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CMS Pub. 100-16, ch. 21, § 50.1.3

Distribution of Compliance Policies and Procedures and

activein force · 2026-08-25 – presentas-observed

Standards of Conduct

(Chapter 21 - Rev. 109, Issued: 07-27-12, Effective: 07-20-12; Implementation: 07- 20-12)

(Chapter 9 - Rev. 15, Issued: 07-27-12, Effective: 07-20-12; Implementation: 07-20- 12)

42 C.F.R. §§ 422.503(b)(4)(vi)(A), 423.504(b)(4)(vi)(A)

In order to be effective, compliance policies and procedures and Standards of Conduct

must be distributed to employees who support the sponsor’s Medicare business.

Distribution must occur within 90 days of hire, when there are updates to the policies,

and annually thereafter. Sponsors may choose their distribution method. Some examples

are furnishing hard copies at the time of hire and electronic copies thereafter, emailing an

electronic copy, or posting on the company intranet. The sponsors should have a method

to demonstrate that the Standards of Conduct and policies and procedures were

distributed to employees.

The Standards of Conduct should be written in a format that is easy to read and

comprehend. Sponsors should consider translating Standards of Conduct and policies

and procedures into other languages as necessary.

In order to communicate the sponsor’s compliance expectations for FDRs, sponsors

should ensure that Standards of Conduct and policies and procedures are distributed to

FDRs’ employees. Sponsors may make their Standards of Conduct and policies and

procedures available to their FDRs. Alternatively, the sponsor may ensure that the FDR

has comparable policies and procedures and Standards of Conduct of their own.

The sponsors should have a method to demonstrate that Standards of Conduct and

policies and procedures were distributed to FDRs’ employees. Sponsors or the FDR may

make the policies available through methods such as a fax blast, placement on an FDR

portal, in contract materials, etc. A best practice is to include appropriate contract

provisions in the FDR contract, coupled with periodic monitoring of a sample of FDRs

based on risk assessment, including a review of the FDRs’ compliance policies and

procedures and Standards of Conduct.

History

(Chapter 21 - Rev. 109, Issued: 07-27-12, Effective: 07-20-12; Implementation: 07- 20-12)

Provenance

Source
cms.gov
Retrieved
2026-08-25
Edition
iom-2026-08-25
Content hash
f383ae001a00a67b2f69c9bd659c69d0ec7dbd88fbc16280ef83f475aac17cf9
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