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

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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
Standarrd II: Utilizatio on Managemen nt CONTTRACT SECTION CONTRACT T REQUIREMEN NT 15. Deniials by The health plan ensur res that all decisio ons to Apprropriate deny y a service author rization request, or o limit a Heallth Care servi ice in amount, du uration, or scope that t is less Profe fessionals than requested, are made m by health car re profe essionals who hav ve the appropriate clinical 42 CFR 4388.210(b)(3) CC-VIII.B.11.a.4.e expe ertise in treating th he enrollee’s con ndition or disea ase. 16. Emergency The health plan provi ides post authoriz zation to Sheltter Coun nty Health Depar rtments (CHDs) for f Meddical emer rgency shelter me edical screenings provided Screeenings CC-VIII.B.11.a.4.g for th he Department of f Children & Fam milies (DCF F) clients. 17. Autoomated Heal lth plans with aut tomated authoriza ation Authhorization syste ems may not requ uire paper authori ization as Systeems a con ndition for provid ding treatment. CC-VIII.B.11.a.4.h 18. Writtten Docuumenta- tion CC-VIII.B.11.a.4.i CC-IV.A.8.ee 19. Apprroval for Claimms Withhout Writtten Docuumenta- tion CC-VIII.B.11.a.4.i CC-IV.A.8.ee State of Florrida The health plan will not n delay service autho orization if writte en documentation n is not avail lable in a timely manner. m The health plan is not t required to appr rove claim ms for which it ha as not received written docu umentation. 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 Yes 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 4 Coompliance Monitoring_Sttandard_II_F2_07_11
Page 3 and 4: Attachment I Special Term and Condi
Page 5 and 6: Attachment II Special Term and Cond
Page 7 and 8: RICK SCOTT GOVERNOR 272 7 Mah an Dr
Page 9 and 10: • Encounter data • Systems issu
Page 11 and 12: Appendix A How to Become a Florida
Page 13 and 14: How to Become a Florida Medicaid He
Page 15 and 16: Appendix B MCO Application Checklis
Page 17 and 18: 4 5 6 7 8 9 10 Service Level(s) are
Page 19 and 20: 19 b. Total number of employees; AP
Page 21 and 22: APPLICATION ITEM 25 3. In the past
Page 23 and 24: 32 33 34 35 36 APPLICATION ITEM 10.
Page 25 and 26: APPLICATION ITEM C. Criminal Backgr
Page 27 and 28: APPLICATION ITEM 43 13. For medical
Page 29 and 30: 46 47 APPLICATION ITEM 16. Indicate
Page 31 and 32: 49 APPLICATION ITEM 19. Describe in
Page 33 and 34: 51 52 53 54 55 56 APPLICATION ITEM
Page 35 and 36: Attachment III Special Term and Con
Page 37 and 38: RICK SCOTT GOVERNOR Regulatory Auth
Page 39 and 40: e. Complete a credentialing review
Page 41 and 42: RICK SCOTT GOVERNOR Regulatory Auth
Page 43 and 44: Compliance Monitoring Tool with Spe
Page 45 and 46: Standard I: Care Management/Continu
Page 51 and 52: Results for Standard I Care Managem
Page 53: Standarrd II: Utilizatio on Managem
Page 57 and 58: Standarrd II: Utilizatio on Managem
Page 59 and 60: Standard III: Eligibility, Enrollme
Page 77 and 78: Standard IV: Enrollee Services & En
Page 103 and 104: Results for Standard IV Enrollee Se
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Standard V: Provider Credentialing
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Standard VI: Provider Services CONT
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Standard VI: Provider Services CC-
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Standard VI: Provider Services CONT
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Standard VII: Provider Contracting
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AGENCY FOR HEALTHCARE ADMINISTRATIO
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Standard VIII: Quality Improvement
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Results for Standard IX Medical Rec
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Standard X: Access and Availability
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Results for Standard X Access and A
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Standard XI: Grievances and Appeals
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Standard XII: Administration and Ma
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Results for Standard XII Administra
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Standard XIII: Community Outreach C
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Results for Standard XIII Community
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Standard XIV: Covered Services AGEN
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Standard XV: Immunizations, Pregnan
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Vendor Name: Review Period: Date of
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Agency For Health Care Administrati
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File # Case ID # Agency For Health
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File # Case ID # 1 2 3 4 5 6 7 8 9
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13 14 15 Agency For Health Care Adm
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f. Posting of the Agency Summary of
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Name: Review Period: Date of Review
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5. 6. 7. 8. 9. local WIC office to
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14 Agency For Health Care Administr
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8 providers Agency For Health Care
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Medical Loss Ratio The following dr
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RICK SCOTT GOVERNOR Better Health C
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Plan Name: AGENCY FOR HEALTH CARE A
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DRAFT ATTESTATION OF 201_ QUARTER E
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Draft MLR Reporting Schedule Health
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RICK SCOTT GOVERNOR PLAN TYPES: Bet
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Attachment V Special Term and Condi
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RICK SCOTT GOVERNOR Mission to Ensu
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• Obtaining data from the health
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RICK SCOTT GOVERNOR Mission to Ensu
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Attachment VI Special Term and Cond
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RICK SCOTT GOVERNOR Better Health C
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