Common use of Fraud, Waste, and Abuse Clause in Contracts

Fraud, Waste, and Abuse. 1. The provider/subcontractor agrees to assist the Contractor as necessary in meeting its obligations under its contract with the State to identify, investigate, and take appropriate corrective action against fraud, waste, and/or abuse (as defined in 42 CFR 455.2) in the provision of health care services. 2. If the State has withheld payment and/or initiated a recovery action against the provider/subcontractor, or withheld payments pursuant to 42 CFR 455.23 and NJAC 10:49-9.10(a), the Contractor shall have the right to withhold payments from the provider/subcontractor and/or forward those payments to the State. 3. The Contractor and its providers, and subcontractors, whether or not they are enrolled Medicaid providers, shall cooperate fully with state and federal oversight and prosecutorial agencies, including but not limited to, DMAHS, MFD, DOH, MFCU, HHS-OIG, FBI, DEA, FDA, and the U.S. Attorney’s Office. The Contractor shall include language in its contracts with its providers and subcontractors, requiring cooperation, and stating that a failure to cooperate shall be grounds for termination of the Contractor’s agreement with the provider or subcontractor. Such cooperation shall include providing access to all necessary recipient information, medical and clinical information, correspondence, documents, computer files, and appropriate staff. 4. MFD shall have the right to recover directly from providers and enrollees in the Contractor’s network for the audits and investigations MFD solely conducts. Such money that MFD recovers directly shall not be shared with the Contractor, but reported to DMAHS in the format that the Contractor reports its recoveries to DMAHS. In addition, as a part of its recovery process, MFD shall have the right to request the Contractor to withhold payment to a provider in its network as a result of an MFD audit or investigation of managed care claims. Money withheld from a provider by the Contractor shall be sent to MFD from the Contractor and reported to DMAHS in the format that the Contractor reports its recoveries to DMAHS. 5. The Contractor shall have the right to recover directly from providers and enrollees in the Contractor’s network for the audits and investigations the Contractor solely conducts.

Fraud, Waste, and Abuse. 1. The provider/subcontractor agrees to assist the Contractor as necessary in meeting its obligations under its contract with the State to identify, investigate, and take appropriate corrective action against fraud, waste, and/or abuse (as defined in 42 CFR 455.2) in the provision of health care services. 2. If the State has withheld payment and/or initiated a recovery action against the provider/subcontractor, or withheld payments pursuant to 42 CFR 455.23 and NJAC 10:49-9.10(a), the Contractor shall have the right to withhold payments from the provider/subcontractor and/or forward those payments to the State. 3. The Contractor and its providers, and subcontractors, whether or not they are enrolled Medicaid providers, shall cooperate fully with state and federal oversight and prosecutorial agencies, including but not limited to, DMAHS, MFD, DOH, MFCU, HHS-OIG, FBI, DEA, FDA, and the U.S. Attorney’s Office. The Contractor shall include language in its contracts with its providers and subcontractors, requiring cooperation, and stating that a failure to cooperate shall be grounds for termination of the Contractor’s agreement with the provider or subcontractor. Such cooperation shall include providing access to all necessary recipient information, medical and clinical information, correspondence, documents, computer files, and appropriate staff. 4. MFD shall have the right to recover directly from providers and enrollees in the Contractor’s network for the audits and investigations MFD solely conducts. Such money that MFD recovers directly shall not be shared with the Contractor, but reported to DMAHS in the format that the Contractor reports its recoveries to DMAHS. In addition, as a part of its recovery process, MFD shall have the right to request the Contractor to withhold payment to a provider in its network as a result of an MFD audit or investigation of managed care claims. Money withheld from a provider by the Contractor shall be sent to MFD from the Contractor and reported to DMAHS in the format that the Contractor reports its recoveries to DMAHS. 5. The Contractor shall have the right to recover directly from providers and enrollees in the Contractor’s network for the audits and investigations the Contractor solely conducts. 6. The Contractor shall have a nationally recognized standard criteria for inpatient hospital admissions that shall substantially conform to the Milliman Care Guidelines (MCG). The Contractor shall inform and include in all provider contracts for network provider hospitals or clinical care review team subcontractors, that for purposes of audits of inpatient hospital admissions by DMAHS or MFD or its subcontractors, MCG criteria will be applied. 7. Hospital Acquired Conditions and Provider–Preventable Conditions. All Network hospitals agrees to comply with the Contractors no payment policy and quality monitoring program consistent with the Centers for Medicare and Medicaid Services (CMS) that addresses Hospital Acquired Conditions and Provider- Preventable Conditions according to federal regulations at CFR 434,438, and 447. The ICD-10 Version 33 Hospital Acquired Condition (HAC) list may be accessed at: https://www.cms.gov/Medicare/Medicare- Fee-for-Service-Payment/HospitalAcqCond/icd10_hacs.html. The Contractor’s specific policies that have been prior approved by DMAHS are included in the Contractor’s Provider Manual.

