Fraud and Abuse. A MCO is subject to all state and federal laws and regulations relating to Fraud, Abuse, and Waste in health care and the Medicaid and CHIP programs. The MCO must cooperate and assist HHSC and any state or federal agency charged with the duty of identifying, investigating, sanctioning or prosecuting suspected Fraud, Abuse or Waste. In order to facilitate cooperation with the Office of Inspector General (OIG) at HHSC, the MCO must have staff available for Special Investigative Unit (SIU) representation located in the state. The MCO must allow access to premises and provide originals and/or copies of all records and information requested free of charge to the Inspector General for the Texas Health and Human Services System, HHSC or its authorized agent(s), the Centers for Medicare and Medicaid Services (CMS), the U.S. Department of Health and Human Services (DHHS), Federal Bureau of Investigation, the Office of the Attorney General, TDI, or other units of state government. Each MCO must designate one primary and one secondary contact person for all HHSC OIG records requests. HHSC OIG records requests will be sent to the designated MCO contact person(s) in writing via email, fax or regular mail, and will provide the specifics of the information being requested (see below). The MCO will respond to the appropriate HHSC OIG staff member within the timeframe designated in the request. If the MCO is unable to provide all of the requested information with in the designated timeframe, an extension may be granted and must be request in writing (email) by the MCO no less than two (2) Business Days prior to the due date. When a request for data is provided to the MCO, the MCO's response must include data for all data fields, as available. If any data field is left blank, an explanation must accompany the response. The data must be provided in the order and format requested. The MCO must not include any additional data fields in its response. All requested information must be accompanied by a notarized Business Records Affidavit unless indicated otherwise in HHSC OIG's record request. The most common requests will include: Ø 1099 data and other financial information - three (3) Business Days. ØClaims data for sampling - 5 Business Days. Ø Urgent claims data requests - three (3) Business Days (with OIG manager's approval). Ø Provider education information - 10 Business Days. Ø Files associated with an HMO conducted investigation - 15 Business Days. Ø Other time-sensitive requests - as needed.
Appears in 5 contracts
Samples: Centene Corp, Centene Corp, Centene Corp
Fraud and Abuse. A MCO is subject to all state and federal laws and regulations relating to Fraud, Abuse, and Waste in health care and the Medicaid and CHIP programs. The MCO must cooperate and assist HHSC and any state or federal agency charged with the duty of identifying, investigating, sanctioning or prosecuting suspected Fraud, Abuse or Waste. In order to facilitate cooperation with the Office of Inspector General (OIG) at HHSC, the MCO must have staff available for Special Investigative Unit (SIU) representation located in the state. The MCO must allow access to premises and provide originals and/or copies of all records and information requested free of charge to the Inspector General for the Texas Health and Human Services System, HHSC or its authorized agent(s), the Centers for Medicare and Medicaid Services (CMS), the U.S. Department of Health and Human Services (DHHS), Federal Bureau of Investigation, the Office of the Attorney General, TDI, or other units of state government. Each MCO must designate one primary and one secondary contact person for all HHSC OIG records requests. HHSC OIG records requests will be sent to the designated MCO contact person(s) in writing via email, fax or regular mail, and will provide the specifics of the information being requested (see below). The MCO will respond to the appropriate HHSC OIG staff member within the timeframe designated in the request. If the MCO is unable to provide all of the requested information with in the designated timeframe, an extension may be granted and must be request in writing (email) by the MCO no less than two (2) Business Days prior to the due date. When a request for data is provided to the MCO, the MCO's response must include data for all data fields, as available. If any data field is left blank, an explanation must accompany the response. The data must be provided in the order and format requested. The MCO must not include any additional data fields in its response. All requested information must be accompanied by a notarized Business Records Affidavit unless indicated otherwise in HHSC OIG's record request. The most common requests will include: Ø 1099 data and other financial information - three (3) Business Days. ØClaims Claims data for sampling - 5 Business Days. Ø Urgent claims data requests - three (3) Business Days (with OIG manager's approval). Ø Provider education information - 10 Business Days. Ø Files associated with an HMO conducted investigation - 15 Business Days. Ø Other time-sensitive requests - as needed. The MCO must submit a written Fraud and