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

Medicaid Compliance Analyst Responsibilities:
1. Upon receipt of a health plan application, the analyst will document all application
related activities on the Application Review Workplan. The analyst will ensure that the
requests includes:
• County(ies) and anticipated enrollment levels for each county
• A completed provider network checklist
• Spreadsheet of providers
• GeoAccess maps or comparable mapping to demonstrate accessibility
• First and last page of contracts for ALL provider types
• Model subcontracts (both medical, non-medical and behavioral health) as
appropriate
2. The analyst will review the Provider Network Checklist, the Medicaid Health Provider
Network Spreadsheet, supporting contracts and GeoAccess Maps to verify the network’s
adequate for the requested enrollment level. All reviewed documents shall be saved on
SharePoint in the Health Plan’s library (document type=application). If any deficiencies are
determined, the analyst shall include such in the appropriate Deficiency Log located on
SharePoint.
3. Begin quality review of policies and procedures (and any accompanying documentation
such as provider materials and member materials handbooks, directories, letters, provider
training plan), and be in regular contact with the applicant to provide opportunity to
address any concerns or areas in need of improvement. If any deficiencies are determined
and have not been resolved with communication between the Agency and the applicant,
include such in the appropriate Deficiency Log located on SharePoint.
4. Schedule site visit (readiness review). Coordinate with the Bureaus of HSD and MPI.
Use approved letter template.
5. Schedule internal pre-survey meeting with all parties (BMHC, HSD & MPI) for agenda
discussion and coordination. The final agenda is sent to the applicant two weeks prior to
the on-site visit.
6. Conduct on-site readiness review.
7. The on-site readiness review will consist of:
a. Perform review of any remaining documents (P&Ps, provider and member
materials) to ensure they meet contract standards
b. Comprehensive interviews conducted by the analyst and team members with
Administrative and Clinical Staff to verify application of policies and procedures,
protocols, standards and processes. (Areas of interest: Member Services,
Enrollment/Disenrollment, Claims Processing, Grievances and Appeals, Provider
Services, Case Management/Care Coordination, Utilization management, Quality
Improvement, Behavioral Health Oversight, and Fraud and Abuse)
c. Tour the facility
d. Review all proprietary materials on site such as Utilization Management Program
(minutes, etc) and Quality Management (minutes, etc.) Case Management and
Coordination protocols and forms
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