8.1 Applicant must confirm it can provide certain detailed documentation as defined by the Exchange in the NOD 23 Gross to Network Report as specified in Appendix J Issuer Payment Discrepancy Resolution and Appendix K NOD 23 Report Glossary. No space for details provided. Single, Pull-down list. 1: Yes, confirmed, 2: No, not confirmed Attached Document(s): , 8.2 Applicant must confirm it can perform financial reconciliation at a member and group level for each monthly coverage period. No for details provided. Single, Pull-down list. 1: Yes, confirmed, 2: No, not confirmed 9 Fraud, Waste and Abuse Detection This section not required if Applicant has completed the Qualified Health Plan Application Plan Year 2019Individual Marketplace. 9.4.8 and 9.4.17 required for currently contracted Individual Market Applicants. Section not required for currently contracted CCSB Market Applicants. All questions required for new entrant Applicants. The Exchange is committed to working with its QHP issuers to minimize waste and abuse. The framework for managing fraud risks is detailed in Appendix O U.S. Government Accountability Office circular (available in Manage Documents). The Exchange expects QHP issuers to adopt leading practices outlined in the framework to the extent applicable. Fraud prevention is centered on integrity and expected behaviors from employees and others. All measures to detect, deter, and prevent fraud before it occurs are vital to all issuer and Exchange operations. Definitions: Fraud Consists of an intentional misrepresentation, deceit, or concealment of a material fact known to the – defendant with the intention on the part of the defendant of thereby depriving a person of property or legal rights or otherwise causing injury. (CA Civil Code §3294 (c)(3), CA Penal Code §§470-483.5). Prevention and early detection of fraudulent activities is crucial to ensuring affordable healthcare for all individuals. Examples of fraud include, but not limited to, false applications to obtain payment, false information to obtain insurance, billing for services that were not rendered. - Intentional or unintentional, extravagant careless or needless expenditures, consumption, mismanagement, use, or squandering of resources, to the detriment or potential detriment of entities, but without an intent to deceive or misrepresent. Waste includes incurring unnecessary costs as a result of inefficient or ineffective practices, systems, decisions, or controls.
8.1 Applicant must confirm it can provide certain detailed documentation as defined by the Exchange in the NOD 23 Gross to Network Report as specified in Appendix J Issuer Payment Discrepancy Resolution and Appendix K NOD 23 Report Glossary. No space for details provided. Single, Pull-down list. 1: Yes, confirmed, 2: No, not confirmed Attached Document(s): , 8.2 Applicant must confirm it can perform financial reconciliation at a member and group level for each monthly coverage period. No for details provided. Single, Pull-down list. 1: Yes, confirmed, 2: No, not confirmed 9 Fraud, Waste and Abuse Detection This section not required if Applicant has completed the Qualified Health Plan Application Plan Year 2019Individual Marketplace. 9.4.8 and 9.4.17 required for currently contracted Individual Market Applicants. Section not required for currently contracted CCSB Market Applicants. All questions required for new entrant Applicants. The Exchange is committed to working with its QHP issuers to minimize waste and abuse. The framework for managing fraud risks is detailed in Appendix O U.S. Government Accountability Office circular (available in Manage Documents). The Exchange expects QHP issuers to adopt leading practices outlined in the framework to the extent applicable. Fraud prevention is centered on integrity and expected behaviors from employees and others. All measures to detect, deter, and prevent fraud before it occurs are vital to all issuer and Exchange operations. Definitions: Fraud – Consists of an intentional misrepresentation, deceit, or concealment of a material fact known to the defendant with the intention on the part of the defendant of thereby depriving a person of property or legal rights or otherwise causing injury. (CA Civil Code §3294 (c)(3), CA Penal Code §§470-483.5). Prevention and early detection of fraudulent activities is crucial to ensuring affordable healthcare for all individuals. Examples of fraud include, but not limited to, false applications to obtain payment, false information to obtain insurance, billing for services that were not rendered. - Intentional or unintentional, extravagant careless or needless expenditures, consumption, mismanagement, use, or squandering of resources, to the detriment or potential detriment of entities, but without an intent to deceive or misrepresent. Waste includes incurring unnecessary costs as a result of inefficient or ineffective practices, systems, decisions, or controls.
CCSB%20QHP%20Certification%20Application%20Plan%20Year%202019%20Quarterly%20Application_Final.docx