December 2025 The Compliance4U newsletter offers insight into the day-to-day functions of the Health Plan’s Compliance Program and serves as a resource to help staff stay informed about key regulatory updates, reporting obligations, audit activities, and policy changes. Its goal is to promote awareness, accountability, and a culture of compliance across all departments within HPSJ/MVHP (“Health Plan”).
Regulatory Affairs (RA) The Plan has been engaged by both the Department of Health Care Services (DHCS) and the Department of Managed Health Care (DMHC) for our routine medical surveys. These audits are essential to ensure compliance with regulatory standards and to maintain the highest quality of care for our members. DHCS Medical Audit • •
Review Period: August 1, 2024 – December 31, 2025 Virtual Onsite Interviews: January 12, 2026 – January 23, 2026
The DHCS audit will focus on Medi-Cal program compliance, including access to care, quality improvement, and member services. Please ensure all documentation and processes for this review period are accurate and up to date. DMHC Routine Survey •
Review Period: December 1, 2023 – November 30, 2025
•
Physical Onsite Interviews Begin: May 4, 2026
The DMHC survey will assess compliance with Knox-Keene Act requirements, including grievance handling, timely access, and provider network adequacy. Preparations will include document submission and readiness for onsite interviews. What You Can Expect • • •
Pre-Audit Preparation: Compliance has coordinated with departments gathering required materials and conduct internal reviews. Staff Engagement: Some teams may be asked to participate in interviews or provide supporting documentation. Continuous Readiness: Maintaining compliance is an ongoing effort— please review your processes and address any gaps now.
Your collaboration is critical to the success of these audits. Thank you for your commitment to quality and compliance!
What’s going on at the State and Federal levels? To support you in your role and ensure timely awareness of changes to regulatory and contractual requirements, Regulatory Affairs staff attends regulatory calls (e.g., DHCS Managed Care Plan Call - MCPC) and other regulatory meetings/calls where key regulatory information is shared. Calls Held by Health Plan’s Regulators
Regulatory Affairs staff maintains materials from regulator calls. Check out previous meetings HERE. DMHC Fines Three Centene-owned plans $1.7 million for Failing to Meet
Appointment Timely Access Standards The California Department of Managed Health Care (DMHC) has taken enforcement action against three plans owned by Centene Corporation (Centene), issuing a significant fine for failing to comply with appointment timely access standards. DMHC levied a $1.7 million fine in total. Centene agreed to pay the fine and implement corrections actions to correct its process.
Important takeaways from this report: • This situation highlights the critical importance of ensuring that Health Plan complies with the requirements of the Knox-Keene Act and keeps its policies and procedures on file with the Department updated. • Health Plan must ensure proper oversight of its providers and their participation in the Timely Access Report (Provider Appointment Availability Surveying). � For more details, read the official press release here.
