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

Standarrd
II: Utilizatio on Managemen nt
CONTTRACT
SECTION
CONTRACT T REQUIREMEN NT
CO OMPLIANT
5. Evalluation
of The health plan has a UM program tha at includes Yes
Priorr
and the process p used to ev valuate prior and
No
Conccurrent
Authhoriza
tionss
conc current authorizat tions.
42 CFR 4566
42 CFR 4555.1.a.1
CC-VIII.B.11.a.4
6. Conssistent
Appllication
of Reeview
Criteeria
42 CFR 4566
42 CFR 4555.1.a.1
CC-VIII.B.11.a.4
7. Conssultation
with
Requuesting
Provviders
42 CFR 4566
42 CFR 4555.1.a.1
CC-VIII.B.11.a.4
8. Hosppital
Discharge
Plannning
42 CFR 4566
42 CFR 4555.1.a.1
CC-VIII.B.11.a.4
9. Physsician
Profi filing
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
mech hanisms to ensure e consistent appli ication of
revie ew criteria for aut thorization decisi ions.
The health plan has a UM program tha at includes
cons sultation with requ uesting providers s when
appr ropriate.
Yes
No
Yes
No
The health plan has a UM program tha at includes Yes
hosp pital discharge pla anning.
No
The health plan has a UM program tha at includes Yes
phys sician profiling.
No
SCORING
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
DOCUMENTTS
REVIEWEDD
FFINDINGS
PPage
2
Coompliance
Monitoring_Sttandard_II_F2_07_11