Common use of Program Integrity Clause in Contracts

Program Integrity. 1. To implement and require its responsible subcontractors to implement procedures that are designed to detect and prevent fraud, waste, and abuse set forth in 42 CFR 438.608 and COMAR 10.67.07 (Appendix M). 2. To designate a compliance officer, who reports directly to the chief executive officer and the board of directors and is responsible for developing and implementing policies, procedures, and practices designed to ensure compliance with the requirements of the contract, and at minimum the following staff members: a. An investigator who is responsible for fraud, waste, and abuse investigations; b. An auditor who is responsible for identifying potential fraud, waste, and abuse through analysis of claims and related information; and c. An analyst capable of reviewing data and codes who is responsible for reviewing and researching evidence of potential fraud, waste, and abuse. 3. To maintain staffing and resources located in Maryland to identify and investigate potential fraud, waste, and abuse, which shall be based on criteria determined by the Department that may include but are not limited to: a. Number of enrollees; b. Number of claims received on an annual basis; c. Volume of suspected fraudulent and abusive claims currently being detected; d. Other factors relating to the vulnerability of the MCO to fraud and abuse; and e. An assessment of optimal caseload which can be handled by an investigator on an annual basis. 4. To permit the Department, the Maryland Insurance Administration, and/or DHHS, or any of their respective designees, with respect to the MCO and any of its subcontractors, as required by 42 CFR 438.6(h), to: a. Evaluate the quality, appropriateness, and timeliness of services performed through inspection, or other means, including accessing the MCO and its subcontractors’ facilities using enrollment cards and identities established in the manner specified by the Department; and b. Inspect and audit any financial records, including but not limited to reimbursement rates. 5. To inform its subcontractors of the provisions of the Social Security Act §1128 B (Criminal Penalties for Acts Involving Federal Health Care Programs). 6. In accordance with Section 1903(m)(4)(B) of the Social Security Act, to report to the State and, upon request, to the Secretary or the Inspector General of the Department of Health and Human Services, the Comptroller General and Enrollees, a description of transactions between the MCO and a party in interest (as defined in section 1318(b) of The Public Health Service Act, including the following transactions: a. Any sale, exchange, or leasing of any property between the MCO and such a party. b. Any furnishing for consideration of goods, services (including management services), or facilities between the MCO and such a party, but not including salaries paid to employees for services provided in the normal course of their employment. c. Any lending of money or other extension of credit between the MCO and such a party. 7. To comply with 42 CFR 438.610 by not knowingly having as a director, officer, partner, owner of more than five percent (5%) of the MCO’s equity, a network provider, or a person with an employment, consulting, or other arrangement with the MCO for the provision of items and services that are significant and material to the MCO’s obligations under its Agreement with the Department, who is: a. 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; b. An individual who is an affiliate, as defined in the Federal Acquisition Regulation, of a person described in paragraph HH(1) above; or c. An individual or entity that is excluded from participation in any Federal health care program under sections 1128 or 1128A of the Social Security Act. 8. To acknowledge the sanction provisions under 42 CFR, Part 438, Subpart I, in Health-General Article §15-103(b)(9), and COMAR 10.67.10.01 (Appendix M). 9. To search the DHHS-OIG’s List of Excluded Individuals/Entities, the General Services Administration Excluded Parties List System, the Social Security Administration Death Master File, and the National Plan & Provider Enumeration System for individuals excluded from the Medicaid Program. Searches shall be done upon execution of this Agreement, and the LEIE and EPLS shall be checked at least monthly thereafter, using the names of all contracted individuals and entities, those with an ownership or control interest, and their agents and managing employees, in accordance with 42 CFR 455.436. 10. To create and manage mechanisms to conduct verifications with Enrollees whether services billed by network providers were received and provide evidence of verification efforts to the Department at least annually. 11. To require MCO program integrity representatives to attend in-person meetings with the Department and report ongoing efforts to detect and prevent fraud, waste, and abuse. 12. To identify and collect monies owing from responsible third parties liable for the cost of medical care furnished by the MCO to Enrollees in accordance with COMAR 10.67.04.18 (Appendix M). 13. To create and manage mechanisms to detect fraud and abuse and report to the Department’s Office of the Inspector General (OIG), in accordance with OIG protocols.

