MCPS Survey Sample Design

ATTACHMENT 1
MCPSS NATIONAL IMPLEMENTATION
SAMPLE DESIGN

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

FI

01: Assoc Hosp Serv, ME

1: Hospital

14

ME

50

21%

25

0

25

FI

01: Assoc Hosp Serv, ME

2: SNF

14

ME

99

42%

50

0

50

FI

01: Assoc Hosp Serv, ME

3: RHC

14

ME

47

20%

24

0

24

FI

01: Assoc Hosp Serv, ME

5: FQHC

14

MA

1

0%

1

0

1

FI

01: Assoc Hosp Serv, ME

8: Other

13

CT

17

7%

9

0

9

FI

01: Assoc Hosp Serv, ME

8: Other

14

MA

3

1%

2

0

2

FI

01: Assoc Hosp Serv, ME

8: Other

14

ME

12

5%

6

0

6

FI

01: Assoc Hosp Serv, ME

8: Other

14

NH

3

1%

2

0

2

FI

01: Assoc Hosp Serv, ME

8: Other

14

RI

2

1%

1

0

1

FI

01: Assoc Hosp Serv, ME

8: Other

14

VT

1

0%

1

0

1
39

FI

02: Assoc Hosp Serv, MA

1: Hospital

14

MA

94

27%

39

0

FI

02: Assoc Hosp Serv, MA

2: SNF

13

CT

4

1%

2

0

2

FI

02: Assoc Hosp Serv, MA

2: SNF

13

NY

3

1%

1

0

1

FI

02: Assoc Hosp Serv, MA

2: SNF

14

MA

141

41%

59

0

59

FI

02: Assoc Hosp Serv, MA

4: ESRD

12

NJ

12

3%

5

0

5

FI

02: Assoc Hosp Serv, MA

4: ESRD

13

CT

5

1%

2

0

2
17

FI

02: Assoc Hosp Serv, MA

4: ESRD

14

MA

41

12%

17

0

FI

02: Assoc Hosp Serv, MA

4: ESRD

14

ME

10

3%

4

0

4

FI

02: Assoc Hosp Serv, MA

4: ESRD

14

NH

8

2%

3

0

3

FI

02: Assoc Hosp Serv, MA

4: ESRD

14

RI

13

4%

5

0

5

FI

02: Assoc Hosp Serv, MA

8: Other

14

MA

13

4%

5

0

5

FI

03: AdminaStar Federal

1: Hospital

06

IL

190

12%

21

9

30

FI

03: AdminaStar Federal

1: Hospital

08

IN

167

11%

18

12

30

FI

03: AdminaStar Federal

1: Hospital

08

ZZ

1

0%

0

0

0

FI

03: AdminaStar Federal

1: Hospital

15

KY

111

7%

12

18

30

FI

03: AdminaStar Federal

1: Hospital

15

OH

225

14%

24

6

30

FI

03: AdminaStar Federal

1: Hospital

99

ZZ

7

0%

1

0

1

FI

03: AdminaStar Federal

2: SNF

06

IL

438

28%

47

0

47

FI

03: AdminaStar Federal

2: SNF

06

ZZ

13

1%

1

0

1

FI

03: AdminaStar Federal

2: SNF

08

IN

362

23%

39

0

39

FI

03: AdminaStar Federal

2: SNF

08

MI

71

5%

8

22

30

FI

03: AdminaStar Federal

2: SNF

15

KY

221

14%

24

6

30

FI

03: AdminaStar Federal

2: SNF

15

OH

854

55%

92

0

92

FI

03: AdminaStar Federal

2: SNF

99

ZZ

236

15%

26

0

26

Page 1

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

FI

03: AdminaStar Federal

3: RHC

99

ZZ

94

6%

10

20

30

FI

03: AdminaStar Federal

4: ESRD

06

IL

72

5%

8

22

30
30

FI

03: AdminaStar Federal

4: ESRD

12

PA

62

4%

7

23

FI

03: AdminaStar Federal

4: ESRD

12

ZZ

27

2%

3

0

3

FI

03: AdminaStar Federal

4: ESRD

15

OH

97

6%

10

20

30

FI

03: AdminaStar Federal

4: ESRD

15

ZZ

42

3%

5

0

5

FI

03: AdminaStar Federal

4: ESRD

99

ZZ

100

6%

11

0

11
7

FI

03: AdminaStar Federal

8: Other

06

IL

63

4%

7

0

FI

03: AdminaStar Federal

8: Other

15

KY

82

5%

9

0

9

FI

03: AdminaStar Federal

8: Other

15

OH

109

7%

12

0

12

FI

03: AdminaStar Federal

8: Other

99

ZZ

54

3%

6

0

6

FI

04: Cahaba GBA

1: Hospital

03

SD

73

6%

17

13

30

FI

04: Cahaba GBA

1: Hospital

03

ZZ

5

0%

1

0

1

FI

04: Cahaba GBA

1: Hospital

05

IA

153

12%

36

0

36

FI

04: Cahaba GBA

1: Hospital

05

ZZ

2

0%

0

0

0

FI

04: Cahaba GBA

1: Hospital

10

AL

112

9%

26

4

30

FI

04: Cahaba GBA

1: Hospital

10

ZZ

7

1%

2

0

2

FI

04: Cahaba GBA

1: Hospital

99

ZZ

65

5%

15

0

15

FI

04: Cahaba GBA

2: SNF

03

SD

66

5%

15

15

30

FI

04: Cahaba GBA

2: SNF

03

ZZ

22

2%

5

0

5

FI

04: Cahaba GBA

2: SNF

05

IA

323

25%

75

0

75

FI

04: Cahaba GBA

2: SNF

05

ZZ

50

4%

12

0

12

FI

04: Cahaba GBA

2: SNF

10

AL

90

7%

21

9

30

FI

04: Cahaba GBA

2: SNF

10

ZZ

1

0%

0

0

0

FI

04: Cahaba GBA

2: SNF

99

ZZ

135

10%

31

0

31

FI

04: Cahaba GBA

3: RHC

05

IA

69

5%

16

14

30

FI

04: Cahaba GBA

3: RHC

05

ZZ

4

0%

1

0

1

FI

04: Cahaba GBA

3: RHC

99

ZZ

37

3%

9

0

9

FI

04: Cahaba GBA

8: Other

05

IA

128

10%

30

0

30

FI

04: Cahaba GBA

8: Other

05

ZZ

37

3%

9

0

9

FI

04: Cahaba GBA

8: Other

10

ZZ

76

6%

18

0

18

FI

04: Cahaba GBA

8: Other

99

ZZ

268

20%

62

0

62

FI

06: PBS / BCBS Arkansas

1: Hospital

07

AR

88

8%

49

0

49

FI

06: PBS / BCBS Arkansas

1: Hospital

14

RI

16

1%

9

0

9

Page 2

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

FI

06: PBS / BCBS Arkansas

2: SNF

07

AR

137

12%

77

0

77

FI

06: PBS / BCBS Arkansas

2: SNF

14

RI

78

7%

44

0

44

FI

06: PBS / BCBS Arkansas

3: RHC

05

MO

1

0%

1

0

1

FI

06: PBS / BCBS Arkansas

3: RHC

07

AR

30

3%

17

0

17
12

FI

06: PBS / BCBS Arkansas

8: Other

07

AR

22

2%

12

0

FI

06: PBS / BCBS Arkansas

8: Other

14

RI

5

0%

3

0

3

FI

07: First Coast Service

1: Hospital

09

FL

154

27%

49

0

49

FI

07: First Coast Service

1: Hospital

99

ZZ

16

3%

5

0

5

FI

07: First Coast Service

2: SNF

09

FL

410

72%

130

0

130

FI

07: First Coast Service

2: SNF

99

ZZ

3

1%

1

0

1

FI

07: First Coast Service

4: ESRD

09

FL

68

12%

22

8

30

FI

07: First Coast Service

4: ESRD

99

ZZ

4

1%

1

0

1

FI

07: First Coast Service

8: Other

09

FL

603

106%

191

0

191

FI

07: First Coast Service

8: Other

99

ZZ

5

1%

2

0

2

FI

08: BCBS Georgia

1: Hospital

10

GA

144

3%

26

0

26
18

FI

08: BCBS Georgia

2: SNF

10

GA

101

2%

18

0

FI

08: BCBS Georgia

3: RHC

10

GA

45

1%

8

0

8

FI

08: BCBS Georgia

4: ESRD

01

CA

89

2%

16

0

16

FI

08: BCBS Georgia

4: ESRD

01

NV

4

0%

1

0

1

FI

08: BCBS Georgia

4: ESRD

02

OR

4

0%

1

0

1

FI

08: BCBS Georgia

4: ESRD

03

AZ

12

0%

2

0

2

FI

08: BCBS Georgia

4: ESRD

03

MT

4

0%

1

0

1

FI

08: BCBS Georgia

4: ESRD

04

CO

2

0%

0

0

0

FI

08: BCBS Georgia

4: ESRD

04

NM

8

0%

1

0

1
1

FI

08: BCBS Georgia

4: ESRD

04

OK

5

0%

1

0

FI

08: BCBS Georgia

4: ESRD

04

TX

39

1%

7

0

7

FI

08: BCBS Georgia

4: ESRD

05

IA

2

0%

0

0

0
1

FI

08: BCBS Georgia

4: ESRD

05

KS

5

0%

1

0

FI

08: BCBS Georgia

4: ESRD

05

MO

41

1%

7

0

7

FI

08: BCBS Georgia

4: ESRD

05

NE

9

0%

2

0

2

FI

08: BCBS Georgia

4: ESRD

06

IL

15

0%

3

0

3

FI

08: BCBS Georgia

4: ESRD

06

WI

16

0%

3

0

3

FI

08: BCBS Georgia

4: ESRD

07

AR

1

0%

0

0

0

FI

08: BCBS Georgia

4: ESRD

07

LA

35

1%

6

0

6

Page 3

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

FI

08: BCBS Georgia

4: ESRD

07

MS

5

0%

1

0

1

FI

08: BCBS Georgia

4: ESRD

08

IN

4

0%

1

0

1

FI

08: BCBS Georgia

4: ESRD

08

MI

17

0%

3

0

3

FI

08: BCBS Georgia

4: ESRD

09

FL

65

1%

12

0

12

FI

08: BCBS Georgia

4: ESRD

10

AL

53

1%

10

0

10

FI

08: BCBS Georgia

4: ESRD

10

GA

124

3%

22

0

22

FI

08: BCBS Georgia

4: ESRD

10

TN

61

1%

11

0

11

FI

08: BCBS Georgia

4: ESRD

11

NC

18

0%

3

0

3

FI

08: BCBS Georgia

4: ESRD

11

SC

39

1%

7

0

7

FI

08: BCBS Georgia

4: ESRD

11

VA

27

1%

5

0

5

FI

08: BCBS Georgia

4: ESRD

11

WV

2

0%

0

0

0

FI

08: BCBS Georgia

4: ESRD

12

DC

4

0%

1

0

1

FI

08: BCBS Georgia

4: ESRD

12

MD

26

1%

5

0

5

FI

08: BCBS Georgia

4: ESRD

12

NJ

29

1%

5

0

5

FI

08: BCBS Georgia

4: ESRD

12

PA

59

1%

11

0

11

FI

08: BCBS Georgia

4: ESRD

13

CT

14

0%

3

0

3

FI

08: BCBS Georgia

4: ESRD

13

NY

12

0%

2

0

2

FI

08: BCBS Georgia

4: ESRD

14

MA

19

0%

3

0

3

FI

08: BCBS Georgia

4: ESRD

14

ME

2

0%

0

0

0

FI

08: BCBS Georgia

4: ESRD

14

NH

1

0%

0

0

0

FI

08: BCBS Georgia

4: ESRD

14

RI

2

0%

0

0

0

FI

08: BCBS Georgia

4: ESRD

15

KY

18

0%

3

0

3

FI

08: BCBS Georgia

4: ESRD

15

OH

34

1%

6

0

6

FI

08: BCBS Georgia

8: Other

10

GA

59

1%

11

0

11

FI

09: BCBS of Kansas

1: Hospital

05

KS

147

10%

85

0

85

FI

09: BCBS of Kansas

2: SNF

04

OK

1

0%

1

0

1

FI

09: BCBS of Kansas

2: SNF

05

KS

130

9%

75

0

75

FI

09: BCBS of Kansas

2: SNF

05

MO

6

0%

3

0

3

FI

09: BCBS of Kansas

2: SNF

07

AR

1

0%

1

0

1

FI

09: BCBS of Kansas

3: RHC

05

KS

102

7%

59

0

59

FI

09: BCBS of Kansas

3: RHC

05

NE

1

0%

1

0

1

FI

09: BCBS of Kansas

4: ESRD

05

KS

11

1%

6

0

6

FI

09: BCBS of Kansas

8: Other

05

KS

15

1%

9

0

9

FI

09: BCBS of Kansas

8: Other

05

MO

1

0%

1

0

1

Page 4

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

FI

11: Trispan Health Service

1: Hospital

05

MO

64

4%

18

12

30

FI

11: Trispan Health Service

1: Hospital

07

LA

162

9%

45

0

45
30

FI

11: Trispan Health Service

1: Hospital

07

MS

95

5%

26

4

FI

11: Trispan Health Service

1: Hospital

99

ZZ

5

0%

1

0

1

FI

11: Trispan Health Service

2: SNF

05

MO

271

15%

75

0

75