All Plan Letters (APLs) DHCS and DMHC issue All Plan Letters (APLs) to formally communicate updates to federal or state policy, regulatory requirements, or operational procedures. These directives are intended to guide Managed Care Plans (MCPs) on how to implement changes and ensure compliance with applicable laws and regulations. RA reviews and analyzes each APL to interpret its impact, coordinate internal implementation, and ensure timely compliance and required filings. Draft APLs—often identified with placeholder codes such as “XXX”—are released by the regulators to solicit feedback from MCPs before finalization. During this comment period, MCPs can raise concerns or seek clarification, which may influence the final version of the policy. Below is a list of recently released APLs for your awareness: A. DHCS Regulatory Notices APL 25-016 Alternative Format Selections For Members With Visual Impairments (Supersedes APL 22-002) Issue Date: November 12, 2025 Summary: This APL notifies provides information about the DHCS processes to ensure effective communication with Members with visual impairments or other disabilities requiring the provision of written materials in alternative formats, by tracking Members’ Alternative Format Selections (AFS). B. DMHC Regulatory Notices APL 25-017 Introduction of a New Independent Medical Review Organization
Issue Date: December 8, 2025 Summary: This APL informs licensed health plans under the Department’s jurisdiction and subject to independent medical reviews (IMR) of the addition of Managed Medical Review Organization, Inc. (MMRO) to perform contracted IMRs for the Department. APL 25-018 Notice of Rate Changes for Independent Medical Reviews Issue Date: December 5, 2025 Summary: This APL informs licensed health plans under the Department’s jurisdiction and subject to independent medical reviews (IMR) of an upcoming rate increase by MAXIMUS Federal Services, Inc. (Maximus) to complete IMRs for the Department. APL 25-019 Notice of Amendments to Rules 1300.51, 1300.67.1.3, and 1300.67.2 and Incorporated Documents – Network Adequacy Standards and Methodology for RY 2026 Issue Date: December 12, 2025 Summary: This APL provides notice of network adequacy amendments to 28 CCR sections 1300.51, 1300.67.1.3, and 1300.67.2, Health and Safety Code section 1367.03(f)(5), and the documents incorporated by reference, for Reporting Year 2026 Timely Access Reporting.
Regulatory Reports Under the terms of our contract with DHCS and in alignment with our KnoxKeene license requirements regulated by DMHC the Plan is required to routinely submit reports that demonstrate operational performance and regulatory compliance. RA tracks and coordinates these submissions to ensure timeliness and accuracy across all departments. Below is a list of upcoming regulatory reports due to our regulators this month. The table includes the accountable Director and Executive sponsor for awareness and coordination. Please review the list to determine which reports fall within your area. Reports due for the upcoming month should be saved in this Dropbox Folder.
Monthly 274 File
Accountable Director Clarence Rao
Monthly CBAS Waiver File
Pamela Lee
Monthly Consolidated Billing Supplemental File Monthly ECM/CS File
Clarence Rao
Weekly Encounter Data Files
Clarence Rao
Monthly MCPD/PCPA Files
Clarence Rao
Monthly Financial Reports
Somatra Sourng Vena Ford Dale Standfill Christopher Navarro Ana Aranda
Accountable Executive Victoria Worthy Lakshmi Dhanvanthari Victoria Worthy Victoria Worthy Victoria Worthy Victoria Worthy Michelle Tetreault Evert Hendrix Liz Le Michelle Tetreault Liz Le
Ana Aranda
Liz Le
Toni White Pamela Lee
Betty Clark Lakshmi Dhanvanthari Victoria Worthy Lakshmi Dhanvanthari Lakshmi Dhanvanthari Liz Le Liz Le Lakshmi Dhanvanthari
Report Title
Monthly New Member Mailing Attestation Monthly NEMT/NMT Report Monthly Post-Payment Recovery (PPR) Report Monthly Provider Directory File and Use Submission Monthly Provider Information Network (PIN) Files Monthly Restricted Provider Site Verification Quarterly CBAS Report
Clarence Rao
Quarterly Interoperability API Utilization
Clarence Rao
Quarterly MCPAR CI
Johnathan Yeh Ramanpreet Kaur Ana Aranda Ana Aranda Jeanette Lucht
Quarterly Pending & Unresolved Grievances Quarterly Provider Network Impact Report Quarterly Network Report (QNR) Quarterly MOU Good Faith Efforts Status Report