Program Integrity. 1. To implement and require its responsible subcontractors to implement procedures that are designed to detect and prevent fraud, waste, and abuse set forth in 42 CFR 438.608 and COMAR 10.67.07 (Appendix MQ). 2. To designate a compliance officer, who reports directly to the chief executive officer and the board of directors and is responsible for developing and implementing policies, procedures, and practices designed to ensure compliance with the requirements of the contract, and at minimum the following staff members: a. A. An investigator who is responsible for fraud, waste, and abuse investigations; b. B. An auditor who is responsible for identifying potential fraud, waste, and abuse through analysis of claims and related information; and c. C. An analyst capable of reviewing data and codes who is responsible for reviewing and researching evidence of potential fraud, waste, and abuse. 3. To maintain staffing and resources located in Maryland to identify and investigate potential fraud, waste, and abuse, which shall be based on criteria determined by the Department that may include but are not limited to: a. A. Number of enrollees; b. B. Number of claims received on an annual basis; c. C. Volume of suspected fraudulent and abusive claims currently being detected; d. D. Other factors relating to the vulnerability of the MCO to fraud and abuse; and e. E. An assessment of optimal caseload which can be handled by an investigator on an annual basis. 4. To permit the Department, the Maryland Office of the Inspector General for Health (MOIGH), the Maryland Insurance Administration, and/or DHHS, or any of their respective designees, with respect to the MCO and any of its subcontractors, as required by 42 CFR 438.6(h), to: a. A. Evaluate the quality, appropriateness, and timeliness of services performed through inspection, or other means, including accessing the MCO and its subcontractors’ facilities using enrollment cards and identities established in the manner specified by the Department; and b. B. Inspect and audit any financial records, including but not limited to reimbursement rates. 5. To inform its subcontractors of the provisions of the Social Security Act §1128 B (Criminal Penalties for Acts Involving Federal Health Care Programs). 6. In accordance with Section 1903(m)(4)(B) of the Social Security Act, to report to the State and, upon request, to the Secretary or the Inspector General of the Department of Health and Human Services, the Comptroller General and Enrollees, a description of transactions between the MCO and a party in interest (as defined in section 1318(b) of The Public Health Service Act, including the following transactions: a. A. Any sale, exchange, or leasing of any property between the MCO and such a party. b. B. Any furnishing for consideration of goods, services (including management services), or facilities between the MCO and such a party, but not including salaries paid to employees for services provided in the normal course of their employment. c. C. Any lending of money or other extension of credit between the MCO and such a party. 7. To comply with 42 CFR 438.610 by not knowingly having as a director, officer, partner, owner of more than five percent (5%) of the MCO’s equity, a network provider, or a person with an employment, consulting, or other arrangement with the MCO for the provision of items and services that are significant and material to the MCO’s obligations under its Agreement with the Department, who is: a. DebarredX. Xxxxxxxx, 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; b. B. An individual who is an affiliate, as defined in the Federal Acquisition Regulation, of a person described in paragraph HH(1) above; or c. C. An individual or entity that is excluded from participation in any Federal health care program under sections 1128 or 1128A of the Social Security Act. 8. To acknowledge the sanction provisions under 42 CFR, Part 438, Subpart I, in Health-General Article §15-103(b)(9), and COMAR 10.67.10.01 (Appendix MQ). 9. To search the DHHS-OIG’s List of Excluded Individuals/Entities, the General Services Administration Excluded Parties List System, the Social Security Administration Death Master File, and the National Plan & Provider Enumeration System for individuals excluded from the Medicaid Program. Searches shall be done upon execution of this Agreement, and the LEIE and EPLS shall be checked at least monthly thereafter, using the names of all contracted individuals and entities, those with an ownership or control interest, and their agents and managing employees, in accordance with 42 CFR 455.436. 10. To create and manage mechanisms processes to conduct verifications with Enrollees verify by sampling or other methods whether services billed by network providers were received by Enrollees on a regular basis in accordance with 42 CFR 438.608(a)(5) and provide evidence of verification efforts to the Department at least annually. 11. To require MCO program integrity representatives to attend in-person meetings with the Department and report ongoing efforts to detect and prevent fraud, waste, and abuse. 12. To identify and collect monies owing from responsible third parties liable for the cost of medical care furnished by the MCO to Enrollees in accordance with COMAR 10.67.04.18 (Appendix MQ). 