Pre-Delegation Audit

The purpose of the Pre-Delegation Audit is to fully assess a proposed delegate’s capacity to manage and perform  the  delegated  function  in  accordance  with  state  and  federal  laws,  rules,  and  regulations, accreditation  organization  standards  and  CarePlus  requirements.  The  pre-delegation  audit  is  conducted prior to the effective date of delegation. It consists of a desktop review of documentation, review of the proposed delegate’s provider downstream agreements and an on-site visit, if necessary. During the pre-delegation audit proposed delegates are notified of any reporting requirements and frequency, the process by  which  performance  will  be  evaluated  and  the  remedies  available  to  CarePlus  if  obligations  are  not fulfilled.  Pre-delegation  audits  are  conducted  by  CarePlus  in  collaboration  with  our  parent  company, Humana, when applicable.

Collected  information  for  the  various  delegated  functions  includes,  but  may  not  be  limited,  to  the following:

** Policies and procedures
** Program descriptions and work plans
** Forms, tools, systems and reports
** Sub-delegation agreements
** Letters of Accreditation
** Financial Solvency
** File Audit

CarePlus  requires  all  delegated  providers  to  enter  into  a  written,  mutually  agreed  upon  contract.  The Delegation  Services  Addendum  and  applicable  attachments  at  a  minimum  includes  the  following provisions: (i) delineates the duties and responsibilities of both the Plan and the delegated provider; (ii)  outlines the services to be performed by the delegated provider, including reporting responsibilities; (iii) specifies that performance of the delegated provider is monitored on an ongoing basis by the Plan; (iv) retains the CarePlus’ right to approve, suspend and terminate individual practitioners, providers and sites where it has delegated decision making; (v) the credentials of medical professionals  affiliated with the delegated provider will be either reviewed by CarePlus or the credentialing process will be reviewed and approved  by  CarePlus  and  will  be  subject  to  auditing  on  an  ongoing  basis;  (vi)  if  CarePlus  delegates selection of providers to the delegated provider, written arrangements must state CarePlus retains the right
to approve, suspend, or terminate any provider selected by the delegated providers; (vii) must comply with all applicable Medicare laws, regulations and CMS instructions; and (viii) provide for revocation of the delegation activities and/or other remedies in instances where the delegated provider is not performing satisfactorily. Grids within each delegation attachment are designed to delineate the actual functions and detail the requirements in each delegated arrangement, and may be tailored to define each agreement.