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The Contractor shall comply with state and federal law and regulations, including, but not limited to, 42 CFR 433.32, 42 CFR 433.51, 42 CFR 431.800 et. seq., 42 CFR 440.230, 42 CFR 440.260, 42 CFR 455 et. seq., 42 CFR 456 et. seq., 42 CFR 456.23, 22 CCR 51490, 22 CCR 51490.1, 22 CCR 51341.1, 22 CCR 51159, WIC 14124.1, and WIC 14124.2; 42 CFR 438.600, 42 CFR 438.602, 42 CFR 438.608.\nB. The Contractor shall comply with the provisions of 42 CFR 438.600(a), (b), and (c), 438.604, 438.606 and 438.608, regarding the certification of accurate data submitted by the Contractor to DHCS and which require the Contractor to have administrative or management arrangements or procedures and a mandatory compliance plan designed to guard against fraud and abuse.\n1) The management arrangements or procedures shall include:\na) Written policies and procedures and standards of conduct that articulate the Contractor\u2019s commitment to comply with all applicable federal and State standards;\nb) The designation of a compliance officer and a compliance committee that are accountable to senior management;\nc) Effective training and education for the compliance officer, the Contractor\u2019s employees and all subcontractor;\nd) Effective lines of communication between the compliance officer and the Contractor\u2019s employees and subcontractor;\ne) Enforcement of standards through well publicized disciplinary guidelines;\nf) Provision for internal and subcontractor monitoring and auditing; and\ng) Provision for prompt response to detected offenses and for development of corrective action initiatives relating to this Agreement and any subcontracts relating to this Agreement,\ni. The Contractor\u2019s shall provide the following data certified by the Contractor\u2019s Chief Executive Officer, Chief Financial Officer or an individual who has delegated authority to sign for and reports directly to the CEO or CFO:\na. Enrollment information;\nb. Encounter data;\nc. Other information required by DHCS and contained in Intergovernmental Agreements, proposals and related documents for purposes of developing MCE payments; and\nd. The certification of this information must attest, based on best knowledge, information and belief as follows:\n(i) To the accuracy, completeness and truthfulness of the data;\n(ii) To the accuracy, completeness and truthfulness of the documents specified by DHCS; and\n(iii) The certification must be submitted concurrently with the certified data.\nC. The Contractor shall comply with the provisions of 42 CFR 438.610:\n1) The Contractor may not knowingly have a relationship of the type described in paragraph (2)(i) of this section with the following:\ni. An individual who is debarred, suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in nonprocurement activities under regulations issued under Executive Order No. 12549 or under guidelines implementing Executive Order No. 12549.\nii. An individual who is an affiliate, as defined in the Federal Acquisition Regulation, of a person described in paragraph (1)(i) of this section.", "hash": "bf8b44b4123c7e8ef3604f8f7236cd0e", "id": 1}, {"size": 5, "samples": [{"hash": "4KHZsm1I84k", "uri": "/contracts/4KHZsm1I84k#program-integrity-requirements", "label": "Standard Agreement", "score": 24.2766289934, "published": true}, {"hash": "8s7sNsMRsMj", "uri": "/contracts/8s7sNsMRsMj#program-integrity-requirements", "label": "Service Agreement", "score": 21.6386036961, "published": true}, {"hash": "khMqYkNGzE1", "uri": "/contracts/khMqYkNGzE1#program-integrity-requirements", "label": "Service Agreement", "score": 21.5509924709, "published": true}], "snippet_links": [{"key": "the-contractor-shall", "type": "clause", "offset": [3, 23]}, {"key": "the-provisions-of", "type": "clause", "offset": [36, 53]}, {"key": "certification-of", "type": "clause", "offset": [111, 127]}, {"key": "contractor-to", "type": "clause", "offset": [159, 172]}, {"key": "the-state", "type": "clause", "offset": [173, 182]}, {"key": "require-the", "type": "clause", "offset": [193, 204]}, {"key": "management-arrangements", "type": "definition", "offset": [242, 265]}, {"key": "fraud-and-abuse", "type": "clause", "offset": [306, 321]}, {"key": "relate-to", "type": "definition", "offset": [404, 413]}, {"key": "prohibited-affiliations", "type": "clause", "offset": [414, 437]}, {"key": "participating-in", "type": "definition", "offset": [532, 548]}, {"key": "activities-under", "type": "clause", "offset": [561, 577]}, {"key": "federal-acquisition-regulation", "type": "clause", "offset": [582, 612]}, {"key": "executive-order-no", "type": "clause", "offset": [696, 714]}, {"key": "the-guidelines", "type": "clause", "offset": [731, 745]}, {"key": "pursuant-to", "type": "definition", "offset": [789, 800]}, {"key": "with-providers", "type": "clause", "offset": [869, 883]}, {"key": "other-individuals", "type": "definition", "offset": [887, 904]}, {"key": "participation-in-federal-health-care-programs", "type": "clause", "offset": [932, 977]}, {"key": "defined-in-section", "type": "clause", "offset": [982, 