13. To create and manage mechanisms to detect fraud and abuse and report to MOIGH, in accordance with MOIGH protocols. 14. To report excess capitation or other contract overpayments to the Department within 60 calendar days of discovery, in accordance with 42 CFR 438.608(c). 15. To establish edits in the MCO’s claims processing system to cross- reference known deceased Enrollees’ names and dates of death. 16. To perform activities to ensure payments are not issued for deceased Enrollees, including but not limited to analytical reviews of encounter data looking for indications of payments for services after death, including billing patterns (e.g., multiple types of service pre-death and only one type of service after death or large differences in spending before and after death). 17. To develop written policies and procedures for payment suspensions in cases of credible allegations of fraud that comply with 42 CFR 455.23 and 438.608(a)(8). 18. To provide to the Department’s , monthly in a format directed by the Department, data on recoveries from responsible third parties at the claim level, including but not limited to: A. Paid amount; B. Other insurance billed/paid; C. Units billed; D. Provider information, including NPI and Tax ID. 19. To attend and participate in quarterly meetings with the Maryland Office of the Inspector General (OIG)for Health to discuss fraud, in accordance with OIG protocolswaste, and abuse efforts; training initiatives; and other information to strengthen program integrity. 20. To recover, through claims submission or other appropriate means, from responsible third-party insurers, including but not limited to commercial carriers, Medicaid, and Medicare, within 18 months from the MCO’s claims payment date for the cost of covered services incurred by the MCO on behalf of an enrollee for services that should have been paid through a third party, for the full amount of medical assistance provided. A. All recoveries from responsible third-party insurers outside of the 18-month period may be pursued by the Department at the Department’s discretion. B. Tort cases are excluded from the third-party insurer recovery process identified above.

Program Integrity. 1. To implement and require its responsible subcontractors to implement procedures that are designed to detect and prevent fraud, waste, and abuse set forth in 42 CFR 438.608 and COMAR 10.67.07 (Appendix MO). 2. To designate a compliance officer, who reports directly to the chief executive officer and the board of directors and is responsible for developing and implementing policies, procedures, and practices designed to ensure compliance with the requirements of the contract, and at minimum the following staff members: a. An investigator who is responsible for fraud, waste, and abuse investigations; b. An auditor who is responsible for identifying potential fraud, waste, and abuse through analysis of claims and related information; and c. An analyst capable of reviewing data and codes who is responsible for reviewing and researching evidence of potential fraud, waste, and abuse. 3. To maintain staffing and resources located in Maryland to identify and investigate potential fraud, waste, and abuse, which shall be based on criteria determined by the Department that may include but are not limited to: a. Number of enrollees; b. Number of claims received on an annual basis; c. Volume of suspected fraudulent and abusive claims currently being detected; d. Other factors relating to the vulnerability of the MCO to fraud and abuse; and e. An assessment of optimal caseload which can be handled by an investigator on an annual basis. 4. To permit the Department, the Maryland Insurance Administration, and/or DHHS, or any of their respective designees, with respect to the MCO and any of its subcontractors, as required by 42 CFR 438.6(h), to: a. Evaluate the quality, appropriateness, and timeliness of services performed through inspection, or other means, including accessing the MCO and its subcontractors’ facilities using enrollment cards and identities established in the manner specified by the Department; and b. Inspect and audit any financial records, including but not limited to reimbursement rates. 5. To inform its subcontractors of the provisions of the Social Security Act §1128 B (Criminal Penalties for Acts Involving Federal Health Care Programs). 6. In accordance with Section 1903(m)(4)(B) of the Social Security Act, to report to the State and, upon request, to the Secretary or the Inspector General of the Department of Health and Human Services, the Comptroller General and Enrollees, a description of transactions between the MCO and a party in interest (as defined in section 1318(b) of The Public Health Service Act, including the following transactions: a. Any sale, exchange, or leasing of any property between the MCO and such a party. b. Any furnishing for consideration of goods, services (including management services), or facilities between the MCO and such a party, but not including salaries paid to employees for services provided in the normal course of their employment. c. Any lending of money or other extension of credit between the MCO and such a party. 