Medicare Advantage compliance
We value our partners who help us serve our members and share our commitment to excellence in service, performance and compliance. Moda Health and each First Tier, Downstream and Related Entity (FDR) we contract with to assist in administration of the Medicare Advantage and prescription drug program must have a compliance program that meets CMS requirements.
An effective compliance plan must include the CMS requirements listed below. Moda Health may periodically request that a contracted entity provide evidence they are in compliance with the listed requirements.
Compliance Plan and policies
Moda Health's Medicare Compliance Department oversees and monitors our First Tier, Downstream and Related Entities (FDRs) as required by CMS and described in CMS Compliance Program Guidelines in the Medicare Managed Care Manual Chapters 9 and 21 and as required by Moda Health's Medicare Compliance Plan and policies regarding FDRs. All our FDR partners are expected to adhere to CMS program requirements and compliance guidance we provide.
Additional information about the requirements on this page can be found in the Medicare Advantage FDR guide under Documents.
Code of Conduct
Please distribute or make available Moda Health's Code of Conduct to your employees, contractors and Board Members if your Code of Conduct is not comparable to ours. A Code of Conduct and compliance policies and procedures must be distributed within 90 days of hire or contracting, when there are updates, and annually thereafter.
Report compliance concerns
You must report and use the contact information below to report suspected Medicare program violations and fraud, waste, and abuse (FWA) concerns that affect Moda Health payments and members. Failure to report suspected Medicare program violations and/or fraud, waste and abuse concerns may result in disciplinary action up to and including termination of your contract with Moda Health.
Moda Health has a strict no retaliation policy for good faith reporting.
Fraud, Waste and Abuse Hotline
Toll-free: 855-801-2991
Email: stopfraud@modahealth.com
In addition, FDR partners are expected to provide notice to their employees throughout their facilities of their duty to report any observed or suspected noncompliance or potential fraud, waste, or abuse. This notice should be provided through the use of posters, table tents, mouse pads, or other forms of notice.
The notice must provide the alternative to contact EthicsPoint (toll free number 866-294-5591 or online at www.ethicspoint.com) provided by Moda or the Moda Medicare compliance officer at medicarecompliance@modahealth.com or some other third-party reporting service provided by the FDR so that a reporting party can remain anonymous. The notice must make it clear that there are strict rules forbidding any retaliation against anyone for making such a report.
Disciplinary standards
Moda Health expects (1) that you have disciplinary standards in place for noncompliant, unethical or illegal behavior; and (2) that those standards are publicized for your employees and downstream and related entities.
Examples of downstream subcontracted work may be services performed by clinics or physicians, or services provided by your subcontractor for Moda Health. A related entity is a subsidiary or affiliated corporation. CMS requires that you monitor the compliance of your downstream entities and Moda Health may request proof of the monitoring activities.
You are expected to inform Moda Health prior to entering into a contract that transfers an obligation under your contract with Moda Health to a third party (subcontracting).
General Compliance and FWA Training
Employees, contractors, and Board members of the FDR who have any involvement in the administration of Moda's Medicare Advantage plans must receive Fraud, Waste, and Abuse and General Compliance trainings within 90 days of their hiring date and annually thereafter. Training can be administered by incorporating the content of the training below into the FDR's internal training materials/systems.
CMS' Fraud, Waste, and Abuse training is found at Combating Medicare Parts C & D Fraud, Waste, & Abuse (cms.gov)
Exclusions from participation in federal healthcare programs
For any employee or downstream and/or related entity relationships administrating or delivering Medicare Parts C and D benefits, you must ensure they are not excluded from participation in federal health care programs prior to hire or contract and monthly thereafter. Medicare payments may not be made for items or sources furnished or prescribed by a producer or entity excluded by the office of the Inspector General at the U.S. Department of Health and Human Services (HHS) or the General Services Administration (GSA).
Offshore Activities
If your company utilizes any off-shore service or subcontracts to any offshore entity that involves processing, transferring, handling, storing, or accessing protected health information (PHI), you must complete an off-shore attestation and send it to Moda Health. Off-shore refers to any country that is not the United States or its territories (i.e., American Samoa, Guam, Northern Mariana Islands, Puerto Rico and U.S. Virgin Islands). The attestation is found below under Documents.
Retention of Records
All records other than medical records must be retained by Medicare Advantage providers for at least ten years and furnished to Moda Health and Summit Health, the Comptroller General, or CMS upon request.
Provider Sign-off to Compliance Reminder
The 2023 Compliance attestation is an acknowledgement that you have read the compliance requirements stated on this webpage. If you are a provider or facility that contracts with Moda Health's Medicare Advantage Plan, you will need to acknowledge reading this web page.
NOTE: Completing one compliance sign-off will satisfy the requirement for both Moda Health and Summit Health.
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