ATTACHMENT A. The following list contains a representative (but not comprehensive) list of CMS information systems to which the Data Use Attestation applies. CMS will update the list periodically as necessary to reflect changes in the agency’s information systems Automated Plan Payment System (APPS) Common Medicare Environment (CME) Common Working File (CWF) Coordination of Benefits Contractor (COBC) Drug Data Processing System (DDPS) Electronic Correspondence Referral System (ECRS) Enrollment Database (EDB) Financial Accounting and Control System (FACS) Front End Risk Adjustment System (FERAS) Health Plan Management System (HPMS), including Complaints Tracking and all other modules HI Master Record (HIMR) Individuals Authorized Access to CMS Computer Services (IACS) Integrated User Interface (IUI) Medicare Advantage Prescription Drug System (XXXx) Medicare Appeals System (MAS) Medicare Beneficiary Database (MBD) Payment Reconciliation System (PRS) Premium Withholding System (PWS) Prescription Drug Event Front End System (PDFS) Retiree Drug System (RDS) Risk Adjustments Processing Systems (RAPS) Appendix G: Model File & Use Certification Form Pursuant to the Contract between the Centers for Medicare & Medicaid Services (CMS), the state of California, acting by and through the Department of Health Care Services (DHCS) and Plan hereafter referred to as the Contractor, governing the operations of the following health plan: , the Contractor hereby certifies that all qualified materials for the Demonstration is accurate, truthful and not misleading. Organizations using File & Use Certification agree to retract and revise any materials (without cost to the government) that are determined by CMS or DHCS to be misleading or inaccurate or that do not follow established Medicare Marketing Guidelines, Regulations, and sub-regulatory guidance. In addition, organizations may be held accountable for any beneficiary financial loss as a result of mistakes in marketing materials or for misleading information that results in uninformed decision by a beneficiary to elect the plan. Compliance criteria include, without limitation, the requirements in 42 C.F.R. §§422.2260 – 422.2276 and 42 C.F.R. §422.111 for Cal MediConnect and the Medicare Marketing Guidelines. I agree that CMS or DHCS may inspect any and all information including those held at the premises of the Contractor to ensure compliance with these requirements. I further agree to notify CMS and DHCS immediately if I become aware of any circumstances that indicate noncompliance with the requirements described above. I possess the requisite authority to make this certification on behalf of the Contractor. Appendix H: Medicare Xxxx License Agreement THIS AGREEMENT is made and entered into January 1, 2018 by and between THE CENTERS FOR MEDICARE & MEDICAID SERVICES (hereinafter “Licensor”), with offices located at 0000 Xxxxxxxx Xxxx., Xxxxxxxxx, XX 00000 and Plan (hereinafter “Licensee”), with offices located at . CMS Contract ID:
Appears in 1 contract
Samples: www.cms.gov
ATTACHMENT A. The following list contains a representative (but not comprehensive) list of CMS information systems to which the Data Use Attestation applies. CMS will update the list periodically as necessary to reflect changes in the agency’s information systems Automated Plan Payment System (APPS) Common Medicare Environment (CME) Common Working File (CWF) Coordination of Benefits Contractor (COBC) Drug Data Processing System (DDPS) Electronic Correspondence Referral System (ECRS) Enrollment Database (EDB) Financial Accounting and Control System (FACS) Front End Risk Adjustment System (FERAS) Health Plan Management System (HPMS), including Complaints Tracking and all other modules HI Master Record (HIMR) Individuals Authorized Access to CMS Computer Services (IACS) Integrated User Interface (IUI) Medicare Advantage Prescription Drug System (XXXx) Medicare Appeals System (MAS) Medicare Beneficiary Database (MBD) Payment Reconciliation System (PRS) Premium Withholding System (PWS) Prescription Drug Event Front End System (PDFS) Retiree Drug System (RDS) Risk Adjustments Processing Systems (RAPS) Appendix GThis document has been electronically signed by: Model File & Use Certification Form Pursuant Xxxxxx Xxxx Contracting Official Name 9/2/2010 Date Organization 0000 Xxxxxxxxx Xxxx TAMPA, FL 33634 Address SIGNATURE ATTESTATION Contract ID: ____________ Contract Name: ____________________ I understand that by signing and dating this form, I am acknowledging that I am an authorized representative of the above named organization and that I am the contracting official associated with the user ID used to log on to the Contract between Health Plan Management System (HPMS) to sign the Centers for 2011 Medicare & Medicaid Services (CMS), the state of California, acting by and through the Department of Health Care Services (DHCS) and Plan hereafter referred to as the Contractor, governing the operations of the following health plan: , the Contractor hereby certifies that all qualified materials for the Demonstration is accurate, truthful and not misleading. Organizations using File & Use Certification agree to retract and revise any materials (without cost to the government) that are determined by CMS or DHCS to be misleading or inaccurate or that do not follow established Medicare Marketing Guidelines, Regulations, and sub-regulatory guidance. In addition, organizations may be held accountable for any beneficiary financial loss as a result of mistakes in marketing materials or for misleading information that results in uninformed decision by a beneficiary to elect the plan. Compliance criteria include, without limitation, the requirements in 42 C.F.R. §§422.2260 – 422.2276 and 42 C.F.R. §422.111 for Cal MediConnect and the Medicare Marketing Guidelinescontracting documents. I agree also acknowledge that CMS or DHCS may inspect any and all information including those held at the premises of the Contractor to ensure compliance with these requirements. I further agree to notify CMS and DHCS immediately if I become aware of any circumstances that indicate noncompliance in accordance with the requirements described aboveHPMS Rules of Behavior, sharing user IDs is strictly prohibited. I possess the requisite authority to make this certification on behalf of the Contractor. Appendix HThis document has been electronically signed by: Medicare Xxxxxx Xxxx License Agreement THIS AGREEMENT is made and entered into January 1Contracting Official Name 9/2/2010 Date Organization 0000 Xxxxxxxxx Xxxx TAMPA, 2018 by and between THE CENTERS FOR MEDICARE & MEDICAID SERVICES (hereinafter “Licensor”), with offices located at 0000 Xxxxxxxx Xxxx., Xxxxxxxxx, XX 00000 and Plan (hereinafter “Licensee”), with offices located at . CMS Contract ID:FL 33634 Address
Appears in 1 contract
Samples: Wellcare Health Plans, Inc.
