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Regence contracts with the Centers for Medicare & Medicaid Services (CMS) to provide Medicare Advantage and Prescription Drug Plans that provide health care and prescription drug benefits to Medicare beneficiaries. As a part of these contracts, CMS requires us to oversee our first tier, downstream and related entities (FDRs) that assist us in providing services for our Medicare beneficiaries. Examples of FDRs include providers, agents and brokers, pharmacies, claims processors, healthcare facilities and other vendors who help us deliver benefits.

As an FDR in Regence Medicare Advantage and Part D plans, you are an important partner in the continued success of our Medicare program. As such, Medicare requires FDRs to participate in our Medicare compliance program.

Regence is committed to providing you with the tools needed to ensure you meet the obligations under our Medicare compliance program. We provide our standards of conduct, resources for reporting concerns or issues and more, on a public website for you.

Examples of expectations include reading the Code of Business Conduct, completing Medicare Fraud, Waste & Abuse training and filling out the Conflict of Interest statement and keeping it on file. See your contract and the link below for additional requirements. Please contact your Regence representative with any questions.

Medicare Fraud, Waste, and Abuse Training

CMS requires FDR employees to complete its Medicare fraud, waste, and abuse training within 90 days of hire and annually thereafter.

Required FWA training is developed and provided by CMS and is available through the CMS Medicare Learning Network (MLN) at http://www.cms.gov/MLNProducts. Once done, you must complete the attestation form on the last page of the training.

Note: FDRs must use only CMS or Regence FWA training to be compliant with this requirement.

Completed attestations or training logs must be made available for review, upon request.

Thank you for your cooperation. If you have any questions about whether your organization is required to complete FWA training, please contact your Regence representative. If you need assistance or have comments, please email the webmaster.

Code of Business Conduct

CMS expects Regence to share our standards of conduct with our FDRs and either ensure that these entities adhere to our standards or ensure that these entities adopt and follow their own standards of conduct. These standards reflect a commitment to detecting, preventing and correcting noncompliance with Medicare requirements, including detecting, preventing and correcting fraud, waste and abuse.

The following links are to Regence's Code of Business Conduct and Code of Business Conduct Guide.

Sample Conflict of Interest Disclosure Certification

CMS expects Regence to regularly audit conflict of interest certifications from our FDRs. Regence requires annual completion of these certifications because it ensures that each FDR has effectively screened managers, officers, and directors responsible for the administration or delivery of Medicare Advantage and Part D benefits. An annually or upon hire signed conflict of interest statement attests that the manager, officer, or director is free from any conflict of interest in administering or delivering these benefits.

Completed COI disclosure forms must be made available for review, upon request.

Office of Inspector General (OIG) & General Services Administration (GSA) Exclusion Lists

All FDRs must review the exclusion databases listed below prior to hire and monthly thereafter for current employees, officers & directors, board members, subcontractors, consultants and vendors, as applicable. You must notify Regence immediately if an exclusion is identified. Excluded persons or entities are prohibited from receiving payment.

Exclusion logs that include employee name, date each database was checked and whether or not an exclusion was found must be made available for review, upon request.

Review this FDR FAQ to determine if your Medicare Compliance program and documentation meet current guidelines.

Member appeals and grievances

Members who indicate dissatisfaction to you or your employee regarding any aspect of their Medicare experience must be immediately directed to the health plan. If you are dealing directly with our Medicare members and receive a grievance and/or appeal request, send the member's name, member ID, date, time of contact and description of issue to:

Medicare Appeals and Grievances Department
PO BOX 12625
Mail Station S5D
Salem OR 97309

FAX 888-309-8784

Phone 866-749-0355

Email: FAX_Medicare_Appeals_and_Grievances@regence.com

Reminder: Providing information that identifies a member is considered protected health information and must be sent in a secure format.

Ethics, Compliance and Fraud

Regence is committed to ethical business practices; complying with all Medicare requirements; and detecting, preventing and correcting fraud, waste and abuse. If you have concerns about ethics, compliance, or fraud, please consult the following resources.

Medicare Compliance

Anonymous Medicare Compliance Hotline: (877) 878-2273

Fraud and Abuse

Fraud Related to Medicare Part D: (877) 479-8477

Fraud Related to Medicare Part C: (800) 548-4850

Ethics and Compliance