Common use of Category 2 Clause in Contracts

Category 2. 23.3.1 Liquidated damages up to $25,000 per violation may be imposed for the Category 2 events. For Category 2 events, the Contractor shall submit a written CAPA/PC to DCH for review and approval prior to implementing the corrective action. Category 2 events are monitored by DCH to determine compliance and include the following: · Substantial failure to provide medically necessary services that the Contractor is required to provide under law, or under this Contract, to a Member covered under this Contract; · Misrepresentation or falsification of information furnished to a Member, Potential Member, or health care Provider; · Failure to comply with the requirements for physician incentive plans, as set forth in 42 CFR 422.208 and 422.210; · Distribution directly, or indirectly, through any Agent or independent contractor, marketing materials that have not been approved by the State or that contain false or materially misleading information; · Violation of any other applicable requirements of section 1903(m) or 1932 of the Social Security Act and any implementing regulations; · Failure of the Contractor to assume full operation of its duties under this Contract in accordance with the transition timeframes specified herein; · Imposition of premiums or charges on Members that are in excess of the premiums or charges permitted under the Medicaid program (the State will deduct the amount of the overcharge and return it to the affected Member). · Failure to resolve Member Appeals and Grievances within the timeframes specified in this Contract; · Failure to ensure client confidentiality in accordance with 45 CFR 160 and 45 CFR 164; and an incident of noncompliance will be assessed as per member and/or per HIPAA regulatory violation. · Violation of a subcontracting requirement in the Contract.

Category 2. 23.3.1 Liquidated damages up to $25,000 per violation may be imposed for the Category 2 events. For Category 2 events, the Contractor shall submit a written CAPA/PC to DCH for review and approval prior to implementing the corrective action. Category 2 events are monitored by DCH to determine compliance and include the following: · Substantial failure to provide medically necessary services that the Contractor is required to provide under law, or under this Contract, to a Member covered under this Contract; · Misrepresentation or falsification of information furnished to a Member, Potential Member, or health care Provider; · Failure to comply with the requirements for physician incentive plans, as set forth in 42 CFR 422.208 and 422.210; · Distribution directly, or indirectly, through any Agent or independent contractor, marketing materials that have not been approved by the State or that contain false or materially misleading information; · Violation of any other applicable requirements of section 1903(m) or 1932 of the Social Security Act and any implementing regulations; · Failure of the Contractor to assume full operation of its duties under this Contract in accordance with the transition timeframes specified herein; · Imposition of premiums or charges on Members that are in excess of the premiums or charges permitted under the Medicaid program (the State will deduct the amount of the overcharge and return it to the affected Member). · Failure to resolve Member Appeals and Grievances within the timeframes specified in this Contract; 215 · Failure to ensure client confidentiality in accordance with 45 CFR 160 and 45 CFR 164; and an incident of noncompliance will be assessed as per member and/or per HIPAA regulatory violation. · Violation of a subcontracting requirement in the Contract.

Category 2. 23.3.1 Liquidated damages up to $25,000 per violation may be imposed for the Category 2 events. For Category 2 events, the Contractor shall submit a written CAPA/PC to DCH for review and approval prior to implementing the corrective action. Category 2 events are monitored by DCH to determine compliance and include the following: · • Substantial failure to provide medically necessary services that the Contractor is required to provide under law, or under this Contract, to a Member covered under this Contract; · • Misrepresentation or falsification of information furnished to a Member, Potential Member, or health care Provider; · • Failure to comply with the requirements for physician incentive plans, as set forth in 42 CFR 422.208 and 422.210; · • Distribution directly, or indirectly, through any Agent or independent contractor, marketing materials that have not been approved by the State or that contain false or materially misleading information; · • Violation of any other applicable requirements of section 1903(m) or 1932 of the Social Security Act and any implementing regulations; · • Failure of the Contractor to assume full operation of its duties under this Contract in accordance with the transition timeframes specified herein; · • Imposition of premiums or charges on Members that are in excess of the premiums or charges permitted under the Medicaid program (the State will deduct the amount of the overcharge and return it to the affected Member). · 145 • Failure to resolve Member Appeals and Grievances within the timeframes specified in this Contract; · • Failure to ensure client confidentiality in accordance with 45 CFR 160 and 45 CFR 164; and an incident of noncompliance will be assessed as per member and/or per HIPAA regulatory violation. · • Violation of a subcontracting requirement in the Contract.