Program Integrity Requirements. A. The Contractor shall comply with state and federal law and regulations, including, but not limited to, 42 CFR 433.32, 42 CFR 433.51, 42 CFR 431.800 et. seq., 42 CFR 440.230, 42 CFR 440.260, 42 CFR 455 et. seq., 42 CFR 456 et. seq., 42 CFR 456.23, 22 CCR 51490, 22 CCR 51490.1, 22 CCR 51341.1, 22 CCR 51159, WIC 14124.1, and WIC 14124.2; 42 CFR 438.600, 42 CFR 438.602, 42 CFR 438.608.
B. The Contractor shall comply with the provisions of 42 CFR 438.600(a), (b), and (c), 438.604, 438.606 and 438.608, regarding the certification of accurate data submitted by the Contractor to DHCS and which require the Contractor to have administrative or management arrangements or procedures and a mandatory compliance plan designed to guard against fraud and abuse.
1) The management arrangements or procedures shall include:
a) Written policies and procedures and standards of conduct that articulate the Contractor’s commitment to comply with all applicable federal and State standards;
b) The designation of a compliance officer and a compliance committee that are accountable to senior management;
c) Effective training and education for the compliance officer, the Contractor’s employees and all subcontractor;
d) Effective lines of communication between the compliance officer and the Contractor’s employees and subcontractor;
e) Enforcement of standards through well publicized disciplinary guidelines;
f) Provision for internal and subcontractor monitoring and auditing; and
g) Provision for prompt response to detected offenses and for development of corrective action initiatives relating to this Agreement and any subcontracts relating to this Agreement,
i. The Contractor’s shall provide the following data certified by the Contractor’s Chief Executive Officer, Chief Financial Officer or an individual who has delegated authority to sign for and reports directly to the CEO or CFO:
a. Enrollment information;
b. Encounter data;
c. Other information required by DHCS and contained in Intergovernmental Agreements, proposals and related documents for purposes of developing MCE payments; and
d. The certification of this information must attest, based on best knowledge, information and belief as follows:
(i) To the accuracy, completeness and truthfulness of the data;
(ii) To the accuracy, completeness and truthfulness of the documents specified by DHCS; and
(iii) The certification must be submitted concurrently with the certified data.
C. The Contractor shall comply with the provisions of 4...
Program Integrity Requirements. A. The Contractor shall comply with the provisions of 42 C.F.R. §§ 438.604, 438.606 and 438.608, regarding the certification of accurate data submitted by the Contractor to the State and which require the Contractor to have administrative or management arrangements or procedures designed to guard against fraud and abuse.
B. The Contractor shall comply with the provisions of 42 C.F.R. § 438.610, which relate to prohibited affiliations with individuals or affiliates of individuals debarred, suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in non-procurement activities under regulations issued under Executive Order No. 12549 or under the guidelines implementing Executive Order No. 12549.
C. Pursuant to 42 C.F.R. § 438.214(d), the Contractor shall not employ or contract with providers or other individuals and entities excluded from participation in federal health care programs (as defined in section 1128B(f) of the Social Security Act) under either Section 1128, 1128A, or 1156 of the Social Security Act. FFP is not available for amounts expended for providers excluded by Medicare, Medicaid, or the State Children's Health Insurance Program, except for emergency services.
D. The Contractor shall periodically check the Office of the Inspector General’s List of Excluded Individuals/Entities and the Medi-Cal Suspended and Ineligible Provider List (S & I List) to prevent employment of, or payments to, any individuals or entities on those lists, and per DMH Letter Number 10-05, this must be satisfied prior to Medi-Cal certification of any individual or organizational provider. If the provider is listed on either the Office of the Inspector General’s List of Excluded Individuals/Entities or the Medi-Cal S & I List, the Contractor shall not certify or pay any provider with Medi-Cal funds, and any such inappropriate payments or overpayments may be subject to recovery and/or be the basis for other sanctions by the appropriate authority.
Program Integrity Requirements. Ensure Contractor sponsored Certified Peer Counselor trainings are offered in accordance with DBHR policies. Policy requirements include the use of DBHR approved curriculum, trainers, testers and applicants.
