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Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 49 - regarding fraud and abuse activities by, but not limited to, MCOs, providers, subcontractors, MO HealthNet beneficiaries, MO HealthNet managed care enrollee or employees. The MCOs must report to and cooperate with the DSS, MO HealthNet Division and other key players as appropriate. On a quarterly basis, the MCOs report fraud and abuse activities, to the Quality Services Unit of the MO HealthNet Division, as indicated in the QI Strategy. Each MCO must implement internal controls, policies and procedure for prevention, coordination, detection, investigation, enforcement and reporting of fraud and abuse in accordance with the MO HealthNet Managed Care contract and the MCO's Fraud and Abuse Plan. The policies and procedures shall articulate the MCO's commitment to comply with all applicable federal and state standards. The MCO's Fraud and Abuse Plan must designate a compliance officer and compliance committee that is responsible for the Fraud and Abuse Program and activities. The MCO must submit a written Fraud and Abuse Plan to the state agency for approval prior to implementation. Any changes to the approved fraud and abuse plan must have state agency approval prior to implementation. 11.3.1 In accordance with the Recipient Lock-In Program, the MCOs must implement a method to limit or restrict the use of the recipient's MO HealthNet identification care to designated providers of medical services. The MCO must submit its lock- in policies and procedures to the state agency for approval prior to implementation. When a member or provider is suspected of fraud or abuse, the MCO notifies the state agency of the suspected activity as well as includes the information in their quarterly reporting.