Report Title Quarterly PHM Key Performance Indicators (KPI) Semi-Annual Adult Expansion Default Assignment Report Semi-Annual Facility Site Review/Medical Record Review (FSR/MRR) Annual Member Mailing Attestation Annual Medi-Cal for Kids & Teens Materials Attestation Annual Claims Settlement and PDR Report Annual High-Volume SPD Provider Report Annual Delegation Reporting and Compliance Plan Annual MOU Report Annual LTC Quality Assurance and Performance Improvement (QAPI) Program Template Annual Cooperative Agreements Annual Medical Director Information Annual Provider Manual Submission Annual Attestation of EOC Mailing/Posting
Accountable Director Johnathan Yeh Ana Aranda
Accountable Executive Lakshmi Dhanvanthari Liz Le
Ramanpreet Kaur Vena Ford Kathleen Dalziel Aimee Griffin
Lakshmi Dhanvanthari Evert Hendrix Lakshmi Dhanvanthari Michelle Tetreault Lakshmi Dhanvanthari Betty Clark
Sandeep Mital Reshonah Hunte Jeanette Lucht Kathleen Dalziel Eric Cubillo Lakshmi Dhanvanthari Vena Ford Vena Ford
Lakshmi Dhanvanthari Lakshmi Dhanvanthari Michelle Tetreault Lakshmi Dhanvanthari Evert Hendrix Evert Hendrix
Provider Complaints Provider complaints come to Health Plan in different forms (e.g., direct call to us or dispute submission to DMHC). While our Provider Services and Claims teams address those coming into us, Compliance is the point of contact for those coming through DMHC. In 2025, Health Plan received 68 requests (39 new Provider Complaints and 29 additional information requests), disputing 46 claims. In 2024, we received 67 requests (28 Provider Complaints and 39 additional information requests), disputing 56 claims. In 2023, Health Plan
received 20 requests (13 Provider Complaints and 7 additional information requests), disputing 28 claims. In addition, each complaint may contain multiple issues that require a response. Compliance coordinates a cross-functional group to review each complaint we receive. This group investigates the cases (from the original request to claim processing and dispute resolution) and prepares a comprehensive response to the DMHC about the provider’s concerns and the actions taken by us. These tables outline the status: Table 1: Provider Complaints Received from DMHC as of December 11, 2025: 2023 Request Type
Count
Original Request Additional Information Request (AIR) Total
2024 Count
13
# of Claims 28
7 20
2025 Count
28
# of Claims 56
39
# of Claims 46
22
39
84
29
29
50
67
140
68
75
Table 2: Provider Complaint Closures by Decision as of December 11, 2025:
Decision
2023 Count
Health Plan’s Favor Provider’s Favor Pending Decision / Under Review
8 5 0
# of Claims 23 5 0
Total
13
28
2024 Count 7 15 6
# of Claims 7 43 6
28
56
2025 Count
# of Claims
1 12 13
1 12 26
26
39
DMHC Consumer Complaints and Independent Medical Review (IMR): Effective May 2025, RA manages the intake, tracking, and submission of all DMHC consumer complaints and Independent Medical Reviews (IMR) to ensure timely, compliance, and coordinated responses in collaboration with Grievance & Appeals.
DMHC Consumer Complaints
The following reflects the Consumer Complaints received, including analyses by case reason, urgency and outcome. • •
Table A displays the Consumer Complaint reasons for Standard Cases, Expedited Cases and Additional Information Requests. Table B shows the Consumer Complaint outcomes for Standard Cases, Expedited Cases and Additional Information Requests.
Table A: DMHC Consumer Complaints by Case Reason (May 30, 2025-Dec 11, 2025) Case Reason
Standard Cases
Expedited Cases
AIR Count
Access to Care
4
3
10
Benefits and Coverage
9
3
3
Continuity of Care
-
1
9
Pharmacy/Medication Access
1
-
-
Privacy
-
1
-
Quality of Care/Clinical Issue
1
-
-
Transportation
1
-
Total:
16
8
22
Table B: DMHC Consumer Complaints by Case Outcome (May 30, 2025-Dec 11, 2025) Case Outcome Pending DMHC Determination
Standard Cases 6
Expedited Cases 3
AIR Count 10
Resolved
10
5
12
Total:
16
8
22
DMHC Independent Medical Review Table C below reflects the number of IMR cases received from the Department since May 30, 2025, and their outcomes. Table C: DMHC Independent Medical Review (IMR) (May 30, 2025-Dec 11, 2025) Case Outcome
Standard Cases
Expedited
AIR Count
Pending DMHC Determination
1
2
1
Plan Decision Overturned
-
-
-
Plan Decision Partially Overturned
-
-
-
Plan Decision Upheld
-
1
-
Return to Plan Granted
1
-
-
Total:
2
3
1
Do you have a question for Compliance? To submit an inquiry, go to Team Sites > Compliance > Requests > Submit an Inquiry on SharePoint or simply use this link: check it out here.
