First Tier, Downstream or Related Entity Compliance

Yes, if you or your company has a written arrangement with Health First Health Plans (HFHP), which is a Medicare Advantage organization, or you have an arrangement with a company contracted with HFHP to provide:

• Administrative services (vendors, suppliers, etc.) relating to HFHP's Medicare Advantage contract with the Centers for Medicare and Medicaid Services (CMS); or
• Healthcare services as part of the HFHP network

Examples of First Tier entities, Downstream entities and Related entities (FDRs):

• First Tier entities: Network providers (such as a doctor), broker, pharmacy benefit manager, claims processor, etc.
• Downstream entities: Pharmacies, pharmacists, etc.
• Related entities: Health First Family Pharmacy, etc.

Thank you for partnering with us to provide services for our members. We appreciate the relationship between your organization and Health First as partners in compliance.

• Report within a reasonable time frame to HFHP all suspected or known instances of non-compliance and/or fraud, waste or abuse

• Sign the Medicare FDR Statement of Attestation every year

  • Providers: Click here to complete the online Provider Attestation (Only complete one attestation per practice/medical group.)
  • Brokers: To get access to the Broker Attestation form, Contact HFBroker@hf.org
  • Vendors: To get an email with a link to your organization's Attestation form, contact the Vendor Management Office at VMO@hf.org or HFHP Corporate Integrity at HFHPComplianceTeam@hf.org

• Provide the Health First's Code of Ethics & Business Conduct or your organization's Code of Conduct and applicable policies and procedures to employees, contractors, board members and volunteers who have an involvement with administering services related to HFHP's Medicare Advantage contract with CMS

• Health First's Code of Ethics & Business Conduct

• Compliance Policies and Procedures

  CC 01.01 POL	Compliance Program Policy
  CC 01.01 PRO	Procedure for Reporting Compliance Concerns
  CC 01.02 POL	Non-Retaliation and Non-Intimidation Policy
  CC 01.04 POL	Exclusion and Sanction Screening Policy
  HP 03.01.01 PRO	Health Plans Compliance Program Policies, Procedures, and Standards of Conduct
  HP 03.01.02 PRO	Health Plans Designation of a Compliance Officer, Committee and High Level Oversight
  HP 03.01.03 PRO	Health Plans Effective Training and Education
  HP 03.01.04 PRO	Health Plans Effective Lines of Communication
  HP 03.01.05 PRO	Health Plans Well Publicized Disciplinary Guidelines
  HP 03.01.06 PRO	Health Plans Effective System for Routine Monitoring, Auditing and Identification of Compliance Risks
  HP 03.01.07 PRO	Health Plans Procedures and System for Prompt Responses to Compliance Issues
  HP 03.02 POL	Health Plans First Tier, Downstream and Related Entity (FDR) Oversight
  HP 03.02.02 PRO	Health Plans First Tier, Downstream and Related Entity (FDR) Oversight - Initial and Ongoing Training Requirements
  HP 03.02.03 PRO	Health Plans First Tier, Downstream and Related Entity (FDR) Oversight - Monitoring

• Perform exclusion screening of employees, contractors, board members and volunteers prior to hire/contracting and monthly thereafter

  • Quick Reference Guide to Exclusion Screening

  • OIG List of Excluded Individuals/Entities (LEIE)

  • GSA's System for Award Management (SAM)

• Retain records for 10 years (training records and records relating to services)

• Maintain privacy and security of HFHP member information

  • Protecting Privacy

• Maintain oversight of your Downstream entities providing services relating to HFHP's Medicare Advantage contract with CMS

• Inform HFHP Vendor Management Office before offshoring services or PHI out of the country

• Correct any deficiencies related to misconduct or Medicare program non-compliance

Yes, monitoring and auditing by our Compliance Program is a CMS requirement.

Examples of routine monitoring and auditing:

• Verifying exclusion screening has been performed prior to hire/contracting and monthly thereafter

• Verifying training has occurred after hire/contracting and yearly thereafter

• Documentation (policies, procedures, standards of conduct) is in compliance with Chapter 21 of the Medicare Managed Care Manual

Should my organization be monitoring and auditing our Downstream entities that perform services related to HFHP's Medicare Advantage contract with CMS?

• Yes

Education:

• HFHP - Combating Fraud, Waste and Abuse

Reporting:

• Contact the Special Investigations Unit to report suspicions of fraud, waste or abuse

• Contact your business contact person at HFHP

• Contact the HFHP Compliance Department:

  Email:	HFHPCorporateIntegrity@hf.org
  Phone:	321.434.7496
  Mail:	6450 US Highway 1, Rockledge, FL 32955
  	Submit anonymous concerns via mail

• Contact the Special Investigations Unit to report suspicions of fraud, waste or abuse