1000]}, {"key": "social-security-act", "type": "clause", "offset": [1017, 1036]}, {"key": "not-available", "type": "definition", "offset": [1115, 1128]}, {"key": "for-providers", "type": "clause", "offset": [1150, 1163]}, {"key": "state-children", "type": "definition", "offset": [1203, 1217]}, {"key": "health-insurance-program", "type": "clause", "offset": [1220, 1244]}, {"key": "emergency-services", "type": "definition", "offset": [1257, 1275]}, {"key": "office-of-the-inspector-general", "type": "clause", "offset": [1324, 1355]}, {"key": "excluded-individuals", "type": "definition", "offset": [1366, 1386]}, {"key": "provider-list", "type": "definition", "offset": [1438, 1451]}, {"key": "employment-of", "type": "clause", "offset": [1476, 1489]}, {"key": "payments-to", "type": "definition", "offset": [1494, 1505]}, {"key": "prior-to", "type": "definition", "offset": [1607, 1615]}, {"key": "organizational-provider", "type": "definition", "offset": [1660, 1683]}, {"key": "the-provider", "type": "clause", "offset": [1688, 1700]}, {"key": "inappropriate-payments", "type": "definition", "offset": [1912, 1934]}, {"key": "subject-to", "type": "definition", "offset": [1958, 1968]}, {"key": "the-basis", "type": "clause", "offset": [1988, 1997]}, {"key": "other-sanctions", "type": "clause", "offset": [2002, 2017]}, {"key": "appropriate-authority", "type": "definition", "offset": [2025, 2046]}], "snippet": "A. The Contractor shall comply with the provisions of 42 C.F.R. \u00a7\u00a7 438.604, 438.606 and 438.608, regarding the certification of accurate data submitted by the Contractor to the State and which require the Contractor to have administrative or management arrangements or procedures designed to guard against fraud and abuse.\nB. The Contractor shall comply with the provisions of 42 C.F.R. \u00a7 438.610, which relate to prohibited affiliations with individuals or affiliates of individuals debarred, suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in non-procurement activities under regulations issued under Executive Order No. 12549 or under the guidelines implementing Executive Order No. 12549.\nC. Pursuant to 42 C.F.R. \u00a7 438.214(d), the Contractor shall not employ or contract with providers or other individuals and entities excluded from participation in federal health care programs (as defined in section 1128B(f) of the Social Security Act) under either Section 1128, 1128A, or 1156 of the Social Security Act. FFP is not available for amounts expended for providers excluded by Medicare, Medicaid, or the State Children's Health Insurance Program, except for emergency services.\nD. The Contractor shall periodically check the Office of the Inspector General\u2019s List of Excluded Individuals/Entities and the Medi-Cal Suspended and Ineligible Provider List (S & I List) to prevent employment of, or payments to, any individuals or entities on those lists, and per DMH Letter Number 10-05, this must be satisfied prior to Medi-Cal certification of any individual or organizational provider. If the provider is listed on either the Office of the Inspector General\u2019s List of Excluded Individuals/Entities or the Medi-Cal S & I List, the Contractor shall not certify or pay any provider with Medi-Cal funds, and any such inappropriate payments or overpayments may be subject to recovery and/or be the basis for other sanctions by the appropriate authority.", "hash": "c8c45ab5cea319421a2786b87fc1421d", "id": 2}, {"size": 2, "samples": [{"hash": "1KSdYqXPY61", "uri": "/contracts/1KSdYqXPY61#program-integrity-requirements", "label": "Behavioral Health Administrative Services Organization Contract", "score": 31.3217523115, "published": true}, {"hash": "jYM520jZKuk", "uri": "/contracts/jYM520jZKuk#program-integrity-requirements", "label": "Behavioral Health \u2013 Administrative Services Organization Contract", "score": 30.4540067886, "published": true}], "snippet_links": [{"key": "certified-peer-counselor", "type": "definition", "offset": [28, 52]}, {"key": "in-accordance-with", "type": "definition", "offset": [75, 93]}, {"key": "policy-requirements", "type": "definition", "offset": [109, 128]}, {"key": "approved-curriculum", "type": "definition", "offset": [153, 172]}], "snippet": "Ensure Contractor sponsored Certified Peer Counselor trainings are offered in accordance with DBHR policies. Policy requirements include the use of DBHR approved curriculum, trainers, testers and applicants.", "hash": "cccbfa46999ccfffd8bdd7977a63451c", "id": 3}, {"size": 2, "samples": [{"hash": "4A44WS1PSad", "uri": "/contracts/4A44WS1PSad#program-integrity-requirements", "label": "Single Case Agreement", "score": 36.0729434771, "published": true}], "snippet_links": [{"key": "provider-shall", "type": "clause", "offset": [0, 14]}, {"key": "comply-with", "type": "clause", "offset": [15, 26]}, {"key": "approved-program", "type": "clause", "offset": [43, 59]}, {"key": "policies-and-procedures", "type": "clause", "offset": [70, 93]}, {"key": "the-program", "type": "clause", "offset": [98, 109]}, {"key": "government-contract", "type": "definition", "offset": [140, 