The Compliance Attestation form is used to confirm that the FDR or Affiliate is in compliance with VA Premier FDR and Affiliate Compliance Policy for the Commonwealth Coordinated Care program. Step 1 of 3 33% First Tier, Downstream, or Related Entity (FDR) and Affiliate Compliance AttestationThe Compliance Attestation is used to confirm that the FDR or Affiliate is in compliance with VA Premier FDR and Affiliate Compliance Policy for the Commonwealth Coordinated Care program.All First Tier, Downstream or Related Entity and Affiliates that are contracted to provide administrative and healthcare services to Medicare and Medicaid enrollees by Virginia Premier CompleteCare must complete a Compliance Attestation. The Attestation must be signed by an authorized representative when the FDR or Affiliate first contract with VA Premier CompleteCare and annually thereafter.An authorized representative is a Compliance Officer, Chief Medical Officer, Practice Manager, Executive Officer, Provider, Owner, or equivalent authoritative representative. Only one Compliance Attestation form is required for each FDR and Affiliate.Attestation* I attest that I have reviewed and understand the VA Premier CompleteCare FDR and Affiliate Compliance Guide. My organization will abide by the established VA Premier CompleteCare Vendor Code of Conduct and compliance policies. 1. FDR and Affiliate Compliance Guide and Vendor Code of Conduct (select one)*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 (10) years and can be provided upon request.My organization does not have established compliance policies and/or Standards of Conduct. The VA Premier CompleteCare Compliance FDR and Affiliate Guide and Vendor Code of Conduct has been disseminated to all employees and contractors. It includes: The VA Premier CompleteCare Compliance Vendor Code of Conduct, compliance policies, and information on select regulations including, but not limited to, the Deficit Reduction Act of 2005 and the False Claims Act. A record of all employees and contractors receipt of the VA Premier CompleteCare Compliance FDR and Affiliate Guide will be maintained for a period of ten (10) years and can be provided upon request.2. Fraud, Waste and Abuse (FWA) and General Compliance Training (select one)*My organization has fulfilled the FWA and General Compliance training requirement via the CMS FWA and General Compliance training or another training that meets or exceeds the requirements as outlined by CMS in 42 § CFR 422.503(b)(4)(vi)(C) and 42 CFR § 423.504(b)(4)(vi)(C). All employees and contractors have completed this FWA and General Compliance training within 90 days of hire/contract and annually thereafter.The CMS FWA and General Compliance Training can be accessed through https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud-Waste_Abuse-Training_12_13_11.pdf or https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedCandDGenCompdownload.pdfMy organization will fulfill the FWA and General Compliance training requirement within 90 days of this attestation via the CMS FWA and General Compliance training or through another FWA and General Compliance training that meets or exceeds the requirements as outlined by CMS in 42 CFR § 422.503(b)(4)(vi)(C) and 42 CFR § 423.504(b)(4)(vi)(C). All employees and contractors will complete this FWA and General Compliance training within 90 days of hire/contract and annually thereafter.The CMS FWA and General Compliance Training can be accessed through https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud-Waste_Abuse-Training_12_13_11.pdf or https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedCandDGenCompdownload.pdf3. Fraud, Waste and Abuse and Compliance Issues reporting mechanisms (select one)*My organization maintains a confidential FWA and Compliance reporting mechanism. It has been distributed and widely publicized for all employees and contractors within the organization to encourage reporting potential FWA and Compliance issues. All reported acts of noncompliance, both potential and actual, will be reported to VA Premier CompleteCare immediately.My organization does not maintain a confidential FWA and Compliance reporting mechanism. The location of the contact information for VPHP’s Program IntegrityProgram Integrity department (https://www.virginiapremier.com/program-integrity/contact-information/) has been distributed and widely publicized for all employees and contractors within our organization to encourage reporting potential FWA and Compliance issues. If any reported acts of noncompliance, both potential and actual, are received, they will be reported to VA Premier CompleteCare immediately.4. My organization understands that we must comply with mandated requirements to participate in federally funded healthcare programs. The mandated requirements include the following:* First level employees (managing staff), physicians and nurses were or will be screened prior to hiring and monthly thereafter against the Office of Inspector General’s (OIG) List of Excluded Individuals and Entities (LEIE) and the General Services Administration’s (GSA) System for Award Management (SAM) – formerly known as EPLS. We have policies in place to require the removal of an individual or entity that appears on the LEIE or SAM from any work on all federal healthcare programs. Downstream entities of my organization were or will be screened prior to contracting and monthly thereafter against the LEIE and SAM. My organization will use best efforts to provide notice to VA Premier CompleteCare, within five (5) business days of discovery, of any first level employees or Downstream entities on the LEIE or SAM. 5. OIG and GSA Exclusion Screening Continued (select one)*My organization has taken necessary steps to comply with the above listed OIG and GSA Exclusion Screening requirements and will provide appropriate documentation of the above upon request from VA Premier CompleteCare.My organization does not currently have one or more of the above processes in place; however, within 90 days of this attestation, my organization will take the necessary steps to comply with the above listed OIG and GSA Exclusion Screening requirements and will provide appropriate documentation of the above upon request from VA Premier CompleteCare.Subcontractor InformationPlease list any subcontracted or affiliated vendors you currently utilize for any contracted duties assigned to your organization for Virginia Premier’s CompleteCare Program. Attestation* I certify, as an authorized representative having responsibility directly or indirectly for all employees, contracted personnel, providers/practitioners, and vendors who provide health care 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 agrees to maintain supporting documentation for a period of ten (10) years and will furnish evidence of the above to VA Premier CompleteCare upon request for monitoring and auditing purposes. * Indicates a required fieldName of Organization* Taxpayer Identification No. (TIN)* NPI Name* First Last Title* Phone Number*Email Address* Additional Comments Electronic Signature: Please type your full name. By typing your name, you are signing this Compliance Attestation electronically. You agree your electronic signature is the legal equivalent of your handwritten signature.* Date Date Format: MM slash DD slash YYYY Notice: Please print a copy of this page for your records. Thank you. {all_fields}PhoneThis field is for validation purposes and should be left unchanged.