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Welcome SelectHealth Advantage® Providers

At SelectHealth we value our contracted providers, pharmacies, vendors, and other business partners, and we understand that navigating Medicare Advantage rules and regulations can be difficult. If you or your organization contracts with SelectHealth for participation in the SelectHealth Advantage provider or pharmacy network, you are considered a “first-tier entity, downstream, and related entity” (FDR) under the Centers for Medicare & Medicaid Services (CMS) guidelines.

View FDR definitions​

To assist our contracted business partners who are FDRs, SelectHealth provides reference tools for your use in understanding the Medicare Advantage compliance requirements. Our commitment to compliance includes ensuring our FDRs also observe applicable laws, regulations, and sub-regulatory guidance.​

Compliance Obligations

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SelectHealth providers and business partners (FDRs) are required to: ​​

  1. Implement a compliance program that includes:
  • ​Adoption of policies and procedures to prevent FWA, promote ethical conduct, and ensure compliance with Federal and State laws, regulations, and other requirements relating to the Medicare program
  • A code of conduct
  • Exclusion screening (Department of Health and Human Services Office of Inspector General [OIG] List of Excluded Entities and Individuals [LEIE] and the General Services Administration System for Award Management [SAM])
  • Program for maintaining reporting and communication channels
  • Downstream entities audit and monitoring for compliance with CMS requirements
  • Ten-year records retention ​
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  1. Annually train employees and contractors supporting SelectHealth Medicare Advantage plans on compliance policies and FWA.

       Key parameters of recommended training include:

  • FDRs no longer need to conduct training within 90 days of contract/hire; however, SelectHealth suggests this time frame as a best practice.
  • The content of the training is at the discretion of your organization; however, it should incorporate the elements found in No. 1 above. Although use of the CMS-developed compliance and FWA training material is no longer required, you can access and download the CMS training materials here​. (CMS indicates that it will be removing this training altogether from their website at some point; SelectHealth will continue to link to these resources as long as they are available on the CMS website.)
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  1. Attest to compliance with SelectHealth requirements. An online attestation can be completed by clicking on the green button shown below. These attestation records may be reviewed by CMS during compliance audit proceedings.
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FDR Compliance Guide

The Medicare compliance requirements apply to you, any of your downstream entities, and all of your employees who perform services related to the SelectHealth Advantage product or enrollees. Therefore, please also share the SelectHealth FDR Compliance Guide information with your downstream contractors and employees.

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Record Retention

You are responsible for maintaining records of training completion and distribution of standards of conduct as proof of your organization's compliance with Medicare requirements for a period of 10 years. (Examples of proof of training may include copies of sign-in sheets, employee attestations, and electronic certifications from the employees taking and completing the training.) SelectHealth or CMS may request that you provide documentation of your compliance, please be prepared to produce the required documentation.

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Download or view a Sample Training Log​

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Standards of Conduct

Your organization's standards of conduct must be distributed annually. If your organization does not have its own standards of conduct, share the SelectHealth Code of Ethics with your employees.

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Medicare Advantage Regulations and Guidance

  • Regulations governing the MA program are found at 42 CFR Part 422 and Part 423. Review the Code of Federal Regulations (CFR).
  • CMS provides additional guidance for MA plans in the Medicare Managed Care Manual (Publication # 100-16) available through the CMS Internet-Only Manuals.
  • CMS provides additional guidance for Prescription Drug Plans in the Medicare Prescription Drug Benefit Manual (Publication # 100-18) available through the CMS Internet-Only Manuals​.
  • CMS requires MA plans and their FDRs to check the OIG/GSA Exclusion lists each month to prevent inappropriate payment to providers, pharmacies, and other entities that have been excluded from participation in federal programs. MA plans are also required to check the Preclusion List each month for providers who have been precluded by CMS from receiving payment from a Medicare plan for health care items and services furnished to beneficiaries enrolled in the Medicare plan.
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OIG’s List of Excluded Individuals and Entities (LEIE) includes all health care providers and suppliers that are excluded from participation in federal health care programs.
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GSA’s System for Award Management (SAM) includes health care providers on the LEIE and also includes other non-health care contractors that are excluded from federal programs.​
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The CMS Preclusion List includes providers (individuals and entities) who are currently precluded from receiving payment from the Medicare plan.
 



 

SelectHealth Reporting Flyer

 

Reporting is essential for the prevention, detection, and correction of fraud, waste and abuse. The SelectHealth Reporting Flyer is a document you can post in your facilities or distribute to employees to let them know how to report Medicare program compliance concerns and/or FWA to SelectHealth without fear of intimidation or retaliation.

 


 

Reporting Fraud, Waste, and Abuse

 

To report potential fraud, waste, and abuse, call the Compliance Hotline at 800-442-4845. Anonymous reporting and interpretation services are available. To speak to someone or ask questions about plan benefits or coverage, call Member Services at 855-442-9900 (TTY: 711).

 

More information is available by requesting the guide titled “Protecting Medicare and You from Fraud” by calling 800-Medicare (800-633-4227). TTY/TDD users should call 877-486-2048. A Medicare Customer Service representative can answer your questions 24 hours a day, 7 days a week.

 
 
 
 
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