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

17
Agency For Health Care Administration
Managed Care Organizations
Provider Contract Audit Tool
Provider Contracts Review Tool
Item Number Standard Standard Met Reference Comments
The provider contracts:
Specify that DHHS, the Agency, Medicaid Program Integrity (MPI), and
MFCU has the right to inspect, evaluate and audit all of the following
related to this Contract:
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19
20
21
22
23
24
25
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a. Pertinent books.
b. Financial records.
c. Medical records.
d. Documents, papers, and records of any provider involving financial
transactions.
Specify the covered services and populations to be served under the
provider contract.
Require that providers comply with the health plan’s cultural
competency plan.
Require that any community outreach materials related to this Contract
that are displayed by the provider be submitted to the BMHC for written
approval before use.
Require submission of all reports and clinical information required by
the health plan, including CHCU reporting, if applicable.
Require providers of transitioning enrollees to cooperate in all respects
with providers of other health plans to assure maximum health outcomes
for enrollees.
Require providers to submit notice of withdrawal from the network at
least 90 calendars days before the effective date of such withdrawal.
Require that all providers agreeing to participate in the network as PCPs
fully accept and agree to responsibilities and duties associated with the
PCP designation.
Requires providers to submit all NPIs to the health plan within 15
business days of receipt.
Require all providers to notify the health plan in the event of a lapse in
general liability or medical malpractice insurance, or if assets fall below
the amount necessary for licensure under Florida statutes.
a. Y N
b. Y N
c. Y N
d. Y N
CC-VII.D.2.p
Y N CC-VII.D.2.q
Y N CC-VII.D.2.r
Y N CC-VII.D.2.s
Managed Care Organizations Page 3
Provider Contract Audit Tool F1_03_10
Florida Medicaid
Y N
CC-VII.D.2.t
Y N CC-VII.D.2.u
Y N CC-VII.D.2.v
Y N CC-VII.D.2.w
Y N
m. 1173(b) Social
Security Act
s, 4707(a) BBA
CC-VII.A.9.a-b
Y N CC-VII.D.2.x