J.1 - PPI MEDIC- Statement of Work Amendment 1.docx
Posted: April 15, 2026
• Type: .docx
• Size: 0.17MB
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Summary
Amendment to the Statement of Work (SOW) for the Plan Program Integrity Medicare Drug Integrity Contractor (PPI MEDIC). The primary purpose of this SOW is to outline the responsibilities and tasks assigned to the PPI MEDIC in overseeing Medicare Parts C and D programs, specifically focusing on fraud, waste, and abuse (FWA) detection and prevention.
The PPI MEDIC is tasked with conducting audits, data analyses, outreach and education efforts, and coordinating with the Centers for Medicare & Medicaid Services (CMS) and other stakeholders to ensure compliance with applicable federal regulations. The document details various tasks including the creation of Peer Activity Reports (PARs), Plan Sponsor Alerts (PSAs), and oversight of Medicare Prescription Payment processes.
The amendment specifies that the PPI MEDIC must adhere to a range of federal statutes and regulations while performing its duties. It emphasizes the importance of retaining records for ten years and outlines specific audit protocols, including Self-Audits, National Audits, and Program Integrity Audits.
Additionally, it introduces a structured appeals process for plan sponsors regarding audit findings, detailing the roles of the PPI MEDIC in managing these appeals at various levels. The document also highlights requirements for reporting, stakeholder communication, and information security compliance as part of the operational framework for maintaining program integrity within Medicare Parts C and D. This amendment serves to clarify expectations and enhance the operational effectiveness of the PPI MEDIC in safeguarding Medicare resources.
The PPI MEDIC is tasked with conducting audits, data analyses, outreach and education efforts, and coordinating with the Centers for Medicare & Medicaid Services (CMS) and other stakeholders to ensure compliance with applicable federal regulations. The document details various tasks including the creation of Peer Activity Reports (PARs), Plan Sponsor Alerts (PSAs), and oversight of Medicare Prescription Payment processes.
The amendment specifies that the PPI MEDIC must adhere to a range of federal statutes and regulations while performing its duties. It emphasizes the importance of retaining records for ten years and outlines specific audit protocols, including Self-Audits, National Audits, and Program Integrity Audits.
Additionally, it introduces a structured appeals process for plan sponsors regarding audit findings, detailing the roles of the PPI MEDIC in managing these appeals at various levels. The document also highlights requirements for reporting, stakeholder communication, and information security compliance as part of the operational framework for maintaining program integrity within Medicare Parts C and D. This amendment serves to clarify expectations and enhance the operational effectiveness of the PPI MEDIC in safeguarding Medicare resources.
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