7. To comply with 42 CFR 438.610 by not knowingly having as a director, officer, partner, owner of more than five percent (5%) of the MCO’s equity, a network provider, or a person with an employment, consulting, or other arrangement with the MCO for the provision of items and services that are significant and material to the MCO’s obligations under its Agreement with the Department, who is: a. 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; b. An individual who is an affiliate, as defined in the Federal Acquisition Regulation, of a person described in paragraph HH(1) above; or c. An individual or entity that is excluded from participation in any Federal health care program under sections 1128 or 1128A of the Social Security Act. 8. To acknowledge the sanction provisions under 42 CFR, Part 438, Subpart I, in Health-General Article §15-103(b)(9), and COMAR 10.67.10.01 (Appendix MO). 9. To search the DHHS-OIG’s List of Excluded Individuals/Entities, the General Services Administration Excluded Parties List System, the Social Security Administration Death Master File, and the National Plan & Provider Enumeration System for individuals excluded from the Medicaid Program. Searches shall be done upon execution of this Agreement, and the LEIE and EPLS shall be checked at least monthly thereafter, using the names of all contracted individuals and entities, those with an ownership or control interest, and their agents and managing employees, in accordance with 42 CFR 455.436. 10. To create and manage mechanisms to conduct verifications with Enrollees whether services billed by network providers were received and provide evidence of verification efforts to the Department at least annually. 11. To require MCO program integrity representatives to attend in-person meetings with the Department and report ongoing efforts to detect and prevent fraud, waste, and abuse. 12. To identify and collect monies owing from responsible third parties liable for the cost of medical care furnished by the MCO to Enrollees in accordance with COMAR 10.67.04.18 (Appendix MO). 13. To create and manage mechanisms to detect fraud and abuse and report to the Department’s Office of the Inspector General (OIG), in accordance with OIG protocols. 14. To report excess capitation or other contract overpayments to the Department within 60 calendar days of discovery, in accordance with 42 CFR 438.608(c). 15. To establish edits in the MCO’s claims processing system to xxxxx-xxxxxxxxx known deceased Enrollees’ names and dates of death. 16. To perform activities to ensure payments are not issued for deceased Enrollees, including but not limited to analytical reviews of encounter data looking for indications of payments for services after death, including billing patterns (e.g., multiple types of service pre-death and only one type of service after death or large differences in spending before and after death). 17. To provide to the Department, on a monthly basis in a format directed by the Department, data on recoveries from responsible third parties at the claim level, including but not limited to: a. Paid amount; b. Other insurance billed/paid; c. Units billed; d. Provider information, including NPI and Tax ID.

Program Integrity. 1. To implement and require its responsible subcontractors to implement procedures that are designed to detect and prevent fraud, waste, and abuse set forth in 42 CFR 438.608 and COMAR 10.67.07 10.09.68 (Appendix MH). 2. To designate a compliance officer, who reports directly to the chief executive officer and the board of directors and is responsible for developing and implementing policies, procedures, and practices designed to ensure compliance with the requirements of the contract, and at minimum the following staff members: a. An investigator who is responsible for fraud, waste, and abuse investigations; b. An auditor who is responsible for identifying potential fraud, waste, and abuse through analysis of claims and related information; and c. An analyst capable of reviewing data and codes who is responsible for reviewing and researching evidence of potential fraud, waste, and abuse. 3. To maintain staffing and resources located in Maryland to identify and investigate potential fraud, waste, and abuse, which shall be based on criteria determined by the Department that may include but are not limited to: a. Number of enrollees; b. Number of claims received on an annual basis; c. Volume of suspected fraudulent and abusive claims currently being detected; d. Other factors relating to the vulnerability of the MCO to fraud and abuse; and e. An assessment of optimal caseload which can be handled by an investigator on an annual basis. 4. To permit the Department, the Maryland Insurance Administration, and/or DHHS, or any of their respective designees, with respect to the MCO and any of its subcontractors, as required by 42 CFR 438.6(h), to: a. Evaluate the quality, appropriateness, and timeliness of services performed through inspection, or other means, including accessing the MCO and its subcontractors’ facilities using enrollment cards and identities established in the manner specified by the Department; and b. Inspect and audit any financial records, including but not limited to reimbursement rates. 5. To inform its subcontractors of the provisions of the Social Security Act §1128 B (Criminal Penalties for Acts Involving Federal Health Care Programs). 