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Medicare Advantage FDR Compliance Program

Harvard Pilgrim has implemented a comprehensive Medicare Compliance Program designed to ensure Harvard Pilgrim’s compliance with applicable laws, rules and regulations; help reduce or eliminate fraud, waste, and abuse; and reinforce Harvard Pilgrim’s commitment to compliance.

Our Medicare Compliance Program addresses important topics such as:

  • Standards of Conduct and Compliance Policies & Procedures
  • Compliance Officer and Compliance Committee
  • Training and education
  • Monitoring and auditing
  • How to report compliance issues
  • How we look into and resolve compliance issues

First Tier, Downstream, and Related Entities, commonly known as FDRs, are expected to comply with all Centers for Medicare & Medicaid Services (CMS) regulatory requirements for functions delegated to them by Harvard Pilgrim. You have been directed to this website because you have contracted with Harvard Pilgrim to provide administrative or health care services for our Medicare Advantage Stride members. You, therefore, are a “First Tier Entity”, defined by CMS as “any party that enters into a written arrangement with Harvard Pilgrim to provide administrative or health care services for Medicare-eligible individuals.”

As a first-tier entity, you must comply with the Medicare Compliance Program requirements set by the Code of Federal Regulations and further detailed by the CMS in:

Harvard Pilgrim is required to effectively manage and oversee its FDRs which assist us in providing administrative and/or healthcare services to our Medicare members. Examples of FDRs include, but are not limited to physicians, hospitals, sales agents/brokers, pharmacy benefit managers, claim administration, fulfillment vendors, and other entities who help us deliver benefits.

The documents and links below provide a summary of Harvard Pilgrim’s Medicare Compliance Program and to assist you, your organization, and any downstream entity for which you contract in complying with CMS requirements and Harvard Pilgrim policies.

Thank you for your partnership with Harvard Pilgrim to help us provide exceptional service to our Medicare members.

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Standards of Conduct
Harvard Pilgrim maintains a corporate-wide Code of Conduct that outlines the values and standards that guide our business practices and day-to-day actions. As part of our comprehensive Medicare Compliance Program, we have created Medicare Standards of Conduct to assist FDRs in understanding how Harvard Pilgrim does business and to outline your responsibilities as a business partner that provides services to Harvard Pilgrim and/or our members. Please review our Standards of Conduct for First Tier, Downstream and Related Entities (Standards) and share it with the appropriate employees. You may to choose to adopt our Standards should you not have your own.

As per CMS requirements, you must distribute the Standards to employees within 90 days of hire/contracting and annually thereafter. Copies of your Standards and proof of distribution must be made available for audit upon request by Harvard Pilgrim or CMS.

Please note that these Standards are not intended to replace provisions contained in any agreement you have with Harvard Pilgrim and/or its subsidiaries. In the event of any inconsistency between these Standards and the terms of your agreement with Harvard Pilgrim and/or its subsidiaries, the terms of the agreement shall prevail.

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Annual Compliance Training

Effective January 1, 2016, FDRs must ensure its employees complete certain CMS training to meet General Compliance and FWA training requirements. (Note: If you have met the fraud, waste, and abuse certification requirements through enrollment into the Original Medicare program, you do not have to take FWA training, but you must still complete compliance training).

CMS’ Medicare Parts C & D General Compliance Training is available through its Medicare Learning Network and will help you learn:

  • How a compliance program operates
  • How compliance program violations should be reported

CMS’ Combating Medicare Parts C & D Fraud, Waste and Abuse Training is also available through its Medicare Learning Network and will help you learn about:

  • The major laws and regulations pertaining to FWA
  • Potential consequences and penalties associated with violations
  • Methods of preventing FWA
  • How to report FWA
  • FWA in the Medicare program
  • How to correct FWA

As per CMS requirements, General Compliance and Fraud, Waste, and Abuse training is required within 90 days of hire/contracting and annually thereafter for all FDR employees who are assigned to perform work for Harvard Pilgrim’s Medicare product. Please retain proof of completion. Copies of your completed training attendance logs must be made available for audit upon request by Harvard Pilgrim or CMS.

Instructions to complete the training online via CMS’ Medicare Learning Network

Document downloads:

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Office of Inspector General (OIG) & General Services Administration’s System for Award Management (SAM) exclusion lists
All FDRs must review the exclusion databases listed below prior to hire and monthly thereafter for current employees, officers & directors, board members, subcontractors, consultants and vendors, as applicable. Please note that exclusion logs that include employee name, date each database was checked, and whether or not an exclusion was found must be made available for review, upon request by Harvard Pilgrim or CMS.

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Reporting Potential Compliance and/or FWA Issues
Laws, regulations and organizational policies can be complex. While Harvard Pilgrim expects that its FDRs try to do what is right, the right thing may not always be clear. To avoid confusion and facilitate compliant behavior, all FDRs are expected to promptly report any good faith belief of a violation of the state and/or federal laws and regulations that govern Harvard Pilgrim’s business. To ask a question or report a concern you can contact:

Contact Harvard Pilgrim’s Medicare Compliance Officer:

  • Through e-mail: Compliance_Programs@harvardpilgrim.org
  • By telephone: 617-509-1411
  • By fax: 617-509-7531
  • By US mail: Taline Avakian, Medicare Compliance Officer

    Harvard Pilgrim Health Care
    93 Worcester Street
    Wellesley, MA 02181
  • Contact the Compliance Hotline 24 hours a day/7 days a week at 1-877-548-6712 (anonymous reporting is available)
  • Contact Harvard Pilgrim’s Special Investigations Unit (SIU) at 617-509-1029

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Medicare Member Appeals and/or Grievances
Members who indicate dissatisfaction to you or your employee regarding any aspect of their experience must be immediately directed to Harvard Pilgrim. If you are dealing directly with our members and receive a grievance and/or appeal request, you must send the member's name, member ID, date, time of contact and description of issue to Harvard Pilgrim:



Mailing Address



Harvard Pilgrim Health Care
Appeals & Grievances
PO Box 690545
Quincy, MA 02269

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Compliance Program Attestation
Harvard Pilgrim requires that you review the requirements referenced within its Medicare Standards of Conduct for First Tier, Downstream and Related Entities and confirm that your organization has internal processes in place to support your compliance with all of the referenced requirements.

An authorized representative from your organization is required to complete the Compliance Program Attestation on an annual basis to attest to your organization’s awareness, completion and compliance with these Medicare Compliance Program requirements. Instructions for the return of the attestation are found on the last page of the document.

For monitoring and auditing purposes, Harvard Pilgrim or CMS may request that you provide evidence of your compliance with any of the referenced requirements. And, Harvard Pilgrim may require corrective action if you fail to comply with either Medicare Program or Harvard Pilgrim’s Compliance Program requirements.

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Y0098_17134 Approved
Last Update 05/16/2017

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Key Resources

Medicare Advantage Provider Portal

Medicare Advantage Provider Portal Registration Form

Quick Reference Guide

Stride (HMO) Medicare Advantage Prior Authorization and Referral Chart

Prior Authorization Request Forms

Referral Form

Claim Review Form

Claims Appeal Form

Claim Overpayment Refund Form

Medicare Compliance Program

Pharmacy Management Utilization Criteria

Step Therapy Requirements

Prior Authorization Requirements

Medicare Advantage Provider Service Center:
8:30 a.m. to 5 p.m.

To mail Medicare claims:
Harvard Pilgrim Health Care, Inc.
c/o Stride Claims Processing
P.O. Box 151288
Tampa, FL 33684-1288

Claims appeal:
Medicare Advantage Provider Appeals
P.O. Box 690546
Quincy, MA 02169