Your organization is required to comply with and distribute the Jefferson Health Plans Code of Business Conduct and Compliance Program documents provided below or its own materially similar versions to all personnel assigned to perform our services within 90 days of contracting, annually thereafter and upon revision.

Jefferson Health Plans Code of Business Conduct (COBC) (PDF)

Jefferson Health Plans Compliance Program (PDF)

Medicare Downstream Entity Code of Business Conduct (COBC)/Compliance Policies and Procedures (Applies to Medicare only)

If your organization contracts with downstream entities to perform Jefferson Health Plans Medicare Part C or D services, your organization must:

• Provide Jefferson Health Plans' COBC and Compliance Program documents or its own similar versions to its downstream entities within 90 days of hire or contracting, upon revision, and annually thereafter; or
• Contractually require your downstream entities to have and distribute their own COBC and Compliance Policies and conduct a review of their COBC and Compliance Policies to ensure the content is sufficient.
• Monitor and audit your downstream entities’ performance to ensure compliance with all applicable CMS requirements and the requirements discussed in this Compliance Guide, Jefferson Health Plans’ Code of Business Conduct and Compliance Program document.

There are certain Compliance Attestations and Forms we require Delegated Vendors to submit to help us monitor their fulfillment of General Compliance and FWA requirements related to our Medicare, Medicaid and CHIP programs.

Please see the table below for the links to the required attestations and forms your organization must submit along with due date timeframes and requirement applicability based on Program and Delegated Vendor types.

Newly Contracted Delegated Vendor Compliance Attestation

Medicaid Subcontractors: Required
CHIP Subcontractors: Required
Medicare First-Tier Entities: Required

Due Date Timeframe: Within 90 days of contracting with Jefferson Health Plans

Annual Delegated Vendor Compliance Attestation

Medicaid Subcontractors: Required
CHIP Subcontractors: Required
Medicare First-Tier Entities: Required

Due Date Timeframe: Within 30 days of Jefferson Health Plans notification

Offshore Subcontractor*

Medicaid Subcontractors: Required
CHIP Subcontractors: Required
Medicare First-Tier Entities: Required

Due Date Timeframe: Within 15 days after Offshore contract signing
*Note: Jefferson Health Plans approval for Offshore Subcontracting is required prior to your offshore contract signing.

Downstream Entity

Medicaid Subcontractors: Not Applicable
CHIP Subcontractors: Not Applicable
Medicare First-Tier Entities: Required only for Jefferson Health Plans Medicare First Tier entities that are not Jefferson Health Plans Medicare Network providers

Due Date Timeframe: Submit within 90 days of contracting with Jefferson Health Plans and when your organization contracts with new downstreams post- Jefferson Health Plans contracting

Please ensure all personnel assigned to perform Jefferson Health Plans services within your organization and its downstreams (when applicable) know the reporting mechanisms that are available to report non-compliance and FWA issues internally.

Your Jefferson Health Plans -assigned personnel should know:

• Their managers and/or direct reports are available to apply their business experience and help with making the right decisions.
• How to contact your organization's compliance department or general counsel.
• How to use other reporting methods made available by your organization.

Your organization must also have processes to report non-compliance and FWA issues that impact Jefferson Health Plans business to Jefferson Health Plans.  

Various mechanisms are in place for reporting concerns directly to Jefferson Health Plans, such as:

• File a report through https://secure.ethicspoint.com/domain/media/en/gui/1003032/index.html. Reports filed through this webpage will be handled by a third-party vendor on behalf of Jefferson Health Plans. An option for anonymous reporting is provided on the webpage.
• Call the Compliance Hotline - 1-866-477-4848. The hotline is answered by a third-party vendor on behalf of Jefferson Health Plans, and is available 24/7. Although you may identify yourself within your report, you also have the right to remain anonymous. At the end of your report, you will be provided with an ID number that you may also use to call back and receive updates on any investigations.
• Email compliance concerns to compliance@jeffersonhealthplans.com.
• Email suspected or actual fraud, waste and abuse concerns to SIUtips@jeffersonhealthplans.com.
• HIPAA Privacy and Security Complaints can be sent directly to the Privacy Office by emailing PrivacyOfficial@jeffersonhealthplans.com.

Additional Information

The Jefferson Health Plans Reporting Mechanisms listed above are also provided in Jefferson Health Plans’ Code of Business Conduct and Compliance Program Documents.

If your organization or its downstream or related entities plan to delegate any Jefferson Health Plans Medicare-, Medicaid- or CHIP-related work to an offshore subcontractor, approval from an authorized representative must be obtained prior to delegation.

Our Offshore Subcontractor Attestation form must be submitted within 15 calendar days from the offshore contract signing.

Your organization must ensure that its Jefferson Health Plans -assigned/contracted personnel, downstream entities or downstream entity personnel do not appear on any of the Federal and/or State exclusion lists shown on the table below. These screenings must be performed prior to hiring or contracting and monthly thereafter.

Exclusion Screening Requirements by Program

OIG Excluded List - Department of Health and Human Services (DHHS) Office of Inspector General (OIG) List of Excluded Individuals and Entities

Medicare: Pre-hire/contracting & Monthly
Medicaid and CHIP: Pre-hire/contracting & Monthly

SAM Excluded List - General Service Administration System for Award Management (SAM)

Medicare: Pre-hire/contracting & Monthly
Medicaid and CHIP: Pre-hire/contracting & Monthly

XPA Medicheck (State Exclusion List - Required for Medicaid and CHIP personnel only)

Medicare: Not Applicable
Medicaid and CHIP: Pre-hire/contracting & Monthly

Jefferson Health Plans is required to provide our Medicaid and CHIP Delegated Vendors with our written FWA policies to educate them and their Jefferson Health Plans Medicaid and CHIP personnel about Healthcare FWA laws including:

• Federal and State laws regarding false claims, provider prohibited acts, civil or criminal penalties for false claims and statements, and whistleblower protections (including Section 6032 (A) of the Deficit Reduction Act (DRA), 42 U.S.C. § 1396a(a)(68), 62 P.S. §§ 1407 and 1408, and 43 P.S. §§ 1421-1428); and
• methods to detect, prevent and report FWA.

This information is provided in Jefferson Health Plan’s Code of Business Conduct (COBC) and Compliance Program Documents, located in section 1 of this webpage.

To ensure your organization fulfills Medicaid and/or CHIP FWA Education requirements, it must take one or more of the following actions:

• Comply with and distribute Jefferson Health Plans' Compliance Program Document and Code of Business Conduct documents to all personnel performing Jefferson Health Plans Medicaid and/or CHIP services. To meet this requirement, distribution of paper copies is not required; however, your personnel must be made aware of these documents and their location; or
• Receive and comply with Jefferson Health Plans' FWA policies contained in our Compliance Program Document and Code of Business Conduct documents and provide your own similar FWA policies and procedures (P&Ps) and/or training to your Jefferson Health Plans Medicaid and/or CHIP -assigned personnel. If your organization chooses this second option, your FWA P&Ps and/or training content must include detailed information about Healthcare FWA laws including Federal and State laws regarding false claims, provider prohibited acts, civil or criminal penalties for false claims and statements, and whistleblower protections (including Section 6032 (A) of the Deficit Reduction Act (DRA), 42 U.S.C. § 1396a(a)(68), 62 P.S. §§ 1407 and 1408, and 43 P.S. §§ 1421-1428) and methods to detect, prevent and report fraud, waste and abuse.

Additional Resources for FWA Education content: Medical Assistance Bulletin 99-07-13.