ATTACHMENT A. The following list contains a representative (but not comprehensive) list of CMS information systems to which the Data Use Attestation applies. CMS will update the list periodically as necessary to reflect changes in the agency’s information systems Automated Plan Payment System (APPS) Common Medicare Environment (CME) Common Working File (CWF) Coordination of Benefits Contractor ICDS Plan (COBC) Drug Data Processing System (DDPS) Electronic Correspondence Referral System (ECRS) Enrollment Database (EDB) Financial Accounting and Control System (FACS) Front End Risk Adjustment System (FERAS) Health Plan Management System (HPMS), including Complaints Tracking and all other modules HI Master Record (HIMR) Individuals Authorized Access to CMS Computer Services (IACS) Integrated User Interface (IUI) Medicare Advantage Prescription Drug System (XXXx) Medicare Appeals System (MAS) Medicare Beneficiary Database (MBD) Payment Reconciliation System (PRS) Premium Withholding System (PWS) Prescription Drug Event Front End System (PDFS) Retiree Drug System (RDS) Risk Adjustments Processing Systems (RAPS) Appendix G: F. Model File & Use Certification Form Form Pursuant to the Contract contract between the Centers for Medicare & Medicaid Services (CMS), the state State of CaliforniaOhio, acting by and through the Ohio Department of Health Care Services Medicaid (DHCS) ODM), and Plan (insert organization name), hereafter referred to as the ContractorICDS Plan, governing the operations of the following health plan: (insert health plan name and Contract number), the Contractor ICDS Plan hereby certifies that all qualified materials for the Demonstration is accurate, truthful and not misleading. Organizations using File & Use Certification agree to retract and revise any materials (without cost to the government) that are determined by CMS or DHCS ODM to be misleading or inaccurate or that do not follow established Medicare Marketing Guidelines, Regulations, and sub-regulatory guidance. In addition, organizations may be held accountable for any beneficiary financial loss as a result of mistakes in marketing materials or for misleading information that results in uninformed decision by a beneficiary to elect the plan. Compliance criteria include, without limitation, the requirements in 42 C.F.R. §§CFR § 422.2260 – § 422.2276 and 42 C.F.R. §CFR § 422.111 for Cal MediConnect the ICDS Plan and the Medicare Marketing Guidelines. I agree that CMS or DHCS ODM may inspect any and all information including those held at the premises of the Contractor ICDS Plan to ensure compliance with these requirements. I further agree to notify CMS and DHCS ODM immediately if I become aware of any circumstances that indicate noncompliance with the requirements described above. I possess the requisite authority to make this certification on behalf of the ContractorICDS Plan. Signature Name & Title <CEO, CFO, or designee able to legally bind the organization> On behalf of Name of ICDS Plan Date Appendix H: G. Medicare Xxxx Mark License Agreement Agreement THIS AGREEMENT is made and entered into January October 1, 2018 2017 by and between THE CENTERS FOR MEDICARE & MEDICAID SERVICES (hereinafter “Licensor”), with offices located at 0000 Xxxxxxxx Xxxx., Xxxxxxxxx, XX 00000 and Plan <<CONTRACT_NAME>> (hereinafter “Licensee”), with offices located at <<ADDRESS>>. CMS Contract ID:: <<CONTRACT_ID>>
Appears in 1 contract
Samples: www.cms.gov
ATTACHMENT A. The following list contains a representative (but not comprehensive) list of CMS information systems to which the Data Use Attestation applies. CMS will update the list periodically as necessary to reflect changes in the agency’s 's information systems Automated Plan Payment System (APPS) Common Medicare Environment (CME) Common Working File (CWF) Coordination of Benefits Contractor (COBC) Drug Data Processing System (DDPS) Electronic Correspondence Referral System (ECRS) Enrollment Database (EDB) Financial Accounting and Control System (FACS) Front End Risk Adjustment System (FERAS) Health Plan Management System (HPMS), including Complaints Tracking and all other modules HI Master Record (HIMR) Individuals Authorized Access to CMS Computer Services (IACS) Integrated User Interface (IUI) Medicare Advantage Prescription Drug System (XXXx) Medicare Appeals System (MAS) Medicare