Common use of Special Investigations Unit Clause in Contracts

Special Investigations Unit. An HMO that provides or arranges for the provision of health care services to an individual under the Medical Assistance Program (Medicaid), must arrange for a special investigative unit to investigate fraudulent claims and other types of program abuse by recipients and providers. An HMO may choose to: (1) Establish and maintain the special investigative unit within the managed care organization; or (2) Contract with another entity for the investigation. 5.3.7.1 An HMO must develop a plan to prevent and reduce waste, abuse, and fraud. The plan must meet the requirements of the rules established by HHSC and be submitted annually to the HHSCOIG for approval each year the HMO is enrolled with the State of Texas. The plan must be submitted 60 days prior to the start of the State fiscal year. 5.3.7.1.1 If the initial plan to prevent and reduce waste, abuse, and fraud is not approved, the HMO must resubmit the plan to HHSCOIG within 15 working days of receiving the denial letter, which will explain the deficiencies. If the plan is not resubmitted within the time allotted, the HMO will be in default and sanctions may be imposed. 5.3.7.2 If the HMO elects to contract with another entity for the investigation of fraudulent claims and other types of program abuse as referenced in paragraph (b)(2) of this section, the HMO must adhere to all requirements of Chapter 42, § 438.230 of the Code of Federal Regulations.