Abuse compliance plan to the HHSC OIG for approval each year. The plan must be submitted 90 days prior to the start of the State Fiscal Year. (See Section 7, Transition Phase Requirements. for requirements regarding timeframes for submitting the original plan.) If an MCO has not made any changes to its plan from the previous year, it may notify the HHSC OIG that: (1) no changes have been made to the previously-approved plan, (2) the plan will remain in place for the upcoming State Fiscal Year. The notification must be signed and certified by an officer or director of the MCO that is responsible for carrying out the Fraud and Abuse compliance plan. Upon receipt of a written request from the HHSC OIG, the MCO must submit the complete Fraud and Abuse compliance plan. The MCO is subject to and must meet all requirements in Section 531.113 of the Texas Government Code, Section 533.012 of the Texas Government Code, Title 1 Texas Administrative Code (TAC), Part 15, Chapter 353, Subchapter F, Rule 353.501-353.505, and Title 1 Texas Administrative Code (TAC), Part 15, Chapter 370, Subchapter F, Rule 370.501-370.505 as well as all laws specified in Attachment A, Section 7.02. Failure to comply with any requirement of 8.1.19 and 8.1.20.2(c) and (d) subjects the MCO to enforcement pursuant to 1 TEX. ADMIN. CODE Chapter 371 Subchapter G in addition to any other legal remedy. 42 C.F.R. § 455.23 requires the State Medicaid agency to suspend all Medicaid payments to a provider after the agency determines there is a credible allegation of fraud for which an investigation is pending under the Medicaid program against an individual or entity unless the agency has good cause to not suspend payments or suspend payment only in part. In Texas, HHSC OIG is responsible for evaluating allegations of fraud and imposing payment suspensions when appropriate. The rules governing payment suspensions based upon pending investigations of credible allegations of fraud apply to Medicaid managed care entities. Managed care capitation payments may be included in a suspension when an individual network provider is under investigation based upon credible allegations of fraud, depending on the allegations at issue. The MCO is required to cooperate with HHSC OIG when payment suspensions are imposed. When HHSC OIG sends notice that payments to a provider have been suspended, the MCO must also suspend payments to the provider within 1 business day. When such notice is received, the MCO must respond to the notice within 3 business days and inform HHSC OIG of whether the MCO has implemented the suspension. The MCO must also report all of the following information to HHSC OIG after it suspends payments to the provider: date the suspension was imposed, date the suspension was discontinued, reason for discontinuing the suspension, outcome of any appeals, amount of payments held, and, if applicable, the good cause rationale for not suspending payment (for example, the provider is not enrolled in the MCO's network) or imposing a partial payment suspension. If the MCO does not suspend payments to the provider, HHSC may impose contractual or other remedies. For payment suspensions initiated by the MCO, the MCO must report the following information to HHSC OIG: the nature of the suspected fraud, basis for the suspension, date the suspension was imposed, date the suspension was discontinued, reason for discontinuing the suspension, outcome of any appeals, the amount of payments held, and, if applicable, the good cause rationale for imposing a partial payment suspension. Additional Requirements for STAR and STAR+PLUS MCOs: In accordance with Section 1902(a)(68) of the Social Security Act, STAR and STAR+PLUS MCOs and their Subcontractors that receive or make annual Medicaid payments of at least $5 million must:
Appears in 3 contracts
Samples: Centene Corp, Centene Corp, Centene Corp
Fraud and Abuse. A MCO HMO is subject to all state and federal laws and regulations relating to Fraud, Abuse, and Waste in health care and the Medicaid and CHIP programs. The MCO HMO must cooperate and assist HHSC and any state or federal agency charged with the duty of identifying, investigating, sanctioning or prosecuting suspected Fraud, Abuse or Waste. In order to facilitate cooperation with the Office of Inspector General (OIG) at HHSC, the MCO The HMO must have staff available for Special Investigative Unit (SIU) representation located in the state. The MCO must allow access to premises and provide originals and/or copies of all records and information requested free of charge and allow access to premises and provide records to the Inspector General for the Texas Health and Human Services System, HHSC or its authorized agent(s), the Centers for Medicare and Medicaid Services (CMS), the U.S. Department of Health and Human Services (DHHS), Federal Bureau of Investigation, the Office of the Attorney General, TDI, or other units of state government. The HMO must provide all copies of records free of charge. Each MCO HMO must designate one primary and one secondary contact person for all HHSC OIG records requests. HHSC OIG records requests will be sent to the designated MCO HMO