Program Integrity Requirements. A. Compliance with state and federal law and regulations, including, but not limited to, 42 CFR 433.32, 42 CFR 433.51, 42 CFR 431.800 et. seq., 42 CFR 440.230, 42 CFR 440.260, 42 CFR 455 et. seq., 42 CFR 456 et. seq., 42 CFR 456.23, 22 CCR 51490, 22 CCR 51490.1, 22 CCR 51341.1, 22 CCR 51159, WIC 14124.1, and WIC 14124.2; 42 CFR 438.600, 42 CFR 438.602, 42 CFR 438.608.
B. The Contractor shall comply with the provisions of 42 C.F.R. §§ 438.604, 438.606 and 438.608, regarding the certification of accurate data submitted by the Contractor to the State and which require the Contractor to have administrative or management arrangements or procedures designed to guard against fraud and abuse.
C. The Contractor shall comply with the provisions of 42 C.F.R. § 438.610, which relate to prohibited affiliations with individuals or affiliates of individuals debarred, suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in non-procurement activities under regulations issued under Executive Order No. 12549 or under the guidelines implementing Executive Order No. 12549.
D. Pursuant to 42 C.F.R. § 438.214(d), the Contractor shall not employ or contract with providers or other individuals and entities excluded from participation in federal health care programs (as defined in section 1128B(f) of the Social Security Act) under either Section 1128, 1128A, or 1156 of the Social Security Act. FFP is not available for amounts expended for providers excluded by Medicare, Medicaid, or the State Children's Health Insurance Program, except for emergency services.
E. The Contractor shall periodically check the Office of the Inspector General’s List of Excluded Individuals/Entities and the Medi-Cal Suspended and Ineligible Provider List (S & I List) to prevent employment of, or payments to, any individuals or entities on those lists, and per DMH Letter Number 10-05, this must be satisfied prior to Medi-Cal certification of any individual or organizational provider. If the provider is listed on either the Office of the Inspector General’s List of Excluded Individuals/Entities or the Medi-Cal S & I List, the Contractor shall not certify or pay any provider with Medi-Cal funds, and any such inappropriate payments or overpayments may be subject to recovery and/or be the basis for other sanctions by the appropriate authority.
Program Integrity Requirements. A. Program Integrity Requirements
1. Written policies, procedures, and standards of conduct that articulate the Contractor’s commitment to comply with all applicable federal and state standards;
2. Provision for internal monitoring and auditing;
3. Provision for prompt response to detected offenses, and for development of corrective action initiatives;
4. The designation of a compliance officer and a compliance committee that are accountable to senior management;
5. Effective training and education for the compliance officer and the Contractor's employees;
6. Effective lines of communication between the compliance officer and the Contractor’s employees; and,
7. Enforcement of standards through well-publicized disciplinary guidelines.
B. Fraud and Abuse Prevention, Detection and Reporting
1. Develop a comprehensive internal fraud and abuse program, as part of the Contractor’s compliance program to prevent and detect program violations;
2. Not discriminate against an employee for reporting a fraudulent activity or for cooperating in any government or law enforcement authority’s investigation or prosecution In conformance with M.G.L. c. 12, §5J;
3. Upon a Complaint of fraud or abuse from any source or upon identifying any questionable practices, conduct a preliminary review to determine whether in the Contractor’s judgment, there is reason to believe that a Provider, an Enrollee, or a Contractor employee, has engaged in fraud or abuse. For each complaint of fraud and abuse that warrants a preliminary investigation, report to EOHHS the name and identification number of the Enrollee/Provider, the source of the complaint; the type of Provider; the nature of the complaint; the approximate dollars involved and the legal and administrative disposition of the preliminary investigation;
4. Make diligent efforts to avoid or recover any improper payments or funds misspent due to fraudulent or abusive actions by the Contractor, or its parent organization, its Providers or its Subcontractors;
5. Require Providers to implement corrective actions or terminate Provider agreements, as appropriate;
6. Notify EOHHS in writing within ten (10) calendar days if it or, where applicable, any of its Subcontractors receive or identify any information that gives them reason to suspect that a MassHealth Provider or Member has engaged in fraud as defined under 42 CFR 455.2. In the event of suspected fraud, no further contact shall be initiated with the Provider or Member on that specifi...