Beneficiary Database (MBD) Payment Reconciliation System (PRS) Premium Withholding System (PWS) Prescription Drug Event Front End System (PDFS) Retiree Drug System (RDS) Risk Adjustments Processing Systems (RAPS) Appendix GThis document has been electronically signed by: Model File & Use Certification Form Pursuant XXXXXX XXXX Contracting Official Name 8/29/2013 4:35:13 PM Date WELLCARE PRESCRIPTION INSURANCE, INC. Organization 0000 Xxxxxxxxx Xx, Renaissance 2 Tampa, FL 33634 Address S5967 SIGNATURE ATTESTATION Contract ID: S5967 Contract Name: WELLCARE PRESCRIPTION INSURANCE, INC. I understand that by signing and dating this form, I am acknowledging that I am an authorized representative of the above named organization and that I am the contracting official associated with the user ID used to log on to the Contract between Health Plan Management System (HPMS) to sign the 2014 Medicare contracting documents. I also acknowledge that in accordance with the HPMS Rule of Behavior, sharing user IDs is strictly prohibited. This document has been electronically signed by: XXXXXX XXXX Contracting Official Name 8/29/2013 4:35:13 PM Date WELLCARE PRESCRIPTION INSURANCE, INC. Organization 0000 Xxxxxxxxx Xx, Renaissance 2 Tampa, FL 33634 Address S5967 EMPLOYER/UNION-ONLY GROUP PART D ADDENDUM TO CONTRACT WITH APPROVED ENTITY PURSUANT TO SECTIONS 1860D-1 THROUGH 1860D-43 OF THE SOCIAL SECURITY ACT FOR THE OPERATION OF A VOLUNTARY MEDICARE PRESCRIPTION DRUG PLAN The Centers for Medicare & Medicaid Services (CMS), the state of California, acting by and through the Department of Health Care Services (DHCS) and Plan hereafter hereinafter referred to as "CMS") and WELLCARE PRESCRIPTION INSURANCE, INC., a Prescription Drug Plan (PDP) Sponsor (hereinafter referred to as "PDP Sponsor"), agree to amend the Contractorcontract S5967 governing PDP Sponsor's operation of one or more Voluntary Medicare Prescription Drug Plans, governing the operations pursuant to §§1860D-1 through 1860D-43 of the following health plan: Social Security Act (hereinafter referred to as "the Act"), to permit PDP Sponsor to offer employer-sponsored group prescription drug plans (as defined at 42 CFR 423.454) (hereinafter referred to in this Addendum as "employer/union-only group PDPs") in accordance with the Contractor hereby certifies that all qualified materials for the Demonstration is accurate, truthful and not misleading. Organizations using File & Use Certification agree to retract and revise any materials (without cost to the government) that are determined waivers granted by CMS or DHCS to be misleading or inaccurate or that do not follow established Medicare Marketing Guidelines, Regulations, and sub-regulatory guidance. In addition, organizations may be held accountable for any beneficiary financial loss as a result of mistakes in marketing materials or for misleading information that results in uninformed decision by a beneficiary to elect the plan. Compliance criteria include, without limitation, the requirements in 42 C.F.R. under §§422.2260 – 422.2276 and 1860D-22(b) of the Act. The terms of this Addendum shall only apply to employer/union-only group PDPs offered by PDP Sponsor exclusively to Part D eligible individuals enrolled in employment-based retiree health coverage (as defined at 42 C.F.R. CFR §422.111 for Cal MediConnect 423.882) under a contract between PDP Sponsor and the Medicare Marketing Guidelines. I agree that CMS or DHCS may inspect any and all information including those held at the premises employer/union sponsor of the Contractor to ensure compliance with these requirementsemployment-based retiree health coverage. I further agree to notify CMS and DHCS immediately if I become aware of any circumstances that indicate noncompliance with the requirements described above. I possess the requisite authority to make this certification on behalf of the Contractor. Appendix H: Medicare Xxxx License Agreement THIS AGREEMENT This Addendum is made and entered into January 1, 2018 by and between THE CENTERS FOR MEDICARE & MEDICAID SERVICES (hereinafter “Licensor”), with offices located at 0000 Xxxxxxxx Xxxx., Xxxxxxxxx, XX 00000 and Plan (hereinafter “Licensee”), with offices located at pursuant to Subpart K of 42 CFR Part 423. CMS Contract ID:S5967
Appears in 1 contract
Samples: Wellcare Health Plans, Inc.