contact person(s) in writing via email, fax or regular mail, and will provide the specifics of the information being requested (see below). The MCO HMO will respond to the appropriate HHSC OIG staff member within the timeframe designated in the request. If the MCO HMO is unable to provide all of the requested information with in the designated timeframe, an extension may be granted and must be request in writing (email) by the MCO HMO no less than two (2) Business Days prior to the due date. When a request for data is provided to the MCOHMO, the MCOHMO's response must include data for all data fields, as available. If any data field is left blank, an explanation must accompany the response. The data must be provided in the order and format requested. The MCO HMO must not include any additional data fields in its response. All requested information must be accompanied by a notarized Business Records Affidavit unless indicated otherwise in HHSC OIG's record request. The most common requests will include: Ø 1099 data and other financial information - three five (35) Business Days. ØClaims Claims data for sampling - 5 20 Business Days. Ø Urgent claims data requests - three (3) 15 Business Days (with OIG manager's approval). Ø Provider education information - 10 Business Days. Ø Files associated with an HMO conducted investigation - 15 Business DaysDay. Ø Other time-sensitive requests - as needed. The HMO must submit a written Fraud and Abuse compliance plan to the Office of Inspector General at HHSC for approval each year. The plan must be submitted 60 days prior to the start of the State fiscal year. (See Attachment B-1, Section 7 for requirements regarding timeframes for submitting the original plan.) If an HMO has not made any changes to its plan from the previous year, it may notify the HHSC OIG that: (1) no changes have been made to the privously-approved plan, (2) the plan will remain in place for the upcoming State Fiscal Year. The notification must be signed and certified by an officer or director of the HMO that is responsible for carrying out the Fraud and Abuse compliance plan. Upon receipt of a written request from the HHSC OIG, the HMO must submit the complete Fraud and Abuse compliance plan. The HMO is subject to and must meet all requirements in Section 531.113 of the Texas Government Code, Section 533.012 of the Texas Government Code, Title 1 Texas Administrative Code (TAC), Part 15, Chapter 353, Subchapter F, Rule 353.501-353.505, and Title 1 Texas Administrative Code (TAC), Part 15, Chapter 370, Subchapter F, Rule 370.501-370.505. Additional Requirements for STAR and STAR+PLUS HMOs: In accordance with Section 1902(a)(68) of the Social Security Act, STAR and STAR+PLUS HMOs that receive or make annual Medicaid payments of at least $5 million must:
Appears in 2 contracts
Samples: Explanatory Note (Centene Corp), Centene Corp
Fraud and Abuse. A MCO is subject to all state and federal laws and regulations relating to Fraud, Abuse, and Waste in health care and the Medicaid and CHIP programs. The MCO must cooperate and assist HHSC and any state or federal agency charged with the duty of identifying, investigating, sanctioning or prosecuting suspected Fraud, Abuse or Waste. In order to facilitate cooperation with the Office of Inspector General (OIG) at HHSC, the MCO must have staff available for Special Investigative Unit (SIU) representation located in the state. The MCO must allow access to premises and provide originals and/or copies of all records and information requested free of charge to the Inspector General for the Texas Health and Human Services System, HHSC or its authorized agent(s), the Centers for Medicare and Medicaid Services (CMS), the U.S. Department of Health and Human Services (DHHS), Federal Bureau of Investigation, the Office of the Attorney General, TDI, or other units of state government. Each MCO must designate one primary and one secondary contact person for all HHSC OIG records requests. HHSC OIG records requests will be sent to the designated MCO contact person(s) in writing via email, fax or regular mail, and will provide the specifics of the information being requested (see below). The MCO will respond to the appropriate HHSC OIG staff member within the timeframe designated in the request. If the MCO is unable to provide all of the requested information with in the designated timeframe, an extension may be granted and must be request in writing (email) by the MCO no less than two (2) Business Days prior to the due date. When a request for data is provided to the MCO, the MCO's ’s response must include data for all data fields, as available. If any data field is left blank, an explanation must accompany the response. The data must be provided in the order and format requested. The MCO must not include any additional data fields in its response. All requested information must be accompanied by a notarized Business Records Affidavit unless indicated otherwise in HHSC OIG's ’s record request. The most common requests will include: Ø 1099 data and other financial information - three – five (35) Business Days. ØClaims Ø Claims data for sampling - 5 – 15 Business Days. Ø Urgent