Healthfirst's commitment to compliance includes ensuring that our First Tier, Downstream and Related Entities (FDRs) are in compliance with applicable state and federal regulations. Healthfirst contracts with FDRs to provide administrative or healthcare services to our enrollees; we are ultimately responsible for fulfilling the terms and conditions with our contract with the Center for Medicare & Medicaid services (CMS) and meeting the Medicare and Medicaid program requirements. Therefore, Healthfirst has developed a process to validate that each contracted FDR and Affiliate has met the requirements. Each FDR and Affiliate must complete the Attestation below to confirm compliance with the Healthfirst FDR compliance requirements.
What is an "FDR" or "Affiliate"?
An FDR is a First Tier, Downstream or Related Entity. An FDR provides administrative or health care services relating to Healthfirst Medicare contracts. Healthfirst's FDRs include hospitals, providers, ancillaries, and some vendors.
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 MA benefit or Part D benefit, below the level of the arrangement between an MAO 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 an MAO or Part D sponsor by common ownership or control and
- Performs some of the MAO or Part D plan sponsor's management functions under contract or delegation;
- Furnishes services to Medicare enrollees under an oral or written agreement; or
- Leases real property or sells materials to the MAO 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.
What is required of FDRs?
The FDR and Affiliate Requirements are detailed in the FDR and Affiliate Compliance Guide PDF.
The requirements include:
- Distribution of Code of Conduct and Compliance Policies
- Fraud Waste and Abuse Training
- Exclusion Screening
- Fraud, Waste, Abuse and Compliance Concerns Reporting
In addition, all FDRs must complete the Compliance Attestation Form below annually. The 2015 Compliance Attestation must be completed annually.