Common use of Xxxxx, Xxxxx and Abuse; Ethical Conduct Clause in Contracts

Xxxxx, Xxxxx and Abuse; Ethical Conduct. Contractor shall maintain and enforce policies, procedures, processes, systems, and internal controls (i) to reduce Fraud, Waste, and Abuse, and (ii) to enhance compliance with other applicable laws, rules, and regulations in connection with the performance of Contractor’s obligations under this Agreement. Contractor shall maintain an effective compliance program that includes a minimum of the following “7 Core Elements” as defined by CMS: Written Policies, Procedures and Standards of Conduct; Compliance Program Oversight; Training and Education Communication; Auditing and Monitoring; Consistent Discipline; and Corrective Actions and meets the requirements of applicable laws, rules, and regulations. Contractor shall provide evidence of such compliance program as reasonably requested by Covered California. Contractor shall communicate within ten (10) Days to Covered California any material concerns identified by Contractor or material concerns, including any enforcement actions resulting in monetary penalties equal to or exceeding $10,000, identified by State and Federal Regulators related to regulatory compliance that may impact performance under this Agreement following Contractor’s knowledge of such occurrence; provided, however, such notification shall be provided immediately if such occurrence may reasonably be deemed to adversely affect the quality of care or safety of Covered California Enrollees. All notifications shall be made according to the “Contract Reporting Requirements” table posted on Contractor’s extranet website provided by Covered California (Carrier Management (External) page, PMD Resources, Contract Reporting Compliance). Contractor shall provide Covered California with a description of its fraud, waste and abuse detection and prevention programs and report total monies recovered by Contractor from providers in the most recent 12-month period for Contractor’s total book of business as well as, total monies recovered for Covered California business only. This description shall be updated during each year that this Agreement is in effect and shall include an overview of fraud and abuse detection and prevention program activities conducted by Contractor, Participating Providers, other Subcontractors and their authorized agents, including a summary of key findings, relevant data analytics and fraud risk assessments to circumvent fraud, waste, and abuse, and the development, implementation and enforcement of any corrective action plans for changing, upgrading, or improving these programs. If Contractor receives any preliminary or final reports, findings, or orders related to material concerns identified by State and Federal Regulators that may impact performance under this Agreement pursuant to this Section, it shall provide Covered California with copies of them within 48 hours of receiving them from State and Federal Regulators. Contractor shall maintain and enforce a code of ethical conduct and make it available to Covered California upon request. Contractor shall refer potential fraud activities identified through fraud detection and response measures to Covered California. Contractor shall follow the established Carrier Referral Process posted on the Contractor’s extranet website provided by Covered California (Carrier Management (External) page, Contractor’s folder, Data Integrity, Fraud Referral folder). Contractor shall not terminate Covered California Enrollee coverage for fraud without prior review and approval from Covered California.

