Medicare FDR Compliance Program Statement of Attestation

Medicare FDR Compliance Program Statement of Attestation

Please read and ensure all requirements are met, select your organization's chosen methods by checking the appropriate boxes, initial and date the bottom of each page, complete all requested information in this "Statement of Attestation," and return this document (as well as any supporting documents) to the Health First Corporate Compliance Department.

FDR Name:

"FDR" Date:

Health First Health Plans, Inc. (HFHP) enters into written agreements with First Tier, Downstream or Related Entities (FDR) to provide administrative or healthcare services to Medicare enrollees. In accordance with the Centers for Medicare & Medicaid Services (CMS), HFHP must ensure FDRs comply with program requirements within Chapter 42 of the Code of Federal Regulations, Parts 422 and 423, also referred to as Medicare Parts C and D. Through this attestation our FDRs assist HFHP in demonstrating effective communication and attest to complying with the following program requirements:

A. Code of Conduct/Policies and Procedures 42 CFR 422.503 and 423.504(b)(4)(vi)(A) Health First's Code is available on our website: BeCompliant

FDR ensures that Health First's Code of Ethics & Business Conduct and applicable policies and procedures were provided to, at a minimum, employees and Downstream Entities who have an involvement in the administration or delivery of Parts C and D benefits related to the contract with Health First within ninety (90) days of hire or contracting and annually thereafter.

FDR created its own Code of Ethics and policies and procedures which are significantly similar to the Health First Code of Ethics & Business Conduct. These documents from your organization were provided to, at a minimum employees and Downstream Entities who have an involvement in the administration or delivery of Parts C and D benefits related to the contract with Health First within ninety (90) days of hire or contracting and annually thereafter.

Initials __________ *If this method is chosen, I attest that I will send a copy of the referenced document(s) to Health First Corporate Compliance via fax, mail or email within 24 hours of submitting this form.

B. General Compliance Training 42 CFR 422.503 and 423.504(b)(4)(vi)(C) FDR shall present compliance training to all new and established employees (including temporary workers and volunteers) and downstream entities within ninety (90) days of hire or contracting and annually thereafter. Please indicate the method in which General Compliance Training is satisfied:

Complete CMS web based training module through the Medicare Learning Network? (MLN) and retain the certificate of completion for each employee and downstream entity.

Complete comparable training adopted by your organization and retain proof of completion for each employee and downstream entity. Your training materials must incorporate the

Initials __________ Date ___________

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Medicare FDR Compliance Program Statement of Attestation

content of the CMS standardized training modules from the CMS website. CMS does not allow training content to be modified, except for the appearance of the content.

Initials __________ *If this method is chosen, I attest that I will send a copy of the referenced document(s) to Health First Corporate Compliance via fax, mail or email within 24 hours of submitting this form.

Additional Option for Providers Only: Incorporate content of CMS training modules into written documents for providers (e.g. Provider Guides, Business Associate Agreements, etc.) and retain documented proof of distribution.

C. Fraud, Waste and Abuse (FWA) Training (not required for deemed providers of Medicare Parts A/B) 42 CFR 422.503 and 423.504(b)(4)(vi)(C) FDR shall present FWA training to all new and established employees (including temporary workers and volunteers) and downstream entities within ninety (90) days of hire or contracting and annually thereafter. Please indicate the method in which FWA training is satisfied:

Complete CMS web based training module through the Medicare Learning Network? (MLN) and retain the certificate of completion for each employee and downstream entity.

Complete comparable training adopted by your organization and retain proof of completion for each employee and downstream entity. Please note: This training material must incorporate the content of the CMS standardized training modules from the CMS website. CMS does not allow training content to be modified, except for the appearance of the content.

Initials __________ *If this method is chosen, I attest that I will send a copy of the referenced document(s) to Health First Corporate Compliance via fax, mail or email within 24 hours of submitting this form.

Additional Option for Providers Only: Incorporate content of CMS training modules into written documents for providers (e.g. Provider Guides, Business Associate Agreements, etc.) and retain documented proof of distribution.

For Deemed Providers Only: FWA training is not required for deemed providers of Medicare Parts A/B.

D. Record Retention 422 CFR 422.503 and 423.504(b)(4)(vi)(C) FDR agrees to comply with Medicare laws, regulations, and CMS instructions as it relates to maintaining training records of employees and downstream entities for a period of 10 years.

