Form CMS-10237 2013_HSD_Exception_Request_Template

CY2013 MEDICARE ADVANTAGE HSD EXCEPTION REQUEST TEMPLATE
(File naming convention: Contract ID_County Code_Specialty Code) – 15 characters
CONTRACT ID:
COUNTY CODE:
SPECIALTY CODE:

JUSTIFICATION FOR
EXCEPTION:
(Select the one most
relevant
justification)

YOUR PLAN FOR
ENSURING ACCESS
TO SERVICES:

Patterns of Care do not support the criteria
RPPO

1.)
Are there providers/facilities of the type that failed the ACC for this county, with which you
have not contracted, located within the time/distance requirement? If yes, please provide their
names and addresses (and telephone numbers, if available).
2.)
What sources of information or research did you rely on to identify the providers/facilities
(or lack thereof)? If published or Internet site, please provide the full citation and location of the
specific information.
3.)
If you answered yes to Question 1, explain in detail why you have not contracted with the
providers/facilities you listed.
4.)
Is there an unusual pattern of distribution of Medicare beneficiary residences in the specified
county that you are able to document? If yes, as indicated in Question 2, please provide the sources
for your information and explain how that pattern affects the local patterns of care for the county.
5.)
Describe any unusual local pattern of care in the county for FFS Medicare beneficiaries when
they seek and receive care and services normally offered by providers/facilities of the type that
failed the ACC for this county. Support this description with data and provide sources of the data.
6.)
Please describe how you will provide the services of the failed provider/facility type to
beneficiaries who enroll in your plan(s) offered in the specified county.
7.)
If you are proposing to use an “alternate” provider or facility to provide some, or all, of the
Medicare covered services provided by the failed provider/facility type, please include a justification
for using the alternate provider/facility. Please also include written assurance from the alternate
provider/facility stating that it is currently providing services of the failed provider/facility type to
Medicare beneficiaries, is willing to provide these services to your plan enrollees, and provides
authorization to list it in your provider directory as offering the services in question. In addition,
provide documentation that the alternate provider/facility meets all license, education, and
experience requirements to meet your credentialing policies and procedures, and all State and
Federal laws and requirements that apply to the specified services.

CONTRACTED PROVIDER(S) LISTED ON HSD TABLE THAT WILL ENSURE ACCESS
NAME FROM HSD TABLE:
PROVIDER NPI:
SPECIALTY TYPE:
ADDRESS (street, city, state, zip code, and
telephone number):
DISTANCE FROM BENEFICIARIES (Based on
Sample Beneficiary File in HPMS):
NAME FROM HSD TABLE:
PROVIDER NPI:
SPECIALTY TYPE:

ADDRESS (street, city, state, zip code, and
telephone number):
DISTANCE FROM BENEFICIARIES (Based on
Sample Beneficiary File in HPMS):
NAME FROM HSD TABLE:
PROVIDER NPI:
SPECIALTY TYPE:
ADDRESS (street, city, state, zip code, and
telephone number):
DISTANCE FROM BENEFICIARIES (Based on
Sample Beneficiary File in HPMS):