2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

LegalChapter 9 that are required by a First-Tier Entityproviding the Services set forth in the agreement(s)or this amendment.Provider Training and EducationIn accordance with Chapter 9, provider shallimplement annual compliance training andeducation of all employees, independentcontractors, agents, participating pharmacies, andsubcontractors with any Medicare Advantage orPart D responsibilities on behalf of Presbyterian.Such training shall include, at a minimum, all topicsincluded in Section 50.2.3 of Prescription DrugBenefit Manual Chapter 9. Upon request, providershall report to Presbyterian certified, fact-specificinformation on the training and the provider’seducation compliance. (Source: 42 CFR§§422.503(b)(4)(vi)(C).)Provider CommunicationsProvider shall report to Presbyterian’s ComplianceOfficer through telephone and follow-up electronicmail communication any suspected or potentialfraud or other misconduct by provider (or anemployee, agent of practitioner/provider) or asubcontractor (or an employee or agent of asubcontractor) or any other entity of whichbecomes aware. Provider shall also have aninternal reporting process for provider andsubcontractor employees and agents to reportsuspected or potential fraud to provider’scompliance officer. Provider shall report toPresbyterian any potential fraud or othermisconduct by provider or a subcontractor. Thisreport shall be made as soon as the providerbecomes aware of the potential fraud or othermisconduct.Reasonable AssurancesProvider will, as of the effective date of thisagreement, and thereafter as reasonably requestedby Presbyterian provide reasonable assurances toPresbyterian that provider’s and subcontractors’performance of these fraud, waste, and abuserequirements. Such assurances may include,among other things, providing written certificationthat the subcontractors are in compliance with allMedicare requirements or providing Presbyterianwith copies of provider’s policies and procedures,compliance program, documentation of training,and any other information necessary to providePresbyterian with reasonable assurances ofsubcontractor’s compliance with all applicableMedicare Advantage requirements.Revocation of Delegation or Termination ofAgreementPresbyterian may revoke its delegation of anyMedicare Advantage duties to provider or terminatethe agreement(s) if Presbyterian determines, in itssole discretion after a good faith investigation, thata provider or a subcontractor is not satisfactorilyperforming their Medicare Advantage duties orresponsibilities to the extent that it may cause harmto MA plan enrollees or may cause Presbyterian tobe in non-compliance with any Medicare Advantagerequirements. (Source: 42 CFR §422.504(i)(4)(ii).)14-132014 Practitioner and Provider Manual - Ver. 3