HomeMy WebLinkAboutSpecialty Health Code of ConductC900-059 (Last reviewed: December 2018) 2019 ASH Code of Conduct and Ethics Program 1
C900-059 (Last reviewed: December 2018) 2019 ASH Code of Conduct and Ethics Program 2
CHAPTER ONE |Personal Responsibilities ...........................................................5
•Our Leaders Serve as Role Models
•We Support the Critical Roles of Management
•We Obey the Law
•We Respect the Individual
CHAPTER TWO |Workplace Responsibilities .......................................................9
•We Live Our Values
•We Promote Diversity
•We Provide a Safe Workplace
•We Create a Positive Environment
•We Respect Each Other's Privacy
•We Safeguard American Specialty Health (ASH)'s Property
•We Protect the Privacy of Our Members
•We Protect the Confidentiality of Proprietary Information
•Remember These Rules When You Handle Confidential Information
CHAPTER THREE |Marketplace and Global Responsibilities ...........................13
•We Are Careful About Accepting Gifts
•We Require Ethical Behavior From Our Outside Consultants
and Contracted Service Providers
•We Conduct Business Openly and Honestly
•We Safeguard the Property of Others
•We Refer Contacts From Government Representatives to Regulatory Compliance
•We Refer All Inquiries From Government Officials to Regulatory Compliance
•We Refer All Inquiries From the News Media to Marketing
•We Protect the Environment
•We Prevent and Report Issues of Suspected Fraud, Waste, and Abuse
CHAPTER FOUR |Resources for Complying With the Code of
Conduct and Ethics Program..................................................................................19
•Our Personal and Corporate Responsibility
•Our Ethics and Integrity Committee
•Role of Our Management Team
•Non-Compliance
•Contact List
•Attestation to Adhere to ASH’s Code of Conduct and Ethics Program
•Appendix A: Laws and Regulations
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Message from the Chairman & CEO
Here at American Specialty Health, our success has largely been
achieved by diligently abiding by principles of integrity and ethics.
These fundamental business practices are an integral part of who we
are and the way we work. Not only does our Code of Conduct and
Ethics Program help us to achieve our corporate mission and values, it
establishes a foundation of trust with our clients, our networks, and the
tens of millions of members we serve.
As a symbol of our commitment to ethical practices, we have created
this Program. Please review it now and whenever you feel it may be
necessary. The Program provides details that will help you apply our values and outlines
standards for behavior in specific situations, while giving you practical guidance. I believe it is
necessary to publish this information for two reasons: first and foremost, we must adhere to
applicable law, and the standards outlined here will help us do so. Compliance with these
standards is mandatory and violations will result in serious consequences, up to and including
termination of employment. But in a more general sense, I believe that this Program will be a
welcome source of information to help us all function at our best in an often complex work
environment.
Our Code of Conduct and Ethics Program is meant to serve as a guide and does not cover
every possible ethical or legal circumstance. Please use your own wisdom, discretion, and
sound judgment when it comes to questionable situations, and be sure to seek guidance when
appropriate. It takes years to build a reputation that people can trust, and that reputation can be
destroyed in a heartbeat, as some companies—once highly respected—have unfortunately
learned. It is satisfying to know that you are all committed to preserving and enhancing our
integrity and reputation by adhering to the guidelines herein.
ASH Purpose
To improve clinical outcomes and reduce health care costs.
ASH Values
•Honesty, integrity, and ethics
•Culture of both entrepreneurism and discipline
•Change paradigms; be part of something special
•Meritocracy and opportunity
•Careful financial stewardship
George DeVries
Chairman & CEO
C900-059 (Last reviewed: December 2018) 2019 ASH Code of Conduct and Ethics Program 4
Introduction by the Compliance Officer
As George mentions, our ability to fulfil our purpose with the trust of those we
serve depends on each of us as individuals adhering to the company’s
values and the principles set forth in this Code of Conduct and Ethics
Program. Our success here is also a team effort.
We must all work together to succeed with these goals and to maintain
compliant practices. For me, as well as the entire ASH leadership team, this
means working with you so that you have the support you need to ensure
your choices are ethical and compliant.
This Code of Conduct and Ethics Program is intended to help guide you in making ethical and
compliant choices. It applies to all employees and board members of our company. We expect
similar conduct from our credentialed practitioners, contracted providers, contracted fitness facilities,
suppliers, and vendors. These standards are required and will not be suspended for any purpose.
Under exceptional circumstances, only the Board of Directors may grant a waiver of all or part of the
Program.
Any actions that violate this Program will be addressed through appropriate sanctions, including
disciplinary action up to and including immediate termination of employment. As such, it is
imperative that you not only complete Code of Conduct and Ethics training on an annual basis but
that you be familiar with the principles described in this Program and seek assistance as needed
with any questions.
Should you have any questions about this Program or with ethics or compliance generally, you can
contact the Ethics and Integrity Hotline at 866.998.2746 or email your concern to
EthicsAndIntegrity@ashn.com. I am also available to you, and you can contact me directly at any
time regarding compliance with this Program and our standards for ethical conduct.
While this Program covers many areas of conduct, the following principles are essential to the
choices we make:
•We treat people inside and outside the company with integrity, fairness, dignity,and
respect.
•We strive to be fact-based and use sound supporting analysis and data to arrive at our
decisions so that our financial and operating reports and communications to each other
and to all stakeholders of the company are accurate, honest, accountable,and well-
reasoned.