ATTACHMENT A. The following list contains a representative (but not comprehensive) list of CMS information systems to which the Data Use Attestation applies. CMS will update the list periodically as necessary to reflect changes in the agency’s 's information systems Automated Plan Payment System (APPS) Common Medicare Environment (CME) Common Working File (CWF) Coordination of Benefits Contractor (COBC) Drug Data Processing System (DDPS) Electronic Correspondence Referral System (ECRS) Enrollment Database (EDB) Financial Accounting and Control System (FACS) Front End Risk Adjustment System (FERAS) Health Plan Management System (HPMS), including Complaints Tracking and all other modules HI Master Record (HIMR) Individuals Authorized Access to CMS Computer Services (IACS) Integrated User Interface (IUI) Medicare Advantage Prescription Drug System (XXXx) Medicare Appeals System (MAS) Medicare Beneficiary Database (MBD) Payment Reconciliation System (PRS) Premium Withholding System (PWS) Prescription Drug Event Front End System (PDFS) Retiree Drug System (RDS) Risk Adjustments Processing Systems (RAPS) Appendix GThis document has been electronically signed by: Model File & Use Certification Form Pursuant /s/ XXXXXX XXXX Contracting Official Name 8/29/2012 2:09:55 PM Date WELLCARE PRESCRIPTION INSURANCE, INC. Organization 0000 Xxxxxxxxx Xx, Renaissance 2 Tampa, FL 33634 Address SIGNATURE ATTESTATION Contract ID: S5967 Contract Name: WELLCARE PRESCRIPTION INSURANCE, INC. I understand that by signing and dating this form, I am acknowledging that I am an authorized representative of the above named organization and that I am the contracting official associated with the user ID used to log on to the Contract between Health Plan Management System (HPMS) to sign the 2013 Medicare contracting documents. I also acknowledge that in accordance with the HPMS Rule of Behavior, sharing user IDs is strictly prohibited. This document has been electronically signed by: /s/ XXXXXX XXXX Contracting Official Name Date WELLCARE PRESCRIPTION INSURANCE, INC. Organization 0000 Xxxxxxxxx Xx, Renaissance 2 Tampa, FL 33634 Address S5967 EMPLOYER/UNION-ONLY GROUP PART D ADDENDUM TO CONTRACT WITH APPROVED ENTITY PURSUANT TO SECTIONS 1860D-1 THROUGH 1860D-43 OF THE SOCIAL SECURITY ACT FOR THE OPERATION OF A VOLUNTARY MEDICARE PRESCRIPTION DRUG PLAN The Centers for Medicare & Medicaid Services (CMS), the state of California, acting by and through the Department of Health Care Services (DHCS) and Plan hereafter hereinafter referred to as "CMS") and WELLCARE PRESCRIPTION INSURANCE, INC., a Prescription Drug Plan (PDP) Sponsor (hereinafter referred to as "PDP Sponsor"), agree to amend the Contractorcontract S5967 governing PDP Sponsor's operation of one or more Voluntary Medicare Prescription Drug Plans, governing the operations pursuant to §§1860D-1 through 1860D-43 of the following health plan: Social Security Act (hereinafter referred to as "the Act"), to permit PDP Sponsor to offer employer-sponsored group prescription drug plans (as defined at 42 CFR 423.454) (hereinafter referred to in this Addendum as "employer/union-only group PDPs") in accordance with the Contractor hereby certifies that all qualified materials for the Demonstration is accurate, truthful and not misleading. Organizations using File & Use Certification agree to retract and revise any materials (without cost to the government) that are determined waivers granted by CMS or DHCS to be misleading or inaccurate or that do not follow established Medicare Marketing Guidelines, Regulations, and sub-regulatory guidance. In addition, organizations may be held accountable for any beneficiary financial loss as a result of mistakes in marketing materials or for misleading information that results in uninformed decision by a beneficiary to elect the plan. Compliance criteria include, without limitation, the requirements in 42 C.F.R. under §§422.2260 – 422.2276 and 1860D-22(b) of the Act. The terms of this Addendum shall only apply to employer/union-only group PDPs offered by PDP Sponsor exclusively to Part D eligible individuals enrolled in employment-based retiree health coverage (as defined at 42 C.F.R. CFR §422.111 for Cal MediConnect 423.882) under a contract between PDP Sponsor and the Medicare Marketing Guidelines. I agree that CMS or DHCS may inspect any and all information including those held at the premises employer/union sponsor of the Contractor to ensure compliance with these requirementsemployment-based retiree health coverage. I further agree to notify CMS and DHCS immediately if I become aware of any circumstances that indicate noncompliance with the requirements described above. I possess the requisite authority to make this certification on behalf of the Contractor. Appendix H: Medicare Xxxx License Agreement THIS AGREEMENT This Addendum is made and entered into January 1, 2018 by and between THE CENTERS FOR MEDICARE & MEDICAID SERVICES (hereinafter “Licensor”), with offices located at 0000 Xxxxxxxx Xxxxpursuant to Subpart K of 42 CFR Part 423., Xxxxxxxxx, XX 00000 and Plan (hereinafter “Licensee”), with offices located at . CMS Contract ID:
Appears in 1 contract
Samples: Signature Attestation (Wellcare Health Plans, Inc.)
