Three-Year Network Adequacy Review for Medicare Advantage Organizations

Medicare Advantage Network Adequacy Criteria Guidance
(Last updated: January 10, 2017)

4. Health Service Delivery Table Upload Instructions
Note: Detailed Technical instructions are outlined in the HPMS User Guides
Organizations must demonstrate that they have an adequate contracted provider network that is
sufficient to provide access to covered services, as required by 42 CFR 417.414, 42 CFR
417.416, 42 CFR 422.112(a)(1)(i) and 42 CFR 422.114(a)(3)(ii). Organizations are able to
demonstrate network adequacy through the submission of Provider and Facility Health Service
Delivery (HSD) Tables. Organizations shall only list providers and facilities with which the
organization has fully executed contracts on the HSD Tables. CMS considers a contract fully
executed when both parties have signed and should be executed on or prior to the HSD
submission deadline. The HSD Tables templates are available in Appendix H and Appendix J
and in the MA Download file in HPMS.

4.1 Populating the HSD Tables
4.1.1 Provider HSD Table
The Provider HSD Table is where you will list every contracted provider in your network. The
Provider HSD Table template has several fields to record the state/county code for the county
that the provider will be serving, the provider’s name, National Provider Identifier Number
(NPI), specialty, specialty code, contract type, provider service address, if accepts new patients,
medical group affiliation and if uses CMS MA contract amendment (see Appendix I for the
Provider HSD Table field definitions). CMS has created specific specialty codes for each
provider specialty type. Organizations must use these codes when completing the Provider HSD
Table (see Appendix D for a complete list of Provider Type specialty codes). If a provider serves
beneficiaries from multiple counties in the service area, list the provider multiple times on the
Provider HSD Table in the appropriate state/county code to account for each county. Providers
may serve enrollees residing in a different county/or state than their office locations. However,
organizations should not list contracted provider in state/county codes where enrollees could not
reasonably access services and that are outside the pattern of care (e.g. listing a primary care
provider practicing in California for a county in Massachusetts). Such extraneous listing of
provider affects CMS’ ability to quickly and efficiently assess provider networks against the
network adequacy criteria.
Organizations must ensure that the Provider HSD Table meets the conditions described below.
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Providers must not have opted out of Medicare.
Providers are not currently sanctioned by a federal program or relevant state licensing
boards.
Physicians and specialists must not be pediatric providers, as they do not routinely
provide services to the aged Medicare population.
Mid-level practitioners, such as physician assistants and nurse practitioners, must not be
used to satisfy the network adequacy criteria for specialties other than the Primary Care
Providers (see the HSD Reference File for additional conditions related to physician
assistants and nurse practitioners).

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Organizations are responsible for ensuring contracted providers meet state and federal licensing
requirements as well as the organization’s credentialing requirements for the specialty type prior
to including them on the Provider HSD Table. Verification of credentialing documentation may
be requested at any time. Including providers that are not qualified to provide the full range of
specialty services listed in the Provider HSD Table will result in inaccurate ACC results and
possible network deficiencies.
In order for the automated network review tool to appropriately process this information, MAOs
must submit Provider and Facility names and addresses exactly the same way each time they are
entered, including spelling, abbreviations, etc. Any errors will result in problems with processing
of submitted data and may result in findings of network deficiencies. CMS expects all
organizations to fully utilize the NMM to check their networks and to fully review the ACC
reports to ensure that their HSD tables are accurate and complete.
4.1.2 Facility HSD Table
The Facility HSD Table is where you will list every contracted facility in your network. Only
list the facilities that are contracted and Medicare-certified. Please do not list any additional
facilities or services except those included in the list of facility specialty codes (see Appendix E
for a complete list of Facility Type specialty codes). The Facility HSD Table template has
several fields to record the state/county code for the county that the facility will be serving,
facility or service type, NPI number, number of staffed/Medicare-certified beds, facility name,
provider service address, and if uses CMS MA contract amendment (see Appendix K for the
Facility HSD Table field definitions).
Facilities may serve enrollees residing in a different county and/or state than their office location.
However, organizations should NOT list contracted facilities in state/county codes where the
enrollee could not reasonably access services and that are outside the pattern of care. Such
extraneous listing of facilities affects CMS’ ability to quickly and efficiently assess facility
networks against the network adequacy criteria.
If the facility offers more than one of the defined services and/or provide services in multiple
counties, the facility should be listed multiple times with the appropriate “SSA State/County
Code” and “Specialty Code” for each service.

