Declaración de cumplimiento de proveedores delegados anual

Formulario de cumplimiento de proveedores delegados

Los CMS y el DHS exigen que toda organización o persona que establece contratos con Health Partners Plans (HPP) para brindar servicios administrativos o de atención médica en nombre de HPP cumplan con varios requisitos del programa CMS. Al completar la siguiente declaración, usted certifica que su organización se compromete a cumplir con los requisitos del Programa de Cumplimiento de Medicare, Medicaid y/o CHIP y con cualquier requisito del Programa de Cumplimiento implementado por Health Partners Plans.

This attestation is for existing HPP Delegated Vendors only.

Please submit within 30 days of notification.

Questions or concerns regarding this attestation can be directed to MedicareFDR@hpplans.com.

1. Líneas de negocios

Select all HPP lines of business that your organization performs services for.

Medicare

Medicaid

CHIP

2. Code of Business Conduct and Compliance Program Policy Distribution

Select 1 option that best describes your organization's actions or enter an explanation in the comment box.

El Código de conducta empresarial (Code of Business Conduct, COBC) y las Políticas del programa de cumplimiento de HPP se pusieron a disposición de nuestra organización en 2023. We have provided HPP's COBC/Compliance Program Policies to all our employees initially within 90 days of hire or contracting, upon revision, and will continue to provide them anually thereafter.

My organization's Code of Business Conduct (COBC) and/or Compliance Program Policies are materially similar to HPP's COBC and Compliance Program Policy content and were provided to all our employees in 2023 within 90 days of hire and upon revision. We will continue to provide them anually thereafter.

If the organization does not adopt and comply with HPP's COBC and Compliance Policy, or a materially similar version, please explain below.

3. OIG/SAM/Medicheck Exclusion Screening

Select the option below or enter an explanation in the comment box.

In 2023, my organization reviewed the OIG LEIE, SAM EPLS and Medicheck (applicable to work related to HPP's Medicaid/CHIP lines of business) prior to the hiring or contracting of all personnel involved in the administration or delivery of HPP benefits and monthly thereafter.

If the organization did not perform exlusion screenings as stated above, please explain below.

4. Reporting Mechanisms

Select the option below or enter an explanation in the comment box.

En 2023, se informó a los empleados internos acerca de su obligación y del modo de denunciar cualquier sospecha o certeza de incumplimiento o posible FWA para llevar a cabo una investigación interna. Los mecanismos de denuncia garantizan la confidencialidad y permiten el anonimato, según se desee. Además, no permitiremos represalias ni intimidación contra las personas que informen de buena fe. A su vez, nuestra organización informa los incidentes a HPP a medida que surgen.

If the language stated above does not align with the actions of your organization, please explain below.

5. Informes sobre subcontratistas en el extranjero

During 2023, my organization and/or any of our downstream/related entities

DID NOT engage in offshore operations for any administrative or healthcare services related to HPP business

DID engage in offshore operations for any administrative or healthcare services related to HPP business

If your organization and/or any of its downstream/related entities engaged in offshore operations related to HPP business, please obtain HPP approval prior to delegation. Once approval is received, complete the 'Offshore Subcontractor Attestation', located on the Delegated Vendor Information webpage.

Como representante autorizado de la organización nombrada a continuación, certifico haber revisado y comprender todos los requisitos de la política de proveedores de HPP, que las declaraciones anteriores son verdaderas a mi entender y que mi organización mantiene registros que respaldan nuestro cumplimiento.

Organization Name *

Organization Address *

Organization Address (line 2)

Ciudad *

Estado *

Código postal *

Organization's Authorized Representative *

Title of Organization's Authorized Representative *

Phone Number of Organization's Authorized Representative *

Email Address of Organization's Authorized Representative *