FI

11: Trispan Health Service

2: SNF

05

ZZ

10

1%

3

0

3

FI

11: Trispan Health Service

2: SNF

07

LA

248

14%

68

0

68
36

FI

11: Trispan Health Service

2: SNF

07

MS

129

7%

36

0

FI

11: Trispan Health Service

2: SNF

07

ZZ

29

2%

8

0

8

FI

11: Trispan Health Service

2: SNF

99

ZZ

39

2%

11

0

11
30

FI

11: Trispan Health Service

3: RHC

05

MO

80

4%

22

8

FI

11: Trispan Health Service

3: RHC

07

MS

64

4%

18

12

30

FI

11: Trispan Health Service

3: RHC

07

ZZ

36

2%

10

0

10

FI

11: Trispan Health Service

3: RHC

99

ZZ

2

0%

1

0

1

FI

11: Trispan Health Service

4: ESRD

07

ZZ

50

3%

14

16

30

FI

11: Trispan Health Service

4: ESRD

99

ZZ

9

1%

2

0

2

FI

11: Trispan Health Service

8: Other

07

LA

81

5%

22

0

22
13

FI

11: Trispan Health Service

8: Other

07

ZZ

46

3%

13

0

FI

11: Trispan Health Service

8: Other

99

ZZ

30

2%

8

0

8

FI

13: BCBS Nebraska

1: Hospital

05

NE

84

35%

49

0

49

FI

13: BCBS Nebraska

2: SNF

05

NE

11

5%

6

0

6

FI

13: BCBS Nebraska

3: RHC

05

NE

76

31%

44

0

44

FI

13: BCBS Nebraska

4: ESRD

05

NE

5

2%

3

0

3

FI

13: BCBS Nebraska

8: Other

05

NE

6

2%

3

0

3

FI

14: Chisholm Adm Service

1: Hospital

04

OK

122

469%

67

0

67

FI

14: Chisholm Adm Service

2: SNF

04

OK

22

85%

12

0

12

FI

14: Chisholm Adm Service

3: RHC

04

OK

21

81%

12

0

12

FI

14: Chisholm Adm Service

8: Other

04

OK

20

77%

11

0

11

FI

15: Palmetto, GBA

1: Hospital

11

NC

127

25%

56

0

56

FI

15: Palmetto, GBA

1: Hospital

11

SC

55

11%

24

6

30

FI

15: Palmetto, GBA

2: SNF

11

NC

293

58%

130

0

130

FI

15: Palmetto, GBA

2: SNF

11

SC

113

22%

50

0

50

FI

15: Palmetto, GBA

2: SNF

11

ZZ

4

1%

2

0

2

FI

15: Palmetto, GBA

2: SNF

99

ZZ

3

1%

1

0

1

Page 5

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

FI

15: Palmetto, GBA

4: ESRD

11

NC

85

17%

38

0

FI

15: Palmetto, GBA

4: ESRD

11

ZZ

45

9%

20

0

38
20

FI

15: Palmetto, GBA

8: Other

11

NC

67

13%

30

0

30

FI

15: Palmetto, GBA

8: Other

11

SC

55

11%

24

0

24

FI

15: Palmetto, GBA

8: Other

99

ZZ

53

11%

24

0

24

FI

16: Riverbend, GBA

1: Hospital

10

TN

118

3%

18

12

30

FI

16: Riverbend, GBA

1: Hospital

10

ZZ

1

0%

0

0

0

FI

16: Riverbend, GBA

1: Hospital

12

NJ

131

4%

20

10

30

FI

16: Riverbend, GBA

1: Hospital

99

ZZ

6

0%

1

0

1

FI

16: Riverbend, GBA

2: SNF

10

TN

195

5%

29

1

30

FI

16: Riverbend, GBA

2: SNF

10

ZZ

8

0%

1

0

1

FI

16: Riverbend, GBA

2: SNF

12

NJ

222

6%

33

0

33

FI

16: Riverbend, GBA

2: SNF

12

ZZ

18

0%

3

0

3

FI

16: Riverbend, GBA

2: SNF

99

ZZ

268

7%

40

0

40

FI

16: Riverbend, GBA

3: RHC

01

CA

129

3%

19

11

30

FI

16: Riverbend, GBA

3: RHC

02

WA

59

2%

9

21

30

FI

16: Riverbend, GBA

3: RHC

02

ZZ

56

2%

8

0

8

FI

16: Riverbend, GBA

3: RHC

05

IA

69

2%

10

20

30

FI

16: Riverbend, GBA

3: RHC

05

KS

69

2%

10

20

30

FI

16: Riverbend, GBA

3: RHC

05

MO

153

4%

23

7

30

FI

16: Riverbend, GBA

3: RHC

05

ZZ

25

1%

4

0

4

FI

16: Riverbend, GBA

3: RHC

06

IL

147

4%

22

8

30

FI

16: Riverbend, GBA

3: RHC

06

ZZ

50

1%

7

0

7

FI

16: Riverbend, GBA

3: RHC

07

MS

71

2%

11

19

30

FI

16: Riverbend, GBA

3: RHC

08

MI

81

2%

12

18

30

FI

16: Riverbend, GBA

3: RHC

08

ZZ

37

1%

6

0

6

FI

16: Riverbend, GBA

3: RHC

09

FL

74

2%

11

19

30

FI

16: Riverbend, GBA

3: RHC

10

ZZ

116

3%

17

13

30

FI

16: Riverbend, GBA

3: RHC

11

NC

75

2%

11

19

30

FI

16: Riverbend, GBA

3: RHC

11

SC

66

2%

10

20

30

FI

16: Riverbend, GBA

3: RHC

15

KY

82

2%

12

18

30

FI

16: Riverbend, GBA

3: RHC

15

ZZ

8

0%

1

0

1

FI

16: Riverbend, GBA

3: RHC

99

ZZ

2

0%

0

0

0

FI

16: Riverbend, GBA

4: ESRD

10

ZZ

118

3%

18

12

30

Page 6

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

FI

16: Riverbend, GBA

4: ESRD

99

ZZ

74

2%

11

0

11

FI

16: Riverbend, GBA

8: Other

10

TN

73

2%

11

0

11

FI

16: Riverbend, GBA

8: Other

10

ZZ

1

0%

0

0

0

FI

16: Riverbend, GBA

8: Other

12

NJ

62

2%

9

0

9

FI

16: Riverbend, GBA

8: Other

99

ZZ

16

0%

2

0

2

FI

18: COSVI

1: Hospital

09

PR

63

54%

27

0

27

FI

18: COSVI

1: Hospital

09

VI

4

3%

2

0

2

FI

18: COSVI

2: SNF

09

PR

6

5%

3

0

3

FI

18: COSVI

4: ESRD

09

PR

9

8%

4

0

4

FI

18: COSVI

4: ESRD

09

VI

1

1%

0

0

0

FI

18: COSVI

5: FQHC

09

PR

1

1%

0

0

0

FI

18: COSVI

8: Other

09

PR

8

7%

3

0

3

FI

19: Empire Medicare Service

1: Hospital

13

NY

335

20%

88

0

88

FI

19: Empire Medicare Service

1: Hospital

13

ZZ

51

3%

13

0

13

FI

19: Empire Medicare Service

1: Hospital

99

ZZ

10

1%

3

0

3

FI

19: Empire Medicare Service

2: SNF

13

CT

214

13%

56

0

56

FI

19: Empire Medicare Service

2: SNF

13

NY

644

38%

169

0

169

FI

19: Empire Medicare Service

2: SNF

99

ZZ

72

4%

19

0

19

FI

19: Empire Medicare Service

4: ESRD

13

NY

121

7%

32

0

32

FI

19: Empire Medicare Service

4: ESRD

13

ZZ

6

0%

2

0

2

FI

19: Empire Medicare Service

4: ESRD

99

ZZ

4

0%

1

0

1
14

FI

19: Empire Medicare Service

8: Other

13

ZZ

54

3%

14

0

FI

19: Empire Medicare Service

8: Other

99

ZZ

13

1%

3

0

3

FI

20: Mutual Omaha-Medicare Div

1: Hospital

01

CA

152

5%

11

19

30

FI

20: Mutual Omaha-Medicare Div

1: Hospital

01

ZZ

45

2%

3

0

3

FI

20: Mutual Omaha-Medicare Div

1: Hospital

04

TX

169

6%

12

18

30

FI

20: Mutual Omaha-Medicare Div

1: Hospital

04

ZZ

94

3%

7

0

7

FI

20: Mutual Omaha-Medicare Div

1: Hospital

05

MO

101

3%

7

23

30

FI

20: Mutual Omaha-Medicare Div

1: Hospital

05

ZZ

37

1%

3

0

3

FI

20: Mutual Omaha-Medicare Div

1: Hospital

07

LA

79

3%

6

24

30

FI

20: Mutual Omaha-Medicare Div

1: Hospital

07

ZZ

37

1%

3

0

3

FI

20: Mutual Omaha-Medicare Div

1: Hospital

09

FL

79

3%

6

24

30

FI

20: Mutual Omaha-Medicare Div

1: Hospital

10

ZZ

83

3%

6

24

30

FI

20: Mutual Omaha-Medicare Div

1: Hospital

12

PA

69

2%

5

25

30

Page 7

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

FI

20: Mutual Omaha-Medicare Div

1: Hospital

12

ZZ

18

1%

1

0

1

FI

20: Mutual Omaha-Medicare Div

1: Hospital

99

ZZ

266

9%

20

0

20

FI

20: Mutual Omaha-Medicare Div

2: SNF

01

CA

678

23%

50

0

50

FI

20: Mutual Omaha-Medicare Div

2: SNF

01

ZZ

20

1%

1

0

1

FI

20: Mutual Omaha-Medicare Div

2: SNF

02

WA

110

4%

8

22

30

FI

20: Mutual Omaha-Medicare Div

2: SNF

02

ZZ

47

2%

3

0

3

FI

20: Mutual Omaha-Medicare Div

2: SNF

03

ZZ

73

2%

5

25

30

FI

20: Mutual Omaha-Medicare Div

2: SNF

04

OK

227

8%

17

13

30

FI

20: Mutual Omaha-Medicare Div

2: SNF

04

TX

648

22%

48

0

48

FI

20: Mutual Omaha-Medicare Div

2: SNF

04

ZZ

61

2%

4

0

4

FI

20: Mutual Omaha-Medicare Div

2: SNF

05

IA

66

2%

5

25

30

FI

20: Mutual Omaha-Medicare Div

2: SNF

05

MO

150

5%

11

19

30

FI

20: Mutual Omaha-Medicare Div

2: SNF

05

NE

110

4%

8

22

30

FI

20: Mutual Omaha-Medicare Div

2: SNF

05

ZZ

53

2%

4

0

4

FI

20: Mutual Omaha-Medicare Div

2: SNF

06

IL

197

7%

14

16

30

FI

20: Mutual Omaha-Medicare Div

2: SNF

06

ZZ

19

1%

1

0

1

FI

20: Mutual Omaha-Medicare Div

2: SNF

07

ZZ

60

2%

4

26

30

FI

20: Mutual Omaha-Medicare Div

2: SNF

08

ZZ

92

3%

7

23

30

FI

20: Mutual Omaha-Medicare Div

2: SNF

09

FL

120

4%

9

21

30

FI

20: Mutual Omaha-Medicare Div

2: SNF

09

ZZ

1

0%

0

0

0

FI

20: Mutual Omaha-Medicare Div

2: SNF

10

AL

105

4%

8

22

30

FI

20: Mutual Omaha-Medicare Div

2: SNF

10

GA

207

7%

15

15

30

FI

20: Mutual Omaha-Medicare Div

2: SNF

10

TN

82

3%

6

24

30
30

FI

20: Mutual Omaha-Medicare Div

2: SNF

11

NC

76

3%

6

24

FI

20: Mutual Omaha-Medicare Div

2: SNF

11

ZZ

57

2%

4

0

4

FI

20: Mutual Omaha-Medicare Div

2: SNF

12

MD

102

3%

7

23

30
30

FI

20: Mutual Omaha-Medicare Div

2: SNF

12

NJ

103

3%

8

22

FI

20: Mutual Omaha-Medicare Div

2: SNF

12

ZZ

68

2%

5

0

5

FI

20: Mutual Omaha-Medicare Div

2: SNF

14

MA

192

7%

14

16

30

FI

20: Mutual Omaha-Medicare Div

2: SNF

14

ZZ

18

1%

1

0

1

FI

20: Mutual Omaha-Medicare Div

2: SNF

99

ZZ

61

2%

4

0

4

FI

20: Mutual Omaha-Medicare Div

3: RHC

05

ZZ

72

2%

5

25

30

FI

20: Mutual Omaha-Medicare Div

3: RHC

99

ZZ

84

3%

6

0

6

FI

20: Mutual Omaha-Medicare Div

8: Other

04

ZZ

76

3%

6

0

6

Page 8

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

FI

20: Mutual Omaha-Medicare Div

8: Other

99

ZZ

182

6%

13

0

13

FI

21: Anthem Health Plans of NH

1: Hospital

14

NH

31

8%

16

0

16

FI

21: Anthem Health Plans of NH

