Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) contracts with external entities for the management and administration of select organizational functions in aims of providing efficient and cost-effective care to our members. Delegates/First Tier, Downstream, and Related Entities (FDRs) must perform all delegated services in accordance with contractual and regulatory requirements outlined by the Department of Health Care Services (DHCS), the Department of Managed Health Care (DMHC), and the Centers for Medicare and Medicaid Services (CMS).
Health Plan prioritizes assessment of each external entity in consideration of risk to ensure its ability to perform delegated functions and compliance. Assessments are conducted prior to executing a formal agreement, and ongoing oversight is performed at least on an annual basis or through performance monitoring activities, focused or ad hoc audits. Assessments include a review of policies and procedures, data, and file review, as appliable.
Delegates/FDRs may not subdelegate any assigned functions to another entity (whether on- or off-shore) without the written consent and approval by Health Plan. If sub-delegation is approved by Health Plan, Delegates/FDRs are responsible for monitoring and overseeing their subcontractors’ performance, and its oversight activities will be assessed by Health Plan at least annually.
Our Health Plan’s delegation model is unique to entities that administer core Benefits on our behalf, such as Vision, Transportation, and Pharmacy. Health Plan may also delegate Administrative functions including, but not limited to, Credentialing, Claims and Provider Dispute Resolutions (PDR), Language Assistance, and DHCS CalAIM Programs, such as Enhanced Care Management and Community Supports.
In addition to evaluating how entities perform delegated functions, Health Plan also conducts oversight of the following essential Compliance program requirements to ensure protection of member information and program integrity in accordance with contractual obligations:
- Fraud, Waste, and Abuse
- HIPAA Privacy and Security
- Disclosure of Ownership and Control
If instances of non-compliance are identified during any oversight activities or following a disclosure, Health Plan will request a Delegate/FDR develops a comprehensive Corrective Action Plan (CAP), including development of a comprehensive root cause analysis and remediation plan. Follow-up monitoring activities or validation audits may occur to ensure corrective actions are implemented, as reported. Health Plan will also request and collect evidence of updated or newly developed documents and processes, trainings, policies, etc. within the corrective action plan.
Delegates/FDRs must implement approved CAPs and Health Plan will monitor their completion, including through follow-up audits as necessary. If instances of non-compliance are unresolved or pose a significant risk to Health Plan, they will be escalated to internal committees that may direct implementation of administrative or monetary sanctions.
Health Plan also retains the right to directly monitor and oversee delegates/FDRs’ subcontractors when sub-delegation is authorized. Oversight includes continuous monitoring and annual oversight audits.