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Medicare FDR Statement of Attestation

Health First Health Plans, Inc. (HFHP) has entered into a written agreement(s) with your organization to provide administrative or healthcare services to Medicare enrollees, making your organization a First Tier or Related Entity of HFHP.

HFHP and its First Tier, Downstream or Related entities (FDRs) must all comply with the Centers for Medicare & Medicaid Services (CMS) program requirements within Chapter 42 of the Code of Federal Regulations, Parts 422 and 423, also referred to as Medicare Parts C and D. This attestation assists HFHP in demonstrating effective communication of these requirements, as well as confirmation of our FDRs compliance with the program requirements.

To gain further understanding of these requirements and ensure they are all met, please visit our FDR Compliance Webpage located at: hf.org/health_plans/fdrattestation/compliance.cfm

Please select your organization's chosen method of compliance by checking the appropriate boxes and initial where necessary:

INSTRUCTIONS

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

  1. Please read and ensure all requirements are met.
  2. Under Sections A, B, C and J below, select your chosen answer from the dropdown options.
  3. Under Sections D through I below, check the corresponding statement to show your agreement with that statement.
  4. Attach supporting documents as needed.
  5. Fill in all fields under the “Statement of Attestation” heading.
  6. Click the “Submit” button.
  7. Contact the Health First Corporate Compliance Department for assistance if needed. See contact information below.

A. Code of Conduct/Policies and Procedures

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

  • FDR provides Health First's Code of Ethics & Business Conduct and applicable policies and procedures 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.
  • The FDR created its own Code of Ethics and policies and procedures which are significantly similar to the Health First Code of Ethics & Business Conduct and policies and procedures, and 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.

B. General Compliance Training

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

FDR presents 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 and retains logs, sign-in sheets, certificates of completion or other evidence that each employee and downstream entity has taken the training. Please indicate the method in which general compliance training is satisfied:

  • FDR provides HFHP's "Medicare Parts C & D Annual Compliance Training" and retains proof of completion for each employee and downstream entity. HFHP's general compliance training is available at: hf.org/health_plans/fdrattestation/compliance.cfm
  • 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 general compliance training adopted by your organization and retain proof of completion for each employee and downstream entity.

C. Fraud, Waste and Abuse (FWA) Training

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

FDR presents 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 and retains logs, sign-in sheets, certificates of completion or other evidence that each employee and downstream entity has taken the training. Please indicate the method in which fraud, waste and abuse training is satisfied:

  • FDR provides HFHP's "Annual Fraud, Waste and Abuse Training" and retains proof of completion for each employee and downstream entity. HFHP's FWA training is available at: hf.org/health_plans/fdrattestation/compliance.cfm
  • 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 FWA training adopted by your organization and retain proof of completion for each employee and downstream entity.

D. Record Retention

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

  • FDR complies 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

  • FDR's 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 HFHP contractually delegated to your organization to perform, FDR/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, your organization as the First Tier Entity will maintain active oversight and monitoring of such activity to ensure any 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 (OIG) 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 all current employees, new employees, temporary employees, volunteers, contractors and consultants 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 the Health First Code of Ethics & Business Conduct for reporting methods. FDR is obligated to report within a reasonable time frame to HFHP all suspected or known instances of non-compliance and/or FWA.

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.

J. Non-United States/Offshore Subcontractors

FDR shall not utilize Offshore Subcontractors in connection with providing administrative or healthcare services for HFHP without first gaining approval from HFHP. CMS defines an “Offshore Subcontractor” as a FDR entity that the Company contracts with to fulfill or help fulfill requirements in their Part C and/or Part D contracts. The term “offshore” refers to any country that is not one of the fifty United States or one of the United States territories. Offshore Subcontractors can be American-owned companies with portions of their operations performed outside the United States or foreign-owned companies with operations performed outside of the United States.

  • FDR does not utilize offshore subcontractors in connection with providing administrative or healthcare services for HFHP.
  • FDR does utilize offshore subcontractors in connection with providing administrative or healthcare services for HFHP. FDR will contact the HFHP Vendor Management Office at VendorManagement@Health-First.org if FDR has not already completed an Off-Shoring Addendum with HFHP.

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 J, 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, the Health First 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 the 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 bylaws, the board of directors, executive leadership or a similar level of authority.

Today’s Date: 
FDR’s Legal Name: 
FDR’s Physical Address with City, State & Zip: 
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: 

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.

If you have any questions, please contact:

HFHP Compliance Team
Phone: 321.434.7439
Email: HFHPComplianceTeam@Health-First.org
Fax: 321.434.4798
Mail: Corporate Compliance
ATTN: HFHP Compliance Team
6450 US Highway 1
Rockledge, FL 32955

 

Last updated: 6/28/2019