E. Privacy and Security 422 CFR 422.504(a)(13) and 422.118

Initials __________ Date ___________

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Medicare FDR Compliance Program Statement of Attestation

FDR ensures that employees and downstream entities agree to safeguard beneficiary privacy and confidentiality and assure accuracy of beneficiary health records pursuant to applicable laws. FDR affirms that its employees and downstream entities will comply with the confidentiality and enrollee record accuracy requirements, including: (1) abiding by all Federal and State laws regarding confidentiality and disclosure of medical records, or other health and enrollment information, (2) ensuring that medical information is released only in accordance with applicable Federal or Florida law, or pursuant to court orders or subpoenas, (3) maintaining the records and information in an accurate and timely manner, and (4) ensuring timely access by enrollees to the records and information that pertains to them. FDR affirms that it has provided or required appropriate training and/or education on these subjects to its employees and downstream entities.

F. Contracting with Downstream Entities FDR agrees that if it decides to subcontract with other entities to perform any of the services contractually delegated to your organization to perform on behalf of HFHP, your organization is required to obtain permission from HFHP prior to subcontracting with these entities to perform services as directed in the contract. Should a subcontract be granted, the FDR will maintain active oversight and monitoring of such activity to ensure downstream entities are complying with CMS program requirements.

G. OIG and GSA Exclusion Screening 42 CFR 422.503, 422.752(a)(8), 423.504(b)(4)(vi)(F), and 423.752(a)(6) FDR ensures that employees and downstream entities are screened against the DHHS Office of Inspector General List of Excluded Individuals and Entities (LEIE) and the System for Award Management (SAM) list prior to hire or contracting and monthly thereafter. Monthly screening must include any current employee, new employee, temporary employee, volunteer, contractor and consultant to ensure individuals are not excluded or become excluded from participation in federal programs.

H. Disciplinary Action/Reporting Non-Compliance 42 CFR 422.503 and 423.504(b)(4)(vi)(E) FDR ensures that the FDR's employees and downstream entities understand the disciplinary standards and duty to report all suspected or known instances of non-compliance and/or FWA activity, as well as maintaining and enforcing disciplinary standards in a timely and consistent manner. Please review Health First's Code of Ethics & Business Conduct for reporting methods.

I. Notification and Correction of Identified Deficiencies

HFHP is obligated to ensure the FDR corrects any deficiencies related to misconduct or

Medicare program non-compliance and detail the elements of any corrective action in a written

agreement with the FDR, which includes ramifications if the FDR fails to implement the

corrective action satisfactorily. To substantiate compliance, the FDR organization will furnish

reasonable documentation to support any CMS requirements to HFHP upon request, at no

cost. FDR shall reasonably cooperate and fulfill any corrective action requested by HFHP.

Initials __________ Date ___________

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Medicare FDR Compliance Program Statement of Attestation

Statement of Attestation FDR certifies the above statements are true and correct. FDR agrees to continually maintain the obligations and requirements in this agreement, specifically but not limited to those items in Sections A through H, and the FDR shall immediately report in writing to HFHP any changes or violations of the agreed terms. Any violations of the CMS Compliance Program, including those related to compliance and FWA training requirements, Health First's Code of Ethics & Business Conduct, laws, rules and regulations and/or requirements for FDRs, is a violation of FDR's contract with HFHP, which may result in corrective actions, up to and including contract termination. Both parties agree that terms not included in this Statement of Attestation, regardless of whether or not they were discussed and agreed upon, are not effective. The FDR warrants that the party signing the Statement of Attestation is an authorized representative of the FDR. The authorized representative must be given the full authority to bind the FDR to this agreement, at a minimum, by the FDR's policies and procedures, the corporate by laws, the board of directors, executive leadership or a similar level of authority.

FDR's Legal Name:

FDR's Physical Address: FDR's NPI or Tax ID: Authorized Representative's Name: Authorized Representative's Title: Authorized Representative's Phone: Authorized Representative's Email:

Authorized Representative's Signature_____________________________________ Date_______________

Please ensure your organization has met all applicable requirements and forward the Compliance Program Statement of Attestation within 30 days from the date of the cover letter. Completed forms may be submitted by mail, e-mail or by facsimile transmission.

Email: HFHPComplianceTeam@Health- Fax Number: 321.434.7545

Mailing Address: Corporate Compliance ATTN: HFHP Compliance Team 6450 US Hwy 1 Rockledge, FL 32955

Initials __________ Date ___________

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