Code of Conduct


Part of HNE’s mission is to be a leading corporate citizen. This means that HNE, and all HNE associates and agents, are required to follow these three rules when conducting business on behalf of HNE:

• Act ethically and responsibly.
• Obey the law.

• If you learn that someone connected with HNE is breaking either of the first two rules, you have an obligation to report it.


It is Health New England’s (“HNE”) policy to conduct its business in compliance with all applicable federal and state laws and regulations and to assure that HNE operates in a manner consistent with the letter and the spirit of the laws. HNE expects its employees, management, governing body members and first tier, downstream and related entities (FDR’s) (“Covered Individuals” – refer to section E for definitions), to adhere to this Code of Conduct when conducting business on behalf of HNE and its subsidiaries.

A. Compliance with Laws, Regulations and Policies

All Covered Individuals must:

1. Operate in accordance with all applicable federal and state laws, regulations and Medicare and Medicaid program requirements including, but not limited to the following:
a. Title XVIII of the Social Security Act 
b. Medicare regulations governing Parts C and D (42 C.F.R. §§ 422 and 423 respectively)
c. Patient Protection and Affordable Care Act (Pub.L. No. 111-148)
d. Health Insurance Portability and Accountability Act (HIPAA)
e. False Claims Acts (31 U.S.C. §§ 3729-3733)
f. Federal Criminal False Claims Statutes (18 U.S.C. §§ 287,1001) 
   a. Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b))
   b. Fraud and Abuse, Privacy and Security Provisions of the Health Insurance Portability and Accountability Act, as modified by HITECH Act 
   c. The Beneficiary Inducement Statute (42 U.S.C. § 1320a-7a(a)
   d. Prohibitions against employing or contracting with persons or entities that have been excluded from doing    business with the Federal government 
   e. Fraud Enforcement and Recovery Act of 2009 
   f. All sub-regulatory guidance produced by Centers for Medicare & Medicaid Service (CMS) and HHS such as manuals, training materials, Health Plan Management System (HPMS) memos, and guides
  g. Other applicable criminal statutes
  h. Contractual commitments 

2. Operate in compliance with all HNE policies and procedures, including, but not limited to HNE’s:
a. Compliance Policies and Procedures
b. Privacy and Security Policies and Procedures
c. Fraud, Waste, and Abuse Prevention Policy

Copies of these policies are posted to the HNE intranet and are available in HNE’s document management system for internal use. Otherwise, they are available upon request as applicable. 

3. Avoid and report actual or apparent conflicts of interest, any sanctions or exclusions from government health care programs, or any personal interest or involvement that might be an actual or apparent conflict of interest. 
4. Not accept gifts, entertainment and/or other favors from any individual or company that does business with, is seeking to do business with or is a competitor of HNE. 
5. Protect confidential business information and individuals’ right to privacy in accordance with applicable laws, regulations and contract terms
6. Understand and comply with applicable fraud, waste & abuse (FWA) laws and regulations
7. Not submit false statements and/or claims to Federal and State funded programs.
8. Identify and return overpayments promptly in order to comply with the Fraud Enforcement and Recovery Act (FERA)
9. Complete compliance and FWA training upon hire and annually thereafter.
10. Act in accordance with equal employment and affirmative action by law by committing to a workplace environment that treats individuals with dignity and respect and is free of discrimination of all types, including abusive, offensive or harassing behavior.


B. Reporting and Investigation All Covered Individuals are required to:

1. Promptly report potential compliance or FWA issues of which they have knowledge or a good faith belief. This obligation to report applies even if the individual with the information is not in a position to solve the potential problem.  
2. Cooperate with all investigations of potential or actual violations. All reports will be taken seriously and, if warranted, investigated. HNE takes appropriate actions to mitigate any harmful effects and works to identify opportunities for improvement and corrective actions designed to correct any underlying problems.
3. Report in one of the following ways:
a. Call the HNE Compliance Hotline at (800) 453-3959 (available 24/7, toll-free; reports can be made anonymously)
b. Contact the HNE Compliance Officer, by phone, e-mail, interoffice, or in person
c. Contact the HNE Compliance for reports of Fraud, Waste or Abuse 
d. Contact the HNE Human Resource Manager, for reports of harassment or discrimination
e. Contact your supervisor or manager. Any supervisor or manager who receives a report of a compliance violation shall report the violation to the Compliance Program.