1: Hospital

14

VT

23

6%

12

0

12

FI

21: Anthem Health Plans of NH

2: SNF

14

NH

46

12%

23

0

23

FI

21: Anthem Health Plans of NH

2: SNF

14

VT

32

8%

16

0

16

FI

21: Anthem Health Plans of NH

3: RHC

14

NH

17

4%

9

0

9

FI

21: Anthem Health Plans of NH

3: RHC

14

VT

17

4%

9

0

9

FI

21: Anthem Health Plans of NH

4: ESRD

14

NH

1

0%

1

0

1

FI

21: Anthem Health Plans of NH

4: ESRD

14

VT

1

0%

1

0

1

FI

21: Anthem Health Plans of NH

8: Other

14

MA

1

0%

1

0

1

FI

21: Anthem Health Plans of NH

8: Other

14

NH

8

2%

4

0

4

FI

21: Anthem Health Plans of NH

8: Other

14

VT

1

0%

1

0

1

FI

22: Noridian Adm Serv, LLC

1: Hospital

02

OR

59

2%

18

12

30

FI

22: Noridian Adm Serv, LLC

1: Hospital

02

WA

97

4%

29

1

30

FI

22: Noridian Adm Serv, LLC

1: Hospital

02

ZZ

57

2%

17

0

17

FI

22: Noridian Adm Serv, LLC

1: Hospital

03

UT

45

2%

14

16

30

FI

22: Noridian Adm Serv, LLC

1: Hospital

03

ZZ

1

0%

0

0

0

FI

22: Noridian Adm Serv, LLC

1: Hospital

06

MN

177

7%

53

0

53

FI

22: Noridian Adm Serv, LLC

1: Hospital

99

ZZ

2

0%

1

0

1

FI

22: Noridian Adm Serv, LLC

2: SNF

02

OR

83

3%

25

5

30

FI

22: Noridian Adm Serv, LLC

2: SNF

02

WA

73

3%

22

8

30

FI

22: Noridian Adm Serv, LLC

2: SNF

02

ZZ

43

2%

13

0

13

FI

22: Noridian Adm Serv, LLC

2: SNF

03

UT

54

2%

16

14

30

FI

22: Noridian Adm Serv, LLC

2: SNF

03

ZZ

10

0%

3

0

3

FI

22: Noridian Adm Serv, LLC

2: SNF

06

MN

309

12%

93

0

93

FI

22: Noridian Adm Serv, LLC

2: SNF

99

ZZ

19

1%

6

0

6

FI

22: Noridian Adm Serv, LLC

3: RHC

02

WA

50

2%

15

15

30

FI

22: Noridian Adm Serv, LLC

3: RHC

02

ZZ

32

1%

10

0

10

FI

22: Noridian Adm Serv, LLC

3: RHC

06

MN

46

2%

14

16

30

FI

22: Noridian Adm Serv, LLC

3: RHC

99

ZZ

7

0%

2

0

2

FI

22: Noridian Adm Serv, LLC

4: ESRD

02

ZZ

66

3%

20

10

30

FI

22: Noridian Adm Serv, LLC

4: ESRD

99

ZZ

18

1%

5

0

5

FI

22: Noridian Adm Serv, LLC

8: Other

99

ZZ

85

3%

26

0

26

FI

24: TrailBlazer Health Enterpr

1: Hospital

04

TX

377

12%

49

0

49

Page 9

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

FI

24: TrailBlazer Health Enterpr

1: Hospital

04

ZZ

94

3%

12

0

FI

24: TrailBlazer Health Enterpr

1: Hospital

99

ZZ

51

2%

7

0

12
7

FI

24: TrailBlazer Health Enterpr

2: SNF

04

CO

85

3%

11

19

30
37

FI

24: TrailBlazer Health Enterpr

2: SNF

04

TX

289

9%

37

0

FI

24: TrailBlazer Health Enterpr

2: SNF

04

ZZ

63

2%

8

0

8

FI

24: TrailBlazer Health Enterpr

2: SNF

99

ZZ

116

4%

15

0

15

FI

24: TrailBlazer Health Enterpr

3: RHC

04

TX

301

10%

39

0

39

FI

24: TrailBlazer Health Enterpr

3: RHC

04

ZZ

61

2%

8

0

8

FI

24: TrailBlazer Health Enterpr

3: RHC

99

ZZ

143

5%

19

0

19

FI

24: TrailBlazer Health Enterpr

4: ESRD

01

CA

92

3%

12

18

30

FI

24: TrailBlazer Health Enterpr

4: ESRD

01

ZZ

16

1%

2

0

2

FI

24: TrailBlazer Health Enterpr

4: ESRD

04

TX

281

9%

36

0

36

FI

24: TrailBlazer Health Enterpr

4: ESRD

04

ZZ

95

3%

12

0

12

FI

24: TrailBlazer Health Enterpr

4: ESRD

05

ZZ

85

3%

11

19

30

FI

24: TrailBlazer Health Enterpr

4: ESRD

06

ZZ

101

3%

13

17

30

FI

24: TrailBlazer Health Enterpr

4: ESRD

07

LA

98

3%

13

17

30

FI

24: TrailBlazer Health Enterpr

4: ESRD

07

ZZ

67

2%

9

0

9

FI

24: TrailBlazer Health Enterpr

4: ESRD

09

FL

91

3%

12

18

30

FI

24: TrailBlazer Health Enterpr

4: ESRD

09

ZZ

18

1%

2

0

2

FI

24: TrailBlazer Health Enterpr

4: ESRD

99

ZZ

301

10%

39

0

39
24

FI

24: TrailBlazer Health Enterpr

8: Other

04

TX

184

6%

24

0

FI

24: TrailBlazer Health Enterpr

8: Other

04

ZZ

72

2%

9

0

9

FI

24: TrailBlazer Health Enterpr

8: Other

99

ZZ

4

0%

1

0

1

FI

25: United Government Serv, LL

1: Hospital

01

CA

289

5%

17

13

30

FI

25: United Government Serv, LL

1: Hospital

01

ZZ

42

1%

3

0

3

FI

25: United Government Serv, LL

1: Hospital

06

WI

184

3%

11

19

30

FI

25: United Government Serv, LL

1: Hospital

08

MI

191

3%

11

19

30

FI

25: United Government Serv, LL

1: Hospital

11

VA

114

2%

7

23

30

FI

25: United Government Serv, LL

1: Hospital

11

WV

56

1%

3

27

30

FI

25: United Government Serv, LL

2: SNF

01

CA

451

8%

27

3

30

FI

25: United Government Serv, LL

2: SNF

01

ZZ

41

1%

2

0

2

FI

25: United Government Serv, LL

2: SNF

05

ZZ

68

1%

4

26

30

FI

25: United Government Serv, LL

2: SNF

06

WI

324

5%

19

11

30

FI

25: United Government Serv, LL

2: SNF

06

ZZ

40

1%

2

0

2

Page 10

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

FI

25: United Government Serv, LL

2: SNF

08

MI

275

5%

16

14

FI

25: United Government Serv, LL

2: SNF

08

ZZ

44

1%

3

0

30
3

FI

25: United Government Serv, LL

2: SNF

11

VA

194

3%

12

18

30
30

FI

25: United Government Serv, LL

2: SNF

11

WV

89

1%

5

25

FI

25: United Government Serv, LL

2: SNF

11

ZZ

15

0%

1

0

1

FI

25: United Government Serv, LL

2: SNF

12

PA

65

1%

4

26

30

FI

25: United Government Serv, LL

2: SNF

12

ZZ

7

0%

0

0

0

FI

25: United Government Serv, LL

2: SNF

99

ZZ

219

4%

13

0

13
30

FI

25: United Government Serv, LL

3: RHC

01

CA

89

1%

5

25

FI

25: United Government Serv, LL

3: RHC

01

ZZ

6

0%

0

0

0

FI

25: United Government Serv, LL

3: RHC

08

MI

69

1%

4

26

30
0

FI

25: United Government Serv, LL

3: RHC

08

ZZ

1

0%

0

0

FI

25: United Government Serv, LL

3: RHC

99

ZZ

60

1%

4

0

4

FI

25: United Government Serv, LL

4: ESRD

01

CA

186

3%

11

19

30

FI

25: United Government Serv, LL

4: ESRD

01

ZZ

17

0%

1

0

1

FI

25: United Government Serv, LL

4: ESRD

06

ZZ

68

1%

4

26

30

FI

25: United Government Serv, LL

4: ESRD

08

ZZ

54

1%

3

27

30

FI

25: United Government Serv, LL

4: ESRD

11

ZZ

57

1%

3

27

30

FI

25: United Government Serv, LL

4: ESRD

99

ZZ

152

3%

9

0

9

FI

25: United Government Serv, LL

5: FQHC

01

CA

341

6%

20

10

30

FI

25: United Government Serv, LL

5: FQHC

01

ZZ

38

1%

2

0

2

FI

25: United Government Serv, LL

5: FQHC

02

WA

78

1%

5

25

30

FI

25: United Government Serv, LL

5: FQHC

02

ZZ

89

1%

5

0

5

FI

25: United Government Serv, LL

5: FQHC

03

ZZ

117

2%

7

23

30

FI

25: United Government Serv, LL

5: FQHC

04

CO

58

1%

3

27

30

FI

25: United Government Serv, LL

5: FQHC

04

NM

85

1%

5

25

30
30

FI

25: United Government Serv, LL

5: FQHC

04

TX

117

2%

7

23

FI

25: United Government Serv, LL

5: FQHC

04

ZZ

22

0%

1

0

1

FI

25: United Government Serv, LL

5: FQHC

05

MO

64

1%

4

26

30

FI

25: United Government Serv, LL

5: FQHC

05

ZZ

42

1%

3

0

3

FI

25: United Government Serv, LL

5: FQHC

06

IL

154

3%

9

21

30

FI

25: United Government Serv, LL

5: FQHC

06

ZZ

36

1%

2

0

2

FI

25: United Government Serv, LL

5: FQHC

07

MS

73

1%

4

26

30

FI

25: United Government Serv, LL

5: FQHC

07

ZZ

85

1%

5

0

5

Page 11

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

FI

25: United Government Serv, LL

5: FQHC

08

MI

78

1%

5

25

FI

25: United Government Serv, LL

5: FQHC

08

ZZ

23

0%

1

0

30
1

FI

25: United Government Serv, LL

5: FQHC

09

FL

97

2%

6

24

30

FI

25: United Government Serv, LL

5: FQHC

09

ZZ

6

0%

0

0

0

FI

25: United Government Serv, LL

5: FQHC

10

AL

71

1%

4

26

30

FI

25: United Government Serv, LL

5: FQHC

10

GA

64

1%

4

26

30

FI

25: United Government Serv, LL

5: FQHC

10

TN

68

1%

4

26

30

FI

25: United Government Serv, LL

5: FQHC

11

NC

72

1%

4

26

30

FI

25: United Government Serv, LL

5: FQHC

11

SC

58

1%

3

27

30

FI

25: United Government Serv, LL

5: FQHC

11

VA

53

1%

3

27

30

FI

25: United Government Serv, LL

5: FQHC

11

WV

75

1%

4

26

30
30

FI

25: United Government Serv, LL

5: FQHC

12

PA

118

2%

7

23

FI

25: United Government Serv, LL

5: FQHC

12

ZZ

89

1%

5

0

5

FI

25: United Government Serv, LL

5: FQHC

13

NY

82

1%

5

25

30

FI

25: United Government Serv, LL

5: FQHC

13

ZZ

17

0%

1

0

1

FI

25: United Government Serv, LL

5: FQHC

14

ZZ

138

2%

8

22

30

FI

25: United Government Serv, LL

5: FQHC

15

OH

74

1%

4

26

30

FI

25: United Government Serv, LL

5: FQHC

15

ZZ

39

1%

2

0

2

FI

25: United Government Serv, LL

8: Other

01

CA

147

2%

9

0

9

FI

25: United Government Serv, LL

8: Other

01

ZZ

13

0%

1

0

1

FI

25: United Government Serv, LL

8: Other

06

ZZ

93

2%

6

0

6

FI

25: United Government Serv, LL

8: Other

08

MI

264

4%

16

0

16

FI

25: United Government Serv, LL

8: Other

11

VA

72

1%

4

0

4

FI

25: United Government Serv, LL

