Compliance 4 U - Monthly Compliance Newsletter_20250416 by Health Plan of San Joaquin/Mountain Valley Health Plan

April 16, 2025

Compliance4U newsletter provides you with insight into the day-to-day functions of the Health Plan’s Compliance Program.

Regulatory Affairs & Communication (RAC)

Welcome to the Compliance RAC SLA series, where we delve into Service Level Agreements (SLAs) frequently encountered in daily operations. In this first installment, we will focus on the Compliance Inquiry Log, an important tool for efficiently managing compliance and regulatory inquiries.

The Compliance Inquiry Log serves as a centralized platform for submitting compliance or regulatory questions, as well as documents required for regulatory submissions. This log ensures inquiries are handled efficiently and directed to the appropriate Subject Matter Expert (SME) for resolution.

Inquiries submitted to the Compliance Inquiry Log are categorized into three types: Standard, Urgent, and Expedited. With the process for each type as follows:

• Standard and Urgent Inquiries: The Inquiry Intake Lead will confirm receipt of the inquiry within one business day, as well as assign the inquiry to the appropriate SME, who will take on the role of the compliance lead.

• Expedited Inquiries: For inquiries marked as expedited, the Inquiry Intake Lead will prioritize the review and immediately assign the inquiry to the relevant SME. The compliance lead will then contact the submitter following their initial review.

Once assigned, the compliance lead will commence their research and aim to complete it within:

• 3-5 business days for standard inquiries

• 1-2 business days for urgent inquiries

• ASAP for expedited inquiries

However, in cases where the compliance lead is unable to complete the research, or if regulatory review is needed, the inquiry will be escalated to the appropriate regulator. It is important to note that our internal SLAs no longer apply once an inquiry is transferred to regulators, as they operate under their own timelines and processes. The compliance lead will continue to follow-up with the regulator until a response is received.

What’s going on at the State and Federal levels? To support you in your role and ensure timely awareness of changes to regulatory and contractual requirements, RAC attends regulatory calls (DHCS Managed Care Plan Call - MCPC) and other regulatory meetings/calls where key regulatory information is shared

 DHCS hosted the Birthing Care Pathway Webinar

On Wednesday, March 5th, DHCS conducted the Birthing Care Pathway webinar. The session focused on the development of the Birthing Care Pathway, a program designed to support Medi-Cal members from conception through twelve months postpartum. The webinar highlighted key findings from member engagement efforts and outlined actions taken to address identified concerns, including the creation and implementation of 42 policies targeting provider access, behavioral health, risk assessment, payment models, and support for justice-involved individuals. Additionally, the webinar introduced strategic opportunities for further improvements, such as enhancing provider diversity, expanding behavioral health resources, and fostering collaboration between state agencies to strengthen maternal care services.

For more details, please refer to “CA Birthing Care Pathway Webinar.”

 DHCS hosted the March CalAIM MCP TA Meeting

On Thursday, March 27th, DHCS hosted the CalAIM March meeting to provide updates on several key topics, including the Knowledge Gap of PCPs, ECM/CS/CCM JSON Exchange, new time limits for Community Supports services, and an update for the Asthma Remediation Community Support. Additionally, DHCS used this meeting as a forum for Kings/Tulare and RAMP to introduce valuable resources for MCPs and their providers. Kings/Tulare

presented their Knowledge Management Page, designed to build a connected community of care by centralizing and curating provider resources. RAMP shared their best practices and introduced their technical assistance services to further support MCPs in their efforts to improve their Asthma Preventative Services, and the updated Asthma Remediation Community Support. For more details, please refer to “March CalAIM MCP TA Meeting.”

RAC maintains materials from those weekly calls. Check out previous meetings HERE.

All Plan Letters (APLs)

DHCS and DMHC release APLs to communicate changes in federal or state policy or procedure and instruct managed care plans (MCPs) on implementing these changes. RAC analyzes the APLs to ensure compliance with the requirements and to meet timely filing. Draft APLs (denoted by “XXX” indicating that both regulators have not assigned a policy number) are issued by both DHCS and DMHC regularly to solicit feedback from MCPs before they are officially published and become effective. During this period, MCPs can provide feedback or concerns to DHCS and DMHC on upcoming APLs. Here are the APLs that were recently released:

A. DHCS Regulatory Notices

No new DHCS APLs or draft APLs have been issued since the last reporting period that are applicable to Health Plan.

