Annual Compliance Attestation Acknowledgement Form - Providers

Please review the below attestations and submit the following information in order to complete your submission.

PLEASE NOTE: Please use the tax ID number registered with Delta Dental. We require the business TIN to be able to appropriately document your required submission.

ANNUAL COMPLIANCE ATTESTATIONS

My organization, is contracted with Delta Dental of Illinois (DDIL) to provide administrative or health care service functions that relate to DDIL’s Medicare Parts C and D contract(s). The Centers for Medicare and Medicaid Services (CMS) requires any individual or organization to comply with various CMS program requirements. By completing this attestation, you certify that you and your organization are committed to ensuring compliance with CMS and DDIL requirements. As used in this attestation, a Downstream Entity is an individual or entity with whom you or your organization contracts and who is involved in the benefits provided to Medicare Advantage Enrollees. You attest to the following:

1. Compliance Program: My organization and I will maintain a compliance program appropriate for the size of my organization to
   ensure compliance with federal and state laws and regulations and DDIL’s policies and procedures.
2. General Compliance and Fraud, Waste & Abuse (FWA) Training: My organization attests that we provided General Compliance and FWA Training for all employees involved in the administration and delivery of Medicare Advantage benefits within 90 days of hire or contracting, and on an annual basis thereafter.
3. Code of Conduct and Compliance Policies: Code of Conduct and compliance policies have been made available to our organization or we use our own comparable version of these policies. The Code of Conduct/compliance policies have been made available to all employees within 90 days of hire or contracting and annually thereafter.
4. OIG and GSA Exclusion Screening: My organization attests we review the Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE) and General Services Administration (GSA) for our employees, temporary employees, board members, volunteers, and contractors involved in the administration and delivery of Medicare Advantage beneficiaries. Exclusion screenings from these sources are checked prior to initial hire or contracting and monthly thereafter. Any individual found on such lists, will immediately be removed from any work directly or indirectly related to Medicare Advantage programs.
5. Preclusion List: Neither my organization nor am I on the CMS Medicare Preclusion List. If either my organization or I am ever placed on the CMS Medicare Preclusion List, we will promptly notify DDIL.
6. Reporting Mechanisms: Internal employees were informed of their obligation and how to report any suspected noncompliance or potential FWA for internal review and investigation. The reporting mechanisms ensure confidentiality and allow for anonymity, as desired. We do not allow retaliation or intimidation against anyone who reports a concern in good faith, and our organization reports any applicable incidents to DDIL as they occur.
7. Record Retention: Our organization agrees to maintain records of training, disciplinary standards, and exclusion checking of all employees, including temporary employees and volunteers, board members as well as downstream entities, for a minimum of 10 years. Records maintained must include, but are not limited to: training materials and training logs, documentation of exclusion checks, and dissemination of Code of Conduct/compliance program policies.
8. Compliance Information (applicable to organization with Downstream Entities): My organization attests that we have and will continue to obtain attestations from our downstream entities for which we have contracted to provide services for Medicare Advantage Beneficiaries, and will upon DDIL’s request, obtain the same documentation requirements listed above from those entities, my organization attests that we ensure compliance is maintained by our organization and perform ongoing oversight of our downstream entities and disclose issues identified to DDIL as soon as possible, or not applicable.
9.  Offshore Subcontractor Reporting: My organization and/or any of our downstream and related entities Do Not engage in offshore operations of any administrative or health care services related to Medicare Advantage business.

Attestation Authorization

I certify as an authorized representative that the information above is true and correct to the best of my knowledge, and the above compliance program and annual training requirements have been met. In addition, my organization will furnish evidence of completion of the above to DDIL upon request for monitoring and auditing purposes.

For questions about this form and attestation or general questions about your Medicare Advantage Network participation contact the Delta Dental of Illinois Professional Relations Department at 630-718-4990.