CMS-10237 CY 2015 Medicare Advantage HSD Exception Request Templat

CY 2015 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 CMS
netword criteria)
RPPO (only for RPPOs proposing alternative arrangements to a contracted provider
network)

1.)
Are there non-contracted providers/facilities of the specialty (code) type, for which
you are requesting an exception to the CMS network criteria, located (1) within the CMS time
and distance criteria and/or (2) outside CMS time and distance criteria but are closer than
your nearest contracted provider to Medicare beneficiaries residing in zip codes failing to
meet the ACC accessibility requirements? If so, list each physician’s or other practitioner’s
name, address, and telephone number as well as the travel time/distance from each deficient
city and zip code. Separately identify non-contracted providers/facilities located within CMS
time and distance criteria and non-contracted providers/facilities located beyond CMS time
and distance criteria but closer than the applicant’s nearest contracted provider/facility. You
should refer to the HSD Beneficiary Coverage Zip Code Report to identify those beneficiary
residences’ locations that are preventing your contracted network configuration from fully
and completely meeting the CMS network criteria and the ACC Report 90% accessibility
requirements.
2.)
What are the sources of the information you have relied upon to identify
providers/facilities of the type for which you are requesting the local pattern of care
exception? Indicate the sources you relied upon and clearly indicate if you were unable to
identify any of the type for which you are requesting the exception. (When using
medicare.gov, search on each deficient zip code, the specialty type and travel distance (25
miles, 50 miles, 100 miles) to search for non-contracted providers.) CMS must verify the
sources of your information so do not simply provide a name or title or a person but provide a
full and verifiable citation including page number, web site address and all necessary specifics
for a reviewer to access the source(s).
3.)
If you answered “yes” to the first question in Number #1, explain why you have not
negotiated a contract with those providers/facilities of the specialty type that are serving
Medicare patients within the CMS network time and distance criteria. Be very specific in your
response!
4.)
What are the specific local patterns of care issues that you have identified with regard
to access to services of providers/facilities of the specialty code type for which you are
requesting the exception? Do not generalize! Be as specific as you can. You must support
this narrative with data and, as with Question #2, provide us with a full citation of verifiable

sources for this data. We must verify the data and the source to adequately and fairly grant
your request for an exception to the CMS network criteria. Also provide a detailed
explanation as to why Medicare beneficiaries residing in zip codes failing to meet the CMS
network accessibility requirements would not seek care from non-contracted provider(s)
located closer than the nearest contracted provider(s). Be specific with your response and
include travel time and distance information.
5.)
If CMS recognizes the relevance and validity of your information about local patterns
of care issues, we still need to understand where your plan’s enrollees will get the services of
this specialty type, if you were granted an exception. Explain where the plan’s enrollees
would be expected to go to have access to these services and how far they would have to
travel to do so for each deficient zip code or primary zip code city/town. You must include
travel time in your response for Large Metro Counties. That access must meet the patterns of
care that you describe in Number #4. These sources of care must be individually listed on
your uploaded HSD Tables as contracted providers or facilities or services for the county or
counties in question. You must also list the closest contracted provider below with the
deficient zip code(s) and primary city(ies) and town(s) to which he/she will provide services.
Use a central point within each zip code, city or town to determine the distance.
6.)
You may propose in addition to or instead of providers/facilities beyond the CMS
network time and distance requirements an “alternate” provider type to provide the services
of the specialty code type that has failed the CMS network standard and for which you have
provided a local pattern of care issue narrative, data and data source citation(s). If you do
so, explain this substitution, such as an Orthopedist to provide Podiatric Care, with specifics
as to the alternate provider or facility or service provider. Include documents that include
signed assurances from the alternate source of the service that he or she or it: (a) is currently
providing the services of the code type to Medicare beneficiaries and receiving payment from
Medicare for these services; (b) is willing to provide these services to your plan’s Medicare
enrollees, and (c) provides your organization authorization to indicate this in a Medicare
Provider Directory and other listings. Provide documentation as to how your organization
established that the alternate provider, facility or service has met all licensing, educational,
state scope of practice, and experience requirements to meet your credentialing standards as
well as any other State and/or Federal laws and requirements that apply to this specialty
type. Complete the information below for this alternate source as well as for the next
geographically closest provider/facility of this type with which you have negotiated a
contract to serve your plan’s Medicare enrollees.

LIST THE CONTRACTED PROVIDERS/FACILITIES THAT WILL ENSURE ACCESS (THEY MUST BE LISTED IN THE
HSD TABLE UNDER THE COUNTY IN WHICH THEY ARE PROVIDING SERVICES). 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):
TIME AND DISTANCE BETWEEN EACH
DEFICIENT ZIP CODE/CITY AND CLOSEST

CONTRACTED PROVIDER: For each deficient
zip code/city, list the closest contracted
provider/facility and the time and/or
distance between them.
NAME FROM HSD TABLE:
PROVIDER NPI:
SPECIALTY TYPE:
ADDRESS (street, city, state, zip code, and
telephone number):
TIME AND DISTANCE BETWEEN EACH
DEFICIENT ZIP CODE/CITY AND CLOSEST
CONTRACTED PROVIDER: For each deficient
zip code/city, list the closest contracted
provider/facility and the time and/or
distance between them.
NAME FROM HSD TABLE:
PROVIDER NPI:
SPECIALTY TYPE:
ADDRESS (street, city, state, zip code, and
telephone number):
TIME AND DISTANCE BETWEEN EACH
DEFICIENT ZIP CODE/CITY AND CLOSEST
CONTRACTED PROVIDER: For each deficient
zip code/city, list the closest contracted
provider/facility and the time and/or
distance between them.