This section provides education, important links and resources to guide delegated entities for our organization through compliance program requirements.
The Centers for Medicare and Medicaid Services (CMS) and federal and state regulators take protection of their consumers seriously, and they pass that responsibility to our organization when we are acting in their capacity as a CMS contractor or plan sponsor. CMS and state regulators hold our organization directly accountable for delegate activities and performance.
Information for all delegated entities working on behalf of our organization.
As part of an effective compliance program, the Centers for Medicare and Medicaid Services (CMS) and other federal and state regulators require that UnitedHealth Group and its affiliate organizations (collectively, our organization) communicate and monitor specific compliance and fraud, waste and abuse (FWA) requirements to our employees and delegated entities (delegates) – including first tier, downstream, and related entities (FDRs). In the event of a CMS, federal or state audit, our organization must demonstrate that we evaluate our delegates’ compliance with program requirements, including effective monitoring and oversight of such delegates.
Our organization uses the terms: delegates; delegated entities; vendor; first-tier, downstream entity and related entity (FDR); subcontractor; and, occasionally, others interchangeably to name the parties with whom we contract with to support administration of benefits, access to care and other services performed on our behalf.
Definitions within the Medicaid program may vary by state requirement, but generally will be consistent with the definition of a delegated entity as an individual or entity that has a contract with an MCO, PIHP, PAHP, or PCCM entity’s obligations under its contract with the state.
While the entities our organization oversees may be broader, the definitions below apply to entities to which the QHP issuer has delegated the performance of one or more of its activities or obligations under the FFM QHP Issuer Standards set forth in 45 CFR 156.340(a):
If a delegate submits or stores FFE data, the delegate must comply with the following CMS requirements: