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    Reporting

    • The State Regulatory Guidance (All Plan letters) responsibilities include, but are not limited to:
      1. DHCS All Plan Letter (APL) and Policy Letter (PL) Applicable Notices
      2. DHCS All Plan Letter (APL) and Policy Letter (PL) - Non-Applicable Notices
      3. Submits proof of APL and PL compliance documents to DHCS
    • The Organization Risk Assessment responsibilities include, but are not limited to:
      1. Review of new potential risks with assigned accountable business owners
      2. 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:
      1. Creation of audit folders
      2. Tracking of documents/universe and requests received from the auditor and distributed to the business owners
      3. Audit Readiness Questionnaires
    • The Regulatory Routine Reporting responsibilities include, but are not limited to:
      1. Maintaining calendar for all regulatory compliance
      2. Tracking timeliness of business owner’s submissions and attestation

    Monitoring

    • The Enterprise Monitoring and Oversight workstream responsibilities include, but are not limited to:
      1. CMS Program Audit universe scrubber (for all universes)
    • The Federal Regulatory Guidance (CMS HPMS memos) responsibilities include, but are not limited to:
      1. Tracking of regulatory guidance changes (2017 Medicare Marketing Guidance Changes)
      2. 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:
      1. Review of prior and current year ORA risks
      2. 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:
      1. UM audits
      2. Quality Management (QM) audits
      3. Special Needs Plan (SNP) audits
      4. Service Denial audits

    Pre-delegation audit

    Credentialing, Facility Site Review (FSR), Medical Record Review (MRR) and Utilization Management (UM).

    • Credentialing audits include:
      1. Adverse Action Monitoring
      2. Annual Credentialing
      3. Credentialing Initial File
      4. Credentialing

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