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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**

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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