Fraud Control and Management Sample Clauses

Fraud Control and Management a. The insurer is expected to have the capability of develop a comprehensive fraud control system for the scheme which shall at the minimum include regular monitoring, data analytics, ecards audit, medical audit, field investigation, hospital audit, corrective action etc It shall comply with provisions of PMJAY Anti-Fraud Guidelines and Advisories as issued time to time. b. For an indicative (not exhaustive) list of fraud triggers that may be automatically and on a real-time basis be tracked as provided in Schedule 13. The Insurer shall have capactities and track the indicative (not exhaustive) triggers and it can add more triggers to the list. c. For all trigger alerts related to possible fraud at the level of EHCPs, the Insurer shall take the lead in immediate investigation of the case in close coordination and under constant supervision of the SHA. d. Investigations pursuant to any such alert shall be concluded within 07 (seven) days and all final decision related to outcome of the Investigation and consequent penal action, if the fraud is proven, shall vest solely with the SHA. e. The SHA shall take all such decision within the provisions of the Insurance Contract, PMJAY Anti Fraud Guidelines, Recovery Guidelines and Advisories etc.and be founded on the Principles of Natural Justice and as per applicable laws. f. The SHA shall on an ongoing basis measure the effectiveness of anti-fraud measures in the Scheme through a set of indicators. For a list of such indicative (not exhaustive) indicators, refer to Schedule 14. g. The Insurer shall be responsible for monitoring and controlling the implementation of the AB-PMJAY in the State in accordance with Clause 23. h. In the event of a fraudulent Claim being made or a false statement or declaration being made or used in support of a fraudulent Claim or any fraudulent means or device being used by any Empanelled Health Care Provider or the TPA or other intermediary hired by the Insurer or any of the Beneficiaries to obtain any benefits under this Insurance Contract or any Policy issued by the Insurer (each a Fraudulent Activity), then the Insurer’s sole remedies as per the approval of SHA shall be to: (i) refuse to honour a fraudulent Claim or Claim arising out of Fraudulent Activity or reclaim all benefits paid in respect of a fraudulent Claim or any Fraudulent Activity relating to a Claim from the Empanelled Health Care Provider and/or any entity that has undertaken or participated in a Fraudulent Activity; ...
Sample 1Sample 2See All (9)
AutoNDA by SimpleDocs
Fraud Control and Management. ‌ a. The Scheme shall use an integrated centralized IT platform for detecting outlier behaviour and predictive modelling to identify fraud. b. The MIS software will be designed to generate automatic reports and present trends including outlier behaviours against the list of trigger alerts. c. For an indicative (not exhaustive) list of fraud triggers that may be automatically and on a real-time basis be tracked by the centralised AB PM-XXX – KASP IT platform, refer to Schedule 13. The TPA/ISA shall have capactities and track the indicative (not exhaustive) triggers and it can add more triggers to the list. d. For all trigger alerts related to possible fraud at the level of EHCPs, the TPA/ISA shall take the lead in immediate investigation of the case in close coordination and under constant supervision of the SHA. e. Investigations pursuant to any such alert shall be concluded within 15 days and all final decision related to outcome of the Investigation and consequent penal action, if the fraud is proven, shall vest solely with the SHA. f. The SHA shall take all such decision within the provisions of the Implementation Support Contract and be founded on the Principles of Natural Justice. g. The SHA shall on an ongoing basis measure the effectiveness of anti-fraud measures in the Scheme through a set of indicators. For a list of such indicative (not exhaustive) indicators, refer to Schedule 14.
Sample 1

Related to Fraud Control and Management

  • Virus Management DST shall maintain a malware protection program designed to deter malware infections, detect the presence of malware within DST environment.

  • Network Maintenance and Management 38.1 The Parties will work cooperatively to implement this Agreement. The Parties will exchange appropriate information (for example, maintenance contact numbers, network information, information required to comply with law enforcement and other security agencies of the government, escalation processes, etc.) to achieve this desired result. 38.2 Each Party will administer its network to ensure acceptable service levels to all users of its network services. Service levels are generally considered acceptable only when End Users are able to establish connections with little or no delay encountered in the network. Each Party will provide a twenty four (24)-hour contact number for Network Traffic Management issues to the other’s surveillance management center. 38.3 Each Party maintains the right to implement protective network traffic management controls, such as “cancel to”, “call gapping” or seven (7)-digit and ten (10)-digit code gaps, to selectively cancel the completion of traffic over its network, including traffic destined for the other Party’s network, when required to protect the public-switched network from congestion as a result of occurrences such as facility failures, switch congestion or failure or focused overload. Each Party shall immediately notify the other Party of any protective control action planned or executed. 38.4 Where the capability exists, originating or terminating traffic reroutes may be implemented by either Party to temporarily relieve network congestion due to facility failures or abnormal calling patterns. Reroutes shall not be used to circumvent normal trunk servicing. Expansive controls shall be used only when mutually agreed to by the Parties. 38.5 The Parties shall cooperate and share pre-planning information regarding cross-network call-ins expected to generate large or focused temporary increases in call volumes to prevent or mitigate the impact of these events on the public-switched network, including any disruption or loss of service to the other Party’s End Users. Facsimile (FAX) numbers must be exchanged by the Parties to facilitate event notifications for planned mass calling events. 38.6 Neither Party shall use any Interconnection Service provided under this Agreement or any other service related thereto or used in combination therewith in any manner that interferes with or impairs service over any facilities of AT&T-21STATE, its affiliated companies or other connecting telecommunications carriers, prevents any carrier from using its Telecommunications Service, impairs the quality or the privacy of Telecommunications Service to other carriers or to either Party’s End Users, causes hazards to either Party’s personnel or the public, damage to either Party’s or any connecting carrier’s facilities or equipment, including any malfunction of ordering or billing systems or equipment. Upon such occurrence either Party may discontinue or refuse service, but only for so long as the other Party is violating this provision. Upon any such violation, either Party shall provide the other Party notice of the violation at the earliest practicable time. 38.7 AT&T TENNESSEE hereby commits to provide Disaster Recovery to CLEC according to the plan below. 38.7.1 AT&T TENNESSEE Disaster Recovery Plan 38.7.2 In the unlikely event of a disaster occurring that affects AT&T TENNESSEE’s long-term ability to deliver traffic to a CLEC, general procedures have been developed by AT&T TENNESSEE to hasten the recovery process in accordance with the Telecommunications Service Priority (TSP) Program established by the FCC to identify and prioritize telecommunication services that support national security or emergency preparedness (NS/EP) missions. A description of the TSP Program as it may be amended from time to time is available on AT&T TENNESSEE’s Wholesale – Southeast Region Web site. Since each location is different and could be affected by an assortment of potential problems, a detailed recovery plan is impractical. However, in the process of reviewing recovery activities for specific locations, some basic procedures emerge that appear to be common in most cases. 38.7.3 These general procedures should apply to any disaster that affects the delivery of traffic for an extended time period. Each CLEC will be given the same consideration during an outage, and service will be restored as quickly as possible. AT&T TENNESSEE reserves the right to make changes to these procedures as improvements become available or as business conditions dictate. 38.7.4 This plan will cover the basic recovery procedures that would apply to every CLEC.

Draft better contracts in just 5 minutes Get the weekly Law Insider newsletter packed with expert videos, webinars, ebooks, and more!