Common use of Specific Requirements for Contractor’s Management Arrangements or Procedures Clause in Contracts

Specific Requirements for Contractor’s Management Arrangements or Procedures. (A) The Contractor’s (and Subcontractor’s to the extent that the Subcontractor is delegated responsibility for coverage of services and payment of claims) shall implement and maintain management arrangements or procedures and compliance plan to guard against Fraud, Waste, and Xxxxx shall include the following: (1) Written policies, procedures, and standards of conduct that articulates the Contractor’s commitment to comply with all applicable requirements and standards under the Contract, as well as all Federal and State standards; (2) The designation of a compliance officer who is responsible for developing and implementing policies, procedures, and practices designed to ensure compliance with the requirements of this Contract, and who reports directly to the Chief Executive Office and the board of directors (3) a Regulatory Compliance Committee (RCC) accountable to senior management level charged with overseeing the organization’s compliance program and its compliance with the requirements under the Contract. (4) Effective training and education for the compliance officer, Contractor’s senior management, and the Contractor’s employees for the Federal and State standards and requirements under this Contract; (5) a system for effective training and education for the compliance officer, the Contractor’s senior management and the Contractor’s employees on the Federal and State standard and requirements under this Contract; (6) effective lines of communication between the compliance officer and the Contractor’s employees; (7) Enforcement of standards through well-publicized disciplinary guidelines; (8) Establishment and implementation of procedures and a system with dedicated staff for routine internal monitoring and auditing of compliance risks, prompt response to compliance issues as they are raised, investigation of potential compliance problems as they are raised, investigation of potential compliance problems as identified in the course of self-evaluation and audits, correction of such problems promptly and thoroughly (or coordination of suspected criminal acts with law enforcement agencies) to reduce the potential for recurrence, and ongoing compliance with the requirements under the Contract, (9) As detailed in Article 6.1.6 mechanisms for verifying with Enrollees that Covered Services provided or reimbursed by the Contractor were actually furnished to Enrollees (such as periodic questionnaires, telephone calls, etc., to a sample of Enrollees); and documentation of the sampling methodology and the schedule for conducting the verifications; and (10) Provisions for prompt reporting of all Overpayments identified or recovered, specifying the Overpayments due to potential Fraud, to the Department; (11) Provision for prompt notification to the Department when it receives information about changes in an Enrollee’s circumstances that may affect eligibility including changes in residence or death of Enrollee; (12) Provision for notification to the Department when it receives information about a change in a Network Provider’s circumstances that may affect that Network Provider’s eligibility to participate in the managed care program, including the termination of the Network Provider agreement with Contractor; (13) As detailed in Article 6.2, provision for written policies for all employees of the Contractor, and of any Subcontractor or agent, that provide detailed information about the False Claims Act and other Federal and State laws described in section 1902(a)(68) of the Social Security Act, including information about rights of employees to be protected as whistleblowers; (14) As detailed in Article 6.1.3, provision for the prompt referral of any potential Fraud, Waste, or Abuse that the Contractor identifies to the Department, the Utah OIG, or MFCU; and (15) As detailed in Article 6.1.5, Provision for the Contractor’s suspension of payments to a Network Provider for which the Department determines there is a credible allegation of Fraud. (16) A provision for notification to the Department within 60 calendar days when the Contractor has identified the capitation payments or other payments in excess of amounts specified in the Contract.