B. DMHC Regulatory Notices

APL 25-007 (OFR) – Assembly Bill 3275 Guidance (Claim Reimbursement)

Issue Date: April 1st, 2025

Summary: Assembly Bill 3275 (Soria, 2024) amended Health and Safety Code sections 1371 and 1371.35 relating to reimbursement of claims for health care services, and enacted Health and Safety Code section 1371.34 enhancing consumer protections relating to grievances about claims for health care services. Beginning January 1, 2026, Health Plan must ensure the following requirements in regard to Claim Reimbursement are in place:

• Health Plan must acknowledge receipt of all claims per Rule 1300.71(c)

• Health Plan must reimburse complete claims within 30 calendar days of receipt

• If a claim is contested or denied, the plan must notify the claimant in writing within 30 days.

• Claims paid after 30 days will accrue 15% annual interest starting from the 31st day.

• Failure to pay the required interest will result in an additional penalty of $15 or 10% of accrued interest (whichever is greater).

• Written notices must specify which parts of a claim are contested or denied and the reason.

• If a claim is contested due to missing information, it must be resolved within 30 days of receiving additional details.

• Any complaint about claim payment delays or denials from an enrollee must be treated as a grievance under Health & Safety Code Section 1371.34.

• Review and update provider contracts, claims policies, service agreements, and disclosures to ensure compliance with AB 3275.

• Submit an amendment filing affirming compliance with AB 3275 and APL 25-007 by August 1, 2025.

• Ensure delegated entities (e.g., claims processors, risk-bearing organizations) comply with the new rules.

• Compliance will be reaching out soon to schedule a kick-off meeting on this new APL.

Reminder All Plan Letter (APL) Policy Filing Process

All policies must complete the policy workflow before submission to DHCS/DMHC. Policy owners must ensure their policies are approved by their department executive on the Policy Management Application (PMA). Upon receipt of the policies, the Compliance Policy team will review and then send the policies for CEO approval. Once all approvals have been obtained, Compliance will submit the policies to DHCS/DMHC.

RESPONSIBLE PERSON

Regulatory Reports

Under our contract with DHCS and in compliance with our Knox-Keene license (DMHC), we must routinely submit reports demonstrating compliance and performance. Below is a list of reports due for submission in the next few weeks. The table includes a hyperlink to the report and the accountable Director and

Executive for the report. Check out the list to find out which ones are in your department. Click on the report title for more information.

Report Title

Provider Directory File & Use 2025-04

Provider Directory Spring Summer 2025

ECM/JSON 2025-03

CBAS Waiver 2024-03

CBAS Quarterly 2025-Q1

274 File 2025-03

MCPDIP 2025-03

Data Certification 2025-03

Quarterly FWA 2025-Q1

Post Payment Recovery 2025-03

PIN 2025-03

Encounter Data 2025-03

Consolidated Billing 2025-03

NEMT/NMT 2025-01

DMHC Monthly Financials 2025-03

Pending Unresolved Grievance 2025-Q1

New Members Mailing Attestation 2025-04

Annual Marketing Plan 2025

CAC Demographic Report 2025

Member Death Notification 2025-Q1

CY 23 Phase 2 Contract Flagging

Provider Network Impact Report 2025-Q1

Quarterly Network Change Report 2025-Q1

LTC QAPI Program

Provider Complaints

Ana Aranda Liz Le

Clarence Rao Victoria Worthy

Pamela Lee Tracy Hitzeman

Clarence Rao Victoria Worthy

Tamara Hayes Betty Clark

Cambria Day Betty Clark

Christopher Navarro Michelle Tetreault

Ana Aranda Liz Le

Clarence Rao Victoria Worthy

Dale Standfill Liz Le

Somatra Sourng Michelle Tetreault

Ramanpreet Kaur Lakshmi Dhanvanthari

Vena Ford Evert Hendrix

Setar Testo Tracy Hitzeman

Somatra Sourng Michelle Tetreault

Clarence Rao Victoria Worthy

Ana Aranda Liz Le

Kathleen Dalziel Robert Ruiz

Provider complaints come to the Health Plan in different forms (e.g., direct call to us or dispute submission to DMHC). While our Provider Services and Claims teams address those coming into us, Compliance is the point of contact for those coming through DMHC. In 2025, Health Plan received 9 requests (2 new Provider Complaints and 7 additional information requests), disputing 2 claims. In 2024, we received 67 requests (28 Provider Complaints and 39 additional information requests), disputing 56 claims. In addition, each complaint may

contain multiple issues that require a response. In 2023, Health Plan received 20 requests (13 Provider Complaints and 7 additional information requests), disputing 28 claims.