ATTACHMENT A. The following list contains a representative (but not comprehensive) list of CMS and NYSDOH information systems to which the Data Use Attestation applies. CMS and NYSDOH will update the list periodically as necessary to reflect changes in the agencyCMS’ and NYSDOH’s information systems systems. Automated Plan Payment System (APPS) Common Medicare Environment (CME) Common Working File (CWF) Coordination of Benefits Contractor (COBC) Drug Data Processing System (DDPS) Electronic Correspondence Referral System (ECRS) Enrollment Database (EDB) Financial Accounting and Control System (FACS) Front End Risk Adjustment System (FERAS) Health Plan Management System (HPMS), including Complaints Tracking and all other modules HI Master Record (HIMR) Individuals Authorized Access to CMS Computer Services (IACS) Integrated User Interface (IUI) Medicare Advantage Prescription Drug System (XXXx) Medicare Appeals System (MAS) Medicare Beneficiary Database (MBD) Payment Reconciliation System (PRS) Premium Withholding System (PWS) Prescription Drug Event Front End System (PDFS) Retiree Drug System (RDS) Risk Adjustments Processing Systems (RAPS) Appendix Gand Any and all systems NYSDOH deems necessary including but not limited to WMS and MMIS. APPENDIX F: Model File MODEL FILE & Use Certification Form USE CERTIFICATION FORM Pursuant to the Contract contract between the Centers for Medicare & Medicaid Services (CMS), the state State of CaliforniaNew York, acting by and through the Department of Health Care Services New York State (DHCS) herein, NYSDOH), and Plan (<PLAN NAME>), hereafter referred to as the ContractorFIDA Plan, governing the operations of the following health plan: <PLAN NAME> (<PLAN CONTRACT ID>), the Contractor FIDA Plan hereby certifies that all qualified materials for the Demonstration is accurate, truthful and not misleading. Organizations using File & Use Certification agree to retract and revise any materials (without cost to the government) that are determined by CMS or DHCS the Department to be misleading or inaccurate or that do not follow established Medicare Marketing Guidelines, Regulations, and sub-regulatory guidance. In addition, organizations may be held accountable for any beneficiary financial loss as a result of mistakes in marketing materials or for misleading information that results in uninformed decision by a beneficiary to elect the plan. Compliance criteria include, without limitation, the requirements in 42 C.F.R. §§§ 422.2260 – § 422.2276 and 42 C.F.R. §§ 422.111 for Cal MediConnect Demonstration Plans and the Medicare Marketing Guidelines. I agree that CMS or DHCS the Department may inspect any and all information information, including those held at the premises of the Contractor FIDA Plan, to ensure compliance with these requirements. I further agree to notify CMS and DHCS New York immediately if I become aware of any circumstances that indicate noncompliance with the requirements described above. I possess the requisite authority to make this certification on behalf of the ContractorFIDA Plan. Appendix HAPPENDIX G: Medicare Xxxx License Agreement MEDICARE XXXX LICENSE AGREEMENT THIS AGREEMENT is made and entered into January 1, 2018 by and between THE CENTERS FOR MEDICARE & MEDICAID SERVICES (hereinafter “Licensor”), with offices located at 0000 Xxxxxxxx Xxxx., Xxxxxxxxx, XX 00000 and Plan <PLAN NAME>. (hereinafter “Licensee”), with offices located at <PLAN ADDRESS>. CMS Contract ID:: <PLAN CONTRACT ID>
Appears in 1 contract
Samples: License Agreement
ATTACHMENT A. The following list contains a representative (but not comprehensive) list of CMS information systems to which the Data Use Attestation applies. CMS will update the list periodically as necessary to reflect changes in the agency’s 's information systems Automated Plan Payment System (APPS) Common Medicare Environment (CME) Common Working File (CWF) Coordination of Benefits Contractor (COBC) Drug Data Processing System (DDPS) Electronic Correspondence Referral System (ECRS) Enrollment Database (EDB) Financial Accounting and Control System (FACS) Front End Risk Adjustment System (FERAS) Health Plan Management System (HPMS), including Complaints Tracking and all other modules HI Master Record (HIMR) Individuals Authorized Access to CMS Computer Services (IACS) Integrated User Interface (IUI) Medicare Advantage Prescription Drug System (XXXx) Medicare Appeals System (MAS) Medicare Beneficiary Database (MBD) Payment Reconciliation System (PRS) Premium Withholding System (PWS) Prescription Drug Event Front End System (PDFS) Retiree Drug System (RDS) Risk Adjustments Processing Systems (RAPS) Appendix GThis document has been electronically signed by: Model File & Use Certification Form Pursuant /s/ XXXXXX XXXX Contracting Official Name 8/28/2014 2:13:35 PM Date WELLCARE OF FLORIDA, INC. Organization 0000 Xxxxxxxxx Xxxx TAMPA, FL 33634 Address H1032 SIGNATURE ATTESTATION Contract ID: H1032 Contract Name: WELLCARE OF FLORIDA, INC I understand that by signing and dating this form, I am acknowledging that I am an authorized representative of the above named organization and that I am the contracting official associated with the user ID used to log on to the Contract between Health Plan Management System (HPMS) to sign the Centers for 2015 Medicare & Medicaid Services (CMS), the state of California, acting by and through the Department of Health Care Services (DHCS) and Plan hereafter referred to as the Contractor, governing the operations of the following health plan: , the Contractor hereby certifies that all qualified materials for the Demonstration is accurate, truthful and not misleading. Organizations using File & Use Certification agree to retract and revise any materials (without cost to the government) that are determined by CMS or DHCS to be misleading or inaccurate or that do not follow established Medicare Marketing Guidelines, Regulations, and sub-regulatory guidance. In addition, organizations may be held accountable for any beneficiary financial loss as a result of mistakes in marketing materials or for misleading information that results in uninformed decision by a beneficiary to elect the plan. Compliance criteria include, without limitation, the requirements in 42 C.F.R. §§422.2260 – 422.2276 and 42 C.F.R. §422.111 for Cal MediConnect and the Medicare Marketing Guidelinescontracting documents. I agree also acknowledge that CMS or DHCS may inspect any and all information including those held at the premises of the Contractor to ensure compliance with these requirements. I further agree to notify CMS and DHCS immediately if I become aware of any circumstances that indicate noncompliance in accordance with the requirements described aboveHPMS Rule of Behavior, sharing user IDs is strictly prohibited. I possess the requisite authority to make this certification on behalf of the ContractorThis document has been electronically signed by: /s/ XXXXXX XXXX Contracting Official Name 8/28/2014 2:13:35 PM Date WELLCARE OF FLORIDA, INC. Appendix H: Medicare Organization 0000 Xxxxxxxxx Xxxx License Agreement THIS AGREEMENT is made and entered into January 1TAMPA, 2018 by and between THE CENTERS FOR MEDICARE & MEDICAID SERVICES (hereinafter “Licensor”), with offices located at 0000 Xxxxxxxx Xxxx., Xxxxxxxxx, XX 00000 and Plan (hereinafter “Licensee”), with offices located at . CMS Contract ID:FL 33634 Address
Appears in 1 contract
Samples: Wellcare Health Plans, Inc.