•We comply with all policies and procedures and actively implement the training we
receive so that our decisions and work product comply with the laws, regulations,
accreditation standards, and contractual obligations applicable to our products and
services.
•If we have questions about our corporate standards, we have the personal responsibility
to seek guidance and answers before acting.
Each of us plays a vital role in preserving the trust of those we serve and together we can
demonstrate to those we serve that their trust in us is well placed. Thank you for your
commitment to fulfilling our company’s purpose and mission in an ethical and compliant manner.
James Van Beek
Vice President, Regulatory & Program Compliance
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CHAPTER ONE |Personal Responsibilities
This Code of Conduct and Ethics Program provides guidelines to help you in situations that you
may face during your career. The Program is led by ASH’s Compliance Officer. ASH’s Ethics
and Integrity Committee and the Quality and Compliance Committee of ASH’s Board of
Directors oversee the Program and receive periodic reports from the Compliance Officer and
other senior managers as needed. The Program does not create any contractual rights between
you and ASH. It may be changed or modified by ASH at any time without notice. We should not
interpret the Program as a promise of employment or continued employment.
Conduct Yourself in an Ethical Manner and Seek Guidance When Needed
You must conduct yourself in an ethical manner. American Specialty Health (ASH) relies on
your good judgment to take appropriate action. If you are in doubt about any situation or
behavior, you may speak to your supervisor or manager, the head of Human Resources, or the
Compliance Officer. You may also call our Ethics and Integrity Hotline at 866.998.2746 and
leave a message 24 hours a day, seven days a week, if you prefer a confidential way to get
advice or to report a situation that may violate a law or conflict with our values.You may
remain anonymous if you choose.
Report Suspect Conduct in Good Faith
If you suspect a violation of the Code of Conduct and Ethics Program has occurred, you
have an obligation to report the issue.
Reports can be made to the Compliance Officer, or as noted above. You may also call our
Ethics and Integrity Hotline at 866.998.2746 and leave an anonymous message 24 hours a day,
seven days a week. The information you provide will be investigated and relayed to our Ethics
and Integrity Committee as needed.You will be protected from retaliation for all reports
made by you in good faith even if no violation of the Code of Conduct and Ethics Program was
found to have occurred. A good faith report is one where you have a reasonable belief that the
information provided relates to possible misconduct.
Examples of activity to report include:
•Falsified company records.
•Harassment of, or discrimination against, other employees.
•Embezzlement or theft of company property.
•Misuse of proprietary and/or personal information.
•Violation of any company policy.
•Potential fraud, waste, and abuse.
To report suspected violations of the Code of Conduct and Ethics Program:
Call our Ethics and Integrity Hotline at 866.998.2746.
ASH does not tolerate any form of retaliation against anyone reporting concerns in good faith.
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The Ethics and Integrity Hotline is just one of several resources available when you need to
raise concerns about workplace activities that may be unethical, illegal, or inconsistent with our
values. See Chapter Four: Our Resources for Complying with the Code of Conduct and
Ethics Program for additional information.
Our Leaders Serve as Role Models
People who lead others need to be ethical role models for employees and foster an environment
of integrity, trust, and cooperation by:
•Demonstrating the highest standards of integrity and responsibility when dealing with
employees, customers, vendors, and the community.
•Contributing to and maintaining a work environment conducive to, and encouraging of,
ethical behavior.
•Contributing to a work environment that encourages employees to voice concerns and
get help when faced with potentially compromising situations. This also means supporting
employees who make the sometimes difficult decision to speak out and never retaliating
against someone for reporting concerns about suspected
non-compliance.
•Avoiding any approval of conduct that may be unethical, dishonest, or potentially
damaging to ASH’s reputation.
We Support the Critical Roles of Management
Management is expected to demonstrate personal commitment to the company's standards of
behavior and manage employees according to those standards. Management is also expected
to identify and properly manage risks, working with their employees to deploy efficient and
effective controls that appropriately minimize risks. They must maintain a workplace
environment that ensures compliance with our Code of Conduct and Ethics Program. Yet, from
time to time, we may question their decisions or actions. At such times, employees are obliged
by our values to seek guidance from their supervisor or manager, the head of Human
Resources, the Compliance Officer, or through the Ethics and Integrity Hotline:866.998.2746.
We Obey the Law
ASH is committed to complying with all applicable laws, rules, and regulations wherever we do
business. Proper employee conduct ensures that all laws are obeyed and that all conduct is
ethical and above reproach. If the company violates its legal and ethical obligations, the
company and individual employees can suffer severe consequences ranging from fines and
criminal penalties to disciplinary action up to and including termination of employment. While
you are not expected to be an expert on the law, you are expected to read and become familiar
with company policies and procedures, including this Program, so you can identify and report
situations in which compliance or ethical issues might arise. Use the following principles to
guide your day-to-day behavior:
•Never do anything you know or think would violate any laws. If you are in doubt seek
guidance from your supervisor or manager, the head of Human Resources, or the
Compliance Officer.
•Never use ASH's property, information, or position for your own personal gain.
•Never falsify company books, reports, or records.
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•Take special care to ensure that company books and records and the documentation
relating to company transactions are accurate and retained in compliance with our
document retention guidelines and any in-force litigation hold orders.
•Follow all company policies, procedures, and training instructions.