8: Other

11

ZZ

7

0%

0

0

0

FI

25: United Government Serv, LL

8: Other

99

ZZ

20

0%

1

0

1

FI

26: Highmark Medicare Service

1: Hospital

12

MD

72

16%

16

14

30

FI

26: Highmark Medicare Service

1: Hospital

12

PA

190

43%

42

0

42

FI

26: Highmark Medicare Service

1: Hospital

12

ZZ

11

3%

2

0

2

FI

26: Highmark Medicare Service

1: Hospital

99

ZZ

16

4%

4

0

4

FI

26: Highmark Medicare Service

2: SNF

04

ZZ

66

15%

15

15

30

FI

26: Highmark Medicare Service

2: SNF

09

FL

56

13%

13

17

30

FI

26: Highmark Medicare Service

2: SNF

12

MD

104

24%

23

7

30

FI

26: Highmark Medicare Service

2: SNF

12

PA

553

127%

124

0

124

FI

26: Highmark Medicare Service

2: SNF

12

ZZ

43

10%

10

0

10

Page 12

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

FI

26: Highmark Medicare Service

2: SNF

99

ZZ

249

57%

56

0

FI

26: Highmark Medicare Service

3: RHC

11

ZZ

79

18%

18

12

56
30

FI

26: Highmark Medicare Service

3: RHC

99

ZZ

48

11%

11

0

11

FI

26: Highmark Medicare Service

4: ESRD

12

ZZ

69

16%

15

15

30

FI

26: Highmark Medicare Service

4: ESRD

99

ZZ

13

3%

3

0

3

FI

26: Highmark Medicare Service

8: Other

12

PA

133

30%

30

0

30
14

FI

26: Highmark Medicare Service

8: Other

12

ZZ

64

15%

14

0

FI

26: Highmark Medicare Service

8: Other

99

ZZ

23

5%

5

0

5

FI A MAC

27: Noridian - J3

1: Hospital

01

CA

1

0%

1

0

1

FI A MAC

27: Noridian - J3

1: Hospital

03

AZ

57

12%

31

0

31

FI A MAC

27: Noridian - J3

1: Hospital

03

MT

68

14%

37

0

37

FI A MAC

27: Noridian - J3

1: Hospital

03

WY

27

5%

15

0

15

FI A MAC

27: Noridian - J3

2: SNF

03

AZ

49

10%

27

0

27

FI A MAC

27: Noridian - J3

2: SNF

03

MT

76

15%

42

0

42

FI A MAC

27: Noridian - J3

2: SNF

03

WY

17

3%

9

0

9

FI A MAC

27: Noridian - J3

2: SNF

04

TX

14

3%

8

0

8

FI A MAC

27: Noridian - J3

3: RHC

03

AZ

10

2%

6

0

6

FI A MAC

27: Noridian - J3

3: RHC

03

MT

37

7%

20

0

20

FI A MAC

27: Noridian - J3

3: RHC

03

WY

9

2%

5

0

5

FI A MAC

27: Noridian - J3

4: ESRD

03

AZ

40

8%

22

0

22

FI A MAC

27: Noridian - J3

4: ESRD

03

MT

2

0%

1

0

1

FI A MAC

27: Noridian - J3

4: ESRD

03

WY

1

0%

1

0

1

FI A MAC

27: Noridian - J3

8: Other

01

NV

1

0%

1

0

1

FI A MAC

27: Noridian - J3

8: Other

03

AZ

23

5%

13

0

13

FI A MAC

27: Noridian - J3

8: Other

03

MT

4

1%

2

0

2

FI A MAC

27: Noridian - J3

8: Other

03

WY

2

0%

1

0

1

FI Subtotals

35,316

6,326

2,258

8,584

Carrier

40: AdminaStar Federal

09: Physician

08

IN

3,460

34%

134

0

134

Carrier

40: AdminaStar Federal

09: Physician

15

KY

2,878

28%

112

0

112

Carrier

40: AdminaStar Federal

09: Physician

15

ZZ

2

0%

0

0

0

Carrier

40: AdminaStar Federal

09: Physician

99

ZZ

1

0%

0

0

0

Carrier

40: AdminaStar Federal

10: Licen Pra

08

IN

2,056

20%

80

0

80

Carrier

40: AdminaStar Federal

10: Licen Pra

15

KY

1,298

13%

50

0

50

Page 13

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

Carrier

40: AdminaStar Federal

10: Licen Pra

15

ZZ

1

0%

0

0

0

Carrier

40: AdminaStar Federal

10: Licen Pra

99

ZZ

1

0%

0

0

0

Carrier

40: AdminaStar Federal

11: Ambulance

08

IN

223

2%

9

21

30

Carrier

40: AdminaStar Federal

11: Ambulance

15

KY

166

2%

6

24

30

Carrier

40: AdminaStar Federal

12: Lab

99

ZZ

50

0%

2

28

30

Carrier

40: AdminaStar Federal

13: Other

08

IN

81

1%

3

0

3

Carrier

40: AdminaStar Federal

13: Other

15

KY

80

1%

3

0

3

Carrier

41: P B S/BCBS Arkansas

09: Physician

04

NM

1,025

5%

19

11

30
47

Carrier

41: P B S/BCBS Arkansas

09: Physician

04

OK

2,537

12%

47

0

Carrier

41: P B S/BCBS Arkansas

09: Physician

04

ZZ

1

0%

0

0

0

Carrier

41: P B S/BCBS Arkansas

09: Physician

05

MO

2,659

12%

49

0

49

Carrier

41: P B S/BCBS Arkansas

09: Physician

05

ZZ

1

0%

0

0

0

Carrier

41: P B S/BCBS Arkansas

09: Physician

07

AR

2,007

9%

37

0

37

Carrier

41: P B S/BCBS Arkansas

09: Physician

07

LA

4,189

19%

77

0

77

Carrier

41: P B S/BCBS Arkansas

09: Physician

14

RI

1,012

5%

19

11

30

Carrier

41: P B S/BCBS Arkansas

09: Physician

99

ZZ

7

0%

0

0

0

Carrier

41: P B S/BCBS Arkansas

10: Licen Pra

04

NM

739

3%

14

16

30

Carrier

41: P B S/BCBS Arkansas

10: Licen Pra

04

OK

1,386

6%

26

4

30

Carrier

41: P B S/BCBS Arkansas

10: Licen Pra

05

MO

1,825

8%

34

0

34

Carrier

41: P B S/BCBS Arkansas

10: Licen Pra

05

ZZ

1

0%

0

0

0

Carrier

41: P B S/BCBS Arkansas

10: Licen Pra

07

AR

1,095

5%

20

10

30
30

Carrier

41: P B S/BCBS Arkansas

10: Licen Pra

07

LA

1,445

7%

27

3

Carrier

41: P B S/BCBS Arkansas

10: Licen Pra

14

RI

655

3%

12

18

30

Carrier

41: P B S/BCBS Arkansas

11: Ambulance

04

NM

63

0%

1

29

30
30

Carrier

41: P B S/BCBS Arkansas

11: Ambulance

04

OK

125

1%

2

28

Carrier

41: P B S/BCBS Arkansas

11: Ambulance

05

MO

109

1%

2

28

30

Carrier

41: P B S/BCBS Arkansas

11: Ambulance

07

AR

89

0%

2

28

30

Carrier

41: P B S/BCBS Arkansas

11: Ambulance

07

ZZ

40

0%

1

0

1

Carrier

41: P B S/BCBS Arkansas

11: Ambulance

14

RI

57

0%

1

29

30

Carrier

41: P B S/BCBS Arkansas

11: Ambulance

99

ZZ

1

0%

0

0

0

Carrier

41: P B S/BCBS Arkansas

12: Lab

99

ZZ

87

0%

2

28

30

Carrier

41: P B S/BCBS Arkansas

13: Other

04

OK

94

0%

2

0

2

Carrier

41: P B S/BCBS Arkansas

13: Other

04

ZZ

27

0%

0

0

0

Carrier

41: P B S/BCBS Arkansas

13: Other

05

MO

149

1%

3

0

3

Page 14

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

Carrier

41: P B S/BCBS Arkansas

13: Other

07

AR

67

0%

1

0

Carrier

41: P B S/BCBS Arkansas

13: Other

07

LA

135

1%

2

0

1
2

Carrier

41: P B S/BCBS Arkansas

13: Other

99

ZZ

6

0%

0

0

0
49

Carrier

42: Cahaba GBA

09: Physician

07

MS

1,949

12%

49

0

Carrier

42: Cahaba GBA

09: Physician

07

ZZ

1

0%

0

0

0

Carrier

42: Cahaba GBA

09: Physician

10

AL

2,964

19%

75

0

75
141

Carrier

42: Cahaba GBA

09: Physician

10

GA

5,577

35%

141

0

Carrier

42: Cahaba GBA

09: Physician

10

ZZ

6

0%

0

0

0

Carrier

42: Cahaba GBA

09: Physician

99

ZZ

8

0%

0

0

0

Carrier

42: Cahaba GBA

10: Licen Pra

07

MS

755

5%

19

11

30

Carrier

42: Cahaba GBA

10: Licen Pra

10

AL

1,173

7%

30

0

30
67

Carrier

42: Cahaba GBA

10: Licen Pra

10

GA

2,653

17%

67

0

Carrier

42: Cahaba GBA

10: Licen Pra

10

ZZ

1

0%

0

0

0

Carrier

42: Cahaba GBA

10: Licen Pra

99

ZZ

1

0%

0

0

0

Carrier

42: Cahaba GBA

11: Ambulance

10

AL

128

1%

3

27

30

Carrier

42: Cahaba GBA

11: Ambulance

10

GA

157

1%

4

26

30

Carrier

42: Cahaba GBA

11: Ambulance

99

ZZ

30

0%

1

0

1

Carrier

42: Cahaba GBA

12: Lab

99

ZZ

60

0%

2

28

30

Carrier

42: Cahaba GBA

13: Other

07

MS

56

0%

1

0

1

Carrier

42: Cahaba GBA

13: Other

10

AL

115

1%

3

0

3

Carrier

42: Cahaba GBA

13: Other

10

GA

221

1%

6

0

6

Carrier

42: Cahaba GBA

13: Other

99

ZZ

2

0%

0

0

0

Carrier

43: First Coast S O

09: Physician

09

FL

17,512

56%

224

0

224

Carrier

43: First Coast S O

09: Physician

13

CT

2,881

9%

37

0

37

Carrier

43: First Coast S O

09: Physician

13

ZZ

2

0%

0

0

0

Carrier

43: First Coast S O

09: Physician

99

ZZ

11

0%

0

0

0

Carrier

43: First Coast S O

10: Licen Pra

09

FL

7,585

24%

97

0

97
30

Carrier

43: First Coast S O

10: Licen Pra

13

CT

2,068

7%

26

4

Carrier

43: First Coast S O

10: Licen Pra

13

ZZ

1

0%

0

0

0

Carrier

43: First Coast S O

10: Licen Pra

99

ZZ

4

0%

0

0

0

Carrier

43: First Coast S O

11: Ambulance

09

FL

166

1%

2

28

30

Carrier

43: First Coast S O

11: Ambulance

13

CT

130

0%

2

28

30

Carrier

43: First Coast S O

12: Lab

09

FL

123

0%

2

28

30

Carrier

43: First Coast S O

12: Lab

99

ZZ

14

0%

0

0

0

Page 15

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

Carrier

43: First Coast S O

13: Other

09

FL

704

2%

9

0

Carrier

43: First Coast S O

13: Other

13

CT

57

0%

1

0

9
1

Carrier

43: First Coast S O

13: Other

99

ZZ

2

0%

0

0

0
184

Carrier

44: BCBS, Kansas

09: Physician

05

KS

1,643

46%

184

0

Carrier

44: BCBS, Kansas

09: Physician

05

ZZ

11

0%

1

0

1

Carrier

44: BCBS, Kansas

09: Physician

99

ZZ

2

0%

0

0

0
183

Carrier

44: BCBS, Kansas

10: Licen Pra

05

KS

1,636

46%

183

0

Carrier

44: BCBS, Kansas

10: Licen Pra

05

ZZ

3

0%

0

0

0

Carrier

44: BCBS, Kansas

10: Licen Pra

99

ZZ

1

0%

0

0

0

Carrier

44: BCBS, Kansas

11: Ambulance

05

KS

134

4%

15

15

30

Carrier

44: BCBS, Kansas

13: Other

05

KS

135

4%

15

0

15

Carrier

44: BCBS, Kansas

13: Other

05

ZZ

2

0%

0

