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

Standard IV: Enrollee Services & Enrollee Rights
CONTRACT
SECTION
34. Ongoing Covered
Services
CC-IV.A.8.c
35. Release of Medical
and Behavioral
Health Records
CC-IV.A.8.b
36. Services
Approved by Prior
Authorization
CC-IV.A.8.d.1-3
37. Receipt of Written
Documentation
CC-VIII.B.1.a.4.i
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
The health plan honors any written
documentation of prior authorization of
ongoing covered services for a period of
thirty (30) calendar days after the
effective date of enrollment, or until the
enrollee’s PCP reviews the enrollee’s
treatment plan, whichever comes first.
Within thirty (30) calendar days of
enrollment, the health plan asks the
enrollee to authorize release of the
medical and behavioral health records to
the new PCP or other appropriate
provider and assists the enrollee by
requesting those records from the
enrollee’s previous providers.
For all enrollees, written documentation
of prior authorization of ongoing
services includes the following, provided
that the services were prearranged prior
to enrollment with the health plan:
a. Prior existing orders.
b. Provider appointments, (i.e., dental
appointments, surgeries, etc.).
c. Prescriptions (including prescriptions
at non-particiating pharmacies).
The health plan will not delay service
authorization if written documentation is
not available in a timely manner.
However, the health plan is not required
Yes
No
Yes
No
a. Yes
No
b. Yes
No
c. Yes
No
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_IV_F2_07_11
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