Common use of Xxxxx, Xxxxx and Abuse 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 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 to Covered California any material concerns identified by Contractor or by State and Federal Regulators related to regulatory compliance that may impact performance under this 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 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 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. 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 (Data Home, Contractor’s folder, Fraud Referral folder). Contractor shall not terminate Enrollee coverage for fraud without prior review and approval from Covered California.

Xxxxx, Xxxxx and Abuse. Ethical Conduct 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 meets the requirements of applicable laws, rules and regulations. Contractor shall provide evidence of such compliance program as reasonably requested by Covered Californiathe Exchange. Contractor shall timely communicate to Covered California the Exchange any material concerns identified by Contractor or by State and Federal Regulators related to regulatory compliance that may impact performance under this Agreement. Contractor shall provide Covered California the Exchange with a description of its fraud, waste and abuse detection and prevention programs and report total monies recovered by Contractor in the most recent 12-12- 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 the Exchange 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 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. Contractor shall maintain and enforce a code of ethical conduct and make it available to Covered California the Exchange upon request. Contractor shall refer potential fraud activities identified through fraud detection and response measures to Covered Californiathe Exchange. Contractor shall follow the established Carrier Referral Process posted on the Contractor’s extranet website provided by Covered California the Exchange (Data Home, Contractor’s folder, Fraud Referral folder). Contractor shall not terminate Enrollee coverage for fraud without prior review and approval from Covered Californiathe Exchange.