Medicare first-tier downstream & related entities

Thank you for your service to our members. We appreciate your partnership with Providence Health Assurance. Please refer to our Medicare Delegation Oversight Manual for detailed information regarding FDR obligations and responsibilities.

If you have a compliance question, please email us at PHAMedicareCompliance@providence.org.

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What are first-tier, downstream & related entities?

First tier, downstream and related entities (FDR’s) are the providers, vendors and related entities that contract with Providence Health Assurance (PHA) to support Medicare members.



PHA contracts with The Centers for Medicare & Medicaid Services


PHA is contracted with The Centers for Medicare & Medicaid Services (CMS) to provide healthcare and prescription drug coverage to our Medicare beneficiaries.

As a condition of our contract with CMS, PHA is required to provide and oversee the training listed below and the educational presentations that are given to our contracted providers, vendors and related entities that provide service to our members. These providers, vendors and related entities are PHA’s first-tier, downstream and related entities, also known as FDRs.

CMS requires that FDR’s receive general compliance and fraud, waste and abuse training within 90 days of hire and annually thereafter.


How to meet training obligations:


In order to successfully meet our training obligation (42 CFR §422.503 (b)(4)(vi)(C)(3) and §423.504 (b)(4)(vi)(C)(3)) with CMS, please complete one the following steps.

Each year you will be asked to attest during your annual FDR Attestation. To do this, please complete one of the following steps:


Be sure to download your certificate and keep for your records.

Please keep records of all compliance training conducted within your organization. Documentation of training may be requested. If you have any additional questions regarding this required training, please contact your PHA Medicare Delegation Program Consultant or email us at PHAMedicareCompliance@providence.org.



Medicare Compliance


Providence Medicare Advantage Plans is committed to a culture of compliance. As part of our contract with The Centers for Medicare & Medicaid Services (CMS), we have developed and adopted an effective compliance program. Our compliance program reinforces our commitment to high ethical standards and conduct, and establishes our expectation that all Providence Medicare Advantage Plan caregivers, governing board, FDR’s and members conduct themselves in an ethical and lawful manner and comply with all federal, state and local laws and regulations.



Excluded entities


All FDR's must screen their board members, executives, employees, and contractors that work with the PHA line of business to ensure that none are barred from participation in Government Programs. The OIG prohibits Medicare Advantage Plans from issuing payments to those providers excluded by the Medicare/Medicaid Program and/or sanctioned by the OIG. Health and Human Services Office of the Inspector General (HHS OIG) LEIE exclusion lists, and the EPLS found on the System for Award Management (SAM) debarment lists must be checked pre-hire and monthly thereafter. The Preclusion list is a spreadsheet of providers and prescribers who are precluded from receiving payment for Medicare Advantage items and services or Part D drugs furnished or prescribed to Medicare beneficiaries. This list will be provided monthly to applicable FDR's via secure email.



If you have an employee on an excluded list


CMS requires Medicare Advantage Plans to obtain certifications that if an employee of the FDR responsible for administering or delivering Part D benefits is on such lists, that employee will be immediately removed from any work related directly or indirectly to all federal health care programs and the entity will take appropriate corrective actions.

If you have any employees or providers that are on one of the excluded lists, please notify us via email at PHAMedicareCompliance@providence.org.



Excluded Provider Attestation


CMS requires all Medicare Advantage Plans to obtain certifications from all FDR’s. 
When initially hired and monthly thereafter, we are required to review the excluded provider lists to ensure that any employee or manager responsible for administering or delivering Part D benefits is not excluded from federal healthcare programs. 

You can find the exclusion lists here:



How to Report Potential Non-Compliance Concerns


You can report potential concerns in one of these ways:

  • Fill out our secure online form
  • Download and print the potential non-compliance external referral form (PDF)
    • Fax the completed form to:
      Fax 503-574-6543
    • OR

    • Mail the completed form to:
      Attention: Medicare Compliance Manager
      3601 SW Murray Blvd, Suite 10
      Beaverton, Oregon 97005

  • Contact the Providence Health Assurance Chief Compliance and Risk Officer and the Medicare Compliance Officer at 503-574-6562
  • Call the confidential Providence Integrity Hotline at 888-294-8455, 24 hours a day, seven days a week.


Conflict of interest


All FDR's will have a conflict of interest process in place for all employees who work with the PHA line of business.



Policy & Procedures


Providers

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