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Centers for Medicare & Medicaid Services (CMS) requires Medicare Advantage Organizations (MAOs) to ensure their first-tier, downstream and related entities (FDRs), including FDR employees who are in critical roles related to any delegated functions, receive general compliance training as well as fraud, waste and abuse (FWA) training, and that a monitoring process is in place to ensure the training is completed by December 31 of each year. FDRs are prohibited from developing, implementing or completing supplemental trainings to fulfil this requirement. FDRs must access the CMS standardized course modules available at the CMS Medicare Learning Network website at:
For Cal MediConnect Plan (Medicare–Medi-Cal Plan) participating providers, these requirements are Medicare-specific, and not applicable to Medi-Cal.
FWA and General Compliance Training Requirements
Health Net participating physician groups (PPGs), independent practice associations (IPAs) and medical groups delegated to perform administrative functions, such as claims processing, credentialing or utilization management, on Health Net's behalf, are required to ensure that their employees who are in critical roles related to these delegated functions complete the CMS-developed FWA and general compliance training. The training must occur within 90 days of initial hiring and annually thereafter. The annual training can be completed any time between January 1 and December 31. In accordance with CMS guidance, examples of the critical roles within a PPG, IPA and medical group that should clearly be required to fulfill these training requirements include the following positions or roles:
- Senior administrators or managers directly responsible for the PPG's, IPA's or medical group's contract with Health Net, such as senior vice president, departmental managers or chief medical officer;
- Individuals directly involved with establishing and administering any administrative function, such as claims processing, credentialing or utilization management, and/or medical benefits coverage policies and procedures, on Health Net's behalf;
- Individuals involved with decision-making authority on behalf of Health Net, such as clinical decisions, coverage determinations, credentialing, or processing of medical claims;
- Reviewers of beneficiary claims and services submitted for payment; or
- Individuals with job functions that place the PPG, IPA and medical group in a position to commit significant noncompliance with CMS program requirements or health care FWA.
Delegated PPGs, IPAs, and medical groups that can provide evidence that they are deemed to have met the FWA training and education requirements due to their enrollment in Medicare Parts A or B, or have accreditation as a supplier of durable medical equipment, prosthetics, orthotics, and supplies (DME-POS), only need their employees to complete the CMS-developed general compliance training.
There are two options from which delegated PPGs, IPAs and medical groups can choose to fulfill these training requirements:
- Direct employees to complete the FWA and/or general compliance training modules through the CMS Medicare Learning Network website. Once an individual completes the training, the system generates a certificate of completion that the PPG, IPA or medical group, collects and tracks on an annual basis as indicated below under Training Attestation Record Maintenance Requirements.
- The PPG, IPA or medical group can download and incorporate the content of the CMS standardized training modules from the CMS Medicare Learning Network website into their organization's existing compliance training materials and systems. According to CMS, the training content cannot be modified; however, CMS allows modifications to the appearance of the content, such as font, color, background, and format, and allows organizations to augment the CMS training content by adding topics specific to their organization or the employee's job function.
The CMS Medicare Parts C and D General Compliance Training (January 2017) and the Combating Medicare Parts C and D Fraud, Waste, and Abuse Training (January 2017) are accessible through the CMS Medicare Learning Network website at:
Providers must create an account to access the training. To create an account, select the Create Account link. Once logged in, use the search engine to search for each training module. A certificate of completion is generated upon passing a short test with a score of 70 percent or higher at the end of each training module. CMS may update the training modules, so providers must ensure their employees take the most recent course provided by CMS.
Training Attestation Record Maintenance Requirements
By March 31 of each year, delegated PPGs, IPAs and medical groups are required to attest that all identified staff completed the FWA and general compliance training in the prior year. A parent PPG, IPA or medical group may submit one attestation on behalf of itself and its satellites by listing each satellite including the National Provider Identifier (NPI) or tax identification number (TIN) on the attestation. The attestation form may be sent to Health Net’s Provider Services Operations Department via:
- Fax at 1-800-828-7518
- Email to firstname.lastname@example.org
There is an option on the attestation to indicate whether a PPG meets the deeming requirement for FWA and which option was selected for how their employees accessed the CMS modules. Providers may access the attestation form and requirements in the Health Net Provider Library under Operations Manuals > Provider Oversight > Fraud, Waste and Abuse and General Compliance Training > Training and Attestation Requirements.
Delegated PPGs, IPAs and medical groups are accountable for maintaining FWA and general compliance training records for a period of 10 years. The type of training records may include certificates of completion, training logs, system generated reports, or spreadsheets. At a minimum, employee names, dates of employment, dates of training completion, and passing scores (if captured) must be included to clearly document training completion. Health Net routinely monitors for compliance with these requirements, and this information is subject to audit upon request from Health Net or CMS.
CMS FWA and General Compliance Requirements
The FWA and general compliance training requirements are based on the following CMS regulations and requirements:
- Title 42 Code of Federal Regulations (CFR) 422.503(b)(4)(vi)(C)(1)-(3), 423.504(b)(4)(vi)(C)(1)-(4)
- CMS Medicare Managed Care Manual, Chapter 21 – Compliance Program Guidelines, and Prescription Drug Benefit Manual Chapter 9 – Compliance Program Guidelines, Section 40: Sponsor Accountability for and Oversight of FDRs and Section 50.3: Element III: Effective Training and Education
CMS recently issued a requirement related to the settlement of the 2013 Jimmo v. Sebelius class action lawsuit. The settlement addresses the delivery of skilled nursing services to Medicare beneficiaries and applies to nursing facilities, home health, and outpatient therapy benefits when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration (provided all other coverage criteria are met).
All Medicare providers are required to review this training in order to ensure that services are provided and coverage determinations are adjudicated accurately and appropriately in accordance with existing Medicare policy.
The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage organizations (MAOs) to provide annual Special Needs Plans (SNP) Model of Care Annual training for all SNP participating providers (§422.102(f)(2)(ii)). In accordance with the regulations, Health Net has developed the SNP Model of Care Annual training. This requirement is applicable to SNP providers only.
CMS requires that SNP providers and appropriate staff (those involved in any aspect of the provision of SNP services) complete the SNP model of care annual training each year by December 31. The training can be provided in any of a variety of modalities, such as printed, face-to-face, Web-based, or audio and visual formats. SNP providers do not have to submit confirmation of training upon completion; however, providers are subject to audit by CMS and Health Net to demonstrate that the training was provided to appropriate staff. Therefore, providers must maintain training records, which may consist of a mailing list, fax list, sign-in sheet, or other formats. If you choose to use the model of care annual training that Health Net created, select SNP Model of Care Annual Training (pdf) to open the file and begin the training.