Current through Reg. 50, No. 187; September 24, 2024
(1)
Each Managing Entity shall develop and implement a Care Coordination Policy
applicable to its subcontracted service providers. Care Coordination policies
and practices shall assure eligibility for services, the appropriateness of
services, and the need for services. Care Coordination includes fiscal
accountability as described in this rule. The Care Coordination Policy shall:
(a) Specify methods that shall be used to
reduce, manage, and eliminate waitlists for services;
(b) Promote increased planning, use, and
delivery of services to all individuals receiving services, including those
with co-occurring substance abuse disorders and mental illnesses;
(c) Ensure access to and use of clinically
appropriate services using screening, assessment and placement tools designed
to identify appropriate level and intensity of care for an individual within a
continuum of services;
(d) Promote
the use of service outcome data to achieve desired outcomes;
(e) Include a methodology to ensure that
people are served at the clinically indicated least restrictive level of care,
and are diverted from higher levels of care when clinically indicated; and,
(f) Monitor and implement system
changes to promote efficiencies.
(2) The service provider shall assist clients
who may be eligible for Medicaid or other benefit programs to:
(a) Complete the program's application
process;
(b) Assist with required
eligibility documentation; and,
(c)
Provide guidance and assistance, if necessary, to appeal a denial of
eligibility or coverage.
(3) SAMH-Funded Entities shall not bill the
department for services provided to:
(a)
Individuals who have third party insurance coverage when the services provided
are paid under the insurance plan, or
(b) Recipients of Medicaid, or another
publically funded health benefits assistance program, when the services
provided are paid by said program.
(4) SAMH-Funded Entities may bill the
department if services are provided to individuals who have lost Medicaid, or
another publicly funded health benefits assistance program coverage for any
reason during the period of non-coverage subject to the sliding fee scale
requirements in Rule 65E-14.018, F.A.C.
(5) In all subcontracts with service
providers, a Managing Entity shall specify:
(a) Procedures under which financial
transactions and service provision are to be documented with sufficient clarity
and detail to support audit compliance under Generally Accepted Accounting
Principles;
(b) The type of
services purchased and a description of the manner in which the services are to
be provided;
(c) The setting,
circumstance, and other operational aspects of the agreement;
(d) The billing and payment mechanism; third
party billings and fee collection procedures which prevent duplicate payments
for services provided;
(e)
Documentation of the performance of billed services;
(f) The duration of the subcontract; and,
(g) The mechanism by which any
overpayment will be recovered.
(6) A SAMH-Funded Entity shall refund to the
department any amount paid for:
(a) Ineligible
services;
(b) Services to
individuals which exceed the standards set forth under subsections (3) and (4),
in this rule;
(c) Services not
actually provided;
(d) Undocumented
services;
(e) Services provided to
a Medicaid-eligible individual prior to becoming a Medicaid recipient when
those services are subsequently covered under a retroactive Medicaid
reimbursement determination; and,
(f) Any amount owed because of a violation of
contract or rules.
(7)
The review and approval of contracts or subcontracts by the department or by a
Managing Entity shall not diminish the responsibility for each SAMH-Funded
Entity to perform in accordance with all rules in Chapter 65E-14,
F.A.C.
(8) Financial monitoring of
service providers shall include a review of a representative sample of
individual recipient records for each type of service provided. Monitoring
shall include verification of the following:
(a) That billing adequately reflects the
contracted dollar amounts for each service provided;
(b) Compliance with provision of services to
eligible persons per priority population criteria as defined in Section
394.674, F.S., and financial
eligibility criteria specified in subsection (3), of this rule; and,
(c) Verification that the number of service
units purchased equals service event data reported to the Managing Entity and
the department's service event data reporting
system.
Rulemaking Authority
394.78(1), (5),
394.9082(3) FS.
Law Implemented 394.78(5),
394.9082
FS.
New 2-23-83, Amended 2-25-85, Formerly 10E-14.14, Amended
7-29-96, Formerly 10E-14.014, Amended 8-17-97, 7-1-03,
7-27-14.
