FLORIDA MEDICAID REGULATORY ... - Ubhonline.com

2.4 Covered Services: A health care service or product for which a Covered Person
is enrolled to receive coverage under the State Medicaid Contract.
2.5 Health Plan: An appropriately licensed entity that has entered into a contract
with the State (the “State Medicaid Contract” as defined below) for the purpose of
providing and paying for Covered Services to Covered Persons enrolled in the State
Medicaid Program.
2.6 Payor: An entity obligated to a Covered Person to provide reimbursement to
providers for Covered Services on a Covered Person’s behalf.
2.7 State: The State of Florida or its designated regulatory agencies.
2.8 State Medicaid Contract: Health Plan’s contract with AHCA for the purpose of
providing and paying for Covered Services to Covered Persons enrolled in the State
Medicaid Program.
SECTION 3
PROVIDER REQUIREMENTS
The State Medicaid Program, through contractual requirements, federal and State statutes
and regulations, requires the Agreement to contain certain conditions that OptumHealth,
Health Plan, and Provider, as applicable, agree to undertake, which include the following:
3.1 Provider shall not seek payment from a Covered Person for any Covered Services
provided to the Covered Person within the terms of the State Medicaid Contract.
3.2 Provider shall look solely to Payor for compensation for services rendered, with
the exception of nominal cost sharing, pursuant to the Florida State Medicaid Plan and
the Florida Coverage and Limitations Handbooks.
3.3 Provider shall cooperate with OptumHealth and/or Health Plan's peer review,
grievance, quality improvement program and utilization management activities, and
recognizes that OptumHealth or Health Plan will provide monitoring and oversight of
Provider, including monitoring of services rendered to Covered Persons. If OptumHealth
has delegated credentialing to Provider, Provider shall ensure that all licensed medical
professionals are credentialed in accordance with Health Plan’s and the Agency’s
credentialing requirements as set forth in the State Medicaid Contract.
3.4 Provider shall cooperate with OptumHealth and Health Plan, as applicable, in the
event an immediate transfer to another primary care physician (PCP) or health plan is
warranted if the Covered Person’s health or safety is in jeopardy.
3.5 Provider shall provide for timely access for Covered Person appointments in
accordance with appointment waiting time standards established under the State
Medicaid Contract. These shall include, but not be limited to, assuring that PCP services
and referrals to participating specialists are available on a timely basis, as follows:
UnitedHealthcare/AmeriChoice Provider Agreement 2 Confidential and Proprietary
UHC/DOWNSTREAM PROVIDER-MEDICAIDREGAPX.11.09.FL AHCA-B-N-044 12/09-8/12