Three-Year Network Adequacy Review for Medicare Advantage Organizations

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Medicare
7500 Security Boulevard
Baltimore, Maryland 21244-1850

MEDICARE DRUG & HEALTH PLAN CONTRACT ADMINISTRATION GROUP
NOTICE OF ENTIRE NETWORK REVIEW
Month XX, 20XX
Contract ID: HXXXX

<CONTRACT/LEGAL ENTITY NAME>
<ADDRESS>
<CITY>, <STATE> <ZIP>
VIA E-MAIL: <COMPLIANCE OFFICER E-MAIL>
Dear <Mr./Ms.> <COMPLIANCE OFFICER SURNAME>:

CMS has determined that [MAO Name] has not received an entire network review for Contract
[HXXXX] since [Date of last entire network upload for this contract #]. CMS regulations at 42
CFR 417.414, 417.416, 422.112(a)(1)(i), and 422.114(a)(3)(ii) require that all Medicare
Advantage organizations (MAOs) offering coordinated care plans, network-based private feefor-service (PFFS) plans, and network-based medical savings account (MSA) plans, as well as
section 1876 cost organizations, maintain a network of appropriate providers that is sufficient to
provide adequate access to covered services to meet the needs of the population served.
In order for CMS to verify that [MAO Name] is compliant with current CMS network adequacy
criteria, the organization is required to upload its entire network for Contract [HXXXX] to the
Network Management Module (NMM) in the Health Plan Management System (HPMS) by
[Due Date—60 days after date of this letter]. The current CMS Medicare Advantage Network
Adequacy Criteria Guidance is updated and published annually on CMS’s Medicare Advantage
Applications website. Additional network policy guidance is also located in chapter 4 of the
Medicare Managed Care Manual.
The NMM submission gates will open on [DATE—50 days after date of this letter], at
8:00AM EST, and will close on [DATE—10 days after gates open], at 6:00PM EST. Please
upload the Health Service Delivery (HSD) tables for [HXXXX] within this timeframe. To locate
the NMM in HPMS, look under the “Monitoring” tab and select “Network Management.” Refer
to the “Plan User Guide” under “Guidance” for instructions on how to upload the HSD tables.
In the rare case where a specialty type cannot meet the current CMS network adequacy criteria
for a specific county, an Exception Request may be submitted to CMS for consideration
following the HSD table upload. All previously approved Exception Requests and Partial
County Justifications must be resubmitted using the current templates.

If, upon review of the entire network and Exception Requests for Contract [HXXXX], CMS
finds network deficiencies, [MAO Name] will be considered noncompliant with current CMS
network adequacy criteria and may be subject to compliance actions. Please note, CMS will
require the next entire network review for Contract [HXXXX] at least three years from the date
of the present review.
If you have any questions about this request, please submit an inquiry to the Medicare Part C
Policy Mailbox, located at: https://dpap.lmi.org. If you need technical assistance with your
network upload, please contact the HPMS Help Desk at hpms@cms.hhs.gov.
Thank you for your cooperation.
Sincerely,

Kathryn A. Coleman
Director

PRA Disclosure Statement
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PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

</pre><Table class="table"><tr><Td>File Type</td><td>application/pdf</td></tr><tr><Td>File Title</td><td>Notice of Entire Network Review</td></tr><tr><Td>Author</td><td>Theresa Wachter</td></tr><tr><Td>File Modified</td><td>2017-08-15</td></tr><tr><Td>File Created</td><td>2017-07-20</td></tr></table></div></div></div><hr>
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