Fraud, Waste and Abuse and Cultural Competency Trainings Acknowledgment Form

Thank you for taking Delta Dental’s Fraud, Waste and Abuse and Cultural Competency Trainings. Please review the below attestations and submit the following information in order to complete your submission.

PLEASE NOTE: Please use the tax ID number registered with Delta Dental. We require the business TIN to be able to appropriately document your required submission.    

 

ANNUAL COMPLIANCE ATTESTATIONS

Because you are contracted with Delta Dental to provide dental services to its Medicare Advantage and Medicaid members, the Centers for Medicare and Medicaid Services (CMS) requires you to comply with various CMS program requirements. By completing this attestation, you certify that you and your organization are committed to ensuring compliance with CMS and Delta Dental requirements.  As used in this Attestation, a Downstream Entity is an individual or entity with whom you or your organization contracts and who is involved in the benefits provided to Medicare Advantage or Medicaid members. You attest to the following: 

  1. Fraud, Waste, and Abuse (FWA) Training

My organization has completed the Fraud, Waste, and Abuse Training for all employees (including temporary employees and volunteers), board members, and contractors involved in the delivery of Medicare Advantage or Medicaid benefits.

  1. Compliance Program

My organization and I will maintain a compliance program appropriate for the size of my organization to ensure compliance with federal and state laws and regulations and Delta Dental’s provider manual, policies and procedures. I agree to deliver services in a culturally competent manner to all members, including those with limited English proficiency and diverse cultural and ethnic backgrounds.  I agree to provide physical access, reasonable accommodations, and accessible equipment for Medicare Advantage and Medicaid members with physical or mental disabilities.   

  1. Exclusion Screening

Neither my organization nor I am on the Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE), the CMS Preclusion List, and the General Services Administration (GSA) List. If I am ever placed on any of these lists, I will immediately notify Delta Dental.

  1. Reporting Mechanisms

My organization informs employees how to report suspected or detected non-compliance or potential Fraud, Waste, or Abuse for internal review and investigation. My organization does not allow retaliation or intimidation against anyone who reports a concern in good faith, and my organization reports any applicable incidents to Delta Dental as they occur.

  1. Record Retention

My organization maintains records for a minimum of 10 years to adequately document compliance with Delta Dental’s contract.

  1. Offshore Operations

My organization does not engage in offshore operations of any administrative or health care services related to Medicare Advantage or Medicaid business.

If your organization does engage in offshore operation of any administrative or health care services related to Medicare Advantage or Medicaid business, please contact us for an “Offshore Subcontractor Attestation” for completion and submission to Delta Dental.

  1. Operational Oversight

My organization conducts internal oversight of the services that we perform for Delta Dental’s Medicare Advantage or Medicaid members to ensure that compliance is maintained with applicable laws, rules, and regulations including CMS regulatory/sub-regulatory guidance.

  1. Downstream Entity Oversight (Applicable only if your organization uses Downstream Entities)

My organization either doesn’t use Downstream Entities, or uses Downstream Entities for Delta Dental Medicare Advantage or Medicaid business and conducts oversight to ensure that they abide by all laws, rules, and regulations that apply.

Attestation Authorization

I certify, as an authorized representative of my organization, that the statements above are true and correct to the best of my knowledge, and the above compliance program requirements and annual training requirements have been met.

NOTE: Please make sure you enter the correct Tax Identification Number (TIN) for your business. Do not include spaces or dashes. If you do not enter the correct information that Delta Dental has on file for your business, your training will not be recorded. As a result you will continue to receive notifications that your office is noncompliant.

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Indicate Training Courses Taken*:

By submitting this form, I hereby certify that all persons associated with the TIN entered above have completed Delta Dental’s Fraud, Waste and Abuse and Cultural Competency trainings. In addition, I hereby certify compliance with the Annual Compliance Attestations above for this calendar year.