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
Provider Handbook Audit Tool
Provider Handbook Review Tool
Item Number Standard Found in Handbook Reference Comments
The provider handbook contains:
1 A description of the Medicaid program Y N CC-VII.I.2.a.1
2 A description of the covered services Y N CC-VII.I.2.a.2
3 A description of emergency services and the responsibilities Y N
CC-VII.I.2.a.3
4 The Child Health Check-Up (CHCUP) Program services and standards Y N CC-VII.I.2.a.4
5
6
7
Policies and procedures covering the provider complaint system to
include:
a. Specific instructions regarding how to file a provider complaint,
including complaints about claims issues
b. Which individual(s) has authority to review a provider complaint
The procedural steps in the enrollee grievance process, including:
a. Address, toll-free telephone number, and office hours of the
grievance staff
b. The enrollee’s right to request continuation of benefits while
utilizing the grievance system
c. Information about the Subscriber Assistance Program (SAP, for
HMOs only) and the Beneficiary Assistance Program (BAP, for
PSNs only)
d. Toll-free telephone number to call to present a complaint,
grievance, or appeal
Medical necessity standards and practice protocols, including guidelines
pertaining to the treatment of chronic and complex conditions
a. Y N
b. Y N
a. Y N
b. Y N
c. Y N
d. Y N
CC-VII.I.2.a.5
CC-VII.I.5.b
CC-VII.I.2.a.6
Managed Care Organizations Page 1
Provider Handbook Audit Tool F1_06_10
Florida Medicaid
Y N
CC-VII.I.2.a.7
8 An explanation of PCP responsibilities Y N CC-VII.I.2.a.8
9 Other provider or subcontractor responsibilities
Y N
CC-VII.I.2.a.9