MMP Training Attestation Form 123 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. Learn More 1 What is an "FDR" or "Affiliate"? 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.Learn More 2 What is required of FDRs and Affiliates? 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.Standards of Conduct, Compliance Policies, and Compliance Information - I have reviewed and understand the Neighborhood Health Plan of Rhode Island FDR and Affiliate Compliance and Training Guide. My organization will abide by the Neighborhood compliance policies. In addition,*Standards of Conduct, Compliance Policies, and Compliance Information - I have reviewed and understand the Neighborhood Health Plan of Rhode Island FDR and Affiliate Compliance and Training Guide. My organization will abide by the Neighborhood 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. The Neighborhood Health Plan of Rhode Island Compliance FDR and Affiliate Guide has been adopted and distributed to all employees and contractors. A record of all employees' and contractors' receipt of the Neighborhood Health Plan of Rhode Island Compliance FDR and Affiliate Guide will be maintained for a period of ten years and can be provided upon request.Fraud, Waste and Abuse Training - FDRs and Affiliates are required to complete Fraud, Waste and Abuse training within 90 days of contract/hire and annually thereafter. The training requirement extends to all employees and contractors. Each FDR and Affiliate will be required to attest that all employees and contractors have satisfied the FWA training via one of the options listed below.*Fraud, Waste and Abuse Training - FDRs and Affiliates are required to complete Fraud, Waste and Abuse training within 90 days of contract/hire and annually thereafter. The training requirement extends to all employees and contractors. Each FDR and Affiliate will be required to attest that all employees and contractors have satisfied the FWA training via one of the options listed below. *My organization has fulfilled the FWA training requirement via the CMS Fraud, Waste and Abuse (FWA) training, accessed at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud-Waste_Abuse-Training_12_13_11.zip.My organization has fulfilled the FWA training requirement via another FWA training that meets CMS requirements outlined in 42 CFR § 422.503(b)(4)(vi)(C) and 42 CFR § 423.504(b)(4)(vi)(C).My organization is deemed by CMS to have met the FWA training requirement through enrollment into Parts A or B of the Medicare program or through accreditation as the supplier of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).Reporting Fraud, Waste, Abuse and Compliance Issues*Reporting Fraud, Waste, Abuse and Compliance Issues *My organization maintains and publicizes a confidential FWA and Compliance reporting mechanism. It has been distributed to all employees and contractors within the organization to encourage reporting of potential compliance issues, fraud, waste, abuse, conflict of interests, violations of compliance policies and/or any applicable regulation.My organization does not maintain a confidential FWA and Compliance reporting mechanism. The Neighborhood Health Plan of Rhode Island Confidential Hotline and website information have been distributed and widely publicized for all employees and contractors within the organization to encourage reporting of potential compliance issues, fraud, waste, abuse, conflict of interests, violations of compliance policies and/or any applicable regulation.OIG and GSA Exclusion Screening*OIG and GSA Exclusion Screening *My organization currently performs exclusion screening prior to hire and/or contract and monthly thereafter to confirm that employees and contractors are not are excluded to participate in Federally-funded health care programs according to the OIG and GSA exclusion lists. 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.My organization does not currently perform exclusion screening prior to hire and/or contract and monthly thereafter. Within 60 days of receipt of this form, and monthly thereafter, a check will be done to confirm that employees and contractors are not are excluded to participate in Federally-funded health care programs according to the OIG and GSA exclusion lists. 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.Neighborhood Health Plan of Rhode Island's INTEGRITY Medicare Medicaid Plan (MMP) Training*I have completed Neighborhood Health Plan of Rhode Island's INTEGRITY Medicare Medicaid Plan (MMP) training modules listed below (accessed through the Provider section of www.nhpri.org) and agree that my organization adopts and trains its employees and downstream entities using these training modules: Introduction to INTEGRITY Enrollee Rights Cultural Competence Model of Care, Planning, and Assessment Putting Cultural and Disability Competency into Action Integrating Behavioral Health and Long Term Services and Supports (LTSS) 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:Name of Organization/Name of Provider* Name* First Last Title* Phone*Email (optional) National Provider Identifier (NPI)* For provider groups, enter the Type 2 NPI, for individual providers with no Type 2 NPI, enter the Type 1 NPI. Format must be 10 digits.Tax Identification Number (TIN)* Please enter in xx-xxxxxxx format.If you have questions about training, please email training@nhpri.org. For questions about compliance, please email compliance@nhpri.org.