Inovaare

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