Program Integrity Requirements. A. Program Integrity Requirements In accordance with 42 CFR 438.608, the Contractor shall have administrative and management arrangements or procedures, including a mandatory compliance plan, which is designed to guard against fraud and abuse. The compliance plan must be submitted to EOHHS annually on the anniversary of the contract start date. The arrangements or procedures must include the following:
1. Written policies, procedures, and standards of conduct that articulate the Contractor’s commitment to comply with all applicable federal and state standards;
2. Provision for internal monitoring and auditing;
3. Provision for prompt response to detected offenses, and for development of corrective action initiatives;
4. The designation of a compliance officer and a compliance committee that are accountable to senior management;
5. Effective training and education for the compliance officer and the Contractor's employees;
6. Effective lines of communication between the compliance officer and the Contractor’s employees; and,
7. Enforcement of standards through well-publicized disciplinary guidelines.
B. Fraud and Abuse Prevention, Detection and Reporting The Contractor shall:
1. Develop a comprehensive internal fraud and abuse program, as part of the Contractor’s compliance program to prevent and detect program violations;
2. Not discriminate against an employee for reporting a fraudulent activity or for cooperating in any government or law enforcement authority’s investigation or prosecution In conformance with MGL c. 12, §5J;
3. Upon a Complaint of fraud or abuse from any source or upon identifying any questionable practices, conduct a preliminary review to determine whether in the Contractor’s judgment, there is reason to believe that a Provider, an Enrollee, or a Contractor employee, has engaged in fraud or abuse. For each complaint of fraud and abuse that warrants a preliminary investigation, report to EOHHS the name and identification number of the Enrollee/Provider, the source of the complaint; the type of Provider; the nature of the complaint; the approximate dollars involved and the legal and administrative disposition of the preliminary investigation;
4. Make diligent efforts to avoid or recover any improper payments or funds misspent due to fraudulent or abusive actions by the Contractor, or its parent organization, its Providers or its Subcontractors;
5. Require Providers to implement corrective actions or terminate Provider agreements, as approp...
Program Integrity Requirements. Long-term services and supports including availability of home and community based care.
Program Integrity Requirements. Program Integrity Requirements The Contractor shall:
1) General Provisions
a) Comply with all applicable federal and state program integrity laws and regulations regarding fraud, waste and abuse, including but not limited to, the Social Security Act and 42 CFR Parts 438, 455, and 456.
b) Have adequate Massachusetts-based staffing and resources to assist the Contractor in preventing and detecting potential fraud, waste and abuse. Staff conducting program integrity activities for the Contractor shall be familiar with MassHealth and state and federal regulations on fraud, waste and abuse.
c) Have written internal controls and policies and procedures in place that are designed to prevent, detect, reduce, investigate, correct and report known or suspected fraud, waste and abuse activities.
d) In accordance with Section 6032 of the federal Deficit Reduction Act of 2005, make available written fraud and abuse policies to all employees. If the Contractor has an employee handbook, the Contractor shall include specific information about Section 6032, the Contractor’s policies, and the rights of employees to be protected as whistleblowers.
e) Meet with EOHHS at least quarterly to discuss fraud, waste and abuse, audits, and overpayment issues.
f) At EOHHS’ discretion, implement certain program integrity requirements for providers, as specified by EOHHS, including but not limited to implementing National Correct Coding Initiative edits or other CMS claims processing/provider reimbursement manuals;
2) Compliance Plan and Anti-Fraud, Waste, and Abuse Plan Have in place a Compliance Plan and Anti-Fraud, Waste, and Abuse Program Plan in accordance with this Section, copies of which shall be provided to EOHHS, in a form and format specified by EOHHS, in accordance with Appendix A, by the Contract Operational Start Date and annually thereafter. The Contractor shall make any modifications requested by EOHHS within thirty
Program Integrity Requirements. Subcontractor agrees to comply with the Program Integrity requirements listed Exhibit B, Part 9, Sections 11-18 which is summarized above in this Exhibit under Section 6(h), to the extent they apply to Subcontractor’s scope of work under this Exhibit.
Program Integrity Requirements. The Contractor shall comply with Title 42, CFR, Section 438.608, in which the Contractor is a PlHP (Prepaid Inpatient Health Plan), which provides:
(a) General requirement. The MCO or must have administrative and management arrangements or procedures, including a mandatory compliance plan, that are designed to guard against fraud and abuse. Xxxx County Mental Health and Abuse Services Contract 04-74057-000 Exhibit A -Attachment 1
(b) Specific requirements. The arrangements or procedures must include
(1) Written policies, procedures, and standards of conduct that articulate the organization's commitment to comply with all applicable Federal and State standards.
(2) The designation of a compliance officer and a compliance committee that are accountable to senior management.
(3) Effective training and education for the compliance officer and the organization's employees.
(4) Effective lines of communication between the compliance officer and the organization's employees.
