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

Vendor Name:
Review Period:
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Reviewer:
Participating Vendor Staff Member:
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Agency For Health Care Administration
Managed Care Organizations
Newborn Requirements
CONTRACT SECTION V.H.15
REQUIREMENTS FOR NEWBORN REVIEWS
Required Components File #1 File #2 File #3 File #4 File #5
A copy of the completed Florida Healthy Start Infant (Postnatal) Risk
Screening Instrument (DH Form 3135) was:
a. In the enrollee's medical record. Y N Y N Y N Y N Y N
b. Provided to the enrollee. Y N Y N Y N Y N Y N
Infants who did not score high enough to be eligible for Healthy
Start care coordination were referred for services, regardless of their
score on the Healthy Start risk screen.
a. If the referral was made at the same time the Healthy Start
risk screen was administered, the provider may have
indicated on the risk screening form that the enrollee or infant
is invited to participate based on factors other than score.
b. If the determination was made subsequent to risk screening,
the provider may have referred the enrollee or infant directly
to the Healthy Start care coordinator based on assessment of
actual or potential factors associated with high risk, such as
HIV, Hepatitis B, substance abuse or domestic violence.
3. At initial referral, the provider:
a. Completed Florida WIC program medical referral form with
the current height or length and weight (taken within sixty [60]
calendar days of the WIC appointment).
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
Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A
b. Completed a hemoglobin or hematocrit. Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A
c. Identified any medical/nutritional problems. Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A
4. For subsequent WIC certifications, the provider coordinated with the
Managed Care Organizations Page 1
Newborn Review Tool F1_07_11
Florida Medicaid