4.2 Organization-Initiated Testing of Contracted Networks
Organizations that received a contract ID number from CMS, either through the Notice of Intent
to Apply process or receipt of a signed contract, have the opportunity to test their contracted
networks’ compliance with network adequacy criteria at any time throughout the year via the
Network Management Module (NMM) in HPMS. To test networks, organizations may access
the following navigation path: HPMS Home Page>Monitoring>Network
Management>Organization Initiated Upload. Once an organization uploads their HSD tables
through the Organization Initiated Upload, HPMS will automatically review the contracted
network against CMS network adequacy criteria for each required provider and facility type in
each county.

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Medicare Advantage Network Adequacy Criteria Guidance
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The results of the HSD tables review will be available through the HSD Automated Criteria
Check (ACC) report in HPMS. The ACC reports may be accessed at the following navigation
path: HPMS Home Page>Monitoring>Network Management>ACC Extracts.
The ACC report displays the results of the automated network assessment for each provider and
facility. The results are displayed as either “PASS” or “FAIL”. Results displayed as “PASS”
means that the specific provider or facility met the CMS network adequacy criteria. Results
displayed as “FAIL” means that the specific provider or facility did not meet the criteria. In
addition, HPMS has available the HSD Zip Code Report that indicates the areas in which
enrollees do not have adequate access. The ACC reports may be accessed at the following
navigation path: HPMS Home Page>Monitoring>Network Management>ACC Extracts.
Organizations should use the feedback received during the network self-checks to revise HSD
tables and formally submit them by the application initial submission date.
Specific instructions on how to submit each table and access the ACC reports will be outlined in
the NMM Organization Quick Reference Guide. The NMM Reference Guide may be accessed at
the following navigation path: HPMS Home Page>Monitoring>Network Management>User
Guide>NMM Org Quick Reference User Guide.

4.3 CMS Network Adequacy Reviews
As discussed in section 1, several events trigger CMS’s review of an organization’s contracted
network. The type of triggering event dictates where CMS requires an organization to upload
their HSD tables, as shown in Table 4-1.
Table 4-1: HPMS Module for CMS Network Adequacy Reviews

Triggering Event

Application Module

Application
Provider-Specific Plan
Provider/Facility Contract
Termination
Change of Ownership
Network Access Complaint
Organization-Disclosed Network
Deficiency

Network Management
Module

X
X
X
X
X
X

As reflected in Table 4-1, the NMM supports network reviews of existing, operational contracts
only. The Application Module supports networks reviewed as part of the application review
process that qualifies an entity to offer Medicare Advantage plans in a service area pursuant to
42 CFR 422 Subpart K. The sections below provide instructions for uploading HSD tables in the
HPMS.
4.3.1 HPMS Application Module
By the application initial submission date, organizations will formally submit HSD tables via the
HPMS Online Application module. The Online Application upload requirements are completed
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Medicare Advantage Network Adequacy Criteria Guidance
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in the following navigation path: HPMS Home Page> Contract Management>Basic Contract
Management>Select Contract Number>Contract Management Start Page>Online
Application>Upload Files>HSD Tables. Organizations applying for a Service Area Expansion
(SAE) must upload HSD tables for the entire network not just the counties targeted in the SAE
application.
HSD tables will be automatically reviewed against CMS network adequacy criteria for each
required provider and facility type in each county. After each submission, the results of the HSD
tables review will be available through the HSD Automated Criteria Check (ACC) Report in
HPMS. The ACC reports may be accessed at the following navigation path: HPMS Home Page
> Contract Management > Basic Contract Management > Select Contract Number >
Submit Application Data > HSD Submission Reports.
4.3.2 HPMS Network Management Module
The NMM, Org-Initiated Functionality, may be used to check Networks against the current
criteria. To Utilize the Org-Initiated Functionality, please reference the User Guide located at:
HPMS Home Page>Monitoring>Network Management>User Guide.

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