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

Vendor Name:
Review Period:
Date of Review:
Reviewer:
Participating Vendor Staff Member:
Agency For Health Care Administration
Managed Care Organizations
Pregnancy Related Requirements
CONTRACT SECTION V.H.15
REQUIREMENTS FOR PREGNANCY-RELATED REVIEWS
Required Components File #1 File #2 File #3 File #4 File #5
The health plan provides the most appropriate and highest level of quality
care for pregnant enrollees.
Providers offer Florida’s Healthy Start prenatal risk screening to
1. pregnant enrollees during the first prenatal visit as required by s.
383.14, F.S., s. 381.004, F.S., and 64C-7.009, F.A.C.
Y N Y N Y N Y N Y N
a. The provider used the DOH prenatal risk form (DH Form
3134)
Y N Y N Y N Y N Y N
b. The provider kept a copy of the completed screening
instrument in the enrollee’s medical record and provided a
copy to the enrollee
Y N Y N Y N Y N Y N
Pregnant enrollees who do not score high enough to be eligible for
Healthy Start care coordination may be referred for services,
2. regardless of their score on the Healthy Start risk screen, in the
following ways:
a. If the referral was made at the same time the Healthy Start
risk screen was administered, the provider indicated on the
risk screening form that the enrollee was invited to participate
based on factors other than score; or
Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A
b. If the determination was made subsequent to risk screening,
the provider referred the enrollee 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
The health plan referred all pregnant, breast-feeding and postpartum
Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A
women to the local WIC office. Each time the provider completed a
3.
WIC referral form, the provider gave a copy to the enrollee and kept a
copy in the enrollee’s medical record
Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A
Managed Care Organizations Page 1
Pregnancy Related Review Tool F1_07_11
Florida Medicaid