42 C.F.R. § 438.608 Program integrity requirements.
Title 42 - Public Health
(a) General requirement. The MCO or PIHP must have administrative and management arrangements or procedures, including a mandatory compliance plan, that are designed to guard against fraud and abuse. (b) Specific requirements. The arrangements or procedures must include the following: (1) Written policies, procedures, and standards of conduct that articulate the organization's commitment to comply with all applicable Federal and State standards. (2) The designation of a compliance officer and a compliance committee that are accountable to senior management. (3) Effective training and education for the compliance officer and the organization's employees. (4) Effective lines of communication between the compliance officer and the organization's employees. (5) Enforcement of standards through well-publicized disciplinary guidelines. (6) Provision for internal monitoring and auditing. (7) Provision for prompt response to detected offenses, and for development of corrective action initiatives relating to the MCO's or PIHP's contract.
Title 42: Public Health
PART 438—MANAGED CARE
Subpart H—Certifications and Program Integrity
§ 438.608 Program integrity requirements.
