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' distribution of the Code of Conduct (COC) and Compliance Policies requirements. HPP provides access to HPP's COC and Compliance Policy via the Provider Manual. Furthermore, HPP ensures the documents are readily available on HPP's Medicare FDR Webpage.

I hereby acknowledge and agree that my organization:

	Has been provided, read, understands and is compliant with HPP's COC and Compliance Policy Either adopts and complies with HPP's COC and Compliance Policy or has its own policy that is materially similar to the HPP's COC & Compliance Policy and complies with that policy
	Accept My organization adopts and complies with HPP's COC and Compliance Policy.
	Accept My organization has adopted another policy that is materially similar to the HPP COC and Compliance Policy and complies with that policy.

If the organization does not adopt and comply with HPP's COC and Compliance Policy, or a materially similar version, please provide an explanation below.

Organizations with Downstream Entities

	My organization does not contract with any downstream entities who are assigned to work on HPP's business.
	Accept- My organization ensures our downstream entities (if applicable) who are assigned to work on HPP's business receive HPP's Provider Manual, which includes HPP's COC and Compliance Policies. We have provided HPP's Provider Manual to all of our downstream entities initially within 90 days of hire or contracting, upon revision, and annually thereafter.
	Accept- My organization ensures our downstream entities (if applicable) who are assigned to work on HPP's business receive our organization's Provider Manual, which includes our COC and Compliance Policies. We have provided our Provider Manual to all of our downstream entities initially within 90 days of hire or contracting, upon revision, and annually thereafter.
	Accept- My organization ensures our downstream entities (if applicable) who are assigned to work on HPP's business receive our organization's COC and Compliance Policies. We have provided our COC and Compliance Policies to all of our downstream entities initially within 90 days of hire or contracting, upon revision, and annually thereafter.
	Accept- My organization ensures downstream entities have been contractually required to have and distribute their own COC and Compliance Policies. If our downstreams utilize their own comparable versions, my organization conducts a review of those policies from a sample of downstream entities to ensure the content is sufficient.

If the Organization either does not comply with CMS’ COC & Compliance Policies distribution requirements, or satisfies the requirements via a different method not listed above, please provide an explanation below.

OIG/SAM Exclusion Screening
	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.
Reporting Mechanisms
	Employees and downstream entities (if applicable) 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.

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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*
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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*