159]}, {"key": "not-limited", "type": "clause", "offset": [175, 186]}, {"key": "compliance-with-section", "type": "clause", "offset": [191, 214]}, {"key": "social-security-act", "type": "clause", "offset": [234, 253]}, {"key": "a-subcontractor", "type": "definition", "offset": [373, 388]}, {"key": "by-provider", "type": "clause", "offset": [463, 474]}, {"key": "medicaid-members", "type": "clause", "offset": [501, 517]}, {"key": "encounter-data", "type": "definition", "offset": [592, 606]}, {"key": "audits-and-investigations", "type": "clause", "offset": [644, 669]}, {"key": "downstream-entities", "type": "clause", "offset": [703, 722]}], "snippet": "Provider shall comply with Wellpoint's HCA approved program integrity policies and procedures and the program integrity requirements of the Government Contract including, but not limited to, compliance with section 1902(a)(68) of the Social Security Act, 42 C.F.R. \u00a7 438.610, 42 C.F.R. \u00a7455, 42 C.F.R. \u00a71000 through 1008 and Chapter 182-502A WAC. If Provider is defined as a subcontractor under the Government Contract, Provider shall verify that services billed by Provider were actually provided to Medicaid Members and shall conduct ongoing analysis of utilization, claims, billing and/or encounter data to detect overpayments and including audits and investigations of Provider's subcontractors and downstream entities.", "hash": "878f809fe475429cccf5d500ca8f9b7b", "id": 4}, {"size": 1, "samples": [{"hash": "kIAoJO4Ix6R", "uri": "/contracts/kIAoJO4Ix6R#program-integrity-requirements", "label": "Managed Care Contract", "score": 21.9125591053, "published": true}], "snippet_links": [{"key": "term-services-and-supports", "type": "clause", "offset": [5, 31]}, {"key": "availability-of", "type": "clause", "offset": [42, 57]}, {"key": "home-and-community-based-care", "type": "clause", "offset": [58, 87]}], "snippet": "Long-term services and supports including availability of home and community based care.", "hash": "429f6d937bb2a150c51cfcc2600b1593", "id": 5}, {"size": 1, "samples": [{"hash": "c8cBAlOAc7v", "uri": "/contracts/c8cBAlOAc7v#program-integrity-requirements", "label": "Management Services Agreement", "score": 33.9888091678, "published": true}], "snippet_links": [{"key": "agrees-to", "type": "clause", "offset": [14, 23]}, {"key": "the-program", "type": "clause", "offset": [36, 47]}, {"key": "exhibit-b", "type": "definition", "offset": [78, 87]}, {"key": "sections-11", "type": "clause", "offset": [97, 108]}, {"key": "this-exhibit", "type": "definition", "offset": [141, 153]}, {"key": "to-the-extent", "type": "clause", "offset": [174, 187]}, {"key": "scope-of-work", "type": "definition", "offset": [218, 231]}], "snippet": "Subcontractor agrees to comply with the Program Integrity requirements listed Exhibit B, Part 9, Sections 11-18 which is summarized above in this Exhibit under Section 6(h), to the extent they apply to Subcontractor\u2019s scope of work under this Exhibit.", "hash": 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"offset": [3971, 4000]}, {"key": "covered-by", "type": "definition", "offset": [4080, 4090]}, {"key": "provider-overpayments", "type": "clause", "offset": [4211, 4232]}, {"key": "receipt-of", "type": "clause", "offset": [4299, 4309]}, {"key": "employee-education-about-false-claims-laws", "type": "clause", "offset": [4402, 4444]}, {"key": "for-employee", "type": "clause", "offset": [4506, 4518]}, {"key": "if-the-contractor", "type": "clause", "offset": [4580, 4597]}, {"key": "payments-in", "type": "clause", "offset": [4624, 4635]}, {"key": "federal-fiscal-year", "type": "clause", "offset": [4687, 4706]}, {"key": "subject-to", "type": "definition", "offset": [4732, 4742]}, {"key": "the-contractor-must", "type": "clause", "offset": [4770, 4789]}, {"key": "before-april", "type": "clause", "offset": [4800, 4812]}, {"key": "contract-year", "type": "definition", "offset": [4826, 4839]}, {"key": "as-specified", "type": "clause", "offset": [4860, 4872]}, {"key": "written-certification", "type": "clause", "offset": [4891, 4912]}, {"key": "available-to", "type": "definition", "offset": [5051, 5063]}, {"key": "upon-request", "type": "definition", "offset": [5071, 5083]}, {"key": "a-copy-of", "type": "clause", "offset": [5085, 5094]}, {"key": "employee-handbook", "type": "clause", "offset": [5173, 5190]}, {"key": "other-information", "type": "definition", "offset": [5201, 5218]}, {"key": "failure-to-comply-with-this-section", "type": "clause", "offset": [5383, 5418]}, {"key": "intermediate-sanctions", "type": "definition", "offset": [5433, 5455]}], "snippet": "A. Program Integrity Requirements In accordance with 42 CFR 438.608, the Contractor shall have administrative and management arrangements or procedures, including a mandatory compliance plan, which is designed to guard against fraud and abuse. The compliance plan must be submitted to EOHHS annually on the anniversary of the contract start date. The arrangements or procedures must include the following:\n1. Written policies, procedures, and standards of conduct that articulate the Contractor\u2019s commitment to comply with all applicable federal and state standards;\n2. Provision for internal monitoring and auditing;\n3. Provision for prompt response to detected offenses, and for development of corrective action initiatives;\n4. The designation of a compliance officer and a compliance committee that are accountable to senior management;\n5. Effective training and education for the compliance officer and the Contractor's employees;\n6. Effective lines of communication between the compliance officer and the Contractor\u2019s employees; and,\n7. Enforcement of standards through well-publicized disciplinary guidelines.