Network Provider Pharmacy Fraud, Waste and Abuse (FWA) and General Compliance Training; Terms and Conditions
Network Pharmacy Providers are required to sign electronically by submitting the online attestation below to satisfy mandatory compliance requirements related to guidance from the Centers for Medicare & Medicaid Services (CMS). CMS has set forth expressed guidance within the Federal Register at Title 42 of the Code of Federal Regulations (CFR), Parts 422/423 and other agency guidance requiring Medicare Advantage (MA), Medicare-Medicaid Plans (MMP) and Medicare Part D (PDP) sponsors ("Plan Sponsors") or First-tier, Down-stream and Related (FDR) entities to demonstrate compliance with the following:
- Network Pharmacy Provider hereby attests to completion of the two (2) NEW FREE Web-Based Training (WBT) courses as provided by CMS and MLN, including providing staff with links to our Plan Sponsor Code of Conduct policies, information specific to "Know your Rights" and "Cultural Competency with Abuse, Neglect and Exploitation Training".
- In addition, Network Pharmacy Provider hereby attests to no exclusion from participation in Federal health care programs by checking their status in the exclusion lists maintained by the Office of Inspector General (OIG) U.S. Department of Health & Human Services (HHS) and U.S. General Services Administration (GSA) System for Award Management (SAM). Network Pharmacy Provider has reviewed the OIG-HHS and GSA-SAM lists prior to hire/contracting and monthly thereafter for its current employees/contractors, health professionals or subcontracted delegates, working with Plan Sponsor programs to ensure none are excluded from participating in these programs.
- Medicare Managed Care Manual and Prescription Drug Benefit
Manual Chapter 9/Chapter 21 - Section 50.6.8 at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c21.pdf
Social Security Act §1862(e)(1)(B), 42 CFR §§
422.503(b)(4)(vi)(F), 422.752(a)(8), 423.504 (b)(4)(vi)(F),
- Medicaid - The authority for the requirement to review for exclusions is 42 CFR 1001.1901 (b). The extension to state exclusion lists is under the authority of: 42 CFR 1002.2; applicable state law; and state Medicaid contracts, which control for all services performed for State health plans (e.g. UnitedHealthcare Community & State) in any given state, if applicable.
Organizations contracted to administer Federal and State health care programs are prohibited from hiring, continuing to employ, contract, make payments to persons/entities previously excluded/debarred from participation or procurement with Federal and/or State health care programs.
You are required to review the OIG-HHS and GSA Federal programs exclusion lists prior to hiring/contracting employees who are involved in the administration/delivery of Plan Sponsor benefits/services to ensure none of these persons/entities are excluded or become excluded from participation in federal programs. You are required to continue to monitor the federal exclusions lists on a monthly basis thereafter.
Please note: : If you serve state health plans (e.g. UnitedHealthcare Community & State), you are also required to review state exclusion lists prior to hire and monthly thereafter, as referenced in the regulatory appendix of your vendor contract(s) or as modified by state requirements since contract execution
These requirements are included in the following regulatory references:
This information is available at the following sites:
- Office of Inspector General's (OIG) - U.S. Department of Health & Human Services (HHS) ~ List of Excluded Individuals/Entities (LEIE)- http://oig.hhs.gov/exclusions/index.asp
- General Services Administration (GSA) - System for Award Management (SAM) ~ Excluded Parties Listing System (EPLS) -https://www.sam.gov/portal/SAM/#1
Please ensure the following steps are implemented :
- Access the CMS Medicare Learning Network® (MLN) Provider Compliance site(link):
- Medicare Parts C and D Fraud, Waste, and Abuse Training and Medicare Parts C and D General Compliance Training
- Complete two required WBT courses and obtain copies of the
two certificates of completion:
- Test Medicare Parts C and D General Compliance Training
- Combatting Medicare Parts C and D Fraud, Waste, and Abuse
- Do not send the two WBT courses certificates of completion
to OptumRx, unless requested. However, please note CMS requires
Network Pharmacy Providers to maintain records (e.g. training program
completion and training logs in an easily accessible format)
demonstrating compliance with these requirements for ten (10) years.
- Sponsors and FDRs must maintain certificates or documentation of training completion and will furnish upon request a certificate of training such as certificates of completion, training logs, system generated reports, spreadsheets etc.
- FDRs providing training logs, reports, etc. must include at least employee names, dates of employment, dates of completion, passing scores (if captured) to clearly document training completion.
- A sample-training log, which includes all CMS required fields/information, has been provided for your use. If you provide your own training log, please ensure it includes at a minimum the following required information for audit-purposes:
- Employee names
- Dates of employment
- Dates of completion
- Passing scores
- A copy of the training log should be kept on file for future audit-purposes or as requested. Do not send training log to OptumRx.
- Click Here for the 2016 sample-training Log.
Network Pharmacy Agreement
* Indicates Required Field for Authorized Individual Completing Attestation