Compliance coordinates a cross-functional group to review each complaint we receive. This group investigates the cases (from the original request to claim processing and dispute resolution) and prepares a comprehensive response to the DMHC about the provider’s concerns and the actions taken by us These tables outline the status:

Table 1: Provider Complaints Received from DMHC as of April 2nd, 2025:

Table 2: Provider Complaint Closures by Decision

Word Scramble

Instructions: Rearrange the letters to form the correct word in each of the lines below.

Do you have a question for Compliance? To submit an inquiry, go to Team Sites > Compliance > Requests > Submit an Inquiry on SharePoint or simply use this link: check it out here.

TIAUD

Program Integrity Unit (PIU)

The PIU investigates and reports all potential fraud, waste, or abuse (FWA) and HIPAA violations We also conduct exclusion monitoring of our third parties, provide subject matter expertise for audits, manage members’ rights to access/limit their PHI and plan and track annual compliance training. Here are some things we’ve been working on:

Privacy & Security

PHI Microsoft Teams

We want to reiterate what we shared in the last All Staff and Monthly Managers’ meetings regarding the sharing of PHI internally within the Health Plan.

It is okay for you to enter reference numbers such as member IDs, claim numbers, or authorization numbers into and links for files containing PHI into Microsoft Teams chat and channel function

Please note that we always want to focus on following the minimum necessary rule when it comes to sharing PHI. This means that you want to share the least amount of PHI that is necessary to complete the task that you are working on. Please remember that the sharing of PHI over Microsoft Teams chats that could be used to identify a member such as their name, address, date of birth, email and etc. is still not okay and if it occurs will result in a privacy incident.

PHI in Email

We want to remind you that you are still required to encrypt emails internal or external emails, if they contain PHI.

When naming any documents, files or emails, please remember not to include PHI in the title that could be used to identify a member, such as their name. Instead, we encourage you to use a reference number that can be used for your own tracking purposes.

Privacy & Security Incidents

We had 24 HIPAA incidents occur between March 1 – March 31, 2025. Three (3) of these were reportable to DHCS. Below are some prevention tips related to March reportable incident:

Reminder:

1. Slow down and take your time when working with data that contains member PHI.

2. Double check your work.

3. Ensure that you are sending PHI to the intended recipient(s)

4. Have another team member check your work if possible.

5. Remember that you are not allowed to send any PHI to your personal email or to anyone outside of the Health Plan. Ensure that you do not use any member PHI for your own personal use.

Fraud, Waste, and Abuse (FWA)

Medical records reviews play a crucial role in helping the PIU verify that providers are billing correctly and documenting properly, but what exactly do we look at?

We review service codes, units billed, modifiers, place of service codes, diagnosis codes, and more to ensure that the medical documentation fully supports what was billed. Our goal is to confirm accuracy, prevent improper payments, and uphold compliance standards.

The PIU will pursue overpayment recovery when a provider lacks requested documentation or is unable to provide medical records and when there is a clear regulatory violation.

Recent Updates

In the last month, our team opened one (1) case and closed five (5). Our team investigated 24 active cases and monitored three (3) cases

Your Role

If you notice a suspicious activity, don’t hesitate to report it. Stay vigilant. Stay committed.

Upcoming Compliance Trainings

HIPAA - Apr 1, and due Apr 30

General Compliance and FWA Training – Apr 1, and due Apr 30

Sexual Harassment Prevention – Jun 7, and due Jul 7

Diversity, Equity, and Inclusion (DEI) – Nov 3, and due Dec 3

Provider Exclusion Monitoring

PIU regularly monitors vendors and providers we contract with for exclusions, per 42 Code of Federal Regulations (C.F.R.) §438.610, which prohibits Medi-Cal Managed Care Plans (MCPs) from contracting or maintaining a contract with physicians or other health care providers who are excluded, suspended, or terminated from participating in the Medicare or Medi-Cal programs.

Recent Updates

In case you missed this information last month, here is the update again. The PIU streamlined the process for notifying the BOs of excluded providers by creating an email template and removing excess information and attachments. This allows the BO to have all the information in a consolidated format with one click.

LOA Exclusion Monitoring

Zero (0) provider exclusions were identified

Audit & Oversight (A&O)

Introducing the Audit & Oversight Team: Ensuring Compliance and Operational Excellence

The Audit & Oversight Department (A&O) ensures regulatory adherence and quality improvement through comprehensive auditing and monitoring of both clinical and non-clinical functions.

A&O is divided into two primary areas: Clinical Audit & Oversight and NonClinical Audit & Oversight, each focusing on key operational functions that drive compliance and service excellence.

