64C-2.002. Eligibility for CMS Network Services

(1) Clinical eligibility for the CMS Managed Care Plan may be established by an authorized representative of the Department through completion of the CMS Clinical Eligibility Screening Form, DH8000-CMS (12/2015), incorporated by reference and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-06270.

(2) Clinical eligibility for the CMS Managed Care Plan may be established by a diagnosis of one or more of the health conditions listed on the CMS Clinical Eligibility Attestation form. The CMS Clinical Eligibility Attestation, Form DH8001-CMS (05/2016) is incorporated by reference and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-07444.

(3) If clinical eligibility is not established after the evaluations described in subsections (1) and (2), re-screening may be requested by contacting the CMS Plan office or at www.cmsplan.floridahealth.gov.

(4) Application may be made for children with a diagnosis of one or more health conditions not listed on the CMS Clinical Eligibility Attestation form, by requesting a review by a panel of medical professionals assigned by the CMS Managed Care Plan, to determine the child’s clinical eligibility. The Medical Review Panel shall consist of the Deputy Secretary for CMS or designee, one CMS Regional Medical Director and one CMS Regional Nursing Director. The Medical Review Panel will complete the CMS Medical Panel Review for Clinical Eligibility Determination Form DH8002-CMS (05/2016) incorporated by reference and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-07445.

(5) Review Process for Clinical Eligibility Determinations.

(a) As used in this provision, “potential enrollee” means a child referred to the Children’s Medical Services Managed Care Plan for clinical eligibility determination for services whose eligibility for the CMS Managed Care Plan has not been established.

(b) Potential enrollees who have been determined not clinically eligible for the CMS Managed Care Plan after completion of the Clinical Eligibility Screening Form DH8000-CMS or CMS Eligibility Attestation DH8001-CMS and completion of the CMS Medical Panel Review for Clinical Eligibility may seek review of the ineligibility determination by filing a petition for hearing with the Agency Clerk for the Department. Potential enrollees will be notified of the final medical panel review and denial by certified mail as well as their right of appeal.

(c) A hearing shall be conducted by an impartial hearing officer employed or contracted by the Department in accordance with Section 120.80(15), F.S.

Rulemaking Authority 391.026(18) FS. Law Implemented 391.021, 391.026(3), 391.029 FS. History–New 1-1-77, Formerly 10J-2.08, Amended 3-28-96, Formerly 10J-2.008, Amended 1-20-03, 1-11-16, 9-27-16.