VBP QIP MCO Contract List Attestation

Submission Guidelines

• Attestation is also available in Portable Document Format (PDF)

Each Facility participating in the Value Based Purchasing Quality Improvement Program (VBP QIP) is expected to provide an updated MCO Contract List with calendar year 2016 Medicaid Managed Care revenue and VBP arrangement information outlining a plan to meet the 80% VBP contracting target. The MCO Contract List must be accompanied by a signed attestation confirming the accuracy of the data provided by the Facility. Said attestation must be signed by an authorized senior financial manager at the Facility.

Attestation submission:

1. June 30, 2017 deadline:
   • Attestation must be submitted together with the updated MCO Contract List.

VBP QIP Facilities must submit this attestation to the NYS DOH for record keeping together with the MCO Contract List, sent to: vbp_qip@health.ny.gov with "VBP QIP – MCO Contract List and Attestation" in the subject line.

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Attestation

I, _____(Name)________________, employed by ______(Facility Name) ___________, as ________(Title)___________, hereby attest that the calendar year 2016 data provided in the Facility´s MCO Contract List to the Department of Health as part of the VBP QIP, has been reviewed and is deemed accurate.

Date                                    _______________________________

Authorizing Signature:     _______________________________