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First Tier or Related Entity Annual Compliance Attestation

INSTRUCTIONS:

This attestation confirms your organization’s receipt of the Provider Partners Code of Ethical Business Conduct and Medicare Compliance Guide for First Tier, Downstream, and Related Entities (FDRs) and Key Compliance Policies Document. It also confirms your commitment to comply with the Centers for Medicare & Medicaid Services (CMS) requirements1 and Provider Partners Health Plans requirements. These requirements apply to services your organization, as a First-Tier Entity2 or Related Entity3, provide for Provider Partners and, also applies to any of the related or downstream entities4 you use for Provider Partners contracted services.

1. Code of Conduct and/or Compliance Policies
2. General Compliance and Fraud, Waste and Abuse (“FWA”) Training
3. Model of Care (MOC) Training for Health Care Providers and FDRs who provide healthcare services for our Institutional and Institutional Equivalent Special Needs Members (I-SNP & IE-SNP)
CMS requires Provider Partners to administer initial and annual MOC training to contracted health care providers and to out-of-network providers who treat our members on a routine basis. Provider Partners Model of Care training for providers is available on our website and providers are required to attest to MOC training completion.

MOC FDRs5 must administer Provider Partners MOC training to clinical staff who provide/arrange for MOC services to Provider Partners’ I-SNP and/or IE-SNP MOC members.

Please specify which of the following applies to your organization:
4. Exclusion/Debarment Screenings
5. Reporting Potential Non-Compliance to Provider Partners
6. Offshore Operations & Reporting
Check the appropriate box for your organization to attest to compliance:
7. Downstream Entity Oversight (if applicable)
As an authorized representative for the below named organization, I certify that the statements made herein are true and correct to the best of my knowledge and that my organization maintains records that support our compliance. We will maintain this documentation in accordance with federal laws and our contract with Provider Partners, for a period of no less than ten (10) years. My organization will produce this evidence upon request and understands that the inability to produce this evidence may result in a request for a Corrective Action Plan (CAP) or other contractual remedies, up to and including contract termination.
Organization Street Address(Required)

Organization’s Authorized Representative

Name(Required)
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Authorized Representative’s Digital Signature
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[1] CMS’s guidance for Medicare Advantage organizations and Part D sponsors are published in both, Pub. 100-18, Medicare Prescription Drug Benefit Manual, Chapter 9 and in Pub.100-16, Medicare Managed Care Manual, Chapter 21, and are identical in each. Other applicable CMS regulatory/sub-regulatory guidance includes but is not limited to: CY2019 Final Rule CMS-4182-F published April 16, 2018; 42C.F.R.§§422 & 423; and associated CMS Manuals and HPMS memos.

[2] First-tier entity is any party that enters into a written arrangement, acceptable to CMS, with a Medicare Advantage or Part D plan sponsor, or applicant to provide administrative services or health care services to Medicare eligible individual under the Medicare Advantage program or Part D program (See, 42 C.F.R. §§422.500 & 423.501)

[3] Related Entity means any entity that is related to a MA Organization (MAO) or Part D Sponsor by common ownership or control and (1) performs some of the MAO or Part D Sponsor’s management functions under contract or delegation. (2) Furnishes services to Medicare enrollees under an oral or written agreement; or leases real property or sells materials to the MAO or Part D Plan Sponsor at a cost more than $2,500 during a contract period.

[4] Downstream Entity is any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the Medicare Advantage benefit or Part D benefit, below the level of the arrangement between a Medicare Advantage Organization or applicant or a Part D plan sponsor or applicant and a first-tier entity. These written arrangements continue down to the level of the ultimate provider of both health and administrative services. (See, 42 C.F.R. §§ 422.500 & 423.501)

[5] MOC FDRs are those FDRs to whom Provider Partners delegates Model of Care Requirements.

[6] Provider Partners MOC Training is available on our website. Healthcare provider MOC training completion is tracked by Provider Partners. Provider Partners is responsible for conducting outreach to providers regarding training completion.

Page Last Updated:  4/9/2024

Provider Partner Health Plans are HMO-SNPs with Medicare contracts. Enrollment in Provider Partner Health Plans depends on contract renewal. Y0135_PPHPWEB_2024