Distinct Unit Sample Clauses

Distinct Unit. The contractor shall establish a distinct fraud and abuse unit, separate from the contractor's utilization review and quality of care functions. The unit can either be part of the contractor's corporate structure, or operate under contract with the contractor. The unit shall be staffed with individuals with the qualifications and an investigator-to-beneficiary ratio consistent, at a minimum, with the Department of Banking and Insurance requirements for fraud units within health insurance carriers or greater ratio as needed to meet the demands.
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Distinct Unit. The contractor shall establish a distinct fraud and abuse unit, solely dedicated to the detection and investigation of fraud and abuse by its New Jersey Medicaid and NJ FamilyCare beneficiaries and providers. It shall be separate from the contractor’s utilization review and quality of care functions. The unit can either be part of the contractor’s corporate structure, or operate under contract with the contractor. 1. The unit shall be staffed with investigators who shall have at least one of the following: (1) a Bachelor’s degree; (2) an Associate’s degree plus a minimum of two years experience with health care related employment; (3) a minimum of four years of experience with health care related employment; or (4) a minimum of five years of law enforcement experience. When approved by DMAHS, the contractor shall be permitted to employ a limited number of specialists who shall possess unique qualifications by way of training, technical skill, and/or experience to investigate and identify cases of fraud, but who lack the specific educational requirements set forth above to be investigators. The unit shall have an investigator-to-beneficiary ratio for the New Jersey Medicaid/NJ FamilyCare enrollment of at least one investigator per exists relating to the contractor, its providers, subcontractors, enrollees, employees, or anyone who can order or refer services, and related parties.
Sample 1
Distinct Unit. The contractor shall establish a distinct fraud and abuse unit, solely dedicated to the detection and investigation of fraud and abuse by its New Jersey Medicaid/NJ FamilyCare beneficiaries and providers It shall be separate from the contractor’s utilization review and quality of care functions. The unit can either be part of the contractor’s corporate structure, or operate under contract with the contractor. 1. The unit shall be staffed with investigators who shall have at least one of the following: (1) a Bachelor’s degree; (2) an Associate’s degree plus a minimum of two years experience with health care related employment; (3) a minimum of four years experience with health care related employment; or (4) a minimum of five years of law enforcement experience. When approved by DMASH, the contractor shall be permitted to employ a limited number of specialist who shall possess unique qualifications by way of training, technical skill and/or experience to investigate and identify cases of fraud, but who lack the specific educational requirements set forth above to be investigators. The unit shall have an investigator to beneficiary ratio for the New Jersey Medicaid/NJ FamilyCare enrollment of at least one investigator per 60,000 or fewer New Jersey enrollees or a greater ratio as needed to meet the investigative demands. The requirement of at least on investigator per 60,000 or fewer New Jersey enrollees can be satisfied by the use of full- time equivalents rather than dedicated investigators, but only if the contractor submits to DMAHS on a quarterly basis the statistics ask for in Section A.7.2 of the Appendix documenting that at least one full-time equivalent investigator per 60,000 or fewer enrollees is being devoted to DMAHS-related fraud and abuse cases. 2. Claims analysts who are reviewing claims specifically for trends of fraud and/or abuse can be counted toward the FTEs. However, reviewing claims primarily for quality of care may not be counted. Exclusive use of 8.4 MEDICAL COST RATIO 8.4.1 MEDICAL COST RATIO STANDARD The contractor shall maintain direct medical expenditures for enrollees equal to or greater than eighty (80) percent of premiums paid in all forms from the State. This medical cost ratio (MCR) shall apply to annual periods from the contractor effective date (if the contract ends before the completion of an annual period, the MCR shall apply to that shorter period). The MCR shall be based on reports completed by the contractor and accep...
Sample 1

Related to Distinct Unit

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