Please Confirm:

* Required Information


1. Has your organization distributed the established compliance policies, procedures, and Standards of Conduct in accordance with the requirements outlined in the FDR Guide?*

2. Does your organization require employees involved with providing or supporting Medicare Advantage services on behalf of MMO, to take the General Compliance training within 90 days of hire and annually thereafter?*

3. Does your organization require employees involved with providing or supporting Medicare Advantage services on behalf of MMO to take the Fraud, Waste, and Abuse (FWA) training within 90 days of hire and annually thereafter or has your organization been deemed to have met the FWA certification requirements through enrollment in the Medicare program or accreditation as a supplier of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies(DMEPOS)?*

4. Does your organization confirm that prior to hiring and then monthly thereafter that it and all employees, board members, officers, consultants, volunteers, temporary employees, providers and contractors involved in the administration or delivery of Medicare Advantage services are not excluded from participating in any Federally funded programs?*

5. Does your organization have at least one anonymous mechanism for employees to report suspected FWA or noncompliance, and has the reporting mechanism been distributed to employees?*

6. Does your organization maintain all books, records, and documents regarding the Medicare Advantage services you perform for Medical Mutual of Ohio, as well as documentation of compliance with all Medicare requirements for at least ten (10) years, consistent with 42 C.F.R. §§ 422.504(d)–(e) and/or 423.505(d)–(e)?*

7. Does your organization confirm that all subcontracted, downstream entities that assist with Medicare Advantage services, if any, adhere to these compliance requirements? If you do not sub-contract other entities to perform delegated functions, answer not applicable.*

8. Is your organization free of any conflict of interest in administering or delivering Medicare Advantage or other Federally-funded program benefits to Medical Mutual beneficiaries?*

9. Does your organization employ or utilize any offshore entities to perform Medicare Advantage services for Medical Mutual of Ohio that involves processing, handling, or accessing Protected Health Information (PHI)? *

By completing this Attestation, you are attesting on behalf of the Provider named above, and all other entities on whose behalf Provider has contracted with Medical Mutual for Medicare Advantage network participation, that all information is true and correct.*

Responses provided on this attestation are subject to audit or verification by Medical Mutual.