Please provide the information on ownership and control listed below in accordance with section 2930 of the Medicare Intermediary Manual and Section 5250 of the Carriers Manual.
DEFINITIONS
“Ownership Interest” or “Investment Interest” means an ownership or investment interest of 5 percent or greater of the total value of the entity.
“Subcontractor” is an organization with which the contractor has entered into any contract, agreement, purchase order or lease (including leases of real property) to obtain space, supplies, equipment, or services under the Medicare agreement.
“Responsible Employee” is one who makes significant decisions affecting Medicare program payments or the awarding of subcontracts involving Medicare funds or any employee identified by the contractor as one whose ownership or investment interests could create a conflict of interest.
“Officers, Directors and Responsible Employees” includes spouses, dependent children and any other family members who reside with an officer, director or responsible employee.
A. Ownership and Control Information
1. The names of the officers and directors of the contractor.
2. The names of persons, including corporate entities, that have ownership interest in the contractor, including persons with an ownership interest in any mortgage, deed of trust, note or other obligation secured by the contractor if such interest equals at least 5 percent of the total value of the contractor's property or assets. For those persons who have an ownership interest of 5 percent or more state the actual percentage of ownership by such person.
3. The names of any contractor officers, directors or responsible employees who are also either an officer, director, or have an ownership interest in an entity which submits claims to the Medicare program, including, but not limited to, a participating
provider of services, an independent clinical laboratory, a renal disease facility or a Health Maintenance Organization. For each officer, director or responsible employee who has such an ownership interest, state the name of the entity and the actual percentage of ownership for each entity identified.
4. The names of any contractor officers, directors or responsible employees who are also an officer, director or who have an ownership interest in any subcontractor. For each subcontractor identified in this section, state the name of such subcontractor and, if applicable, the actual percentage of ownership.
5. The name of any subcontractors in which the contractor has an ownership interest. For each subcontractor identified, state the actual percentage of ownership.
B. Conflict of Interest Data
1. The name of those officers, directors and responsible employees who have received any gift in excess of $50 in value, any payment and/or entertainment (other than common business courtesies which are reasonable in nature and cost) from people or companies doing business with the contractor involving Medicare funds. For each person identified, list the item received and its value.
2. The names of those officers, directors and responsible employees who have outside employment in organizations or entities receiving Medicare funds. For each person identified, state the name of the employer and the position held in the organization or entity.
3. Provide a certification by the compliance officer or equivalent official that the contractor's officers and employees are familiar with the standards of conduct or guidelines for employee conduct and that they have not engaged in any activities contrary to such standards or guidelines. The certification should be in the format set forth in Attachment A.
For each responsible employee named in Section A or B above, set forth the basis for identifying the employee as a “responsible employee.”
Provide a sample of the form or questionnaire that was used in obtaining conflict of interest information from officers, directors and responsible employees. Any form or questionnaire submitted by an individual to a contractor must contain a certification that the information submitted is complete and accurate to the best of the submitting person’s knowledge. The actual completed forms should be maintained by the contractor and be made available to CMS at its request.
C. Contractor Ownership and Investment Information
1. The names of all entities or organizations, including, but not limited to physician groups, independent clinical laboratories and renal disease facilities that receive reimbursement from the Medicare program, in which the contractor has an ownership interest or investment interest. For each entity or organization identified, state the actual percentage of ownership or investment interest.
2. The names of any entities or organizations identified under paragraph C.1 above that submit Medicare claims to the contractor for payment.
3. The names of all health maintenance organizations (HMO) in which the contractor has an ownership interest or investment interest. Indicate whether each HMO currently has a contract with CMS and, if so, what type of contract.
4. The names of all subcontractors in which the contractor has an ownership interest or investment interest. For each subcontractor identified, state the actual percentage of ownership or investment interest.
5. The names of all billing services, electronic media claims subsidiaries, clearinghouses for crossover claims, Medical management staffing organizations, and similar entities or organizations which are, in any way, involved in the handling, processing or preparation of Medicare claims in which the contractor has an ownership interest or investment interest. For each entity or organization identified, state the actual percentage of ownership or investment interest.
6. Identify all investment interests in any entity that exist through equity, debt, loans, other financial instruments or any other financial activity that might be considered a conflict of interest.
Certification of the Contractor’s Submitting Official
The contractor’s submitting official, who is at least the senior executive in charge of the contractor’s Medicare operation, certifies as follows:
OMB 0938-0795
SUBMITTING OFFICIAL CERTIFICATION
I, , herby certify that:
1. I am the (title) and supervise the Medicare operations of ;
I have reviewed the information submitted to me in the Conflict of Interest and Ownership and Control Information questionnaire report (COI Report); and
Based upon my knowledge and belief, the information set forth in COI Report does not contain any untrue statement of a material fact or omit to state a material fact necessary in order to make the statements made, in light of the circumstances under which such statements were made, not misleading.
Dated: By:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0795. The time required to complete this information collection is estimated to average 300 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
CMS-R-312 (exp. 09/30/2007)
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0795. The time required to complete this information collection is estimated to average 300 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
CMS-R-312 (exp. 09/30/2007)
OMB 0938-0795
ATTACHMENT A
COMPLIANCE OFFICER CERTIFICATION
I, , herby certify that I am the compliance officer or equivalent official of , a Medicare contractor; that the officers, directors and employees of the company are familiar with the company’s standards of business and ethical conduct or guidelines for employee behavior; and that to the best of my knowledge and belief the officers, directors and employees of the company have not engaged in any activities contrary to such business and ethical standards or guidelines, other than what has been previously reported to the government.
Date: By:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0795. The time required to complete this information collection is estimated to average 300 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
CMS-R-312 (exp. 09/30/2007)
| File Type | application/msword |
| File Title | DATE: |
| Author | HCFA Software Control |
| Last Modified By | CMS |
| File Modified | 2007-07-20 |
| File Created | 2007-07-20 |