ATTACHMENT A. The following list contains a representative (but not comprehensive) list of CMS information systems to which the Data Use Attestation applies. CMS will update the list periodically as necessary to reflect changes in the agency’s 's information systems Automated Plan Payment System (APPS) Common Medicare Environment (CME) Common Working File (CWF) Coordination of Benefits Contractor (COBC) Drug Data Processing System (DDPS) Electronic Correspondence Referral System (ECRS) Enrollment Database (EDB) Financial Accounting and Control System (FACS) Front End Risk Adjustment System (FERAS) Health Plan Management System (HPMS), including Complaints Tracking and all other modules HI Master Record (HIMR) Individuals Authorized Access to CMS Computer Services (IACS) Integrated User Interface (IUI) Medicare Advantage Prescription Drug System (XXXx) Medicare Appeals System (MAS) Medicare Beneficiary Database (MBD) Payment Reconciliation System (PRS) Premium Withholding System (PWS) Prescription Drug Event Front End System (PDFS) Retiree Drug System (RDS) Risk Adjustments Processing Systems (RAPS) Appendix GThis document has been electronically signed by: Model File & Use Certification Form Pursuant /s/ XXXXXX XXXX Contracting Official Name 8/29/2012 Date [ ] Organization [ ] Address SIGNATURE ATTESTATION Contract ID: [_____] Contract Name: [___________] I understand that by signing and dating this form, I am acknowledging that I am an authorized representative of the above named organization and that I am the contracting official associated with the user ID used to log on to the Contract between Health Plan Management System (HPMS) to sign the Centers for 2013 Medicare & Medicaid Services (CMS), the state of California, acting by and through the Department of Health Care Services (DHCS) and Plan hereafter referred to as the Contractor, governing the operations of the following health plan: , the Contractor hereby certifies that all qualified materials for the Demonstration is accurate, truthful and not misleading. Organizations using File & Use Certification agree to retract and revise any materials (without cost to the government) that are determined by CMS or DHCS to be misleading or inaccurate or that do not follow established Medicare Marketing Guidelines, Regulations, and sub-regulatory guidance. In addition, organizations may be held accountable for any beneficiary financial loss as a result of mistakes in marketing materials or for misleading information that results in uninformed decision by a beneficiary to elect the plan. Compliance criteria include, without limitation, the requirements in 42 C.F.R. §§422.2260 – 422.2276 and 42 C.F.R. §422.111 for Cal MediConnect and the Medicare Marketing Guidelinescontracting documents. I agree also acknowledge that CMS or DHCS may inspect any and all information including those held at the premises of the Contractor to ensure compliance with these requirements. I further agree to notify CMS and DHCS immediately if I become aware of any circumstances that indicate noncompliance in accordance with the requirements described aboveHPMS Rule of Behavior, sharing user IDs is strictly prohibited. I possess the requisite authority to make this certification on behalf of the Contractor. Appendix HThis document has been electronically signed by: Medicare Xxxx License Agreement THIS AGREEMENT is made and entered into January 1, 2018 by and between THE CENTERS FOR MEDICARE & MEDICAID SERVICES (hereinafter “Licensor”), with offices located at 0000 Xxxxxxxx Xxxx., Xxxxxxxxx, XX 00000 and Plan (hereinafter “Licensee”), with offices located at . CMS Contract ID:/s/ XXXXXX XXXX Contracting Official Name 8/29/2012 Date [ ] Organization [ ] Address
Appears in 1 contract
Samples: Wellcare Health Plans, Inc.