0

0

Carrier

46: Palmetto GBA RRB

09: Physician

01

CA

1,122

4%

14

16

30
30

Carrier

46: Palmetto GBA RRB

09: Physician

01

HI

223

1%

3

27

Carrier

46: Palmetto GBA RRB

09: Physician

01

NV

917

3%

12

18

30

Carrier

46: Palmetto GBA RRB

09: Physician

02

AK

147

0%

2

28

30

Carrier

46: Palmetto GBA RRB

09: Physician

02

OR

1,317

4%

17

13

30

Carrier

46: Palmetto GBA RRB

09: Physician

02

WA

1,841

6%

24

6

30

Carrier

46: Palmetto GBA RRB

09: Physician

02

ZZ

47

0%

1

0

1

Carrier

46: Palmetto GBA RRB

09: Physician

03

AZ

2,435

8%

31

0

31
30

Carrier

46: Palmetto GBA RRB

09: Physician

03

UT

70

0%

1

29

Carrier

46: Palmetto GBA RRB

09: Physician

03

ZZ

42

0%

1

0

1

Carrier

46: Palmetto GBA RRB

09: Physician

04

CO

69

0%

1

29

30

Carrier

46: Palmetto GBA RRB

09: Physician

04

NM

77

0%

1

29

30

Carrier

46: Palmetto GBA RRB

09: Physician

04

OK

231

1%

3

27

30

Carrier

46: Palmetto GBA RRB

09: Physician

04

TX

745

2%

10

20

30

Carrier

46: Palmetto GBA RRB

09: Physician

05

IA

769

2%

10

20

30

Carrier

46: Palmetto GBA RRB

09: Physician

05

KS

55

0%

1

29

30

Carrier

46: Palmetto GBA RRB

09: Physician

05

MO

646

2%

8

22

30

Carrier

46: Palmetto GBA RRB

09: Physician

05

NE

681

2%

9

21

30
30

Carrier

46: Palmetto GBA RRB

09: Physician

06

IL

275

1%

4

26

Carrier

46: Palmetto GBA RRB

09: Physician

06

ZZ

46

0%

1

0

1

Carrier

46: Palmetto GBA RRB

09: Physician

07

AR

89

0%

1

29

30

Carrier

46: Palmetto GBA RRB

09: Physician

07

LA

311

1%

4

26

30

Page 16

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

Carrier

46: Palmetto GBA RRB

09: Physician

07

MS

158

1%

2

28

30

Carrier

46: Palmetto GBA RRB

09: Physician

08

IN

264

1%

3

27

30

Carrier

46: Palmetto GBA RRB

09: Physician

08

MI

298

1%

4

26

30

Carrier

46: Palmetto GBA RRB

09: Physician

09

FL

679

2%

9

21

30

Carrier

46: Palmetto GBA RRB

09: Physician

09

ZZ

9

0%

0

0

0

Carrier

46: Palmetto GBA RRB

09: Physician

10

GA

178

1%

2

28

30
30

Carrier

46: Palmetto GBA RRB

09: Physician

10

TN

173

1%

2

28

Carrier

46: Palmetto GBA RRB

09: Physician

10

ZZ

43

0%

1

0

1

Carrier

46: Palmetto GBA RRB

09: Physician

11

NC

99

0%

1

29

30

Carrier

46: Palmetto GBA RRB

09: Physician

11

SC

93

0%

1

29

30

Carrier

46: Palmetto GBA RRB

09: Physician

11

VA

629

2%

8

22

30

Carrier

46: Palmetto GBA RRB

09: Physician

11

WV

1,086

3%

14

16

30

Carrier

46: Palmetto GBA RRB

09: Physician

12

DC

263

1%

3

27

30
30

Carrier

46: Palmetto GBA RRB

09: Physician

12

DE

504

2%

6

24

Carrier

46: Palmetto GBA RRB

09: Physician

12

MD

911

3%

12

18

30

Carrier

46: Palmetto GBA RRB

09: Physician

12

NJ

424

1%

5

25

30

Carrier

46: Palmetto GBA RRB

09: Physician

12

PA

828

3%

11

19

30

Carrier

46: Palmetto GBA RRB

09: Physician

13

CT

111

0%

1

29

30

Carrier

46: Palmetto GBA RRB

09: Physician

13

NY

1,063

3%

14

16

30

Carrier

46: Palmetto GBA RRB

09: Physician

14

MA

294

1%

4

26

30

Carrier

46: Palmetto GBA RRB

09: Physician

14

ME

584

2%

7

23

30

Carrier

46: Palmetto GBA RRB

09: Physician

14

NH

363

1%

5

25

30

Carrier

46: Palmetto GBA RRB

09: Physician

14

RI

60

0%

1

29

30

Carrier

46: Palmetto GBA RRB

09: Physician

14

VT

251

1%

3

27

30

Carrier

46: Palmetto GBA RRB

09: Physician

15

KY

120

0%

2

28

30

Carrier

46: Palmetto GBA RRB

09: Physician

15

OH

394

1%

5

25

30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

01

CA

278

1%

4

26

30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

01

NV

209

1%

3

27

30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

01

ZZ

26

0%

0

0

0

Carrier

46: Palmetto GBA RRB

10: Licen Pra

02

OR

437

1%

6

24

30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

02

WA

908

3%

12

18

30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

02

ZZ

63

0%

1

0

1

Carrier

46: Palmetto GBA RRB

10: Licen Pra

03

AZ

613

2%

8

22

30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

03

UT

59

0%

1

29

30

Page 17

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

Carrier

46: Palmetto GBA RRB

10: Licen Pra

03

ZZ

66

0%

1

0

1

Carrier

46: Palmetto GBA RRB

10: Licen Pra

04

OK

57

0%

1

29

30
30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

04

TX

232

1%

3

27

Carrier

46: Palmetto GBA RRB

10: Licen Pra

04

ZZ

85

0%

1

0

1

Carrier

46: Palmetto GBA RRB

10: Licen Pra

05

IA

613

2%

8

22

30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

05

KS

68

0%

1

29

30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

05

MO

357

1%

5

25

30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

05

NE

388

1%

5

25

30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

06

IL

177

1%

2

28

30
30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

06

MN

59

0%

1

29

Carrier

46: Palmetto GBA RRB

10: Licen Pra

06

ZZ

41

0%

1

0

1

Carrier

46: Palmetto GBA RRB

10: Licen Pra

07

LA

55

0%

1

29

30
30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

07

MS

59

0%

1

29

Carrier

46: Palmetto GBA RRB

10: Licen Pra

07

ZZ

40

0%

1

0

1

Carrier

46: Palmetto GBA RRB

10: Licen Pra

08

IN

136

0%

2

28

30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

08

MI

137

0%

2

28

30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

09

FL

182

1%

2

28

30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

10

GA

56

0%

1

29

30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

10

TN

75

0%

1

29

30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

10

ZZ

23

0%

0

0

0

Carrier

46: Palmetto GBA RRB

10: Licen Pra

11

VA

111

0%

1

29

30
30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

11

WV

262

1%

3

27

Carrier

46: Palmetto GBA RRB

10: Licen Pra

11

ZZ

89

0%

1

0

1

Carrier

46: Palmetto GBA RRB

10: Licen Pra

12

DE

95

0%

1

29

30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

12

MD

126

0%

2

28

30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

12

NJ

157

1%

2

28

30
30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

12

PA

467

1%

6

24

Carrier

46: Palmetto GBA RRB

10: Licen Pra

12

ZZ

31

0%

0

0

0

Carrier

46: Palmetto GBA RRB

10: Licen Pra

13

NY

285

1%

4

26

30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

13

ZZ

20

0%

0

0

0

Carrier

46: Palmetto GBA RRB

10: Licen Pra

14

MA

99

0%

1

29

30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

14

ME

227

1%

3

27

30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

14

NH

102

0%

1

29

30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

14

VT

71

0%

1

29

30

Page 18

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

Carrier

46: Palmetto GBA RRB

10: Licen Pra

14

ZZ

6

0%

0

0

0

Carrier

46: Palmetto GBA RRB

10: Licen Pra

15

KY

62

0%

1

29

30

Carrier

46: Palmetto GBA RRB

10: Licen Pra

15

OH

228

1%

3

27

30

Carrier

46: Palmetto GBA RRB

11: Ambulance

02

OR

61

0%

1

29

30
30

Carrier

46: Palmetto GBA RRB

11: Ambulance

02

WA

84

0%

1

29

Carrier

46: Palmetto GBA RRB

11: Ambulance

02

ZZ

8

0%

0

0

0

Carrier

46: Palmetto GBA RRB

11: Ambulance

03

AZ

60

0%

1

29

30

Carrier

46: Palmetto GBA RRB

11: Ambulance

03

ZZ

8

0%

0

0

0

Carrier

46: Palmetto GBA RRB

11: Ambulance

05

IA

108

0%

1

29

30
30

Carrier

46: Palmetto GBA RRB

11: Ambulance

05

NE

84

0%

1

29

Carrier

46: Palmetto GBA RRB

11: Ambulance

05

ZZ

55

0%

1

0

1

Carrier

46: Palmetto GBA RRB

11: Ambulance

11

WV

98

0%

1

29

30

Carrier

46: Palmetto GBA RRB

11: Ambulance

11

ZZ

11

0%

0

0

0

Carrier

46: Palmetto GBA RRB

11: Ambulance

12

ZZ

66

0%

1

29

30

Carrier

46: Palmetto GBA RRB

11: Ambulance

14

ME

65

0%

1

29

30

Carrier

46: Palmetto GBA RRB

11: Ambulance

14

ZZ

83

0%

1

0

1

Carrier

46: Palmetto GBA RRB

11: Ambulance

99

ZZ

87

0%

1

0

1

Carrier

46: Palmetto GBA RRB

12: Lab

99

ZZ

103

0%

1

29

30

Carrier

46: Palmetto GBA RRB

13: Other

02

WA

59

0%

1

0

1

Carrier

46: Palmetto GBA RRB

13: Other

02

ZZ

40

0%

1

0

1

Carrier

46: Palmetto GBA RRB

13: Other

05

ZZ

65

0%

1

0

1

Carrier

46: Palmetto GBA RRB

13: Other

99

ZZ

180

1%

2

0

2

Carrier

47: Palmetto GBA

09: Physician

11

SC

2,307

14%

57

0

57

Carrier

47: Palmetto GBA

09: Physician

11

ZZ

14

0%

0

0

0

Carrier

47: Palmetto GBA

09: Physician

15

OH

7,430

46%

182

0

182

Carrier

47: Palmetto GBA

09: Physician

15

ZZ

1

0%

0

0

0

Carrier

47: Palmetto GBA

09: Physician

99

ZZ

2

0%

0

0

0
32

Carrier

47: Palmetto GBA

10: Licen Pra

