Part C Medicare Advantage Applications and 1876 Cost Plan Expansion Application (CY 2012)

HSD Instructions
This document contains information needed to complete the HSD tables required for the online
application process (you will not need to complete HSD tables if you are applying for an
employer-only SAE). It also contains frequently asked questions (FAQ) regarding HSD
submission and processing, guidance on developing valid addresses and field edits for the MA
Provider and MA Facility tables.

Contents
Specialty Codes for the MA Provider Table ................................................................................... 2
Specialty Codes for the MA Facility Table .................................................................................... 3
HSD Table Instructions................................................................................................................... 4
MA Provider Table ......................................................................................................................... 4
MA Facility Table ........................................................................................................................... 7
HSD Exceptions Guidance - Requesting Exceptions ..................................................................... 9

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CY 2013 HSD Instructions (Draft)

SPECIALTY CODES
CMS has created specific specialty codes for each of the physician/provider and facility types.
Applicants must use the codes when completing HSD tables (MA Provider and MA Facility
tables).

Specialty Codes for the MA Provider Table
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001 – General Practice
002 – Family Practice
003 – Internal Medicine
004 – Geriatrics
005 – Primary Care – Physician Assistants
006 – Primary Care – Nurse Practitioners
007 – Allergy and Immunology
008 – Cardiology
009 – Cardiac Surgery
010 - Chiropractor
011 – Dermatology
012 – Endocrinology
013 – ENT/Otolaryngology
014 – Gastroenterology
015 – General Surgery
016 – Gynecology, OB/GYN
017 – Infectious Diseases
018 - Nephrology
019 - Neurology
020 - Neurosurgery
021 - Oncology - Medical, Surgical
022 - Oncology - Radiation/Radiation Oncology
023 – Ophthalmology
024 - Oral Surgery
025 - Orthopedic Surgery
026 - Physiatry, Rehabilitative Medicine
027 - Plastic Surgery
028 - Podiatry
029 - Psychiatry
030 - Pulmonology
031 - Rheumatology
032 - Thoracic Surgery
033 - Urology
034 - Vascular Surgery
000 – OTHER

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Specialty Codes for the MA Facility Table
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040 – Acute Inpatient Hospitals
041 - Cardiac Surgery Program
042 - Cardiac Catheterization Services
043 - Critical Care Services – Intensive Care Units (ICU)
044 - Outpatient Dialysis
045 - Surgical Services (Outpatient or ASC)
046 - Skilled Nursing Facilities
047 - Diagnostic Radiology
048 - Mammography
049 - Physical Therapy
050 - Occupational Therapy
051 - Speech Therapy
052 - Inpatient Psychiatric Facility Services
053 – NOT IN USE
054 - Orthotics and Prosthetics
055 - Home Health
056 - Durable Medical Equipment
057 - Outpatient Infusion/Chemotherapy
058 - Laboratory Services
059 – NOT IN USE
060 – NOT IN USE
061 - Heart Transplant Program
062 - Heart/Lung Transplant Program
063 - Intestinal Transplant Program
064 - Kidney Transplant Program
065 - Liver Transplant Program
066 - Lung Transplant Program
067 - Pancreas Transplant Program

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CY 2013 HSD Instructions (Draft)

HSD Table Instructions
The tables should reflect the applicants’ executed contracted network on the date of submission.
CMS considers a contract fully executed when both parties have signed. Applicants should only
list providers with whom they have a fully executed updated contract. These contracts should be
executed on or prior to application submission deadline. In order for the automated network
review tool to appropriately process this information, applicants 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 applicants to fully utilize
the opportunities for pre-checks and to fully review the Automated Criteria Check (ACC) reports
to ensure that their HSD tables are accurate and complete.

MA Provider Table
This table captures information on the specific physicians/providers in the applicant’s contracted
network. If a provider serves beneficiaries residing in multiple counties in the service area, list
the provider multiple times with the appropriate state/county code to account for each county
served. Providers that have opted out of Medicare cannot be included in the applicant’s
contracted network or on this table.
Column Explanations
A. SSA State/County Code – Enter the SSA State/County code of the county which the
listed physician/provider will serve. The state/county code is a five digit number. Please
include any leading zeros (e.g., 01010). The state and county codes on the HSD Criteria
Reference Table are the codes you should use. Format the cell as “text” to ensure that
codes beginning with a “0” appear as five digits.
B. Name of Physician or Mid-Level Practitioner – Self-explanatory. Up to 150
characters.
C. National Provider Identifier (NPI) Number – The provider’s assigned NPI number
must be included in this column. Enter the provider’s individual NPI number whether the
provider is part of a medical group or not. The NPI is a ten digit numeric field. Include
leading zeros.
D. Specialty – Name of specialty of listed physician/provider. This should be copied
directly off of the HSD Criteria Reference Table.
E. Specialty Code – Specialty codes are unique codes assigned by CMS to process data.
Enter the appropriate specialty code. If the applicant is proposing to rely on a provider
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CY 2013 HSD Instructions (Draft)

