-mail address available
13 h. Computer Link available
14 i. Non-English speaking personnel
15 j. Hearing impaired facilities available
If checked, enter number of
delinquencies _____
If checked, enter number of
delinquencies _____
If checked, enter number of
delinquencies _____
If checked, enter number of
delinquencies _____
If checked, enter number of
delinquencies _____
If checked, enter number of
delinquencies _____
If checked, enter number of
delinquencies _____
16 Total number of delinquencies are completed on the report Y N N/A
17
18
If delinquencies are noted, the schedule for the health plan’s retraining
and reevaluation are attached
If delinquencies are noted, the date of the reevaluation is noted on the
report
Y N N/A
Y N N/A
19 The health plan submitted the HSA log with the report Y N
Total # Applicable Elements
Total # Compliant Elements
Total Percent Compliant
Managed Care Organizations Page 2
HSA Report Audit Tool F1_03_10
Florida Medicaid