CMS-10237 CY 2018 Medicare Advantage HSD Exception Request Templat

CY 2018 MEDICARE ADVANTAGE HEALTH SERVICE DELIVERY EXCEPTION REQUEST TEMPLATE
(File naming convention: Contract ID_County Code_Specialty Code) – 15 characters
Part I: Exception Information
Please enter the Contract ID, County/SSA Code, and Specialty Code, for which you are requesting an exception. The County Name, State, and
Specialty Name fields will auto-populate based on your responses. If you need to make changes to the fields, please delete the County/SSA Code
and the Specialty Code fields.
Contract ID
County/SSA Code
County Name
State
Specialty Code
Specialty Name

Part II: Rationale for Exception
Please respond to the questions below by selecting either "Yes" or "No" from the drop-down list for each question.
Question 1: Does the applicant attest that it
has reviewed publicly available databases
and other sources to determine availability
of providers/facilities with respect to the
exception being requested?
Question 2: If the applicant responded “yes”
to Question 1, above, did the applicant’s
review identify providers/facilities within
CMS’s network adequacy criteria, and with
which the applicant has not contracted?
Question 3: Did the applicant contract with
providers/facilities who are outside CMS’s
current network adequacy criteria?

OMB Control Number: 0938-0935 (Expires: TBD)

Question 4: Are there other non-contracted
providers/facilities outside CMS’s current
network adequacy criteria who are located
closer to plan enrollees?

Part III: Sources
In the rows below, please enter any sources (up to five) you used to identify provider/facilities within or nearby CMS’s network adequacy criteria.
To enter a source, select an option from the drop-down list, which is comprised of sources commonly used by MAOs and CMS. If you have more
than five sources, or a source not included on the drop-down list, please describe the additional sources in the Part IV: Narrative Text section
below. The drop-down options for the sources are:
-Physician Compare
-Hospital Compare
-Nursing Home Compare
-Dialysis Compare
-NPI file/NPPES
-Provider of Services (POS) file
-Direct outreach to provider
-Provider website
-State licensing data
-Online mapping tool
-Other (Note to MAOs: Please describe the other source(s) in the “Part IV: Narrative Text” section)
Additionally, if you select “Other,” please describe the other sources in the Part IV: Narrative Text section below.
Source 1

Source 2

Source 3

OMB Control Number: 0938-0935 (Expires: TBD)

Source 4

Source 5

Part IV: Narrative Text (Optional)
Please use the below box to enter any additional text to justify your exception request. This section may also be used to explain “Other” and
additional sources from the Part III: Sources section.

Part V: Table of Non-Contracted Providers
Please list below any providers/facilities you have identified within or nearby CMS's network adequacy criteria with whom you have not
contracted. Each additional provider/facility should be listed on a separate row. For each additional provider, please complete all columns. Please
note, the “Provider State” field and “Additional Notes on Reason for Not Contracting” field have drop-down lists. From the “Reason for Not
Contracting” drop-down list, you can select one of the following options:
-Provider is no longer practicing (e.g., deceased, retired),
-Provider does not provide services at the office/facility address listed in database,
-Provider does not provide services in the specialty type listed in the database and for which this exception is being requested,
-Provider has opted out of Medicare,
-Provider does not contract with any Medicare Advantage Organization,
-Sanctioned provider on List of Excluded Individuals and Entities,
-Inability to contract with provider (Note to MAOs: This is not a valid rationale for submitting an exception),
-In the process of negotiating a contract with provider (Note to MAOs: This is not a valid rationale for submitting an exception,
-Provider is at capacity and is not accepting new patients,
-Other (Note to MAOs: Please provide an explanation in the “Additional Notes on Reason for Not Contracting” field
If you need to provide additional notes, the “Additional Notes on Reason for Not Contracting” field is a free-text field without any character limits.
If you select “Other” from the “Reason for Not Contracting” drop-down list, please elaborate on this reason in the “Additional Notes on Reason for
Not Contracting” field.

OMB Control Number: 0938-0935 (Expires: TBD)

Provider/Facility Name

Provider Street
Address

OMB Control Number: 0938-0935 (Expires: TBD)

Provider City

Provider
State
(DropDown)

Provider
ZIP Code
(5 Digits)

Additional
Reason for
Provider Phone
Notes on
Not
NPI
Number
Contracting Reason for Not
(10 Digits)
(10 Digits)
Contracting
(Drop-Down)