Instructions for Completing CMS HSD Tables
Overview
Applicants will demonstrate network adequacy through submission of network information captured on Health Service Delivery (HSD) Tables reviewed through a largely automated process. The information on the HSD tables will be assessed against default adequacy measures for each required provider and facility type in each county. CMS expects to annually post the criteria for determining network adequacy in November of each year, prior to the final date for submission of the Notice of Intent to Apply.
Note: Network adequacy assessments for 2012 Special Needs Plan Applications will continue to be handled on a manual review basis.
HSD tables must be completed by those applying to offer any MA product-types that rely on contracted-networks. Non-network Private Fee-for-Service or Medicare Savings Account Applicants need not complete and submit these tables. Instructions specific to each HSD table are below.
The submitted tables should reflect only those providers and facilities that are contractually bound to serve the Applicant’s potential enrollees through fully executed contracts that are in place on the date of submission. (Contracts are considered fully executed only when signed by both parties.) The HSD tables are a major portion but not the only part of the network review. The documentation supporting the HSD data, including contract templates, signed contracts, and other documentation is required.
Applicants who do not meet the network criteria may request an Exception under limited and narrowly defined circumstances. An Exception may only be requested at the time of the initial application submission. Applicants seeking Exceptions for one or more provider/facility types for one or multiple counties must submit supporting documentation, as defined by CMS (see page___), in addition to the network information on the completed HSD tables. Exception requests must fall into one of CMS’ pre-defined Exception Types. Each Exception Request will be reviewed and approved or denied by CMS. Where CMS denies an Exception Request, the Applicant will need to further develop its network for that particular provider or facility type in that specific county to meet the relevant access criteria or anticipate denial of the submitted application.
SPECIALTY CODES
CMS has created specific specialty codes to each of the physician/provider and facility types. You must use the codes when completing your HSD tables (MA Provider and MA Facility tables).
Specialty Codes for the MA Provider Table
001 – General Practice
002 – Family Practice
003 – Internal Medicine
004 – Gerontology
005 – Primary Care – Physician Assistants
006 – Primary Care – Nurse Practitioners
007 – Allergy and Immunology
008 – Cardiac Surgery
009– Cardiology
010 - Chiropractor
011 – Dermatology
012 – Endocrinology
013 – ENT/Otolaryngology
014 – Gastroenterology
015 – General Surgery
016 – Gynecology, OB/GYN
017 – Infectious Diseases
018 - Nephrology
019 - Neurology
020 - Neurosurgery
021 - Oncology - Medical, Surgical
022 - Oncology - Radiation/Radiation Oncology
023 – Ophthalmology
024 - Oral Surgery
025 - Orthopedic Surgery
026 - Physiatry, Rehabilitative Medicine
027 - Plastic Surgery
028 - Podiatry
029 - Psychiatry
030 - Pulmonology
031 - Rheumatology
032 - Thoracic Surgery
033 - Urology
034 - Vascular Surgery
035 – NOT CURRENTLY IN USE
036 - Anesthesia
037 - Emergency Medicine
038 - Pathology
039 - Radiology
000 - OTHER
Specialty Codes for the MA Facility Table
040 – Acute Inpatient Hospitals
041 - Cardiac Surgery Program
042 - Cardiac Catheterization Services
043 - Critical Care Services – Intensive Care Units (ICU)
044 - Outpatient Dialysis
045 - Surgical Services (Outpatient or ASC)
046 - Skilled Nursing Facilities
047 - Diagnostic Radiology
048 - Mammography
049 - Physical Therapy
050 - Occupational Therapy
051 - Speech Therapy
052 - Inpatient Psychiatric Facility Services
053 - Inpatient Substance Abuse
054 - Orthotics and Prosthetics
055 - Home Health
056 - Durable Medical Equipment
057 - Outpatient Infusion/Chemotherapy
058 - Laboratory Services
059 - Outpatient Mental Health
060 - Outpatient Substance Abuse
061 - Heart Transplant Program
062 - Heart/Lung Transplant Program
063 - Intestinal Transplant Program
064 - Kidney Transplant Program
065 - Liver Transplant Program
066 - Lung Transplant Program
067 - Pancreas Transplant Program
HSD Table Instructions
The tables should reflect the applicants’ executed contracted network on the date of submission. For CMS purposes, contracts are considered fully executed when both parties have signed. Provider and Facility names and addresses MUST be entered exactly the same way each time, including spelling, abbreviations, etc. in order for the automated network review tool to appropriately process this information. Any errors will result in problems with processing of submitted data that may result in findings of network deficiencies.