6. In accordance with Section 1903(m)(4)(B) of the Social Security Act, to report to the State and, upon request, to the Secretary or the Inspector General of the Department of Health and Human Services, the Comptroller General and Enrollees, a description of transactions between the MCO and a party in interest (as defined in section 1318(b) of The Public Health Service Act, including the following transactions: a. Any sale, sale or exchange, or leasing of any property between the MCO and such a party. b. Any furnishing for consideration of goods, services (including management services), or facilities between the MCO and such a party, but not including salaries paid to employees for services provided in the normal course of their employment. c. Any lending of money or other extension of credit between the MCO and such a party. 7. To comply with 42 CFR 438.610 by not knowingly having as a director, officer, partner, owner of more than five percent (5%) of the MCO’s equity, a network provider, or a person with an employment, consulting, or other arrangement with the MCO for the provision of items and services that are significant and material to the MCO’s obligations under its Agreement with the Department, who is: a. 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; b. An individual who is an affiliate, as defined in the Federal Acquisition Regulation, of a person described in paragraph HH(1) above; or c. An individual or entity that is excluded from participation in any Federal health care program under sections 1128 or 1128A of the Social Security Act. 8. To acknowledge the sanction provisions under 42 CFR, Part 438, Subpart I, in Health-General Article §15-103(b)(9), and COMAR 10.67.10.01 10.09.73.01 (Appendix MH). 9. To search the DHHS-OIG’s List of Excluded Individuals/Entities, the General Services Administration Excluded Parties List System, the Social Security Administration Death Master File, and the National Plan & Provider Enumeration System for individuals excluded from the Medicaid Program. Searches shall be done upon execution of this Agreement, and the LEIE and EPLS shall be checked at least monthly thereafter, using the names of all contracted individuals and entities, those with an ownership or control interest, and their agents and managing employees, in accordance with 42 CFR 455.436. 10. To create and manage mechanisms to conduct verifications with Enrollees whether services billed by network providers were received and provide evidence of verification efforts to the Department at least annually. 11. To require MCO program integrity representatives to attend in-person meetings with the Department and report ongoing efforts to detect and prevent fraud, waste, and abuse. 12. To identify and collect monies owing from responsible third parties liable for the cost of medical care furnished by the MCO to Enrollees in accordance with COMAR 10.67.04.18 10.09.65.18 (Appendix MH). 13. To create and manage mechanisms to detect fraud and abuse and report to the Department’s Office of the Inspector General (OIG), in accordance with OIG protocols.

Program Integrity. 1. To implement and require its responsible subcontractors to implement procedures that are designed to detect and prevent fraud, waste, and abuse set forth in 42 CFR 438.608 and COMAR 10.67.07 (Appendix MQ). 2. To designate a compliance officer, who reports directly to the chief executive officer and the board of directors and is responsible for developing and implementing policies, procedures, and practices designed to ensure compliance with the requirements of the contract, and at minimum the following staff members: a. A. An investigator who is responsible for fraud, waste, and abuse investigations; b. B. An auditor who is responsible for identifying potential fraud, waste, and abuse through analysis of claims and related information; and c. C. An analyst capable of reviewing data and codes who is responsible for reviewing and researching evidence of potential fraud, waste, and abuse. 3. To maintain staffing and resources located in Maryland to identify and investigate potential fraud, waste, and abuse, which shall be based on criteria determined by the Department that may include but are not limited to: a. A. Number of enrollees; b. B. Number of claims received on an annual basis; c. C. Volume of suspected fraudulent and abusive claims currently being detected; d. D. Other factors relating to the vulnerability of the MCO to fraud and abuse; and e. E. An assessment of optimal caseload which can be handled by an investigator on an annual basis. 4. To permit the Department, the Maryland Office of the Inspector General for Health (MOIGH), the Maryland Insurance Administration, and/or DHHS, or any of their respective designees, with respect to the MCO and any of its subcontractors, as required by 42 CFR 438.6(h), to: a. A. Evaluate the quality, appropriateness, and timeliness of services performed through inspection, or other means, including accessing the MCO and its subcontractors’ facilities using enrollment cards and identities established in the manner specified by the Department; and b. B. Inspect and audit any financial records, including but not limited to reimbursement rates. 