Fraud, Waste, and Abuse. 1. The provider/subcontractor agrees to assist the Contractor as necessary in meeting its obligations under its contract with the State to identify, investigate, and take appropriate corrective action against fraud, waste, and/or abuse (as defined in 42 CFR 455.2) in the provision of health care services. 2. If the State has withheld payment and/or initiated a recovery action against the provider/subcontractor, or withheld payments pursuant to 42 CFR 455.23 and NJAC 10:49-10:49- 9.10(a), the Contractor shall have the right to withhold payments from the provider/subcontractor and/or forward those payments to the State. 3. The Contractor and its providers, and subcontractors, whether or not they are enrolled Medicaid providers, shall cooperate fully with state and federal oversight and prosecutorial agencies, including but not limited to, DMAHS, MFD, DOH, MFCU, HHS-OIG, FBI, DEA, FDA, and the U.S. Attorney’s Office. The Contractor shall include language in its contracts with its providers and subcontractors, requiring cooperation, and stating that a failure to cooperate shall be grounds for termination of the Contractor’s agreement with the provider or subcontractor. Such cooperation shall include providing access to all necessary recipient information, medical and clinical information, correspondence, documents, computer files, and appropriate staff. 4. MFD shall have the right to recover directly from providers and enrollees in the Contractor’s network for the audits and investigations MFD solely conducts. Such money that MFD recovers directly shall not be shared with the Contractor, but reported to DMAHS in the format that the Contractor reports its recoveries to DMAHS. In addition, as a part of its recovery process, MFD shall have the right to request the Contractor to withhold payment to a provider in its network as a result of an MFD audit or investigation of managed care claims. Money withheld from a provider by the Contractor shall be sent to MFD from the Contractor and reported to DMAHS in the format that the Contractor reports its recoveries to DMAHS. 5. The Contractor shall have the right to recover directly from providers and enrollees in the Contractor’s network for the audits and investigations the Contractor solely conducts. 6. The Contractor shall have a nationally recognized standard criteria for inpatient hospital admissions that shall substantially conform to the Xxxxxxxx Care Guidelines (MCG). The Contractor shall inform and include in all provider contracts for network provider hospitals or clinical care review team subcontractors - that for purposes of audits of inpatient hospital admissions by DMAHS or MFD or its subcontractors - MCG criteria will be applied. 7. The provider/subcontractor shall comply with the provisions of Section 6032 of the federal Deficit Reduction Act of 2005. The provider/subcontractor and its employees, contractors, subcontractors and vendors, shall agree to abide by the Contractor’s policies and procedures regarding Section 6032 of the federal Deficit Reduction Act of 2005. As part of these policies and procedures, the provider/subcontractor shall perform monthly exclusions, certification, and licensure checks of its employees, contractors, subcontractors and vendors, who directly or indirectly will be furnishing, ordering, directing, managing or prescribing Medicaid items or services in whole or in part, using the following databases: a. State of New Jersey debarment list (mandatory): xxxxx://xx.xxx/comptroller/doc/nj_debarment_list.pdf b. Federal exclusions database (mandatory): xxxxx://xxxxxxxxxx.xxx.xxx.xxx/ c. N.J. Treasurer’s exclusions database (mandatory): xxxx://xxx.xxxxx.xx.xx/treasury/revenue/debarment/debarsearch.shtml d. N.J. Division of Consumer Affairs licensure databases, including all licensed healthcare professionals (mandatory, if applicable): xxxx://xxx.xxxxxxxxxxxxxxxxx.xxx/Pages/verification.aspx e. N.J. Department of Health licensure and certification database, including:, Nursing Home Administrators, Certified Assisted Living Administrators, Certified Nurse Aides/Personal Care Assistants, and Certified Medication Aides (mandatory, if applicable): xxxxx://xxxx.xxxxxxxx.xxx/.

