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 conducting its operations in compliance with ethical standards, contractual obligations, and all applicable statutes, regulations and rules, including those pertaining to Medi-Cal, Medicare, PACE (Program of All-Inclusive Care for the Elderly), MSSP (Multipurpose Senior Services Program), and other CalOptima programs.

CalOptima’s compliance commitment encompasses its own internal operations, as well as its oversight and monitoring responsibilities related to CalOptima’s First Tier, Downstream and Related Entities (FDRs), such as health networks, physician groups, participating providers, suppliers, pharmacy benefit manager (PBM), and consultants. The term FDR refers to CalOptima’s delegated subcontractors that perform administrative functions and/or provide health care services that CalOptima is required to perform and/or provide under its state and federal contracts with the Centers for Medicare & Medicaid Services (CMS) and the Department of Health Care Services (DHCS). Such persons/entities referred to as FDR, include those that directly contract with CalOptima and those that are Downstream or Related Entities (i.e. subcontracts) with CalOptima’s First Tier Entities.

CalOptima has developed a comprehensive Compliance Program applicable to all of CalOptima’s Programs, including, but not limited to, its Medi-Cal Program, its Medicare Advantage Prescription Drug Program (MA-PDP referred to as “OneCare”), its Medicare-Medicaid Plan (MMP referred to as “OneCare Connect”), PACE, and MSSP. The Compliance Program incorporates all of the elements of an effective compliance program as recommended by the Office of the Inspector General (OIG) and required by CMS regulations. The Compliance Program is continually evolving and may be modified and enhanced based on compliance monitoring and identification of new areas of operational, regulatory, or legal risk. CalOptima requires that CalOptima Board Members, Employees, and FDRs conduct themselves in accordance with the requirements of CalOptima’s Compliance Program.

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

Disability Awareness Training

Cultural Competency Training

Educational tools

How to Use the Fishbone Tool for Root Cause Analysis

Five Whys Tool for Root Cause Analysis

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