ATTACHMENT A. The following list contains a representative (but not comprehensive) list of CMS information systems to which the Data Use Attestation applies. CMS will update the list periodically as necessary to reflect changes in the agency’s agencys information systems Automated Plan Payment System (APPS) Common Medicare Environment (CME) Common Working File (CWF) Coordination of Benefits Contractor (COBC) Drug Data Processing System (DDPS) Electronic Correspondence Referral System (ECRS) Enrollment Database (EDB) Financial Accounting and Control System (FACS) Front End Risk Adjustment System (FERAS) Health Plan Management System (HPMS), including Complaints Tracking and all other modules HI Master Record (HIMR) Individuals Authorized Access to CMS Computer Services (IACS) Integrated User Interface (IUI) Medicare Advantage Prescription Drug System (XXXx) Medicare Appeals System (MAS) Medicare Beneficiary Database (MBD) Payment Reconciliation System (PRS) Premium Withholding System (PWS) Prescription Drug Event Front End System (PDFS) Retiree Drug System (RDS) Risk Adjustments Processing Systems (RAPS) Appendix GS5967 This document has been electronically signed by: Model File & Use Certification Form Pursuant Xxxxxx Xxxx Contracting Official Name 8/31/2010 11:16:53 AM Date WELLCARE PRESCRIPTION INSURANCE, INC. Organization 0000 Xxxxxxxxx Xx, Renaissance 2 Tampa, FL 33634 Address S5967 SIGNATURE ATTESTATION Contract ID: S5967 Contract Name: WELLCARE PRESCRIPTION INSURANCE, INC. I understand that by signing and dating this form, I am acknowledging that I am an authorized representative of the above named organization and that I am the contracting official associated with the user ID used to log on to the Contract between Health Plan Management System (HPMS) to sign the Centers for 2011 Medicare & Medicaid Services (CMS), the state of California, acting by and through the Department of Health Care Services (DHCS) and Plan hereafter referred to as the Contractor, governing the operations of the following health plan: , the Contractor hereby certifies that all qualified materials for the Demonstration is accurate, truthful and not misleading. Organizations using File & Use Certification agree to retract and revise any materials (without cost to the government) that are determined by CMS or DHCS to be misleading or inaccurate or that do not follow established Medicare Marketing Guidelines, Regulations, and sub-regulatory guidance. In addition, organizations may be held accountable for any beneficiary financial loss as a result of mistakes in marketing materials or for misleading information that results in uninformed decision by a beneficiary to elect the plan. Compliance criteria include, without limitation, the requirements in 42 C.F.R. §§422.2260 – 422.2276 and 42 C.F.R. §422.111 for Cal MediConnect and the Medicare Marketing Guidelinescontracting documents. I agree also acknowledge that CMS or DHCS may inspect any and all information including those held at the premises of the Contractor to ensure compliance with these requirements. I further agree to notify CMS and DHCS immediately if I become aware of any circumstances that indicate noncompliance in accordance with the requirements described aboveHPMS Rules of Behavior, sharing user IDs is strictly prohibited. I possess the requisite authority to make this certification on behalf of the ContractorThis document has been electronically signed by: Xxxxxx Xxxx Contracting Official Name 8/31/2010 11:16:53 AM Date WELLCARE PRESCRIPTION INSURANCE, INC. Appendix H: Medicare Xxxx License Agreement THIS AGREEMENT is made and entered into January 1Organization 0000 Xxxxxxxxx Xx, 2018 by and between THE CENTERS FOR MEDICARE & MEDICAID SERVICES (hereinafter “Licensor”)Renaissance 2 Tampa, with offices located at 0000 Xxxxxxxx Xxxx., Xxxxxxxxx, XX 00000 and Plan (hereinafter “Licensee”), with offices located at . CMS Contract ID:FL 33634 Address
Appears in 1 contract
Samples: Wellcare Health Plans, Inc.
ATTACHMENT A. The following list contains a representative (but not comprehensive) list of CMS information systems to which the Data Use Attestation applies. CMS will update the list periodically as necessary to reflect changes in the agency’s agencys information systems Automated Plan Payment System (APPS) Common Medicare Environment (CME) Common Working File (CWF) Coordination of Benefits Contractor (COBC) Drug Data Processing System (DDPS) Electronic Correspondence Referral System (ECRS) Enrollment Database (EDB) Financial Accounting and Control System (FACS) Front End Risk Adjustment System (FERAS) Health Plan Management System (HPMS), including Complaints Tracking and all other modules HI Master Record (HIMR) Individuals Authorized Access to CMS Computer Services (IACS) Integrated User Interface (IUI) Medicare Advantage Prescription Drug System (XXXx) Medicare Appeals System (MAS) Medicare Beneficiary Database (MBD) Payment Reconciliation System (PRS) Premium Withholding System (PWS) Prescription Drug Event Front End System (PDFS) Retiree Drug System (RDS) Risk Adjustments Processing Systems (RAPS) Appendix GThis document has been electronically signed by: Model File & Use Certification Form Pursuant XXXXXX XXXX Contracting Official Name 9/1/2011 Date [ ] Organization 0000 Xxxxxxxxx Xx Ren 1 Tampa, FL 33634 Address SIGNATURE ATTESTATION Contract ID: _______ Contract Name: ______________________ I understand that by signing and dating this form, I am acknowledging that I am an authorized representative of the above named organization and that I am the contracting official associated with the user ID used to log on to the Contract between Health Plan Management System (HPMS) to sign the Centers for 2012 Medicare & Medicaid Services (CMS), the state of California, acting by and through the Department of Health Care Services (DHCS) and Plan hereafter referred to as the Contractor, governing the operations of the following health plan: , the Contractor hereby certifies that all qualified materials for the Demonstration is accurate, truthful and not misleading. Organizations using File & Use Certification agree to retract and revise any materials (without cost to the government) that are determined by CMS or DHCS to be misleading or inaccurate or that do not follow established Medicare Marketing Guidelines, Regulations, and sub-regulatory guidance. In addition, organizations may be held accountable for any beneficiary financial loss as a result of mistakes in marketing materials or for misleading information that results in uninformed decision by a beneficiary to elect the plan. Compliance criteria include, without limitation, the requirements in 42 C.F.R. §§422.2260 – 422.2276 and 42 C.F.R. §422.111 for Cal MediConnect and the Medicare Marketing Guidelinescontracting documents. I agree also acknowledge that CMS or DHCS may inspect any and all information including those held at the premises of the Contractor to ensure compliance with these requirements. I further agree to notify CMS and DHCS immediately if I become aware of any circumstances that indicate noncompliance in accordance with the requirements described aboveHPMS Rule of Behavior, sharing user IDs is strictly prohibited. I possess the requisite authority to make this certification on behalf of the Contractor. Appendix HThis document has been electronically signed by: Medicare Xxxx License Agreement THIS AGREEMENT is made and entered into January 1XXXXXX XXXX Contracting Official Name 9/1/2011 Date [ ] Organization 0000 Xxxxxxxxx Xx Ren 1 Tampa, 2018 by and between THE CENTERS FOR MEDICARE & MEDICAID SERVICES (hereinafter “Licensor”), with offices located at 0000 Xxxxxxxx Xxxx., Xxxxxxxxx, XX 00000 and Plan (hereinafter “Licensee”), with offices located at . CMS Contract ID:FL 33634 Address
Appears in 1 contract
Samples: Wellcare Health Plans, Inc.
