FDR Compliance Resources

Welcome to the Compliance Resource Center for the Central California Alliance for Health's (the Alliance’s) contracted First Tier, Downstream, and Related Entities (FDRs). This page provides critical information and tools to help you meet your compliance obligations under CMS requirements.

At the Alliance, we are committed to conducting business with honesty, integrity, and accountability. Our Compliance Program is designed to support a culture of ethical conduct and regulatory excellence. Through this program, we aim to:

• Reinforce our organization-wide commitment to upholding the highest standards of compliance and ethical behavior
• Prevent, detect, and correct fraud, waste, and abuse (FWA)
• Ensure full compliance with all applicable laws, regulations, and CMS requirements
• We expect all First Tier, Downstream, and Related Entities (FDRs) to share this commitment as essential partners in delivering high-quality care to our Medicare members.

Working with Our First Tier, Downstream, and Related Entities (FDRs)

If your organization performs administrative or health care service functions on behalf of the Alliance’s Medicare Advantage program, you are considered an FDR. This classification applies whether you contract directly with the Alliance or are part of a delegated arrangement through another entity. As an FDR, you play an important role in supporting our compliance with Medicare program requirements and are expected to meet all applicable regulatory obligations.

First Tier, Downstream, and Related Entities are defined by CMS as follows:

First Tier Entity is any party that enters into a written agreement, acceptable to CMS, with an MA Organization or Part D plan sponsor or applicant to provide administrative services or healthcare services to a Medicare eligible individual under the MA program or Part D program.

Downstream Entity is any party that enters into a written agreement, acceptable to CMS, with persons or entities involved with MA benefit or Part D benefit, below the level of the arrangement between an MA organization or applicant or a Part D plan sponsor or applicant and a first tier entity. These written arrangements continue down to the level of the ultimate provider of both health and administrative services

Related Entity means any entity that is related to the MA or Part D sponsor by common ownership or control and:

1. Performs some of the MA organization or Part D plan sponsor’s management functions under contract or delegation; or
2. Furnishes services to Medicare enrollees under an oral or written agreement; or
3. Leases real property or sells material to the MA organization or Part D plan sponsor at a cost of more than $2,500 during a contract period.

These definitions are established in 42 CFR §§ 422.500 and 423.501 and further clarified in Chapter 9 (Part D) and Chapter 21 (Part C) of the Medicare Managed Care Manual.

Designation of a Compliance Officer

As part of our ongoing commitment to compliance and ethical conduct, the Alliance has designated a Compliance Officer who is responsible for overseeing our Compliance Program and ensuring adherence to all applicable state and Federal regulations. If you have any questions, concerns, or would like to report a potential compliance issue, you may contact our Compliance Officer directly:

• Jenifer Mandella
  Chief Compliance Officer, Central California Alliance for Health (“the Alliance”)
  Mailing Address:
  Central California Alliance for Health
  1600 Green Hills Road
  Scotts Valley, CA  95066

You may also report issues anonymously on the Alliance website: Report Compliance and Fraud, Waste and Abuse Concerns