CurrentprominencehealthfirstoffloridaPolicy COMP.FDR.005
First Tier, Downstream and Related Entity Audit, Monitoring and Oversight
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Governance of Prominence HealthFirst of Florida's audit, monitoring, and oversight of first-tier, downstream and related entities (FDRs) that perform administrative or healthcare functions on the plan's behalf; applies to all contracted FDRs and internal staff responsible for delegation oversight.
Policy Summary
Payerprominencehealthfirstofflorida
PolicyFirst Tier, Downstream and Related Entity Audit, Monitoring and Oversight
Policy CodePolicy COMP.FDR.005
Change TypeInformational / no material change
Effective DateJan 1, 2017
Last ReviewMay 21, 2021
Next Review DateJun 1, 2021
Key ActionFDRs must comply with Prominence Health Plan audit requests, internal monitoring and CMS audits and report suspected compliance issues and fraud, waste, or abuse to specified contacts.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
10 yearsdocument retention (MA)
monthlyexclusion screening
90 daysnew hire training
annualrecurring training
FDR Oversight Criteria
FDR oversight criteria
Requirements and procedures Prominence Health Plan applies to FDRs and internal compliance staff:
ALL of the following
- All FDRs, including contracted providers and producers, must abide by Prominence Health Plan's Code of Conduct and all applicable state and federal laws and regulations.
- Comply with all reporting requirements, including Prominence Health Plan and/or CMS requests.
- Comply with all applicable Prominence Health Plan policies and procedures.
- Comply with all Prominence Health Plan audit requests, including internal monitoring and auditing, compliance audits, and CMS audits.
- Report any suspected and/or potential compliance issues to Prominence Health Plan's Medicare Compliance Officer or the anonymous compliance hotline at 1-800-852-3449.
- Report any suspected fraud, waste, or abuse to Prominence Health Plan or the OIG Hotline at 1-800-HHS-TIPS (1-800-447-8477).
- Deliver Medicare Advantage compliance and FWA training and education programs, and track and maintain documentation of completion for first-tier entity employees; training must be delivered within 90 days of hire and annually thereafter.
training timeframe: within 90 days of hire; annually thereafter.
- Appropriately administer disciplinary standards for first-tier entity employees.
- Create lines of communication and processes for reporting fraud, waste and abuse and non-compliance issues, including processes for investigation, resolution, and corrective action.
- Administer an effective self-monitoring and auditing program.
- Create and annually review and approve applicable Medicare Advantage related policies and procedures for all delegated functions.
- Interpret and disseminate CMS regulations and guidance, ensuring implementation and providing day-to-day expertise on compliance requirements for applicable delegated functions.
- Retain all Medicare Advantage documents in accordance with CMS requirements (i.e., 10 years).
document retention period: 10 years.
- Monitor employees against the DHHS OIG List of Excluded Individuals and Entities (LEIE) and the GSA Excluded Parties List (EPLS) prior to hiring/contracting and monthly thereafter.
- Submit documents or reports to CMS via the HPMS system as assigned by Prominence Health Plan.
- Ensure any FDRs of the first-tier entity are in compliance with all CMS requirements as outlined in this policy.
- Prominence Health Plan's Compliance Manager will provide FDRs timely notifications of modifications to plan systems, operations and regulatory changes/updates and provide the Prominence Health Plan Code of Conduct to all FDRs.
On-site audits may include
- Analysis of tools and processes for prospective management of contractual and regulatory compliance.
- Evaluation of staff, tools, and processes performed during the onsite audit.
- Validation of data reported by the delegated entities and other assessments to assure data integrity.
If deficiencies identified
- Explore alternatives through collaboration with the FDR which may include a Corrective Action Plan (CAP).
- Remedial training.
- Written notice or termination of contract agreement.
- For URAC-accredited vendors Prominence Health Plan will verify URAC accreditation is current and accept URAC accreditation in lieu of audits performed in the scope of delegation oversight.
- Violations of this policy by Prominence Health Plan staff may be grounds for disciplinary action up to termination; violations by FDRs may result in increased auditing and monitoring, performance guarantees or other contractual penalties, and/or termination of the contract.
