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Prospective & Enrolled Members: 800-405-9681 (TTY 711)

Provider Inquiries: 1-855-969-5907 (TTY 711)

INSTRUCTIONS:

  • This attestation must be completed by First Tier Entity1 that:
    • contracts directly with Provider Partners Health Plans (PPHP) and has a contract with a vendor that receives, processes, transfers, handles, stores, or accesses Medicare Advantage member PHI offshore2, or
    • contracts directly with Provider Partners Health Plan and has a contract with another further subcontracted vendor, and that vendor will be supporting or performing work for our Medicare Advantage plans. Or they may support the work one of our first tiers does for our Medicare Advantage plans, and receives, processes, transfers, handles, stores, or accesses Medicare Advantage member Protected Health Information (“PHI”) offshore
  • Please be sure to complete each field in its entirety.
  • Sign and complete the last page of the Attestation.
  • Submission of this Offshore Services Attestation is due to PPHP within 30 days of the proposed or actual effective date of the offshore activity or service.
  • Please submit the completed form below.

**Note: Individual attestations must be completed for each offshore entity**

SECTION I: FIRST TIER INFORMATION

SECTION II: OFFSHORE SUBCONTRACTOR INFORMATION

The offshore entity address should include the full address for each offshore location, including the country, which will receive, process, transfer, handle, store, or access PHI.
The proposed or actual effective date is either the effective date of the Medicare contract with Provider Partners Health Plan or the effective date of the contract with the entity, whichever is later. The proposed or actual effective date for the services must include the month, date, and year. Please use this format: MM/DD/YYYY.
MM slash DD slash YYYY
6. Description of the PHI that will be provided to the offshore entity:
When describing any alternatives considered to avoid using PHI, be sure to include the reason why the alternative was rejected.
9. With respect to the offshore services provided by the above-named offshore entity, first tier certifies and attests that:
(i) The agreement it has with the offshore entity requires the offshore entity to have policies and procedures in place to ensure that Provider Partners Health Plan’s Medicare Plans’ PHI remains secure.
(ii) The agreement it has with the offshore entity prohibits the offshore entity’s access to data not associated with the agreement.
(ii) The agreement it has with the offshore entity prohibits the offshore entity’s access to data not associated with the agreement.
(iii) The agreement with the offshore entity allows the first tier to immediately terminate the offshore services upon discovery of a significant security breach.
(iii) The agreement with the offshore entity allows the first tier to immediately terminate the offshore services upon discovery of a significant security breach.
(iv) The agreement it has with the offshore entity includes all required Medicare Part C and Part D language (e.g., record retention requirements, compliance with all Medicare Part C and D requirements, etc.).
(iv) The agreement it has with the offshore entity includes all required Medicare Part C and Part D language (e.g., record retention requirements, compliance with all Medicare Part C and D requirements, etc.).
(v) The first tier conducts an annual audit or review of its relationship with the offshore entity.
(v) The first tier conducts an annual audit or review of its relationship with the offshore entity.
(vi) The results from the annual audit or review are used to evaluate the continuation of the relationship with the offshore entity.
(vi) The results from the annual audit or review are used to evaluate the continuation of the relationship with the offshore entity.
(vii) The agreement it has with the offshore entity requires the offshore entity to share such audit results with the Centers for Medicare and Medicaid Services (“CMS”) directly or with a plan sponsor (here, Provider Partners Health Plan) upon request.
(vii) The agreement it has with the offshore entity requires the offshore entity to share such audit results with the Centers for Medicare and Medicaid Services (“CMS”) directly or with a plan sponsor (here, Provider Partners Health Plan) upon request.
(viii) Additional information about its agreement with the offshore entity will be provided to CMS directly or its authorized agents or a plan sponsor (here, PPHP) upon request.
(viii) Additional information about its agreement with the offshore entity will be provided to CMS directly or its authorized agents or a plan sponsor (here, PPHP) upon request.
First Tier Authorized Representative (Printed Name)
MM slash DD slash YYYY
First Tier’s Mailing Address

1First-Tier Entity is any party that enters into a written arrangement, acceptable to CMS, with a Medicare Advantage Organization or Part D plan sponsor or applicant to provide administrative services or healthcare services to a Medicare eligible individual under the Medicare Advantage program or Part D program. (See, 42 C.F.R. §§ 422.500 & 423.501)

2The term offshore refers to any country that is not within the United States or one of the United States territories (American Samoa, Guam, Northern Marianas, Puerto Rico, and Virgin Islands). Examples of countries that meet the definition of ‘offshore’ include Mexico, Canada, India, Germany, and Japan. Subcontractors that are considered offshore can be either American-owned companies with certain portions of their operations performed outside the United States or foreign-owned companies with their operations performed outside the United States. Offshore subcontractors provide services that are performed by workers located in offshore countries, regardless of whether the workers are employees of American or foreign companies.

Page Last Updated:  10/15/2021

Provider Partner Health Plans are HMO-SNPs with Medicare contracts. Enrollment in Provider Partner Health Plans depends on contract renewal. Y0135_PPHPWEB_2022