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

Standard III: Eligibility, Enrollment, and Disenrollment
CONTRACT
SECTION
CC-III.B.3.c.3-4
20. Monitoring for
a Newborn
Activation
CC-III.B.3.c.6
21. Monitoring to
Find a
Newborn’s
Medicaid ID
CC-III.B.3.c.6.a-d
22. CAPITATED
PLANS:
Enrollment
Date of
Newborn
CC-III.B.3.c.7
23. Unborn
Eligibility
Records
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
plan. Only one e-mail submission per day will
be sent to each DCF customer call center
region.
The health plan periodically checks Medicaid
eligibility to determine if the baby’s Medicaid
ID has been activated.
Monitoring is performed by:
a. The health plan contacts the Medicaid
Eligibility Vendor System (MEVS).
b. The health plan contacts the Medicaid
Fiscal Agent’s provider inquiry line and
asks a representative for assistance.
c. The health plan accesses the Medicaid
Automated Voice Response System
(AVRS).
d. The health plan completes the X12-270
transmission to the Medicaid fiscal agent.
If the unborn activation process is properly
completed by a capitated health plan, then the
newborn is enrolled in the health plan
retroactive to birth.
If a pregnant enrollee presents for delivery
without having an unborn eligibility record
that is awaiting activation, the health plan or
designee submits the spreadsheet to DCF
Yes
No
a. Yes
No
N/A
b. Yes
No
N/A
c. Yes
No
N/A
d. Yes
No
N/A
Yes
No
N/A
Yes
No
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
DOCUMENTS
REVIEWED
FINDINGS
State of Florida Compliance Monitoring_Standard_III_F2_07_11
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