Xxxxx, Xxxxx and Abuse; Ethical Conduct. ‌ Contractor shall maintain and enforce policies, procedures, processes, systems, and internal controls (i) to reduce Fraud, Waste, and Abuse, and (ii) to enhance compliance with other applicable laws, rules, and regulations in connection with the performance of Contractor’s obligations under this Agreement. . a) Contractor shall maintain an effective compliance program that includes a minimum of the following “7 Core Elements” as defined by CMS: Written Policies, Procedures and Standards of Conduct; Compliance Program Oversight; Training and Education Communication; Auditing and Monitoring; Consistent Discipline; and Corrective Actions and meets the requirements of applicable laws, rules, and regulations. regulations Contractor shall provide evidence of such compliance program as reasonably requested by Covered California. . b) Contractor shall communicate within ten (10) Days to Covered California any material concerns identified by Contractor or material concerns, including any enforcement actions resulting in monetary penalties equal to or exceeding $10,000100,000, identified by State and Federal Regulators related to regulatory compliance that may impact performance under this Agreement following Contractor’s knowledge of such occurrence; provided, however, such notification shall be provided immediately if such occurrence may reasonably be deemed to adversely affect the quality of care or safety of Covered California Enrollees. All notifications shall be made according to the “Contract Reporting Requirements” table posted on Contractor’s extranet website provided by Covered California (Carrier Management (External) page, PMD Resources, Contract Reporting Compliance). . c) If Contractor receives any preliminary or final reports, findings, or orders related to material concerns identified by State and Federal Regulators that may impact performance under this Agreement pursuant to this Section, it shall provide Covered California with copies of them within 48 hours of receiving them from State and Federal Regulators. d) Contractor shall provide Covered California with a description of its fraud, waste waste, and abuse detection and prevention programs and report total monies recovered by Contractor from providers in the most recent 12-month period for Contractor’s total book of business as well as, total monies recovered for Covered California business only. This description shall be updated during each year that this Agreement is in effect and shall include an overview of fraud and abuse detection and prevention program activities conducted by Contractor, Participating Providers, other Subcontractors and their authorized agentsAgents, including a summary of key findings, relevant data analytics and fraud risk assessments to circumvent fraud, waste, and abuse, and the development, implementation implementation, and enforcement of any corrective action plans for changing, upgrading, or improving these programs. If Contractor receives any preliminary or final reports, findings, or orders related to material concerns identified by State and Federal Regulators that may impact performance under this Agreement pursuant to this Section, it shall provide Covered California with copies of them within 48 hours of receiving them from State and Federal Regulators. . e) Contractor shall maintain and enforce a code of ethical conduct and make it available to Covered California upon request. . f) Contractor shall refer potential fraud activities identified through fraud detection and response measures to Covered California. Contractor shall follow the established Carrier Referral Process posted on the Contractor’s extranet website provided by Covered California (Carrier Management (External) page, Contractor’s folder, Data Integrity, Fraud Referral folder). . g) Contractor shall not terminate Covered California Enrollee coverage for fraud without prior review and approval from Covered California.

Xxxxx, Xxxxx and Abuse; Ethical Conduct. Contractor shall maintain and enforce policies, procedures, processes, systems, and internal controls (i) to reduce Fraudfraud, Wastewaste, and Abuseabuse, and (ii) to enhance compliance with other applicable laws, rules, and regulations in connection with the performance of Contractor’s obligations under this Agreement. Contractor shall maintain an effective compliance program that includes a minimum of the following “7 Core Elements” as defined by CMS: Written Policies, Procedures and Standards of Conduct; Compliance Program Oversight; Training and Education Communication; Auditing and Monitoring; Consistent Discipline; and Corrective Actions and meets the requirements of applicable laws, rules, and regulations. Contractor shall provide evidence of such compliance program as reasonably requested by Covered California. Contractor shall timely communicate within ten (10) Days to Covered California any material concerns identified by Contractor or material concerns, including any enforcement actions resulting in monetary penalties equal to or exceeding $10,000, identified by State and Federal Regulators related to regulatory compliance that may impact performance under this Agreement following Contractor’s knowledge of such occurrence; provided, however, such notification shall be provided immediately if such occurrence may reasonably be deemed to adversely affect the quality of care or safety of Covered California Enrollees. All notifications shall be made according to the “Contract Reporting Requirements” table posted on Contractor’s extranet website provided by Covered California (Carrier Management (External) page, PMD Resources, Contract Reporting Compliance)Agreement. Contractor shall provide Covered California with a description of its fraud, waste waste, and abuse detection and prevention programs and report total monies recovered by Contractor from providers in the most recent 12-month period for Contractor’s total book of business as well as, if available, total monies recovered for Covered California business only. This description shall be provided upon the request of Covered California and will be updated upon request during each year that this Agreement is in effect and shall include an overview of fraud and abuse detection and prevention program activities conducted by Contractor, Participating Providers, other Subcontractors subcontractors and their authorized agentsAgents, including a summary of key findings, relevant data analytics and fraud risk assessments to circumvent fraud, waste, and abuse, and the development, implementation implementation, and enforcement of any corrective action plans for changing, upgrading, or improving these programs. If Contractor receives any preliminary or final reports, findings, or orders related to material concerns identified by State and Federal Regulators that may impact performance under this Agreement pursuant to this Section, it shall provide Covered California with copies of them within 48 hours of receiving them from State and Federal Regulators. Contractor shall maintain and enforce a code of ethical conduct and make it available to Covered California upon request. Contractor shall refer potential fraud activities identified through fraud detection and response measures to Covered California. Contractor shall follow the established Carrier Referral Process posted on the Contractor’s extranet website provided by Covered California (Carrier Management (External) Hub page, Contractor’s foldersubsite, Data Integrity, Fraud Referral folder). Contractor shall not terminate Covered California Enrollee coverage for fraud without prior review and approval from Covered California.