•Always treat your fellow employees with respect.
•Deal fairly with ASH's customers, vendors, competitors, and employees.
Remember that company policies and trainings are available to you on the company intranet
and online training modules. Department procedures and trainings are available from your
manager and supervisor. Please also see Appendix A for a list of some of the laws and
regulations that ASH must comply with. If you are in doubt or have any questions you should
contact your supervisor, manager, or ASH’s Compliance Officer.
We Respect the Individual
As a company, we recognize the dignity of the individual. We respect each employee. In return,
employees must:
•Not tolerate any type of discrimination or harassment against applicants for employment,
employees, or independent contractors on the basis of race, color, religion, sex, gender,
gender identity, gender expression, pregnancy, marital status, age, national origin,
ancestry, physical or mental disability, medical condition, sexual orientation, military or
veteran status, genetic information, or any other category protected by applicable local,
state, or federal law. ASH also prohibits discrimination and harassment based on the
perception that an applicant for employment, employee, or independent contractor has
any of those characteristics, or is associated with a person who has or is perceived as
having any of those characteristics.
•Not use or be under the influence of drugs or alcohol in the workplace. The use of drugs
or alcohol while at work or performing work on behalf of the company is prohibited.
•Immediately report any employee you suspect may be under the influence of alcohol or
any illegal drugs to your supervisor, manager, or the head of Human Resources.
Discrimination is the act of differentiating among employees or applicants for employment on
the basis of any protected characteristic described above.
Harassment is unwelcome verbal, visual, or physical conduct based on a protected
characteristic described above that creates an intimidating, offensive, or hostile working
environment or that interferes with work performance. Prohibited conduct includes, but is not
limited to, any of the following when based upon a protected category: making comments, slurs,
innuendos, or jokes; the display of cartoons, posters, or other materials; distributing pictures or
words in written, pictorial, or electronic form; touching or other unwanted attention; threats,
intimidation, or other abusive behavior.
Sexual harassment is one form of unlawful harassment. Applicable state and federal law define
sexual harassment as unwelcome sexual advances, requests for sexual favors, or other verbal
or physical conduct of a sexual or sex-based nature when (1) submission to that conduct is
made either explicitly or implicitly a term or condition of an individual’s employment, (2)
submission to or rejection of the conduct is used as a basis for employment decisions affecting
the individual or (3) such conduct has the purpose or effect of unreasonably interfering with an
individual’s work performance or creating an intimating, hostile, or offensive work environment.
C900-059 (Last reviewed: December 2018) 2019 ASH Code of Conduct and Ethics Program 8
Unwelcome sexual advances, requests for sexual favors, and other physical, verbal, or visual
conduct based on sex are not allowed. This includes such things as sexual innuendoes,
suggestive comments, sexually oriented teasing or practical jokes, display of sexually
suggestive pictures or other materials, suggestive or insulting sounds, looks, or gestures, and
any unwanted physical contact. Obviously, more severe forms of harassment, such as sexual
assault, are also prohibited. ASH does not allow anyone, including any supervisor, co-worker,
vendor, client, or provider to harass company employees, applicants, or independent
contractors.
ASH will not tolerate any form of retaliation against any employee for engaging in protected
activity, such as making a good faith complaint of harassment or discrimination or participating
in an investigation.
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CHAPTER TWO |Workplace Responsibilities
Job performance involves achieving results through ethical and responsible behavior in all
workplace dealings with each other and with people outside the company.
We Live Our Values
As representatives of ASH, we act responsibly and in a manner that reflects favorably upon
ourselves and the entire company. We rely on the company's values in making decisions that
will enable us to be the best for our customers and employees.
We Promote Diversity
ASH is committed to providing challenging, meaningful, and rewarding opportunities for
personal and professional growth to all employees without regard to race, color, religion, sex,
gender, gender identity, gender expression, pregnancy, marital status, age, national origin,
ancestry, physical or mental disability, medical condition, sexual orientation, military or veteran
status, genetic information, or any other category protected by applicable local, state, or federal
law. This policy applies to all phases of employment, including the hiring of new employees,
training, development, compensation, promotions, demotions, transfers, layoffs, terminations,
use of facilities, and selection for special programs.
We Provide a Safe Workplace
All employees must assist the company in providing a workplace that is free from safety or
health hazards or disease, and one in which operational hazards are controlled to acceptable
levels. Employees, particularly management, should take responsibility in reporting any potential
safety concerns to the head of Human Resources immediately.
We Create a Positive Environment
ASH aims to create an environment that allows individuals to excel, be creative, take initiative,
seek new ways to solve problems, generate opportunities, be accountable for our actions, and
be recognized for our contributions and teamwork.
Because of this, the company prohibits:
•The manufacture, distribution, sale, purchase, transfer, possession, use, or being under
the influence of illegal drugs in the workplace (including state-authorized marijuana). The
same restrictions apply to alcohol unless the company authorizes its use for special
occasions.
•All forms of harassment of employees by fellow employees, employees of outside
contractors, or visitors. In addition, we will not tolerate harassment from vendors or
customers. This includes any demeaning, insulting, embarrassing or intimidating behavior
directed at any employee because of race, color, religion, sex, gender, gender identity,
gender expression, pregnancy, marital status, age, national origin, ancestry, physical or
mental disability, medical condition, sexual orientation, military or veteran status, genetic
information, or any other category protected by applicable local, state, or federal law.
