Md. Code Regs. 10.67.07.03

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.67.07.03 - Reporting

A. An MCO shall submit to the Department the following:

(1) Encounter data in the form and manner described in COMAR 10.67.65.15B, 42 CFR § 438.242(c), and 42 CFR § 438.818.

(2) Data required by the Department in order to certify the actuarial soundness of capitation rates to an MCO, under 42 CFR § 438.3, including base data described in 42 CFR § 438.5(c) that is generated by the MCO.

(3) Data required by the Department to determine compliance of the MCO with the medical loss ratio requirement described in 42 CFR § 438.8.

(4) Data required by the Department and the Maryland Insurance Administration to determine that the MCO has made adequate provision against the risk of insolvency as required under 42 CFR § 438.116.

(5) Documentation described in 42 CFR § 438.207(b) on which the Department bases its certification that the MCO has complied with the State's requirements for availability and accessibility of services, including the adequacy of the provider network, as set forth in 42 CFR § 438.206

(6) In accordance with §F of this regulation, information on ownership and control described in 42 CFR § 455.104 from an MCO and its subcontractors, as governed by 42 CFR § 438.230.

(7) An annual report of overpayment recoveries as required in 42 CFR § 438.608(d)(3).

(8) Any other data, documentation, or information relating to the performance of the entity's obligations under its contract with the Department, or required by the Department or the Secretary of the Department of Health and Human Services.

B. An MCO shall report to the Department any identified inaccuracies in the encounter data reported by the MCO or its subcontractors within 30 days of the date discovered regardless of the effect which the inaccuracy has upon MCO reimbursement.

C. An MCO shall promptly report to the Department's Office of Inspector General (OIG) any potential fraud, waste, abuse, or information it has received from whistleblowers relating to the integrity of the MCO, its network providers, or its subcontractors.

D. An MCO shall report any potential fraud directly to the Medicaid Fraud Control Unit and the Department's OIG, including fraud by providers, employees and subcontractors of the MCO, enrollment agents, and enrollees.

E. After reporting any potential fraud, waste, or abuse to the Department's OIG and to the Medicaid Fraud Control Unit, the MCO may not take the following actions without prior written approval from the State:

(1) Contact the subject of the investigation about any matter related to the investigation;

(2) Enter into or attempt to negotiate any settlement or agreement regarding the incident; or

(3) Accept any monetary or other type of consideration offered by the subject of the investigation in connection with the incident.

F. For complaints of provider fraud and abuse that warrant a preliminary investigation, the MCO's reports required in §§C and D of this regulation shall include:

(1) The number of complaints;

(2) The name and identification number of the provider being investigated;

(3) The source of the complaint;

(4) The type of provider;

(5) The nature of the complaint;

(6) The approximate dollar amount involved;

(7) The legal and administrative disposition of the case; and

(8) The method by which the MCO verified that the services being investigated were actually provided to the enrollee.

G. An MCO shall provide to the Department written disclosure of any affiliation prohibited under 42 CFR § 438.610 and take action as directed by the Department.

H. An MCO shall provide to the Department written disclosures of information on ownership and control required under 42 CFR § 455.104, including:

(1) The following information for any individual or corporation with an ownership or control interest in the MCO:

(a) For individuals:

(i) Name;

(ii) Address;

(iii) Date of birth; and

(iv) Social Security number; and

(b) For corporate entities:

(i) Name;

(ii) Applicable primary business address;

(iii) Every business location and applicable P.O. Box address; and

(iv) Other tax identification number or any subcontractor in which the MCO has a 5 percent or more interest;

(2) Whether the individual or corporation with an ownership or control interest in the MCO:

(a) Is related to another person with ownership or control interest in the disclosing entity as a spouse, parent, child, or sibling; or

(b) Whether the individual or corporation with an ownership or control interest in any subcontractor in which the MCO has a 5 percent or more interest is related to another person with ownership or control interest in the MCO as a spouse, parent, child, or sibling;

(3) The name of any other MCO in which an owner of the MCO has an ownership or control interest;

(4) The name, address, date of birth, and Social Security number of any managing employee or agent of the MCO;

(5) Disclosures of ownership and control information from MCOs are due at the following times:

(a) Upon application;

(b) Upon the managed care entity executing the contract with the State;

(c) Upon renewal or extension of the contract; and

(d) Within 35 days after any change in ownership of the managed care entity.

I. An MCO shall report to the Department all overpayments identified and recovered, specifying the overpayments due to fraud.

J. An MCO shall report third-party liability collection activities as described in COMAR 10.67.65.18.

K. An MCO shall report to the Department the amounts the MCO has cost-avoided and the number of third-party liability cases the MCO has handled.

L. An MCO shall notify the Department promptly when it has knowledge of an enrollee's change of residence or death.

M. An MCO shall notify the Department promptly when the MCO receives information about a change in a network provider's circumstances that may affect the network provider's eligibility to participate in the Program, including the termination of the provider agreement with the MCO.

N. An MCO shall submit all required data, documentation and information in the format specified by the Department.

O. An MCO's chief executive officer, chief financial officer, or directly-reporting authorized employee shall certify to the best of that individual's information, knowledge, and belief, that any records, data, or other documents requested under regulations are accurate, complete and truthful.

P. As directed by the Department's OIG, the MCO shall submit written reports documenting its Program Integrity efforts, including but not limited to:

(1) The dollar amount of losses and recoveries attributable to overpayment, abuse, and fraud; and

(2) The number of referrals to the Department's OIG during the prior State fiscal year.

Md. Code Regs. 10.67.07.03

Regulations .03 recodified from 10.09.68.03 effective 46:22 Md. R. 976, eff. 11/1/2019