Form CMS-10728 Participant's OUD Care Team

Value in Opioid Use Disorder Treatment Demonstration Program (Value in Treatment)
Participant's OUD Care Team

Instructions
1) Please specify the Participant Name and billing information in rows 20 to 24.
1(a) Note that the unique TIN and NPI combo is for billing purposes only, as that combination would be what is submitted to the MACs for
2) All columns below, except those with a "*" are required. Columns with a "*" are if applicable only; if not applicable, please fill with "N/A". Please verify
that all information is accurate and completed.
2(a) If listed OUD care team member is associated with more than one TIN, please list and separate with a comma (,).
3) The first three rows in the table below (green filled color) must identify a Medicare-enrolled primary care provider (PCP) or addiction treatment
provider, and a Medicare-enrolled provider authorized to prescribe/dispense narcotic drugs to applicable beneficiary, per participation requirements. The
listed providers in these three rows were identified by the participant as meeting these requirements. Specifically:
3(a) If one provider is all three (a PCP, an addiction treatment provider, and provider authorized to prescribe narcotics), then this individual can
be listed three times in the first three rows with the same information, but in Column B separately select “PCP- Required”, “Addiction Provider3(b) If one provider is both a PCP and an addiction treatment provider, but not authorized to prescribe narcotics, then this individual can be
listed twice in the first two rows with the same information, but in Column B separately select “PCP- Required” and “Addiction ProviderRequired” drop down options. The third row must separately list the provider authorized to prescribe narcotics and have “Prescriber- Required”
3(c) If the OUD Care Team only includes a PCP or an addiction treatment provider, but not both, then the applicable individual must be listed in
the first row and select one of the two drop down option (“PCP- Required” or “Addiction Provider- Required”) in Column B. The second row
must separately list the provider authorized to prescribe narcotics, even if it is the same individual listed in the first row, and have “PrescriberRequired” drop down option selected. The third row may be left blank.
3(d) If the PCP, addiction treatment provider, and prescribe of narcotics are three separate providers, then these three individuals can be
separately listed in the first three rows. Please select the “PCP- Required”, “Addiction Provider- Required”, and “Prescriber- Required” drop
4) All other care team members, including those that may also be PCPs, addiction treatment providers, and prescribers of narcotics, and non-healthcare
providers (social service providers, care coordinators, etc.) may be listed in the rest of the rows, with “Additional OUD Care Team” drop down option
5) For each OUD care team member, the address refers to the mailing address.
6) For all OUD care team members, please select the appropriate “STATUS” dropdown option.
6(a) Add each team member with requested information and select the “New Member” status.
6(b) During the demonstration performance period, OUD care team members no longer furnishing Value in Treatment services will be
reflected as “Inactive” while those that are will be reflected as "Active". DO NOT delete "Inactive" members from the roster. A team member
may go from active to inactive during the duration of the demonstration; the status may be updated to reflect current status.
Participant Name:
Billing Tax Identification Number (TIN):
Billing National Provider Identification (NPI):
Billing Provider Transaction Access Number (PTAN):
Billing CMS Certification Number (CCN):
Drop Down Selection

STATUS

Drop Down Selection

Required Physician or
Additional OUD Team
Members?

Drop Down Selection

Last Name

First Name

Middle Name

Title/Position

Credentials

TIN*

NPI*

PTAN*

CCN*

DEA Registration Number*

Maximum Number of Patients
Eligible to Treat*

Relationship to
Applicant (select
drop down)

Street Address

City

State

Nine Digit
Zip Code

Phone
Number

Value in Opioid Use Disorder Treatment Demonstration Program (Value in Treatment)
Participant's OUD Care Team

