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

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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
Standarrd II: Utilizatio on Managemen nt CONTTRACT SECTION CONTRACT T REQUIREMEN NT 25. Exteensions A he ealth plan may ex xtend the three (3) ) working for EExpedited days s for expedited ca ases by up to fourt teen (14) Requuests calen ndar days if the enrollee requests an a CC-IV.A.166.e exten nsion or if the hea alth plan justifies s the exten nsion. 26. Writtten The health plan provi ides no less than 30 3 Notice of calen ndar days written n notice to BMHC C before Channges to maki ing any changes to t the administrat tion UM and/o or management procedures p and/or r CC-VIII.B.44 autho orization, denial or review procedures, inclu uding any delegat tions. Resullts for Standard II Utilization Manag gement Score # Elements Met Par rtially Met Not Met Not Applicable A Total # Elements Total # Applicable Elements Percent of Elem ments Met State of Florrida AGENCY Y FOR HEALTHCARE ADMMINISTRATIOON MANAGED M CA ARE ORGANIIZATIONS Compliance Monitoring To ool with Speciffic Contract Staandards CO OMPLIANT Yes No Yes No SCORING Met Partially Met Not Met Met Partially Met Not Met DOCUMENTTS REVIEWEDD FFINDINGS PPage 6 Coompliance Monitoring_Sttandard_II_F2_07_11
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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 and 54: Standarrd II: Utilizatio on Managem
Page 55: 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
Page 105 and 106: 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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Letter to CMS - Medicaid Managed Care Policies - Agency for ...

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