MA Provider Table
This table captures information on the specific physicians/providers in the applicant’s contracted network. If a provider serves beneficiaries residing in multiple counties in the service area, list the provider multiple times with the appropriate state/county code to account for each county served. Providers that have opted out of Medicare cannot be included in the applicant’s contracted network or on this table.
Column Explanations
SSA State/County Code – Enter the SSA State/County code of the county which the listed physician/provider will serve. The state/county code is a five digit number. Please include any leading zeros (e.g., 01010). The state and county codes on the HSD Criteria Reference Table are the codes you should use. Format the cell as “text” to ensure that codes beginning with a “0” appear as five digits.
Name of Physician or Mid-Level Practitioner – Self-explanatory. Up to 150 characters.
National Provider Identifier (NPI) Number – The provider’s assigned NPI number must be included in this column. Enter the provider’s individual NPI number whether the provider is part of a medical group or not. The NPI is a ten digit numeric field. Include leading zeros.
Specialty – Name of specialty of listed physician/provider. This should be copied directly off of the HSD Criteria Reference Table.
Specialty Code – Specialty codes are unique codes assigned by CMS to process data. Enter the appropriate specialty code as described in Appendix A. If the applicant is proposing to rely on a provider type that is not on the CMS Specialty code list, please add a line to the HSD provider table and enter that provider’s information along with “000” (3 zeros) as the specialty code for that provider.
Contract Type – Enter the type of contract the Applicant holds with listed provider. Use “DC” for direct contract and “DS” for downstream (define DS) contract.
Provider Service Address Columns- Enter the address (i.e., street, city, state and zip code) of the location at which the provider sees patients. Do not list P.O. Box or street intersections.
Provider Service Address: Street Address – up to 250 characters
Provider Service Address: City – up to 150 characters
Provider Service Address: State – 2 characters
Provider Service Address: Zip Code – up to 10 characters
Provider Previously Listed – Enter "Y" if the provider is previously listed on this HSD table. Enter "N" if a provider is not previously listed on this table (i.e. for other counties or in the same county for another type of Specialty).
Contracted Hospital Where Privileged – Enter the name of the contracted hospital in the service area where the listed physician/provider has admitting privileges, other than courtesy privileges. If the provider does not have admitting privileges at a contracted hospital in the service area, please leave this cell blank. If the provider has admitting privileges at more than one contracted hospital in the service area, please insert additional rows into the table as needed and fill in all corresponding data on each line for all other contracted hospitals, in the service area, where the provider has admitting privileges. Note: The spelling of the contracted hospital(s) in this column must correspond exactly to the spelling of the contracted hospital as it is listed on the Facilities and Services HSD Table. Field Length is 250 characters.
Hospital National Provider Identifier (NPI) Number – Enter the NPI number for the contracted hospital(s) where the provider has admitting privileges. If the provider does not have admitting privileges at a contracted hospital in the service area, leave blank. The NPI number is a 10 digit numeric field. Include leading zeros.
If PCP Accepts New Patients? – Indicate if provider is accepting new patients by entering a "Y" or "N" response.
If PCP Accepts Established Patients? – Indicate if provider is limiting practice to only established patients by entering a "Y" or "N" response.
Does Applicant Delegate Credentialing? – Enter "Y" if the applicant delegates the credentialing of the physician. Enter "N" if the applicant does not delegate credentialing of the physician. If credentialing is not required, leave cell blank.
