First tier, downstream or related entity (FDR)

Refer to Section 40, Sponsor Accountability for and Oversight of FDRs Medicare Managed Care Manual, Chapter 21 Compliance Program Guidelines (PDF). This section explains the Centers for Medicare & Medicaid Services (CMS) expectations of oversight and accountability responsibilities when Mercy Care has delegated administrative or health care service functions under our Medicare Advantage plan contract.

The FDR compliance packet and attestation (PDF) explains the Medicare compliance program requirements that apply to those who perform services for our Medicare Advantage plan contract:

• First tier delegates

• Downstream entities

• Individual employees

Under a plan management services agreement with Aetna®, Mercy Care uses the CVS Health Code of Conduct (PDF) to comply with the Medicare compliance program requirements. Contracted FDRs must supply all employees and downstream entities who provide administrative and/or health care services for our Medicare Advantage plan with one of these: 

• The CVS Health code of conduct and our Medicare compliance policies  

• Your own comparable code of conduct/compliance policies (collectively, “standards of conduct”)  

The Mercy Care Advantage compliance program and policies are designed to conduct monitoring and oversight to prevent, detect and correct: 

• Medicare Part C and D program noncompliance  

• Fraud, waste and abuse (FWA) 

Contracted FDRs and sub-contractors must: 

• Maintain an effective compliance program that includes standards of conduct as well as specific policies and procedures that implement the operations of the compliance program 

• Have processes in place to prevent, detect and correct identified noncompliance and fraud, waste and abuse (FWA), which includes required disclosure 

• Abide by federal laws related to the Medicare program as well as CMS rules, regulations and sub-regulatory guidance 

Please review our Medicare compliance program (PDF) to help your organization understand the elements required by CMS for an effective compliance program. You may also email email Wendy Jones to request a copy of our Mercy Care Advantage compliance policies.  

Medicare Advantage compliance policies available by request 

• Effective lines of communication 

• Disciplinary action and enforcement 

• Compliance training and education 

• Compliance monitoring and auditing 

• Maintenance and record retention 

• Deficit reduction act and false claims act compliance 

• Federal disaster or public health emergency declarations 

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