CMS-10636 Exception Request Template

Version: MA-2022.0

MEDICARE ADVANTAGE HEALTH SERVICE DELIVERY EXCEPTION REQUEST TEMPLATE
(File naming convention: Contract ID_County Code_Specialty Code) – 15 characters
Part I: Exception Information
Please enter the Contract ID and select the County and Specialty for which you are requesting an exception.
Contract ID:
State:
County:
Specialty:

Select a State
Select a County
Select a Specialty

Part II: Rationale for Exception
Please respond to the questions below by selecting either "Yes" or "No" from the drop-down list for each question.
Question 1: Does the applicant attest that it has reviewed publicly
available databases and other sources to determine availability of
providers/facilities with respect to the exception being requested?
Question 2: If the applicant responded “yes” to
Question 1, above, did the applicant’s review identify
providers/ facilities within CMS’s network adequacy
criteria, and with which the applicant has not
contracted?
Question 3: Did the applicant contract with
providers/facilities who are outside CMS’s current network
adequacy criteria?
Question 4: Are there other non-contracted
providers/ facilities outside CMS’s current network
adequacy criteria who are located closer to plan
enrollees?
OMB Control Number: 0938-1346 (Expires: 11/30/2024)

Part III: Sources
In the rows below, please enter any sources (up to five) you used to identify provider/facilities within or nearby CMS’s network adequacy criteria.
To enter a source, select an option from the drop-down list, which is comprised of sources commonly used by MAOs and CMS. If you have more
than five sources, or a source not included on the drop-down list, please describe the additional sources in the Part IV: Narrative Text section
below. The drop-down options for the sources are:
-Physician Compare
-Hospital Compare
-Nursing Home Compare
-Dialysis Compare
-NPI file/NPPES
-Provider of Services (POS) file
-Direct outreach to provider
-Provider website
-State licensing data
-Online mapping tool
-Other (Note to MAOs: Please describe the other source(s) in the “Part IV: Narrative Text” section)
Additionally, if you select “Other,” please describe the other sources in the Part IV: Narrative Text section below.
Source 1

Source 2

Source 3

Source 4

Source 5

OMB Control Number: 0938-1346 (Expires: 11/30/2024)

Part IV: Narrative Text (Optional)
Please use the below box to enter any additional text to justify your exception request. This section may also be used to explain “Other” and
additional sources from the Part III: Sources section.

Part V: Table of Non-Contracted Providers
Please list below any providers/facilities you have identified within or nearby CMS's network adequacy criteria with whom you have not
contracted. Each additional provider/facility should be listed on a separate row. For each additional provider, please complete all columns. Please
note, the “Provider State” field and “Additional Notes on Reason for Not Contracting” field have drop-down lists. From the “Reason for Not
Contracting” drop-down list, you can select one of the following options:
-Provider is no longer practicing (e.g., deceased, retired),
-Provider does not provide services at the office/facility address listed in database,
-Provider does not provide services in the specialty type listed in the database and for which this exception is being requested,
-Provider has opted out of Medicare,
-Provider does not contract with any Medicare Advantage Organization,
-Sanctioned provider on List of Excluded Individuals and Entities,
-Inability to contract with provider (Note to MAOs: This is not a valid rationale for submitting an exception),
-In the process of negotiating a contract with provider (Note to MAOs: This is not a valid rationale for submitting an exception),
-Provider is at capacity and is not accepting new patients,
-Other (Note to MAOs: Please provide an explanation in the “Additional Notes on Reason for Not Contracting” field)
If you need to provide additional notes, the “Additional Notes on Reason for Not Contracting” field is a free-text field without any character limits.
If you select “Other” from the “Reason for Not Contracting” drop-down list, please elaborate on this reason in the “Additional Notes on Reason for
Not Contracting” field.
Provider/
Provider
Provider
Provider
Reason for Not
Provider Provider
Additional Notes
NPI
on Reason for Not
Facility Name Street
State
ZIP Code
Phone
Contracting
City
(10 Digits)
Contracting
Address
(Drop(5 Digits)
Number
(Drop-Down)
(10 Digits)
Down)

OMB Control Number: 0938-1346 (Expires: 11/30/2024)

Provider/
Facility Name

Provider
Street
Address

Provider
City

Provider
State
(DropDown)

OMB Control Number: 0938-1346 (Expires: 11/30/2024)

Provider
ZIP Code
(5 Digits)

NPI
(10 Digits)

Provider
Phone
Number
(10 Digits)

Reason for Not
Contracting
(Drop-Down)

Additional Notes
on Reason for Not
Contracting

Provider/
Facility Name

Provider
Street
Address

Provider
City

Provider
State
(DropDown)

OMB Control Number: 0938-1346 (Expires: 11/30/2024)

Provider
ZIP Code
(5 Digits)

NPI
(10 Digits)

Provider
Phone
Number
(10 Digits)

Reason for Not
Contracting
(Drop-Down)

Additional Notes
on Reason for Not
Contracting

Provider/
Facility Name

Provider
Street
Address

Provider
City

Provider
State
(DropDown)

OMB Control Number: 0938-1346 (Expires: 11/30/2024)

Provider
ZIP Code
(5 Digits)

NPI
(10 Digits)

Provider
Phone
Number
(10 Digits)

Reason for Not
Contracting
(Drop-Down)

Additional Notes
on Reason for Not
Contracting

PRA Disclosure Statement: This form is required by CMS to determine MAO compliance with network adequacy criteria under §422.116 and
requirements under §§417.414, 417.416, 422.112(a)(1)(i), and 422.114(a)(3)(ii). The form is required when CMS performs a contract-level network
review. Use of this form is considered mandatory under the authority of Section 1852(d)(1) of the Social Security Act which permits an MAO to
select the providers from which an enrollee may receive covered benefits. Under the Privacy Act of 1974 any personally identifying information
obtained will be kept private to the extent of the law.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-1346 (Expires: XX/XX/20XX). The time required to
complete this information collection is estimated to average 16 hours per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop
C4-26-05, Baltimore, Maryland 21244-1850.