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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) requirements and Provider Partners Health Plans requirements. These requirements apply to services your organization, as a First-Tier Entity or Related Entity, provide for Provider Partners and, also applies to any of the related or downstream entities 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 Training (For Health Care Providers and FDRs who provide healthcare services for our Institutional Special Needs Members)
CMS requires all staff and contracted health care providers to receive basic training about Provider Partners’ Institutional-Based Program Model of Care (MOC), which was provided by Provider Partners. All applicable staff were trained within 90 days of hire or contracting, upon revision, and annually thereafter.

Check the appropriate box for your organization to attest to compliance:
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 Address

Organization’s Authorized Representative

Name
Hidden
Authorized Representative’s Digital Signature
MM slash DD slash YYYY

[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)

Page Last Updated:  11/17/2022

Provider Partner Health Plans are HMO-SNPs with Medicare contracts. Enrollment in Provider Partner Health Plans depends on contract renewal. Y0135_PPHPWEB_2023