(1.b) Consistent with Article III, paragraph C, provision for the continuation of benefits.
2. Accountability provisions that indicate that the MA Organization may only delegate activities or functions to a first tier, downstream, or related entity in a manner consistent with requirements set forth at paragraph D of this Article.
3. A provision requiring that any services or other activity performed by a first tier, downstream, and related entity in accordance with a contract or written agreement will be consistent and comply with the MA Organizations contractual obligations.[422.504(i)(3)]
D. If any of the MA Organizations activities or responsibilities under this contract with CMS is delegated to other parties, the following requirements apply to any related entity, contractor, subcontractor, or provider:
1. Each and every contract must specify delegated activities and reporting responsibilities.
2. Each and every contract must either provide for revocation of the delegation activities and reporting requirements or specify other remedies in instances where CMS or the MA Organization determine that such parties have not performed satisfactorily.
3. Each and every contract must specify that the performance of the parties is monitored by the MA Organization on an ongoing basis.
4. Each and every contract must specify that either-
(4.a) The credentials of medical professionals affiliated with the party or parties will be either reviewed by the MA Organization; or
(4.b) The credentialing process will be reviewed and approved by the MA Organization and the MA Organization must audit the credentialing process on an ongoing basis.
5. Each and every contract must specify that the first tier, downstream, or related entity comply with all applicable Medicare laws, regulations, and CMS instructions. [422.504(i)(4)]
E. If the MA Organization delegates selection of the providers, contractors, or subcontractors to another organization, the MA Organizations contract with that organization must state that the CMS-contracting MA Organization retains the right to approve, suspend, or terminate any such arrangement. [422.504(i)(5)]
F. As of the date of this contract and throughout its term, the MA Organization
1. Agrees that any physician incentive plan it operates meets the requirements of 42 CFR §422.208, and
2. Has assured that all physicians and physician groups that the MA Organizations physician incentive plan places at substantial financial risk have adequate stop-loss protection in accordance with 42 CFR §422.208(f). [422.208]
A. MAINTENANCE OF RECORDS
1. The MA Organization agrees to maintain for 10 years books, records, documents, and other evidence of accounting procedures and practices that-
(1.a) Are sufficient to do the following:
(1.a.i) Accommodate periodic auditing of the financial records (including data related to Medicare utilization, costs, and computation of the benefit and price bid) of the MA Organization.
(1.a.ii) Enable CMS to inspect or otherwise evaluate the quality, appropriateness and timeliness of services performed under the contract, and the facilities of the MA Organization.
(1.a.iii) Enable CMS to audit and inspect any books and records of the MA Organization that pertain to the ability of the organization to bear the risk of potential financial losses, or to services performed or determinations of amounts payable under the contract.
(1.a.iv) Properly reflect all direct and indirect costs claimed to have been incurred and used in the preparation of the benefit and price bid proposal.
(1.a.v) Establish component rates of the benefit and price bid for determining additional and supplementary benefits.
(1.a.vi) Determine the rates utilized in setting premiums for State insurance agency purposes and for other government and private purchasers; and
(1.b) Include at least records of the following:
(1.b.i) Ownership and operation of the MA Organizations financial, medical, and other record keeping systems.
(1.b.ii) Financial statements for the current contract period and ten prior periods.
(1.b.iii) Federal income tax or informational returns for the current contract period and ten prior periods.
(1.b.iv) Asset acquisition, lease, sale, or other action.
(1.b.v) Agreements, contracts (including, but not limited to, with related or unrelated prescription drug benefit managers) and subcontracts.
(1.b.vi) Franchise, marketing, and management agreements.
(1.b.vii) Schedules of charges for the MA Organizations fee-for-service patients.
(1.b.viii) Matters pertaining to costs of operations.
(1.b.ix) Amounts of income received, by source and payment.
(1.b.x) Cash flow statements.
(1.b.xi) Any financial reports filed with other Federal programs or State authorities.[422.504(d)]
2. Access to facilities and records. The MA Organization agrees to the following:
(2.a) The Department of Health and Human Services (HHS), the Comptroller General, or their designee may evaluate, through inspection or other means
(2.a.i) The quality, appropriateness, and timeliness of services furnished to Medicare enrollees under the contract;
(2.a.ii) Compliance with CMS requirements for maintaining the privacy and security of protected health information and other personally identifiable information of Medicare enrollees;
(2.a.iii) The facilities of the MA Organization; and
(2.a.iv) The enrollment and disenrollment records for the current contract period and ten prior periods.
(2.b) HHS, the Comptroller General, or their designees may audit, evaluate, or inspect any books, contracts, medical records, documents, papers, patient care documentation, and other records of the MA Organization, related entity, contractor, subcontractor, or its transferee that pertain to any aspect of services performed, reconciliation of benefit liabilities, and determination of amounts payable under the contract, or as the Secretary may deem necessary to enforce the contract.
(2.c) The MA Organization agrees to make available, for the purposes specified in paragraph A of this Article, its premises, physical facilities and equipment, records relating to its Medicare enrollees, and any additional relevant information that CMS may require.
(2.d) HHS, the Comptroller General, or their designees right to inspect, evaluate, and audit extends through 10 years from the final date of the contract period or completion of audit, whichever is later unless-
(2.d.i) CMS determines there is a special need to retain a particular record or group of records for a longer period and notifies the MA Organization at least 30 days before the normal disposition date;
(2.d.ii) There has been a termination, dispute, or fraud or similar fault by the MA Organization, in which case the retention may be extended to 10 years from the date of any resulting final resolution of the termination, dispute, or fraud or similar fault; or
(2.d.iii) HHS, the Comptroller General, or their designee determines that there is a reasonable possibility of fraud, in which case they may inspect, evaluate, and audit the MA Organization at any time. [422.504(e)]