\nB. Fraud and Abuse Prevention, Detection and Reporting The Contractor shall:\n1. Develop a comprehensive internal fraud and abuse program, as part of the Contractor\u2019s compliance program to prevent and detect program violations;\n2. Not discriminate against an employee for reporting a fraudulent activity or for cooperating in any government or law enforcement authority\u2019s investigation or prosecution In conformance with MGL c. 12, \u00a75J;\n3. Upon a Complaint of fraud or abuse from any source or upon identifying any questionable practices, conduct a preliminary review to determine whether in the Contractor\u2019s judgment, there is reason to believe that a Provider, an Enrollee, or a Contractor employee, has engaged in fraud or abuse. For each complaint of fraud and abuse that warrants a preliminary investigation, report to EOHHS the name and identification number of the Enrollee/Provider, the source of the complaint; the type of Provider; the nature of the complaint; the approximate dollars involved and the legal and administrative disposition of the preliminary investigation;\n4. Make diligent efforts to avoid or recover any improper payments or funds misspent due to fraudulent or abusive actions by the Contractor, or its parent organization, its Providers or its Subcontractors;\n5. Require Providers to implement corrective actions or terminate Provider agreements, as appropriate;\n6. Notify EOHHS in writing within ten (10) calendar days if it or, where applicable, any of its Subcontractors receive or identify any information that gives them reason to suspect that a MassHealth Provider or Member has engaged in fraud as defined under 42 CFR 455.2. In the event of suspected fraud, no further contact shall be initiated with the Provider or Member on that specific matter without EOHHS\u2019s approval; and\n7. The Contractor and, where applicable, its Subcontractors shall cooperate fully with the Office of the Attorney General\u2019s Medicaid Fraud Control Unit (MFCU) and the Office of the State Auditor\u2019s Bureau of Special Investigations (BSI). Such cooperation shall, include, but not be limited to, providing at no charge, prompt access and copies of any documents and other available information determined necessary by such agencies to carry out their responsibilities regarding Medicaid fraud and abuse, maintaining the confidentiality of any such investigations, and making knowledgeable staff available at no charge to support any investigation, court, or administrative proceeding.\n8. Submit on an annual basis a fraud and abuse report according to the format specified by EOHHS, and submit ad hoc reports as needed, or as requested by EOHHS in accordance with Appendix D.\u201d\n9. Have the CEO or CFO certify in writing on an annual basis to EOHHS that after a diligent inquiry, to the best of his/her knowledge and belief, the Contractor is in compliance with this Contract and has not been made aware of any instances of Fraud and Abuse in any program covered by this Contract, other than those that have been reported by the Contractor in writing to EOHHS.\u201d\n10. Notify EOHHS of all Provider overpayments above $75,000, or any voluntary Provider disclosures resulting in receipt of overpayments in excess of $75,000, even if there is no suspicion of fraudulent activity.\nC. Employee Education about False Claims Laws\n1. The Contractor shall comply with all federal requirements for employee education about false claims laws under 42 USC \u00a71396a(a)(68) if the Contractor received or made Medicaid payments in the amount of at least $5 million during the prior Federal fiscal year.\n2. If the Contractor is subject to such federal requirements, the Contractor must:\na. On or before April 30th of each Contract Year, or such other date as specified by EOHHS, provide written certification, in a form acceptable to EOHHS and signed under the pains and penalties of perjury, of compliance with such federal requirements;\nb. Make available to EOHHS, upon request, a copy of all written policies implemented in accordance with 42 USC \u00a71396a(a)(68), any employee handbook, and such other information as EOHHS may deem necessary to determine compliance; and\nc. Initiate such corrective action as EOHHS deems appropriate to comply with such federal requirements.