Newly-Contracted Delegated Vendor Compliance Attestation

Declaración de cumplimiento de las FDR con contrato nuevo

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 newly contracted Delegated Vendors only.

Please submit within 90 days of contracting.

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.

HPP's Code of Business Conduct (COBC) and Compliance Program Policies were made available to our organization. We will provide 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 will be provided to all our employees within 90 days of hire, upon revision, and 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.

My organization attests that we review 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 exclusion screenings as stated above, please explain below.

4. Reporting Mechanisms

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

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

My organization and/or any of our downstream/related entities

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

Do 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 plan to engage 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, within 15 days of contracting.

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 *

Organization's Authorized Representative's Title *

Organization's Authorized Representative's Phone Number *

Organization's Authorized Representative's Email Address *

This attestation is for newly contracted Delegated Vendors only.

Please submit within 90 days of contracting.

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.

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.

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

4. Reporting Mechanisms

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

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

5. Informes sobre subcontratistas en el extranjero

My organization and/or any of our downstream/related entities

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

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

Organization Name *

Organization Address *

Organization Address (line 2)

Ciudad *

Estado *

Código postal *

Organization's Authorized Representative *

Organization's Authorized Representative's Title *

Organization's Authorized Representative's Phone Number *

Organization's Authorized Representative's Email Address *