print page email page Home Vendor Compliance Attestation Vendor Compliance Attestation *Indicates required field. First Tier, Downstream and Related Entity (FDR) Compliance Attestation CMS requires any organization or individual that contracts with Health Partners Plans (HPP) to provide administrative or healthcare service functions on behalf of HPP 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 For newly contracted FDRs, this attestation must be submitted back to HPP within 90 days of contract. Fraud, Waste, and Abuse (FWA) & General Compliance Training (Select all that apply): My organization is newly contracted with HPP to provide administrative or healthcare service functions. We will ensure that all personnel involved in the administration or delivery of healthcare benefits complete FWA and General Compliance training within 90 days of execution of the HPP contract via one of the options listed below: CMS Medicare Learning Network (MLN) FWA training and General Compliance education modules, with certificates of completion available upon request (Available option to satisfy requirements for the Medicare line of business) My organization downloads and incorporates the content from the CMS standardized FWA and General Compliance training module from the CMS website into our existing compliance training materials/systems. We ensure the CMS module content that is included is not modified beyond the modification to the appearance of the content (i.e. font, color background, format, etc.) that we can provide proof of training completion upon request (Available option to satisfy requirements for the Medicare line of business) HPP's FWA and General Compliance Training (May be acceptable for Non-Medicare Lines of Business ONLY effective CY 2016 and beyond) My organization's own equivalent version of the HPP FWA and General Compliance training (May be acceptable for Non-Medicare line of business ONLY effective CY 2016 and beyond) If the above stated verbiage does not align with the actions of your organization, please provide an explanation below: Compliance Information: My organization affirms that we have a Code of Conduct and Compliance Policies that communicates the organization’s compliance expectations in year 2016. We affirm that our COC and Compliance Policies are distributed to all the organization’s employees. Distribution occurs within 90 days of hire/contracting, when there are updates/revisions, and annually thereafter. My organization will utilize HPP's Code of Conduct (COC) and Compliance Policies will be made available to our organization. We have provided HPP’s COC/Compliance policies to all our employees within 90 days of this contract execution. 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: Compliance Information (applicable to organizations with Downstream Entities only): My organization will ensure that our downstream entities who are assigned to work on HPP’s business receive (choose one): My organization’s Code of Conduct and Compliance Policies My downstream entity(s) may use their own comparable Code of Conduct and Compliance policies. We ensure that it captures the downstream entity’s intent to comply with federal regulations. In addition, my organization conducts reviews of those policies from a sample to ensure the content is sufficient. My organization provides our downstream entities with a copy of HPP’s Code of Conduct and Compliance Policies. If the organization does not perform ongoing oversight over the downstream entities, please provide an explanation below: OIG/SAM/Medicheck Exclusion Screening: My organization attests that we review the OIG LEIE, SAM EPLS and Medicheck (applicable to work related to HPP’s Medicaid/ CHIP lines of business), prior to the hiring or contracting of all personnel involved in the administration or delivery of healthcare and on a monthly basis thereafter. If the organization did not perform exclusion screenings as stated above, please provide an explanation below: Reporting Mechanisms: Internal 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 the above stated verbiage does not align with the actions of your organization, please provide an explanation below: Offshore Subcontractor Reporting: My organization and/or any of our downstream/related entities (CHECK ONE) DO DO NOT engage in offshore operations for any administrative or healthcare services related to HPP business. If yes, please complete the “Offshore Subcontractor Attestation” for each entity. Downstream Entity Oversight (only applicable to First Tiers that subcontract delegated functions to another organization): My organization attests that we will ensure compliance is maintained by our organization and perform ongoing oversight of our downstream entities and disclose issues identified to HPP as soon as possible. If the organization does not perform ongoing oversight over the downstream entities, please provide an explanation below: By completing this attestation your organization is acknowledging your intent to comply with HPP’s vendor policy and with Federal and State requirements. Be advised that in the upcoming year, your organization will be required to affirm that the aforementioned vendor requirements were completed. As an 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 Full Legal Entity Name* Organization Full Legal Entity 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* Organization's Authorized Representative* Organization's Authorized Representative's Title* Organization's Authorized Representative Phone Number* Organization's Authorized Representative Email Address* Organization TIN/EIN* Please direct questions or concerns regarding this attestation to MedicareFDR@hpplans.com.