Provider Compliance Program Attestation

If you answer YES to any of the following questions, you are required to have an effective compliance program in New York State.

1. Is your organization subject to Article 28 or Article 36 of the NYS Public Health Law (PBH)?
2. Is your organization subject to Article 16 or Article 31 of the NYS Mental Hygiene Law?
3. Notwithstanding the provisions of § 4414 of the NYS PBH, is your organization a managed care provider, as defined in SOS § 364-j, which includes managed long-term care plans?
4. Does your organization claim —and/or can be reasonably expected to claim—Medicaid services or supplies of at least $1,000,000 in any consecutive 12-month period?
5. Does your organization receive Medicaid payments—and/or can be reasonably expected to receive payments—either directly or indirectly, of at least $1,000,000 in any consecutive 12-month period? Indirect Medicaid reimbursement is any payment that you receive for the delivery of Medicaid care, services, or supplies that comes from a source other than the State of New York. For example, if you provide covered services to a Medicaid beneficiary who is enrolled in a Medicaid Managed Care Plan, the payment you receive from the Managed Care Organization is considered an indirect payment.

Sign Attestation
By signing this attestation, the signatory attests that he/she has the authority to sign on behalf of the Contractor. Further, the signatory attests that the Contractor has adopted and implemented, where applicable, an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Codes, Rules and Regulations Part 521.

If you answer No to the above questions, please check the box below and fill in the information below.