\n3. Failure to comply with this section may result in intermediate sanctions in accordance with this Contract.", "hash": "f63d73f4b70c1d9226931c581e5dc205", "id": 7}, {"size": 1, "samples": [{"hash": "1v0WxX9NAv8", "uri": "/contracts/1v0WxX9NAv8#program-integrity-requirements", "label": "Masshealth Managed Care Organization Contract", "score": 31.3353543466, "published": true}], "snippet_links": [{"key": "program-integrity-requirements-the-contractor-shall", "type": "clause", "offset": [0, 51]}, {"key": "general-provisions", "type": "clause", "offset": [56, 74]}, {"key": "comply-with", "type": "clause", "offset": [78, 89]}, {"key": "state-program", "type": "clause", "offset": [117, 130]}, {"key": "laws-and-regulations", "type": "definition", "offset": [141, 161]}, {"key": "not-limited", "type": "clause", "offset": [210, 221]}, {"key": "social-security-act", "type": "clause", "offset": [230, 249]}, {"key": "staffing-and-resources", "type": "clause", "offset": [323, 345]}, {"key": "assist-the", "type": "clause", "offset": [349, 359]}, {"key": "for-the-contractor", "type": "definition", "offset": [479, 497]}, {"key": "state-and-federal-regulations", "type": "clause", "offset": [536, 565]}, {"key": "internal-controls", "type": "definition", "offset": [609, 626]}, {"key": "policies-and-procedures", "type": "clause", "offset": [631, 654]}, {"key": "in-place", "type": "definition", "offset": [655, 663]}, {"key": "suspected-fraud", "type": "definition", "offset": [751, 766]}, {"key": "in-accordance-with", "type": "definition", "offset": [799, 817]}, {"key": "act-of-2005", "type": "definition", "offset": [864, 875]}, {"key": "make-available", "type": "definition", "offset": [877, 891]}, {"key": "fraud-and-abuse", "type": "clause", "offset": [900, 915]}, {"key": "all-employees", "type": "definition", "offset": [928, 941]}, {"key": "if-the-contractor", "type": "clause", "offset": [943, 960]}, {"key": "employee-handbook", "type": "clause", "offset": [968, 985]}, {"key": "specific-information", "type": "clause", "offset": [1016, 1036]}, {"key": "rights-of-employees", "type": "clause", "offset": [1092, 1111]}, {"key": "to-discuss", "type": "definition", "offset": [1185, 1195]}, {"key": "requirements-for-providers", "type": "definition", "offset": [1313, 1339]}, {"key": "as-specified", "type": "clause", "offset": [1341, 1353]}, {"key": "national-correct-coding-initiative", "type": "clause", "offset": [1406, 1440]}, {"key": "claims-processing", "type": "clause", "offset": [1460, 1477]}, {"key": "provider-reimbursement", "type": "clause", "offset": [1478, 1500]}, {"key": "compliance-plan", "type": "clause", "offset": [1513, 1528]}, {"key": "program-plan", "type": "definition", "offset": [1632, 1644]}, {"key": "copies-of", "type": "definition", "offset": [1678, 1687]}, {"key": "form-and-format", "type": "clause", "offset": [1727, 1742]}, {"key": "appendix-a", "type": "clause", "offset": [1782, 1792]}, {"key": "contract-operational-start-date", "type": "clause", "offset": [1801, 1832]}, {"key": "requested-by", "type": "definition", "offset": [1902, 1914]}, {"key": "within-thirty", "type": "clause", "offset": [1921, 1934]}], "snippet": "Program Integrity Requirements The Contractor shall:\n1) General Provisions\na) Comply with all applicable federal and state program integrity laws and regulations regarding fraud, waste and abuse, including but not limited to, the Social Security Act and 42 CFR Parts 438, 455, and 456.\nb) Have adequate Massachusetts-based staffing and resources to assist the Contractor in preventing and detecting potential fraud, waste and abuse. Staff conducting program integrity activities for the Contractor shall be familiar with MassHealth and state and federal regulations on fraud, waste and abuse.\nc) Have written internal controls and policies and procedures in place that are designed to prevent, detect, reduce, investigate, correct and report known or suspected fraud, waste and abuse activities.\nd) In accordance with Section 6032 of the federal Deficit Reduction Act of 2005, make available written fraud and abuse policies to all employees. If the Contractor has an employee handbook, the Contractor shall include specific information about Section 6032, the Contractor\u2019s policies, and the rights of employees to be protected as whistleblowers.\ne) Meet with EOHHS at least quarterly to discuss fraud, waste and abuse, audits, and overpayment issues.\nf) At EOHHS\u2019 discretion, implement certain program integrity requirements for providers, as specified by EOHHS, including but not limited to implementing National Correct Coding Initiative edits or other CMS claims processing/provider reimbursement manuals;\n2) Compliance Plan and Anti-Fraud, Waste, and Abuse Plan Have in place a Compliance Plan and Anti-Fraud, Waste, and Abuse Program Plan in accordance with this Section, copies of which shall be provided to EOHHS, in a form and format specified by EOHHS, in accordance with Appendix A, by the Contract Operational Start Date and annually thereafter. The Contractor shall make any modifications requested by EOHHS within thirty", "hash": "d5f4fff5ea7fec9e3b99d963a8bf1d97", "id": 8}, {"size": 1, "samples": [{"hash": "7522XeYYVYP", "uri": "/contracts/7522XeYYVYP#program-integrity-requirements", "label": "Contract for Senior Care Organizations", "score": 19.4572210815, "published": true}], "snippet_links": [{"key": "written-policies", "type": "clause", "offset": [37, 53]}, {"key": "standards-of-conduct", "type": "clause", "offset": [71, 91]}, {"key": "commitment-to", "type": "clause", "offset": [125, 138]}, {"key": "comply-with", "type": "clause", "offset": [139, 150]}, {"key": "federal-and-state-standards", "type": "clause", "offset": [166, 193]}, {"key": "internal-monitoring-and-auditing", "type": "clause", "offset": [212, 244]}, {"key": "prompt-response", "type": "clause", "offset": [263, 278]}, {"key": "development-of", "type": "clause", "offset": [309, 323]}, {"key": "designation-of-a", "type": "clause", "offset": [362, 378]}, {"key": "compliance-officer", "type": "clause", "offset": [379, 397]}, {"key": "compliance-committee", "type": "definition", "offset": [404, 424]}, {"key": "senior-management", "type": "clause", "offset": [449, 466]}, {"key": "training-and-education", "type": "definition", "offset": [481, 503]}, {"key": "and-the-contractor", "type": "clause", "offset": [531, 549]}, {"key": "lines-of-communication", "type": "clause", "offset": [576, 598]}, {"key": "enforcement-of-standards", "type": "clause", "offset": [670, 694]}, {"key": "disciplinary-guidelines", "type": "clause", "offset": [719, 742]}, {"key": "fraud-and-abuse-prevention", "type": "clause", "offset": [747, 773]}, {"key": "fraud-and-abuse-program", "type": "clause", "offset": [835, 858]}, {"key": "of-the-contractor", "type": "clause", "offset": [868, 885]}, {"key": "compliance-program", "type": "definition", "offset": [888, 906]}, {"key": "discriminate-against", "type": "definition", "offset": [956, 976]}, {"key": "an-employee", "type": "clause", "offset": [977, 988]}, {"key": "fraudulent-activity", "type": "clause", "offset": [1005, 1024]}, {"key": "enforcement-authority", "type": "clause", "offset": [1069, 1090]}, {"key": "fraud-or-abuse", "type": "clause", "offset": [1184, 1198]}, {"key": "determine-whether", "type": "clause", "offset": [1295, 1312]}, {"key": "reason-to-believe", "type": "definition", "offset": [1352, 1369]}, {"key": "contractor-employee", "type": "definition", "offset": [1405, 1424]}, {"key": "engaged-in", "type": "definition", "offset": [1430, 1440]}, {"key": "preliminary-investigation", "type": "clause", "offset": [1511, 1536]}, {"key": "report-to", "type": "definition", "offset": [1538, 1547]}, {"key": "number-of", "type": "clause", "offset": [1582, 1591]}, {"key": "source-of", "type": "definition", "offset": [1619, 1628]}, {"key": "type-of", "type": "definition", "offset": [1648, 1655]}, {"key": "nature-of-the", "type": "clause", "offset": [1670, 1683]}, {"key": "disposition-of", "type": "clause", "offset": [1761, 1775]}, {"key": "the-preliminary", "type": "clause", "offset": [1776, 1791]}, {"key": "diligent-efforts", "type": "definition", "offset": [1815, 1831]}, {"key": "improper-payments", "type": "definition", "offset": [1856, 1873]}, {"key": "by-the-contractor", "type": "clause", "offset": [1929, 1946]}, {"key": "parent-organization", "type": "definition", "offset": [1955, 1974]}, {"key": "corrective-actions", "type": "definition", "offset": [2047, 2065]}, {"key": "provider-agreements", "type": "clause", "offset": [2079, 2098]}, {"key": "in-writing", "type": "clause", "offset": [2132, 2142]}, {"key": "calendar-days", "type": "definition", "offset": [2159, 2172]}, {"key": "where-applicable", "type": "clause", "offset": [2183, 2199]}, {"key": "reason-to-suspect", "type": "definition", "offset": [2279, 2296]}, {"key": "in-the-event-of", "type": "definition", "offset": [2386, 2401]}, {"key": "suspected-fraud", "type": "definition", "offset": [2402, 2417]}, {"key": "no-further-contact", "type": "definition", "offset": [2419, 2437]}, {"key": "the-provider", "type": "clause", "offset": [2462, 2474]}, {"key": "office-of-the-attorney-general", "type": "definition", "offset": [2630, 2660]}, {"key": "medicaid-fraud-control-unit", "type": "definition", "offset": [2663, 2690]}, {"key": "state-auditor", "type": "definition", "offset": [2720, 2733]}, {"key": "special-investigations", "type": "clause", "offset": [2746, 2768]}, {"key": "no-charge", "type": "clause", "offset": [2845, 2854]}, {"key": "copies-of", "type": "definition", "offset": [2874, 2883]}, {"key": "documents-and-other", "type": "clause", "offset": [2888, 2907]}, {"key": "available-information", "type": "clause", "offset": [2908, 2929]}, {"key": "available-at", "type": "definition", "offset": [3131, 3143]}, {"key": "administrative-proceeding", "type": "definition", "offset": [3194, 3219]}], "snippet": "A. Program Integrity Requirements\n1. Written policies, procedures, and standards of conduct that articulate the Contractor\u2019s commitment to comply with all applicable federal and state standards;\n2. Provision for internal monitoring and auditing;\n3. Provision for prompt response to detected offenses, and for development of corrective action initiatives;\n4. The designation of a compliance officer and a compliance committee that are accountable to senior management;\n5. Effective training and education for the compliance officer and the Contractor's employees;\n6. Effective lines of communication between the compliance officer and the Contractor\u2019s employees; and,\n7. Enforcement of standards through well-publicized disciplinary guidelines.