CurrentprominencehealthfirstoffloridaPolicy COMP.COMM.041

Governance Communication and Deadline Management

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Defines the Compliance Department's process for receiving, analyzing, summarizing, communicating, tracking, and closing statutory, regulatory, and sub-regulatory guidance that affects Prominence Health Plan and its first-tier, downstream, and related entities (FDRs). Applies to Prominence Management Services, LLC and relevant PHP departments/FDRs.

Policy Summary

Payerprominencehealthfirstofflorida

PolicyGovernance Communication and Deadline Management

Policy CodePolicy COMP.COMM.041

Change TypeInformational

Effective DateJan 1, 2017

Last ReviewApr 30, 2021

Next Review DateJun 1, 2021

Key ActionCompliance will analyze regulatory guidance, summarize deadlines and operational impacts, communicate to department contacts, and track memos in the HPMS Memo Tracking Sheet until closure.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2017-01-01Effective

2021-04-30Last review

2021-06-01Next review

ComplianceDepartment

AllApplies to

Regulatory Communication and Required Actions

Documentation Required

Regulatory communication and tracking — analyze, communicate, assign, track, and close memos

Compliance will analyze received statutory, regulatory, and sub‑regulatory guidance (e.g., HPMS memos, manuals, guides, training materials) for implications to the Plan, summarize key points and deadlines, communicate the original guidance plus analysis and summary via email to appropriate department contacts and business owners, record the topic in the HPMS Memo Tracking Sheet on the shared Compliance drive, enter responsible individuals into the Tracking Sheet's Business Owner cell for follow‑up, and mark memos as closed with a closure date when directives are fully implemented.

Analyze incoming guidance to identify operational impacts and deadlines (Policy Procedure: Analysis).
Prepare a summary emphasizing crucial deadlines and operational impact (Policy Procedure: Summary).
Email original communication, analysis, and summary to appropriate department contacts; enter responsible individuals into the Tracking Sheet Business Owner cell and hold them accountable for updates and actions (Policy Procedure: Communication of Information to Departments).
Record receipt of the communication in the HPMS Memo Tracking Sheet on the shared Compliance drive (Policy Procedure: Recordation of Topic).
Change a memo's status to 'closed' and enter the closure date when the memo directive has been fully implemented (Policy Procedure: Memo Closure).

Key Definitions

Centers for Medicare and Medicaid Services (CMS)

DefinitionThe federal agency that runs the Medicare program; works to ensure beneficiaries receive high-quality health care.

Websitehttps://cms.gov/

RoleIssues statutory, regulatory, and sub-regulatory guidance (e.g., HPMS memos) relevant to plan operations.

Delegated Entity

DefinitionAny party, including an agent or broker, that enters into an agreement with a Qualified Health Plan (QHP) issuer to provide administrative or health care services to qualified individuals, qualified employers, or qualified employees and their dependents (45 C.F.R. 156.20).

ExamplesAgents, brokers, vendors performing enrollment, claims processing, or other administrative services.

ContextDelegated entities may be subject to plan oversight when regulatory guidance affects delegated activities.

Downstream Entity

DefinitionAny 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 ChainOccurs below first-tier entities and may include subcontractors and individual providers.

ImplicationDownstream entities are included in the scope of regulatory oversight through contractual chains.

First-Tier Entity

DefinitionAny 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).

ExamplesEntities contracting directly with the MA organization or Part D sponsor to perform claims administration, care management, or provider network services.

RelationshipFirst-tier entities contract directly with the plan sponsor and may further contract with downstream entities.

Related Entity

DefinitionAny entity that is related to an MA and/or Part D sponsor by common ownership or control.

ImplicationRelated entities may be within the scope of plan oversight and are considered when assessing organizational relationships and compliance.

ScopeIncludes entities connected through ownership or control structures, as relevant to MA/Part D sponsors.

URAC

DefinitionAn independent organization that promotes health care quality through accreditation of organizations involved in medical care services.

RecognitionURAC accreditation is recognized nationwide by state and federal regulators and its standards appear in legislation and regulation.

Websitewww.urac.org

Agency for Health Care Administration (AHCA)

DefinitionFlorida state agency statutorily created by Chapter 20, Florida Statutes as the chief health policy and planning entity for the state.

Primary ResponsibilitiesResponsible for oversight of the state's Medicaid program, licensure of health care facilities, and sharing of health care data through the Florida Center for Health Information and Policy Analysis.

RelevanceAHCA-issued guidance impacts plan operations and is included in the Compliance Department's tracking and communication processes.

Policy Summary

Payerprominencehealthfirstofflorida

PolicyGovernance Communication and Deadline Management

Policy CodePolicy COMP.COMM.041

Change TypeInformational

Effective DateJan 1, 2017

Last ReviewApr 30, 2021

Next Review DateJun 1, 2021

Key ActionCompliance will analyze regulatory guidance, summarize deadlines and operational impacts, communicate to department contacts, and track memos in the HPMS Memo Tracking Sheet until closure.

SourceLink

On This Page

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Governance Communication and Deadline Management

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Sign up for prominencehealthfirstofflorida Policy COMP.COMM.041 alerts

Get alerted when Policy COMP.COMM.041 changes without checking for updates manually.

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Regulatory Communication and Required Actions

Documentation Required

Regulatory communication and tracking — analyze, communicate, assign, track, and close memos

Analyze incoming guidance to identify operational impacts and deadlines (Policy Procedure: Analysis).
Prepare a summary emphasizing crucial deadlines and operational impact (Policy Procedure: Summary).
Email original communication, analysis, and summary to appropriate department contacts; enter responsible individuals into the Tracking Sheet Business Owner cell and hold them accountable for updates and actions (Policy Procedure: Communication of Information to Departments).
Record receipt of the communication in the HPMS Memo Tracking Sheet on the shared Compliance drive (Policy Procedure: Recordation of Topic).
Change a memo's status to 'closed' and enter the closure date when the memo directive has been fully implemented (Policy Procedure: Memo Closure).

Key Definitions

Centers for Medicare and Medicaid Services (CMS)

DefinitionThe federal agency that runs the Medicare program; works to ensure beneficiaries receive high-quality health care.

Websitehttps://cms.gov/

RoleIssues statutory, regulatory, and sub-regulatory guidance (e.g., HPMS memos) relevant to plan operations.

Delegated Entity

ExamplesAgents, brokers, vendors performing enrollment, claims processing, or other administrative services.

ContextDelegated entities may be subject to plan oversight when regulatory guidance affects delegated activities.

Downstream Entity

Position in ChainOccurs below first-tier entities and may include subcontractors and individual providers.

ImplicationDownstream entities are included in the scope of regulatory oversight through contractual chains.

First-Tier Entity

ExamplesEntities contracting directly with the MA organization or Part D sponsor to perform claims administration, care management, or provider network services.

RelationshipFirst-tier entities contract directly with the plan sponsor and may further contract with downstream entities.

Related Entity

DefinitionAny entity that is related to an MA and/or Part D sponsor by common ownership or control.

ImplicationRelated entities may be within the scope of plan oversight and are considered when assessing organizational relationships and compliance.

ScopeIncludes entities connected through ownership or control structures, as relevant to MA/Part D sponsors.

URAC

DefinitionAn independent organization that promotes health care quality through accreditation of organizations involved in medical care services.

RecognitionURAC accreditation is recognized nationwide by state and federal regulators and its standards appear in legislation and regulation.

Websitewww.urac.org

Agency for Health Care Administration (AHCA)

DefinitionFlorida state agency statutorily created by Chapter 20, Florida Statutes as the chief health policy and planning entity for the state.

RelevanceAHCA-issued guidance impacts plan operations and is included in the Compliance Department's tracking and communication processes.