11

SC

1,313

8%

32

0

Carrier

47: Palmetto GBA

10: Licen Pra

11

ZZ

6

0%

0

0

0

Carrier

47: Palmetto GBA

10: Licen Pra

15

OH

4,044

25%

99

0

99

Carrier

47: Palmetto GBA

10: Licen Pra

99

ZZ

1

0%

0

0

0

Carrier

47: Palmetto GBA

11: Ambulance

11

SC

110

1%

3

27

30

Carrier

47: Palmetto GBA

11: Ambulance

15

OH

697

4%

17

13

30

Carrier

47: Palmetto GBA

11: Ambulance

99

ZZ

3

0%

0

0

0

Page 19

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

Carrier

47: Palmetto GBA

13: Other

11

SC

69

0%

2

0

2

Carrier

47: Palmetto GBA

13: Other

11

ZZ

1

0%

0

0

0

Carrier

47: Palmetto GBA

13: Other

15

OH

323

2%

8

0

8

Carrier

48: CIGNA Gov Serv

09: Physician

02

ID

1,081

7%

26

4

30

Carrier

48: CIGNA Gov Serv

09: Physician

02

ZZ

1

0%

0

0

0

Carrier

48: CIGNA Gov Serv

09: Physician

10

TN

4,346

27%

106

0

106
111

Carrier

48: CIGNA Gov Serv

09: Physician

11

NC

4,537

28%

111

0

Carrier

48: CIGNA Gov Serv

09: Physician

11

ZZ

3

0%

0

0

0

Carrier

48: CIGNA Gov Serv

09: Physician

99

ZZ

7

0%

0

0

0

Carrier

48: CIGNA Gov Serv

10: Licen Pra

02

ID

787

5%

19

11

30

Carrier

48: CIGNA Gov Serv

10: Licen Pra

10

TN

2,268

14%

55

0

55
65

Carrier

48: CIGNA Gov Serv

10: Licen Pra

11

NC

2,670

16%

65

0

Carrier

48: CIGNA Gov Serv

10: Licen Pra

11

ZZ

2

0%

0

0

0

Carrier

48: CIGNA Gov Serv

10: Licen Pra

99

ZZ

7

0%

0

0

0

Carrier

48: CIGNA Gov Serv

11: Ambulance

02

ID

69

0%

2

28

30

Carrier

48: CIGNA Gov Serv

11: Ambulance

10

TN

102

1%

2

28

30
30

Carrier

48: CIGNA Gov Serv

11: Ambulance

11

NC

173

1%

4

26

Carrier

48: CIGNA Gov Serv

11: Ambulance

99

ZZ

2

0%

0

0

0

Carrier

48: CIGNA Gov Serv

12: Lab

99

ZZ

61

0%

1

29

30

Carrier

48: CIGNA Gov Serv

13: Other

10

TN

116

1%

3

0

3

Carrier

48: CIGNA Gov Serv

13: Other

11

NC

120

1%

3

0

3

Carrier

48: CIGNA Gov Serv

13: Other

99

ZZ

31

0%

1

0

1

Carrier

49: Empire Medical S

09: Physician

12

NJ

10,444

22%

87

0

87

Carrier

49: Empire Medical S

09: Physician

12

ZZ

10

0%

0

0

0

Carrier

49: Empire Medical S

09: Physician

13

NY

19,847

41%

165

0

165

Carrier

49: Empire Medical S

09: Physician

13

ZZ

9

0%

0

0

0

Carrier

49: Empire Medical S

09: Physician

99

ZZ

9

0%

0

0

0
54

Carrier

49: Empire Medical S

10: Licen Pra

12

NJ

6,473

13%

54

0

Carrier

49: Empire Medical S

10: Licen Pra

12

ZZ

6

0%

0

0

0

Carrier

49: Empire Medical S

10: Licen Pra

13

NY

10,741

22%

89

0

89

Carrier

49: Empire Medical S

10: Licen Pra

13

ZZ

3

0%

0

0

0

Carrier

49: Empire Medical S

10: Licen Pra

99

ZZ

2

0%

0

0

0

Carrier

49: Empire Medical S

11: Ambulance

12

NJ

180

0%

1

29

30

Carrier

49: Empire Medical S

11: Ambulance

13

NY

134

0%

1

29

30

Page 20

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

Carrier

49: Empire Medical S

12: Lab

99

ZZ

105

0%

1

29

30

Carrier

49: Empire Medical S

13: Other

12

NJ

182

0%

2

0

2

Carrier

49: Empire Medical S

13: Other

99

ZZ

40

0%

0

0

0

Carrier

50: GHI Carrier Serv

09: Physician

13

NY

2,554

71%

282

0

282
114

Carrier

50: GHI Carrier Serv

10: Licen Pra

13

NY

1,028

28%

114

0

Carrier

50: GHI Carrier Serv

13: Other

99

ZZ

39

1%

4

0

4

Carrier

51: HealthNow NY

09: Physician

13

NY

4,112

55%

220

0

220

Carrier

51: HealthNow NY

09: Physician

99

ZZ

1

0%

0

0

0

Carrier

51: HealthNow NY

10: Licen Pra

13

NY

3,051

41%

163

0

163

Carrier

51: HealthNow NY

10: Licen Pra

99

ZZ

1

0%

0

0

0

Carrier

51: HealthNow NY

11: Ambulance

13

NY

253

3%

14

16

30
0

Carrier

51: HealthNow NY

11: Ambulance

99

ZZ

1

0%

0

0

Carrier

51: HealthNow NY

13: Other

13

NY

59

1%

3

0

3

Carrier

52: HGSAdmin (Highmark)

09: Physician

12

PA

8,932

52%

209

0

209
0

Carrier

52: HGSAdmin (Highmark)

09: Physician

12

ZZ

7

0%

0

0

Carrier

52: HGSAdmin (Highmark)

09: Physician

99

ZZ

12

0%

0

0

0

Carrier

52: HGSAdmin (Highmark)

10: Licen Pra

12

PA

7,026

41%

165

0

165

Carrier

52: HGSAdmin (Highmark)

10: Licen Pra

12

ZZ

6

0%

0

0

0

Carrier

52: HGSAdmin (Highmark)

10: Licen Pra

99

ZZ

8

0%

0

0

0
30

Carrier

52: HGSAdmin (Highmark)

11: Ambulance

12

PA

888

5%

21

9

Carrier

52: HGSAdmin (Highmark)

13: Other

12

PA

192

1%

4

0

4

Carrier

52: HGSAdmin (Highmark)

12: Lab

99

ZZ

4

0%

0

0

0

Carrier

53: NHIC

09: Physician

01

CA

28,424

43%

171

0

171

Carrier

53: NHIC

09: Physician

01

ZZ

2

0%

0

0

0

Carrier

53: NHIC

09: Physician

14

MA

13,389

20%

81

0

81

Carrier

53: NHIC

09: Physician

14

ZZ

5

0%

0

0

0

Carrier

53: NHIC

09: Physician

99

ZZ

3

0%

0

0

0

Carrier

53: NHIC

10: Licen Pra

01

CA

15,082

23%

91

0

91

Carrier

53: NHIC

10: Licen Pra

14

MA

7,835

12%

47

0

47

Carrier

53: NHIC

10: Licen Pra

14

ZZ

1

0%

0

0

0

Carrier

53: NHIC

10: Licen Pra

99

ZZ

3

0%

0

0

0

Carrier

53: NHIC

11: Ambulance

01

CA

257

0%

2

28

30

Carrier

53: NHIC

11: Ambulance

14

MA

268

0%

2

28

30

Carrier

53: NHIC

12: Lab

01

CA

206

0%

1

29

30

Page 21

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

Carrier

53: NHIC

12: Lab

99

ZZ

37

0%

0

0

0

Carrier

53: NHIC

13: Other

01

CA

699

1%

4

0

4

Carrier

53: NHIC

13: Other

14

MA

110

0%

1

0

1

Carrier

53: NHIC

13: Other

14

ZZ

1

0%

0

0

0

Carrier

53: NHIC

13: Other

99

ZZ

8

0%

0

0

0

Carrier

54: Noridian MIC

09: Physician

03

ND

225

3%

12

18

30

Carrier

54: Noridian MIC

09: Physician

03

SD

385

5%

20

10

30

Carrier

54: Noridian MIC

09: Physician

03

WY

419

6%

22

8

30

Carrier

54: Noridian MIC

09: Physician

03

ZZ

5

0%

0

0

0

Carrier

54: Noridian MIC

09: Physician

04

CO

2,888

38%

152

0

152

Carrier

54: Noridian MIC

09: Physician

99

ZZ

5

0%

0

0

0

Carrier

54: Noridian MIC

10: Licen Pra

03

ND

318

4%

17

13

30
30

Carrier

54: Noridian MIC

10: Licen Pra

03

SD

423

6%

22

8

Carrier

54: Noridian MIC

10: Licen Pra

03

WY

281

4%

15

15

30

Carrier

54: Noridian MIC

10: Licen Pra

04

CO

2,045

27%

108

0

108

Carrier

54: Noridian MIC

10: Licen Pra

04

ZZ

2

0%

0

0

0

Carrier

54: Noridian MIC

10: Licen Pra

99

ZZ

1

0%

0

0

0

Carrier

54: Noridian MIC

11: Ambulance

03

ND

112

1%

6

24

30

Carrier

54: Noridian MIC

11: Ambulance

03

SD

102

1%

5

25

30

Carrier

54: Noridian MIC

11: Ambulance

03

ZZ

26

0%

1

0

1

Carrier

54: Noridian MIC

11: Ambulance

04

CO

142

2%

7

23

30

Carrier

54: Noridian MIC

11: Ambulance

04

ZZ

1

0%

0

0

0

Carrier

54: Noridian MIC

13: Other

03

ZZ

86

1%

5

0

5

Carrier

54: Noridian MIC

13: Other

04

CO

122

2%

6

0

6

Carrier

54: Noridian MIC

13: Other

99

ZZ

1

0%

0

0

0

Carrier

56: Trailblazer, Part B

09: Physician

04

TX

15,559

46%

186

0

186

Carrier

56: Trailblazer, Part B

09: Physician

04

ZZ

37

0%

0

0

0

Carrier

56: Trailblazer, Part B

09: Physician

11

VA

3,077

9%

37

0

37

Carrier

56: Trailblazer, Part B

09: Physician

11

ZZ

Carrier

56: Trailblazer, Part B

09: Physician

12

MD

5

0%

0

0

0

3,165

9%

38

0

38
0

Carrier

56: Trailblazer, Part B

09: Physician

12

ZZ

1

0%

0

0

Carrier

56: Trailblazer, Part B

09: Physician

99

ZZ

67

0%

1

0

1

Carrier

56: Trailblazer, Part B

10: Licen Pra

04

TX

6,480

19%

77

0

77

Carrier

56: Trailblazer, Part B

10: Licen Pra

11

VA

1,938

6%

23

7

30

Page 22

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

Carrier

56: Trailblazer, Part B

10: Licen Pra

12

MD

1,425

4%

17

13

Carrier

56: Trailblazer, Part B

10: Licen Pra

12

ZZ

1

0%

0

0

30
0

Carrier

56: Trailblazer, Part B

10: Licen Pra

99

ZZ

5

0%

0

0

0
30

Carrier

56: Trailblazer, Part B

11: Ambulance

04

TX

698

2%

8

22

Carrier

56: Trailblazer, Part B

11: Ambulance

04

ZZ

1

0%

0

0

0

Carrier

56: Trailblazer, Part B

11: Ambulance

11

VA

128

0%

2

28

30

Carrier

56: Trailblazer, Part B

11: Ambulance

12

MD

122

0%

1

29

30

Carrier

56: Trailblazer, Part B

12: Lab

04

TX

131

0%

2

28

30
0

Carrier

56: Trailblazer, Part B

12: Lab

99

ZZ

39

0%

0

0

Carrier

56: Trailblazer, Part B

13: Other

04

TX

530

2%

6

0

6

Carrier

56: Trailblazer, Part B

13: Other

04

ZZ

3

0%

0

0

0

Carrier

56: Trailblazer, Part B

13: Other

11

VA

64

0%

1

0

1

Carrier

56: Trailblazer, Part B

13: Other

99

ZZ

61

0%

1

0

1

Carrier

57: Triple S, Inc.

09: Physician

09

PR

5,681

79%

317

0

317
30

Carrier

57: Triple S, Inc.

09: Physician

09

VI

116

2%

6

24

Carrier

57: Triple S, Inc.

09: Physician

99

ZZ

2

0%

0

0

0

Carrier

57: Triple S, Inc.

