Attestation – Americare Vendor Portal

Attestation Instructions:

This form must be completed by an authorized representative (i.e., a Compliance Officer, Administrator, an Executive Officer, or Owner) prior to contract initiation, and annually thereafter.

Click each of the links below and select the appropriate response for each category. All five items must be completed. Please check one box in each category.

1. Standards of Conduct, Compliance Program, and DRA/FCA (Required)

I have reviewed and understand the Americare CSS Standard of Conduct, Compliance Program and policies. In addition,

My organization has established and publicized compliance policies, Standards of Conduct and Compliance Program. This information is disseminated to employees upon hire and annually thereafter. The compliance policies and/or Standards of Conduct reflect a commitment to preventing, detecting, and correcting non-compliance. The compliance reference material includes, at minimum, information on the Deficit Reduction Act of 2005 and the False Claims Act.My organization does not have established compliance policies and/or Standards of Conduct. Therefore, the Americare Compliance Program, Standards of Conduct and information on select regulations have been disseminated to all personnel that is assigned to service Americare patients.

2. Fraud, Waste and Abuse and Compliance Issues Reporting Mechanisms (Required)

My organization maintains a confidential FWA and Compliance reporting mechanism. It has been distributed and widely publicized for all employees and contractors within the organization to encourage reporting potential FWA and Compliance issues.My organization does not maintain a confidential FWA and Compliance reporting mechanism. The info for the Americare CSS Compliance Confidential Hotline (1-800-452-1897) has been distributed and widely publicized for all employees and contractors within our organization to encourage reporting potential FWA and Compliance issues.

3. OIG, GSA (SAM), and NYS Exclusion Screening (Required)

Related Documents:
Vendor Exclusion Check Requirement Policy

My organization currently performs exclusion screening prior to hire/ contract and monthly thereafter to confirm that employees and contractors are not excluded to participate in federally funded healthcare programs according to the OIG, OMIG and SAM exclusion lists. If an employee or contractor is on an exclusion list he or she shall be removed from any work related directly or indirectly to federal health care programs and appropriate corrective action will be taken.My organization does not currently perform exclusion screening prior to hire and/or contract and monthly thereafter. However, Within 7 days of receipt of this form, and monthly thereafter, a check will be done to confirm that employees assigned to Americare CSS cases are not excluded to participate in federally funded health care programs according to the OIG, OMIG and SAM exclusion lists. If an employee or contractor is on an exclusion list he or she will be removed from any work related to federal health care programs and appropriate corrective action will be taken.

Below are links to the exclusion screening websites:

OMIG
OIG
SAM

4. Electronic Visit Verification Protocol (Required)

My organization is in agreement to utilize Electronic Visit Verification (EVV) system that is compatible with the Americare CSS Verification Organization (HHA exchange) in order to ensure compliance with time and attendance requirements imposed by the NY state Office of the Medicaid Inspector General. Self-audits on 5% sample of exceptions and 100% of conflicts will be conducted on a quarterly basis in order to evaluate the attendance , performance and measure the compliance as it pertains to the resolution and documentation of the exceptions and conflicts.

5. HIPAA Business Associate (Required)

I understand my obligations to report any PHI breaches to Americare CSS as soon as they occur but no later than 30 days of the occurrence.

Please complete the attestation below:

I certify, as the authorized representative having directly responsibility for all contracted personnel who provide health care or administrative services under Medicaid and/or Medicare, that the statements above are true and correct to the best of my knowledge.

I understand that the rules and policies reflect Americare CSS's earnest commitment to integrity and compliance with all applicable federal, state, and local laws, regulations and rules.

I fully understand the requirements set forth in the above. I hereby agree to abide by the principles and standards set forth in the above documentation and to conduct myself during my association with Americare CSS in full accordance with all rules and policies of Americare CSS and the highest ethical standards.

I fully understand my obligation as a contracted vendor provide education to all personnel assigned to Americare CSS cases about applicable federal, state, and local laws, regulations and rules and/or Americare CSS Compliance program/ Reporting expectations.

Name of Organization/Name of Provider (required)

Authorized Representative's Name (required)

Authorized Representative's Title (required)

Authorized Representative's Phone Number (required)

Authorized Representative's Email Address (required)

Comments

If you have any questions, please contact Americare CSS Compliance Department at compliance@americareny.com or dial 718-535-3100