Questions billers ask › What must Medicaid managed care organization contracts include?
What must Medicaid managed care organization contracts include?
The rule, word for word
“(a) Administrative and management arrangements or procedures to detect and prevent fraud, waste and abuse. The State, through its contract with the MCO, PIHP or PAHP, must require that the MCO, PIHP, or PAHP, or subcontractor to the extent that the subcontractor is delegated responsibility by the MCO, PIHP, or PAHP for coverage of services and payment of claims under the contract between the State and the MCO, PIHP, or PAHP, implement and maintain arrangements or procedures that are designed to detect and prevent fraud, waste, and abuse. The arrangements or procedures must include the following: (1) A compliance program that includes, at a minimum, all of the following elements: (i) Written policies, procedures, and standards of conduct that articulate the organization's commitment to comply with all applicable requirements and standards under the contract, and all applicable Federal and State requirements. (ii) The designation of a Compliance Officer who is responsible for developing and implementing policies, procedures, and practices designed to ensure compliance with the requirements of the contract and who reports directly to the Chief Executive Officer and the board of directors. (iii) The establishment of a Regulatory Compliance Committee on the Board of Directors and at the senior management level charged with overseeing the organization's compliance program and its [...]”
Published2026-04-06 Captured2026-04-06
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What our AI found in the sources
Medicaid managed care organization (MCO) contracts must include a comprehensive set of requirements covering program integrity, provider networks, beneficiary protections, and administrative standards. The core requirements include: (1) administrative arrangements to detect and prevent fraud, waste, and abuse, including a compliance program with a designated Compliance Officer and Regulatory Compliance Committee; (2) provider screening and enrollment consistent with part 455 requirements; (3) inspection and audit rights for the State, CMS, and federal oversight agencies for 10 years; (4) compliance with civil rights laws and conflict of interest safeguards; (5) beneficiary information safeguarding per part 431, subpart F; (6) specifications for covered populations, enrollment procedures, and scope of services; (7) quality evaluation provisions; (8) contract termination procedures; (9) subcontracting specifications and requirements; (10) third-party liability procedures; (11) provider-preventable condition payment prohibitions; (12) physician incentive plan compliance; (13) advance directives policies; (14) audited financial reports; (15) mental health parity compliance; and (16) for contracts covering outpatient drugs, drug utilization review programs, rebate reporting within 45 days, and unique Medicaid BIN/PCN identifiers.
Also cited
Published2026-04-06 Captured2026-04-06
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Published2026-04-06 Captured2026-04-06
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Published2026-04-06 Captured2026-04-06
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If this comes up on one of your claims
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