ATTACHMENT A. The following list contains a representative (but not comprehensive) list of CMS information systems to which the Data Use Attestation applies. CMS will update the list periodically as necessary to reflect changes in the agency’s 's information systems Automated Plan Payment System (APPS) Common Medicare Environment (CME) Common Working File (CWF) Coordination of Benefits Contractor (COBC) Drug Data Processing System (DDPS) Electronic Correspondence Referral System (ECRS) Enrollment Database (EDB) Financial Accounting and Control System (FACS) Front End Risk Adjustment System (FERAS) Health Plan Management System (HPMS), including Complaints Tracking and all other modules HI Master Record (HIMR) Individuals Authorized Access to CMS Computer Services (IACS) Integrated User Interface (IUI) Medicare Advantage Prescription Drug System (XXXx) Medicare Appeals System (MAS) Medicare Beneficiary Database (MBD) Payment Reconciliation System (PRS) Premium Withholding System (PWS) Prescription Drug Event Front End System (PDFS) Retiree Drug System (RDS) Risk Adjustments Processing Systems (RAPS) Appendix GThis document has been electronically signed by: Model File & Use Certification Form Pursuant XXXXXX XXXX Contracting Official Name 8/29/2013 4:20:05 PM Date WELLCARE OF FLORIDA, INC. Organization 0000 Xxxxxxxxx Xxxx TAMPA, FL 33634 Address H1032 SIGNATURE ATTESTATION Contract ID: H1032 Contract Name: WELLCARE OF FLORIDA, INC I understand that by signing and dating this form, I am acknowledging that I am an authorized representative of the above named organization and that I am the contracting official associated with the user ID used to log on to the Contract between Health Plan Management System (HPMS) to sign the Centers for 2014 Medicare & Medicaid Services (CMS), the state of California, acting by and through the Department of Health Care Services (DHCS) and Plan hereafter referred to as the Contractor, governing the operations of the following health plan: , the Contractor hereby certifies that all qualified materials for the Demonstration is accurate, truthful and not misleading. Organizations using File & Use Certification agree to retract and revise any materials (without cost to the government) that are determined by CMS or DHCS to be misleading or inaccurate or that do not follow established Medicare Marketing Guidelines, Regulations, and sub-regulatory guidance. In addition, organizations may be held accountable for any beneficiary financial loss as a result of mistakes in marketing materials or for misleading information that results in uninformed decision by a beneficiary to elect the plan. Compliance criteria include, without limitation, the requirements in 42 C.F.R. §§422.2260 – 422.2276 and 42 C.F.R. §422.111 for Cal MediConnect and the Medicare Marketing Guidelinescontracting documents. I agree also acknowledge that CMS or DHCS may inspect any and all information including those held at the premises of the Contractor to ensure compliance with these requirements. I further agree to notify CMS and DHCS immediately if I become aware of any circumstances that indicate noncompliance in accordance with the requirements described aboveHPMS Rule of Behavior, sharing user IDs is strictly prohibited. I possess the requisite authority to make this certification on behalf of the ContractorThis document has been electronically signed by: XXXXXX XXXX Contracting Official Name 8/29/2013 4:20:05 PM Date WELLCARE OF FLORIDA, INC. Appendix H: Medicare Organization 0000 Xxxxxxxxx Xxxx License Agreement THIS AGREEMENT is made and entered into January 1TAMPA, 2018 by and between THE CENTERS FOR MEDICARE & MEDICAID SERVICES (hereinafter “Licensor”), with offices located at 0000 Xxxxxxxx Xxxx., Xxxxxxxxx, XX 00000 and Plan (hereinafter “Licensee”), with offices located at . CMS Contract ID:FL 33634 Address
Appears in 1 contract
Samples: Wellcare Health Plans, Inc.
