FDR Medicare Compliance Program Guidelines Attestation: DSNP Subcontractor

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This form is intended for vendors that are considered First Tier Entities providing administrative services and/or health care services for Devoted Health's Medicare products. This attestation confirms your commitment to comply with the Centers for Medicare & Medicaid Services (CMS) requirements. These requirements are listed below and apply to all services your organization, as Devoted Health's Downstream Entity, provides for Devoted Health's Medicare products. The requirements also apply to any of the Downstream Entities you use for Devoted Health's Medicare Products.

This form may only be completed by your organization's Compliance Officer or Senior Leadership.

PLEASE DO NOT COMPLETE THIS FORM UNLESS YOU HAVE RECEIVED A REQUEST FROM DEVOTED HEALTH TO SUBMIT A SIGNED FDR ATTESTATION.

Email *

Organization Name: *

Compliance Officer Name: *

Compliance Officer Email: *

Name and title of Authorized Representative completing form: *

Today's date: *

YYYY

I. Code of Conduct

42 CFR 422.503 and 423.504(b)(4)(vi)(A)
Note: Devoted Health’s Code of Conduct is available on our website: www.devoted.com

My organization (select one): *

Will distribute Devoted Health’s Code of Conduct to all applicable employees within 90 days of hire, upon revision, and annually thereafter.

Distributes our own Code of Conduct to all applicable employees within 90 days of hire, upon revision, and annually thereafter.

II. General Compliance and Fraud, Waste and Abuse ("FWA) Training

My organization: *

Will communicate FWA and General Compliance requirements to its employees via Code of Conduct and/or Compliance Program Policy and Procedure content and will comply with the Code of Conduct/Compliance P&P distribution requirements to all applicable employees within 90 days of hire, upon revision, and annually thereafter.

Required

III. Office of Inspector General (OIG) and General Services Administration's System for Award Management (SAM) Exclusion Screening

42 CFR 422.503, 422.752(a)(8), 423.504(b)(4)(vi)(F), and 423.752(a)(6)

My organization: *

Ensures that employees and downstream entities are screened against the US Department of Health & Human Services Office of Inspector General (OIG) and the General Services Administration’s System for Award Management (SAM) exclusion lists prior to hire or contracting, and monthly thereafter Monthly screening must include any current employee, new employee, temporary employee, volunteer, contractor and consultant to ensure individuals are not excluded or become excluded from participation in federal programs. My organization removes any person/entity from work on Devoted Health’s Medicare products if found on these lists.

Required

IV. Reporting Mechanisms

42 CFR 422.503 and 423.504(b)(4)(vi)(E)

My organization: *

Ensures that employees and downstream entities understand the disciplinary standards and duty to report all suspected or known instances of non-compliance and/or FWA activity, as well as maintaining and enforcing disciplinary standards in a timely and consistent manner. This is communicated to applicable employees and downstream entities, and will include how to report suspected or detected non-compliance or potential FWA, and that it is their obligation to report without fear of retaliation or intimidation against anyone who reports in good faith. Please review Devoted Health's Code of Conduct for reporting methods.

Required

V. Offshore Operations

Devoted Health Offshore Approval Request Form

For any work my organization performs that involves the receipt, processing, transferring, handling, storing or accessing of Protected Health Information (“PHI”), my organization (select one): *

Doesn’t do the work offshore and doesn’t have Downstream Entities that do the work offshore

Completes work offshore and has already received approval from Devoted Health

Would like to request the ability to perform work that is Delegated by Devoted offshore. We will complete and submit the Devoted Offshore Vendor Approval form for official approval from Devoted Health prior to send Devoted Health member information off-shore.

VI. Downstream Entity Oversight

(only applicable to First Tiers that subcontract delegated functions to another organization)

My organization (select one): *

Doesn’t use Downstream Entities to perform Devoted Health delegated work

Does use Downstream Entities for Devoted Medicare products and conducts robust oversight to ensure that they comply with all the requirements described in this attestation (e.g. FWA training, OIG and GSA’s SAM exclusion screening, etc.) and any applicable laws, rules and regulations

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