claims data requests - three (3) – 10 Business Days (with OIG manager's ’s approval). Ø Provider education information - – 10 Business Days. Ø Files associated with an HMO conducted investigation - – 15 Business DaysDay. Ø Other time-sensitive requests - – as needed. The MCO must submit a written Fraud and Abuse compliance plan to the HHSC OIG for approval each year. The plan must be submitted 90 days prior to the start of the State Fiscal Year. (See Section 7, “Transition Phase Requirements.” for requirements regarding timeframes for submitting the original plan.) If an MCO has not made any changes to its plan from the previous year, it may notify the HHSC OIG that: (1) no changes have been made to the previously-approved plan, (2) the plan will remain in place for the upcoming State Fiscal Year. The notification must be signed and certified by an officer or director of the MCO that is responsible for carrying out the Fraud and Abuse compliance plan. Upon receipt of a written request from the HHSC OIG, the MCO must submit the complete Fraud and Abuse compliance plan. The MCO is subject to and must meet all requirements in Section 531.113 of the Texas Government Code, Section 533.012 of the Texas Government Code, Title 1 Texas Administrative Code (TAC), Part 15, Chapter 353, Subchapter F, Rule 353.501-353.505, and Title 1 Texas Administrative Code (TAC), Part 15, Chapter 370, Subchapter F, Rule 370.501-370.505 as well as all laws specified in Attachment A, Section 7.02. Failure to comply with any requirement of 8.1.19 and 8.1.20.2(c) and (d) subjects the MCO to enforcement pursuant to 1 TEX. ADMIN. CODE Chapter 371 Subchapter G in addition to any other legal remedy. Additional Requirements for STAR and STAR+PLUS MCOs: In accordance with Section 1902(a)(68) of the Social Security Act, STAR and STAR+PLUS MCOs and their Subcontractors that receive or make annual Medicaid payments of at least $5 million must:
Appears in 1 contract
Samples: Centene Corp
Fraud and Abuse. A MCO is subject to all state and federal laws and regulations relating to Fraud, Abuse, and Waste in health care and the Medicaid and CHIP programs. The MCO must cooperate and assist HHSC and any state or federal agency charged with the duty of identifying, investigating, sanctioning or prosecuting suspected Fraud, Abuse or Waste. In order to facilitate cooperation with the Office of Inspector General (OIG) at HHSC, the MCO must have staff available for Special Investigative Unit (SIU) representation located in the state. The MCO must allow access to premises and provide originals and/or copies of all records and information requested free of charge to the Inspector General for the Texas Health and Human Services System, HHSC or its authorized agent(s), the Centers for Medicare and Medicaid Services (CMS), the U.S. Department of Health and Human Services (DHHS), Federal Bureau of Investigation, the Office of the Attorney General, TDI, or other units of state government. Each MCO must designate one primary and one secondary contact person for all HHSC OIG records requests. HHSC OIG records requests will be sent to the designated MCO contact person(s) in writing via email, fax or regular mail, and will provide the specifics of the information being requested (see below). The MCO will respond to the appropriate HHSC OIG staff member within the timeframe designated in the request. If the MCO is unable to provide all of the requested information with in the designated timeframe, an extension may be granted and must be request in writing (email) by the MCO no less than two (2) Business Days prior to the due date. When a request for data is provided to the MCO, the MCO's ’s response must include data for all data fields, as available. If any data field is left blank, an explanation must accompany the response. The data must be provided in the order and format requested. The MCO must not include any additional data fields in its response. All requested information must be accompanied by a notarized Business Records Affidavit unless indicated otherwise in HHSC OIG's ’s record request. The most common requests will include: Ø ¿ 1099 data and other financial information - three – five (35) Business Days. ØClaims ¿ Claims data for sampling - 5 – 15 Business Days. Ø ¿ Urgent claims data requests - three (3) – 10 Business Days (with OIG manager's ’s approval). Ø ¿ Provider education information - – 10 Business Days. Ø ¿ Files associated with an HMO conducted investigation - – 15 Business DaysDay. Ø ¿ Other time-sensitive requests - – as needed. The MCO must submit a written Fraud and Abuse compliance plan to the HHSC OIG for approval each year. The plan must be submitted 90 days prior to the start of the State Fiscal Year. (See Section 7, “Transition Phase Requirements.” for requirements regarding timeframes for submitting the original plan.) If an MCO has not made any changes to its plan from the previous year, it may notify the HHSC OIG that: (1) no changes have been made to the previously-approved plan, (2) the plan will remain in place for the upcoming State Fiscal Year. The notification must be signed and certified by an officer or director of the