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

Standarrd
II: Utilizatio on Managemen nt
CONTTRACT
SECTION
CONTRACT T REQUIREMEN NT
10. Retroospective
The health plan has a UM program tha at includes
Reviiew
a retr rospective review w of inpatient and d
42 CFR 4566
ambu ulatory claims.
42 CFR 4555.1.a.1
CC-VIII.B.11-3.a.4
11. BMHHC
Apprroval
CC-VIII.B.11.a.4.a
12. Authhorization
Nummber
and
Datee
CC-VIII.B.11.a.4.b
13. Writtten
Conffirmation
of Denials
42 CFR 4388.210(c)
CC-VIII.B.11.a.4.c
14. Notification
to Heealth
Plans
42 CFR 4388.210(c)
CC-VIII.B.11.a.4.d.i-iv
State of Florrida
The health plan has written w approval from fr
Bure eau of Managed Health H Care (BMH HC) for its
servi ices authorization n protocols and an ny
chan nges.
The health plan’s serv vice authorization n system
prov vides the authoriza ation number and d effective
dates s of authorization n to providers and d nonparti
icipating provider rs.
The health plan’s serv vice authorization n system
prov vides written conf firmation of all de enials of
autho orization to provi iders.
The health plan may request r to be noti ified, but
will not deny claims payment p based so olely on
lack of notification, for fo the following:
a. Inpatient I emergen ncy admissions (w within 10
calendar days).
b. Obstetrical O care (a at first visit).
c. Obstetrical O admiss sion exceeding fo orty-eight
(48) hours for va aginal delivery an nd ninety-
six (96) hours for r caesarean sectio on.
d. Transplants. T
AGENCY Y FOR HEALTHCARE
ADMMINISTRATIOON
MANAGED M CA ARE ORGANIIZATIONS
Compliance Monitoring To ool with Speciffic
Contract Staandards
CO OMPLIANT
Yes
No
Yes
No
Yes
No
Yes
No
a. Ye es
No N
b. Ye es
No N
c. Ye es
No o
d. Ye es
No N
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
3
Coompliance
Monitoring_Sttandard_II_F2_07_11