Reporting
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The State Regulatory Guidance (All Plan letters) responsibilities include, but are not limited to:
- DHCS All Plan Letter (APL) and Policy Letter (PL) Applicable Notices
- DHCS All Plan Letter (APL) and Policy Letter (PL) - Non-Applicable Notices
- Submits proof of APL and PL compliance documents to DHCS
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The Organization Risk Assessment responsibilities include, but are not limited to:
- Review of new potential risks with assigned accountable business owners
- Provide final data set to senior executive team for implementation of agreed upon interventions
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The Regulatory Audit Process responsibilities include, but are not limited to:
- Creation of audit folders
- Tracking of documents/universe and requests received from the auditor and distributed to the business owners
- Audit Readiness Questionnaires
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The Regulatory Routine Reporting responsibilities include, but are not limited to:
- Maintaining calendar for all regulatory compliance
- Tracking timeliness of business owner’s submissions and attestation
Monitoring
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The Enterprise Monitoring and Oversight workstream responsibilities include, but are not limited to:
- CMS Program Audit universe scrubber (for all universes)
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The Federal Regulatory Guidance (CMS HPMS memos) responsibilities include, but are not limited to:
- Tracking of regulatory guidance changes (2017 Medicare Marketing Guidance Changes)
- Maintenance of the 2018 Call Letter Grid that illustrates deliverables by business units
Audit and CAP
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The Internal Audit workstream responsibilities include, but are not limited to:
- Review of prior and current year ORA risks
- Initiates Management Action Plans (MAP) for all audits that produce findings
Pre-delegation audit
Pre-Delegation Audit, Healthcare Delivery Organization (HDO) Credentialing, HDO Initial Credentialing, HDO Re-credentialing and Re-credentialing.
- Facility Site Review audits, specifically audit of medical facilities/sites
- Medical Record Review audits, specifically audit of medical records
- Utilization Management audits include:
- UM audits
- Quality Management (QM) audits
- Special Needs Plan (SNP) audits
- Service Denial audits
Pre-delegation audit
Credentialing, Facility Site Review (FSR), Medical Record Review (MRR) and Utilization Management (UM).
- Credentialing audits include:
- Adverse Action Monitoring
- Annual Credentialing
- Credentialing Initial File
- Credentialing

Efficiently Manage FDR Compliance
Inovaare’s Delegation Oversight solution enables health plans to manage first-tier, downstream and related (FDR) delegated entity compliance. Now, Delegation Oversight departments can perform systematic reviews of FDR operations—to ensure they are in line with business requirements—while empowering plan sponsors and MCOs to manage and track all audits and monitoring of delegated entities. The solution also provides a secure portal for communication where delegated entities can scrub their universe files before submitting them to the health plan.
- Deliver real-time audit statuses
- Lower audit backlog, efforts and timelines
- Help health plans with pre- and post-delegation audits
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