coordination services and to ensure there are no delays in authorization or gaps in care. The extent to which the Respondent uses strategies to reduce administrative burdens for the provider (e.g., software capabilities) in requesting authorization and its approach is streamlined with little to no redundancies between and across departments which could contribute to delayed service authorizations. The extent to the Respondent has demonstrated experience with meeting timeliness standards for service authorization requests. The adequacy of the Respondent’s education and training plan providers on the service authorization processes. The extent to which the Respondent ensures transparency in service authorization processes (e.g., makes available all utilization management protocols and criteria in an accessible location for service providers). The extent to which the workflow describing the Respondent’s process for handling service” requests is consistent with Early and Periodic Screening, “special Diagnosis and Treatment (EPSDT) requirements. Score: This section is worth a maximum of 30 raw points with each of the above components being worth a maximum of 5 points each. REMAINDER OF PAGE INTENTIONALLY LEFT BLANK Criteria #34 Coordination of Benefits: – Respondent will describe the strategies utilized in care coordination with other plans and insurers (e.g., Medicare) to provide necessary services for its enrollees when the party payer is the primary insurer. Respondent will include information on its approach in the following circumstances: Florida Medicaid and/or CHIP does not the service, but it is available through the third-party payer; Florida Medicaid and/or CHIP and the third-party payer cover the service, but Medicaid/CHIP is only liable for the coinsurance/copayment expenses. In this scenario, the Respondent will identify any differences in its approach if the enrollee is dually eligible for Medicare and Medicaid; The third-party carrier benefit limit is exhausted and the service is now a Medicaid and/or CHIP expense. In this scenario, the Respondent will identify any differences in its approach if the enrollee is dually eligible for Medicare and Medicaid/CHIP; and The service is not covered by the third party but is available through Florida
coordination services and to ensure there are no delays in authorization or gaps in care. The extent to which the Respondent uses strategies to reduce administrative burdens for the provider (e.g., software capabilities) in requesting authorization and its approach is streamlined with little to no redundancies between and across departments which could contribute to delayed service authorizations. The extent to the Respondent has demonstrated experience with meeting timeliness standards for service authorization requests. The adequacy of the Respondent’s education and training plan providers on the service authorization processes. The extent to which the Respondent ensures transparency in service authorization processes (e.g., makes available all utilization management protocols and criteria in an accessible location for service providers). The extent to which the workflow describing the Respondent’s process for handling “special service” requests is consistent with Early and Periodic Screening, Diagnosis and Treatment (EPSDT) requirements. Score: This section is worth a maximum of 30 raw points with each of the above components being worth a maximum of 5 points each. REMAINDER OF PAGE INTENTIONALLY LEFT BLANK Criteria #34 – Coordination of Benefits: Respondent will describe the strategies utilized in care coordination with other plans and insurers (e.g., Medicare) to provide necessary services for its enrollees when the payer is the primary insurer. Respondent will include information on its approach in the following circumstances: Florida Medicaid and/or CHIP does not the service, but it is available through the third-party payer; Florida Medicaid and/or CHIP and the third-party payer cover the service, but Medicaid/CHIP is only liable for the coinsurance/copayment expenses. In this scenario, the Respondent will identify any differences in its approach if the enrollee is dually eligible for Medicare and Medicaid; The third-party carrier benefit limit is exhausted and the service is now a Medicaid and/or CHIP expense. In this scenario, the Respondent will identify any differences in its approach if the enrollee is dually eligible for Medicare and Medicaid/CHIP; and The service is not covered by the third party but is available through Florida party