[Federal Register Volume 61, Number 52 (Friday, March 15, 1996)]
[Notices]
[Pages 10771-10772]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-6296]



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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration


Statement of Organization, Functions, and Delegations of 
Authority, Denver Regional Office

    Part F of the Statement of Organization, Functions, and Delegations 
of Authority for the Department of Health and Human Services, Health 
Care Financing Administration (HCFA), (Federal Register, Vol. 60, No. 
148, pp. 39404-39409, dated Wednesday, August 2, 1995) is amended to 
reflect a reorganization in the Denver Regional Office.
    The Denver Regional Office (RO) proposes an organizational change, 
as a demonstration of a streamlined customer-focused organization, for 
up to 18 months. The new structure will eliminate one layer of 
management, reduce the number of management positions by nearly half, 
create customer-focused teams, and significantly empower staff.
    The specific amendments to part F are described below:
    Section F.10.D.6., (Organization) is amended to read as follows:

    e1. State Team 1 (FLD8D)
    e2. State Team 2 (FLD8E)
    e3. State Team 3 (FLD8F)
    e4. State Team 4 (FLD8G)

    Section F.20.D.6.e., (Functions) will read as follows:

e.1.-4. State Team 1-4 (FLD8(D-G))

     State Teams will administer the full range of HCFA program 
responsibilities in the field. Teams are comprised of a multi-
disciplinary work force which conducts all statutory, regulatory and 
administrative functions to manage the Medicare and Medicaid benefits 
for those enrolled in HCFA's programs with the six Regional VIII 
States--Colorado, Montana, North Dakota, South Dakota, Utah and 
Wyoming.

Operations

     Assures that health care services provided under the 
Medicare, Medicaid and CLIA programs are furnished in the most 
effective and efficient manner consistent with recognized professional 
standards of care.
     Evaluates services to ensure protection of beneficiaries 
receiving health care services under the Medicare, Medicaid, and CLIA 
programs.
     Determines program eligibility for all providers and 
suppliers under the Medicare program, and executes required agreements.
     Initiates, implements, and coordinates State related 
adverse actions and alternative remedies, including civil money 
penalties, and Federal activities against health care facilities not in 
compliance with Medicare or CLIA requirements.
     Establishes and maintains an extensive data and 
information gathering system involving all aspects of the certification 
program and CLIA.
     Responds to beneficiary, Congressional, provider, and 
public inquiries concerning Medicaid issues, including Freedom of 
Information Act requests.
     Develops and conducts training programs for the State 
survey agencies.
     Monitors and evaluates State activities related to 
Medicare and Medicaid survey and certification.
     Plans, manages and provides Federal leadership to State 
agencies in program development, implementation, maintenance, and the 
regulatory review of State Medicaid program management activities under 
title XIX of the Social Security Act.
     Plans, directs, coordinates, and approves Medicaid State 
agency data processing systems, proposals, modifications, operations, 
contracts and reviews. Assists Medicaid State agencies in developing 
innovative automated data processing health care systems. Assures the 
propriety of Federal expenditures.
     Maintains day-to-day liaison with State agencies and 
monitors their Medicaid program activities and practices by conducting 
periodic program management and financial reviews to assure State 
adherence to Federal Law and regulations.
     Reviews, approves, recommends disapproval, and maintains 
official State plans and plan amendments for medical assistance.

[[Page 10772]]

     Provides consistent guidance, technical assistance, and 
policy interpretation to States on Medicaid program and financial 
issues.
     Reviews and approves managed care contracts and prepaid 
health plans.
     Directs activities in support of the Medicaid managed care 
program including technical support and oversight of these plans.
     Implements Title XIX special initiatives, such as maternal 
and child health, Acquired Immune Deficiency Syndrome, health 
maintenance organization contracts, and other special programs and 
operations of major management initiatives.
     Directs activities in support of the managed care program 
including technical support and oversight of prepaid contractors.
     Monitors all aspects of contractor performance including 
claims/bills processing; coverage decisions; medical review; the 
detection of fraud, abuse, and waste in the Medicare Program; 
overpayment identification and collection; Medicare Secondary Payer 
(MSP); provider payment and audit; payment to physicians and suppliers; 
and electronic media claims.
     Evaluates Medicare contractor performance and prepares 
annual Report of Contractor Performance.
     Recommends renewals, non-renewals, rescissions, and 
terminations of Medicare contracts.
     Coordinates the ESRD program.

Fiscal Integrity

     Makes final determination on all budget requests submitted 
by State Survey Agencies.
     Reviews, evaluates, and determines acceptability of audit 
findings and recommendations and takes necessary clearance and closure 
actions.
     Reviews, approves, and monitors State payment systems and 
determines the allowability of claims for Federal financial 
participation. Takes action to disallow claims when expenditures are 
not in accordance with Federal requirements and defends such action 
before the Departmental Appeals Board and in court. Defers payment 
action on questionable State claims for allowability.
     Reviews States' Medicaid Quarterly Estimates and Statement 
of Expenditures reports and recommends the amount to be estimated and 
allowed in the quarterly grants.
     Coordinates on-going contractor fiscal management 
activities, including subcontracting, cash management activities, and 
compliance with the Chief Financial Officers Act.
     Negotiates and approves Medicare contractor budget and 
budget modifications.

Customer Service

     Authorizes investigation of complaints received from 
beneficiaries, the public, the Congress, the media, and other sources 
which allege deficiencies in the quality of care rendered by certified 
health care providers.
     Actively participates in and takes a lead role in 
training, outreach and collaborative activities involving providers, 
provider groups, health care professionals, professional organizations, 
consumer groups, and State Survey Agencies, relating to quality of 
health care services.
     Conducts customer outreach and service initiatives.
     Manages beneficiary, provider, and public information 
programs.
     Ensures that Medicare beneficiaries are informed of HCFA 
program benefits, rights and responsibilities through a comprehensive 
marketing strategy to varied audiences.
     Coordinates the operation of a public information and 
outreach programs directed at beneficiary groups, professional 
organizations, advocacy organizations, other health care entities, and 
the media.
     Directs the implementation of HCFA beneficiary services 
initiatives, such as the Medigap, Retired Senior Volunteer Programs, 
Information Counseling Assistance grants, and Qualified Medicare 
Beneficiary programs.

Quality Functions

     Directs the review and evaluation of the effectiveness of 
the Medicare program.
     Pro-actively utilizes resources and information to 
effectively and efficiently assure practical quality health care for 
HCFA beneficiaries.
     Interprets and implements health and safety standards and 
evaluates, through surveillance and surveys, the impact on the 
utilization and quality of health care services.
     Provides leadership in the development, implementation and 
continuation of continuous quality improvement activities for the State 
Survey Agencies and providers.
     Provides leadership in the quality improvement aspects of 
HCFA's national managed care program.
     Directs Medicare program administration through working 
relationships with contractors, providers, physicians, beneficiaries, 
the Social Security Administration district offices, the Administration 
on Aging, the Office of Inspector General, and other Federal agencies, 
as well as local and national organizations and individuals, as 
required.

    Dated: March 6, 1996.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
[FR Doc. 96-6296 Filed 3-14-96; 8:45 am]
BILLING CODE 4120-01-P