Program Integrity Unit (PIU) Privacy & Security Did you know the Health Insurance Portability and Accountability Act (HIPAA) allows healthcare employees to leave voicemails? What HIPAA Allows • Permits voicemails: healthcare employees can leave messages, but they should limit the amount of information they state in a voicemail to protect patient privacy. Best Practices • Safeguards are required: Avoid sensitive medical details unless the member has given explicit permission. • Limit content: Use general language like “Your test results are ready. Please call our office.” • Avoid sensitive disclosures: Don’t include diagnoses, lab results, or detailed medical information. • Respect member preferences: Members can tell Health Plan how they want to be contacted (e.g., no voicemail, only cell phone). Member preferences are located in Qnxt. • Confirm contact info: Ensure the voicemail is left at the number the member has authorized.
For more information regarding voicemails and HIPAA, click the link https://www.hhs.gov/hipaa/for-professionals/faq/198/may-health-careproviders-leave-messages/index.html
Privacy & Security Incidents In the month of November, thirty-five (35) HIPAA incidents were reported to PIU. Two (2) of these incidents were reportable to DHCS. These incidents were not reportable to OCR. Fraud, Waste, and Abuse (FWA) The False Claims Act The False Claims Act (FCA) is a federal law that prohibits knowingly submitting, or causing to be submitted, false or fraudulent claims to the government for payment. “Knowingly” includes actual knowledge, deliberate ignorance, or reckless disregard for the truth. Examples of FCA Violations • • • • • • •
Billing for medically unnecessary services Billing for services not rendered Billing for the same service twice Failing to return identified overpayments within 60 days (“reserve false claims”) Failure to provide medical record data to support a claim Upcoding or unbundling Using false records to support a claim
Penalties Under the FCA • • • • •
Civil Monetary Penalties (CMPs): Large fines that can reach tens of thousands of dollars for each violation Corporate Integrity Agreement (CIA): An agreement an organization must follow to avoid being excluded from federal health programs Exclusions: A person or organization is blocked from taking part in government health programs Treble Damages: The government can require repayment of up to three (3) times the amount that was improperly received Criminal Charges: Fines and jail time
Whistleblower Protections
Employees who report suspected fraud are protected from retaliation under the FCA. The government may award a portion of recovered funds to whistleblowers if their report leads to recovery of funds. Why This Matters for Health Plan As a managed care organization, Health Plan must ensure: • • • •
Accuracy in claims adjudication Integrity in encounter data submitted to the State Oversight of provider, vendor, and delegated entity compliance Proper handling of overpayments and recovery efforts
Need to Report a Concern? You can report FWA concerns anonymously, confidentially and without fear of retaliation to the Program Integrity Unit (PIU): • •
Online Reporting Tool: Report Non-Compliance, Privacy or Fraud, Waste & Abuse Issues Email: PIU@hpsj.com
Fraud, Waste, and Abuse Cases In November, the PIU opened one (1) new case and closed two (2) existing cases. At month end, our team had 25 open cases. Provider Exclusion Monitoring PIU regularly monitors vendors and providers we contract with for exclusions, per 42 Code of Federal Regulations (C.F.R.) §438.610, which prohibits Medi-Cal Managed Care Plans (MCPs) from contracting or maintaining a contract with physicians or other health care providers who are excluded, suspended, or terminated from participating in the Medicare or Medi-Cal programs. Identified Excluded Parties Zero (0) excluded, restricted, and suspended providers were identified in the month of November through ad hoc and standard monthly screening. Conflict of Interest (COI) Did you take the quiz in last month’s newsletter? For review quiz question is below.
