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

5. The health plan must assure that PCP services and referrals to participating specialists are
available on a timely basis, as follows:
a. Urgent Care — within one (1) day,
b. Routine Sick Patient Care — within one (1) week,
and c. Well Care Visit — within one (1) month.
Medicaid Compliance Analyst Responsibilities:
1. The analyst must review the submitted report for completeness and accuracy.
2. The analyst must ensure that the attestation is filed along with the report.
3. The analyst must follow up with the health plan if submitted data seems questionable,
i.e. Wait times exceed contractual requirements, wait times reflect unusual patterns,
PCPs reflect no wait time at all
4. The analyst shall determine if the health plan requires a corrective action plan (CAP)
to address issues.
5. If a CAP is deemed necessary, the analyst must follow up with the health plan to
provide such within 10 business days of receiving notification of the violation or noncompliance
from the Agency.
6. Upon receipt of the CAP, the analyst shall review for appropriateness and file such in
the health plan’s electronic library (SharePoint).
7. The analyst must notify the health plan that the CAP is accepted or work with the health
plan to correct any deficiencies within 10 business days of receipt.
Page 2 of 2