Your organization is contracted with CareSource as a First Tier, Downstream or Related Entity (FDR), and/or an Administrative Service Subcontractor or Provider for CareSource’s Medicare, Medicaid, and/or Exchange Products. As such, your organization is subject to all applicable federal and state laws, regulations and sub-regulatory guidance. This includes ensuring the compliance of all organization, contractor and downstream contractor employees.
My organization is contracted with CareSource for the following lines of business:
Directions: Please read the information within each section below. Make one selection per section by checking one of the boxes.
CareSource has developed a corporate compliance plan and code of conduct in order to outline crucial personal, professional, ethical, and legal standards. The compliance plan and code of conduct outline the overarching principles and values by which the company operates. As a first tier entity and/or FDR for CareSource, your organization and its board members, partners, executive management, volunteers, subcontractors, agents and employees (including temporary employees) must abide by your own policies and procedures, standards of conduct, and compliance plan; which must be similar in scope and content to the compliance policies and procedures and code of conduct held by CareSource or utilize CareSource’s compliance policies and procedures (https://www.caresource.com/about-us/corporate-information/).
My Organization has (1) a Conflict of Interest Disclosure Policy and Procedure, requiring annual conflict of interest disclosure; (2) conducts a Standards of Conduct training; and (3) obtains from its board members, partners, executive management, volunteers, subcontractors, agents and employees, if any, conflict of interest statements at least annually. My organization’s code of conduct meets, at a minimum, those elements described at 42 CFR §§ 422.503(b)(4)(vi)(A) and 423.504(b)(vi)(A) and the HIPAA/HITECH regulations described at Public Law 104-191, and 45 CFR Part 160 and Part 164.
Select the appropriate option for method used by your organization to comply with the above requirement:
My organization screens our Board members, partners, executive management, volunteers, contractors, subcontractors, temporary employees, and employees for Conflicts of Interest upon hire and annually thereafter and resolves any identified issues.
My organization’s Board members, partners, executive management, volunteers, contractors, subcontractors, temporary employees, and employees attest annually to following my organization’s (or CareSource’s if applicable) Corporate Compliance Plan, Code of Conduct, Conflict of Interest, Fraud, Waste and Abuse and HIPAA/HITECH Privacy and Security Policies
Fraud is defined as whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice to defraud any health care benefit program; or to obtain, my means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program. (18 U.S.C. 1347). It includes any act that constitutes fraud under applicable federal or state law.
Waste involves taxpayers not receiving reasonable value for money in connection with any government funded activities due to an inappropriate act or omission by a person with control over or access to government resources (e.g., executive, judicial or legislative branch employees, grantees or other recipients). Waste goes beyond fraud and abuse, and most waste does not involve a violation of law. Waste relates primarily to mismanagement, inappropriate actions and inadequate oversight.
Abuse includes actions that may, directly or indirectly, result in: unnecessary costs to the Medicare/Medicaid Program, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Abuse cannot be differentiated categorically from fraud, because the distinction between “fraud” and “abuse” depends on specific facts and circumstances, intent and prior knowledge, and available evidence, among other factors. (Medicare Managed Care Manual; Chapters 9 and 21)
My organization follows all Fraud, Waste and Abuse (FWA) requirements outlined in the CMS Medicare Learning Network (MLN) Module and provides a confidential system of reporting for all instances of FWA. We emphasize a policy of non-retaliation and non-intimidation and this information has been disseminated and is readily available for all employees, subcontractors, and downstream entities within our organization and can be reported anonymously.
My organization understands the definitions of fraud, waste and abuse and will report any concerns or suspected violations of the false claims act, stark law and the anti-kickback statute to CareSource by contacting the special investigations unitspecial investigations unit (http://oig.hhs.gov/fraud/report-fraud/index.asp or https://www.caresource.com/providers/ohio/ohio-providers/plan-participation/report-fraud/)
My organization has reported all compliance, legal, and ethical concerns to CareSource
My organization conducts general compliance training for board members, employees (including temporary employees), subcontractors, volunteers, consultants and members, as applicable, within 90days of initial hiring and annually thereafter per 42 CFR §§ 422.503(b)(4)(vi)(C); 423.504(b)(4)(vi)(C).
My organization is and will remain compliant with all applicable provisions of the Health Care Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act.
My organization will or has reported all non-permitted disclosures and/or breaches of protected health information (PHI). Please visit this site for more information (http://caresource.safe2say.info).
My organization is: (1) not excluded from participation in Federal healthcare programsand (2) further attests that it has screened its board members, employees, subcontractors, providers, volunteers, consultants, as applicable, against the Office of Inspector General (OIG) List of Excluded Individual/Entities (LEIE) and the General Services Administration’s System for Award Management (SAM) (these lists are located here: http://exclusions.oig.hhs.gov/ and https://www.sam.gov) upon their appointment, hire or contracting and at least monthly thereafter, as required for the Medicare Advantage and Prescription Drug Programs in the Code of Federal Regulations; and (3) has adopted and implemented a Policy and Procedure requiring it to disclose their exclusion or that of their board members, employees, subcontractors, volunteers, consultants, as applicable. My company also understands that it must keep a printed copy of all verifications, as well as notify CareSource immediately of any known prohibited affiliation.
Check the appropriate boxes, for method used by your organization to comply with the above requirement:
My organization contracts with offshore subcontractors to provide services in support of CareSource federal and state funded programs*.
If the answer to #1 above is ‘yes’, please click this link to complete the offshore attestation.
My organization has notified CareSource of any offshore contractors and received written approval from CareSource to use such resources for a specific scope of work. My organization understands that should we have any offshore contractors in the future , we must notify CareSource to receive written approval.
My organization will retain documentation evidencing the Compliance requirements have been met (e.g., training materials, sign-in sheets, prohibited affiliation/exclusions checks, attestations) for at least 10 years and will make those documents available for inspection and review by CareSource upon request or in support of an audit, per 42 CFR §§ 422.503(b)(4)(vi)(C); 423.504(b)(4)(vi)(C).
Please note that the attestation is intended to be completed at the contract level. If your organization has multiple tax identification numbers (TINs) under one contract, please complete one form and list each TIN.
By signature, I certify that the information provided here is true and correct and I understand that CareSource, CMS and/or State Medicaid Agencies request additional information to substantiate the statements made in this attestation:
If you have any questions concerning this attestation, please contact the CareSource Special Investigations Unit at 1-800-488-0134 and choose the menu option for providers. Follow the prompts to report fraud or contact us at fraud@caresource.com. Please reference the word “attestation” in your message.