Xxxxx, Xxxxx and Abuse; Ethical Conduct. Contractor shall maintain and enforce policies, procedures, processes, systems, and internal controls (i) to reduce Fraudfraud, Wastewaste, and Abuseabuse, and (ii) to enhance compliance with other applicable laws, rules, and regulations in connection with the performance of Contractor’s obligations under this Agreement. Contractor shall maintain an effective compliance program that includes a minimum of the following “7 Core Elements” as defined by CMS: Written Policies, Procedures and Standards of Conduct; Compliance Program Oversight; Training and Education Communication; Auditing and Monitoring; Consistent Discipline; and Corrective Actions and meets the requirements of applicable laws, rules, and regulations. Contractor shall provide evidence of such compliance program as reasonably requested by Covered California. Contractor shall timely communicate within ten (10) Days to Covered California any material concerns identified by Contractor or material concerns, including any enforcement actions resulting in monetary penalties equal to or exceeding $10,000, identified by State and Federal Regulators related to regulatory compliance that may impact performance under this Agreement following Contractor’s knowledge of such occurrence; provided, however, such notification shall be provided immediately if such occurrence may reasonably be deemed to adversely affect the quality of care or safety of Covered California Enrollees. All notifications shall be made according to the “Contract Reporting Requirements” table posted on Contractor’s extranet website provided by Covered California (Carrier Management (External) page, PMD Resources, Contract Reporting Compliance)Agreement. Contractor shall provide Covered California with a description of its fraud, waste and abuse detection and prevention programs and report total monies recovered by Contractor from providers in the most recent 12-month period for Contractor’s total book of business as well as, if available, total monies recovered for Covered California business only. This description shall be provided upon the request of Covered California and will be updated upon request during each year that this Agreement is in effect and shall include an overview of fraud and abuse detection and prevention program activities conducted by Contractor, Participating Providers, other Subcontractors subcontractors and their authorized agents, including a summary of key findings, relevant data analytics and fraud risk assessments to circumvent fraud, waste, and abuse, and the development, implementation and enforcement of any corrective action plans for changing, upgrading, or improving these programs. If Contractor receives any preliminary or final reports, findings, or orders related to material concerns identified by State and Federal Regulators that may impact performance under this Agreement pursuant to this Section, it shall provide Covered California with copies of them within 48 hours of receiving them from State and Federal Regulators. Contractor shall maintain and enforce a code of ethical conduct and make it available to Covered California upon request. Contractor shall refer potential fraud activities identified through fraud detection and response measures to Covered California. Contractor shall follow the established Carrier Referral Process posted on the Contractor’s extranet website provided by Covered California (Carrier Management (External) Hub page, Contractor’s foldersubsite, Data Integrity, Fraud Referral folder). Contractor shall not terminate Covered California Enrollee coverage for fraud without prior review and approval from Covered California.

