Crosswalk

Resources
Provider of MTM Services:
(Select all options that apply)
[ ] In-house staff
[ ] Pharmacist
[ ] Physician
[ ] Registered Nurse
[ ] Licensed Practical Nurse
[ ] Nurse Practitioner
[ ] Physician’s Assistant
[ ] Pharmacy intern under the direct supervision of a pharmacist
[ ] Pharmacy technician
[ ] Outside personnel
[ ] PBM
[ ] Name of PBM:
(May indicate up to 5 PBM names)
[ ] Pharmacist
[ ] Physician
[ ] Registered Nurse
[ ] Licensed Practical Nurse
[ ] Nurse Practitioner
[ ] Physician’s Assistant
[ ] Pharmacy intern under the direct supervision of a pharmacist
[ ] Pharmacy technician
[ ] Disease Management vendor
[ ] Name of vendor:
(May indicate up to 5 vendor names)
[ ] Pharmacist
[ ] Physician
[ ] Registered Nurse
[ ] Licensed Practical Nurse
[ ] Nurse Practitioner
[ ] Physician’s Assistant
[ ] Pharmacy intern under the direct supervision of a pharmacist
[ ] Pharmacy technician

[ ] Medication Therapy Management vendor Name of vendor:
[ ] Name of vendor:
(May indicate up to 5 vendor names)
[ ] In-house Pharmacist
[ ] Local Pharmacist
[ ] Physician
[ ] Registered Nurse
[ ] Licensed Practical Nurse
[ ] Nurse Practitioner
[ ] Physician’s Assistant
[ ] Pharmacy intern under the direct supervision of a pharmacist
[ ] Pharmacy technician
[ ] Local pharmacists
[ ] Long-Term Care (LTC) consultant pharmacists
[ ] Hospital pharmacists
[ ] Physician
[ ] Registered Nurse
[ ] Licensed Practical Nurse
[ ] Nurse Practitioner

[ ] Physician’s Assistant
[ ] Pharmacy intern under the direct supervision of a pharmacist
[ ] Pharmacy technician

Qualified Provider of Interactive, Person-to-Person CMR with written summaries
(Select all options that apply)
[ ] Local pharmacist
[ ] Long-Term Care (LTC) consultant pharmacist
[ ] Plan Sponsor Pharmacist
[ ] Plan Benefit Manager Pharmacist
[ ] MTM Vendor Local Pharmacist
[ ] MTM Vendor In-house Pharmacist
[ ] Disease Management Pharmacist
[ ] Hospital Pharmacist
[ ] Physician
[ ] Registered Nurse
[ ] Licensed Practical Nurse
[ ] Nurse Practitioner
[ ] Physician’s Assistant
[ ] Pharmacy intern under the direct supervision of a pharmacist

Mapping Qualified Provider of Interactive, Person-to-Person CMR with written summaries to Provider of
MTM Services

Qualified Provider of Interactive,
Person-to-Person CMR with written
summaries
Local pharmacist
Long-Term Care (LTC) consultant pharmacist

Plan Sponsor Pharmacist
Plan Benefit Manager Pharmacist

MTM Vendor Local Pharmacist

MTM Vendor In-house Pharmacist

Disease Management Pharmacist

Hospital Pharmacist
Physician
Registered Nurse
Licensed Practical Nurse
Nurse Practitioner
Physician’s Assistant
Pharmacy intern under the direct supervision
of a pharmacist

Corresponding Provider of MTM Services

•

Outside Personnel
o Local pharmacist
• Outside Personnel
o Long-Term Care (LTC) consultant
pharmacist
• In-house staff
o Pharmacist
• Outside Personnel
o PBM
 Pharmacist
• Outside Personnel
o Medication Therapy Management
vendor
 Local Pharmacist
• Outside Personnel
o Medication Therapy Management
vendor

In-house Pharmacist
• Outside Personnel
o Disease Management
 Pharmacist
• Outside Personnel
o Hospital pharmacists
Found under every Provider of MTM services group
above:
• In-house staff
• Outside personnel
o PBM
o Disease Management vendor
o Medication Therapy Management
vendor

NOTES:
• The text highlighted in yellow are new for the CY 2016 MTM module and should be
incorporated in the Resource sections a depicted in the above example.
• The 10 “Other” line item options under each section should still be included in the CY
2016 MTM Module. The “Other” line items were left off of this crosswalk/example to
highlight the specific matches in the crosswalk.
• Please remember to incorporate the rule: if a sponsor doesn’t check an entry under the
“Provider of MTM Services”, its crosswalk counterpart under Qualified Provider of

Interactive, Person-to-Person CMR with written summaries should not be available as a
selection (grayed out).