•Prohibited conduct includes, but is not limited to any of the following when based upon a
protected category: making comments, slurs, innuendos, or jokes; the display of
cartoons, posters, or other materials; distributing pictures or words in written, pictorial, or
electronic form; touching, or other unwanted attention; threats, intimidation, or other
abusive behavior.
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•ASH will not tolerate any form of retaliation against any employee for engaging in
protected activity, such as making a good faith complaint of harassment or discrimination
or participating in an investigation. You will be protected from retaliation for all reports
made by you in good faith, even if no violation of the Code of Conduct and Ethics
Program was found to have occurred.
Employees must immediately report sexual harassment complaints to their supervisor,
manager, head of Human Resources, or by calling the Ethics and Integrity Hotline.
You may remain anonymous if you choose.
We Respect Each Other's Privacy
ASH respects the privacy of employees’ personnel information and retains only those historical
and current employee personnel records needed for business, legal or contractual purposes,
and restricts access to those records. Additionally, the company will not interfere in our personal
lives off the job unless the conduct impairs our work performance or work environment or
otherwise creates an actual or potential conflict of interest.
We Safeguard American Specialty Health's Property
ASH's ability to compete and serve our customers requires the efficient and proper use of
assets and resources, including, but not limited to, confidential and proprietary information,
trade secrets, electronic devices, electronic communications, files and data, software and
hardware, land, buildings, equipment, and cash. As employees we should use company assets
for legitimate business purposes only. Each of us has a responsibility to do everything we can to
protect these assets. At a minimum, that means using them in accordance with company
policies and complying with security programs that help prevent their unauthorized use or theft.
The systems through which we access email, the internet, and the intranet are company
property. You must use ASH’s information systems and the internet responsibly.
Keep in mind that:
•Any information sent, received, accessed, or stored on ASH’s equipment, including, but
not limited to, its electronic mail system, voicemail system, or computer systems is
company property, and no employee has any privacy rights to this information. When we
use these systems, we consent to the company monitoring and auditing what we put on it
and how we use the internet.
Internet communications and usage are not considered private. ASH’s management team and
Human Resources reserves the right to examine, among other things, websites visited, files
downloaded, time spent on the internet, and any other internet-related information. Such
monitoring ensures appropriate usage, compliance with internal policies, assists with internal
investigations, and assists with the management of information systems.
We Protect the Privacy of Our Members
ASH is committed to protecting members’ rights to privacy and security and complies with
related industry, state, and federal standards (such as HIPAA). ASH provides privacy, security
and related sanctions training for all ASH employees and requires that all employees are aware
of and abide by such policies. As a condition of employment, all employees are required to sign
a Proprietary Information Agreement (PIA) agreeing to maintain and protect the confidentiality of
all member information encountered in the course of their employment. In addition, all new
employees are required to complete and sign an Employee Handbook Acknowledgement Form
documenting that they have reviewed and agree to abide by specified ASH’s policies and
C900-059 (Last reviewed: December 2018) 2019 ASH Code of Conduct and Ethics Program 11
procedures, including privacy, security, and related sanctions policies. Employees are required
to sign an Employee Handbook Acknowledgement Form on an annual basis.
We Protect the Confidentiality of Proprietary Information
In the course of work, many of us may acquire information about the company or our customers
or vendors that is not generally known to the public and, if improperly disclosed, may be harmful
to the company or its customers or vendors or helpful to its competitors. We also acquire
confidential information from former employers and from our customers, providers, and
members. ASH is committed to protecting members’ rights to privacy and security and complies
with related industry, state, and federal standards (such as HIPAA). As stated above, ASH
provides privacy, security, and related sanctions training for all ASH employees and requires
that all employees are aware of and abide by such policies.
Confidential proprietary information takes many forms including, but not limited to, financial or
operations reports and results, operational workflow designs and work tools, business or
marketing plans, sales or promotional activity, programming code, advertising plans or
expenditures, customer lists, new products, product research, price changes, mergers or
acquisitions, securities offerings, management changes, and trade secrets. Laws do not allow
the use of nonpublic information, also known as “insider information,” for financial benefit for
ourselves or others, including family and friends. We must not disclose such information with
other employees or persons outside the company who are not authorized to have such
information.
We Respect Intellectual Property Rights and IT Resources
With respect to using IT resources, keep in mind that you must:
•Only use software as authorized by the company on company computers and devices
that have been purchased, developed, or authorized by ASH for the purpose of
conducting business.
•Not duplicate copyrighted software for any reason, without written authorization from the
software company. Any employee who knowingly or unknowingly duplicates copyrighted
software material is subjecting ASH and themselves to substantial penalties under the
law.
Likewise, we must all respect the copyrights and trademarks of our clients and vendors. We
must only use such materials as permitted in our agreements with our clients and vendors.
Remember these rules when you handle confidential information:
•You must safeguard all passwords and identification codes to prevent unauthorized
access to ASH's electronic data.
•Do not disclose to anyone outside ASH (this includes use in school projects or classroom
discussions), any information relating to the company that has not been disclosed to the
public, unless you first have appropriate management or Privacy Office approval or as
required by law, at any time during or after your employment. Don't even share
confidential information with other employees unless they have a business need to know
about it, and then only share the minimal amount of information needed.