Xxxxx, Xxxxx and Abuse; Ethical Conduct. Contractor shall maintain and enforce policies, procedures, processes, systems, and internal controls (i) to reduce Fraud, Waste, and Abuse, and (ii) to enhance compliance with other applicable laws, rules, and regulations in connection with the performance of Contractor’s obligations under this Agreement. Contractor shall maintain an effective compliance program that includes a minimum of the following “7 Core Elements” as defined by CMS: Written Policies, Procedures and Standards of Conduct; Compliance Program Oversight; Training and Education Communication; Auditing and Monitoring; Consistent Discipline; and Corrective Actions and meets the requirements of applicable laws, rules, and regulations. Contractor shall provide evidence of such compliance program as reasonably requested by Covered California. Contractor shall communicate within ten (10) Days to Covered California any material concerns identified by Contractor or material concerns, including any enforcement actions resulting in monetary penalties equal to or exceeding $10,000, identified by State and Federal Regulators related to regulatory compliance that may impact performance under this Agreement following Contractor’s knowledge of such occurrence; provided, however, such notification shall be provided immediately if such occurrence may reasonably be deemed to adversely affect the quality of care or safety of Covered California Enrollees. All notifications shall be made according to the “Contract Reporting Requirements” table posted on the Contractor’s extranet website provided by Covered California (Carrier Management (External) page, PMD Resources, Contract Reporting Compliance). Contractor shall provide Covered California with a description of its fraud, waste and abuse detection and prevention programs and report total monies recovered by Contractor from providers in the most recent 12-month period for Contractor’s total book of business as well as, total monies recovered for Covered California business only. This description shall be updated during each year that this Agreement is in effect and shall include an overview of fraud and abuse detection and prevention program activities conducted by Contractor, Participating Providers, other Subcontractors and their authorized agents, including a summary of key findings, relevant data analytics and fraud risk assessments to circumvent fraud, waste, and abuse, and the development, implementation and enforcement of any corrective action plans for changing, upgrading, or improving these programs. If Contractor receives any preliminary or final reports, findings, or orders related to material concerns identified by State and Federal Regulators that may impact performance under this Agreement pursuant to this Section, it shall provide Covered California with copies of them within 48 hours of receiving them from State and Federal Regulators. Contractor shall maintain and enforce a code of ethical conduct and make it available to Covered California upon request. Contractor shall refer potential fraud activities identified through fraud detection and response measures to Covered California. Contractor shall follow the established Carrier Referral Process posted on the Contractor’s extranet website provided by Covered California (Carrier Management (External) page, Contractor’s folder, Data Integrity, Fraud Referral folder). Contractor shall not terminate Covered California Enrollee coverage for fraud without prior review and approval from Covered California.

Xxxxx, Xxxxx and Abuse; Ethical Conduct. Contractor shall maintain and enforce policies, procedures, processes, systems, and internal controls (i) to reduce Fraud, Waste, and Abuse, and (ii) to enhance compliance with other applicable laws, rules, and regulations in connection with the performance of Contractor’s obligations under this Agreement. Contractor shall maintain an effective compliance program that includes a minimum of the following “7 Core Elements” as defined by CMS: Written Policies, Procedures and Standards of Conduct; Compliance Program Oversight; Training and Education Communication; Auditing and Monitoring; Consistent Discipline; and Corrective Actions and meets the requirements of applicable laws, rules, and regulations. regulations Contractor shall provide evidence of such compliance program as reasonably requested by Covered California. Contractor shall communicate within ten (10) Days to Covered California any material concerns identified by Contractor or material concerns, including any enforcement actions resulting in monetary penalties equal to or exceeding $10,000100,000, identified by State and Federal Regulators related to regulatory compliance that may impact performance under this Agreement following Contractor’s knowledge of such occurrence; provided, however, such notification shall be provided immediately if such occurrence may reasonably be deemed to adversely affect the quality of care or safety of Covered California Enrollees. All notifications shall be made according to the “Contract Reporting Requirements” table posted on Contractor’s the Contractors extranet website provided by Covered California (Carrier Management (External) page, PMD Resources, Contract Reporting ComplianceCompliance folder). Contractor shall provide Covered California with a description of its fraud, waste waste, and abuse detection