PAM Section 9: Compliance

On this page: 

• Overview
• Monitoring and Auditing First Tier, Downstream and Related Entities (FDR)
• Compliance Reporting

Overview

The Centers for Medicare & Medicaid Services (CMS) requires Medicare Advantage (MA) Organizations, such as Trinity Health Plan Of New England, to implement an effective compliance program that prevents, detects, and corrects Medicare Parts C and D program noncompliance, as well as fraud, waste, and abuse (FWA). The Trinity Health Plan Of New England Compliance Department serves as the hub for all internal and external compliance concerns, compliance reporting, and compliance training. The Trinity Health Plan Of New England Compliance Department also coordinates delegation oversight activities by business unit owners of first-tier, downstream and related entities (FDRs) that are delegated a Medicare Part C or D function.

Monitoring and Auditing First Tier, Downstream and Related Entities (FDR)

Trinity Health Plan Of New England may enter into contracts with FDRs to provide administrative or health care services to Medicare beneficiaries enrolled in the Plan, but Trinity Health Plan Of New England remains ultimately responsible for fulfilling the terms and conditions of its contract with CMS. Medicare program requirements apply to FDRs and Trinity Health Plan Of New England must monitor and audit FDRs to ensure compliance with all applicable federal and state laws, rules and regulations. FDRs that conduct their own audits should provide to the Trinity Health Plan Of New England Compliance Department a summary of the audit work plan and also the audit results that relate to the services the FDR performs for Trinity Health Plan Of New England. When FDR noncompliance with CMS regulations occurs, a Corrective Action Plan (CAP) will be requested by Trinity Health Plan Of New England. Onsite audits may be conducted by Trinity Health Plan Of New England when deemed appropriate by the Plan as the result of a risk assessment, tracking and trending member complaints related to access, service or care provided, or if the FDR’s performance falls below established metrics or other service levels.

Compliance Reporting

You can report compliance concerns, or fraud, waste, and abuse, related to Trinity Health Plan Of New England as follows:

1. Email: MediGoldCompliance@mchs.com.
2. If you prefer, you may make a report anonymously by:
   • Submitting a report online through our anonymous Special Investigations Unit form.
   • Calling our parent company’s (Trinity Health) anonymous Integrity Hotline at 1-866-477-4661. Indicate you want to make a report regarding Trinity Health Plan Of New England.