10: Licen Pra

09

PR

587

8%

33

0

33

Carrier

57: Triple S, Inc.

10: Licen Pra

09

ZZ

21

0%

1

0

1

Carrier

57: Triple S, Inc.

11: Ambulance

09

PR

170

2%

9

21

30

Carrier

57: Triple S, Inc.

11: Ambulance

09

ZZ

2

0%

0

0

0

Carrier

57: Triple S, Inc.

12: Lab

09

PR

550

8%

31

0

31
0

Carrier

57: Triple S, Inc.

12: Lab

09

ZZ

7

0%

0

0

Carrier

57: Triple S, Inc.

13: Other

99

ZZ

37

1%

2

0

2

Carrier

58: Wisconsin Phy Serv

09: Physician

06

IL

8,507

25%

98

0

98

Carrier

58: Wisconsin Phy Serv

09: Physician

06

MN

1,099

3%

13

17

30

Carrier

58: Wisconsin Phy Serv

09: Physician

06

WI

2,085

6%

24

6

30
83

Carrier

58: Wisconsin Phy Serv

09: Physician

08

MI

7,205

21%

83

0

Carrier

58: Wisconsin Phy Serv

09: Physician

99

ZZ

9

0%

0

0

0

Carrier

58: Wisconsin Phy Serv

10: Licen Pra

06

IL

5,036

15%

58

0

58

Carrier

58: Wisconsin Phy Serv

10: Licen Pra

06

MN

2,287

7%

26

4

30

Carrier

58: Wisconsin Phy Serv

10: Licen Pra

06

WI

1,993

6%

23

7

30
53

Carrier

58: Wisconsin Phy Serv

10: Licen Pra

08

MI

4,620

13%

53

0

Carrier

58: Wisconsin Phy Serv

10: Licen Pra

99

ZZ

4

0%

0

0

0

Carrier

58: Wisconsin Phy Serv

11: Ambulance

06

IL

547

2%

6

24

30

Page 23

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

Carrier

58: Wisconsin Phy Serv

11: Ambulance

06

MN

175

1%

2

28

30

Carrier

58: Wisconsin Phy Serv

11: Ambulance

06

WI

363

1%

4

26

30
30

Carrier

58: Wisconsin Phy Serv

11: Ambulance

08

MI

263

1%

3

27

Carrier

58: Wisconsin Phy Serv

11: Ambulance

99

ZZ

1

0%

0

0

0

Carrier

58: Wisconsin Phy Serv

12: Lab

06

ZZ

60

0%

1

29

30

Carrier

58: Wisconsin Phy Serv

12: Lab

99

ZZ

26

0%

0

0

0

Carrier

58: Wisconsin Phy Serv

13: Other

06

IL

219

1%

3

0

3

Carrier

58: Wisconsin Phy Serv

13: Other

06

MN

55

0%

1

0

1

Carrier

58: Wisconsin Phy Serv

13: Other

06

WI

64

0%

1

0

1

Carrier

58: Wisconsin Phy Serv

13: Other

08

MI

79

0%

1

0

1

Carrier

58: Wisconsin Phy Serv

13: Other

99

ZZ

1

0%

0

0

0

Carrier - B MAC

59: Noridian - J3

09: Physician

03

MT

640

18%

71

0

71

Carrier - B MAC

59: Noridian - J3

09: Physician

03

UT

1,099

31%

122

0

122

Carrier - B MAC

59: Noridian - J3

09: Physician

99

ZZ

1

0%

0

0

0

Carrier - B MAC

59: Noridian - J3

10: Licen Pra

03

MT

720

20%

80

0

80

Carrier - B MAC

59: Noridian - J3

10: Licen Pra

03

UT

872

24%

97

0

97

Carrier - B MAC

59: Noridian - J3

11: Ambulance

03

MT

88

2%

10

20

30

Carrier - B MAC

59: Noridian - J3

11: Ambulance

03

UT

65

2%

7

23

30

Carrier - B MAC

59: Noridian - J3

11: Ambulance

99

ZZ

1

0%

0

0

0

Carrier - B MAC

59: Noridian - J3

13: Other

03

MT

60

2%

7

0

7

Carrier - B MAC

59: Noridian - J3

13: Other

03

ZZ

44

1%

5

0

5

7,200

3,598

10,798

Carrier Subtotals

375,890

RHHI

71: Cahaba GBA (RHHI Services)

6: HHA

A

PA

242

11%

43

0

43

RHHI

71: Cahaba GBA (RHHI Services)

6: HHA

A

ZZ

107

5%

19

0

19

RHHI

71: Cahaba GBA (RHHI Services)

6: HHA

B

AR

86

4%

15

15

30

RHHI

71: Cahaba GBA (RHHI Services)

6: HHA

B

CO

115

5%

20

10

30

RHHI

71: Cahaba GBA (RHHI Services)

6: HHA

B

VA

144

6%

26

4

30

RHHI

71: Cahaba GBA (RHHI Services)

6: HHA

B

WV

52

2%

9

21

30

RHHI

71: Cahaba GBA (RHHI Services)

6: HHA

B

ZZ

109

5%

19

0

19

RHHI

71: Cahaba GBA (RHHI Services)

6: HHA

C

ZZ

56

2%

10

20

30

RHHI

71: Cahaba GBA (RHHI Services)

6: HHA

D

CA

69

3%

12

18

30

RHHI

71: Cahaba GBA (RHHI Services)

6: HHA

D

IA

85

4%

15

15

30

RHHI

71: Cahaba GBA (RHHI Services)

6: HHA

D

KS

126

6%

22

8

30

Page 24

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

RHHI

71: Cahaba GBA (RHHI Services)

6: HHA

D

MO

147

7%

26

4

RHHI

71: Cahaba GBA (RHHI Services)

6: HHA

D

NE

55

2%

10

20

30
30

RHHI

71: Cahaba GBA (RHHI Services)

6: HHA

D

UT

52

2%

9

21

30

RHHI

71: Cahaba GBA (RHHI Services)

6: HHA

D

ZZ

175

8%

31

0

31

RHHI

71: Cahaba GBA (RHHI Services)

7: Hospice

A

PA

115

5%

20

10

30

RHHI

71: Cahaba GBA (RHHI Services)

7: Hospice

A

ZZ

37

2%

7

0

7

RHHI

71: Cahaba GBA (RHHI Services)

7: Hospice

B

CO

40

2%

7

23

30
30

RHHI

71: Cahaba GBA (RHHI Services)

7: Hospice

B

VA

47

2%

8

22

RHHI

71: Cahaba GBA (RHHI Services)

7: Hospice

B

ZZ

36

2%

6

0

6

RHHI

71: Cahaba GBA (RHHI Services)

7: Hospice

D

IA

68

3%

12

18

30
30

RHHI

71: Cahaba GBA (RHHI Services)

7: Hospice

D

KS

45

2%

8

22

RHHI

71: Cahaba GBA (RHHI Services)

7: Hospice

D

MO

74

3%

13

17

30

RHHI

71: Cahaba GBA (RHHI Services)

7: Hospice

D

UT

52

2%

9

21

30
21

RHHI

71: Cahaba GBA (RHHI Services)

7: Hospice

D

ZZ

120

5%

21

0

RHHI

71: Cahaba GBA (RHHI Services)