\nB. Fraud and Abuse Prevention, Detection and Reporting\n1. Develop a comprehensive internal fraud and abuse program, as part of the Contractor\u2019s compliance program to prevent and detect program violations;\n2. Not discriminate against an employee for reporting a fraudulent activity or for cooperating in any government or law enforcement authority\u2019s investigation or prosecution In conformance with M.G.L. c. 12, \u00a75J;\n3. Upon a Complaint of fraud or abuse from any source or upon identifying any questionable practices, conduct a preliminary review to determine whether in the Contractor\u2019s judgment, there is reason to believe that a Provider, an Enrollee, or a Contractor employee, has engaged in fraud or abuse. For each complaint of fraud and abuse that warrants a preliminary investigation, report to EOHHS the name and identification number of the Enrollee/Provider, the source of the complaint; the type of Provider; the nature of the complaint; the approximate dollars involved and the legal and administrative disposition of the preliminary investigation;\n4. Make diligent efforts to avoid or recover any improper payments or funds misspent due to fraudulent or abusive actions by the Contractor, or its parent organization, its Providers or its Subcontractors;\n5. Require Providers to implement corrective actions or terminate Provider agreements, as appropriate;\n6. Notify EOHHS in writing within ten (10) calendar days if it or, where applicable, any of its Subcontractors receive or identify any information that gives them reason to suspect that a MassHealth Provider or Member has engaged in fraud as defined under 42 CFR 455.2. In the event of suspected fraud, no further contact shall be initiated with the Provider or Member on that specific matter without EOHHS\u2019s approval; and\n7. The Contractor and, where applicable, its Subcontractors shall cooperate fully with the Office of the Attorney General\u2019s Medicaid Fraud Control Unit (MFCU) and the Office of the State Auditor\u2019s Bureau of Special Investigations (BSI). Such cooperation shall, include, but not be limited to, providing at no charge, prompt access and copies of any documents and other available information determined necessary by such agencies to carry out their responsibilities regarding Medicaid fraud and abuse, maintaining the confidentiality of any such investigations, and making knowledgeable staff available at no charge to support any investigation, court, or administrative proceeding.", "hash": "4d41b0fe46e342c1b8e0bef5f8583b40", "id": 9}, {"size": 1, "samples": [{"hash": "jb7nNLewkAG", "uri": "/contracts/jb7nNLewkAG#program-integrity-requirements", "label": "Program Specifications", "score": 21.5653661875, "published": true}], "snippet_links": [{"key": "federal-law-and-regulations", "type": "clause", "offset": [29, 56]}, {"key": "not-limited", "type": "clause", "offset": [73, 84]}, {"key": "the-contractor-shall", "type": "clause", "offset": [374, 394]}, {"key": "the-provisions-of", "type": "clause", "offset": [407, 424]}, {"key": "certification-of", "type": "clause", "offset": [482, 498]}, {"key": "contractor-to", "type": "clause", "offset": [530, 543]}, {"key": "the-state", "type": "clause", "offset": [544, 553]}, {"key": "require-the", "type": "clause", "offset": [564, 575]}, {"key": "management-arrangements", "type": "definition", "offset": [613, 636]}, {"key": "fraud-and-abuse", "type": "clause", "offset": [677, 692]}, {"key": "relate-to", "type": "definition", "offset": [775, 784]}, {"key": "prohibited-affiliations", "type": "clause", "offset": [785, 808]}, {"key": "participating-in", "type": "definition", "offset": [903, 919]}, {"key": "activities-under", "type": "clause", "offset": [932, 948]}, {"key": "federal-acquisition-regulation", "type": "clause", "offset": [953, 983]}, {"key": "executive-order-no", "type": "clause", "offset": [1067, 1085]}, {"key": "the-guidelines", "type": "clause", "offset": [1102, 1116]}, {"key": "pursuant-to", "type": "definition", "offset": [1160, 1171]}, {"key": "with-providers", "type": "clause", "offset": [1240, 1254]}, {"key": "other-individuals", "type": "definition", "offset": [1258, 1275]}, {"key": "participation-in-federal-health-care-programs", "type": "clause", "offset": [1303, 1348]}, {"key": "defined-in-section", "type": "clause", "offset": [1353, 1371]}, {"key": "social-security-act", "type": "clause", "offset": [1388, 1407]}, {"key": "not-available", "type": "definition", "offset": [1486, 1499]}, {"key": "for-providers", "type": "clause", "offset": [1521, 1534]}, {"key": "state-children", "type": "definition", "offset": [1574, 1588]}, {"key": "health-insurance-program", "type": "clause", "offset": [1591, 1615]}, {"key": "emergency-services", "type": "definition", "offset": [1628, 1646]}, {"key": "office-of-the-inspector-general", "type": "clause", "offset": [1695, 1726]}, {"key": "excluded-individuals", "type": "definition", "offset": [1737, 