What type of things should staff consider about their personal life to determine if you have a reportable potential Conflict-of-Interest? A. Volunteer work B. A side business I own C. My “side hustle” D. All of the above Drum roll… and the answer is… “D. All of the above”. How did you do on the quiz? If you’re unsure about whether you have a COI or need to file Form 700, consult policy CMP23 – Conflict of Interest or contact PIU@hpsj.com for guidance.
Audit & Oversight (A&O) Best Practices for Developing a Corrective Action Plan Using the 5 Whys Method Developing an effective Corrective Action Plan (CAP) begins with understanding the true cause of an issue, not just what happened, but why it happened. The 5 Whys method is a structured approach that helps break down issues to their root cause and supports the design of meaningful actions that prevent recurrence. The steps below outline how to apply this method to create effective and sustainable CAPs. 1. Start With the 5 Whys to Identify the Real Root Cause An effective CAP starts with a clear understanding of why the issue occurred. The 5 Whys method is a structured technique that involves repeatedly asking “Why did this occur?” until the underlying root cause is identified, typically within five iterations. Why the 5 Whys Works • • • •
It avoids guessing or blaming individuals. It helps us separate symptoms from the underlying issue. It keeps our focus on the process, not the people. It prevents us from fixing the wrong problem
Example of the 5 Whys Flow 1. Why did the error occur? Because the system allowed an incorrect code. 2. Why did the system allow it? Because the validation rule was missing. 3. Why was the rule missing? Because the procedure never required it.
4. Why does the procedure not require it? Because the policy is outdated. 5. Why is the policy outdated? Because there is no annual policy review process. Root Cause: Missing policy review process, not just a system error. 2. Convert the Root Cause Into Actionable, SMART Corrections Once the root cause is identified, the Corrective Action Plan should directly address it through clearly defined, actionable steps. SMART Actions • • • • •
Specific: Clearly define the task Measurable: Identify evidence of completion Achievable: Ensure the action is realistic Relevant: Align with the root cause Time-bound: Include clear deadlines
Additional Best Practices • • • •
Each action has an owner (a person or department) The plan is risk-based (high-impact issues first) Cross-department coordination occurs when required Updated policies, procedures, or training reinforce the fix
This ensures the CAP is practical, trackable, and sustainable. 3. Monitor, Validate, and Confirm Effectiveness Developing a CAP is only part of the process. Ongoing oversight is essential to confirm the issue has been fully resolved. Monitoring • • •
Track progress against defined timelines Review evidence supporting completion Ensure required documentation is maintained
Validation • • •
Perform testing to confirm the issue is resolved Obtain verification from internal audit, compliance, or quality teams Confirm no recurrence during follow-up reviews
Sustaining the Improvement • • •
Embed changes into standard workflows Update training materials, policies, and governance processes Monitor key indicators to ensure continued performance
This closed-loop approach promotes accountability, strengthens controls, and supports continuous improvement.
Compliance Operations D-SNP & Medi-Cal Regulatory KPIs Effort Regulatory Requirement KPI enhancements and additions are currently underway. This joint effort between Compliance, BI, and the various business areas focuses on updating the existing Medi-Cal KPIs, adding the new D-SNP KPIs, and ensuring full alignment with regulatory requirements. We are pleased to see strong collaboration across teams as each area gathers its business requirements, works closely with Compliance using the guidance provided, and partners with BI to add these KPIs to their department dashboards.
