Downstream Delegates

Downstream Oversight Requirements

Delegates who subcontract the administrative or health benefit services performed for our organization to a subcontractor, or downstream entity, have an obligation to ensure the downstream entity complies with all same applicable federal and state laws, regulations and requirements through contract language, compliance oversight, monitoring and auditing activities. Records of such activities must be maintained for a minimum of 10 years and be available for review by CMS, state regulators or our organization upon request.

Monitoring and/or Auditing of Subcontracted Delegates

Monitoring activities are reviews performed as part of normal operations to confirm ongoing compliance and to help ensure corrective actions happen and are effective. An audit is a formal review of compliance with a particular set of standards (e.g., policies and procedures, laws and regulations) used as base measures. CMS and state regulators require our organization to monitor and/or audit to confirm delegates’ compliance with the following:

  • Medicare & Medicaid regulations;
  • Sub-regulatory guidance;
  • Contractual agreements;
  • All applicable federal and state laws; and
  • Internal policies and procedures to protect against noncompliance and potential fraud, waste and abuse (FWA).