CMS-10237 CY 2016 Medicare Advantage HSD Exception Request Templat

CY 2017 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:

Other Factors in accordance with 42 CFR 422.112 a (10)(v)that CMS determines are
relevant in setting a standard for an acceptable health care delivery network in a
particular service area.
RPPO (only for RPPOs proposing alternative arrangements to a contracted provider
network contact CMS by sending an email to https://dmao.lmi.org/ and clicking on
the MA Applications tab. Please note: this is a webpage, not an email address.)

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 :
a. within the CMS time and distance criteria and/or
b. 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 Zip Code
Report for Failed Counties to identify those beneficiaries
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 other factors 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 (1 mile to 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 other factors 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.)
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
requested an exception. 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.
6)
If CMS recognizes the relevance and validity of your information about other factors
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 other factors 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.

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
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
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