Form CMS-10237 HSD Tables

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Overview

HSD-1
HSD-2
HSD2A
HSD-3 Summary
HSD-3 Detail
HSD3A
HSD 4
HSD-5

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Sheet 1: HSD-1

SSA State/County Code	Specialty Type	Specialty Code	Medicare Provider Breakdown		Total # of Providers	Total # PCPs Accepting New Patients	# of PCPs Excepting Established Patients Only
			Direct w/Mao	Downstream Arrangement
	General Practice
	Family Practice
	Internal Medicine
	Geriatrician
	Primary Care Physicians Total		(sum of above 4 lines)	(sum of above 4 lines)	(sum of above 4 lines)	(sum of above 4 lines)	(sum of above 4 lines)
	Primary Care - Physician Assistants
	Primary Care - Nurse Practitioners
	Mid -Level Primary Care Practitioners Total		(sum of above 2 lines)	(sum of above 2 lines)	(sum of above 2 lines)	(sum of above 2 lines)	(sum of above 2 lines)
	Primary Care Providers Total (sum of Primary Care Physicians Total and Mid-Level Primary Care Practitioners Total )
	Allergy & Immunology					N/A	N/A
	Cardiac Surgery					N/A	N/A
	Cardiology					N/A	N/A
	Chiropractic					N/A	N/A
	Dermatology					N/A	N/A
	Endocrinology					N/A	N/A
	ENT/Otolaryngology					N/A	N/A
	Gastroenterology					N/A	N/A
	General Surgery					N/A	N/A
	Gynecology, OB/GYN					N/A	N/A
	Infectious Diseases					N/A	N/A
	Nephrology					N/A	N/A
	Neurology					N/A	N/A
	Neurosurgery					N/A	N/A
	Oncology - Medical, Surgical					N/A	N/A
	Oncology - Radiation / Radiation Oncology					N/A	N/A
	Ophthalmology					N/A	N/A
	Oral Surgery					N/A	N/A
	Orthopedic Surgery					N/A	N/A
	Physiatry, Rehabilitative Medicine					N/A	N/A
	Plastic Surgery					N/A	N/A
	Podiatry					N/A	N/A
	Psychiatry					N/A	N/A
	Pulmonology					N/A	N/A
	Rheumatology					N/A	N/A
	Thoracic Surgery					N/A	N/A
	Urology					N/A	N/A
	Vascular Surgery					N/A	N/A

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Sheet 2: HSD-2

SSA State/County Code

Name of Physician or Mid-Level Practitioner

National Provider Identifier (NPI) Number

Specialty

Specialty Code

Contract Type

Provider Service Address

Provider Previously Listed?

Contracted Hospital Where Privelaged

Hospital NPI Number

If PCP, Accepts New Patients?

If PCP, Accepts Only Established Patients?

Does MCO Delegate Credentialing?

If Credentialing is Delegated, List Entity

Medical Group Affiliation

Employment Status

Street Address

City

State

Zip Code

County

Y or N

Y or N

Y or N

Y or N

MGA or DC

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Sheet 3: HSD2A

HSD-2A - CONTRACTS & SIGNATURE PAGES INDEX
(County) SERVICE AREA EXPANSION
PCP / Specialist/ Medical Group	Contract Templates				Existing Network
	Template A	Template B	Template C	Template D

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Sheet 4: HSD-3 Summary

SSA State/County Code	Facility or Service Type	Specialty Code	Total # of Providers/Services	# of Staffed, Medicare-Certified Beds
	Acute Inpatient Hospitals
	Cardiac Surgery Program			N/A
	Cardiac Catheterization Services			N/A
	Critical Care Services - Intensive Care Units (ICU)
	Outpatient Dialysis			N/A
	Surgical Services (Outpatient or ASC)			N/A
	Skilled Nursing Facilities
	Diagnostic Radiology			N/A
	Mammography			N/A
	Physical Therapy			N/A
	Occupational Therapy			N/A
	Speech Therapy			N/A
	Inpatient Psychiatric Facility Services
	Inpatient Substance Abuse
	Orthotics and Prosthetics			N/A
	Home Health			N/A
	Durable Medical Equipment			N/A
	Outpatient Infusion/Chemotherapy			N/A
	Laboratory Services			N/A
	Outpatient Mental Health			N/A
	Outpatient Substance Abuse			N/A
	Transplant Programs			N/A
	Heart Transplant Program			N/A
	Heart/Lung Transplant Program			N/A
	Intestinal Transplant Program			N/A
	Kidney Transplant Program			N/A
	Liver Transplant Program			N/A
	Lung Transplant Program			N/A
	Pancreas Transplant Program			N/A

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Sheet 5: HSD-3 Detail

SSA State/County Code	Facility or Service Type	Specialty Code	Medicare Certification Number (MCN)	National Provider Identifier (NPI) Number	# of Staffed, Medicare-Certified Beds	Provider Name	Provider Service Address
							Street Address	City	State	Zip Code	County

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Sheet 6: HSD3A

HSD-3A - CONTRACTS & SIGNATURE PAGES INDEX, ANCILLARY / HOSPITAL
Date Prepared:
Ancillary / Hospital				Tab Name		Existing Network

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Sheet 7: HSD 4

HSD4_Arrangements for Additional and Supplemental Benefits
Date Prepared:
Applies to plan(s):	Location					Dental Care	Providing Eye Glasses & Contacts	Providing Hearing Aids	Pharmacy Prescription Drugs (outpatient)	Screening - Hearing	Screening - Vision
Name of Provider	Street Address	City	State	Zip Code	County Served By Provider

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Sheet 8: HSD-5

HSD-5 - SIGNATURE AUTHORITY GRID
PRACTICE NAME	SIGNATURE AUTHORITY	PHYSICIANS