type that is not on the CMS Specialty code list, please add a line to the HSD provider
table and enter that provider’s information along with “000” (3 zeros) as the specialty
code for that provider.
F. Contract Type – Enter the type of contract the Applicant holds with listed provider. Use
“DC” for direct contract and “DS” for downstream (define DS) contract.
Provider Service Address Columns- Enter the address (i.e., street, city, state and zip code)
of the location at which the provider sees patients. Do not list P.O. Box, house, apartment,
building or suite numbers, or street intersections.
G. Provider Service Address: Street Address – up to 250 characters
H. Provider Service Address: City – up to 150 characters
I. Provider Service Address: State – 2 characters
J. Provider Service Address: Zip Code – up to 10 characters
K. Provider Previously Listed – Enter "Y" if the provider is listed more than once on the
HSD table. Enter "N" if a provider is not listed more than once on this table (i.e. for
other counties or in the same county for another type of Specialty).
L. Contracted Hospital Where Privileged – Enter the name of the contracted hospital in
the service area where the listed physician/provider has admitting privileges, other than
courtesy privileges. If the provider does not have admitting privileges at a contracted
hospital in the service area, please leave this cell blank. If the provider has admitting
privileges at more than one contracted hospital in the service area, please insert additional
rows into the table as needed and fill in all corresponding data on each line for all other
contracted hospitals, in the service area, where the provider has admitting privileges.
Note: If you enter the same SSA state/county, NPI number, specialty code, and address
combination more than once to accommodate listing multiple entries for the Contracted
Hospital Where Privileged field, only the first occurrence will count in the ACC
processing. The additional rows will count as duplicates and will appear on the Address
Information Report for informational purposes. This will not adversely impact the
evaluation of the submitted HSD tables.
M. Hospital National Provider Identifier (NPI) Number – Enter the NPI number for the
contracted hospital(s) where the provider has admitting privileges. If the provider does
not have admitting privileges at a contracted hospital in the service area, leave blank.
The NPI number is a 10 digit numeric field. Include leading zeros.
N. If PCP Accepts New Patients? – Indicate if provider is accepting new patients by
entering a "Y" or "N" response.

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CY 2013 HSD Instructions (Draft)

O. If PCP Accepts Established Patients? – Indicate if provider is limiting practice to only
established patients by entering a "Y" or "N" response.
P. Does Applicant Delegate Credentialing? – Enter "Y" if the applicant delegates the
credentialing of the physician. Enter "N" if the applicant does not delegate credentialing
of the physician. If credentialing is not required, leave cell blank.
Q. If Credentialing is Delegated, List Entity – - If credentialing is not performed by the
applicant, enter the name of the entity that performs the credentialing. The name entered
must match one of the entities listed on the Delegated Business Function Table in
HPMS. (See Section 3.10.B of the consolidated Part C – Medicare Advantage
Application.) Field Length is 250 characters.
R. Medical Group Affiliation – If provider is affiliated with a medical group/Individual
Practice Association MG/IPA), list the name of the MG/IPA. If the applicant has a direct
contract with the provider, then enter “DC.” Leave this column blank if the provider is
not affiliated with a MG/IPA or does not have a direct contract with applicant.
S. Employment Status – For each provider affiliated with a medical group, enter an “E” if
the provider is an employee of the MG/IPA. Enter “DS” if there is a downstream
contract in place. Otherwise, leave this cell blank.

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CY 2013 HSD Instructions (Draft)

MA Facility Table
Only list the providers that are contracted Medicare-certified providers. Please do not list any
additional providers or services except those included in the list of facility specialty codes.
If a facility offers more than one of the defined services and/or provides services in multiple
counties, the facility should be listed multiple times with the appropriate “SSA State/County
Code” and “Specialty Code” for each service.

Column Explanations:
A. SSA State/County Code – Enter the SSA State/County code of the county for which the
listed facility will serve. The county code should be a five digit number. Please include
any leading zeros (e.g., 01010). The state and county codes on the HSD Criteria
Reference Table are the codes that applicants should use. Format the cell as “text” to
ensure that codes beginning with a “0” appear as five digits.
B. Facility or Service Type – Name of facility/service type of listed facility. This should be
copied directly off of the HSD Criteria Reference Table.
C. Specialty Code – Specialty codes are unique 3 digit numeric codes assigned by CMS to
process data. Enter the Specialty Code that best describes the services offered by each
facility or service. Include leading zeros.
D. Certification Number (CCN) – Enter the facility’s Medicare Certification Number in
this column. If none, leave blank.
E. National Provider Identifier (NPI) Number – Enter the provider’s assigned NPI
number in this column. The NPI is a ten digit numeric field. Include leading zeros.
F. Number of Staffed, Medicare-Certified Beds – For Acute Inpatient Hospitals, Critical
Care Services – Intensive Care Units (ICU)s, Skilled Nursing Facilities, and Inpatient
Psychiatric Facility Services, enter the number of Medicare-certified beds for which the
Applicant has contracted access for Medicare Advantage enrollees. This number should
not include Neo-Natal Intensive Care Unit (NICU) beds.
G. Facility Name – Enter the name of the facility. Field Length is 150 characters.

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CY 2013 HSD Instructions (Draft)

Provider Service Address Columns- Enter the address (i.e., street, city, state and zip code)
from which the provider serves patients. Do not list P.O. Box, house, apartment, building
or suite numbers, or street intersections. For Home Health and Durable Medical
Equipment, indicate the business address where one can contact these vendors.
H. Provider Service Address: Street Address – up to 250 characters
I. Provider Service Address: City – up to 150 characters
J. Provider Service Address: State – 2 characters
K. Provider Service Address: Zip Code – up to 10 characters

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CY 2013 HSD Instructions (Draft)

HSD Exceptions Guidance - Requesting Exceptions
If an applicant discovers Application deficiencies during the pre-check review which indicate the
submitted network does not meet the minimum provider/bed number, time and/or distance
requirements for any individual provider/facility type in a particular county, Applicant may
request an Exception for that deficiency under the following circumstances:

* Patterns of care in the county do not support need for the requested number of the specific
provider/facility type
* (Limited to RPPO applicants) – The RPPO applicant is relying on Alternative Arrangements
to meet access requirements for this provider/facility type in this county.
Applicants requesting Exceptions must complete the CMS Exceptions Template for each
exception requested and provide the appropriate information requested in the template.
Additionally, all Exceptions must be requested and supported with appropriate documentation
within the timeframe established by CMS.

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