If Credentialing is Delegated, List Entity – - If credentialing is not performed by the applicant, enter the name of the entity that performs the credentialing. The name entered must match one of the entities listed on the Delegated Business Function Table in HPMS. (See Section 3.10.B of the consolidated Part C – Medicare Advantage Application.) Field Length is 250 characters.
Medical Group Affiliation – If provider is affiliated with a medical group/Individual Practice Association MG/IPA), list the name of the MG/IPA. If the applicant has a direct contract with the provider, then enter “DC.” Leave this column blank if the provider is not affiliated with a MG/IPA or does not have a direct contract with applicant.
Employment Status – For each provider affiliated with a medical group, enter an “E” if the provider is an employee of the MG/IPA or a “DS” if there is a downstream contract in place. Otherwise, leave this cell blank.
MA Facility Table
Only list the providers that are Medicare-certified providers. Please do not list any additional providers or services except those included in the list of facility specialty codes (page __).
If a facility offers more than one of the defined services and/or provides services in multiple counties, the facility should be listed multiple times with the appropriate “SSA State/County Code” and “Specialty Code” for each service.
Column Explanations:
SSA State/County Code – Enter the SSA State/County code of the county for which the listed facility will serve. The county code should be a five digit number. Please include any leading zeros (e.g., 01010). The state and county codes on the HSD Criteria Reference Table (page __) are the codes you should use. Format the cell as “text” to ensure that codes beginning with a “0” appear as five digits.
Facility or Service Type – Name of facility/service type of listed facility. This should be copied directly off of the HSD Criteria Reference Table (page __).
Specialty Code – Specialty codes are unique 3 digit numeric codes assigned by CMS (page __) to process data. Enter the Specialty Code that best describes the services offered by each facility or service. Include leading zeros.
Certification Number (CCN) – Enter the facility’s Medicare Certification Number (page __) in this column. If none, leave blank.
National Provider Identifier (NPI) Number – Enter the provider’s assigned NPI number in this column. The NPI is a ten digit numeric field. Include leading zeros.
Number of Staffed, Medicare-Certified Beds – For Acute Inpatient Hospitals, ICUs, Skilled Nursing Facilities, Inpatient Psychiatric, and Inpatient Substance Abuse, enter the number of Medicare-certified beds for which the Applicant has contracted access for Medicare Advantage enrollees. This number should not include Neo-Natal Intensive Care Unit (NICU) beds.
Facility Name – Enter the name of the facility. Field Length is 150 characters.
Provider Service Address Columns- Enter the address (i.e., street, city, state and zip code) from which the provider serves patients. Do not list P.O. Box or street intersections. For DME and Home Health, indicate the business address where one would contact these vendors.
Provider Service Address: Street Address – up to 250 characters
Provider Service Address: City – up to 150 characters
Provider Service Address: State – 2 characters
Provider Service Address: Zip Code – up to 10 characters
MA Contract and Signature Index- Providers
The purpose of this index is to link contracted primary care and specialty physicians listed in the MA Provider Table to the template(s) contract used to execute the relationship between the applicant and the provider. For MA applicants, requesting a SAE, the grid will also serve to document whether any of the applicant’s current providers will be part of the network available in the expansion area.
Column Explanations:
PCP/Specialist – Enter the contract name as indicated in the CMS MA Provider Table for all contracted PCPs and specialists.
B – E. Contract Template – Indicate the specific contract template(s) as executed between the applicant and the physician reflected in the PCP/Specialist column. For direct contracted physicians, the applicant must list a single template. For a physician affiliated with an IPA or medical group, whose contracted relationship with the applicant is downstream, the applicant must list the first tier template contract as well as all downstream template contracts.
F. Existing Network for SAE applicants– Indicate whether the provider is part of the applicant’s established network for its existing service area.
MA Contract and Signature Index - Facilities
The purpose of this index is to link contracted ancillary or hospital providers listed in MA Facility Table to the template contract used to execute the official relationship between the applicant and the provider. The grid will also serve to document whether any of the applicant’s current providers will be part of the network relied upon in the expansion area/network.
