Program Integrity Plan. 13.3.1 The Contractor shall develop a Program Integrity Plan that at a minimum:
13.3.1.1 Defines Fraud, waste and Abuse;
13.3.1.2 Specifies methods to detect Fraud, waste and Abuse,
13.3.1.3 Describes a process to perform investigations on each suspected case of Fraud, waste and Abuse;
13.3.1.4 Describes persons responsible for conducting these investigations;
13.3.1.5 Includes a variety of methods for identifying, investigating and referring suspected cases to appropriate entities;
13.3.1.6 Includes a systematic approach to data analysis;
13.3.1.7 Defines mechanisms to monitor frequency of Encounters and services rendered to Enrollees billed by Providers; and
13.3.1.8 Identifies requirements to complete the preliminary investigation of Providers and Enrollees.
13.3.2 The Contractor’s Program Integrity Plan shall comply in all respects with the ASES Guidelines for the Development of Program Integrity Plan, included as Attachment 14 to this Contract. Upon review of the Contractor’s Program Integrity Plan (see Section 13.1.3 of this Contract), ASES will promptly (within twenty (20) Business Days) notify the Contractor of any needed revisions in order for the Program Integrity Plan to comply with the Guidelines for the Development of Program Integrity Plan (Attachment 14) and with federal law. The Contractor, in turn, shall promptly (within twenty (20) Business Days of receipt of the ASES comments) re-submit its Plan for ASES review and approval.
13.3.3 The Contractor shall notify ASES within twenty (20) Business Days of any initiated investigation of a suspected case of Fraud, waste, or Abuse. The Contractor shall subsequently report preliminary results of such investigations activities to ASES and other appropriate Puerto Rico and federal entities. ASES will provide the Contractor with guidance during the pendency of the investigation and will refer the matter to the U.S. Department of Justice.
Program Integrity Plan. 2.1.3.7.1. The Contractor shall submit electronically to DMAS each quarter all activities conducted on behalf of PI by the Contractor and include findings related to these activities. The report will include the following:
2.1.3.7.1.1. Number of cases by providers and Enrollees investigated with resolution;
2.1.3.7.1.2. Provider/Enrollee name; 2.
Program Integrity Plan. 13.3.1 The Contractor shall develop a program integrity plan that at a minimum:
13.3.1.1 Defines Fraud, Waste, and Abuse;
13.3.1.2 Specifies methods to detect Fraud, Waste, and Abuse;
13.3.1.3 Describes a process to perform investigations on each suspected case of Fraud, Waste, and Abuse;
13.3.1.4 Describes the Contractor’s staff responsible for conducting the investigations and reporting of potential Fraud, Waste, or Abuse, including an organizational chart documenting roles and responsibilities;
