FIRST-TIER, DOWNSTREAM & RELATED ENTITIES (FDR) & HIPPA COMPLIANCE

FIRST-TIER, DOWNSTREAM & RELATED ENTITIES (FDR) & HIPPA COMPLIANCE

Our Commitment to Regulatory Compliance

RMHP is committed to assisting all of our FDR business partners in meeting the Centers for Medicare and Medicaid Services (CMS) regulatory requirements by providing convenient access to the required training materials.  The requirements are described in the following regulations and guidelines:

CMS 42 CFR §422.503(b)(4)(vi)(A)

CMS 42 CFR §423.504(b)(4)(vi)(A)

Medicare Compliance Program Guidelines*
*Medicare Compliance Program Guidlelines include Prescription Drug Benefit Manual, Chapter 9/Medicare Managed Care Manual, Chapter 21 


RMHP’s Compliance Plan assists our FDR partners in complying with state and federal law, including, without limitation, Federal Health Care Reform legislation enacted under the Affordable Care Act (ACA). Therefore, all FDR partners should be familiar with and abide by the standards of conduct set forth in the plan.
 
 
RMHP’s Compliance Plan establishes the framework for compliance in all of our lines of business (including Medicare) in order to:

  •  Prevent violation of federal and state laws including healthcare fraud, waste, and abuse.
  •  Ensure operations are unencumbered by regulatory restrictions, sanctions, or fines.
  •  Promote early and accurate detection, as well as prompt resolution in the event of a violation. 

View our Compliance Plan

Fraud, Waste and Abuse

 Fraud, waste, and abuse (FWA) rob the health care system of billions of dollars annually. Several federal laws help combat these problems and reduce costs that are due to FWA, including False Claims Act, portions of the Deficit Reduction Act, and HIPAA. These laws also help safeguard a patient's private information and protect individuals (whistleblowers) who report illegal activities of health care related entities (persons or companies). RMHP's Fraud, Waste, and Abuse training addresses: 

  •  Written policies and procedures and Code of Conduct
  • Medicare Compliance Officer and Compliance Committee
  • Training and educationEffective lines of communication
  • Enforcement of disciplinary standards
  • Auditing and monitoring
  • Prompt and effective responses to detected offenses

Fraud, Waste and Abuse Training

Additional Part D Information

Attestation for Pharmacy Providers

Reporting Fraud, Waste, and Abuse

RMHP is committed to preventing, detecting, investigating, and prosecuting health care and insurance fraud, and we need your help. If you think someone is doing something wrong or illegal with regard to their Rocky Mountain Health Plans health care or insurance, please contact us using one of the following methods:

Telephone
Fraud Hotline
970-248-5101
888-237-1179 

Mail
Fraud Investigator
Rocky Mountain Health Plans
PO Box 10600
Grand Junction, CO 81502-5600

Report by email    Fraud Reporting Form

HIPAA Security and Privacy

Rocky Mountain Health Plans is a Covered Entity as defined by 42 C.F.R. § 160.103 for purposes of the Health Insurance Portability and Accountability Act (HIPAA).  Compliance with the provisions of HIPAA is one of our top priorities, and our Vendors/Business Associates are required to make it a priority as well.  We are committed to maintaining the security and privacy of our members' information.  Towards that end, we train our workforce on our obligations under HIPAA, and we expect our Vendors/Business Associates to train their workforce as well.

HIPAA Security & Privacy Training Presentation

Annual Attestation

RMHP policies and procedures require that all of our FDRs submit verification of their compliance with CMS regulations and guidelines using the following attestation form.To submit the mandatory FDR attestation, please review, complete, and sign the "CMS Compliance Attestation for Rocky Mountain Health Plans Contract" form. The form can be accessed and completed using the button below.

CMS Compliance Attestation for RMHP Contract

RMHP highly values its FDR partners and appreciates and supports your efforts to maintain compliance with CMS regulatory requirements and guidelines. Please direct your questions or concerns related to CMS regulatory compliance activities to MedicareCompliance@rmhp.org.

Email Medicare Compliance