Clinical A&O is responsible for auditing and oversight of Medical Management activities, as well as clinical vendor and delegate operations. This includes areas such as Quality Improvement, Credentialing, Population Health Management, Behavioral Health, Utilization and Case Management, Grievances and Appeals, Pharmacy, and Enhanced Care Management/Community Support programs.

Non-Clinical A&O ensures compliance and efficiency of key operations including Claims Processing, Provider Relations, Customer Service, Enrollment and Disenrollment, Cultural and Linguistic Services, Marketing and Network Adequacy. The team is also responsible for audit and monitoring of non-clinical delegated functions and vendor oversight.

Meet the A&O Team

Clinical A&O Team

Compliance Program Manager Clinical Audit & Oversight (Vacant Role)

Provides strategic oversight for both clinical and non-clinical A&O teams, ensuring alignment with organizational and regulatory goals.

Supports both clinical and non-clinical teams, manages regulatory audit activities, and assists with A&O operational operations and projects.

Oversees and ensures compliance within clinical auditing and monitoring activities and manages day-to-day operations.

Responsible for oversight of Enhanced Care Management providers, Case Management and Clinical Behavioral Health.

Responsible for oversight of Medical Management functions, including Utilization Management, Clinical Pharmacy, and Appeals.

Responsible for oversight of Credentialing, Operational Behavioral Health, and Quality Improvement.

Non-Clinical A&O Team

Responsible for oversight of Community Support Services providers and Grievances.

Responsible for oversight of Population Health Management, including Health Education, Transitional Care Services, Operational Pharmacy and MOUs.

Provides operational support for clinical report monitoring, audit tool development, clinical CAP tracking, clinical DLP development, AOC administrative support, and Exhibit J monitoring and validation.

Oversees and ensures compliance within non-clinical auditing and monitoring activities and manages day-to-day operations.

Responsible for the vendor oversight and management, including readiness assessments and third-party risk assessments.

Responsible for oversight of member services operations, including Customer Service, Cultural & Linguistics, Marketing, and Enrollment/ Disenrollment.

Responsible for oversight of provider services such as Claims Administration, Mailroom Operations, and Provider Data and Operations.

Provides operational support for nonclinical report monitoring, audit tool development, non-clinical CAP tracking, non-clinical DLP

Our Commitment to Excellence

development, regulatory audit support, and administrative support for non-clinical and vendor audits.

The Audit & Oversight team plays a vital role in ensuring compliance, operational efficiency, and service quality across our organization. Through diligent monitoring and continuous improvement, we uphold the highest standards for our members, providers, and stakeholders.

For questions or more information about A&O, please e-mail audits_oversight@hpsj.com or connect directly with any of our team members listed above.

Policies and Procedures

Policy Management Application (PMA) Updates

Do you still have questions about our new Policy Management Application (PMA)? Please refer to our PMA training materials on the Compliance SharePoint page. We will also continue to hold office hours to further assist you with navigating the PMA. The next office hours will be held on Friday, 04/18/2025.

Presentation: Policy Management Application (PMA) Training for Policy Owners Videos: Policy Management Application (PMA) Training Videos

March 2025 Published Policies

Since being reviewed and approved by PRC, the following policies have been published in March 2025. We encourage you to read and be familiar with the policies which may impact your job functions. If you have questions regarding the published policies, please reach out to the policy owner and/or the Compliance Policy Team.

All policies, excluding HR policies, are published by the Compliance policy team onto Health Plan’s SharePoint site. Please see the “Did you know?” section below for the SharePoint link to the published policies.

Policy # and Name:

BH02 Alcohol Misuse Catrina R.

BH03 Responsibilities for Behavioral Health Treatment

Coverage for Members Under the Age of 21 Catrina R.

FAC01 Health Plan Vehicle Use and Maintenance

Nicoli G.

FAC04 Office and Cubicle Assignment Nicoli G.

FAC05 Community Room Guidelines Nicoli G.

FIN08 Business Travel Expenses Somatra S.

IT203 Safeguarding Electronic Confidential Information Mohammed A.

IT250 Security Incident Management Policy Mohammed A.

IT32 Interoperability and Patient Access Victoria W.

MM02 IHCP & AIM Tribal Liaison Jeanette L.

PH05 Prior Authorizations Matthew G.

PH23 Submission of Pharmacy Benefit Prior Authorization & Claims Matthew G.

PH30 Medical vs. Pharmacy Benefit Matthew G.

PH33 Pharmacy Services Matthew G.

Did you know?

The next Policy Review Committee (PRC) meeting will be held on Wednesday, April 23rd, 2025.

You can access all published policies directly via the Policies link on our Intranet. If you have any policy-related questions, please get in touch with the Policy Review Team at Policies@hpsj.com

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