LC-DraftAdminContract Matrix8-13-08clean (3)

ADMINISTRATIVE CONTRACTING REQUIREMENTS FOR MANAGEMENT/DELEGATION OF CONTRACTS AND/OR AGREEMENTS

For contracts and/or agreements that directly relate to MA Organization’s core functions under its contract with CMS

NAME OF CONTRACTOR (FIRST TIER, DOWNSTREAM and RELATED ENTITY)
CMS REGULATIONS – 42 CFR 422		Section/Page	Section/Page	Section/Page	Section/Page	Section/Page
Record Retention. HHS, the Comptroller General or their designees have the right to audit, evaluate and inspect audit any books, contracts, records, including medical records, and documentation related to CMS’ contract with the MA organization for a period of 10 years from the final date of the contract period or the completion of any audit, whichever is later. 422.504(i)(2)(i) and (ii);
Hold Harmless Provisions - Providers may not hold beneficiary liable for payment of fees that are the legal obligation of the MAO. 422.504(g)(1)(i); 422.504(i)(3)(i)
Accordance with MAO’s contractual obligations. A provision requiring that any services performed will be in consistent and comply with the MA organization’s contractual obligations 422.504(i)(3)(iii)
Delegation of Providers. If the MAO delegates selection of providers, written arrangements must state the MAO retains the right to approve, suspend, or terminate such arrangement. 422.504(i)(5)
Accountability Provision – Reporting Responsibilities The contract must clearly state the delegated activities and reporting responsibilities. 422.504(i)(3)(ii); 422.504(i)(4)(i)
Accountability Provision – Revocation. Agreement provides for the revocation of the delegated activities and reporting requirements or specify other remedies in instances when CMS or the MA organization determine that such parties have not performed satisfactorily. 422.504(i)(3)(ii); 422.504(i)(4)(ii)
Accountability Provision – Monitoring Agreement provides that the performance of the parties is monitored by the MA organization on an ongoing basis 422.504(i)(3)(ii); 422.504(i)(4)(iii)
Accountability Provision - Credentialing The credentials of medical professionals affiliated with the party or parties will either be reviewed by the MA organization or the credentialing process will be reviewed and approved by the MA organization; OR the MA organization must audit the credentialing process on an ongoing basis 422.504(i)(3)(ii); 422.504(i)(4)(iv)(A)(B)
Comply with applicable Medicare laws and Regulations Must comply with all applicable Medicare laws, regulations, and CMS instructions 422.504(i)(4)(v)
Dated and Signed

 In addition to the CFR citations provided below, the following contract provisions are required in agreements between MA organizations and provider and suppliers of health care as stated in Chapter 11 of the Medicare Managed Care Manual Section 100.4.

Draft 4-18-08 Provider Matrix Template

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