Thank you for taking the Renaissance Life & Health Insurance Company of America (Renaissance), Fraud, Waste and Abuse and Cultural Competency Trainings. Please review the attestations below and submit the following information in order to complete your submission.
PLEASE NOTE: Please use the full nine-digit Tax Identification Number (TIN) registered with Renaissance. We require the business TIN to be able to appropriately document your required submission.
When you submit this form, it will not automatically collect your details like name and email address unless you provide it yourself.
ANNUAL COMPLIANCE ATTESTATIONS
By completing this attestation, you certify that you and your organization are committed to ensuring compliance with TennCare, CMS and Renaissance contract requirements. As used in this Attestation, a Downstream Entity is an individual or entity with whom you or your organization contracts and who is involved in the benefits provided to Medicaid members. You attest to the following:
- Fraud, Waste, and Abuse (FWA) Training and Cultural Competency Training
All employees (including temporary employees and volunteers), board members, contractors, and providers involved in the delivery of Medicaid benefits at this organization have completed the Fraud, Waste, and Abuse Training and Nondiscrimination and Cultural Competency Training.
- Compliance Program
My organization and I will maintain a compliance program appropriate for the size of my organization to ensure compliance with federal and state laws and regulations and Renaissance’s provider manual, policies, and procedures. I agree to deliver services in a culturally competent manner that is free from discrimination to all members, including those with limited English proficiency and diverse cultural and ethnic backgrounds. I agree to provide physical access, reasonable accommodations, and accessible equipment for Medicaid members with physical or mental disabilities.
- Exclusion Screening
Neither my organization nor I am on the Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE), TennCare Terminated Provider List, and the General Services Administration (GSA) List. If I am ever placed on any of these lists, I will immediately notify Renaissance.
- Reporting Mechanisms
My organization informs employees how to report suspected or detected non-compliance or potential Fraud, Waste, or Abuse for internal review and investigation. My organization does not allow retaliation or intimidation against anyone who reports a concern in good faith, and my organization reports any applicable incidents to Renaissance as they occur.
- Record Retention
My organization maintains records for a minimum of 10 years to adequately document compliance with Renaissance’s contract.
- Offshore Operations
My organization does not engage in offshore operations of any administrative or health care services related to Medicaid business.
- Operational Oversight
My organization conducts internal oversight of the services that we perform for Renaissance’s Medicaid members to ensure that compliance is maintained with applicable laws, rules, and regulations including TennCare and CMS regulatory/sub-regulatory guidance.
- Nondiscrimination and Cultural Competency My organization will ensure that patients will receive effective, understandable, and respectful care that is free from discrimination. I will provide (or contact Renaissance for assistance to provide) language assistance services at no extra charge to the patients – this includes interpretation and translation.
- Downstream Entity Oversight (Applicable only if your organization uses Downstream Entities)
My organization either doesn’t use Downstream Entities or uses Downstream Entities for Renaissance Medicaid business and conducts oversight to ensure that they abide by all laws, rules, and regulations that apply.
- Safeguard of Protected Health Information – My Organization shall safeguard information about members according to applicable state and federal laws including, but not limited to, Health Insurance Portability and Accountability Act of 1996, 42 CFR § 431 Subpart F, §438 Subpart E, and all applicable Tennessee statutes and TennCare rules and regulations.