Fraud, Waste, and Abuse. (1. ) The provider/subcontractor agrees to assist the Contractor contractor as necessary in meeting its obligations under its contract with the State to identify, investigate, and take appropriate corrective action against fraud, waste, and/or abuse (as defined in 42 CFR 455.2) in the provision of health care services. (2. ) If the State has withheld payment and/or initiated a recovery action against the provider/subcontractor, or withheld payments pursuant to 42 CFR 455.23 and NJAC 10:49-9.10(a), the Contractor contractor shall have the right to withhold payments from the provider/subcontractor and/or forward those payments to the State. (3. ) The Contractor contractor and its providers, and subcontractors, whether or not they are enrolled Medicaid providers, shall cooperate fully with state and federal oversight and prosecutorial agencies, including but not limited to, DMAHS, MFD, DOH, MFCU, HHS-HHS- OIG, FBI, DEA, FDA, and the U.S. Attorney’s Office. The Contractor contractor shall include language in its contracts with its providers and subcontractors, requiring cooperation, and stating that a failure to cooperate shall be grounds for termination of the Contractorcontractor’s agreement with the provider or subcontractor. Such cooperation shall include providing access to all necessary recipient information, medical and clinical information, correspondence, documents, computer files, and appropriate staff. (4. ) MFD shall have the right to recover directly from providers and enrollees in the Contractor’s network for the audits and investigations MFD solely conducts. Such money that MFD recovers directly shall not be shared with the Contractor, but reported to DMAHS in the format that the Contractor reports its recoveries to DMAHS. In addition, as a part of its recovery process, MFD shall have the right to request the Contractor to withhold payment to a provider in its network as a result of an MFD audit or investigation of managed care claims. Money withheld from a provider by the Contractor shall be sent to MFD from the Contractor and reported to DMAHS in the format that the Contractor reports its recoveries to DMAHS. (5. ) The Contractor shall have the right to recover directly from providers and enrollees in the Contractor’s network for the audits and investigations the Contractor solely conducts.

Fraud, Waste, and Abuse. 1. The provider/subcontractor agrees to assist the Contractor as necessary in meeting its obligations under its contract with the State to identify, investigate, and take appropriate corrective action against fraud, waste, and/or abuse (as defined in 42 CFR 455.2) in the provision of health care services. 2. If the State has withheld payment and/or initiated a recovery action against the provider/subcontractor, or withheld payments pursuant to 42 CFR 455.23 and NJAC 10:49-9.10(a), the Contractor shall have the right to withhold payments from the provider/subcontractor and/or forward those payments to the State. 3. The Contractor and its providers, and subcontractors, whether or not they are enrolled Medicaid providers, shall cooperate fully with state State and federal oversight and prosecutorial agencies, including but not limited to, DMAHS, MFD, DOH, MFCU, HHS-OIG, FBI, DEA, FDA, and the U.S. Attorney’s Office. The Contractor shall include language in its contracts with its providers and subcontractors, requiring cooperation, and stating that a failure to cooperate shall be grounds for termination of the Contractor’s agreement with the provider or subcontractor. Such cooperation shall include providing access to all necessary recipient information, medical and clinical information, correspondence, documents, computer files, and appropriate staff. 4. MFD shall have the right to recover directly from providers and enrollees in the Contractor’s network for the audits and investigations MFD solely conducts. Such money that MFD recovers directly shall not be shared with the Contractor, but reported to DMAHS in the format that the Contractor reports its recoveries to DMAHS. In addition, as a part of its recovery process, MFD shall have the right to request the Contractor to withhold payment to a provider in its network as a result of an MFD audit or investigation of managed care claims. Money withheld from a provider by the Contractor shall be sent to MFD from the Contractor and reported to DMAHS in the format that the Contractor reports its recoveries to DMAHS. 5. The Contractor shall have the right to recover directly from providers and enrollees in the Contractor’s network for the audits and investigations the Contractor solely conducts.

