LIBERTY Dental Plan Provider Compliance Attestation

By signing below, I certify that I am an authorized representative of the below referenced Organization, and I attest, on behalf of the Organization, its Locations, Providers, and Staff, that the following representations are true, based upon current information and reasonable belief:

The Organization ensures that all employees and other personnel (including dentists and office staff) who support LIBERTY Dental Plan’s (“LIBERTY”) business complete the following LIBERTY trainings, or comparable trainings (as required by CMS, state regulators, and/or contractual requirements), within 30 days of hire or contract, and annually thereafter.

1. LDP and CMS General Compliance & Fraud, Waste, and Abuse Trainings;
2. Cultural Competency, CLAS, Section 1557 & Critical Incident Trainings;
3. HIPAA (Privacy & Security) Compliance Training;
4. Model of Care Training; and
5. Other State and/or Health Plan Required Trainings

The Organization has received and distributes LIBERTY’s Code of Conduct (or comparable) to all its employees and other personnel (including dentists and office staff) who support LIBERTY’s business within 30 days of hire or contract, and annually thereafter. To access LIBERTY’s Code of Conduct, visit www.libertydentalplan.com under Providers, and Providers Resource Library.

*Note: LIBERTY is required to communicate, through dissemination of LIBERTY’s Code of Conduct, its commitment to conducting business in an ethical manner, and consistent with governing law and program requirements. LIBERTY will also accept the dissemination of Organization’s comparable Code of Conduct to fulfill this requirement.

The Organization maintains supporting documentation for a period of ten (10) years after training completion, and Code of Conduct dissemination, for all its employees and other personnel (including dentists and office staff) supporting LIBERTY business and can furnish such documentation upon request.

The Organization agrees to notify LIBERTY immediately upon discovery of any fraud, waste, and abuse, non-compliance, or any suspected violations to HIPAA, HITECH Act, or any other statute, regulation, and/or policy and procedure; and may do so by contacting LIBERTY’s Compliance Department by email at compliancehotline@libertydentalplan.com, through LIBERTY’s confidential Compliance Hotline at 888-704-9833, available 24 hours a day, 7 days a week, or online at www.libertydentalplan.com under About LIBERTY, Compliance, and Report Compliance Concerns.

I have reviewed the directory information listed for the offices and providers affiliated with the organization(s) listed below and attest that it is true and accurate as of the date of my signature below.

*If multiple TINs are affiliated with the Organization and Authorized Signer listed above, please include all TINs separated by commas in the Organization Tax Identification (TIN) Number field. Example: 121234567, 1398765643

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