1757]}, {"key": "provider-list", "type": "definition", "offset": [1809, 1822]}, {"key": "employment-of", "type": "clause", "offset": [1847, 1860]}, {"key": "payments-to", "type": "definition", "offset": [1865, 1876]}, {"key": "prior-to", "type": "definition", "offset": [1978, 1986]}, {"key": "organizational-provider", "type": "definition", "offset": [2031, 2054]}, {"key": "the-provider", "type": "clause", "offset": [2059, 2071]}, {"key": "inappropriate-payments", "type": "definition", "offset": [2283, 2305]}, {"key": "subject-to", "type": "definition", "offset": [2329, 2339]}, {"key": "the-basis", "type": "clause", "offset": [2359, 2368]}, {"key": "other-sanctions", "type": "clause", "offset": [2373, 2388]}, {"key": "appropriate-authority", "type": "definition", "offset": [2396, 2417]}], "snippet": "A. Compliance with state and federal law and regulations, including, but not limited to, 42 CFR 433.32, 42 CFR 433.51, 42 CFR 431.800 et. seq., 42 CFR 440.230, 42 CFR 440.260, 42 CFR 455 et. seq., 42 CFR 456 et. seq., 42 CFR 456.23, 22 CCR 51490, 22 CCR 51490.1, 22 CCR 51341.1, 22 CCR 51159, WIC 14124.1, and WIC 14124.2; 42 CFR 438.600, 42 CFR 438.602, 42 CFR 438.608.\nB. The Contractor shall comply with the provisions of 42 C.F.R. \u00a7\u00a7 438.604, 438.606 and 438.608, regarding the certification of accurate data submitted by the Contractor to the State and which require the Contractor to have administrative or management arrangements or procedures designed to guard against fraud and abuse.\nC. The Contractor shall comply with the provisions of 42 C.F.R. \u00a7 438.610, which relate to prohibited affiliations with individuals or affiliates of individuals debarred, suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in non-procurement activities under regulations issued under Executive Order No. 12549 or under the guidelines implementing Executive Order No. 12549.\nD. Pursuant to 42 C.F.R. \u00a7 438.214(d), the Contractor shall not employ or contract with providers or other individuals and entities excluded from participation in federal health care programs (as defined in section 1128B(f) of the Social Security Act) under either Section 1128, 1128A, or 1156 of the Social Security Act. FFP is not available for amounts expended for providers excluded by Medicare, Medicaid, or the State Children's Health Insurance Program, except for emergency services.\nE. The Contractor shall periodically check the Office of the Inspector General\u2019s List of Excluded Individuals/Entities and the Medi-Cal Suspended and Ineligible Provider List (S & I List) to prevent employment of, or payments to, any individuals or entities on those lists, and per DMH Letter Number 10-05, this must be satisfied prior to Medi-Cal certification of any individual or organizational provider. If the provider is listed on either the Office of the Inspector General\u2019s List of Excluded Individuals/Entities or the Medi-Cal S & I List, the Contractor shall not certify or pay any provider with Medi-Cal funds, and any such inappropriate payments or overpayments may be subject to recovery and/or be the basis for other sanctions by the appropriate authority.", "hash": "f5623d6f15fdea32c95037b21f838f79", "id": 10}], "next_curs": "CmcSYWoVc35sYXdpbnNpZGVyY29udHJhY3RzckMLEhZDbGF1c2VTbmlwcGV0R3JvdXBfdjU2Iidwcm9ncmFtLWludGVncml0eS1yZXF1aXJlbWVudHMjMDAwMDAwMGEMogECZW4YACAA", "clause": {"parents": [["performance-evaluation", "PERFORMANCE EVALUATION"], ["administration-and-contract-management", "Administration and Contract Management"], ["laws-and-regulations", "Laws and Regulations"], ["contractor-responsibilities", "Contractor Responsibilities"], ["compliance-with-state-regulatory-requirements", "Compliance With State Regulatory Requirements"]], "title": "Program Integrity Requirements", "children": [["", ""], ["service-verification", "Service Verification"], ["employee-handbook", "Employee Handbook"], ["prohibition", "Prohibition"], ["non-profit-entities", "Non-Profit Entities"]], "size": 46, "id": "program-integrity-requirements", "related": [["accessibility-requirements", "Accessibility Requirements", "Accessibility Requirements"], ["e-verify-requirements", "E-Verify Requirements", "E-Verify Requirements"], ["program-requirements", "Program Requirements", "Program Requirements"], ["city-requirements", "City Requirements", "City Requirements"], ["quality-requirements", "Quality Requirements", "Quality Requirements"]], "related_snippets": [], "updated": "2025-07-07T12:37:48+00:00", "also_ask": [], "drafting_tip": "", "explanation": "The Program Integrity Requirements clause establishes standards and procedures to ensure that a program operates ethically, transparently, and in compliance with applicable laws and regulations. It typically requires parties to implement controls such as regular audits, reporting mechanisms, and staff training to prevent fraud, waste, or abuse within the program. By setting these expectations, the clause helps maintain trust in the program\u2019s operations and mitigates the risk of misconduct or regulatory violations."}, "json": true, "cursor": ""}}