18 NYCRR 521-1.3 — Required Provider Duties (Compliance Program)

What this rule requires your agency to do

• 1As a condition of receiving payment under the MA program, the required provider shall adopt, implement, and maintain an effective compliance program satisfying this SubPart for the entire period it meets the definition of a required provider (subd. a).(18 NYCRR 521-1.3 — Required Provider Duties (Compliance Program))
• 2The required provider shall comply with the requirements of SubPart 521-3 to report, return, and explain overpayments (subd. g).(18 NYCRR 521-1.3 — Required Provider Duties (Compliance Program))
• 3The required provider shall retain all records demonstrating that it has adopted, implemented, and operated an effective compliance program for a period not less than six (6) years, and shall make copies available to the department, OMIG, or MFCU upon request (subd. b).(18 NYCRR 521-1.3 — Required Provider Duties (Compliance Program))
• 4The required provider shall comply with all directives of the department or OMIG with respect to the adoption, implementation, and maintenance of the compliance program (subd. e).(18 NYCRR 521-1.3 — Required Provider Duties (Compliance Program))
• 5The required provider shall apply its compliance program to its risk areas, including at a minimum billings, payments, ordered services, medical necessity, quality of care, governance, mandatory reporting, credentialing, contractor/subcontractor/agent oversight, and other risk areas reasonably identified through organizational experience (subd. d).(18 NYCRR 521-1.3 — Required Provider Duties (Compliance Program))
• 6The required provider shall certify to the department upon enrollment and annually thereafter, in the form and manner required by OMIG and the department, that it has met the requirements of Social Services Law section 363-d and this SubPart; participating providers that are required providers shall also provide a copy of the certification to each MMCO upon signing the provider agreement and annually thereafter (subd. f).(18 NYCRR 521-1.3 — Required Provider Duties (Compliance Program))
• 7The required provider shall ensure that contracts with contractors, agents, subcontractors, and independent contractors specify that they are subject to the provider's compliance program (within the scope of their contracted authority and affected risk areas) and include termination provisions for failure to adhere; the required provider remains ultimately responsible for the program's adoption, implementation, maintenance, enforcement, and effectiveness (subd. c).(18 NYCRR 521-1.3 — Required Provider Duties (Compliance Program))