Compliance Information

First Tier, Downstream and Related Entities

General Information

CalOptima Health’s comprehensive Compliance Program reflects our commitment to conducting our operations in compliance with ethical standards, contractual obligations, and all applicable statutes, regulations and rules pertaining to our programs: Medi-Cal, OneCare, OneCare Connect, Program of All-Inclusive Care for the Elderly, Multipurpose Senior Services Program and others.
CalOptima Health’s compliance commitment encompasses our own internal operations as well as our oversight and monitoring responsibilities for First Tier, Downstream and Related Entities (FDRs). The term FDR refers to CalOptima Health’s delegated subcontractors that perform administrative functions and/or provide health care services that CalOptima Health is required to perform and/or provide under our federal and state contracts with the Centers for Medicare & Medicaid Services (CMS) and the Department of Health Care Services (DHCS). FDRs include those directly contracted with CalOptima Health and those that are Downstream or Related Entities (i.e., subcontractors) with CalOptima Health’s First Tier Entities, such as health networks, physician groups, participating providers, suppliers, pharmacy benefit managers and consultants.

The Compliance Program incorporates all the elements of an effective compliance program as recommended by the Office of the Inspector General 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 Health requires that its Board members, employees and FDRs conduct themselves in accordance with the requirements of CalOptima Health’s Compliance Program.

If you see any activity that you think is non-compliant, fraudulent or wasteful, we strongly encourage you to call our Compliance and Ethics Hotline at 1-855-507-1805 (TTY 711). You can also report the activity by using CalOptima Health’s Compliance and FWA Reporting form. You do not have to give your name to report fraudulent activity.

Complete the Compliance and Fraud, Waste and Abuse Reporting Form  Use this form to report a suspected non-compliance issue or fraud, waste and abuse (FWA). The confidential form has instructions on how to fill it out and where to send it.

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