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

MCO HHealth
Plan:
Contract
Manager:
Standarrd
II: Utilizatio on Managemen nt
CONTTRACT
SECTION
CONTRACT T REQUIREMEN NT
1. Overr
and The health plan has a utilization manag gement
Undeer
(UM M) program that in ncludes procedure es for
Utiliization
ident tifying patterns of o over-utilization n and
42 CFR 4566
42 CFR 4555.1.a.1
CC-VIII.B.11.a.1
unde er-utilization by enrollees e and for addressing a
poten ntial problems identified
as a result
of these
analy yses.
2. Repoorting
The health plan has a UM program tha at includes
Frauud
and reporting
fraud and ab buse through the UM
Abusse
prog gram to the Agenc cy’s Medicaid Pro ogram
Integ grity Bureau (MP PI) unit.
42 CFR 4566
42 CFR 4555.1.a.1
CC-VIII.B.11.a.2
3. Secoond
Opinnion
42 CFR 4388.206
42 CFR 4566
42 CFR 4555.1.a.1
641.51, F.S. .
CC-VIII.B.11.a.3
4. Protoocols
for
Priorr
Authhoriza
tionss
and
Deniials
42 CFR 4566
42 CFR 4555.1.a.1
CC-VIII.B.11.a.4
State of Florrida
AGENCY Y FOR HEALTHCARE
ADMMINISTRATIOON
MANAGED M CA ARE ORGANIIZATIONS
Compliance Monitoring To ool with Speciffic
Contract Staandards
The health plan has a UM program tha at includes
procedures
for enrolle ees to obtain a second
medi ical opinion, and the health plan is s
respo onsible for author rizing claims for such
servi ices as specified in i 641.51 F.S.
The health plan has a UM program tha at includes
proto ocols for prior au uthorization and denial d of
servi ices.
Contract C Numbeer:
Date(s) D of Moniitoring:
CO OMPLIANT
Yes
No
Yes
No
Yes
No
Yes
No
SCORING
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
DOCUMENTTS
REVIEWEDD
FFINDINGS
PPage
1
Coompliance
Monitoring_Sttandard_II_F2_07_11