•Routinely take precautions to keep confidential information from being disclosed. This
includes making sure such information is not displayed on our desks or in our work area
where it can be seen by anyone. You should also avoid transmitting information
electronically or by fax in ways that might make it available to unauthorized people.
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•Respect the confidentiality of private information concerning our employees and
proprietary information from customers, suppliers, and other third parties that comes to
our attention under an understanding of confidentiality. We must respect the proprietary
nature of such information and not use or disclose it without proper written authority.
•These rules do not prohibit employees from engaging in protected communications
regarding terms and conditions of employment.
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CHAPTER THREE |Marketplace and Global Responsibilities
We Are Careful About Offering Gifts
All employees must use only legitimate practices in commercial operations and in promoting
ASH’s position, when authorized to do so, on issues before governmental authorities. As stated
below, "kickbacks" or "bribes" intended to induce or reward favorable buying decisions and
governmental actions are unacceptable and strictly prohibited. No ASH employee or any agent
acting on ASH’s behalf shall, in violation of any applicable law, offer or make directly or
indirectly through any other person or organization any payment of anything of value (in the
form of compensation, gift, contribution, or otherwise) to:
•Any person or organization employed by or acting for or on behalf of any customer,
whether private or governmental, for the purpose of inducing or rewarding any favorable
action by the customer in any commercial transaction; or any governmental entity, for the
purpose of inducing or rewarding action (or withholding of action) by a governmental
entity in any governmental matter;
•Any governmental official, political party or official of such party, or any candidate for
political office, for the purpose of inducing or rewarding favorable action (or withholding of
action) or the exercise of influence by such official, party, or candidate in any commercial
transaction or in any governmental matter, or any immediate family members of such
persons, including spouses, registered domestic partners, parents, or children.
Prior to giving any gift or extending or accepting any invitation to an event with a public official,
party, or candidate on behalf of ASH, employees must notify the Compliance Officer for
approval. If the total fair market value of such items exceeds $100, then approval must also be
obtained from the Compliance Officer and the Chief Executive Officer, subject to the
requirements of applicable law. Should a gift be approved, a letter of notification of the value of
a gift must be sent to the official within 30 days of the end of the calendar quarter in which the
gift was given. Please request a sample letter template from the Compliance Officer. A copy of
the letter of notification needs to go to the Finance department so it can file a quarterly FPPC
report within 30 days of the end of each calendar quarter in which a gift was given.
In utilizing consultants, agents, sales representatives, or others, ASH will employ only reputable,
qualified individuals or organizations under compensation arrangements that are reasonable in
relation to the services performed. Human Resources will issue from time to time criteria and
procedures to be utilized in international transactions, when applicable, with respect to the
selection and compensation of sales representatives. Consultants, agents, or representatives
retained in relation to the provision of goods or services to federal, state, or local governments
must agree to comply with all related laws, regulations, and ASH policies governing employee
conduct.
We Require Ethical Behavior from Our Outside Consultants and Contracted Service
Providers
We are responsible for ensuring that any outside consultant or contracted service provider that
we engage is held to the same standards of ethics and integrity that ASH requires of our
employees. And that includes obeying all the laws and government regulations that apply to us.
If an outside contractor we engage violates our ethical standards, it can be equivalent to
violating those standards ourselves. A consultant’s or contracted service provider’s failure to
abide by those standards can result in corrective actions being issued by ASH and can be
cause for sanctions under, or termination of, the consultant’s or contracted service provider’s
agreement with ASH.
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We Conduct Business Openly and Honestly
We vigorously market our products and services fairly and based on their proven quality and
reliability and the value they provide. With this in mind we:
•Strictly prohibit our employees or anyone else from giving or accepting bribes,
kickbacks,or any other form of improper payment, direct or indirect, to any
representative of any government, any customer, contractor, supplier, consultant or
advisor, or labor union, for any reason.
•Respect and comply with antitrust laws, which promote competitive marketplaces by
prohibiting price fixing and illegal market manipulations. As such, we price our products
and determine fee schedules independently and do not share confidential information
with or between competitors.
•Make certain that marketing expenditures are necessary, prudent, and job-related and
that procurement decisions are honest and based solely on predetermined selection
criteria that are in the best interests of the company.
•Do not offer to, or accept from, our existing or potential commercial customers’
non-cash gifts, special courtesies, or prizes of more than nominal value (up to $100).
Never offer or accept cash or cash-equivalent gifts to or from existing or potential
commercial clients or vendors.
»It is best to have management or supervisor approval to accept or give a gift, and
when accepted, the gift should be shared with others in your department or the
company. If accepting any gift could compromise your ability to act in ASH’s best
interest, you should politely decline the gift.
»Do not offer members and providers participating in government programs meals
or items of value that are not authorized by the company for established business
or program use.
•Never offer government representatives any meals or items of value. Simple
refreshments provided during a meeting may be acceptable.
•Only permit appropriate business entertainment, including traditional promotional events.
Such entertainment or events are permitted as long as what is offered is consistent with
usual business practice and cannot be construed as a bribe or payoff. Business
entertainment is not reasonable if it violates any law or would embarrass us if disclosed
publicly. Business entertainment is not permitted with respect to any government
representative. Communicate clearly and precisely, either orally or in writing, so that our
clients and vendors understand the terms of our contracts, including performance criteria,
costs, and schedules.
