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

Standarrd
II: Utilizatio on Managemen nt
CONTTRACT
CONTRACT T REQUIREMEN NT
SECTION
20. Commpensation
The health plan’s com mpensation to ind dividuals
for UUM
or en ntities that conduc ct UM activities cannot c be
Activvities
struc ctured to provide incentives for the e
indiv vidual or entity to o deny, limit, or discontinue d
medi ically necessary services s to any en nrollee.
CC-VIII.B.11.b
21. Notice
of
Actioon
42 CFR 4388.404(a)
and
(c)
42 CFR 4388.10(c-d)
CC-IV.A.166.a
22. Standard
Authhorization
Deciisions
42 CFR 4388.210(d)(1)
CC-IV.A.166.b
23. Exteensions
CC-IV.A.166.c
24. Expeedited
Authhorization
Deciisions
42 CFR 4388.210(d)(2)
CC-IV.A.166.d
State of Florrida
The health plan notifi ies the provider and a gives
the enrollee e written notice n of any decis sion to
deny y a service author rization request, or o to
autho orize a service in n an amount, dura ation, or
scop pe that is less than n requested.
For standard s authoriz zation decisions, the t health
plan provides notice as a expeditiously as a the
enrollee’s
health cond dition requires an nd within
no more m than 14 calen ndar days followi ing receipt
of th he request for serv vice.
The timeframe can be e extended up to 14
addit tional calendar da ays if the enrollee e or the
prov vider requests an extension, e or the health
plan justifies the need d for additional in nformation
and how h the extension n is in the enrolle ee’s
inter rest.
Expe edited authorizati ion is required wh hen a
prov vider indicates or the health plan de etermines
that following the stan ndard timeline co ould
serio ously jeopardize the t enrollee’s life,
health,
or ab bility to attain, ma aintain, or regain
maxi imum function.
An expedited e decision n must be made no n later
than 3 working days after a receipt of th he request
for service.
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
5
Coompliance
Monitoring_Sttandard_II_F2_07_11