Attachment A SummaCare FDR Requirements Attestation

Transcription

1 Please complete this form and include it with all additional documentation required as part of your attestation to the Centers for Medicare and Medicaid Services (CMS), Federal regulations and SummaCare policies that (as a designated SummaCare FDR) your organization must meet. SummaCare s Medicare Compliance Department will contact you as required to ensure that the information herein is current and accurate. Organization Name: NPI or Tax ID Number: Street Address: City, State, Zip Code: Please Note: If any of your answers are No, please provide an explanation and a copy of your corrective action and/or implementation plan with a timeline to meet the requirement. Please note that the below items are not an exhaustive list. This list also does not replace existing contractual, State, Federal and other accreditation and regulatory requirements that SummaCare s FDRs are required to comply with carrying out their duties and responsibilities under the Medicare Part C and Part D programs. This form must be completed by an authorized representative of you organization. An authorized representative is an individual who has responsibility directly or indirectly for all employees, contracted personnel, providers/practitioners, and vendors who provide healthcare or administrative services under Medicare. Authorized representatives may include but are not limited to, human resources director, Compliance Officer, Chief Medical Officer, Practice Manager/Administrator, Provider, Executive Officer or similar related positions.

2 1 The Organization complies with the SIC/SummaCare/Apex Code of Ethical Conduct and all other FDR policies and procedures or adopts and complies with Standards of Ethical Conduct and FDR policies and procedures that meet CMS requirements. 42 CFR (b)(4)(vi)(A); (b)(4)(vi)(A); Medicare Manual, Chapters 9 and 21, The Organization complies with Medicare s Fraud, Waste and Abuse (FWA) training requirements by ensuring that all applicable staff members complete FWA training within 90 days of hire and annually thereafter. 42 CFR (b)(4)(vi)(C); (b)(4)(vi)(C); Medicare Manual, Chapters 9 and 21, We attest to the review of the Standards of Ethical Conduct and FDR policies/procedures as provided by our own Organization at least annually and as needed for updates and/or additions. We attest to the review of the Standards of Ethical Conduct and FDR policies/procedures as provided by SummaCare at least annually and as needed for updates and/or additions. NOTE: To view/download these documents, please visit We attest that all appropriate staff members will complete the CMSprovided FWA training within 90 days of hire and annually thereafter. NOTE: For instructions on how to access and complete this training, please visit We attest that our organization is exempt from the FWA training requirement because our organization is deemed by CMS through our enrollment into Part A or B of the Medicare program or through our accreditation as a supplier of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS).

3 3 The Organization complies with Medicare s General Compliance training requirements by ensuring that all applicable staff members complete General Compliance training within 90 days of hire and annually thereafter. We attest that all appropriate staff members will complete the CMSprovided General Compliance training within 90 days of hire and annually thereafter. NOTE: For instructions on how to access and complete this training, please visit 42 CFR (b)(4)(vi)(C); (b)(4)(vi)(C); Medicare Manual, Chapters 9 and 21, The Organization keeps (and can produce upon request) a log of completed FWA and General Compliance training that includes participants names and completion dates. We attest that we will keep a record/log of completed FWA and General Compliance training for a period of at least 10 years. 42 CFR (b)(4)(vi)(C)

4 5 The Organization, its employees, or Downstream entities are not excluded from participation in Federally-funded health care programs according to the Department of Health and Human Services (HHS), Office of the Inspector General (OIG) and General Services Administration (GSA). 42 CFR (b)(4)(vi)(F); (a)(8); (b)(4)(vi)(F); (a)(6); Medicare Prescription Drug & Managed Care Manual, Chapters 9 and 21, We attest to the completion of review of all applicable employees against HHS OIG and GSA exclusion lists prior to hire and monthly thereafter. NOTE: To assist you in complying with this requirement, please visit If discovered, we will immediately disclose all excluded persons and coordinate resulting personnel issues with SummaCare s Compliance Officer.

5 6 The Organization publishes and enforces its disciplinary standards as well as the methods for reporting Medicare program noncompliance and FWA to its employees. The Organization s disciplinary standards include its expectation that employees, officers and directors, board members, subcontractors, consultants, vendors or volunteers report compliance issues and unethical or illegal behavior. Disciplinary standards must state that any violation of these standards will result in appropriate disciplinary action, up to an including termination of employment. The Organization s disciplinary standards contain CMS-required elements and are well publicized to their employees. The Organization enforces its disciplinary standards The Organization has publicized methods for reporting incidents of noncompliance and FWA. NOTE: To assist you in complying with this requirement, please visit Disciplinary standards must include a non-retaliation policy for good faith reporting. 42 CFR (b)(4)(vi)(E); (b)(4)(vi)(E); Medicare Manual, Chapters 9 and 21, 50.5, and

6 7 The Organization reviews all of its Downstream entities which provide health care and/or administrative services to SummaCare Medicare members to verify that Medicare requirements are completed by those other entities. We attest that we require Downstream entities to attest to compliance with all Medicare requirements. Upon request, we agree to submit attestations and/or supporting documentation to SummaCare verifying that all or our applicable downstream entities are compliant with Medicare requirements. *Downstream Entity = 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. 8 Offshore Subcontractor Attestation Do you contract with offshore subcontractors for services? If yes please complete the SummaCare Offshore Attestation document and return it along with this form to the address listed below. NOTE: To download the SummaCare Offshore Attestation form, please visit

7 By signing below, I attest to the accuracy of all of the above information and affirm that our organization will furnish documentation or other related information upon request by SummaCare. Signature: Print Name: Title: Date: Please sign return this completed form to: ( ) FDRCompliance@summacare.com (Fax) (USPS) SummaCare; ATTN: Medicare Compliance; 10 N. Main Street; Akron, OH 44308