Delegated Vendor Compliance Attestation

CMS and DHS require any organization or individual that contracts with Jefferson Health Plans to provide administrative or healthcare service functions on the behalf of Jefferson Health Plans to comply with various compliance program requirements. By completing the following attestation, you certify that your organization is committed to fulfilling Medicare, Medicaid and/or CHIP Compliance Program requirements and any Compliance Program Requirements implemented by Jefferson Health Plans.

This attestation is for existing Jefferson Health Plans Delegated Vendors only.

Please submit within 30 days of notification.

Questions or concerns regarding this attestation can be directed to MedicareFDR@jeffersonhealthplans.com.

1. Lines of Business

Select all Jefferson Health Plans lines of business that your organization performs services for.

Medicare

Medicaid

CHIP

2. Code of Business Conduct and Compliance Program Policy Distribution

Select 1 option that best describes your organization's actions or enter an explanation in the comment box.

Jefferson Health Plans' Code of Business Conduct (COBC) and Compliance Program Policies were made available to our organization in 2023. We have provided Jefferson Health Plans' COBC/Compliance Program Policies to all our employees initially within 90 days of hire or contracting, upon revision, and will continue to provide them anually thereafter.

My organization's Code of Business Conduct (COBC) and/or Compliance Program Policies are materially similar to Jefferson Health Plans' COBC and Compliance Program Policy content and were provided to all our employees in 2023 within 90 days of hire and upon revision. We will continue to provide them anually thereafter.

If the organization does not adopt and comply with Jefferson Health Plans' COBC and Compliance Policy, or a materially similar version, please explain below.

3. OIG/SAM/Medicheck Exclusion Screening

Select the option below or enter an explanation in the comment box.

My organization reviewed the OIG LEIE, SAM EPLS and Medicheck (applicable to work related to Jefferson Health Plans' Medicaid/CHIP lines of business) prior to the hiring or contracting of all personnel involved in the administration or delivery of Jefferson Health Plans' benefits and monthly thereafter.

If the organization did not perform exlusion screenings as stated above, please explain below.

4. Reporting Mechanisms

Select the option below or enter an explanation in the comment box.

Internal employees were informed of their obligation and how to report any suspected or detected non-compliance or potential FWA for internal investigation. The reporting mechanisms ensure confidentiality and allow for anonymity, as desired. In addition, we don't allow retaliation or intimidation against anyone who reports in good faith. In turn, our organization reports any applicable incidents to Jefferson Health Plans as they arise.

If the language stated above does not align with the actions of your organization, please explain below.

5. Offshore Subcontractor Reporting

My organization and/or any of our downstream/related entities

DID NOT engage in offshore operations for any administrative or healthcare services related to Jefferson Health Plans business

DID engage in offshore operations for any administrative or healthcare services related to Jefferson Health Plans business

If your organization and/or any of its downstream/related entities engaged in offshore operations related to Jefferson Health Plans business, please obtain approval from Jefferson Health Plans prior to delegation. Once approval is received, complete the 'Offshore Subcontractor Attestation', located on the Delegated Vendor Information webpage.

As an authorized representative for the organization named below, I certify that I have reviewed and understand all of the requirements within the Jefferson Health Plans vendor policy, that the above statements are true to the best of my knowledge, and that my organization maintains records that support our compliance.

Organization Name *

Organization Address *

Organization Address (line 2)

City *

State *

Zip code *

Organization's Authorized Representative *

Title of Organization's Authorized Representative *

Phone Number of Organization's Authorized Representative *

Email Address of Organization's Authorized Representative *