Form CMS-10237 CY 2014 HSD Exception Request Template

CY 2014 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 (care is accessed from providers/facilities that do not meet the ACC criteria)
RPPO (only for RPPOs proposing alternative arrangements to a contracted provider network)

1.)
Are there providers/facilities of the specialty code type, located within the ACC’s time and
distance criteria, with which you have not contracted? Provide their names and addresses (and
telephone numbers, if available), specifically identifying those providers located within the ACC’s
time and distance criteria of zip codes not meeting the ACC’s 90% accessibility requirement. Use
the HSD Beneficiary Coverage by Zip Code Report to identify the zip codes not meeting the ACC’s
90% accessibility requirement.
2.)
What sources of information did you rely on to identify the providers/facilities (or lack
thereof)? Your sources must be verifiable by CMS. Provide the full citation of your sources and the
location of the specific information.
3.)
If you answered yes to Question 1, explain why you have not contracted with the
providers/facilities.
4.)
What is the pattern of care to access providers/facilities of the specialty code type for this
county? Support this description with data and, following question 2, provide the verifiable
sources.
5.)
Explain how you will provide access to providers/facilities of the specialty code type for this
county. For example, have you contracted with providers/facilities consistent with the pattern of
care described in question 4? In your explanation, include (a) your analysis of the HSD Beneficiary
Coverage by Zip Code Report and the Part D Eligibility File, (b) identify the zip codes in the county
that do not meet the ACC’s 90% accessibility requirement, and(c) explain how those zip codes’
Medicare beneficiaries are ensured access to contracted providers/facilities of the specialty code
type.
6.)
Instead of providers/facilities of the specialty code type, are you proposing using “alternate”
providers/facilities to provide the services of the specialty code type? If yes, explain and include
written assurances from the alternate provider/facility, assuring that it (a) is currently providing
services of the specialty code type to Medicare beneficiaries, (b) is willing to provide these services
to your plan enrollees, and (c) provides authorization to list it in your provider directory as offering
the services of the specialty code type. Provide documentation that the alternate provider/facility
meets all license, education and experience requirements to meet your credentialing policies and
procedures and meets all State and Federal laws and requirements that apply to the specialty code
type’s services. List the contracted alternate providers/facilities, below, as well as the next nearest
providers/facilities of the specialty code type.

LIST THE CONTRACTED PROVIDERS/FACILITIES THAT WILL ENSURE ACCESS (THEY MUST BE LISTED IN THE HSD
TABLE UNDER THE COUNTY THEY’RE PROVIDING SERVICES TO). ALSO, LIST THE CLOSEST CONTRACTED
PROVIDER/FACILITY OF THE SPECIALTY CODE TYPE.
NAME FROM HSD TABLE:
PROVIDER NPI:
SPECIALTY TYPE:
ADDRESS (street, city, state, zip code, and

telephone number):
DISTANCE FROM MEDICARE BENEFICIARIES IN
THE COUNTY:
NAME FROM HSD TABLE:
PROVIDER NPI:
SPECIALTY TYPE:
ADDRESS (street, city, state, zip code, and
telephone number):
DISTANCE FROM MEDICARE BENEFICIARIES IN
THE COUNTY:
NAME FROM HSD TABLE:
PROVIDER NPI:
SPECIALTY TYPE:
ADDRESS (street, city, state, zip code, and
telephone number):
DISTANCE FROM MEDICARE BENEFICIARIES IN
THE COUNTY: