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SMMC 2018-23: Agency-Approved Contract Materials

 CARES Long-Term Care Transition Referral Form and Instructions MS Word Document [29KB]
 Case Management File Audit Report Operational Guidelines MS Excel Document [36KB]
  • Web site updated with this material 2/14/2022.
  • 2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section XVI.A.1., Table 9
 Child Health Screenings Periodicity Schedule
  • Web site updated with this material 9/20/2018.
  • 2018-2023 Dental Contract Citation: Attachment II, Section VI.E.2.a.
  • 2018-2023 Dental Contract Citation: Attachment II, Section VI.E.2.b.(3)
  • 2018-2023 MMA Contract Citation: Attachment II, Exhibit II-A, Section VI.D.3.b.
  • 2018-2023 MMA Contract Citation: Attachment II, Exhibit II-A, Section VI.D.3.c.(4)
 Comprehensive Hemophilia Disease Management Program
  • Web site updated with this material 9/20/2018.
  • 2018-2023 MMA Contract Citation: Attachment II, Exhibit, II-A, Section V.A.1.a.(16)(i)
  • 2018-2023 MMA Contract Citation: Attachment II, Exhibit II-A, Section VI.C.4.
 Consent for Voluntary Suspension of Authorized Services Template in the Statewide Medicaid Managed Care Program Form MS Word Document [40KB]
  • Web site updated with this material 9/20/2018.
  • 2018-2023 MMA Contract Citation: Attachment II, Exhibit II-A, Section VI.E.4.b.
  • 2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section VI.E.6.b.
Disclosure of Ownership and Control Interest Statement [173KB PDF]
  • Web site updated with this material 1/14/2019.
  • 2018-2023 Health/Core Contract Citation: Attachment II, Section XV.C.4.i.
  • 2018-2023 Dental Contract Citation: Attachment II, Section XV.C.6.
Enrollee Handbook Template for Dental Benefits MS Word Document [84KB]
Enrollee Handbook Template for Enrollees with MMA and LTC Benefits MS Word Document [301KB]
Encounter Notification Service (ENS) Through Florida’s Health Information Exchange
  • Web site updated with this material 9/20/2018.
  • 2018-2023 MMA Contract Citation: Attachment B, Exhibit II-A, Section VIII.A.6.a.(3)
Florida Medicaid Pregnancy Notification Form [141KB] Optional
  • Web site updated with this material 12/06/2022.
Freedom of Choice Certification Form for Enrollees with MMA and LTC Benefits MS Word Document [35KB]
  • Web site updated with this material 9/20/2018.
  • 2018-2023 Health/Core Contract Citation: Attachment II, Section VI.E.3.
  • 2018-2023 MMA Contract Citation: Attachment II, Exhibit II-A, Section VI.E.5.
  • 2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section VI.E.8.
Health and Dental Plan Privacy Incidents/Breaches Reporting Form PDF Document [915KB]
  • Web site updated with this material 7/15/2020.
  • 2018-2023 Contract Citation: Attachment II, Exhibit A-8 Standard Contract, Business Associate Agreement
HIV-AIDS Algorithm & HIV-AIDS Algorithm Drug Codes
  • Web site updated with this material 11/1/2022.
  • HIV-AIDS Algorithm - November 1, 2022. [60KB MS Excel]
Hospital Termination Checklist [21 KB MS Excel]
  • Web site updated with this material 7/29/2021.
  • PT 2021-19 issued June 11, 2021
In Lieu of Service (ILOS) Submission Form for SMMC Managed Care Plans [43KB MS Word Document]
  • SMMC ILOS Plan Submission Review AHCA Checklist [34KB MS Word Document]
  • Web site updated with this material 1/4/2022.
  • 2018-2023 Health/Core Contract Citation: Attachment II, Section VI.D.2.
  • 2018-2023 MMA Contract Citation: Attachment II, Exhibit II-A, Section VI.A.2.
  • 2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section VI.A.2.b.
Marketing Requirements
MMA Physician Incentive Program (MPIP)
  • Web site updated with this material 9/20/2018.
  • 2018-2023 MMA Contract Citation: Attachment II, Exhibit II-A, Section VIII.E.1.
  • Section 409.967(2)(a), Florida Statutes
Multiple Signature Verification Agreement Form [53KB PDF] Effective 6/22/2021
  • Web site updated with this material 7/20/2021.
  • 2018-2023 Health/Core Contract Citation: Attachment II, Section XII.A.1.b.
  • 2018-2023 Dental Contract Citation: Attachment II, Section XII.A.1.b.
Multiple Signature Verification Agreement Form for Custody Arrangement [119KB PDF] Effective 6/22/2021
  • Web site updated with this material 7/20/2021.
  • 2018-2023 Health/Core Contract Citation: Attachment II, Section VII.A.3.c.
