Helping People Live the Healthiest Lives Possible.

SelectHealth has a compliance program that is effective in preventing, detecting, and correcting Medicare Advantage and Part D program non-compliance as well as program fraud, waste, and Abuse. Our compliance program is evaluated regularly based on CMS’ seven elements of an effective compliance program.

We have a Compliance Hotline available to our members, employees, and contractors 24 hours per day and seven days per week. The Compliance Hotline is the method for each of these groups to report suspected program non-compliance or potential fraud, waste, or abuse. Anonymity and interpretation services are available. If you believe you have observed or been subjected to Medicare program non-compliance or fraud, waste, or abuse, you should contact the Compliance Hotline at 800-442-4845.

 

Information about SelectHealth Advantage first tier, downstream, and related entities (FDRs)

SelectHealth relies on our contracted providers and other contractors to help us meet the needs of our members. These individuals and organizations are considered First tier, Downstream, and Related Entities ("FDRs"). FDRs provide health or administrative services to the SelectHealth Medicare Advantage members and are a vital part of the SelectHealth Medicare Advantage program. They have specific responsibilities under the Medicare guidelines, including:

  • FDRs are required to comply with all applicable statutory, regulatory, and other Part C or Part D requirements, including adopting their own effective compliance programs.
  • FDRs have a duty to report any violations of law; issues of program non-compliance; or fraud, waste, and abuse (FWA). Reports can be made to the Compliance Hotline at 800-442-4845. The Compliance Hotline is available 24 hours, seven days a week. Anonymity and interpretation services are available.
  • FDRs have a duty to follow their organization’s Code of Conduct that articulates the commitment standards of conduct and ethical rules of behavior. See the Code of Ethics that SelectHealth and its employees commit to.
    • FDRs are required to either provide the SelectHealth Code of Ethics or their own equivalent Code of Conduct to all of the their employees as well as any downstream and related entities that support the SelectHealth Medicare Advantage program. These organizations must provide the applicable Code of Ethics/Conduct to their employees initially upon hire (or effective date of a contract) and annually thereafter.
  • FDRs are required to complete General Compliance and FWA training courses based on CMS regulations. Trainings must be provided initially upon hiring an employee and annually thereafter if the employee’s work supports the SelectHealth Medicare Advantage program.
    • FDRs may use the SelectHealth Compliance and FWA Training, CMS’ standardized FWA and General Compliance training, or substitute equivalent versions. (link to Pace for training registration or provide downloadable version)
    • FDRs are required to maintain evidence of completion for no less than ten (10) years. SelectHealth and/or CMS may request evidence of completion from your organization for these courses. Evidence may include training logs with dates and certificates of completion, sign-in sheets, attestations, or other methods to demonstrate fulfillment of the obligation. CMS has a sample Certificate of Completion that is recommended for use or SelectHealth has developed a Sample Training Log that may also be used.
  • FDRs may not be on, employ individuals who are on, or contract with individuals or entities who are on the Office of Inspector General List of Excluded Individuals and Entities (LEIE) or on the General Services Administration Excluded parties Lists System (EPLS). The exclusion lists must be checked initially upon hiring/contracting and then monthly by the FDR thereafter. Parties found on these lists must be immediately removed from participating in or supporting the SelectHealth Medicare Advantage program.

We understand that navigating Medicare Advantage rules and regulations can be difficult, and we're here to help! We have created the following tools to help our FDRs understand and meet both the Centers for Medicare and Medicaid Services (CMS) and SelectHealth compliance requirements.

  • SelectHealth FDR Compliance Guide - Outlines key compliance requirements for FDRs and recommendations for meeting those requirements.
  • SelectHealth Code of Ethics - Accessible electronically to FDRs and their employees.
  • SelectHealth Reporting Flyer - FDRs and their employees can call the Compliance Hotline toll-free at 800-442-4845 to report issues of suspected noncompliance or potential Fraud, Waste, or Abuse (FWA). The SelectHealth Reporting Flyer is a document you can post in your facilities or distribute to employees to let them know how to report Medicare program compliance concerns and/or FWA to SelectHealth without fear of intimidation or retaliation.

 

Information for providers, pharmacies, and agents

If you are a participating, contracted provider or pharmacy in the SelectHealth Advantage network serving Medicare beneficiaries, access the SelectHealth Compliance/FWA information via the SelectHealth Provider Portal.

If you are a SelectHealth agent, access the SelectHealth Compliance/FWA information via SelectHealth Broker Exchange.

 

Medicare advantage regulations and guidance

  • Regulations governing the MA program are found at 42 CFR Part 422 and Part 423. The Code of Federal Regulations (CFR) can be accessed at: www.gpo.gov
  • CMS provides additional guidance for MA plans in the Medicare Managed Care Manual (Publication # 100-16) available through the CMS Internet-Only Manuals on www.cms.gov
  • CMS provides additional guidance for Prescription Drug Plans in the Medicare Prescription Drug Benefit Manual (Publication # 100-18) available through the CMS Internet-Only Manuals on www.cms.gov
  • CMS requires MA plans and their FDRs to check the OIG/GSA Exclusion lists each month to prevent inappropriate payment to providers, pharmacies, and other entities that have been excluded from participation in federal programs.
    • Individuals and Entities (LEIE) includes all health care providers and suppliers that are excluded from participation in federal health care programs. The LEIE is available oig.hhs.gov
    • GSA’s System for Award Management (SAM) includes health care providers on the LEIE and also includes other non-health care contractors that are excluded from federal programs. The SAM is available at: www.sam.gov
  • CMS makes available a Standardized General Compliance and Fraud, Waste, and Abuse (FWA) Training Module that satisfies the compliance and FWA training and education requirements. The CMS module is available at: www.cms.gov