Reports and Agency Requests



Policy/Procedure Number: CMP-05Lead Department: AdministrationPolicy/Procedure Title: Reports and Agency Requests FORMCHECKBOX External Policy FORMCHECKBOX Internal PolicyOriginal Date: 06/05/2007Next Review Date:08/20/2021Last Review Date:08/20/2020Applies to: FORMCHECKBOX Medi-Cal FORMCHECKBOX Healthy Kids FORMCHECKBOX EmployeesReviewing Entities: FORMCHECKBOX IQI FORMCHECKBOX P & T FORMCHECKBOX QUAC FORMCHECKBOX OPerations FORMCHECKBOX Executive FORMCHECKBOX Compliance FORMCHECKBOX DepartmentApproving Entities: FORMCHECKBOX BOARD FORMCHECKBOX COMPLIANCE FORMCHECKBOX FINANCE FORMCHECKBOX PAC FORMCHECKBOX CEO FORMCHECKBOX COO FORMCHECKBOX Credentialing FORMCHECKBOX DEPT. DIRECTOR/OFFICERApproval Signature: Elizabeth Gibboney, CEOApproval Date: 08/20/2020RELATED POLICIES: CMP-33 Delegated Data MonitoringIMPACTED DEPTS.: AllDEFINITIONS: Certification: a statement, developed in accordance with All-Plan Letter (APL) 17-005 that applies to all data submitted by Partnership HealthPlan of California (PHC) to the Department of Health Care Services (DHCS) which states that the data, information, and documentation to which the statement applies is accurate, complete, and truthful to the signing authority’s best information, knowledge and belief.Contract manager: the individual assigned to PHC at Managed Care Operations Division of DHCS who is the main contact for PHC on day-to-day issues with the Medi-Cal program and PHC’s contract with DHCS.Delegate: An external entity that PHC has given the authority to perform an activity/activities that PHC would otherwise perform.Subcontractor: A person or entity who enters into a subcontract with PHC. Assessing whether an entity is a Subcontractor depends on the relationship between the entities and the services being performed, not on the type of persons or companies involved. A person or entity is deemed a subcontractor if: 1) they are either a provider of health care services that agreed to furnish Covered Services to PHC Members, or 2) has agreed to perform any administrative function or service for PHC specifically related to fulfilling PHC’s obligations to DHCS under the terms of the DHCS/Medi-Cal contract. ATTACHMENTS: CEO Certification Statement to DHCSPURPOSE: To establish guidelines for (1) filing reports with State, Federal and other agencies as contractually required, (2) responding to State, Federal or other agency requests for information pertaining to lines of business in which Partnership HealthPlan of California (PHC) is contracted with the requesting agency, (3) self-disclosure to State and/or Federal agencies and (4) to specify PHC’s compliance with the requirement to certify data, information and documentation set forth under Title 42, Code of Federal Regulations (42 CFR), Sections (§§) 438.604 and 438.606.Medicaid Final Rule.POLICY / PROCEDURE: Policy.PHC shall file reports with State, Federal, or other agencies as required by contractual requirements, federal and state laws, statutes, regulations and other arrangements.Reports shall be filed by Regulatory Affairs & Compliance (RAC) or other specified staff as outlined in PHC’s policies.Reports shall be filed on or before the due date specified in the contract, law, statute or regulation pertaining to the report.RAC shall develop and maintain a reporting calendar for all contractually required reports and shall include those reports that are required to be prepared by subcontractors and/or delegates. The calendar shall specify lead departments for specific reports, subject matter experts, internal due dates, and regulatory agency due datesRequests for information by State or Federal agencies shall be honored according to contractual requirements, statues, laws and/or regulations governing the request.PHC shall self-disclose cases of misconduct, fraud, waste and abuse to the appropriate law enforcement, State and/or Federal agency as required by contractual or statutory requirements.PHC shall submit a certification statement which includes references to all applicable data, information and documentation submitted to DHCS, as specified in the DHCS contract and APL 17-005 (Attachment A).PHC is responsible for ensuring that subcontractors and/or delegates comply with all applicable state and federal laws and regulations, contractual obligations, and as applicable, DHCS All Plan Letters and Policy letters, and PHC policies and procedures. Applicable requirements must be communicated by each MCP to all delegated entities and subcontractors. Procedure.RAC shall review all laws, statutes, regulations and contracts that govern PHC’s lines of business. All reporting requirements contained therein shall be documented on the reporting calendar. RAC shall notify individual PHC departments and subcontractors and/or delegates as applicable, of their reporting responsibilities, reporting elements and reporting due dates. All responsibilities, delegated reports/elements and due dates shall be recorded in the reporting calendar and shared with affected parties.All reports listed on the reporting calendar shall be filed by tRAC unless otherwise specified.Reports filed online shall be sent through SFTP (Secure File Transfer Protocol) connections.Reports