1. finance
2. accounting and auditing

P.O. Box 27489, Albuquerque, NM 87125-7489
www.phs.org
April 3, 2015
Dear Contracted Provider:
NOTE: If you are not a Medicare Provider, STOP, you do not have to complete this form. Please contact
the Contracting Department at 505-923-8376 and ask to be removed from the Medicare list.
Presbyterian Health Plan, Inc. and Presbyterian Insurance Company, Inc. (Presbyterian) are required to oversee
our contracted providers who provide services to our Medicare members to assure their compliance with the
Centers for Medicare and Medicaid Services (CMS) requirements. Contracted providers are considered first-tier
entities under CMS definitions. The compliance requirements for First Tier Entities may be found at 42 CFR §
422.503(b)(4)(vi), chapter nine of the CMS Prescription Drug Manual, and chapter 21 of the CMS Managed Care
Manual.
This letter is intended to provide Presbyterian contracted providers the information they need to ensure
compliance with the CMS Medicare expectations. It includes the following sections:



How to report a compliance concern
Compliance training requirements
Excluded Provider Checking
How to Report a Compliance Concern:
First Tier Entities must report compliance concerns and suspected or actual violations related to the Medicare
program to Presbyterian. This reporting requirement applies to all violations known to the Provider whether or
not Presbyterian is the only Medicare Plan sponsor that is affected by the compliance issue.
All good faith reports of suspected misconduct, non-compliance, or fraud and abuse are protected by the
Presbyterian non-retaliation policy. Retaliation, discrimination, harassment, or retribution against a reporter will
not be tolerated by Presbyterian. Failure to report a violation may be considered a breach of contract and subject
to contractual penalties up to and including contract termination.
Report areas of concern to the Presbyterian Compliance Hotline at 1-888-435-4361, calls to the hotline are
confidential and may be made anonymously, if desired.
Correspondence may be forwarded to:
Ann U. Greenberg, CHC, CCEP, CHP
Director of Compliance
Presbyterian Health Plan/Presbyterian Insurance Company
P.O. Box 27489
Albuquerque, NM 87125-7489
PPC031516
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Presbyterian exists to improve the health of the patients, members, and communities we serve.
www.phs.org
Compliance Training Requirements:
As a First Tier Entity, Presbyterian must ensure that your organization has a Code of Conduct, and trains
workforce members on this Code upon hire and on an annual basis thereafter. If you do not currently have a Code
of Conduct you may use Presbyterian code. Access Presbyterian’s training programs online at
http://www.phs.org/providers, and click on “Training & Reference”. Or you may use the following link:
https://www.phs.org/providers/training-reference.
Additionally, if you have subcontractors who perform healthcare or administrative services within the scope of
your contract with Presbyterian, you must ensure that they provide compliance training to their workforce.
Monitoring and Auditing First Tier Entities:
CMS requires plan sponsors to monitor and audit the services provided by First Tier Entities. As such,
throughout the year, you may receive additional information requests from Presbyterian to ensure that the services
being performed are in compliance with CMS requirements. Additionally, Presbyterian may audit the services
provided by your organization to ensure compliance.
Communicating Regulatory Changes:
Your organization may ask regulatory and compliance questions at any time regarding the scope of services you
provide to Presbyterian. If you have questions please contact your Presbyterian Network Contract Manager or the
Director of Compliance.
You are responsible for monitoring your business practices to ensure you are compliant with the most recent
Medicare requirements. During the course of the year, Medicare requirements impacting the services you provide
to Presbyterian may change. In the event of such change, Presbyterian staff may contact you to notify you of the
change.
ACTION REQUIRED:
In order to meet the communication and oversight requirements, you are being asked to review the
following materials and attest to your organization’s compliance with the CMS expectations by completing
and returning the 2015 Medicare First Tier Oversight Attestation form below to Presbyterian by May 8,
2015 via fax at (505) 923-5440.
We appreciate your timely assistance with these requirements and thank you for your commitment to compliance.
If you have any questions about this letter or the Presbyterian Health Plan First Tier Oversight program, please
contact us at (505) 923-8376.
Sincerely,
Valerie Marrujo
Provider Reimbursement
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Manager of Provider Network Development
(505) 923-5412
[email protected]
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Presbyterian Health Plan/Presbyterian Insurance Company, Inc.
2015 Medicare First Tier Oversight Attestation
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2
Is your office Medicare-certified?
A facility, practitioner or provider, or healthcare agency is Medicare-certified
when it applies for a National Provider Identifier (NPI number), meets the
federal regulations and is approved to provide care and be reimbursed under
Medicare for services rendered.
*If you answered No; you do not need to complete this form and need to contact
Presbyterian at 505-923-8376 to ensure that you are not listed as a Medicare
eligible provider.
Does your office/organization have a Code of Conduct?
(a) If yes, does your Code of Conduct or other relevant policy include language
about non-retaliation for good faith reports about suspected conduct violations?
Yes No
(b) If yes, does your office have a conflict of interest reporting and review
process?
Yes No
Yes
No*
Yes
No*
Yes
No*
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
*If you answered No to any question in Section 2; do you agree to abide by the
Presbyterian Code of Conduct located at https://www.phs.org/providers/trainingreference/Pages/education.aspx?
3
4
Does your office contract with other organizations or use affiliated entities to
provide services to Presbyterian members?
*If you answered No, please skip A and B and proceed to question four
(a) If yes, do you have a system in place to monitor the affiliated entities’
compliance with Medicare program requirements?
(b) Do you ensure that the related entities train their employees on Medicare
compliance expectations?
Does your office have a compliance program?
Presbyterian reserves the right to request a description of your program or seek
additional information about the program.
(a) If yes, does your compliance program include a mechanism(s) for reporting
compliance concerns or violations and investigating all reports received?
(b) If yes, does your office perform compliance training for employees and
governing body members upon hire and annually thereafter?
Check one:
___ We provide our own internal compliance training which includes information
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for employees about how to report a compliance concern or violation.
___ We distribute the compliance training information provided by Presbyterian.
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6
(c) Does your office apply discipline, as appropriate, for compliance-related
incidents (employees and down-stream contractors)?
Yes
No
(d) Does your office implement a corrective action plan for any identified
compliance-related deficiencies?
Yes
No
(e) Does your compliance program include monitoring and auditing of your
business practices to ensure compliance with applicable Federal and State
regulations?
Yes
No
(f) Do you assess your regulatory and compliance risks at least annually?
Yes
No
Do you perform initial hire/contract and on-going monthly verifications to ensure
employees, board members, and contractors are not sanctioned or excluded from
Federal or State public programs?
Yes
No
Yes
No
Presbyterian reserves the right to request documentation of these verifications.
Do you acknowledge that your office will report any compliance-related or fraud
and abuse-related concerns or violations that impact the contracted services we
perform to PHP/PIC immediately?
___________________________________
Office/Organization Name
___________________________________
Tax ID
___________________________________
Authorized Representative Name (please print)
___________________________________
Authorized Representative Title
___________________________________
Authorized Representative Signature
__________________
Date
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