CurrentprominencehealthfirstoffloridaPolicy COMP.COMM.004
Effective Lines of Communication
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Defines Prominence HealthPlan's channels and expectations for confidential compliance communications among staff, leadership, board, delegated entities, and related parties; applies to all organizational constituents.
Policy Summary
Payerprominencehealthfirstofflorida
PolicyEffective Lines of Communication
Policy CodePolicy COMP.COMM.004
Change TypeNo material change
Effective DateJan 1, 2017
Last ReviewApr 30, 2021
Next Review DateJun 1, 2021
Key ActionReport suspected or actual non-compliance to the Compliance Department and seek clarification from the Compliance Officer.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
AllApplies to (populations covered)
quarterlyCompliance Committee frequency
monthlySenior leadership frequency
3/yrBoard reporting frequency
2017 → 2021-04-30Effective → Last revised
Communication and Escalation Criteria
Communication and Escalation Criteria
Procedures and expectations for communication, escalation, and monitoring of compliance issues.
Compliance Officer shall routinely communicate regulations, guidelines, requirements, compliance policies & procedures and other information applicable to staff duties; provide opportunities for staff to seek clarification; document questions and responses for broader dissemination; may hold periodic in-person meetings and solicit staff input to develop targeted communications.
ALL of the following
Examples include
- Performance outside of standards (e.g., CMS untimely appeal decision notifications, nonpayment of interest on claims, lack of prior authorization notifications)
- Reoccurrence of or lack of sustained improvement for previously identified errors
- Fraud, waste, and abuse
- HIPAA privacy or security incidents
Communication with delegated entities: Compliance Officer and the business owner for the delegated function will communicate as needed when regulations, guidelines, requirements, compliance policies & procedures or other applicable information are introduced or updated; delegated entities shall be instructed to seek clarification from the Compliance Officer or business owner if confused or have questions.
Reporting to leadership and governance: Compliance Officer will communicate at least monthly with senior leadership; at least quarterly with the Compliance Committee; and at least three times per year with the Board of Directors. Board-level escalation criteria include audit findings (internal, FDR, FWA), external/regulatory audit engagement and findings, and enforcement actions (e.g., CMS notices of non-compliance, warning letters, sanctions, civil money penalties).
Monitoring and notification: Prominence Health Plan will conduct periodic review and analysis to determine changes in benefits, policies & procedures, or utilization management that impact compliance; delegated contractors should be notified of changes impacting compliance, including parity issues (e.g., mental health/substance use disorder parity).
Inquiry point: Questions about this policy should be directed to the Prominence Health Plan Manager of Compliance.
Reporting and Clarification
Documentation Required
Report non‑compliance and request clarification from Compliance
Report suspected or actual non‑compliance to the Compliance Department and seek clarification from the Compliance Officer on any confusion about company policy, practice, or procedure; the Compliance Officer will document questions and responses and may share them with staff.
- Report suspected or actual non‑compliance to the Compliance Department.
- Seek clarification from the Compliance Officer or compliance department on any questions regarding company policy, practice, or procedure.
- Compliance Officer will document questions and responses and may disseminate answers to staff as appropriate.
Key Definitions
inv-03: Abuse — Definition of Abuse
DefinitionAbuse: provider or beneficiary practices inconsistent with sound fiscal, business, or medical practices that result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for healthcare (42 C.F.R. 455.2).
ScopeIncludes provider practices and beneficiary practices that create unnecessary costs to Medicaid.
Regulatory ReferenceCited authority: 42 C.F.R. 455.2.
inv-04: Delegated Entity — Definition of Delegated Entity
DefinitionDelegated Entity: Any party, including an agent or broker, that enters into an agreement with a Qualified Health Plan (QHP) issuer to provide administrative services or healthcare services to qualified individuals, qualified employers, or qualified employees and their dependents (45 C.F.R. 156.20).
ExamplesMay include agents, brokers, or other parties contracted by a QHP issuer to deliver administrative or healthcare services.
Regulatory ReferenceCited authority: 45 C.F.R. 156.20.
inv-05: Downstream Entity — Definition of Downstream Entity
DefinitionDownstream Entity: Any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the MA organization or Part D benefit, below the level of the arrangement between an MA organization or Part D plan sponsor and a first-tier entity; these arrangements continue down to the ultimate provider of health and administrative services (42 C.F.R. 422.2, 423.4).
Position in Contracting ChainExists below first-tier entities in the chain of written arrangements related to MA or Part D services.
Regulatory ReferenceCited authority: 42 C.F.R. 422.2, 423.4.
inv-06: First-Tier Entity — Definition of First-Tier Entity
DefinitionFirst-Tier Entity: Any party that enters into a written arrangement, acceptable to CMS, with the MA organization or Part D plan sponsor (or applicant) to provide administrative services or health care services to a Medicare-eligible individual under the MA organization or Part D program (42 C.F.R. 422.2, 423.4).
RoleDirect contractual counterparty to the MA organization or Part D sponsor responsible for providing administrative or healthcare services.
Regulatory ReferenceCited authority: 42 C.F.R. 422.2, 423.4.
inv-07: Fraud — Definition of Fraud
DefinitionFraud: A false representation of a material fact, whether by words or conduct, by false or misleading allegations, or by concealment of that which should have been disclosed, which deceives another (paraphrasing Black's Law Dictionary).
CharacteristicInvolves intentional deception through misrepresentation or concealment of material facts.
SourceParaphrase based on Black's Law Dictionary as cited in policy.
inv-08: Waste — Definition of Waste
DefinitionWaste: Occurs when poor or inefficient practices result in unnecessary healthcare expenditures to a Government program.
DistinctionRefers to inefficiency or problem in resource use, distinct from intentional fraud or abusive practices.
ContextIdentified as a concern addressed by the Office of Inspector General and the Compliance program.
Policy Summary
Payerprominencehealthfirstofflorida
PolicyEffective Lines of Communication
Policy CodePolicy COMP.COMM.004
Change TypeNo material change
Effective DateJan 1, 2017
Last ReviewApr 30, 2021
Next Review DateJun 1, 2021
Key ActionReport suspected or actual non-compliance to the Compliance Department and seek clarification from the Compliance Officer.
SourceLink
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