J.7-Conflict_of_Interest.docx

Attachment J.7 – Conflict of Interest Certificate

RFP-CMS-MIDS-2013-0001

(Insert Offeror/Company Name) understands and unconditionally assents to the requirements of the Statement of Work entitled Compliance Program (section C.X.X.XX) and attests that it has in place an effective compliance program that articulates and demonstrates the Offeror’s commitment to ethical and legal conduct. Specifically, the (Insert Offeror/Company Name) attests to the compliance program and compliance-related requirements in the table below.

Compliance Program Requirements

1. (Insert Offeror/Company Name) has a written code of conduct and written compliance policies and procedures, and includes compliance as an element of performance plans.

2. (Insert Offeror/Company Name) has a [Medicare] compliance officer and [Medicare] compliance committee.

3. (Insert Offeror/Company Name) conducts employee training and education program on compliance and conflict of interest issues annually (or more frequent basis).

4. (Insert Offeror/Company Name) has a process to receive ethics and compliance-related complaints that permits anonymous reporting.

5. (Insert Offeror/Company Name) has an internal monitoring and auditing function to help ensure compliance with the requirements of statutes, regulations, and the [Medicare] contracts.

6. (Insert Offeror/Company Name) has an enforcement and disciplinary process to address violations of the contract provisions, code of conduct, and/or federal and state statutes and regulations.

7. (Insert Offeror/Company Name) has processes to conduct investigations of compliance-related complaints, and to prevent compliance-related problems from developing; moreover, Offeror attests that no known suspended, debarred, or excluded person or entity will participate in the [Medicare] Program and/or [MAC] contract.

8. (Insert Offeror/Company Name) has disclosed all known, probable, or suspected [reportable] events to CMS [(see H.21 – Reportable Events)] on completed and current CMS contracts that require(d) the reporting of such events, in accordance with the terms and conditions of the respective contract(s) that included such a reporting requirement.

9. (Insert Offeror/Company Name) has disclosed, in an addendum to this attestation, any and all known criminal or civil investigations or proceedings against the Offeror (whether under the False Claims Act, Civil Monetary Penalty statutes, or other similar authorities), any and all known qui tam lawsuits against the Offeror, and any and all known administrative misconduct of the Offeror, within the past ten (10) years. For this purpose, the term “Offeror” means the Offeror and any parent or affiliate of the Offeror whose conduct may be attributed to the Offeror. If the Offeror has nothing to disclose under this heading, state as much in the attached addendum.

(Insert Offeror/Company Name) agrees that this Attestation and the attached addendum will become a part of the organization’s proposal. As an individual with authority to bind the (Insert Offeror/Company Name), I accept responsibility for this written document.