Exclusion Lists and Record Retention
Exclusion listsmixed
| LEIE | DHHS OIG List of Excluded Individuals and Entities - monitor prior to hire and monthly |
| EPLS | GSA Excluded Parties List System - monitor prior to hire and monthly |
Report retention period
Medicare Advantage document retentionRetain all Medicare Advantage documents in accordance with CMS requirements (10 years)
Applies toAll MA-related records and delegated function documentation
Reference policyProminence Health Plan COMP.FDR.005 — Retention requirement as stated in procedures
FDR Audit, Reporting and Compliance Obligations
Documentation Required
FDR audit and reporting obligations — comply with audits and report issues
As a contracted FDR, you must comply with all Prominence Health Plan and CMS audit and reporting requirements, and promptly report suspected compliance issues and fraud/waste/abuse to the Plan and applicable hotlines. Maintain required training records and document retention per CMS timelines.
- Comply with all Prominence Health Plan audit requests, including internal monitoring, compliance audits, and CMS audits.
- Comply with all reporting requirements, including Prominence Health Plan and/or CMS requests.
- Report suspected compliance issues to the Medicare Compliance Officer or anonymous compliance hotline (1-800-852-3449).
- Report suspected fraud/waste/abuse to Prominence Health Plan or the OIG Hotline (1-800-HHS-TIPS / 1-800-447-8477).
- Deliver MA compliance and FWA training within 90 days of hire and annually thereafter, and track/maintain completion documentation.
- Retain all Medicare Advantage documents in accordance with CMS requirements (10 years).
Key Definitions
FDR
Definition (FDR)FDR: First tier, Downstream and Related entity.
ScopeIncludes health care providers, pharmacies, sales agents, delegates, vendors, suppliers, contractors and related entities acting on behalf of Prominence Health Plan
Regulatory contextUsed for oversight, monitoring and auditing under federal/state requirements
Delegated Entity
Definition (Delegated Entity)Any party, including an agent or broker, that enters into an agreement with a Qualified Health Plan (QHP) issuer to provide administrative services or healthcare services to qualified individuals (45 C.F.R. 156.20).
ExamplesAgents, brokers, delegates providing administrative or healthcare services to QHP enrollees
Relation to FDRsDelegated entities are a type of arrangement requiring assessment and oversight prior to delegation
First‑Tier Entity
Definition (First‑Tier Entity)Any party that enters into a written arrangement, acceptable to CMS, with the MA organization or Part D plan sponsor or applicant to provide administrative services or health care services to a Medicare eligible individual (42 C.F.R. 422.2, 423.4).
FunctionProvides administrative or health care services directly under contract with the MA organization or Part D sponsor
Regulatory citation42 C.F.R. 422.2, 423.4
Downstream Entity
Definition (Downstream Entity)Any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the MA organization or Part D benefit, below the level of the arrangement between a MA organization or Part D plan sponsor and a first‑tier entity; these arrangements continue down to the ultimate provider (42 C.F.R. 422.2, 423.4).
Position in contracting chainArrangements below first‑tier entities, including subcontractors and service providers
InclusionContinues down to the ultimate provider of health and administrative services
Auditing
Auditing — definitionRetrospective review assessing compliance using a methodological approach and sampling of cases against standards (e.g., policies, procedures, laws and/or regulations).
PurposeAssess adherence to external regulatory requirements and Prominence Health Plan procedures; identify compliance gaps requiring Corrective Action Plans (CAPs)
OutcomeFindings reviewed by Medicare Compliance Committee and may result in CAPs, remedial training, contractual penalties, or termination
Monitoring
Monitoring — definitionPeriodic reviews performed as part of normal business operations to detect and correct issues in real time, confirm ongoing compliance, and ensure corrective actions were implemented and effective.
FrequencyPerformed during normal operations as ongoing activity (e.g., monthly exclusion screening and routine checks)
PurposeDetect and correct issues promptly and validate effectiveness of corrective actions
Policy Summary
Payerprominencehealthfirstofflorida
PolicyFirst Tier, Downstream and Related Entity Audit, Monitoring and Oversight
Policy CodePolicy COMP.FDR.005
Change TypeInformational / no material change
Effective DateJan 1, 2017
Last ReviewMay 21, 2021
Next Review DateJun 1, 2021
Key ActionFDRs must comply with Prominence Health Plan audit requests, internal monitoring and CMS audits and report suspected compliance issues and fraud, waste, or abuse to specified contacts.
SourceLink
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