Frequently Asked Questions

 

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As an FDR, you must comply with Medicare Compliance Program requirements. You may review CareFirst’s Third Party Code of Ethical Business Conduct and Compliance requirements to make sure that you have internal processes to support your compliance with these requirements.

Yes. The Code of Federal Regulations (CFR) outlines the Compliance Program requirements and related provisions for Medicare Advantage Organizations (MAO) and Medicare Prescription Drug Plans (PDP). Sections 42 C.F.R. §§ 422.503(b)(4)(vi), 422.504(i), 423.504(b)(4)(vi) and 423.505(i) indicates that these Medicare program requirements apply to FDRs to whom CareFirst has delegated administrative or healthcare service functions relating to the sponsor’s Medicare Parts C and D contracts.

The training requirement and deemed status are noted at 42 CFR 422.503(b)(4)(vi)(C) for Medicare Advantage and 42 CFR 423.504(b)(4)(vi)(C) for Part D.

All Compliance Program requirements are further described within the Medicare Managed Care Manual, Chapter 21 – Compliance Program Guidelines and Prescription Drug Benefit Manual, Chapter 9 – Compliance Program Guidelines.

Yes. As an FDR, your organization will need to provide FWA and General Compliance training to all of your employees and downstream entities that provide administrative and/or healthcare services for our Medicare plans.

Yes. Evidence documenting completion of General Compliance and FWA training must be retained for at least 10 years. Evidence may include, but is not limited to, copies of sign-in sheets, employee attestations and electronic certifications from the employees taking and completing the training. CareFirst BlueCross BlueShield Advantage and/or CMS may request this evidence to ensure completion of these requirements. If you and/or your employees are deemed to have met the FWA training requirements, you should retain proof of the deemed status.

General Compliance and FWA training must be completed within 90 days of initial hire or the effective date of contracting and at least annually thereafter.

You can make a report by taking any of the following actions:

If you have doubts about whether an action or situation may be improper or inappropriate, or if you believe there may be other requirements applicable to your situation, ASK. Questions or concerns can be directed to the CareFirst Compliance and Ethics Office.

Failure to promptly report a suspected violation may result in action up to, and including, termination of your relationship.

How to Make Anonymous Reports—Compliance and Ethics Hotline

You can make an anonymous report by phone or by filing a confidential report online by accessing the Compliance & Ethics webpage on the CareFirst intranet.

The Compliance and Ethics Hotline is available 24 hours a day, seven days a week. Hotline calls are truly anonymous. Calls are not traced. There is no caller ID. The Hotline number is a voicemail number only. You will not speak to a person.

Our FDRs have an obligation to report all suspected violations of this Code or any law or regulation, whether such violations involve your employees or subcontractors or CareFirst employees or other Third Parties. You can make a report by taking any of the following actions:

If you have doubts about whether an action or situation may be improper or inappropriate or if you believe there may be other requirements applicable to your situation, ASK. Questions or concerns can be directed to the CareFirst Compliance and Ethics Office.

Failure to promptly report a suspected violation may result in action up to, and including, termination of your relationship.

Yes. All three must be checked. GSA administers EPLS and SAM, both of which contain debarment actions taken by various Federal agencies, including exclusion actions taken by the OIG. The List of Excluded Individuals/Entities contains only the exclusion actions taken by the OIG.

The checks must be completed initially before hire/contracting and then monthly thereafter.

Any excluded individual or entity, employed or contracted by your organization, must be immediately removed from any direct or indirect servicing of CareFirst ’s Medicare plans. Your organization must report this to CareFirst BlueCross BlueShield Advantage.

The type of evidence that must be retained depends on the system used to complete these checks. Example documentation may include screen prints of the results from manual processes or output reports resulting from an automated process. The documentation should clearly identify the name of the entity/individual checked, the date the check was performed and the results of the check.

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