Highmark Wholecare Medicare Assured Medicare Compliance Program is designed to prevent, detect and correct Medicare Part C and Part D program non-compliance as well as Fraud, Waste and Abuse (FWA).

All parties, including Highmark Wholecare employees, governing body, first tier entities, downstream entities, related entities, and members involved with Highmark Wholecare Medicare Assured must comply with all applicable federal and state laws and regulations.

Compliance Glossary of Terms

Abuse: Abuse involves actions that are inconsistent with accepted, sound medical, business, or fiscal practices. Abuse directly or indirectly results in unnecessary costs to the program through improper payments.

Compliance: Compliance efforts are fundamentally designed to establish a culture within an organization that promotes the prevention, detection and resolution of instances of conduct that do not conform to federal and state law, or to federal healthcare program requirements.

Delegated Entity: An entity with which a Medicare Health Plan has entered into written agreement to perform certain functions required under, or governed by, federal and/or state standards that would otherwise be the responsibility of the Plan.

Downstream Entity: Any party that enters into an acceptable written arrangement below the level of the arrangement between a Medicare Health Plan (and contract applicant) and a first tier entity. These written arrangements continue down to the level of the ultimate provider of health and/or administrative services.

First Tier Entity: Any party that enters into a written arrangement with a Medicare Health Plan or contract applicant to provide administrative services or healthcare services for a Medicare eligible individual.

Fraud: The intentional deception or misrepresentation that an individual knows, or should know, to be false, or does not believe to be true, and makes, knowing the deception could result in some unauthorized benefit to himself or some other person(s).

Related Entity: Any party that is related to the Medicare Health Plan by common ownership or control and:
1. Performs some of the Health Plan’s management functions under contract or delegation;
2. Furnishes services to Medicare enrollees under an oral or written agreement; or
3. Leases real property or sells materials to the Health Plan at a cost of more than $2,500 during a contract period.

Compliance Resources

First Tier, Downstream and Related Entities Code of Conduct

Centers for Medicare and Medicaid Services (CMS)

Federal Register

- Medicare Advantage Program, 42 CFR 422

- Voluntary Medicare Prescription Drug Benefit, 42 CFR 423

Office of Inspector General (OIG)

Reporting Issues

Call Highmark Wholecare Hot Line (calls may be anonymous): (412) 255-4340 or 1-844-718-6400

Highmark Wholecare
Attn: Medicare Compliance Officer
PO Box 535191
Pittsburgh, PA 15253-5191

Last updated on 1/12/2024 9:29:14 AM


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