CenCal Health’s Commitment to Compliance

CenCal Health uses a variety of policies and procedures to document regulatory and contractual requirements and processes to ensure compliance with those requirements. All staff members are notified and trained on new and or revised policies and
procedures. Policies and Procedures are reviewed periodically to ensure compliance with the most up-to date healthcare rules, regulations, contract amendments, and business risks.

Additionally, CenCal Health has adopted the Code of Conduct (the Code) with respect to business conduct and practices governing CenCal Health’s affairs. The Code promotes legal, ethical, and moral behavior meant to support integrity in all organizational actions. Employees are required to adhere to the Code at all times while conducting CenCal Health business.

Additionally, CenCal Health has a Compliance Committee, made up of CenCal Health officers and employees. The Compliance Committee is responsible for the development and oversight of a comprehensive Compliance Program.

The Board of Directors also exercises oversight over the implementation and effectiveness of CenCal Health’s Compliance Program.

CenCal Health provides general and specialized trainings to staff, Board of Directors, Subcontractors, and Downstream Subcontractors that promote and verify their understanding of CenCal Health’s Compliance Plan, CenCal Health policies and procedures, applicable terms and conditions of CenCal Health’s Medi-Cal managed care contract, NCQA accreditation standards, and federal and state requirements.

Training is required for all staff, upon hire and annually thereafter.

CenCal Health maintains effective lines of communication to ensure its staff, members, Network Providers, contractors, Subcontractors and Downstream Subcontractors can report any compliance concerns upon discovery.

Staff are informed about the ways they can reach the Compliance Officer directly, the multiple avenues for reporting, and CenCal Health’s non-retaliation policy.

If you suspect any compliance concerns, report it to CenCal Health here.

CenCal Health establishes appropriate consequences for instances of noncompliance. Consequences for instances of noncompliance are outlined in CenCal Health’s Employee Handbook. The Employee Handbook includes detailed information on when disciplinary action is appropriate. Disciplinary action may include counseling, verbal or written warnings, suspension, and/or termination.

At least annually, CenCal Health conducts risk assessments to evaluate risk associated with CenCal Health’s business operations. From the evaluation of the risk assessment, CenCal Health develops an annual auditing and monitoring work plan to prioritize and address high-risk items for the coming year. Additionally, CenCal Health conducts internal auditing and monitoring as a proactive approach to continually identify and mitigate compliance risks.

Finally, DHCS conducts an annual audit of CenCal Health to ensure the Plan’s ongoing compliance with regulatory and contractual requirements. The audit report can be found here.

SUMMARY OF DELEGATION MODEL

CenCal Health maintains appropriate oversight and monitoring of Delegated Entities for Santa Barbara County and San Luis Obispo County. CenCal Health conducts routine oversight and monitoring of its Delegated Entities to ensure compliance with applicable regulatory requirements, contractual obligations, policies and procedures, CenCal Health’s Compliance Plan, and CenCal Health’s Delegation Plan. CenCal Health has the same Delegation Model for both counties.

CenCal Health’s Delegated Entities are subject to the oversight and monitoring mechanisms of the Delegation Oversight Committee (DOC). Delegated functions may include but are not limited to claims adjudication, network management, utilization management, and credentialing and recredentialing. CenCal Health may delegate any or all of these functions to qualified entities to ensure quality services reach our members in an efficient and timely manner. Other functions not listed above may be delegated to a prospective delegate following a Pre-Delegation Assessment and approval by the DOC and DHCS.

The Director of Audits, Monitoring, & Oversight or designee chairs the DOC, which reports to the Compliance Committee. The DOC is a forum for monitoring and overseeing Delegated Entities’ performance against requirements, communicating audit findings and results with leadership, establishing audit standards and schedules, and providing general updates of Delegated Entity performance. The DOC meets on a quarterly basis and refers matters to the Compliance Committee and Board Compliance and Oversight Committee, as needed.

DELEGATION REPORTING AND COMPLIANCE PLAN

CenCal Health’s Delegation Reporting and Compliance Plan describes: 1) all its contractual relationships with Delegated Entities; 2) CenCal Health’s oversight responsibilities for all delegated obligations; and 3) how CenCal Health intends to oversee all delegated activities, including but not limited to details regarding key personnel who will be overseeing such delegated functions.

CenCal Health submits to DHCS its Delegation Reporting and Compliance Plan using the templates specified by DHCS in Exhibit J of the Medi-Cal Managed Care Contract or as otherwise specified by DHCS, and annual reports indicating changes to its delegation arrangements. CenCal Health provides reports to DHCS if there are changes in the Delegation Reporting and Compliance Plan as specified by DHCS and pre-approved by DHCS. The report is submitted within 30 calendar days following the end of the reporting period.

CenCal Health’s Chief Compliance Officer maintains a system to promptly respond to and conduct investigations of reported or detected instances of non-compliance or compliance issues. Depending on the nature of the referral, outcome, and severity, of the compliance issue, recommendations may be made internally for corrective action.

Corrective Action Plans

• None

• CenCal Health’s Compliance Plan
• Notice of Privacy Practices (English)
• Aviso De Prácticas De Privacidad (Español)

If you suspect any compliance, fraud, waste, abuse, or HIPAA concerns, report it to CenCal Health here.