MMP Training Attestation Form

As part of Neighborhood Health Plan of Rhode Island's (Neighborhood's) commitment to compliance, we must ensure that the First Tier, Downstream and Related Entities (FDRs) that we contract with are in compliance with applicable state and federal regulations, and meet Neighborhood's requirements for training. As part of Neighborhood's contract with the Center for Medicare & Medicaid Services (CMS), there are terms, conditions, and requirements that we must adhere to. Our FDRs and Affiliates provide healthcare and related services to our members, and we are therefore responsible for validating that each FDR or Affiliate is in compliance with Medicare-Medicaid program requirements. Each FDR or Affiliate must complete this Attestation in its entirety in order to be in compliance with Neighborhood Health Plan of Rhode Island's requirements.

Instructions:

An authorized representative from each FDR or Affiliate is required to complete the Neighborhood FDR and Affiliate Compliance Attestation (on behalf of his or her organization) upon contract and on an annual basis to attest to compliance with the standards of conduct, compliance policies, fraud waste and abuse training, Office of Inspector General (OIG) and General Services Administration's (GSA) exclusion screening, and publication of FWA and compliance reporting mechanisms requirements.

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 Medicaid and/or Medicare. Authorized representatives may include, but are not limited to, a Compliance Officer, Chief Medical Officer, Practice Manager/Administrator, Provider, an Executive Officer or similar related positions.

Select from the items below to learn more about FDRs and Affiliates.

Neighborhood utilizes the Centers for Medicare and Medicaid Services (CMS) current definitions to define First Tier, Downstream, and Related Entities (FDRs):

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 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.

Related Entity: Any entity that is related to a Medicare Advantage Organization or Part D sponsor by common ownership or control and:

1. Performs some of the Medicare Advantage Organization or Part D plan Sponsor's management functions under contract or delegation;

2. Furnishes services to Medicare enrollees under an oral or written agreement; or

3. Leases real property or sells materials to the Medicare Advantage Organization or Part D plan sponsor at a cost of more than $2,500 during a contract period.

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 and Training Guide PDF.

The requirements include:

1. Distribution of Code of Conduct and Compliance Policies

2. Fraud Waste and Abuse Training

3. Exclusion Screening

4. Fraud, Waste, Abuse and Compliance Concerns Reporting

The Compliance Attestation must be completed annually.

Additionally, FDRs and Affiliates must complete training on Neighborhood's Medicare Medicaid Plan (MMP) annually.

Step One: Select the appropriate response for each category below. All five items must be completed.

Step Two: Complete the Attestation below.

I certify, as an authorized representative who has responsibility directly or indirectly for all employees, contracted personnel, providers/practitioners, and vendors who provide healthcare 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 will maintain supporting documentation for a period of ten years and will furnish this documentation to Neighborhood Health Plan of Rhode Island upon request for monitoring and auditing purposes.

Authorized Representatives please fill out the form below: