CalOptima's Commitment to Compliance

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To Report Potential Fraud or Abuse, Please Call the Compliance and Ethics Hotline at 1-877-837-4417.

CalOptima FDRs

CalOptima is committed to complying with all applicable Centers for Medicare & Medicaid Services (CMS) regulations, while upholding the highest ethical business laws, rules, and regulations. CalOptima’s commitment to compliance includes ensuring all employees (including Board Members), First Tier, Downstream, and Related Entities (FDRs), and members are responsible for understanding and operating in compliance with applicable law and regulatory guidance. Non-compliance with these laws and failure to report such actions will be subject to further disciplinary action up to, and including, termination. With established company-wide policies to promote a compliant workplace, such as non-retaliation, internal investigation, and self-reporting, we are committed to maintaining this culture.

As a Medicare sponsor, CalOptima can contract with FDRs to perform certain functions on its behalf, however, the sponsor maintains ultimate responsibility for fulfilling the terms and conditions of its contract with CMS and for meeting the Medicare program requirements, including ensuring that FDRs are in compliance with all applicable laws, rules and regulations with respect to Parts C and D delegated responsibilities. This page provides CalOptima FDRs with the tools and information to ensure compliance with CMS rules. If you have any questions, please feel free to contact the Compliance Department.

Resource Documents

CMS Quarterly Provider Updates

CalOptima Policies

Code of Conduct

Attestation Concerning the Use of Offshore Subcontractors

FDR Program Attestation

CalOptima Compliance Plan

Medicare Advantage and Part D Fraud Handbook

Compliance Fraud and PHI Flyer

Request for Compliance Action Form

Training

Fraud, Waste and Abuse and Compliance Training

HIPAA Training

Educational tools

Reporting Issues of Non-Compliance

How to Use the Fishbone Tool for Root Cause Analysis

Five Whys Tool for Root Cause Analysis

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