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

AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
Standard IV: Enrollee Services & Enrollee Rights
CONTRACT
SECTION
CONTRACT REQUIREMENT COMPLIANT SCORING
CC-IV.A.8.e to approve claims for which it has not
received written documentation.
38. Screening Pregnant Within 30 calendar days of enrollment, Yes
Met
Enrollees
the health plan notifies enrollees of, and
ensures the availability of, a screening
for all enrollees known to be pregnant or
who advise the health plan that they may
be pregnant. The health plan refers
enrollees who are, or may be, pregnant to
No
Partially Met
Not Met
CC- IV.A.9.a
a provider to obtain appropriate care.
39. CHCUP
The health plan uses the enrollee’s health Yes
Met
Screenings risk assessments and/or release of
medical records to identify enrollees who
have not received CHCUP screenings in
accordance with the Agency-approved
periodicity schedule.
No
Partially Met
Not Met
CC- IV.A.9.b
40. Appointments for
CHCUP Visits
CC- IV.A.9.c
41. Identifying Urgent
Medical Needs
The health plan contacts, twice if
necessary, any enrollee more than 2
months behind in the Agency-approved
periodicity screening schedule to urge
those enrollees, or their legal
representatives, to make an appointment
with the enrollee’s PCP for a screening
visit.
The health plan takes immediate action
to address any identified urgent medical
needs.
Urgent medical needs means any sudden
or unforeseen situation that requires
immediate action to prevent
Yes
No
Yes
No
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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