and prevention programs and report total monies recovered by Contractor from providers in the most recent 12-month period for Contractor’s total book of business as well as, total monies recovered for Covered California business only. This description shall be updated during each year that this Agreement is in effect and shall include an overview of fraud and abuse detection and prevention program activities conducted by Contractor, Participating Providers, other Subcontractors and their authorized agentsAgents, including a summary of key findings, relevant data analytics and fraud risk assessments to circumvent fraud, waste, and abuse, and the development, implementation implementation, and enforcement of any corrective action plans for changing, upgrading, or improving these programs. If Contractor receives any preliminary or final reports, findings, or orders related to material concerns identified by State and Federal Regulators that may impact performance under this Agreement pursuant to this Section, it shall provide Covered California with copies of them within 48 hours of receiving them from State and Federal Regulators. Contractor shall maintain and enforce a code of ethical conduct and make it available to Covered California upon request. Contractor shall refer potential fraud activities identified through fraud detection and response measures to Covered California. Contractor shall follow the established Carrier Referral Process posted on the Contractor’s extranet website provided by Covered California (Carrier Management (External) page, Contractor’s folderPMD Resources, Data Integrity, Fraud Referral Contract Reporting Compliance folder). Contractor shall not terminate Covered California Enrollee coverage for fraud without prior review and approval from Covered California.

Xxxxx, Xxxxx and Abuse; Ethical Conduct. Contractor shall maintain and enforce policies, procedures, processes, systems, and internal controls (i) to reduce Fraud, Waste, and Abuse, and (ii) to enhance compliance with other applicable laws, rules, and regulations in connection with the performance of Contractor’s obligations under this Agreement. Contractor shall maintain an effective compliance program that includes a minimum of the following “7 Core Elements” as defined by CMS: Written Policies, Procedures and Standards of Conduct; Compliance Program Oversight; Training and Education Communication; Auditing and Monitoring; Consistent Discipline; and Corrective Actions and meets the requirements of applicable laws, rules, and regulations. regulations Contractor shall provide evidence of such compliance program as reasonably requested by Covered California. Contractor shall communicate within ten (10) Days to Covered California any material concerns identified by Contractor or material concerns, including any enforcement actions resulting in monetary penalties equal to or exceeding $10,000100,000, identified by State and Federal Regulators related to regulatory compliance that may impact performance under this Agreement following Contractor’s knowledge of such occurrence; provided, however, such notification shall be provided immediately if such occurrence may reasonably be deemed to adversely affect the quality of care or safety of Covered California Enrollees. All notifications shall be made according to the “Contract Reporting Requirements” table posted on Contractor’s the Contractors extranet website provided by Covered California (Carrier Management (External) page, PMD Resources, Contract Reporting Compliance). Contractor shall provide Covered California with a description of its fraud, waste waste, and abuse detection and prevention programs and report total monies recovered by Contractor from providers in the most recent 12-month period for Contractor’s total book of business as well as, total monies recovered for Covered California business only. This description shall be updated during each year that this Agreement is in effect and shall include an overview of fraud and abuse detection and prevention program activities conducted by Contractor, Participating Providers, other Subcontractors and their authorized agentsAgents, including a summary of key findings, relevant data analytics and fraud risk assessments to circumvent fraud, waste, and abuse, and the development, implementation implementation, and enforcement of any corrective action plans for changing, upgrading, or improving these programs. If Contractor receives any preliminary or final reports, findings, or orders related to material concerns identified by State and Federal Regulators that may impact performance under this Agreement pursuant to this Section, it shall provide Covered California with copies of them within 48 hours of receiving them from State and Federal Regulators. Contractor shall maintain and enforce a code of ethical conduct and make it available to Covered California upon request. Contractor shall refer potential fraud activities identified through fraud detection and response measures to Covered California. Contractor shall follow the established Carrier Referral Process posted on the Contractor’s extranet website provided by Covered California (Carrier Management (External) page, Contractor’s folder, Data Integrity, Fraud Referral folder). Contractor shall not terminate Covered California Enrollee coverage for fraud without prior review and approval from Covered California.