MCO that is responsible for carrying out the Fraud and Abuse compliance plan. Upon receipt of a written request from the HHSC OIG, the MCO must submit the complete Fraud and Abuse compliance plan. The MCO is subject to and must meet all requirements in Section 531.113 of the Texas Government Code, Section 533.012 of the Texas Government Code, Title 1 Texas Administrative Code (TAC), Part 15, Chapter 353, Subchapter F, Rule 353.501-353.505, and Title 1 Texas Administrative Code (TAC), Part 15, Chapter 370, Subchapter F, Rule 370.501-370.505 as well as all laws specified in Attachment A, Section 7.02. Failure to comply with any requirement of 8.1.19 and 8.1.20.2(c) and (d) subjects the MCO to enforcement pursuant to 1 TEX. ADMIN. CODE Chapter 371 Subchapter G in addition to any other legal remedy. Additional Requirements for STAR and STAR+PLUS MCOs: In accordance with Section 1902(a)(68) of the Social Security Act, STAR and STAR+PLUS MCOs and their Subcontractors that receive or make annual Medicaid payments of at least $5 million must:
Appears in 1 contract
Samples: Centene Corp
Fraud and Abuse. A MCO HMO is subject to all state and federal laws and regulations relating to Fraud, Abuse, and Waste in health care and the Medicaid and CHIP programs. The MCO HMO must cooperate and assist HHSC and any state or federal agency charged with the duty of identifying, investigating, sanctioning or prosecuting suspected Fraud, Abuse or Waste. In order to facilitate cooperation with the Office of Inspector General (OIG) at HHSC, the MCO The HMO must have staff available for Special Investigative Unit (SIU) representation located in the state. The MCO must allow access to premises and provide originals and/or copies of all records and information requested free of charge and allow access to premises and provide records to the Inspector General for the Texas Health and Human Services System, HHSC or its authorized agent(s), the Centers for Medicare and Medicaid Services (CMS), the U.S. Department of Health and Human Services (DHHS), Federal Bureau of Investigation, the Office of the Attorney General, TDI, or other units of state government. The HMO must provide all copies of records free of charge. Each MCO HMO must designate one primary and one secondary contact person for all HHSC OIG records requests. HHSC OIG records requests will be sent to the designated MCO HMO contact person(s) in writing via email, fax or regular mail, and will provide the specifics of the information being requested (see below). The MCO HMO will respond to the appropriate HHSC OIG staff member within the timeframe designated in the request. If the MCO HMO is unable to provide all of the requested information with in the designated timeframe, an extension may be granted and must be request in writing (email) by the MCO HMO no less than two (2) Business Days prior to the due date. When a request for data is provided to the MCOHMO, the MCOHMO's response must include data for all data fields, as available. If any data field is left blank, an explanation must accompany the response. The data must be provided in the order and format requested. The MCO HMO must not include any additional data fields in its response. All requested information must be accompanied by a notarized Business Records Affidavit unless indicated otherwise in HHSC OIG's record request. The most common requests will include: Ø 1099 data and other financial information - three five (35) Business Days. ØClaims Claims data for sampling - 5 20 Business Days. Ø Urgent claims data requests - three (3) 15 Business Days (with OIG manager's approval). Ø Provider education information - 10 Business Days. Ø Files associated with an HMO conducted investigation - 15 Business DaysDay. Ø Other time-sensitive requests - as needed. The HMO must submit a written Fraud and Abuse compliance plan to the Office of Inspector General at HHSC for approval each year. The plan must be submitted 60 days prior to the start of the State fiscal year. (See Attachment B-1, Section 7 for requirements regarding timeframes for submitting the original plan.) If an HMO has not made any changes to its plan from the previous year, it may notify the HHSC OIG that: (1) no changes have been made to the privously-approved plan, (2) the plan will remain in place for the upcoming State Fiscal Year. The notification must be signed and certified by an officer or director of the HMO that is responsible for carrying out the Fraud and Abuse compliance plan. Upon receipt of a written request from the HHSC OIG, the HMO must submit the complete Fraud and Abuse compliance plan. The HMO is subject to and must meet all requirements in Section 531.103 of the Texas Government Code, Title 1 Texas Administrative Code (TAC), Part 15, Chapter 353, Subchapter F, Rule 353.501-353.505, and Title 1 Texas Administrative Code (TAC), Part 15, Chapter 370, Subchapter F, Rule 370.501-370.505. Additional Requirements for STAR and STAR+PLUS HMOs: In accordance with Section 1902(a)(68) of the Social Security Act, STAR and STAR+PLUS HMOs that receive or make annual Medicaid payments of at least $5 million must:
Appears in 1 contract
Samples: Centene Corp
