Sample Delegated Oversight Committee Charter

DELEGATED OVERSIGHT COMMITTEE CHARTER

I. INTRODUCTION

ABC Health Plan is committed to ensuring that all First Tier Entity, Downstream Entity, or Related Entity with whom it works (“delegated entities”) can perform the delegated functions that they are contracted to perform and that they can meet the requirements of all applicable laws and regulations.

Performing oversight allows ABC Health Plan to evaluate and monitor its delegated entities compliance with their contractual obligations, as well as ABC Health Plan’s own ongoing compliance with the terms and conditions of its contract with CMS.

The establishment of the ABC Health Plan Delegation Oversight Committee through this charter evidences ABC Health Plan’s commitment to ensuring its compliance and the compliance of its delegated entities with all applicable laws and regulations.

II. PURPOSE AND AUTHORITY

The purpose of the ABC Health Plan Delegated Oversight Committee (DOC) is to ensure that the ABC Health Plan oversight activities ensure and document that delegated entities to are compliant with all applicable laws and regulations and that ABC Health Plan is compliant with regulatory guidelines as it relates to the delegation of core administrative and management functions. These core functions may include, among other things, delegation credentialing, customer service, dental, pharmacy benefit management, grievance and appeals, and claims administration.

The ABC Health Plan Delegation Oversight Committee is responsible for overseeing the on-going monitoring of delegated core administrative and management functions to ensure business goals and regulatory requirements are met.

The ABC Health Plan Delegation Oversight Committee provides oversight and general guidance on all matters relating to potential and current delegated entities’ compliance with the regulations, requirements, and/or standards set forth by the Centers for Medicare & Medicaid Services (CMS), ABC Health Plan internal policies and procedures, and/or any other applicable federal or state regulatory authority. The Delegation Oversight Committee reports to the ABC Health Plan Executive Compliance Committee (ECC).

III. COMPOSITION AND QUALIFICATIONS

The Chair of the Delegation Oversight Committee is the Chief Compliance Officer (CCO) or his/her designee. The CCO is responsible for reporting on delegation-related compliance activities, such as pre-delegation and annual audits, review of delegated entity reports, maintaining the minutes of meetings, and ensuring that the Delegation Oversight Committee decisions are timely implemented.

The Chair with the approval of the ECC shall appoint the initial Delegation Oversight Committee members. The Chair with the approval of the Delegation Oversight Committee shall appoint additional Committee members, additional Ad Hoc members or successor Committee members. The Chair with the approval of the Delegation Oversight Committee shall also remove members from the Committee.

Committee members shall include subject matter experts (SMEs) from each appropriate delegated function, including but not limited to claims, enrollment & eligibility, pharmacy, medical management, finance, network services, and credentialing.

The Committee shall require that all members:

  • Have seniority and comprehensive experience in their operating unit;
  • Are responsible;
  • Demonstrate high integrity and good judgment; and
  • Are not excluded from participation in Federal health care programs.

IV. MEETINGS AND REPORTS

The Committee will meet on a monthly basis at minimum, and more frequently as necessary, to provide reasonable oversight of compliance with the delegation regulations, requirements and/or standards set forth by CMS, ABC Health Plan internal policies and procedures and/or any other applicable federal or state regulatory authority. The Committee shall maintain written minutes of its meetings and activities and distribute meeting minutes to all Committee members. The Committee Chair shall provide regular reports on the Committee’s activities to ABC Health Plan Executive Compliance Committee.

V. COMMITTEE MEMBER ROLES AND RESPONSIBILITIES

The Committee will have the overall responsibility for ABC Health Plan’s compliance with the delegation requirements as set forth by CMS, ABC Health Plan internal policies and procedures and/or any other applicable federal or state regulatory authority, including but not limited to:

Pre-Delegation

  • Ensure that all potential delegates are screened, credentialed and audited in accordance with ABC Health Plan procedures to evaluate, prior to delegation, their ability to perform the delegated functions and meet the delegation requirements;
  • Receive reports from the CCO on the results of pre-delegation audit findings, as well as recommendations regarding whether to award or deny the delegation;
  • Make the final determination regarding whether to award or deny delegation;
  • Ensure adherence to all regulatory and legal requirements in the contracting process;
  • Ensure that delegates receive training in accordance with ABC Health Plan’s policies and procedures; and
  • Ensure that the delegation agreement and/or Scope of Work, provides for monthly reporting on all areas sufficient for ongoing monitoring.

Ongoing

Ensure that monthly monitoring, and annual and ad hoc audits are performed in accordance with ABC Health Plan procedures to assess delegates’compliance with delegation requirements;

  • Define and establish reporting deliverables;
  • Receive reports from the CCO on the results of such audits and monitoring; Establish effective auditing tools to measure administrative/management performance to ensure compliance with regulatory requirements.
  • Review and evaluate vendor performance, identifies opportunities for performance improvement, recommend and issue corrective action plans when a deficiency has been identified. When deficiencies have been identified, review sufficiency of corrective action plans;
  • Oversee follow-up on corrective action plans to ensure deficiencies have been corrected; When deficiencies have not or cannot be corrected, impose sanctions up to and including the revocation and/or termination of delegation if the delegated entity’s performance is inadequate;
  • Ensure that delegates receive annual training in accordance with ABC Health Plan’s policies and procedures; and
  • Ensure ongoing adherence to all regulatory and legal requirements, including but limited to routine sanction screening of all employees and sub-contractors

VI. CONCLUSION

Unless expressly permitted, Committee members may not delegate the responsibilities outlined above to other individuals in the organization. This Charter should be presented to Committee members, as well as to the ABC Health Plan Executive Compliance Committee. The CCO is responsible for periodic reviews and updates to the Charter.

VII. ADOPTION

The Committee adopted this Charter of the ABC Health Plan ‘s Delegation Oversight Committee on MONTH DATE, 2016.

Signature of Chief Compliance Officer /Date

 

APPENDIX A

ABC Plan’s Delegation Oversight Committee Member

[List Committee Member Name and Title/Area  of Responsibility]

Sample Title/Area  of Responsibility

  •   Chief Compliance Officer/Committee Chair
  •   Chief Operations Officer
  •   Fraud Waste and Abuse Officer
  •   Privacy Officer
  •   Credentialing Coordinator
  •   Vice President of Network Development and Contracting
  •   Director of Medical Management and Quality Improvement
  •   Director of Provider Relations
  •   Grievance and Appeals Coordinator
  •   Pharmacy Director
  •   Claims Manager
  •   Director of Government Programs