5. To inform its subcontractors of the provisions of the Social Security Act §1128 B (Criminal Penalties for Acts Involving Federal Health Care Programs). 6. In accordance with Section 1903(m)(4)(B) of the Social Security Act, to report to the State and, upon request, to the Secretary or the Inspector General of the Department of Health and Human Services, the Comptroller General and Enrollees, a description of transactions between the MCO and a party in interest (as defined in section 1318(b) of The Public Health Service Act, including the following transactions: a. A. Any sale, exchange, or leasing of any property between the MCO and such a party. b. B. Any furnishing for consideration of goods, services (including management services), or facilities between the MCO and such a party, but not including salaries paid to employees for services provided in the normal course of their employment. c. C. Any lending of money or other extension of credit between the MCO and such a party. 7. To comply with 42 CFR 438.610 by not knowingly having as a director, officer, partner, owner of more than five percent (5%) of the MCO’s equity, a network provider, or a person with an employment, consulting, or other arrangement with the MCO for the provision of items and services that are significant and material to the MCO’s obligations under its Agreement with the Department, who is: a. A. 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; b. B. An individual who is an affiliate, as defined in the Federal Acquisition Regulation, of a person described in paragraph HH(1) above; or c. C. An individual or entity that is excluded from participation in any Federal health care program under sections 1128 or 1128A of the Social Security Act. 8. To acknowledge the sanction provisions under 42 CFR, Part 438, Subpart I, in Health-General Article §15-103(b)(9), and COMAR 10.67.10.01 (Appendix MQ). 9. To search the DHHS-OIG’s List of Excluded Individuals/Entities, the General Services Administration Excluded Parties List System, the Social Security Administration Death Master File, and the National Plan & Provider Enumeration System for individuals excluded from the Medicaid Program. Searches shall be done upon execution of this Agreement, and the LEIE and EPLS shall be checked at least monthly thereafter, using the names of all contracted individuals and entities, those with an ownership or control interest, and their agents and managing employees, in accordance with 42 CFR 455.436. 10. To create and manage mechanisms processes to conduct verifications with Enrollees verify by sampling or other methods whether services billed by network providers were received by Enrollees on a regular basis in accordance with 42 CFR 438.608(a)(5) and provide evidence of verification efforts to the Department at least annually. 11. To require MCO program integrity representatives to attend in-person meetings with the Department and report ongoing efforts to detect and prevent fraud, waste, and abuse. 12. To identify and collect monies owing from responsible third parties liable for the cost of medical care furnished by the MCO to Enrollees in accordance with COMAR 10.67.04.18 (Appendix MQ). 13. To create and manage mechanisms to detect fraud and abuse and report to MOIGH, in accordance with MOIGH protocols. 14. To report excess capitation or other contract overpayments to the Department within 60 calendar days of discovery, in accordance with 42 CFR 438.608(c). 15. To establish edits in the MCO’s claims processing system to cross- reference known deceased Enrollees’ names and dates of death. 16. To perform activities to ensure payments are not issued for deceased Enrollees, including but not limited to analytical reviews of encounter data looking for indications of payments for services after death, including billing patterns (e.g., multiple types of service pre-death and only one type of service after death or large differences in spending before and after death). 17. To develop written policies and procedures for payment suspensions in cases of credible allegations of fraud that comply with 42 CFR 455.23 and 438.608(a)(8). 18. To provide to the Department’s , monthly in a format directed by the Department, data on recoveries from responsible third parties at the claim level, including but not limited to: A. Paid amount; B. Other insurance billed/paid; C. Units billed; D. Provider information, including NPI and Tax ID. 19. To attend and participate in quarterly meetings with the Maryland Office of the Inspector General (OIG)for Health to discuss fraud, in accordance with OIG protocolswaste, and abuse efforts; training initiatives; and other information to strengthen program integrity. 20. To recover, through claims submission or other appropriate means, from responsible third-party insurers, including but not limited to commercial carriers, Medicaid, and Medicare, within 18 months from the MCO’s claims payment date for the cost of covered services incurred by the MCO on behalf of an enrollee for services that should have been paid through a third party, for the full amount of medical assistance provided. A. All recoveries from responsible third-party insurers outside of the 18-month period may be pursued by the Department at the Department’s discretion. B. Tort cases are excluded from the third-party insurer recovery process identified above.