Xxxxx, Xxxxx and Abuse; Ethical Conduct. Contractor shall maintain and enforce policies, procedures, processes, systems, and internal controls (i) to reduce Fraud, Waste, and Abuse, and (ii) to enhance compliance with other applicable laws, rules, and regulations in connection with the performance of Contractor’s obligations under this Agreement. Contractor shall maintain an effective compliance program that includes a minimum of the following “7 Core Elements” as defined by CMS: Written Policies, Procedures and Standards of Conduct; Compliance Program Oversight; Training and Education Communication; Auditing and Monitoring; Consistent Discipline; and Corrective Actions and meets the requirements of applicable laws, rules, and regulations. regulations Contractor shall provide evidence of such compliance program as reasonably requested by Covered California. Contractor shall communicate within ten (10) Days to Covered California any material concerns identified by Contractor or material concerns, including any enforcement actions resulting in monetary penalties equal to or exceeding $10,000100,000, identified by State and Federal Regulators related to regulatory compliance that may impact performance under this Agreement following Contractor’s knowledge of such occurrence; provided, however, such notification shall be provided immediately if such occurrence may reasonably be deemed to adversely affect the quality of care or safety of Covered California Enrollees. All notifications shall be made according to the “Contract Reporting Requirements” table posted on Contractorthe ContractorsContractor’s extranet website provided by Covered California (Carrier Management (External) page, PMD Resources, Contract Reporting Compliance). Contractor shall provide Covered California with a description of its fraud, waste waste, and abuse detection and prevention programs and report total monies recovered by Contractor from providers in the most recent 12-month period for Contractor’s total book of business as well as, total monies recovered for Covered California business only. This description shall be updated during each year that this Agreement is in effect and shall include an overview of fraud and abuse detection and prevention program activities conducted by Contractor, Participating Providers, other Subcontractors and their authorized agentsAgents, including a summary of key findings, relevant data analytics and fraud risk assessments to circumvent fraud, waste, and abuse, and the development, implementation implementation, and enforcement of any corrective action plans for changing, upgrading, or improving these programs. If Contractor receives any preliminary or final reports, findings, or orders related to material concerns identified by State and Federal Regulators that may impact performance under this Agreement pursuant to this Section, it shall provide Covered California with copies of them within 48 hours of receiving them from State and Federal Regulators. Contractor shall maintain and enforce a code of ethical conduct and make it available to Covered California upon request. Contractor shall refer potential fraud activities identified through fraud detection and response measures to Covered California. Contractor shall follow the established Carrier Referral Process posted on the Contractor’s extranet website provided by Covered California (Carrier Management (External) page, Contractor’s folder, Data Integrity, Fraud Referral folder). Contractor shall not terminate Covered California Enrollee coverage for fraud without prior review and approval from Covered California.

