Downstream provider refers to a health care provider who is in charge of the provider or is responsible for providing services to members. All FDRs participating in Medicare Advantage must meet certain compliance requirements, including all your suppliers that are considered FDRs. As a service organization, non-compliance with your FDR can lead to a corrective action plan, conversion or even termination of your contract with the Medicare Advantage plan administrator. Downstream units are parties that enter into a written agreement acceptable by CMS with individuals or entities participating in the MA-Advantage or Part D performance below the level of agreement between an MAO or an applicant or sponsor or applicant of Part D and an initial level. These written agreements continue to the level of the ultimate provider of health and administrative services (cf. 42 C.F.R., 423.501). First Tier, Downstream und Related Entities (FDRs) are defined by CMS as any party that enters into a written agreement with a Medicare Advantage organization or a Part D sponsor for the provision of administrative or health care services. As a health care provider, this means that your providers can be considered FDRs and you can be responsible for supervising and verifying their compliance with CMS standards as a Medicare Advantage participant. inclusion of specific payment agreements and incentives in agreements with all downstream suppliers.

To facilitate the definition of these key concepts, CMS offers a glossary of essential concepts based on relevant terminology and discussion to understand the relationship between Medicare sponsors and contractors. In this post you will find keywords that help clarify the different agencies in the game. A Pharmacy Benefit Manager is an organization that provides pharmacy services, including contracting with a network of pharmacies; Setting payment levels for network pharmacies; Negotiating discount agreements the development and management of formulas, preferred drug lists and pre-authorization programs; Check the use of drugs and operating programs for disease management. Some sponsors perform these functions internally and do not use external entities such as PBM. Compliance and obligation for all downstream suppliers to comply with applicable government and federal laws and regulations, including Medicare laws and regulations and HCFA instructions. Related entities are any entity linked by a common ownership or control to an MAO or Part-D sponsor and have the following characteristics: With the increased demand for better data and an effective collection process, companies are looking to fill in the gaps with software solutions and data collection specialists. Our ProviderTrust team has developed a model with an innovative registration portal capable of managing supplier certification and FDR qualification. Qualified data experts help communicate with suppliers and get the job done efficiently and cost-effectively to ensure your business stays compliant and has the most up-to-date information! First-animal entities may be defined as a party that enters into a written agreement acceptable to the CMS, with a sponsor or applicant for an MAO or part D plan, administrative services or health care to a person entitled to Medicare under the MA program or part D program (see 42 C.F.R.