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Managed health care programs: program integrity – fraud and abuse, audits, reporting, and record retention – Ohio Admin. Code 5160-26-06

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Managed health care programs (MCPs) must have administrative and managed arrangements or procedures, including a mandatory compliance plan, to guard against fraud and abuse.  These procedures must include the following:

  • Provision for internal monitoring and auditing, including procedures to monitor the service patterns of providers and subcontractors;
  • Prompt reporting of all instances of fraud and abuse to the department of job and family services, and member fraud to the county department of job and family services;
  • Annual submission to the department of a report summarizing the MCP’s fraud and abuse activities for the previous year;
  • The MCP must submit to the department required reports and additional information that relates to its duties and obligations and where needed to assure operation in accordance with applicable regulations or requirements;
  • All hard copy or electronic records originated or prepared in connection with the MCP’s performance of its obligations under the provider agreement, including medical records, will be retained and safeguarded by the MCP and its subcontractors in accordance with applicable regulations;
  • Records stored electronically must be produced at the MCP’s expense; and
  • All records must be maintained for a minimum of six years from the renewal, amendment or termination date of the provider agreement.

Current as of June 2015