Fraud, Waste, and Abuse. 1. The provider/subcontractor agrees to assist the Contractor as necessary in meeting its obligations under its contract with the State to identify, investigate, and take appropriate corrective action against fraud, waste, and/or abuse (as defined in 42 CFR 455.2) in the provision of health care services. 2. If the State has withheld payment and/or initiated a recovery action against the provider/subcontractor, or withheld payments pursuant to 42 CFR 455.23 and NJAC 10:49-9.10(a), the Contractor shall have the right to withhold payments from the provider/subcontractor and/or forward those payments to the State. 3. The Contractor and its providers, and subcontractors, whether or not they are enrolled Medicaid providers, shall cooperate fully with state and federal oversight and prosecutorial agencies, including but not limited to, DMAHS, MFD, DOH, MFCU, HHS-OIG, FBI, DEA, FDA, and the U.S. Attorney’s Office. The Contractor shall include language in its contracts with its providers and subcontractors, requiring cooperation, and stating that a failure to cooperate shall be grounds for termination of the Contractor’s agreement with the provider or subcontractor. Such cooperation shall include providing access to all necessary recipient information, medical and clinical information, correspondence, documents, computer files, and appropriate staff. 4. MFD shall have the right to recover directly from providers and enrollees in the Contractor’s network for the audits and investigations MFD solely conducts. Such money that MFD recovers directly shall not be shared with the Contractor, but reported to DMAHS in the format that the Contractor reports its recoveries to DMAHS. In addition, as a part of its recovery process, MFD shall have the right to request the Contractor to withhold payment to a provider in its network as a result of an MFD audit or investigation of managed care claims. Money withheld from a provider by the Contractor shall be sent to MFD from the Contractor and reported to DMAHS in the format that the Contractor reports its recoveries to DMAHS. 5. The Contractor shall have the right to recover directly from providers and enrollees in the Contractor’s network for the audits and investigations the Contractor solely conducts. 6. The Contractor shall have a nationally recognized standard criteria for inpatient hospital admissions that shall substantially conform to the Xxxxxxxx Care Guidelines (MCG). The Contractor shall inform and include in all provider contracts for network provider hospitals or clinical care review team subcontractors, that for purposes of audits of inpatient hospital admissions by DMAHS or MFD or its subcontractors, MCG criteria will be applied 7. The provider/subcontractor shall comply with the provisions of Section 6032 of the federal Deficit Reduction Act of 2005. The provider/subcontractor and its employees, contractors, subcontractors and vendors, shall agree to abide by the Contractor’s policies and procedures regarding Section 6032 of the federal Deficit Reduction Act of 2005. As part of these policies and procedures, the provider/subcontractor shall perform monthly exclusions, certification, and licensure checks of its employees, contractors, subcontractors and vendors, who directly or indirectly will be furnishing, ordering, directing, managing or prescribing Medicaid items or services in whole or in part, using the following databases: a. State of New Jersey debarment list (mandatory): xxxxx://xx.xxx/comptroller/doc/nj_debarment_list.pdf b. Federal exclusions database (mandatory): xxxxx://xxxxxxxxxx.xxx.xxx.xxx/ c. N.J. Treasurer’s exclusions database (mandatory): xxxx://xxx.xxxxx.xx.xx/treasury/revenue/debarment/debarsearch.shtml d. N.J. Division of Consumer Affairs licensure databases, including all licensed healthcare professionals (mandatory, if applicable): xxxx://xxx.xxxxxxxxxxxxxxxxx.xxx/Pages/verification.aspx e. N.J. Department of Health licensure and certification database, including:, Nursing Home Administrators, Certified Assisted Living Administrators, Certified Nurse Aides/Personal Care Assistants, and Certified Medication Aides (mandatory, if applicable): xxxxx://xxxx.xxxxxxxx.xxx/.

Fraud, Waste, and Abuse. 1. The provider/subcontractor Subcontractor agrees to assist the Contractor as necessary in meeting its obligations under its contract Contract with the State to identify, investigate, and take appropriate corrective action against fraud, waste, and/or abuse (as defined in 42 CFR 455.2) in the provision of health care services. 2. If the State has withheld payment and/or initiated a recovery action against the provider/subcontractorSubcontractor, or withheld payments pursuant to 42 CFR 455.23 and NJAC 10:49-9.10(a), the Contractor shall have the right to withhold payments from the provider/subcontractor Subcontractor and/or forward those payments to the State. 3. The Contractor and its providersSubcontractors, and subcontractors, whether or not they are enrolled Medicaid providersSubcontractors, shall cooperate fully with state and federal oversight and prosecutorial agencies, including but not limited to, DMAHS, MFD, DOH, MFCU, HHS-OIG, FBI, DEA, FDA, and the U.S. Attorney’s Office. The Contractor shall include language in its contracts with its providers and subcontractorsSubcontractors, requiring cooperation, and stating that a failure to cooperate shall be grounds for termination of the Contractor’s agreement with the provider or subcontractorSubcontractor. Such cooperation shall include providing access to all necessary recipient information, medical and clinical information, correspondence, documents, computer files, and appropriate staff. 4. MFD shall have the right to recover directly from providers Subcontractors and enrollees Enrollees in the Contractor’s network for the audits and investigations MFD solely conducts. Such money that MFD recovers directly shall not be shared with the Contractor, but reported to DMAHS in the format that the Contractor reports its recoveries to DMAHS. In addition, as a part of its recovery process, MFD shall have the right to request the Contractor to withhold payment to a provider Subcontractor in its network as a result of an MFD audit or investigation of managed care claims. Money withheld from a provider Subcontractor by the Contractor shall be sent to MFD from the Contractor and reported to DMAHS in the format that the Contractor reports its recoveries to DMAHS. 5. The Contractor shall have the right to recover directly from providers Subcontractor, and enrollees Enrollees in the Contractor’s network for the audits and investigations the Contractor solely conducts. 6. The Contractor and its subcontractors shall have a nationally recognized standard criteria for inpatient hospital admissions that shall substantially conform to the Milliman Care Guidelines (MCG). The Contractor and its subcontractor’s shall inform and include in all provider contracts for network provider hospitals or clinical care review team subcontractors, that for purposes of audits of inpatient hospital admissions by DMAHS or MFD or its subcontractors, MCG criteria will be applied.