Column Explanations:
Ancillary/Hospital – Enter the contracted provider’s name as indicated in the MA Facility Table for all ancillary and hospital contracts.
B – E. Contract Template – Enter the template contract as executed between the provider and the applicant.
F. Existing Network for SAE Applicants – Indicate whether the provider is part of the applicant’s established network for its existing service area. (Not applicable for new MA applicants)
MA Additional and Supplemental Benefits Table
Instructions
If an Applicant is offering Additional and Supplemental Benefits other than those listed in the Additional and Supplemental Benefits Table, the Applicant may add an additional column(s) to the right of the last column on Additional and Supplemental Benefits Table and enter the name of the benefit/service at the top of the column.
Only list the providers who provide the additional and supplemental benefit services as listed in the "services" columns (columns G-L). Note: if other services are added to the right of the "Screening-Vision" column (column L), those providers should also be listed.
If any providers listed on the CMS MA Provider Table provide the services listed on the Additional and Supplemental Benefits Table, list them as follows:
If any of the specialty providers listed on the CMS MA Provider Table provide one or more of the benefits/services listed in columns G – L of the Additional and Supplemental Benefits Table, enter the name of the specialty in column A (Name of Provider); leave columns B – F blank and place an “X” in the applicable benefit/service column (G – L).
If any of the providers listed as “PCP” on the CMS MA Provider Table provide one or more of the benefits/services listed in columns G – L of the Additional and Supplemental Benefits Table, enter “PCP” in column A (Name of Provider); leave columns B – F blank and place an “X” in the applicable benefit/service column (G – L).
Please list all direct and downstream providers of services.
Arrange benefits alphabetically by county and then numerically by zip code.
Column Explanations:
Name of Provider – Enter name of the contracted provider, for example – Comfort Dental Group(Dental); Comfort Eyewear Associates (Eyeglasses/Contacts); Comfort Hearing Aids Associates (Hearing Aids); XYZ Pharmacy (Prescription Drugs – outpatient); Comfort Hearing, Inc. (Screening-Hearing); Comfort Vision Specialists (Screening – Vision).
Street Address
City
State
Zip Code
County Served by Provider – List the county the provider serves from this location. (If more than one county is served, repeat information as entered in columns A-E and columns G-L, changing column G as applicable.) Examples: Canyon County, Peaks County.
G - L. Services – For the providers that are listed in Column A, please indicate which benefit/service they provide by placing an “X” in the applicable box (cell).
CMS MA Signature Authority Grid
The purpose of this grid is to document whether physicians of a contracted provider group are employees of the medical practice. The grid should display the medical group, the person authorized to sign contracts on behalf of the group and the roster of employed physicians of that group.
Column Explanations:
Practice Name – The name of the provider group for which a single signature authority exists on behalf of the group.
Signature Authority – The representative of the medical practice with authority to execute arrangements on behalf of the group.
Physicians – List all of the physicians in MA Physicians and other Practitioners HSD Table for which the signature authority is applicable
HSD Exceptions Guidance - Requesting Exceptions
If an applicant discovers Application deficiencies during the pre-check review which indicate the submitted network does not meet the minimum provider/bed number, time and/or distance requirements for any individual provider/facility type in a particular county, Applicant may request an Exception for that deficiency under the following circumstances:
Patterns of care in the county do not support need for the requested number of the specific provider/facility type
(Limited to RPPO applicants) – The RPPO applicant is relying on Alternative Arrangements to meet access requirements for this provider/facility type in this county.
Applicants requesting Exceptions must submit their requests as described in CMS Health Service Delivery Tables Exceptions Guidance on the CMS website.
Page
Draft 2012 HSD Instructions (30 day notice)
| File Type | application/msword |
| Author | CMS |
| Last Modified By | CMS |
| File Modified | 2010-09-03 |
| File Created | 2010-09-03 |