65E-14.014. SAMH-Funded Entity Responsibilities

(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(11) FS. Law Implemented 394.78(5), 394.9082 FS. History–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.