HFHP Florida Provider Medicare FDR Statement of Attestation

As a provider of healthcare services for Health First Health Plans Inc. (HFHP) Medicare Advantage enrollees, you and your organization are considered a First Tier or Related Entity.

HFHP and its First Tier, Downstream or Related entities (FDRs) must all comply with the Centers for Medicare & Medicaid Services (CMS) program requirements. This includes an annual attestation from you of compliance with these requirements. This document assists HFHP in demonstrating effective communication of these requirements to you, as well as a record of your agreement to comply.

INSTRUCTIONS

Visit hf.org/health_plans/fdrattestation/compliance.cfm for resources and information about the responsibilities of an FDR.

A.Code of Conduct

42 CFR 422.503 and 423.504(b)(4)(vi)(A)

Practice/Provider has viewed Health First's Code of Ethics & Business Conduct, located in the Provider Manual or at myHFHP.org/about_us/code_of_ethics.pdf.

B. Education; HFHP Compliance Policies and Procedures

42 CFR 422.503 and 423.504(b)(4)(vi)(C)

Practice/Provider is aware that the HFHP FDR compliance webpage hf.org/health_plans/fdrattestation/compliance.cfm has educational information about:

General compliance

HFHP compliance/integrity policies and procedures

Fraud, waste and abuse hf.org/health_plans/about_us/fwa/fwa.cfm

C. Record Retention

42 CFR 422.503-504, 423.136, and 423.505

Practice/Provider keeps operations and patient medical records for at least 10 years.

D. Privacy and Security

HIPAA, 42 CFR 422.504(a)(13), 422.118, and 423.136)

Practice/Provider, leadership, employees, contractors, and vendors agree to safeguard patient privacy, confidentiality, and assure accuracy of beneficiary health records pursuant to applicable laws.

E. Exclusion Screening

42 CFR 422.503, 422.752(a)(8), 423.504(b)(4)(vi)(F) and 423.752(a)(6)

Prior to hiring personnel or contracting with subcontractors/vendors, Practice/Provider has reviewed proposed personnel or vendors against the Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE), System for Award Management (SAM) exclusion records. After hire or contracting Practice/Provider has continued this review on an ongoing monthly basis.

F. Reporting Non-Compliance/Enforcement of Standards

42 CFR 422.503 and 423.504(b)(4)(vi)(E)

Practice/Provider will report to HFHP (within a reasonable time frame) all suspected or known instances of non-compliance and/or fraud, waste, or abuse. Reporting methods are contained in Health First's Code of Ethics & Business Conduct.

G. Correction of Identified Deficiencies

42 CFR 422.503, 423.504(b)(4)(vi)(G), and per contractual requirements

Practice/Provider will timely correct any deficiencies related to misconduct or Medicare program non-compliance. Practice/Provider will furnish reasonable documentation to support any CMS requirements to HFHP upon request, at no cost. Practice/Provider shall reasonably cooperate and fulfill any corrective action requested by HFHP.

H. Non-United States/Offshore Subcontractors

HIPAA, CMS HPMS Memos released on 7/23/2007 and 8/26/2008, CMS 2008 Call Letter

With prior approval from HFHP, Practice/Provider can utilize offshore subcontractors/ vendors/ personnel in connection with providing administrative or healthcare services for HFHP.

Offshore subcontractors = companies or individuals that fulfill or help fulfill Medicare requirements or have access to patient data.
Offshore = to any country that is not one of the 50 United States or one of the United States territories. Offshore subcontractors can be American-owned companies with portions of their operations perded outside the United States or foreign-owned companies with operations performed outside of the United States.

If Practice/Provider utilizes or plans to utilize offshore subcontractor(s), contact the HFHP Provider Network Operations (ProviderNetworkOperations@hf.org) to complete an Off-Shoring Addendum.

Statement of Attestation

I certify that the above statements are true and that the obligations will be continually maintained.

The person signing the is an authorized representative of the FDR. The authorized representative must be given the full authority to bind the FDR to this agreement.

Todays Date*

FDR’s Legal/Business/Practice Name*:

Address*

NPI or Tax ID*:

Authorized Representative’s Name*:

Authorized Representative’s Title*:

Authorized Representative’s Phone*:

Authorized Representative’s Email*:

Authorized Representative’s Signature*:

By typing your name in the box above, you are signing this agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this agreement. You consent to be legally bound by this agreement’s terms and conditions. You also affirm that you are a representative of the FDR with authority to bind the FDR to this agreement.

Completed forms may be submitted by mail, email or by facsimile transmission:

Email:	hfhpcorporateintegrity@hf.org
Phone:	321.434.7439
Fax:	321.434.7545
Mail:	Health First Corporate Integrity AATTN: HFHP 6450 US Highway 1 Rockledge, FL 32955

Last updated: 09/10/2021