Reporting
-
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
-
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
-
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
-
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
-
The Enterprise Monitoring and Oversight workstream responsibilities include, but are not limited to:
- CMS Program Audit universe scrubber (for all universes)
-
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
-
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


WEBINAR
Essential Tools to Transform Your
A&G Department in 2022
February 24, 2022
ABOUT THE EVENT
Are you being asked to maximize compliance adherence and operational effectiveness with fewer resources and even less time to effectively focus on Appeals and Grievances processes, especially given the countless meetings each week? You’re not alone.
Join Inovaare’s webinar — The Top 7 Capabilities You Need to Transform Your A&G Department in 2022 — and discover new tools available to improve appeals and grievances performance.
WHAT YOU WILL LEARN
- Discover solutions that can transform you into an omnipresent leader
- Experience the difference of proactive, compliance-driven automation
- Improve the member experience by driving timely responses from departments and vendors

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