7: Hospice

Z

ZZ

2

0%

0

0

0

RHHI

72: Palmetto GBA (RHHI Service

6: HHA

B

AL

132

2%

9

21

30
30

RHHI

72: Palmetto GBA (RHHI Service

6: HHA

B

AR

85

1%

6

24

RHHI

72: Palmetto GBA (RHHI Service

6: HHA

B

FL

621

11%

43

0

43

RHHI

72: Palmetto GBA (RHHI Service

6: HHA

B

GA

92

2%

6

24

30

RHHI

72: Palmetto GBA (RHHI Service

6: HHA

B

LA

216

4%

15

15

30

RHHI

72: Palmetto GBA (RHHI Service

6: HHA

B

MS

56

1%

4

26

30

RHHI

72: Palmetto GBA (RHHI Service

6: HHA

B

NC

155

3%

11

19

30

RHHI

72: Palmetto GBA (RHHI Service

6: HHA

B

NM

62

1%

4

26

30

RHHI

72: Palmetto GBA (RHHI Service

6: HHA

B

OK

187

3%

13

17

30

RHHI

72: Palmetto GBA (RHHI Service

6: HHA

B

SC

68

1%

5

25

30

RHHI

72: Palmetto GBA (RHHI Service

6: HHA

B

TN

124

2%

9

21

30

RHHI

72: Palmetto GBA (RHHI Service

6: HHA

B

TX

1520

26%

105

0

105

RHHI

72: Palmetto GBA (RHHI Service

6: HHA

B

ZZ

30

1%

2

0

2

RHHI

72: Palmetto GBA (RHHI Service

6: HHA

C

IL

363

6%

25

5

30

RHHI

72: Palmetto GBA (RHHI Service

6: HHA

C

IN

143

2%

10

20

30

RHHI

72: Palmetto GBA (RHHI Service

6: HHA

C

KY

94

2%

6

24

30

RHHI

72: Palmetto GBA (RHHI Service

6: HHA

C

OH

351

6%

24

6

30

RHHI

72: Palmetto GBA (RHHI Service

6: HHA

C

ZZ

6

0%

0

0

0

RHHI

72: Palmetto GBA (RHHI Service

6: HHA

Z

ZZ

57

1%

4

0

4

Page 25

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

RHHI

72: Palmetto GBA (RHHI Service

7: Hospice

B

AL

108

2%

7

23

30

RHHI

72: Palmetto GBA (RHHI Service

7: Hospice

B

GA

94

2%

6

24

30

RHHI

72: Palmetto GBA (RHHI Service

7: Hospice

B

LA

93

2%

6

24

30

RHHI

72: Palmetto GBA (RHHI Service

7: Hospice

B

MS

96

2%

7

23

30

RHHI

72: Palmetto GBA (RHHI Service

7: Hospice

B

NC

79

1%

5

25

30

RHHI

72: Palmetto GBA (RHHI Service

7: Hospice

B

OK

135

2%

9

21

30

RHHI

72: Palmetto GBA (RHHI Service

7: Hospice

B

SC

52

1%

4

26

30

RHHI

72: Palmetto GBA (RHHI Service

7: Hospice

B

TN

55

1%

4

26

30

RHHI

72: Palmetto GBA (RHHI Service

7: Hospice

B

TX

228

4%

16

14

30

RHHI

72: Palmetto GBA (RHHI Service

7: Hospice

B

ZZ

141

2%

10

0

10

RHHI

72: Palmetto GBA (RHHI Service

7: Hospice

C

IL

98

2%

7

23

30

RHHI

72: Palmetto GBA (RHHI Service

7: Hospice

C

IN

76

1%

5

25

30

RHHI

72: Palmetto GBA (RHHI Service

7: Hospice

C

OH

93

2%

6

24

30

RHHI

72: Palmetto GBA (RHHI Service

7: Hospice

C

ZZ

35

1%

2

0

2

RHHI

72: Palmetto GBA (RHHI Service

7: Hospice

Z

ZZ

69

1%

5

0

5

RHHI

73: United Government Services

6: HHA

A

NY

158

7%

27

3

30

RHHI

73: United Government Services

6: HHA

A

ZZ

60

3%

10

0

10

RHHI

73: United Government Services

6: HHA

B

PR

48

2%

8

22

30

RHHI

73: United Government Services

6: HHA

B

ZZ

34

1%

6

0

6

RHHI

73: United Government Services

6: HHA

C

MI

280

12%

47

0

47

RHHI

73: United Government Services

6: HHA

C

MN

146

6%

25

5

30

RHHI

73: United Government Services

6: HHA

C

WI

103

4%

17

13

30

RHHI

73: United Government Services

6: HHA

C

ZZ

17

1%

3

0

3

RHHI

73: United Government Services

6: HHA

D

AZ

45

2%

8

22

30

RHHI

73: United Government Services

6: HHA

D

CA

524

22%

88

0

88

RHHI

73: United Government Services

6: HHA

D

NV

54

2%

9

21

30
30

RHHI

73: United Government Services

6: HHA

D

OR

53

2%

9

21

RHHI

73: United Government Services

6: HHA

D

ZZ

123

5%

21

0

21

RHHI

73: United Government Services

7: Hospice

A

NY

49

2%

8

22

30

RHHI

73: United Government Services

7: Hospice

A

ZZ

53

2%

9

0

9

RHHI

73: United Government Services

7: Hospice

B

ZZ

63

3%

11

19

30

RHHI

73: United Government Services

7: Hospice

C

MI

88

4%

15

15

30

RHHI

73: United Government Services

7: Hospice

C

MN

62

3%

10

20

30

RHHI

73: United Government Services

7: Hospice

C

WI

52

2%

9

21

30

Page 26

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

RHHI

73: United Government Services

7: Hospice

C

ZZ

13

1%

2

0

2

RHHI

73: United Government Services

7: Hospice

D

CA

170

7%

29

1

30

RHHI

73: United Government Services

7: Hospice

D

ZZ

175

7%

30

0

30

RHHI

70: Associated Hospital Servic

6: HHA

A

CT

60

16%

35

0

35

RHHI

70: Associated Hospital Servic

6: HHA

A

DE

1

0%

1

0

1

RHHI

70: Associated Hospital Servic

6: HHA

A

MA

94

26%

55

0

55

RHHI

70: Associated Hospital Servic

6: HHA

A

MD

1

0%

1

0

1

RHHI

70: Associated Hospital Servic

6: HHA

A

ME

24

7%

14

0

14

RHHI

70: Associated Hospital Servic

6: HHA

A

NH

30

8%

18

0

18

RHHI

70: Associated Hospital Servic

6: HHA

A

RI

16

4%

9

0

9

RHHI

70: Associated Hospital Servic

6: HHA

A

VT

12

3%

7

0

7

RHHI

70: Associated Hospital Servic

7: Hospice

A

CT

28

8%

13

0

13

RHHI

70: Associated Hospital Servic

7: Hospice

A

MA

48

13%

22

0

22

RHHI

70: Associated Hospital Servic

7: Hospice

A

ME

17

5%

8

0

8

RHHI

70: Associated Hospital Servic

7: Hospice

A

NH

18

5%

8

0

8

RHHI

70: Associated Hospital Servic

7: Hospice

A

RI

8

2%

4

0

4

RHHI

70: Associated Hospital Servic

7: Hospice

A

VT

10

3%

RHHI Subtotals

10,807

5
1,400

0
1,043

5
2,443

DMAC

80: NHIC - A, DMERC

14: Physician

A

MA

111

4%

14

16

30

DMAC

80: NHIC - A, DMERC

14: Physician

A

MD

67

2%

9

21

30

DMAC

80: NHIC - A, DMERC

14: Physician

A

ME

95

3%

12

18

30

DMAC

80: NHIC - A, DMERC

14: Physician

A

NH

51

2%

7

23

30

DMAC

80: NHIC - A, DMERC

14: Physician

A

NJ

79

3%

10

20

30

DMAC

80: NHIC - A, DMERC

14: Physician

A

NY

202

7%

26

4

30
31

DMAC

80: NHIC - A, DMERC

14: Physician

A

PA

243

8%

31

0

DMAC

80: NHIC - A, DMERC

14: Physician

A

ZZ

124

4%

16

0

16

DMAC

80: NHIC - A, DMERC

15: Supplier

A

MD

54

2%

7

23

30

DMAC

80: NHIC - A, DMERC

15: Supplier

A

NJ

87

3%

11

19

30

DMAC

80: NHIC - A, DMERC

15: Supplier

A

NY

175

6%

23

7

30

DMAC

80: NHIC - A, DMERC

15: Supplier

A

PA

123

4%

16

14

30

DMAC

80: NHIC - A, DMERC

15: Supplier

A

ZZ

93

3%

12

0

12

DMAC

80: NHIC - A, DMERC

16: Other

A

CT

53

2%

7

0

7

DMAC

80: NHIC - A, DMERC

16: Other

A

MA

92

3%

12

0

12

Page 27

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

DMAC

80: NHIC - A, DMERC

16: Other

A

MD

92

3%

12

0

12

DMAC

80: NHIC - A, DMERC

16: Other

A

NJ

288

9%

37

0

37

DMAC

80: NHIC - A, DMERC

16: Other

A

NY

520

17%

67

0

67

DMAC

80: NHIC - A, DMERC

16: Other

A

PA

449

15%

58

0

58

DMAC

80: NHIC - A, DMERC

16: Other

A

ZZ

98

3%

13

0

13

DMAC

81: ASF - B, DMERC

14: Physician

C

IL

56

3%

11

19

30

DMAC

81: ASF - B, DMERC

14: Physician

C

IN

73

4%

14

16

30

DMAC

81: ASF - B, DMERC

14: Physician

C

MI

69

3%

13

17

30

DMAC

81: ASF - B, DMERC

14: Physician

C

OH

123

6%

24

6

30

DMAC

81: ASF - B, DMERC

14: Physician

C

ZZ

61

3%

12

0

12

DMAC

81: ASF - B, DMERC

15: Supplier

C

IL

109

5%

21

9

30

DMAC

81: ASF - B, DMERC

15: Supplier

C

KY

60

3%

12

18

30

DMAC

81: ASF - B, DMERC

15: Supplier

C

MI

148

7%

28

2

30

DMAC

81: ASF - B, DMERC

15: Supplier

C

OH

117

6%

22

8

30

DMAC

81: ASF - B, DMERC

15: Supplier

C

ZZ

72

3%

14

0

14

DMAC

81: ASF - B, DMERC

16: Other

C

IL

209

10%

40

0

40

DMAC

81: ASF - B, DMERC

16: Other

C

IN

68

3%

13

0

13

DMAC

81: ASF - B, DMERC

16: Other

C

KY

201

10%

39

0

39

DMAC

81: ASF - B, DMERC

16: Other

C

MI

274

13%

53

0

53

DMAC

81: ASF - B, DMERC

16: Other

C

MN

92

4%

18

0

18

DMAC

81: ASF - B, DMERC

16: Other

C

OH

258

12%

50

0

50

DMAC

81: ASF - B, DMERC

16: Other

C

WI

92

4%

18

0

18

DMAC

82: Palmetto - C DMERC

14: Physician

B

AR

45

1%

3

27

30

DMAC

82: Palmetto - C DMERC

14: Physician

B

FL

125

2%

9

21

30

DMAC

82: Palmetto - C DMERC

14: Physician

B

MS

52

1%

4

26

30

DMAC

82: Palmetto - C DMERC

14: Physician

B

OK

95

2%

7

23

30
30

DMAC

82: Palmetto - C DMERC

14: Physician

B

TX

90

2%

7

23

DMAC

82: Palmetto - C DMERC

14: Physician

B

VA

67

1%

5

25

30

DMAC

82: Palmetto - C DMERC

14: Physician

B

WV

81

2%

6

24

30

DMAC

82: Palmetto - C DMERC

14: Physician

B

ZZ

219

4%

16

0

16

DMAC

82: Palmetto - C DMERC

15: Supplier

B

AL

69

1%

5

25

30
30

DMAC

82: Palmetto - C DMERC

15: Supplier

B

AR

51

1%

4

26

DMAC

82: Palmetto - C DMERC

15: Supplier

B

FL

539

10%

40

0

40

DMAC

82: Palmetto - C DMERC

15: Supplier

B

GA

111

2%

8

22

30

Page 28

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

DMAC

82: Palmetto - C DMERC

15: Supplier

B

LA

99

2%

7

23

30

DMAC

82: Palmetto - C DMERC

15: Supplier

B

MS

53

1%

4

26

30

DMAC

82: Palmetto - C DMERC

15: Supplier

B

NC

107

2%

8

22

30

DMAC

82: Palmetto - C DMERC

15: Supplier

B

OK

63

1%

5

25

30

DMAC

82: Palmetto - C DMERC

15: Supplier

B

PR

252

5%

19

11

30

DMAC

82: Palmetto - C DMERC

15: Supplier

B

SC

52

1%

4

26

30

DMAC

82: Palmetto - C DMERC

15: Supplier

B

TN

82

2%

6

24

30

DMAC

82: Palmetto - C DMERC

15: Supplier

B

TX

357

7%

27

3

30
30

DMAC

82: Palmetto - C DMERC

15: Supplier

B

VA

70

1%

5

25

DMAC

82: Palmetto - C DMERC

15: Supplier

B

ZZ

79

1%

6

0

6

DMAC

82: Palmetto - C DMERC

16: Other

B

AL

164

3%

12

0

12

DMAC

82: Palmetto - C DMERC

16: Other

B

AR

134

2%

10

0

10

DMAC

82: Palmetto - C DMERC

16: Other

B

FL

444

8%

33

0

33

DMAC

82: Palmetto - C DMERC

16: Other

B

GA

219

4%

16

0

16

DMAC

82: Palmetto - C DMERC

16: Other

B

LA

211

4%

16

0

16

DMAC

82: Palmetto - C DMERC

16: Other

B

MS

157

3%

12

0

12

DMAC

82: Palmetto - C DMERC

16: Other

B

NC

163

3%

12

0

12

DMAC

82: Palmetto - C DMERC

16: Other

B

OK

86

2%

6

0

6

DMAC

82: Palmetto - C DMERC

16: Other

B

PR

144

3%

11

0

11

DMAC

82: Palmetto - C DMERC

16: Other

B

SC

110

2%

8

0

8

DMAC

82: Palmetto - C DMERC

16: Other

B

TN

203

4%

15

0

15

DMAC

82: Palmetto - C DMERC

16: Other

B

TX

319

6%

24

0

24

DMAC

82: Palmetto - C DMERC

16: Other

B

VA

137

3%

10

0

10
7

DMAC

82: Palmetto - C DMERC

16: Other

B

WV

88

2%

7

0

DMAC

82: Palmetto - C DMERC

16: Other

B

ZZ

51

1%

4

0

4

DMAC

83: Noridian -D, DMERC

14: Physician

D

AZ

129

4%

15

15

30

DMAC

83: Noridian -D, DMERC

14: Physician

D

CA

259

8%

30

0

30

DMAC

83: Noridian -D, DMERC

14: Physician

D

HI

67

2%

8

22

30

DMAC

83: Noridian -D, DMERC

14: Physician

D

IA

174

5%

20

10

30

DMAC

83: Noridian -D, DMERC

14: Physician

D

NE

83

2%

10

20

30

DMAC

83: Noridian -D, DMERC

14: Physician

D

NV

68

2%

8

22

30

DMAC

83: Noridian -D, DMERC

14: Physician

D

OR

134

4%

16

14

30

DMAC

83: Noridian -D, DMERC

14: Physician

D

WA

257

8%

30

0

30

DMAC

83: Noridian -D, DMERC

14: Physician

D

ZZ

111

3%

13

0

13

Page 29

ATTACHMENT 1
MCPSS
National Implementation Sample

CONTRACTOR
TYPE

Strata ID / Contractor
Name

Provider
Type*

CMS
State
Jurisdiction** Strata**

Total
Population

% of
Contractor

Base
Sample

Over
Sample

Total
Sample

DMAC

83: Noridian -D, DMERC

15: Supplier

D

CA

395

12%

46

0

46

DMAC

83: Noridian -D, DMERC

15: Supplier

D

MO

53

2%

6

24

30
27

DMAC

83: Noridian -D, DMERC

15: Supplier

D

ZZ

226

7%

27

0

DMAC

83: Noridian -D, DMERC

16: Other

D

CA

611

18%

72

0

72

DMAC

83: Noridian -D, DMERC

16: Other

D

IA

131

4%

15

0

15

DMAC

83: Noridian -D, DMERC

16: Other

D

KS

77

2%

9

0

9

DMAC

83: Noridian -D, DMERC

16: Other

D

MO

140

4%

16

0

16

DMAC

83: Noridian -D, DMERC

16: Other

D

NE

103

3%

12

0

12

DMAC

83: Noridian -D, DMERC

16: Other

D

WA

91

3%

11

0

11

DMAC

83: Noridian -D, DMERC

16: Other

D

ZZ

298

9%

DMAC Subtotals
Total

35

0

35

13,973

1,600

814

2,414

435,986

16,526

7,713

24,239

** If there are an insufficient number of providers in the "cell," then the substrata are collapsed (as
indicated by 99 in the jurisdiction column, and by ZZ in the State column)
* Provider Type abbreviations
ESRD = Dialysis facilities
FQHC = Federally Qualified Health Clinic
HHA = Home Health Agency
Licen Pra is short for "Licensed Practitioners"
Other Carrier include other Part B providers, such as Mammography screening centers
Other FI include other Part A providers, such as mental health clinics
RHC = Rural Health Clinics
SNF = Skilled Nursing Facility

Page 30