Medicare Compliance

Please view the Medicare Compliance Plan documents associated with this Attestation.

Required Information

Electronic Signature

First Name

Last Name

Title

Email Address

My company will utilize our internal training materials. Copies of our training materials have been sent to Medicare Compliance for review.

Check if yes

Attestation Agreement

By signing below, I attest that:

I have the signatory authority to attest on behalf of my company,
I have received Rocky Mountain Health Plan’s (RMHP) First Tier, Downstream or Related Entity (FDR) package that includes the following documents and training materials, and
I fully understand the importance of the following CMS regulatory requirements, which apply to all activities, responsibilities, and delegated functions performed by my organization as specified in our contract with RMHP:
1. Code and Standards of Conduct/Compliance Plan
  You may elect to use your organization's Standards of Conduct document
2. Conflict of Interest
  As noted in the Compliance Plan document
3. Fraud, Waste and Abuse (FWA) Compliance, and specialized training requirements in accordance with CMS guidelines. (42CFR423.504)
  Each applicable employee¹ in your organization must complete this course within 90 days of employment and then annually thereafter.
4. Corporate Compliance Plan Training
  Each applicable employee¹ in your organization must complete this course within 90 days of employment and then annually thereafter.
5. Medicare Compliance Program Guidelines (Chapter 9/Medicare Managed Care Manual, Chapter 21, Prescription Drug Benefit Manual)
My company will utilize RMHPs’ training materials or will provide RMHP with copies of my company’s training materials for review (see end of form).

I attest that as of 09/22/2016, and in accordance with CMS requirements, all applicable employees¹ of our company have received the approved training which, at a minimum, meets the requirements described in CMS 42 CFR §422.503(b)(4)(vi)(A) and 42 CFR §423.504(b)(4)(vi)(A).

AND

I attest that in accordance with CMS requirements, all of our applicable employees¹, pharmacies, vendors, board members or related individuals and entities, either directly or indirectly to this agreement, have been verified on the OIG List of Excluded Individuals/Entities and the System for Award Management, (SAM) websites, (see below for links) upon hire, annually thereafter, and/or as requested by RMHP; that all those entities and or individuals found as being excluded have been or will be immediately reported to RMHP's Compliance Officer and have been or will be immediately removed from any work related, directly or indirectly, Federal health care programs.

AND

I attest, in accordance with CMS requirements, we will provide to RMHP, at least quarterly, a signed attestation of all identified applicable employees¹ or vendors or downstream entities which had a disciplinary or termination action related directly to Medicare non-compliance or fraud, waste and abuse. The attestation will detail at least:

Specific steps taken in response to violation;
Information uncovered during the organization's investigation process;
Report of findings/investigation;
Written disciplinary actions issued;
Record of violation and consequences (including disciplinary actions) being reported to the Board, Senior Management, or others within organization.

Note: For current applicable employees¹, or applicable employees¹ within 2014 who had such actions, the above will be reported to RMHP within 3 business days.

I attest, in accordance with CMS requirements, we will immediately report all suspected or known instances of Medicare noncompliance and/or fraud, waste and abuse issues to RMHP no later than 10 days of discovery.

I understand that the above elements are CMS requirements and this Attestation and all other supporting documents are due back to RMHP via email or fax no later than 14 days from date of receipt.
I understand that this Attestation does not release the company I represent from any negligence and that RMHP has full authority to audit our processes and procedures at any time during the terms of the agreement and report any findings to CMS.
I fully understand the importance of the following CMS regulatory requirements, which apply to all activities, responsibilities, and delegated functions performed by my organization as specified in our contract with RMHP.

¹An applicable employee is defined as an employee that performs any CMS activities, responsibilities or delegated functions as specified in your contract with RMHP.

Medicare Compliance

1st Tier, Downstream or Related Entity (FDR) CMS Compliance Attestation for RMHP Contract

Company Information

Electronic Signature

Attestation Agreement