  • 2018-2023 Dental Contract Citation: Attachment II, Section VII.A.3.c.
Notice of Adverse Benefit Determination (NABD) Template for Enrollees with LTC Benefits MS Word Document [41KB]
  • Web site updated with this material 9/20/2018.
  • 2018-2023 Health/Core & Dental Contract Citation: Attachment II, Section VII.E.
  • 2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section VI.G.1.k.
  • 2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section IX.E.3.a.(18)
Notice of Adverse Benefit Determination (NABD) Template for Enrollees with MMA and Dental Benefits MS Word Document [41KB]
  • Web site updated with this material 9/20/2018.
  • 2018-2023 Health/Core & Dental Contract Citation: Attachment II, Section VII.E.
  • 2018-2023 MMA Contract Citation: Attachment II, Exhibit II-A, Section VII.E.1.
Notice of Adverse Benefit Determination (NABD) Template for MediKids MS Word Document [41KB]
  • Web site updated with this material 9/20/2018.
  • 2018-2023 Health/Core & Dental Contract Citation: Attachment II, Section VII.E.
  • 2018-2023 MMA Contract Citation: Attachment II, Exhibit II-A, Section VII.E.1.
Notice of Plan Appeal Resolution (NPAR) Template MS Word Document [30KB]
  • Web site updated with this material 9/20/2018.
  • 2018-2023 Health/Core & Dental Contract Citation: Attachment II, Section VII.I.1.
Notice of Plan Appeal Resolution (NPAR) Template for MediKids Enrollees MS Word Document [31KB]
  • Web site updated with this material 9/20/2018.
  • 2018-2023 Health/Core & Dental Contract Citation: Attachment II, Section Vll.I.1.
Notice of Status Letter Template MS Word Document [20KB]
  • Web site updated 10/27/2021.
  • PT 2021-27 issued Aug. 27, 2021.
  • 2018-2023 Health: Attachment II, Section VIII.D.5.d.(3)
  • 2018-2023 Health: Attachment II, Section VIII.D.5.e.(3)
  • 2018-2023 Dental: Attachment II, Section VIII.D.5.d.(3)
  • 2018-2023 Dental: Attachment II, Section VIII.D.5.e.(4)
Participant Direction Option (PDO) for Enrollees Receiving LTC Benefits
Participant Direction Option (PDO) for Plans Providing LTC Benefits
  • PDO Manual - May 2022 [118KB MS Word]
  • Training Webinar Presentation - January 16, 2019 [503KB PDF]
  • Web site updated with this material May 25, 2022.
  • 2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section Vl.A.3.
  • 2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section VIII.C.2.c.
  • 2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section VIII.C.2.e.
  • 2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section X.B.5.c.(5)
  • 2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section X.B.5.d.(9)
  • 2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section X.B.5.e.(2)
  • 2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section X.C.1.b.
Performance Measures for the Long-Term Care Waiver
  • Web site updated with this material 9/20/2018.
  • 2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section IX.B.2.b.
Pharmacy Lock-In Policy MS Word Document [81KB]
  • Web site updated with this material 9/20/2018.
  • 2018-2023 MMA Contract Citation: Attachment II, Exhibit, II-A, Section VI.A.1.a.(16)(g)
Requirements for Provision of Oral and Written Material in Different Languages
  • Web site updated with this material 2/18/2022.
  • PT 2021-13 Non-Discrimination Compliance Requirements, Issued May 4, 2021
  • 2018-2023 Health/Core Contract Citation: Attachment II, Section V.A.5.
  • 2018-2023 Dental Contract Citation: Attachment II, Section V.A.6.
  • 2018-2023 Health/Core & Dental Contract Citation: Attachment II, Section V.B.2.
  • 2018-2023 Health/Core & Dental Contract Citation: Attachment II, Section V.B.9.a.(7)
  • 2018-2023 Health/Core & Dental Contract Citation: Attachment II, Section V.C.1.b.
  • 2018-2023 Health/Core & Dental Contract Citation: Attachment II, Section V.C.2.
  • 2018-2023 Dental Contract Citation: Attachment II, Section IX.E.3.a.(3)
  • 2018-2023 Health/Core Contract Citation: Attachment II, Section IX.E.3.a.(3)-(4)
  • 2018-2023 Health/Core & Dental Contract Citation: Attachment II, Section X.B.6.
Serious Mental Illness (SMI) Algorithm & SMI Algorithm Diagnosis and Drug Codes
Unborn Activation and Newborn Enrollment Requirements
  • Web site updated with this material 2/23/2022.
  • 2018-2023 MMA Contract Citation: Attachment II, Exhibit II-A, Section III.C.1.a.-b.
  • 2018-2023 MMA Contract Citation: Attachment II, Exhibit II-A, Section VIII.C.4.a.(5)