submitted via email will not contain protected health information (PHI) in the subject line and will be sent via secure means if any of the contents contain PHI. Reports filed in paper form shall be sent through FedEx or USPS Certified Mail in order to confirm receipt of all documents by the designated agency.Individual PHC departments are responsible for validating that all data, information and documentation is accurate, complete and truthful prior to submission to RAC or prior to direct submission to governing agency if otherwise specified that report is submitted by a PHC department other than RAC (i.e. Finance or IT). Validation of data will be completed by department directors or director’s designee. Data will not be considered complete or submitted to DHCS without this validation.Subcontractors and/or delegates are responsible for validating that all data, information and documentation is accurate, complete and truthful prior to submission to PHC and shall include a certification statement (for the specified month) in accordance with PHC policy and procedure CMP-33 Delegated Data Monitoring. Requests made by State or Federal agencies shall be reviewed by RAC. Information shall be released within the constraints of existing rules that govern PHC’s lines of business.PHC shall self-disclose issues of non-compliance, misconduct and/or fraud, waste and abuse to the appropriate law enforcement agency, State, and/or Federal agency as required by contract, statute or applicable regulation governing the line of business. PHC may consult with legal counsel prior to any self-disclosure.DHCS Certification of Document and Data SubmissionDHCS contract Exhibit E, Attachment 2 requires PHC to certify that all data, information and documentation submitted to DHCS is accurate, complete and truthful as set forth in 42 CFR §438.604 and §438.606.RAC is responsible for tracking all data, information and documentation submitted to DHCS by the unit or other specified PHC department and to prepare PHC’s monthly certification statement in compliance with the guidance set forth in APL 17-005.PHC’s certification statement shall be issued using Attachment A, “CEO Certification Statement” as approved by DHCS on May 31, 2017. Subsequent review and approval by DHCS is required if changes are made to the certification statement.The certification statement will be reviewed and signed by PHC’s CEO, CFO, or their delegated signer for submission to PHC’s MCOD contract manager no later than the final business day of each month (Attachment A).PHC’s CEO, CFO, or designee who reports directly to the CEO or CFO and has delegated authority to sign on behalf of the CEO or CFO so that the CEO or CFO is ultimately responsible for the certification and the data, information and documentation submitted to DHCS.PHC’s failure to submit this certification statement may result in a corrective action; DHCS may also impose corrective action due to the submission of inaccurate or incomplete data, information, and documentation that was certified pursuant to § 438.606 and APL 17-005.Subcontractor’s and/or delegates failure to submit data, information, documentation and certification in accordance with the requirements of this policy and APL 17-005 may result in corrective action. Where corrective action is required, subcontractor and/or delegate shall submit to PHC a Corrective Action Plan (CAP) in a form and manner consistent with the requirements established by DHCS for the correction of deficiencies in data submission.DMHC Reporting and Filing RequirementsPHC maintains a dormant Knox-Keene License that is not attached to any PHC lines of business. While the license is dormant PHC must still comply with all Knox-Keene reporting requirements unless an exemption has been previously approved by DMHC. These reporting requirements shall be documented on the reporting calendar. RAC shall notify individual PHC departments and subcontractors and/or delegates as applicable, of their reporting responsibilities, reporting elements and reporting due dates. All responsibilities, delegated reports/elements and due dates shall be recorded in the reporting calendar and shared with affected parties.In accordance of Section 1352(c) and Rule 1300.52.2 PHC shall, within five (5) days, file an amendment when there are any changes in the officers, directors, partners, controlling shareholders, principal creditors, or persons occupying similar positions or performing similar functions, of the plan and of a management company of the plan, and of a parent company of the plan or management company. REFERENCES: PHC-DHCS Contract Exhibit E, Attachment 2, Program Terms and Conditions All-Plan Letter 17-00542 CFR 438.60442 CFR 438.606Section 1352 (c) and Rule 1300.52.2DISTRIBUTION:SharePointDirectorsPOSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:Chief Compliance OfficerREVISION DATES: Medi-Cal03/02/2010, 12/06/2011, 12/01/2015, 12/06/2016, 05/17/2017, 05/24/2018, 05/16/2019, 08/20/2020PREVIOUSLY APPLIED TO:PartnershipAdvantage:CMP-05 – 06/05/2007 to 01/01/2015Healthy Families:CMP-05 – 10/01/2010 to 03/01/2013Healthy KidsCMP – 05 - 06/05/2007 to 12/31/2016 ................
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