Common use of Fraud and Abuse Compliance Clause in Contracts

Fraud and Abuse Compliance. Plan Initially and annually Yes Per 42 CFR 438.608, Contractor shall submit its compliance plan designed to guard against Fraud and Abuse to the Department for Prior Approval. This does not need to be provided to the Department separately by population. Marketing Marketing Gifts and Incentives Initially and as revised Yes Contractor shall submit all plans to distribute gifts and incentives, as well as description of gifts and incentives, for Prior Approval. Marketing Materials Initially and as revised Yes Contractor shall submit all Marketing Materials for Prior Approval. Contractor shall not be required to submit format changes for Prior Approval, provided there is no material change in the information conveyed. Marketing, Outreach and Education Plan Annually Yes As described in Section 4.17.5, Contractor shall submit descriptions of proposed Marketing concepts, strategies, and procedures for Prior Approval. Community Outreach Events Monthly, by the last day of the reporting month No Contractor shall submit to the Department a list of all previously approved community outreach events that occurred during the submission month. The report must include the Event name, date, time, address/location, county, audience type, estimated number of attendees and date of Department approval. Provider Network Primary care Provider, Hospital, and Affiliated Specialist File (CEB Provider File) No less often than weekly Yes Contractor shall submit to the Department or its designee, in a format and medium designated by the Department, an electronic file of Contractor’s PCPs, Hospitals and Affiliated Specialists. The primary care Providers must include, but not limited to, the following information: • Provider name, Provider number, office address, and telephone number; • Type of specialty (e.g., family practitioner, internist, oncologist, etc.), subspecialty if applicable, and treatment age ranges; • Identification of Group Practice, if applicable; • Geographic service area, if limited; • Areas of board-certification, if applicable; • Language(s) spoken by Provider and office staff; • Office hours and days of operation; • Special services offered to the deaf or hearing impaired (i.e., sign language, TDD/TTY, etc.); • Wheelchair accessibility status (e.g., parking, ramps, elevators, automatic doors, personal transfer assistance, etc.); • PCP indicator; • Primary care Provider gender and panel status (open or closed); and • Primary care Provider hospital affiliations, including information about where the primary care Provider has admitting privileges or admitting arrangements and delivery privileges (as appropriate). Provider Terminations As each occurs No Contractor shall submit Provider Termination reports, in a format and medium designated by the Department. Provider Grievance- Resolution System and Procedures Initially and as revised Yes Contractor shall submit details of its Provider Grievance-resolution system and related procedures for Prior Approval. Contractor shall not be required to submit format changes for Prior Approval, provided there is no material change in the information conveyed. Summary of Provider Complaints and Resolutions – Summary Report Frequency as provided in the MCO MPR Guidelines No Reporting will follow the MCO Performance Reporting (MPR) Guidelines. Provider network file (complete) Quarterly and as requested No Contractor shall submit to the Department or its designee, in a format and medium designated by the Department, an electronic file of Contractor’s full provider network.

Fraud and Abuse Compliance. Plan Initially and annually Yes Per 42 CFR 438.608, Contractor shall submit its compliance plan designed to guard against Fraud and Abuse to the Department for Prior Approval. This does not need to be provided to the Department separately by population. Marketing Marketing Gifts and Incentives Initially and as revised within ten (10) Business Days after the Department’s request Yes Contractor shall submit all plans to distribute gifts and incentives, as well as description of gifts and incentives, for Prior Approval. Name of report/submission Frequency HFS Prior Approval Report description and requirements Marketing Materials Initially and as revised Yes Contractor shall submit all Marketing Materials for Prior Approval. Contractor shall not be required to submit format changes for Prior Approval, provided there is no material change in the information conveyed. Marketing, Outreach Marketing Plans and Education Plan Annually Procedures Initially and as revised Yes As described in Section 4.17.5, Contractor shall submit descriptions of proposed Marketing concepts, strategies, and procedures for Prior Approval. Community Outreach Events Monthly, by the last day of the reporting month No Contractor shall submit to the Department a list of all previously approved community outreach events that occurred during the submission month. The report must include the Event name, date, time, address/location, county, audience type, estimated number of attendees and date of Department approval. Provider Network Primary care Provider, Hospital, and Affiliated Specialist File (CEB Provider File) No less often than weekly Yes Contractor shall submit to the Department or its designee, in a format and medium designated by the Department, an electronic file of Contractor’s PCPs, Hospitals and Affiliated Specialists. The primary care Providers must include, but not limited to, the following information: • Provider name, Provider number, office address, and telephone number; • Type of specialty (e.g., family practitioner, internist, oncologist, etc.), subspecialty if applicable, and treatment age ranges; • Identification of Group Practice, if applicable; • Geographic service area, if limited; • Areas of board-certification, if applicable; • Language(s) spoken by Provider and office staff; • Office hours and days of operation; • Special services offered to the deaf or hearing impaired (i.e., sign language, TDD/TTY, etc.); • Wheelchair accessibility status (e.g., parking, ramps, elevators, automatic doors, personal transfer assistance, etc.); • PCP indicator; • Primary care Provider gender and panel status (open or closed); and • Primary care Provider hospital affiliations, including information about where the primary care Provider has admitting privileges or admitting arrangements and delivery privileges (as appropriate). Provider Terminations As each occurs No Contractor shall submit Provider Termination reports, in a format and medium designated by the Department. Provider Grievance- Resolution System and Procedures Initially and as revised Yes Contractor shall submit details of its Provider Grievance-resolution system and related procedures for Prior Approval. Contractor shall not be required to submit format changes for Prior Approval, provided there is no material change in the information conveyed. Summary of Provider Complaints and Resolutions – Summary Report Frequency as provided in the MCO MPR Guidelines No Reporting will follow the MCO Performance Reporting (MPR) Guidelines. Provider network file (complete) Quarterly and as requested No Contractor shall submit to the Department or its designee, in a format and medium designated by the Department, an electronic file of Contractor’s full provider network.

