Contracted Health Care Provider Compliance Attestation

The Centers for Medicare & Medicaid Services (CMS) requires any organization or individual that contracts with Health Partners Plans (HPP) to provide administrative or healthcare services to beneficiaries to comply with various CMS program requirements. By completing the following attestation, you certify that your organization is committed to ensuring compliance with HPP and CMS requirements. Additional information on the below requirements can be found on our website at:

https://medicare.healthpartnersplans.com/medicare-fdr-information

This attestation must be submitted back to HPP within 30 calendar days from the date of request.

Code of Conduct and Compliance Policies for Contracted Health Care Providers

HPP complies with CMS' Code of Business Conduct (COBC) and Compliance Policy distribution requirements. HPP provides access to HPP's COBC and Compliance Policy via HPP’s Provider Manual and Medicare FDR Webpage.

I hereby acknowledge and agree that my organization has been provided, read, understands and is compliant with HPP's COBC and Compliance Program Policies. My organization takes the following actions to ensure its employees are aware of and comply with HPP and CMS Compliance Program requirements:
(Select 1 option that best describes your organization’s actions or enter an explanation in the comment box.)
	HPP's Code of Business Conduct (COBC) and Compliance Program Policies are provided to my organization’s employees within 90 days of hire, upon revision, and annually thereafter.
	My organization’s Code of Conduct and/or Compliance Program Policies are materially similar to HPP’s COBC and Compliance Program Policy content and are provided to all of our employees within 90 days of hire, upon revision, and annually thereafter.

If your organization does not comply with and distribute HPP's COBC and Compliance Policy, or its own similar versions, please provide an explanation below:

OIG/SAM Exclusion Screening

(Select the option below or enter an explanation in the comment box.)

	My organization attests that we review the OIG-LEIE and SAM-EPLS prior to the hiring or contracting of all personnel involved in the administration or delivery of HPP benefits and on a monthly basis thereafter.
If your organization does not comply with OIG/SAM Exclusion Screening Requirements, please provide an explanation below
Reporting Mechanisms (Select the option below or enter an explanation in the comment box.)
	Employees were informed of their obligation and how to report any suspected or detected non-compliance or potential FWA for internal investigation. The reporting mechanisms ensure confidentiality and allow for anonymity, as desired. In addition, we don't allow retaliation or intimidation against anyone who reports in good faith. In turn, our organization reports any applicable incidents to HPP as they arise.
If your organization does not comply with Reporting Requirements, please provide an explanation below:

Downstream Entity Status

Please indicate here if your organization contracts with downstream entities to perform HPP related healthcare services:

(Note: Downstream Entities are Healthcare Providers, organizations or other entities that are contracted with your organization to perform HPP related healthcare services. Internal employees of your organization are not considered to be downstream entities.)

	Yes, my organization contracts with downstream entities to perform HPP related healthcare services.
	No, my organization does not contract with downstream entities to perform HPP related healthcare services.

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As authorized representative for the below named organization, I certify that I have reviewed and understand all of the requirements within HPP's vendor policy, that the above statements are true to the best of my knowledge, and that my organization maintains records that support our compliance.

Organization Name*

Organization Address, Line 1*

Line 2

City*

State*
(please select) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code*

Tax ID Number*

Organization's Authorized Representative*

Organization's Authorized Representative's Title*

Organization's Authorized Representative Phone Number*

Organization's Authorized Representative Email Address*