appendix iv quality assurance and program integrity - RMA USDA ...

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2014 SRA—Appendix IV 07-01-13(4) Implementing procedures for timely detection and reporting of suspectedmisrepresentation, fraud, waste, or abuse by policyholders, employees oraffiliates relating to the Federal crop insurance program.(5) Notifying FCIC of suspected misrepresentation, fraud, waste or abuse inaccordance with section IV of this Appendix and assisting FCIC insubsequent investigations.(6) Implementing administrative procedures to resolve and correct errors andomissions identified during an inspection or review.(7) Correcting any errors or omissions identified during any inspection orreview.(8) Maintaining, in accordance with section IV(g) of the Agreement, alldocumentation related to any inspection or review required by thisAppendix.(9) Establishing a process to respond to complaints by policyholders, thepublic, or state insurance departments, or referred to the Company byFCIC, documenting the complaint and actions taken by the Company inresponse, and providing such documentation to FCIC upon request.(10) Ensuring that companion eligible crop insurance contracts in force forother individuals sharing in the crop are serviced consistently. AnyCompany procedure for ensuring such consistency shall include amechanism for seeking an interpretation of policy or procedure from FCICin the event that the Company and another AIP disagree.(11) Taking such actions necessary to correct any non-compliance with theAgreement.(12) Preparing and providing to FCIC within 20 business days of completingeach review an Electronic Quality Control Review Record (EQCRR)detailing the results of the review in accordance with Appendix III.(13) Retaining all documents, in accordance with section IV(g) of theAgreement, obtained in the course of the reviews conducted and all formscompleted by the quality control reviewer and providing such documentsto FCIC upon request. All review documentation is considered part of thepolicyholder file.(14) Submit an annual Quality Control Report, signed and certified byCompany’s Chief Financial Officer, or individual with similarresponsibilities, by April 30 following the reinsurance year, describing theoverall results of the Company’s reviews and any corrective actions taken,10
2014 SRA—Appendix IV 07-01-13and confirming the Company has performed sufficient reviews to providea reasonable assurance that the requirements of the Agreement have beenmet.(b)Review RequirementsThe Company is required to identify and conduct the following reviews on areinsurance-year basis unless otherwise specified herein and report the results toFCIC. A review that meets the criteria for more than one review requirement willcount toward all such review requirements.(1) Data Mining Reviews. Unless FCIC provides specific review requirementsthat are to be implemented, the Company shall conduct an inspection ofeligible crop insurance contracts for which anomalies have been identifiedby FCIC. These reviews will not exceed three percent of eligible cropinsurance contracts for the reinsurance year, unless FCIC provides noticethat additional inspections are required to address specific programintegrity concerns. These reviews will include, but are not limited to,eligible crop insurance contracts with anomalous actual production history(APH) certifications or identified misapplication of policy or FCICprocedures. FCIC will meet with AIPs annually to consult on the typesand scope of data mining reviews to be conducted.(2) Individual Policy Reviews. The Company shall conduct inspections ormonitoring programs of eligible crop insurance contracts, entities, agents,loss adjusters, or affiliates identified by FCIC as may be determinednecessary by FCIC to protect program integrity.(3) Operational Reviews. These reviews are intended to ensure that theCompany’s internal controls are in place, operational, and providereasonable assurance that the liability and indemnities are properlyestablished in accordance with FCIC procedures.(A)Conflict of Interest Reviews: In accordance with section VI ofAppendix I, the Company shall, prior to the payment of a claim,conduct an inspection for all eligible crop insurance contracts forwhich a conflict of interest has been disclosed or otherwise beenidentified as follows:(i)A conflict of interest review is mandatory when theindividual making a disclosure:(I)Has a share in a crop insured under any eligiblecrop insurance contract insured by the Company, or11
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