Program Integrity. 1. To implement and require its responsible subcontractors to implement procedures that are designed to detect and prevent fraud, waste, and abuse set forth in 42 CFR 438.608 and COMAR 10.67.07 10.09.68 (Appendix MN). 2. To designate a compliance officer, who reports directly to the chief executive officer and the board of directors and is responsible for developing and implementing policies, procedures, and practices designed to ensure compliance with the requirements of the contract, and at minimum the following staff members: a. An investigator who is responsible for fraud, waste, and abuse investigations; b. An auditor who is responsible for identifying potential fraud, waste, and abuse through analysis of claims and related information; and c. An analyst capable of reviewing data and codes who is responsible for reviewing and researching evidence of potential fraud, waste, and abuse. 3. To maintain staffing and resources located in Maryland to identify and investigate potential fraud, waste, and abuse, which shall be based on criteria determined by the Department that may include but are not limited to: a. Number of enrollees; b. Number of claims received on an annual basis; c. Volume of suspected fraudulent and abusive claims currently being detected; d. Other factors relating to the vulnerability of the MCO to fraud and abuse; and e. An assessment of optimal caseload which can be handled by an investigator on an annual basis. 4. To permit the Department, the Maryland Insurance Administration, and/or DHHS, or any of their respective designees, with respect to the MCO and any of its subcontractors, as required by 42 CFR 438.6(h), to: a. Evaluate the quality, appropriateness, and timeliness of services performed through inspection, or other means, including accessing the MCO and its subcontractors’ facilities using enrollment cards and identities established in the manner specified by the Department; and b. Inspect and audit any financial records, including but not limited to reimbursement rates. 5. To inform its subcontractors of the provisions of the Social Security Act §1128 B (Criminal Penalties for Acts Involving Federal Health Care Programs). 6. In accordance with Section 1903(m)(4)(B) of the Social Security Act, to report to the State and, upon request, to the Secretary or the Inspector General of the Department of Health and Human Services, the Comptroller General and Enrollees, a description of transactions between the MCO and a party in interest (as defined in section 1318(b) of The Public Health Service Act, including the following transactions: a. Any sale, exchange, or leasing of any property between the MCO and such a party. b. Any furnishing for consideration of goods, services (including management services), or facilities between the MCO and such a party, but not including salaries paid to employees for services provided in the normal course of their employment. c. Any lending of money or other extension of credit between the MCO and such a party. 7. To comply with 42 CFR 438.610 by not knowingly having as a director, officer, partner, owner of more than five percent (5%) of the MCO’s equity, a network provider, or a person with an employment, consulting, or other arrangement with the MCO for the provision of items and services that are significant and material to the MCO’s obligations under its Agreement with the Department, who is: a. 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; b. An individual who is an affiliate, as defined in the Federal Acquisition Regulation, of a person described in paragraph HH(1) above; or c. An individual or entity that is excluded from participation in any Federal health care program under sections 1128 or 1128A of the Social Security Act. 8. To acknowledge the sanction provisions under 42 CFR, Part 438, Subpart I, in Health-General Article §15-103(b)(9), and COMAR 10.67.10.01 10.09.73.01 (Appendix MN). 9. To search the DHHS-OIG’s List of Excluded Individuals/Entities, the General Services Administration Excluded Parties List System, the Social Security Administration Death Master File, and the National Plan & Provider Enumeration System for individuals excluded from the Medicaid Program. Searches shall be done upon execution of this Agreement, and the LEIE and EPLS shall be checked at least monthly thereafter, using the names of all contracted individuals and entities, those with an ownership or control interest, and their agents and managing employees, in accordance with 42 CFR 455.436. 10. To create and manage mechanisms to conduct verifications with Enrollees whether services billed by network providers were received and provide evidence of verification efforts to the Department at least annually. 11. To require MCO program integrity representatives to attend in-person meetings with the Department and report ongoing efforts to detect and prevent fraud, waste, and abuse. 12. To identify and collect monies owing from responsible third parties liable for the cost of medical care furnished by the MCO to Enrollees in accordance with COMAR 10.67.04.18 10.09.65.18 (Appendix MN). 13. To create and manage mechanisms to detect fraud and abuse and report to the Department’s Office of the Inspector General (OIG), in accordance with OIG protocols.