Policies and Procedures New Policy & Procedure (P&P) Template Health Plan’s P&P template has been updated. Going forward, policy owners should utilize the P&P template found here. You’ll see that we’ve incorporated new instructions and minor structural changes to help in developing D-SNP and Medi-Cal/D-SNP related P&Ps. D-SNP Intake Process As of 9/30/2025, all policies necessary for 10/1 D-SNP readiness have been reviewed, approved and published. This includes Benefits Administration, Sales, Marketing, Enrollment, Pharmacy and HIPAA (Privacy) policies. In August, we began policy intake for Medical Management & QI Health Equity Management. This includes Behavioral Health & Social Services, Case Management, Cultural & Linguistics, Grievances, Health Equity, Population
Health, Quality Management, and Utilization Management policies. The policy team is currently reviewing these policies. In September, we began policy intake for Claims, Provider Contracting, Provider Networks, Procurement and other public facing policies to begin the D-SNP policy intake process. The policy team is currently reviewing these policies. In October, Compliance, IT, Administration, Facilities and Finance policies were scheduled to be added to the D-SNP intake. Thank you to those business units that have already submitted their policies. In November and December, The Policy Team’s focus is to finalize review of the remaining D-SNP policies and work with business owners to get the policies published by 1/1/2026. Look at the updated D-SNP Policy Intake Process schedule here: D-SNP Phased Approach Month Departments Intake Status July Benefits Administration, Complete Sales, Marketing, Enrollment, Pharmacy and HIPAA (Privacy) August Medical Management, In Progress QI Health Equity Management September Claims, Provider In Progress Contracting, Provider Networks, Procurement, Public Facing Policies October Administration, Facilities, In Progress Finance November Compliance, IT In Progress To better support the business units during the D-SNP intake process, the Compliance Policy team is also hosting weekly office hours through the end of the year. We are also holding working sessions with policy owners to ensure the policies accurately include all necessary regulatory requirements and references. We are also hosting ad-hoc trainings, if necessary. Any requests for assistance should be made through the policy inbox at policies@hpsj.com.
As a reminder, the D-SNP Intake form needs to be filled out for every policy submitted for the D-SNP intake process. The D-SNP Intake form can be found here. Also, if you have current Medi-Cal only policies that needs to be made applicable to D-SNP and there are no additional changes to be made to the policy, a D-SNP intake form still needs to be submitted. November 2025 Published Policies Sixteen (16) policies were published in November. Policy# and Name
Published Date
Line of Business
BH01Behavioral Health for Health Plan of San Joaquin Medi-Cal Members CLMS23 Claims Regulatory Reporting CLMS25 Claims Adjustments CLMS26 Claims Reimbursement CMP34 Network Providers and Contractors Corrective Actions and Sanctions CL04 Cultural & Linguistic Services
11/24/2025
Medi-Cal
11/24/2025 11/24/2025 11/24/2025 11/24/2025
D-SNP D-SNP D-SNP Medi-Cal
11/24/2025
Medi-Cal
CONT14 Review and Execution of Provider Contracts (D-SNP)
11/24/2025
D-SNP
FAC06 Mailroom Operations GRV09 Part C Enrollee Reconsiderations (D-SNP) GRV10 Part B, C & D Grievance Procedures (D-SNP) GRV11 Forwarding Cases to the Independent Review Entity (IRE) GRV12 Member Appeals & Grievances Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) GRV13 Non-Contract Provider Reconsiderations (D-SNP) IT14 EDI 274 Healthcare Provider Information File Submission PRO33 Network Adequacy Standards Monitoring
11/24/2025 11/24/2025
Medi-Cal/ D-SNP D-SNP
11/24/2025
D-SNP
11/24/2025
D-SNP
11/24/2025
D-SNP
11/24/2025
D-SNP
11/24/2025
Medi-Cal
11/24/2025
D-SNP
UM55 Emergency Transportation, NonEmergency Medical Transportation and Related Expenses Did you know? You can access all published policies directly via the Policies link on our Intranet. If you have any policy-related questions, please get in touch with the Policy Review Team at Policies@hpsj.com. Stay Connected with Compliance! Stay informed and updated with Compliance4U, a monthly newsletter focused on connecting and informing
11/24/2025
Medi-Cal