Instructions
1) Please specify the Participant Name and billing information in rows 20 to 24.
1(a) Note that the unique TIN and NPI combo is for billing purposes only, as that combination would be what is submitted to the MACs for
2) All columns below, except those with a "*" are required. Columns with a "*" are if applicable only; if not applicable, please fill with "N/A". Please verify
that all information is accurate and completed.
2(a) If listed OUD care team member is associated with more than one TIN, please list and separate with a comma (,).
3) The first three rows in the table below (green filled color) must identify a Medicare-enrolled primary care provider (PCP) or addiction treatment
provider, and a Medicare-enrolled provider authorized to prescribe/dispense narcotic drugs to applicable beneficiary, per participation requirements. The
listed providers in these three rows were identified by the participant as meeting these requirements. Specifically:
3(a) If one provider is all three (a PCP, an addiction treatment provider, and provider authorized to prescribe narcotics), then this individual can
be listed three times in the first three rows with the same information, but in Column B separately select “PCP- Required”, “Addiction Provider3(b) If one provider is both a PCP and an addiction treatment provider, but not authorized to prescribe narcotics, then this individual can be
listed twice in the first two rows with the same information, but in Column B separately select “PCP- Required” and “Addiction ProviderRequired” drop down options. The third row must separately list the provider authorized to prescribe narcotics and have “Prescriber- Required”
3(c) If the OUD Care Team only includes a PCP or an addiction treatment provider, but not both, then the applicable individual must be listed in
the first row and select one of the two drop down option (“PCP- Required” or “Addiction Provider- Required”) in Column B. The second row
must separately list the provider authorized to prescribe narcotics, even if it is the same individual listed in the first row, and have “PrescriberRequired” drop down option selected. The third row may be left blank.
3(d) If the PCP, addiction treatment provider, and prescribe of narcotics are three separate providers, then these three individuals can be
separately listed in the first three rows. Please select the “PCP- Required”, “Addiction Provider- Required”, and “Prescriber- Required” drop
4) All other care team members, including those that may also be PCPs, addiction treatment providers, and prescribers of narcotics, and non-healthcare
providers (social service providers, care coordinators, etc.) may be listed in the rest of the rows, with “Additional OUD Care Team” drop down option
5) For each OUD care team member, the address refers to the mailing address.
6) For all OUD care team members, please select the appropriate “STATUS” dropdown option.
6(a) Add each team member with requested information and select the “New Member” status.
6(b) During the demonstration performance period, OUD care team members no longer furnishing Value in Treatment services will be
reflected as “Inactive” while those that are will be reflected as "Active". DO NOT delete "Inactive" members from the roster. A team member
may go from active to inactive during the duration of the demonstration; the status may be updated to reflect current status.
Participant Name:

Value in Opioid Use Disorder Treatment Demonstration Program (Value in Treatment)
Participant's OUD Care Team

Instructions
1) Please specify the Participant Name and billing information in rows 20 to 24.
1(a) Note that the unique TIN and NPI combo is for billing purposes only, as that combination would be what is submitted to the MACs for
2) All columns below, except those with a "*" are required. Columns with a "*" are if applicable only; if not applicable, please fill with "N/A". Please verify
that all information is accurate and completed.
2(a) If listed OUD care team member is associated with more than one TIN, please list and separate with a comma (,).
3) The first three rows in the table below (green filled color) must identify a Medicare-enrolled primary care provider (PCP) or addiction treatment
provider, and a Medicare-enrolled provider authorized to prescribe/dispense narcotic drugs to applicable beneficiary, per participation requirements. The
listed providers in these three rows were identified by the participant as meeting these requirements. Specifically:
3(a) If one provider is all three (a PCP, an addiction treatment provider, and provider authorized to prescribe narcotics), then this individual can
be listed three times in the first three rows with the same information, but in Column B separately select “PCP- Required”, “Addiction Provider3(b) If one provider is both a PCP and an addiction treatment provider, but not authorized to prescribe narcotics, then this individual can be
listed twice in the first two rows with the same information, but in Column B separately select “PCP- Required” and “Addiction ProviderRequired” drop down options. The third row must separately list the provider authorized to prescribe narcotics and have “Prescriber- Required”
3(c) If the OUD Care Team only includes a PCP or an addiction treatment provider, but not both, then the applicable individual must be listed in
the first row and select one of the two drop down option (“PCP- Required” or “Addiction Provider- Required”) in Column B. The second row
must separately list the provider authorized to prescribe narcotics, even if it is the same individual listed in the first row, and have “PrescriberRequired” drop down option selected. The third row may be left blank.
3(d) If the PCP, addiction treatment provider, and prescribe of narcotics are three separate providers, then these three individuals can be
separately listed in the first three rows. Please select the “PCP- Required”, “Addiction Provider- Required”, and “Prescriber- Required” drop
4) All other care team members, including those that may also be PCPs, addiction treatment providers, and prescribers of narcotics, and non-healthcare
providers (social service providers, care coordinators, etc.) may be listed in the rest of the rows, with “Additional OUD Care Team” drop down option
5) For each OUD care team member, the address refers to the mailing address.
6) For all OUD care team members, please select the appropriate “STATUS” dropdown option.
6(a) Add each team member with requested information and select the “New Member” status.
6(b) During the demonstration performance period, OUD care team members no longer furnishing Value in Treatment services will be
reflected as “Inactive” while those that are will be reflected as "Active". DO NOT delete "Inactive" members from the roster. A team member
may go from active to inactive during the duration of the demonstration; the status may be updated to reflect current status.
Participant Name:

Required?
PCP- Required
Addiction Provider- Required
Prescriber- Required
Additional OUD Care Team Members

Relationship
Employed
Contracted
Self (Owner)
Other

Status
Active
Inactive
New Member