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

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:
10 Prior authorization and referral procedures, including the required forms. Y N CC-VII.I.2.a.10
11 Medical records standards
12
Claims submission protocols and standards, including instructions and all
information necessary to file a clean or complete claim
13 Protocols for submitting encounter data
14
A summary of the health plan’s cultural competency plan and explains
how to get a full copy of the cultural competency plan at no cost to the
provider
Managed Care Organizations Page 2
Provider Handbook Audit Tool F1_06_10
Florida Medicaid
Y N
CC-VII.I.2.a.11
Y N CC-VII.I.2.a.12
Y N
15 Information on the health plan’s quality enhancement programs Y N
16 The enrollee rights and responsibilities. Y N
17
18
19
CMSSP ONLY
Information notifying providers that the health plan is authorized to take
whatever steps are necessary to ensure that the provider is recognized by
the state Medicaid program, including:
a. Its choice counseling/ enrollment broker contractors as a participating
provider of the health plan
b. The provider’s submission of encounter data is accepted by the FL
MMIS and/or the state’s encounter data warehouse
The health plan disseminates bulletins as needed to incorporate changes to
the provider handbook
The health plan includes in its provider handbook a notice that the amount
paid to providers by the Agency is the Medicaid fee schedule amount less
any applicable co-payments.
CC-VII.I.2.a.13
Y N CC-VII.I.2.a.14
a. Y N
b. Y N
Y N
CC-VII.I.2.a.15
42 CFR 438.100
CC-VII.I.2.a.16
CC-VII.I.2.a.17
CC-VII.I.2.b
Y N N/A Exhibit 7