Xxxxx, Xxxxx and Abuse; Ethical Conduct. Contractor shall maintain and enforce policies, procedures, processes, systems, and internal controls (i) to reduce Fraud, Waste, and Abuse, and (ii) to enhance compliance with other applicable laws, rules, and regulations in connection with the performance of Contractor’s obligations under this Agreement. Contractor shall maintain an effective compliance program that includes a minimum of the following “7 Core Elements” as defined by CMS: Written Policies, Procedures and Standards of Conduct; Compliance Program Oversight; Training and Education Communication; Auditing and Monitoring; Consistent Discipline; and Corrective Actions and meets the requirements of applicable laws, rules, and regulations. regulations Contractor shall provide evidence of such compliance program as reasonably requested by Covered California. Contractor shall communicate within ten (10) Days to Covered California any material concerns identified by Contractor or material concerns, including any enforcement actions resulting in monetary penalties equal to or exceeding $10,000100,000, identified by State and Federal Regulators related to regulatory compliance that may impact performance under this Agreement following Contractor’s knowledge of such occurrence; provided, however, such notification shall be provided immediately if such occurrence may reasonably be deemed to adversely affect the quality of care or safety of Covered California Enrollees. All notifications shall be made according to the “Contract Reporting Requirements” table posted on Contractor’s extranet website provided by Covered California (Carrier Management (External) page, PMD Resources, Contract Reporting Compliance). Contractor shall provide Covered California with a description of its fraud, waste waste, and abuse detection and prevention programs and report total monies recovered by Contractor from providers in the most recent 12-month period for Contractor’s total book of business as well as, total monies recovered for Covered California business only. This description shall be updated during each year that this Agreement is in effect and shall include an overview of fraud and abuse detection and prevention program activities conducted by Contractor, Participating Providers, other Subcontractors and their authorized agentsAgents, including a summary of key findings, relevant data analytics and fraud risk assessments to circumvent fraud, waste, and abuse, and the development, implementation implementation, and enforcement of any corrective action plans for changing, upgrading, or improving these programs. If Contractor receives any preliminary or final reports, findings, or orders related to material concerns identified by State and Federal Regulators that may impact performance under this Agreement pursuant to this Section, it shall provide Covered California with copies of them within 48 hours of receiving them from State and Federal Regulators. Contractor shall maintain and enforce a code of ethical conduct and make it available to Covered California upon request. Contractor shall refer potential fraud activities identified through fraud detection and response measures to Covered California. Contractor shall follow the established Carrier Referral Process posted on the Contractor’s extranet website provided by Covered California (Carrier Management (External) page, Contractor’s folder, Data Integrity, Fraud Referral folder). Contractor shall not terminate Covered California Enrollee coverage for fraud without prior review and approval from Covered California.

Xxxxx, Xxxxx and Abuse; Ethical Conduct. Contractor shall maintain and enforce policies, procedures, processes, systems, and internal controls (i) to reduce Fraud, Waste, and Abuse, and (ii) to enhance compliance with other applicable laws, rules, and regulations in connection with the performance of Contractor’s obligations under this Agreement. . a) Contractor shall maintain an effective compliance program that includes a minimum of the following “7 Core Elements” as defined by CMS: Written Policies, Procedures and Standards of Conduct; Compliance Program Oversight; Training and Education Communication; Auditing and Monitoring; Consistent Discipline; and Corrective Actions and meets the requirements of applicable laws, rules, and regulations. Contractor shall provide evidence of such compliance program as reasonably requested by Covered California. . b) Contractor shall communicate within ten (10) Days to Covered California any material concerns identified by Contractor or material concerns, concerns including any enforcement actions resulting in monetary penalties equal to or exceeding $10,000100,000, identified by State and Federal Regulators related to regulatory compliance that may impact performance under this Agreement following Contractor’s knowledge of such occurrence; provided, however, such notification shall be provided immediately if such occurrence may reasonably be deemed to adversely affect the quality of care or safety of Covered California Enrollees. All notifications shall be made according to the “Contract Reporting Requirements” table posted on Contractor’s extranet website provided by Covered California (Carrier Management (External) page, PMD Resources, Contract Reporting ComplianceCompliance folder). Contractor shall provide Covered California with a description of its fraud, waste and abuse detection and prevention programs and report total monies recovered by Contractor from providers in the most recent 12-month period for Contractor’s total book of business as well as, total monies recovered for Covered California business only. This description shall be updated during each year that this Agreement is in effect and shall include an overview of fraud and abuse detection and prevention