Fraud and Abuse Compliance. Plan Initially and annually Yes Per 42 CFR 438.608, Contractor shall submit its compliance plan designed to guard against Fraud and Abuse to the Department for Prior Approval. This does not need to be provided to the Department separately by population. Marketing Marketing Gifts and Incentives Initially and as revised within ten (10) Business Days after the Department’s request Yes Contractor shall submit all plans to distribute gifts and incentives, as well as description of gifts and incentives, for Prior Approval. Name of report/submission Frequency HFS Prior Approval Report description and requirements Marketing Materials Initially and as revised Yes Contractor shall submit all Marketing Materials for Prior Approval. Contractor shall not be required to submit format changes for Prior Approval, provided there is no material change in the information conveyed. Marketing, Marketing and Outreach and Education Plan Annually Yes As described in Section 4.17.5, Contractor shall submit descriptions of proposed Marketing concepts, strategies, and procedures for Prior Approval. Community Outreach Events Monthly, by the last day of the reporting month No Contractor shall submit to the Department a list of all previously approved community outreach events that occurred during the submission month. The report must include the Event name, date, time, address/location, county, audience type, estimated number of attendees and date of Department approval. Provider Network Primary care Provider, Hospital, and Affiliated Specialist File (CEB Provider File) No less often than weekly Yes Contractor shall submit to the Department or its designee, in a format and medium designated by the Department, an electronic file of Contractor’s PCPs, Hospitals and Affiliated Specialists. The primary care Providers must include, but not limited to, the following information: • Provider name, Provider number, office address, and telephone number; • Type of specialty (e.g., family practitioner, internist, oncologist, etc.), subspecialty if applicable, and treatment age ranges; • Identification of Group Practice, if applicable; • Geographic service area, if limited; • Areas of board-certification, if applicable; • Language(s) spoken by Provider and office staff; • Office hours and days of operation; • Special services offered to the deaf or hearing impaired (i.e., sign language, TDD/TTY, etc.); • Wheelchair accessibility status (e.g., parking, ramps, elevators, automatic doors, personal transfer assistance, etc.); • PCP indicator; • Primary care Provider gender and panel status (open or closed); and • Primary care Provider hospital affiliations, including information about where the primary care Provider has admitting privileges or admitting arrangements and delivery privileges (as appropriate). Provider Terminations As each occurs No Contractor shall submit Provider Termination reports, in a format and medium designated by the Department. Provider Grievance- Resolution System and Procedures Initially and as revised Yes Contractor shall submit details of its Provider Grievance-Grievance- resolution system and systemand related procedures for Prior Approval. Contractor shall not be required to submit format changes for Prior Approval, provided there is no material change in the information conveyed. Summary of Provider Complaints and Resolutions – Summary Report Frequency as provided in the MCO MPR Guidelines No Reporting will follow the MCO Performance Reporting (MPR) Guidelines. Provider network file (complete) Quarterly and as requested No Contractor shall submit to the Department or its designee, in a format and medium designated by the Department, an electronic file of Contractor’s full provider network.