Provider actions and implications when compliance issues involve providers

This policy does not place any new requirements on providers for prior authorization or documentation; instead, provider-facing actions for compliance issues are handled internally by Prominence Health Plan through investigation and corrective action processes. Providers should be aware that when non‑compliance or potential FWA involves a provider, corrective actions may be taken that affect the provider relationship (including overpayment recovery, payment suspension, P D E correction/deletion, and possible provider termination) and that provider history will be retained and reviewed as part of investigations. The Compliance Department initiates inquiries promptly (within 24 hours and no later than 3 business days) and documents issues in the Potential Compliance Issues log; corrective actions are tracked, monitored, and revalidated at 90 days and one year.

• Compliance Department will initiate a reasonable inquiry within 24 hours and no later than 3 business days of identification.
• Potential compliance issues are logged and maintained in SmartSheet.
• If non‑compliance or FWA is confirmed, corrective actions will be developed and may include disciplinary actions, overpayment recovery, payment suspension, PDE correction/deletion, policy/system revisions, monitoring, and up to provider termination.
• Corrective actions are documented and tracked by the Compliance Manager and revalidated at 90 days and one year.
• Provider history and complaint/investigation files are maintained and reviewed when new cases are received.