Potential fraud may also be reported directly to the Department of Health and Human Services (HHS) Office of Inspector General (OIG) Hotline.

Contacting the HHS OIG Hotline
Phone: (800) HHS-TIPS (800) 447-8477)
Fax: (800) 223-8164 

TTY: (800) 377-4950 
Mail: US Department of Health and Human Services
Office of Inspector General
P.O. Box 23489  Washington, DC 20026 

C. Confidentiality and Non-Retaliation 
HNE prohibits intimidation or retaliation against any Covered Individual for good faith reporting of potential or actual violations or for cooperating in any government or law enforcement authority’s investigation or prosecution. Reasonable efforts will be made to protect the confidentiality of those who are reporting. However, confidentiality cannot be guaranteed, and will not be possible in some circumstances. Compliance issues will only be discussed with persons with an absolute “need to know.” 

D. Disciplinary Guidelines:
HNE will impose disciplinary actions for violation of the HNE Code of Conduct, failure to report a violation, reporting of a violation in bad faith or for malicious reasons, or discouraging another Covered Individual from reporting a legitimate concern. Disciplinary actions will be imposed on a fair and equitable basis and consistently applied.

Disciplinary action will depend on all of the circumstances and may include, but is not limited to:

• Remedial education and training 
• Oral or written warnings 
• Suspensions
• Contract termination
• Financial penalties 
• Additional monitoring or supervision 
• Potential reporting of the conduct to law enforcement
• Discipline under HNE’s progressive discipline policy (refer to the HNE Associate Handbook) up to and including suspension or termination

HNE also reserves the right to immediately discipline, suspend, or terminate an employee who has knowingly and willfully violated the Code of Conduct, applicable laws or regulations, or HNE policies. This shall include termination of employees or agents that become subject to sanctions or exclusions for government health care programs as described in the HNE Fraud, Waste, and Abuse Prevention Policy. The HNE Human Resources Department will be responsible for documenting any sanctions that are applied and retaining such document for the appropriate retention period.

E. Definitions:

The term “Contractor” means any person or entity, both First Tier Entities and Downstream Entities, and other than a Participating Provider, who is contracted, on behalf of HNE, to carry out a function that HNE would otherwise perform. This includes but may not be limited to functions such as utilization review or authorization of benefit coverage, credentialing, claims processing, collection of premium payments, and enrollment and disenrollment of members. Examples include intermediaries, utilization management, or claims processing delegates, and credentialing verification organizations.

Downstream Entity: The term “Downstream Entity” means a subcontractor of a Contractor or Participating Provider that enters into a written arrangement, below the level of the arrangement between HNE and a First Tier Entity. These written arrangements continue down to the level of ultimate provider of administrative services or health care services. For example, a First Tier Contractor or Participating Provider may delegate to another party, activities or responsibilities related to the provision of administrative services or health care services. The party to whom the First Tier Contractor or Participating Provider delegates such activities or responsibilities is considered a Downstream Entity.

First Tier Entity: The term “First Tier Entity” means a Contractor or Participating Provider that enters into a direct written arrangement with HNE to provide administrative services or health care services. 

Participating Provider: The term “Participating Provider” means a health care practitioner who has elected to participate in and be bound by the terms of an HNE Provider Agreement to provide health care services to HNE members. A Participating Provider may be directly contracted with HNE as a First Tier Entity or subcontracted through a First Tier entity as a Downstream Entity.

Related Entity: The term “Related Entity” means any entity that is related to HNE by common ownership or control and: (1) performs some of the HNE’s management functions under contract or delegation; (2) furnishes services to Medicare enrollees under an oral or written agreement; or (3) leases real property or sells materials to HNE at a cost of more than $2,500 during a contract period.