Healthfirst First Tier, Downstream, and Related Entity and Affiliate Compliance Attestation

Healthfirst’s commitment to compliance includes ensuring that our First Tier, Downstream and Related Entities (FDRs) are in compliance with applicable state and federal regulations. Healthfirst contracts with FDRs to provide administrative or healthcare services to our enrollees; we are ultimately responsible for fulfilling the terms and conditions of our contract with the Center for Medicare & Medicaid services (CMS) and meeting the Medicare and Medicaid program requirements. Therefore, Healthfirst has developed a process to validate that each contracted FDR and Affiliate has met the requirements. Each FDR and Affiliate must complete the Attestation below, to confirm compliance with the Healthfirst FDR compliance requirements.

An FDR is a First Tier, Downstream or Related Entity. An FDR provides administrative or health care services relating to Healthfirst Medicare contracts. Healthfirst’s FDRs include hospitals, providers, ancillaries, and some vendors.

First Tier Entity: any party that enters into a written arrangement, acceptable to CMS, with an MAO or Part D plan sponsor or applicant to provide administrative services or health care services to a Medicare eligible individual under the MA program or Part D program.

Downstream Entity: any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the MA benefit or Part D benefit, below the level of the arrangement between an MAO 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.

Related Entity: any entity that is related to an MAO or Part D sponsor by common ownership or control and

Performs some of the MAO or Part D plan sponsor’s management functions under contract or delegation;
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 of more than $2,500 during a contract period.

An affiliate is a person, provider or entity who provides care, services, or supplies under the Medicaid program, or a
person who submit claims for care, services, or supplies for or on behalf of another person or provider for which the
Medicaid program is or should be reasonably expected by a provider to be a substantial portion of their business
operations.

The FDR and Affiliate Requirements are detailed in the FDR and Affiliate Compliance Guide PDF.

The requirements include:

Distribution of Code of Conduct and Compliance Policies
Exclusion Screening
Fraud, Waste, Abuse and Compliance Concerns Reporting

In addition, all FDRs must complete the Compliance Attestation Form below annually.

Instructions:

This form must be completed by an authorized representative (i.e., a Compliance Officer, Chief Medical Officer, Practice Manager/Administrator, an Executive Officer, Provider, or Owner) to attest to compliance with the Healthfirst FDR and Affiliate Compliance Policy annually.

Step One: Click each of the links below and select the appropriate response for each category. All four items must be completed. Please check one box in each category.

I have reviewed and understand the Healthfirst FDR and Affiliate Compliance Guide. My organization will abide by the Healthfirst compliance policies. In addition,

My organization has established and publicized compliance policies, Standards of Conduct, and compliance reference material that meet the requirements set forth by CMS in 42 CFR § 422.503(b)(4)(vi)(A) and 42 CFR § 423.504(b)(4)(vi)(A). This information is disseminated to employees and contractors upon hire and annually thereafter. A record of all employees and contractors receipt of the policies, Standards of Conduct, and information is maintained for a period of ten years and can be provided upon request.

The compliance policies and/or Standards of Conduct reflect a commitment to preventing, detecting, and correcting non-compliance.
The compliance reference material includes, at minimum, information on the Deficit Reduction Act of 2005 and the False Claims Act.

My organization does not have established compliance policies and/or Standards of Conduct. Therefore, the Healthfirst FDR and Affiliate Compliance Guide has been disseminated to all employees and contractors. It includes: The Healthfirst Compliance Code of Conduct, compliance policies, and information on select regulations, including but not limited to, the Deficit Reduction Act of 2005 and the False Claims Act. A record of all employees' and contractors' receipt of the Healthfirst FDR and Affiliate Compliance Guide will be maintained for a period of ten years and can be provided upon request.

My organization currently performs exclusion screening prior to hire and/or contract and monthly thereafter to confirm that employees and contractors are not excluded from participation in federally funded healthcare programs according to the OIG and GSA (SAM), and New York State exclusion lists (OMIG), or the equivalent for those that are offshore. If an employee or contractor is on an exclusion list he or she shall be removed from any work related directly or indirectly to federal health care programs and appropriate corrective action will be taken.

My organization does not currently perform exclusion screening prior to hire and/or contract nor monthly thereafter. However, within 60 days of receipt of this form, and monthly thereafter, a check will be done to confirm that employees and contractors are not excluded to participate in federally funded health care programs according to the OIG and GSA (SAM), and New York State exclusion lists (OMIG), or the equivalent for those that are offshore. If an employee or contractor is on an exclusion list he or she will be removed from any work related directly or indirectly to federal health care programs and appropriate corrective action will be taken.

Below are links to the exclusion screening websites:

My organization maintains a confidential FWA and compliance reporting mechanism. It has been distributed and widely publicized for all employees and contractors within the organization to encourage reporting potential FWA and compliance issues.

My organization does not maintain a confidential FWA and compliance reporting mechanism. The Healthfirst FWA and Compliance Confidential Hotline (1-877-879-9137) and the address of its website (www.hfcompliance.ethicspoint.com) have been distributed and widely publicized for all employees and contractors within our organization to encourage reporting potential FWA and compliance issues.

My organization and/or any of our downstream/related entities do engage in offshore operations for administrative or healthcare services related to Healthfirst business. My organization (1) maintains contractual agreements with the offshore subcontractor that includes all applicable Medicare and/or Medicaid requirements and HIPAA privacy and security regulations as the vendor’s Business Associate; (2) ensures that the offshore subcontractor maintains policies and procedures that protect beneficiary PHI; and (3) Conduct annual audits of offshore subcontractors and make audit results available upon request.

Please indicate each offshore subcontractor’s name, address, and delegated function.

Comments

My organization and/or any of our downstream/related entities do not engage in offshore operations for administrative or healthcare services related to Healthfirst business.

Step Two: Complete the Attestation below.

I certify, as the authorized representative having responsibility directly or indirectly for all employees, contracted personnel, providers/practitioners, and vendors who provide health care or administrative services under Medicaid and/or Medicare, that the statements above are true and correct to the best of my knowledge. In addition, my organization agrees to maintain supporting documentation for a period of 10 years and will furnish evidence of the above to Healthfirst upon request for monitoring and auditing purposes.

Name of Organization/Provider ^*

Taxpayer Identification Number (TIN) ^*

Representative's First Name ^*

Representative's Last Name ^*

Representative's Title ^*

Representative's Phone Number ^*

Representative's Email Address ^*

Today's Date ^*

Additional Comments max 150

If you have any questions, please contact the Healthfirst Compliance department at compliance@healthfirst.org or 1-212-324-2699.