•Maintain accurate records and follow appropriate accounting practices. To support
compliance with regulatory and financial oversight requirements, all business and
financial records must be complete and accurate. Intentionally making false or fictitious
entries in company records is prohibited. Participation in any such false transactions is
also prohibited. Any actions to intentionally mislead, coerce, manipulate, or falsely
influence auditors, government officials, or any person conducting an internal or external
investigation are prohibited. In addition, failure to document or record accounts, funds, or
assets is not allowed. Company funds must never be placed in personal or non-corporate
accounts. Records must be retained in compliance with our document retention
guidelines and in-force litigation hold orders. Records may only be destroyed or disposed
of as permitted under those guidelines or orders.
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•Prevent and report conflicts of interest. You should not engage in any activity that
creates or could appear to create a conflict between your interests and the best interests
of ASH. Employees should not have any direct or indirect financial interest with a
customer, competitor, or supplier that could cause divided loyalty or the appearance of
divided loyalty. In general, a significant financial interest means ownership by you and/or
your immediate family member(s) of: 1) more than 1 percent of the outstanding
securities/capital value of a business entity, or 2) more than 5 percent of your total assets
and/or those of the immediate family member(s). In addition, conflicts may also come
from engagement in certain activities outside of your ASH employment such as a second
job, a side business, or serving on another company’s board.
»Employees must notify the head of Human Resources before taking any action
under circumstances that might lead to actual or potential conflicts of interest.
This would include, for example, acquiring any financial interest in any customer,
competitor, or supplier.
»Additionally, no employee may conduct Company business with a person with
whom he/she is related in blood or marriage, or a business organization with
which the employee or family member has a significant association, without first
having the written approval of the head of Human Resources.
Factors that could imply a conflict relative to company business may
include benefit determinations, such as making a medical necessity
determinations, for specific members if:
−Staff has past or present relationship with the member;
−Staff has past or present relationship with practitioner, referring
entity, or other care provider previously involved in the case;
−Staff has material professional, familial, financial, or other
affiliation, relationship or interests with or related to the subject
matter that is being recommended (including but not limited to
the development of a treatment, therapy, drug, device,
procedure, or with a facility at which a recommended treatment
has been or is being provided) that could be perceived to
create a conflict of interest.
−A conflict of interest is not limited to member/practitioner
relationships, but can occur when an staff has a material,
familial, financial, or other interest or outside relationship in any
area of operations or administration (i.e. Finance, Sales, etc.)
that creates or can be perceived to create a conflict of interest
with any outside business, vendor/supplier.
−Should an employee establish a competitive business or work
for a competitor, a conflict of interest would exist.
»Please note:we operate in a dynamic environment and conflicts can arise at any
time. You are responsible for immediately reporting any potential conflict you are
reasonably able to identify when you first identify its possibility. You may report
the potential conflict to your manager, Human Resources, or the Compliance
Officer. Remember, too, that conflicts are not about how we think of a situation,
but also involve the perception of others. The question to ask is not how you feel
about the situation, but what would other people think. If you have any doubts, it is
C900-059 (Last reviewed: December 2018) 2019 ASH Code of Conduct and Ethics Program 16
always better to report the issue or seek guidance from your manager, the head
of Human Resources or the Compliance Officer.
•Adhere to ethical principles appropriate to our respective professions.ASH
employees who maintain a professional standing (e.g., licensure) in support of their
employment with ASH (e.g. health professionals) are not asked to provide services or
information that conflict with their adherence to ethical principles appropriate to their
profession or the laws governing their applicable license/credential. Such professionals
employed by ASH commit to comply with ethical principles and obligations of their
profession within the context of their ASH job descriptions. Health professionals will
comply with applicable state and federal regulations and applicable regulatory board
obligations regarding clinical decision-making performed on behalf of ASH.
•Health professionals will keep the health and safety of patients/members as the primary
focus in clinical decision-making, considering all available information provided by the
patient/member and their treating clinician (as applicable).
•Health professionals will report (as required by their license/credential) to applicable
government entities any suspected cases of abuse that might be identified while
engaging in discussions with members/patients or review of health information about a
member/patient. The Privacy Office must be notified of such reports so that accountings
of such disclosures can be tracked.
•ASH professionals who possess licenses/credentials necessary for their ASH job
description will maintain those clinical licenses/credentials in good standing and
immediately report to management any adverse actions taken by a third party against the
individual professional’s credential (e.g., state board action, Medicare sanction, loss of
license, license probation).
We Safeguard the Property of Others
When business requires us to use the tangible and intellectual property of other companies or
individuals, we do so appropriately in accordance with all applicable law and/or contractual
requirements governing the use of that property. We will obtain the tangible and intellectual
property of competitors only through lawful means and will not engage in unfair competition.
We Refer Contacts from Government Representatives to Regulatory Compliance
Accurate and comprehensive responses to government officials are an important part of our
commitment to ethics and integrity. From time to time, you may be asked to assist the
Regulatory and Program Compliance department with preparing and responding to government
inquiries or audits. However, when receiving an unexpected contact from a government
representative, you should direct the government representative to Regulatory and Program
Compliance and alert that department of the contact. Please refer to the contact list in Chapter
Four: Resources for Complying with the Code of Conduct and Ethics Program for additional
information.
We Refer All Financial Inquiries to Finance
Accurate and comprehensive responses to financial inquiries are an important part of our
commitment to ethics and integrity. Not all of us have the appropriate training and experience to
answer such inquiries; as such they should be referred to the Finance department for handling.
