Affinity Health Plan

  • HR Banner
  • Vendor, Supplier, and Other Business Partner Compliance

    Affinity's vendors, suppliers, and other business partners who are either interested in or currently doing business with Affinity Health Plan must utilize the Affinity Health Plan Supplier Registration Portal to register their company profile as part of Affinity's compliance requirements. Please note that registration via this portal should not be considered as a guarantee of business. Click here to visit the Affinity Health Plan Supplier Registration Portal.

    Vendor, Supplier, and Other Business Partner Compliance Requirements

    Within the Affinity Health Plan Supplier Registration Portal, current and potential business partners are given access to download and review our Purchasing Vendor Guidelines and Code of Ethics.  Affinity's Code of Ethics is the standards of conduct for Affinity employees, board members, providers, vendors, and business partners. 

    Affinity requires our business partners to conduct business directly or indirectly related to Affinity in a compliant, ethical, and legal manner. As such, our business partners must annually attest through the Affinity Health Plan Supplier Registration Portal that they have reviewed, understood, and agreed to abide by Affinity's Purchasing Vendor Guidelines and Code of Ethics.  Additionally, vendors must actively monitor the activities of employees (paid or unpaid, regardless of position, including volunteers and interns) and contractors performing Affinity-related business.

    Business partners who perform or will be performing administrative services or health care services to a Medicare eligible individual on Affinity's behalf must annually attest to the requirements set forth by the Centers for Medicare and Medicaid Services (CMS) in 42 CFR § 422.503 and 42 CFR § 423.504.  A business partner who meets this CMS standard is known as a First Tier, Downstream or Related Entity (FDR).  A summary of additional FDR requirements are outlined below:

    • Adopt and distribute a code of conduct as well as compliance policies and procedures to employees (paid or unpaid, including volunteers and interns) and contractors within 90 days of hire or contract and annually thereafter.
    • Distribute annual compliance and fraud, waste, and abuse (FWA) training to employees (paid or unpaid, including volunteers and interns) and contractors within 90 days of hire or contract and annually thereafter. The approved general compliance and FWA training is available through the CMS Medicare Learning Network website.
    • Conduct exclusion screening prior to hire or contract, and monthly thereafter, to confirm employees and contractors are not excluded to participate in Federally funded health care programs according to the OIG-HHS and SAM exclusion lists.
    • Disclose current/changes to ownership and controlling interest, including any debarment or suspension status and any criminal convictions related to Federal health care programs of managing employees and anyone with an ownership or controlling interest in the organization or a related entity. All requests for disclosure of ownership, controlling interest, business transactions, or related information made by Affinity or a governmental agency must be fulfilled within 35 days of the date of a request. 
    • Report actual or potential fraud, waste, and abuse (FWA) and compliance concerns, suspected violations of applicable fraud laws and regulations, including the False Claims Act, as it relates to Affinity.

    Note that all other business partners must maintain information relating to Affinity's business, including evidence of training, for a period of ten (10) years and provide information upon request by Affinity, an Affinity representative, or an authorized party (e.g., the government) for monitoring and auditing purposes. All business partners must cooperate with audits or investigations being conducted by Affinity, a party designated by Affinity, and a law enforcement, regulatory, or oversight agency.

    Definitions of First Tier, Downstream, and Related Entity

    Affinity's business partners considered an FDR include hospitals, providers, ancillaries, and a portion of our suppliers and vendors.  Below is a list of administrative or health care services examples that qualify a vendor as an FDR:

    • Sales and marketing
    • Utilization management
    • Quality improvement
    • Applications processing
    • Enrollment, disenrollment, membership functions
    • Claims administration, processing and coverage adjudication
    • Appeals and grievances
    • Licensing and credentialing
    • Pharmacy benefit management
    • Hotline operations
    • Customer service
    • Bid preparation
    • Outbound enrollment verification
    • Provider network management
    • Processing of pharmacy claims at the point of sale
    • Negotiation with prescription drug manufacturers and others for rebates, discounts or other price concessions on prescription drugs
    • Administration and tracking of enrollees' drug benefits, including true out-of-pocket (TrOOP) balance processing
    • Coordination with other benefit programs such as Medicaid, state pharmaceutical assistance or other insurance programs
    • Entities that generate claims data
    • Health care services

    First Tier Entity is defined as any party that enters into a written arrangement, acceptable to CMS, with a Medicare Advantage Organizations (MAO) or Part D plan sponsor or applicant to provide administrative services or health care services to a Medicare eligible individual under the Medicare Advantage program or Part D program.

    Downstream Entity is defined as any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the Medicare Advantage (MA) benefit or Part D benefit, below the level of the arrangement between an MAO or applicant or a Part D plan sponsor or applicant and a first tier entity. These written arrangements continue down to the level of the ultimate provider of both health and administrative services.

    Related Entity is defined as any entity that is related to an MAO or Part D sponsor by common ownership or control and (1) Performs some of the MAO or Part D plan sponsor's management functions under contract or delegation; (2) Furnishes services to Medicare enrollees under an oral or written agreement; or (3) Leases real property or sells materials to the MAO or Part D plan sponsor at a cost of more than $2,500 during a contract period.

    Summary of Vendor, Supplier, and Other Business Partner Compliance Steps

    • Log into and complete the registration process within the Affinity Health Plan Supplier Registration Portal.
    • Keep a copy of information relating to Affinity's business, including training materials and other compliance-related documentation for audit purposes. 
    • At least annually, or more frequent when changes occur, review and update the information within the portal.
    • Continue to operate in a compliant matter.

    Vendor, Supplier, and Other Business Partner Compliance Resources

    Sanction Screening resources: