FDRs

 

First-Tier, Downstream and Related Entities (FDR) Compliance

As a CareFirst BlueCross BlueShield Medicare Advantage (CareFirst) partner, we know you will embrace the core values that drive our success and culture. We also expect you to respect the following tenets, which are central to how we conduct ourselves and everything we do:

  • Customer First
  • Integrity
  • Personal Accountability for Excellence
  • One Company, One Team
  • Leadership
Business Man on Phone In Office

Benefits IconAre you an FDR?

CareFirst abides by the Centers for Medicare and Medicaid Services (CMS) FDR definition. This means that if your organization provides an administrative or healthcare service for our members relating to our Medicare contracts on our behalf, we consider you to be an FDR.

CareFirst maintains the ultimate responsibility for fulfilling the terms and conditions of its contract with CMS and for meeting all Medicare program requirements. Medicare program requirements also apply to FDRs. As a result, CMS holds CareFirst accountable for the actions and inactions of its FDRs.

Examples of delegated administrative or healthcare service and functions may include, but are not limited to:

  • Customer First
  • Sales and marketing
  • Personal Accountability for Excellence
  • Utilization management
  • Quality improvement
  • Applications processing
  • Enrollment, disenrollment, membership functions
  • Claims administration, processing and coverage adjudication
  • Appeals and grievances
  • Licensing and credentialing
  • Pharmacy benefit management
  • Hotline operations
  • Customer service
  • Bid preparation
  • Outbound enrollment verification
  • Provider network management
  • Processing of pharmacy claims at point of sale
  • Negotiation with prescription drug manufacturers and others for rebates, discounts or other price concessions on prescription drugs
  • Administration and tracking of enrollees’ drug benefits, including TrOOP balance processing
  • Coordination with other benefit programs such as Medicaid, state pharmaceutical assistance or other insurance programs
  • Generation of claims date
  • Healthcare services
 

Definitions of First-Tier, Downstream and Related Entity

First-Tier Entity: Any party that enters into a written arrangement, acceptable to CMS, with a Medicare Advantage (MA) organization or applicant to provide administrative services or healthcare services for a Medicare eligible individual under the MA program

Downstream Entity: Any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the MA benefit, below the level of the arrangement between an MA organization (or applicant) and a first-tier entity. These written arrangements continue down to the level of the ultimate provider of both health and administrative services.

Related Entity: any entity that is related to the MA organization by common ownership or control and:

  1. Performs some of the MA organization's management functions under contract or delegation
  2. Furnishes services to Medicare enrollees under an oral or written agreement
  3. Leases real property or sells materials to the MA organization at a cost of more than $2,500 during a contract period

Failure to Comply with Medicare Program Requirements

CareFirst’s FDR are required to self-report any potential noncompliance or fraud, waste and abuse (FWA) related to services provided on behalf of CareFirst or its members. If potential noncompliance or FWA is identified by an FDR, they must complete the FDR Non-Compliance Self-Reporting Form.

CareFirst will investigate the instance of suspected noncompliance or FWA and determine if additional action is required. Enforcement actions may be taken to both cure the deficiency and prevent future occurrences. Enforcement actions may include corrective action plans and/or contract termination and will be dependent on the severity of the issue.

As an FDR, CareFirst expects that any personnel within your organization who engages in non-compliant or fraudulent behavior is subject to timely, consistent and effective enforcement. These enforcement actions should be communicated through well-publicized disciplinary standards. It is also expected that these requirements are applied to, and by, your downstream and/or related entities, as well.

If you are aware of or suspect noncompliant, unethical or illegal behavior by others, you are obligated to report it to CareFirst.

Offshore Operations and Reporting

CareFirst must comply with applicable Federal and State laws, rules and regulations related to use and reporting of offshore entities. You must notify us immediately if you plan to use an offshore entity. All FDRs will be required to complete an Offshore Services Attestation.