Regional Generic Provider Agreement - Ohio Department of Job and ...

More documents

Recommendations

Info

Appendix I Covered Families and Children population Page 1 APPENDIX I PROGRAM INTEGRITY CFC ELIGIBLE POPULATION MCPs must comply with all applicable program integrity requirements, including those specified in 42 CFR 455 and 42 CFR 438 Subpart H. 1. Fraud and Abuse Program: In addition to the specific requirements of OAC rule 5101:3-26-06, MCPs must have a program that includes administrative and management arrangements or procedures, including a mandatory compliance plan to guard against fraud and abuse. The MCP’s compliance plan must designate staff responsibility for administering the plan and include clear goals, milestones or objectives, measurements, key dates for achieving identified outcomes, and explain how the MCP will determine the compliance plan’s effectiveness. In addition to the requirements in OAC rule 5101:3-26-06, the MCP’s compliance program which safeguards against fraud and abuse must, at a minimum, specifically address the following: a. Employee education about false claims recovery: In order to comply with Section 6032 of the Deficit Reduction Act of 2005 MCPs must, as a condition of receiving Medicaid payment, do the following: i. establish and make readily available to all employees, including the MCP’s management, the following written policies regarding false claims recovery: a. detailed information about the federal False Claims Act and other state and federal laws related to the prevention and detection of fraud, waste, and abuse, including administrative remedies for false claims and statements as well as civil or criminal penalties; b. the MCP’s policies and procedures for detecting and preventing fraud, waste, and abuse; and c. the laws governing the rights of employees to be protected as whistleblowers. ii. include in any employee handbook the required written policies regarding false claims recovery; iii. establish written policies for any MCP contractors and agents that provide detailed information about the federal False Claims Act and other state and federal laws related to the prevention and detection of fraud, waste,
Appendix I Covered Families and Children (CFC) population Page 2 and abuse, including administrative remedies for false claims and statements as well as civil or criminal penalties,; the laws governing the rights of employees to be protected as whistleblowers; and the MCP’s policies and procedures for detecting and preventing fraud, waste, and abuse. MCPs must make such information readily available to their subcontractors; and iv. disseminate the required written policies to all contractors and agents, who must abide by those written policies. b. Monitoring for fraud and abuse The MCP’s program which safeguards against fraud and abuse must specifically address the MCP’s prevention, detection, investigation, and reporting strategies in at least the following areas: i. Embezzlement and theft – MCPs must monitor activities on an ongoing basis to prevent and detect activities involving embezzlement and theft (e.g., by staff, providers, contractors, etc.) and respond promptly to such violations. ii. Underutilization of services – MCPs must monitor for the potential underutilization of services by their members in order to assure that all Medicaid-covered services are being provided, as required. If any underutilized services are identified, the MCP must immediately investigate and, if indicated, correct the problem(s) which resulted in such underutilization of services. The MCP’s monitoring efforts must, at a minimum, include the following activities: a) an annual review of their prior authorization procedures to determine that they do not unreasonably limit a member’s access to Medicaid-covered services; b) an annual review of the procedures providers are to follow in appealing the MCP’s denial of a prior authorization request to determine that the process does not unreasonably limit a member’s access to Medicaid-covered services; and c) ongoing monitoring of MCP service denials and utilization in order to identify services which may be underutilized. iii. Claims submission and billing – On an ongoing basis, MCPs must identify and correct claims submission and billing activities which are potentially fraudulent including, at a minimum, double-billing and improper coding, such as upcoding and bundling. c. Reporting MCP fraud and abuse activities: Pursuant to OAC rule 5101:3-26-06, MCPs are required to submit annually to ODJFS a report which summarizes the MCP’s fraud and abuse activities for the previous year in each of the areas specified above. The MCP’s report must also identify any proposed changes to the MCP’s compliance plan for the coming year.
Page 1 and 2:
Baseline Covered Families and Child
Page 3 and 4:
Page 5 and 6:
Page 7 and 8:
Page 9 and 10:
Page 11 and 12:
Page 13 and 14:
APPENDIX A OAC RULES 5101:3-26 The
Page 15 and 16:
Appendix C Covered Families and Chi
Page 17 and 18:
Page 19 and 20:
Page 21 and 22:
Page 23 and 24:
Page 25 and 26:
Page 27 and 28:
Page 29 and 30:
Page 31 and 32:
Page 33 and 34:
Page 35 and 36:
Page 37 and 38:
Page 39 and 40:
Page 41 and 42:
Appendix D Covered Families and Chi
Page 43 and 44:
Appendix D Covered Families and Chi
Page 45:
APPENDIX E RATE METHODOLOGY CFC ELI
Page 75 and 76: APPENDIX F REGIONAL RATES 2. AT-RIS
Page 77 and 78: Appendix G Covered Families and Chi
Page 93 and 94: Appendix H Covered Families and Chi
Page 101 and 102: Appendix H Page 10 ensure that the
Page 103 and 104: General Hospital 1 Hospital System
Page 105 and 106: Minimum Provider Panel Requirements
Page 107 and 108: Minimum Provider Panel Requirements
Page 109 and 110: General Hospital 1 Total Required H
Page 111 and 112: PCPs Capacity 1 North East Central
Page 113 and 114: County Capacity 1 Central Region -
Page 115 and 116: PCPs Capacity 1 Total Required Adam
Page 117 and 118: County Capacity 1 North West Region
Page 119 and 120: Provider Types Pediatricians 4 Nort
Page 121 and 122: Provider Types Pediatricians 4 Tota
Page 123 and 124: Provider Types Pediatricians 4 Sout
Page 125: Provider Types Pediatricians 4 Nort
Page 129 and 130: Appendix I Covered Families and Chi
Page 131 and 132: Appendix J Page 2 h. Prompt Pay Rep
Page 133 and 134: Appendix J Page 4 If the financial
Page 135 and 136: Appendix J Page 6 Penalty for nonco
Page 137 and 138: Appendix J Page 8 6. NOTIFICATION O
Page 139 and 140: Appendix K Covered Families and Chi
Page 141 and 142: Appendix L Covered Families and Chi
Page 157 and 158: Appendix M Covered Families and Chi
Page 177 and 178:
Appendix N Covered Families and Chi
Page 179 and 180:
Page 181 and 182:
Page 183 and 184:
Page 185 and 186:
Page 187 and 188:
Appendix O Covered Families and Chi
Page 189 and 190:
Page 191 and 192:
Page 193 and 194:
Appendix P Covered Families and Chi
Page 195:
Appendix P Covered Families and Chi
show all

Regional Generic Provider Agreement - Ohio Department of Job and ...

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?