Provider Attestation

Completing this annual attestation confirms acknowledgement of receipt and distribution of the established compliance policies, procedures, and Standards of Conduct in accordance with the requirements outlined in the FDR Program Guide including conflict of interest, record retention, training, and exclusions.

 

To increase efficiencies and response times, faxes and emails are unable to be accepted for submissions. Attestations must be submitted electronically below.

 

If the attestation includes multiple TINs, please enter up to 5 TINs per attestation.

 

NOTE: Submissions received after December 31, 2025 will be accounted for the 2026 attestation period.

 

The CMS Medicare Learning Network provides Fraud, Waste, and Abuse Training as a resource.

Failure to meet the CMS Medicare compliance program requirements may lead to:

  • Education and retraining
  • Development of a corrective action plan
  • Termination of your contract

For additional information, please refer to our First Tier Downstream or Related Entities site for FDR program resources.

Please Confirm:

* Required Information

1. Company Policies/Code of Conduct*

Our organization has received, reviewed, and understands the policies and standards outlined in Medical Mutual’s Code of Conduct and First Tier Downstream or Related Entities site. We comply with the requirements of record retention and remain free of any conflict of interest in delivering Federally funded program benefits. The following information is distributed to our employees upon hire and annually thereafter (select one):

2. Training*

Our organization requires employees involved with providing or supporting Medicare Advantage services on behalf of Medical Mutual to take the Fraud, Waste, and Abuse (FWA) training within 90 days of hire and annually thereafter or our organization has 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).

3. Reporting Mechanisms*

Our organization offers the following options for reporting potential Fraud, Waste, and Abuse (FWA) (select one):

4. US Department of Health & Human Services Office of Inspector General (OIG)/Exclusions*

Our organization complies with screening requirements for applicants and employees against the Department of Health and Human Services (DHHS) Office of Inspector General (OIG) and GSA System for Award Management (SAM) federal programs exclusion lists.

5. Downstream Entities*

Our organization monitors the compliance requirements of any subcontracted or downstream entities that perform services to fulfill our contractual obligations for the Medical Mutual Medicare Advantage plans.

6. Offshoring*

Our organization employs or utilizes offshore entities to perform Medicare Advantage services for Medical Mutual that involves processing, handling, or accessing Protected Health Information (PHI).

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





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