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Medicare first-tier, downstream and related entities

Providence Health Assurance (PHA) is contracted with The Centers for Medicare & Medicaid Services (CMS) to provide health care and prescription drug coverage to our Medicare beneficiaries. These beneficiaries are PHA’s valued members. As a condition of our contract with CMS, PHA is required to provide and oversee training and educational presentations that are given to our contracted providers, vendors and related entities that provide service to our members. These providers, vendors and related entities are PHA’s first-tier, downstream and related entities, also known as FDRs.

Thank you for your service to our members. We appreciate your partnership with Providence Health Assurance. If you have a compliance question, please email us at PHAMedicareCompliance@providence.org.

CMS requires that FDR’s receive general compliance and fraud, waste and abuse training within 90 days of hire and annually thereafter.

In order to successfully meet our training obligation (42 CFR §422.503 (b)(4)(vi)(C)(3) and §423.504 (b)(4)(vi)(C)(3)) with CMS, please complete one of the following steps.

You will be asked to attest during your annual FDR Attestation.

  • Administer the CMS Medicare Learning Network (MLN) training via the CMS website. 
  • Request training modules from PHA's Medicare Delegation Program Consultant
    OR
  • Incorporate the CMS training into your existing training without modifying the content of CMS.

Please keep records of all compliance training conducted within your organization. Documentation of training may be requested. If you have any additional questions regarding this required training, please contact your PHA Medicare Delegation Program Consultant or email us at PHAMedicareCompliance@providence.org.

Medicare Compliance

Medicare Standards of Conduct (PDF)

Providence Code of Conduct (PDF)

Providence Medicare Advantage Plans is committed to a “culture” of compliance. As part of our contract with The Centers for Medicare & Medicaid Services (CMS), we have developed and adopted an effective compliance program. Our compliance program reinforces our commitment to ethical standards and conduct, and establishes our expectation that all Providence Medicare Advantage Plan employees, governing board, first tier, downstream, related entities and members conduct themselves in an ethical and lawful manner, and comply with all federal, state and local laws and regulations.

How to Report Potential Non-Compliance Concerns

1. Please fill out the potential non-compliance external referral form (PDF)

  • Send by fax to: 503-574-6543
OR
  • Send by mail to:
    Attention: Medicare Compliance Manager
    3601 SW Murray Blvd, Suite 10
    Beaverton, Oregon 97005

2. Contact the Providence Health Assurance Chief Compliance and Risk Officer at 503-574-6562 or the Medicare Compliance Officer at 503-574-6437. 

3. Call the confidential Providence Integrity Hotline at 888-294-8455, 24 hours a day, seven days a week.

Conflict of interest

Providence Health Assurance’s expectation of all FDRs is that they should have a conflict of interest process in place for all employees that work with the PHA line of business.

Excluded entities

All FDRs must screen their board members, executives, employees, and contractors that work with the PHA line of business to ensure that none are barred from participation in Government Programs. The OIG prohibits Medicare Advantage Plans from issuing payments to those providers excluded by the Medicare/Medicaid Program and/or sanctioned by the OIG. Health and Human Services Office of the Inspector General (HHS OIG) LEIE exclusion lists, and the EPLS found on the System for Award Management (SAM) debarment lists must be checked pre-hire and monthly thereafter. The Preclusion list is a spreadsheet of providers and prescribers who are precluded from receiving payment for Medicare Advantage items and services or Part D drugs furnished or prescribed to Medicare beneficiaries. This list will be provided monthly to applicable FDRs via secure e-mail.

Policy and procedures