Please refer to the contact list in Chapter Four: Resources for Complying with the Code of
Conduct and Ethics Program for additional information.
We Refer All Inquiries from the News Media to Marketing
C900-059 (Last reviewed: December 2018) 2019 ASH Code of Conduct and Ethics Program 17
Accurate and prompt response to news media inquiries is an important part of our commitment
to ethics and integrity. Most of us, however, do not have the training and experience to deal
effectively with the news media, and even an innocent misunderstanding between the media
and ASH could have serious consequences for us. Employees are not authorized to discuss
company business or information on behalf of the company with the news media on their own.
All inquiries from the media must be referred to the Marketing department with a copy to our
Compliance Officer.
We Protect the Environment
ASH is committed to environmental excellence in the design and distribution of our products.
We abide by all applicable health, safety, and environmental laws and regulations where ASH
operates. In all cases, at a minimum, the company will:
•Communicate honestly and openly with our employees, as well as our neighbors,
customers, and government agencies about the nature of our operations and products
and their relationship to the environment.
•Identify, control, and minimize waste and the use of hazardous materials.
•Provide appropriate health, safety, and environmental training for our employees.
•Work with government and other organizations, as appropriate, to develop realistic laws,
regulations, and standards to protect the public and the environment.
In addition, each of us has a responsibility to:
•Be mindful of the environmental impact of our actions.
•Continually look for opportunities to make our environmental performance better.
•Strive to integrate environmental considerations into our business activities and
processes.
•Report any environmental concern to your supervisor or manager, the head of Human
Resources, the Compliance Officer or to our Ethics and Integrity Hotline.
We Prevent and Report Issues of Suspected Fraud, Waste, and Abuse
ASH has established its Anti-Fraud Policy (AF 1) to comply with state and federal anti-fraud
requirements and to meet generally accepted industry anti-fraud program standards. Our efforts
to fight and report fraud, waste, and abuse impact all our lines of business, but are particularly
important compliance requirements for government funded programs, such as Medicare and
Medicaid.
•Fraud is an intentional act of deception, misrepresentation, or concealment to gain
something of value. An example is when a person submits a claim for services or
treatments that the person knows were never rendered.
•Waste is the misuse of resources and over-utilization of services that is not the result of
criminal intent or criminal negligence. Many of our programs, like our medical necessity
review process, are designed to help prevent waste. Waste could occur when a
practitioner overcharges extra for services or supplies or provides medically unnecessary
services.
•Abuse is the excessive or improper use of services or actions to an extent that goes
against acceptable business or medical practice. Abuse refers to actions that, although
not fraudulent, may directly or indirectly cause financial loss.
C900-059 (Last reviewed: December 2018) 2019 ASH Code of Conduct and Ethics Program 18
While ASH has a Special Investigations Unit (SIU) to investigate suspected fraud activity, ASH
employees are responsible for deterring, identifying, and reporting incidents of suspected fraud,
waste, and abuse. Employees of ASH continuously encounter activities involving ASH’s
operations and the conduct of practitioners, vendors, and members. In doing so, our employees
are key to detecting incidents involving suspected fraudulent activities. ASH employees who
identify suspected fraudulent activity must report it. Employees can report such activity to the
SIU by:
•Advising an SIU member of the suspected activity;
•Completing a “Fraud Referral Form” and submitting it to their supervisor, an SIU member,
or the Compliance Officer;
•Emailing notices of suspected fraud activity to antifraud@ashn.com; or
•Leaving a message on ASH’s Anti-Fraud Hotline at (877) 427-4722.
C900-059 (Last reviewed: December 2018) 2019 ASH Code of Conduct and Ethics Program 19
CHAPTER FOUR |Resources for Complying With the Code of Conduct
and Ethics Program
Our values and policies are the individual responsibility of each of us. This Code of Conduct and
Ethics Program provides guidelines to help you in many situations that you may face day to day,
but it cannot anticipate every possible ethical dilemma. For this reason, the company offers a
number of resources to help you comply with the Program.
Our Personal and Corporate Responsibility
Our values and policies are the individual responsibility of each of us, but our leaders have a
special responsibility for assuring understanding, serving as a role model, communicating the
contents of this Program to employees and assisting with compliance in every way possible.
Employee are encouraged to raise such concerns with their supervisors or managers.
However, should employees not feel comfortable raising a concern with their supervisor or
manager, we also provide alternate ways for them to report possible violations of the Code of
Conduct and Ethics Program or to seek advice. Employees can do this by contacting the
Compliance Officer or by calling our Ethics and Integrity Hotline:866.998.2746.
Our Ethics and Integrity Committee
The Ethics and Integrity Committee is responsible for assuring compliance with our Code of
Conduct and Ethics Program through communication and education for all employees of the
company, as well as monitoring and response. Disciplinary actions related to enforcement of the
Code of Conduct and Ethics Program with respect to internal employees are managed by
Human Resources and supported as needed by the Human Resources Council. Trends and
policy concerns related to such actions are brought to the Ethics and Integrity Committee by
Human Resources as appropriate. The Ethics and Integrity Committee is chaired by the
Compliance Officer. Members include management representatives from Human Resources
and Finance as well as executive representatives, including the Chief Operations Officers for
ASH’s lines of business. The Ethics and Integrity Committee meets at a minimum quarterly and
more often as needed, and provides reports through the Compliance Officer to the Quality and
Compliance Committee of the Company's Board of Directors.