program activities conducted by Contractor, Participating Providers, other Subcontractors and their authorized agents, including a summary of key findings, relevant data analytics and fraud risk assessments to circumvent fraud, waste, and abuse, and the development, implementation and enforcement of any corrective action plans for changing, upgrading, or improving these programs. . c) If Contractor receives any preliminary or final reports, findings, or orders related to material concerns identified by State and Federal Regulators that may impact performance under this Agreement pursuant to this Section, it shall provide Covered California with copies of them within 48 hours of receiving them from State and Federal Regulators. d) Contractor shall provide Covered California with a description of its fraud, waste, and abuse detection and prevention programs and report total monies recovered by Contractor in the most recent 12-month period for Contractor’s total book of business as well as total monies recovered for Covered California business only. This description shall be updated during each year that this Agreement is in effect and shall include an overview of fraud and abuse detection and prevention program activities conducted by Contractor, Participating Providers, other Subcontractors and their authorized Agents, including a summary of key findings, relevant data analytics and fraud risk assessments to circumvent fraud, waste, and abuse, and the development, implementation, and enforcement of any corrective action plans for changing, upgrading, or improving these programs. e) Contractor shall maintain and enforce a code of ethical conduct and make it available to Covered California upon request. . f) Contractor shall refer potential fraud activities identified through fraud detection and response measures to Covered California. Contractor shall follow the established Carrier Referral Process posted on the Contractor’s extranet website provided by Covered California (Carrier Management (External) page, Contractor’s folder, Data Integrity, Fraud Referral folder). . g) Contractor shall not terminate Covered California Enrollee coverage for fraud without prior review and approval from Covered California.

Xxxxx, Xxxxx and Abuse; Ethical Conduct. ‌ Contractor shall maintain and enforce policies, procedures, processes, systems, and internal controls (i) to reduce Fraud, Waste, and Abuse, and (ii) to enhance compliance with other applicable laws, rules, and regulations in connection with the performance of Contractor’s obligations under this Agreement. Contractor shall maintain an effective compliance program that includes a minimum of the following “7 Core Elements” as defined by CMS: Written Policies, Procedures and Standards of Conduct; Compliance Program Oversight; Training and Education Communication; Auditing and Monitoring; Consistent Discipline; and Corrective Actions and meets the requirements of applicable laws, rules, and regulations. regulations Contractor shall provide evidence of such compliance program as reasonably requested by Covered California. Contractor shall communicate within ten (10) Days to Covered California any material concerns identified by Contractor or material concerns, including any enforcement actions resulting in monetary penalties equal to or exceeding $10,000100,000, identified by State and Federal Regulators related to regulatory compliance that may impact performance under this Agreement following Contractor’s knowledge of such occurrence; provided, however, such notification shall be provided immediately if such occurrence may reasonably be deemed to adversely affect the quality of care or safety of Covered California Enrollees. All notifications shall be made according to the “Contract Reporting Requirements” table posted on Contractor’s extranet website provided by Covered California (Carrier Management (External) page, PMD Resources, Contract Reporting Compliance). Contractor shall provide Covered California with a description of its fraud, waste waste, and abuse detection and prevention programs and report total monies recovered by Contractor from providers in the most recent 12-month period for Contractor’s total book of business as well as, total monies recovered for Covered California business only. This description shall be updated during each year that this Agreement is in effect and shall include an overview of fraud and abuse detection and prevention program activities conducted by Contractor, Participating Providers, other Subcontractors and their authorized agentsAgents, including a summary of key findings, relevant data analytics and fraud risk assessments to circumvent fraud, waste, and abuse, and the development, implementation implementation, and enforcement of any corrective action plans for changing, upgrading, or improving these programs. If Contractor receives any preliminary or final reports, findings, or orders related to material concerns identified by State and Federal Regulators that may impact performance under this Agreement pursuant to this Section, it shall provide Covered California with copies of them within 48 hours of receiving them from State and Federal Regulators. Contractor shall maintain and enforce a code of ethical conduct and make it available to Covered California upon request. Contractor shall refer potential fraud activities identified through fraud detection and response measures to Covered California. Contractor shall follow the established Carrier Referral Process posted on the Contractor’s extranet website provided by Covered California (Carrier Management (External) page, Contractor’s folder, Data Integrity, Fraud Referral folder). Contractor shall not terminate Covered California Enrollee coverage for fraud without prior review and approval from Covered California.