2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
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Legaltransactions (federal, state, or local)terminated for cause or defaultYou must immediately notify <strong>Presbyterian</strong> if any ofthe above referenced representations change. Anymisrepresentation of or change in your status maybe grounds for immediate termination of youragreement with <strong>Presbyterian</strong>.False ClaimsYou must have written policies <strong>and</strong> procedures forall employees, agents, or contractors that providedetailed information regarding the New MexicoFalse Claims Act, NMSA 1978, 27-14-1 et seq., theNew Mexico Fraud Against the Taxpayers Act,NMSA 1978, 44-9-1 et seq., <strong>and</strong> the Federal FalseClaims Act established under 31 United StatesCode (USC) §§ 3729-3733, administrativeremedies for false claims established under 31USC 3801 et seq., including but not limited topreventing <strong>and</strong> detecting fraud, waste, <strong>and</strong> abusein federal health care programs (as defined inSocial Security Act § 1128B(f)). Such policies <strong>and</strong>procedures shall articulate <strong>Presbyterian</strong>’scommitment to compliance with federal <strong>and</strong> statest<strong>and</strong>ards.You must cooperate with all appropriate state <strong>and</strong>federal agencies in investigating fraud, waste, <strong>and</strong>abuse. <strong>Presbyterian</strong> has methods for identifying,investigating, <strong>and</strong> referring suspected fraud casespursuant to 42 CFR §§ 455.1, 455.13, 455.14, <strong>and</strong>455.21. Report all confirmed, credible, or suspectedfraud <strong>and</strong> abuse to <strong>Presbyterian</strong> or HSD <strong>and</strong>MFEAD as follows:Suspected fraud, waste, <strong>and</strong> abuse in theadministration of <strong>Presbyterian</strong> CentennialCare shall be reported to <strong>Presbyterian</strong>, HSD,<strong>and</strong> MFEADAll confirmed, credible, or suspected providerfraud, waste, <strong>and</strong> abuse shall immediately bereported to <strong>Presbyterian</strong>, HSD, <strong>and</strong> MFEAD<strong>and</strong> shall include the information provided in42 CFR § 455.17, as applicableAll confirmed or suspected member fraud,waste, <strong>and</strong> abuse shall be reportedimmediately to <strong>Presbyterian</strong><strong>Provider</strong> TerminationRefer to your service agreement with <strong>Presbyterian</strong>for specific time frames <strong>and</strong> obligations regardingterminations.<strong>Presbyterian</strong> has the right to suspend, deny, refuseto renew, or terminate any provider agreement inaccordance with the terms of the serviceagreement <strong>and</strong> applicable statutes <strong>and</strong> regulations.HSD has the right to direct <strong>Presbyterian</strong> toterminate or modify this agreement when HSDdetermines it to be in the best interest of the state.In the event of termination of the agreement, youshall immediately make available to HSD or itsdesignated representative in a usable form any orall records, whether medical or financial, related toyour activities undertaken pursuant to theagreement. The provision of such records shall beat no expense to HSD.14-62014 <strong>Practitioner</strong> <strong>and</strong> <strong>Provider</strong> <strong>Manual</strong> - Ver. 3
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