Role of Our Management Team
Management plays a key role in the compliance program. They are expected to demonstrate
their personal commitment to the company's standards of behavior and manage their
employees according to those standards.
•Management is responsible for seeing that all employees under their supervision
participate in appropriate compliance training programs.
•Management must maintain a workplace environment that ensures compliance with our
Code of Conduct and Ethics Program.
•Management must also use diligence and discretion and consider an individual's
character and behavior, before appointing that individual to any position of authority and
responsibility.
C900-059 (Last reviewed: December 2018) 2019 ASH Code of Conduct and Ethics Program 20
Non-Compliance
It is expected that all employees of ASH will fully comply with the guidelines expressed in this
Code of Conduct and Ethics Program and the policies and procedures that support it.
Employees who do not comply may face disciplinary action up to and including termination of
employment.
Contact List
Ethics and Integrity Hotline—Ethics and Integrity Committee
866.998.2746
EthicsAndIntegrity@ashn.com
Compliance Officer—James Van Beek
858.754.2000, ext. 3111
jamesv@ashn.com
Human Resources Department—Kristin Bragg
858.754.2000, ext. 3697
kbragg@ashn.com
Regulatory Compliance—James Van Beek
858.754.2000, ext. 3111
jamesv@ashn.com
Finance Department—William (Bill) Comer
858.754.2000, ext. 3261
billc@ashn.com
Information Security Officer—Tina Mitchell
858.754.2000, ext. 3159
tinam@ashn.com
Privacy Officer—James Van Beek
858.754.2000, ext. 3111
jamesv@ashn.com
Please contact any of the above if you would like additional information. More detailed
information about many of our company-wide policies can be found on the company intranet.
C900-059 (Last reviewed: December 2018) 2019 ASH Code of Conduct and Ethics Program 21
Attestation to Adhere to
ASH’s Code of Conduct and Ethics Program
Within 90 days of hire, and then on an annual basis (or as materials updates occur) thereafter,
ASH employees must complete and sign this attestation to confirm that they have read and
understand the standards set forth in ASH’s Code of Conduct and Ethics Program, and that they
agree to abide by this Program. Please review the Program before signing. Should you have
any questions about the Program, please seek guidance from your supervisor, the head of
Human Resources, or the Compliance Officer prior to signing this document.
I attest that I have read and understand ASH’s Code of Conduct and Ethics
Program. I agree to abide by and adhere to the standards of conduct set forth in
the Program. I understand that strict compliance with ASH’s policies, procedures,
and the Program are a condition of employment and ASH may take disciplinary
action up to and including termination for my non-compliance under those
policies, procedures, and the Program. I understand that my annual performance
review incorporates consideration of my compliance with the same. I understand
that I am responsible for discussing the importance of compliance with the
employees I supervise, if any. I understand that I must report in good faith any
suspected incident of non-compliance with ASH policies, procedures, or the
Code of Conduct and Ethics Program immediately upon learning of the incident.
I attest that I am not aware of any non-compliance incident, or I have reported or
will immediately report any non-compliance incident that I am aware of. I
understand that ASH does not tolerate any form of retaliation against any
employee for making such good faith reports.
I further attest that I am not aware of any potential conflict of interest with my
employment or duties with ASH that I have not already reported to Human
Resources. I understand that should a potential conflict arise in the future, I must
immediately notify Human Resources.
Signed:
Printed Name:
Date:
C900-059 (Last reviewed: December 2018) 2019 ASH Code of Conduct and Ethics Program 22
Appendix A: Laws and Regulations
ASH complies with all laws applicable to it. The following is lists some of the laws and
regulations applicable to ASH and/or which ASH has committed to complying within its contracts
with health plan clients. If you have any questions regarding these laws and regulations, please
contact your supervisor or manager, the head of Human Resources, or ASH’s Compliance
Officer.
•Title XVIII of the Social Security Act
•Medicare regulations governing Parts C and D found at 42 C.F.R. §§ 422 and 423
respectively
•Patient Protection and Affordable Care Act (Pub. L. No. 111-148, 124 Stat. 119),
including related non-discrimination provisions thereunder.
•Health Insurance Portability and Accountability Act (HIPAA)
(Public Law 104191)
•False Claims Acts (31 U.S.C. §§ 3729-3733)
•False Statements Act
•Federal Criminal False Claims Statutes (18 U.S.C. §§ 287,1001)
•Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b))
•The Beneficiary Inducement Statute (42 U.S.C. § 1320a-7a(a)(5))
•Civil monetary penalties of the Social Security Act (42 U.S.C. § 1395w-27 (g))
•Physician Self-Referral (“Stark”) Statute (42 U.S.C. § 1395nn)
•Fraud and Abuse, Privacy and Security Provisions of the Health Insurance Portability and
Accountability Act, as modified by HITECH Act
•Prohibitions against employing or contracting with persons or entities that have been
excluded from doing business with the Federal Government
(42 U.S.C. §1395w-27(g)(1)(G)
•Fraud Enforcement and Recovery Act of 2009
•All sub-regulatory guidance produced by CMS and HHS such as manuals, training
materials, HPMS memos, and guides.
C900-059 (Last reviewed: December 2018) 2019 ASH Code of Conduct and Ethics Program 23