Medicare Compliance

Medicare Compliance

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

Required Information

Company Information

Electronic Signature

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

Attestation Agreement

  1. I have the signatory authority to attest on behalf of my company,
  2. 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
  3. 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)
  4. 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).
AND
AND
  1. Specific steps taken in response to violation;

  2. Information uncovered during the organization's investigation process;

  3. Report of findings/investigation;

  4. Written disciplinary actions issued;

  5. 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.

  1. 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.

  2. 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.

  3. 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.