42 CFR 422.503 - General provisions
| Cite as | 42 CFR 422.503 |
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38 practice notes
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Hous. Methodist Hosp. v. Humana Ins. Co., CIVIL ACTION NO. H–16–1469
...MA organizations. 42 C.F.R. § 422.2. MA organizations must satisfy detailed requirements to qualify for inclusion in the MA program. 42 C.F.R. § 422.503. Once CMS and an MA organization enter into a contract, CMS makes capitation payments to the MA organization for enrollee health care serv......
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United States ex rel. Ormsby v. Sutter Health, Case No. 15-cv-01062-LB
...of a compliance officer, and other listed minimum requirements." Silingo , 904 F.3d at 673 (internal brackets omitted) (quoting 42 C.F.R. § 422.503(b)(4)(vi) ).21 Among other things, the compliance programs must "includ[e] ‘procedures for internal monitoring and auditing’ and for ‘ensuring ......
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Humana Med. Plan, Inc. v. Reale, No. 3D12–2883.
...which are administered by private insurers known as Medicare Advantage organizations ("MAOs") that enter into contracts with CMS.5 42 C.F.R. § 422.503 ("In order to qualify as an MA organization, enroll beneficiaries in any MA plans it offers, and be paid on behalf of Medicare beneficiaries......
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Halifax Reg'l Med. Ctr. v. UnitedHealthcare of N.C., Inc., 4:20-CV-142-D
...See 42 U.S.C. § 1395w-21, et. seq. Generally, Medicare Advantage Organizations ("MAO") contract with CMS. See 42 U.S.C. § 1395w-21 ; 42 C.F.R. § 422.503. CMS makes monthly pre-beneficiary payments to MAOs, which serve Medicare beneficiaries. See 42 U.S.C. §§ 1395w-23, - 25(b). MAOs may "sel......
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28 cases
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United States ex rel. Ormsby v. Sutter Health, Case No. 15-cv-01062-LB
...of a compliance officer, and other listed minimum requirements." Silingo , 904 F.3d at 673 (internal brackets omitted) (quoting 42 C.F.R. § 422.503(b)(4)(vi) ).21 Among other things, the compliance programs must "includ[e] ‘procedures for internal monitoring and auditing’ and for ‘ensuring ......
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Humana Med. Plan, Inc. v. Reale, No. 3D12–2883.
...which are administered by private insurers known as Medicare Advantage organizations ("MAOs") that enter into contracts with CMS.5 42 C.F.R. § 422.503 ("In order to qualify as an MA organization, enroll beneficiaries in any MA plans it offers, and be paid on behalf of Medicare beneficiaries......
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Hous. Methodist Hosp. v. Humana Ins. Co., CIVIL ACTION NO. H–16–1469
...MA organizations. 42 C.F.R. § 422.2. MA organizations must satisfy detailed requirements to qualify for inclusion in the MA program. 42 C.F.R. § 422.503. Once CMS and an MA organization enter into a contract, CMS makes capitation payments to the MA organization for enrollee health care serv......
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Halifax Reg'l Med. Ctr. v. UnitedHealthcare of N.C., Inc., 4:20-CV-142-D
...See 42 U.S.C. § 1395w-21, et. seq. Generally, Medicare Advantage Organizations ("MAO") contract with CMS. See 42 U.S.C. § 1395w-21 ; 42 C.F.R. § 422.503. CMS makes monthly pre-beneficiary payments to MAOs, which serve Medicare beneficiaries. See 42 U.S.C. §§ 1395w-23, - 25(b). MAOs may "sel......
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8 firm's commentaries
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Healthcare Fraud & Abuse Review 2017
...MA Plans are required to maintain “an effective compliance program, 30. See 42 U.S.C. § 1395w-23. 31. 42 C.F.R. § 422.504(l)(2). 32. 42 C.F.R. § 422.503(b)(vi). 33. See 42 C.F.R. § 422.310. 34. No. 2:09-cv-05013 (C.D. Cal.). 35. No. 2:16-cv-08697 (C.D. Cal.). 36. United States’ Complaint-In......
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CMS Considers Mandating Fraud Reporting By Medicare Advantage Plans
...Fraud and Abuse, OEI-03-10-00310 (February 2012) at http://articles.law360.s3.amazonaws.com/0313000/313099/oig-partc-fraud-report.pdf. 42 CFR § 422.503(b)(4)(vi); 42 CFR § The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be s......
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Medicaid managed care proposed rule expands program integrity obligations
...and Medicaid by making the Medicaid managed care compliance program requirements "consistent" with those of MA, as set forth at 42 C.F.R. § 422.503(b)(4)(vi). CMS's statements notwithstanding, the proposed changes below differ from MA requirements in several fundamental respects (with the i......
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Ready Or Not? Final Compliance Program Guidelines Have Come
...from 68 separately identified entities, including Sponsors, pharmacy associations, and health plan associations. Pursuant to 42 C.F.R. §§ 422.503(b)(4)(vi) ("Conditions necessary to contract as an MA organization") and 423.504(b)(4)(vi) ("Conditions necessary to contract as a Part D plan sp......
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1 books & journal articles
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Pre-Submission Risk Adjustment Audits: Preventing Medicare Advantage Plans from Draining Medicare Funds Dry
...to a local or regional service area.58Once bids are finalized, the Secretary of HHS 49. HOFFMAN ET AL., supra note 2, at 8. 50. 42 C.F.R. § 422.503(b)(4)(i)–(vi) (2016) (describing the minimum requirements for a compliance program including the policies and report structure it must contain)......