Participant Financial

Value in Opioid Use Disorders
Treatment Demonstration - Financial Reporting Guide

Financial Reporting Guide
December xx xxxx

Contents

I.

Annual Financial Report: Overview and Guidance ............................ 3
Due Date and Submission Process ............................................................ 3

II.

OUD Care Team ..................................................................................... 3
Overview and Definitions tab ................................................................... 3
Directions under OUD Care Team tab .................................................... 4

III.

Financial Report ..................................................................................... 5
Overview and Definitions tab ................................................................... 5
Directions under Financial Report tab .................................................... 9

I.

Annual Financial Report: Overview and Guidance

Per the Value in Treatment Participation Agreement (PA), participants are required to complete and
submit an Annual Financial Report as part of their attestation on how CMS demonstration funds were
used. The information collected under this report helps inform CMS how much was paid out to
participants for Value in Treatment through the Care Management Fee (CMF) and how such payments
were used to furnish demonstration services to eligible beneficiaries. This information will also support
the demonstration’s evaluation.
Only CMS and CMS’ implementation and evaluation contractors will view your identifiable financial
reporting data. CMS may share aggregate data at the county or state/program level publicly to the
extent permitted by appropriate regulations.
For Performance Years (PY) 2021, 2022, 2023, and 2024 (reporting period= January 1 to December 31),
participants should use this guidance to prepare the Value in Treatment Annual Financial Report. We
recommend you review this guidance completely to support your reporting efforts.
Due Date and Submission Process
1. At least one month prior to the Annual Financial Report due date, CMS will email participants a
request to complete the financial report. The request will include instructions on how to access
and submit the updated financial report template. Participant’s financial report template is
static and will not change year-over-year. Please note, however, that CMS will calculate and
generate the payment fields for each participant, as specified under this guidance, and include
the most updated OUD care team roster on CMS records for your review.
2. The three tabs (OUD Care Team, Financial Report, Part 1, and Financial Report, Part 2) are to be
completed by each participant. Please follow the instructions listed at the top of the page of
each tab.
3. Complete and submit this report to CMS within a month of receipt via the Box.com. Please refer
to [“ViT Documentation Submission Guidance_Box.pdf”] for detailed submission directions. For
any issues, please email [email protected].
II.

OUD Care Team

Overview and Definitions tab
Overview: This tab is the roster maintained and updated by CMS on an ongoing basis. The list reflects all
OUD care team members submitted by participants as part of their Value in Treatment application and
any additions or changes submitted to CMS since. Per the PA, participants are required to identify to
CMS all OUD care team members throughout the demonstration program performance period. It is the
participant's responsibility to email CMS at [email protected] when any changes occur.
The information in this tab reflects the most updated information CMS has as of the submission of this
request.

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Definitions:
Participant Name: The entity or individual that applied to Value in Treatment and is listed as
such under the PA.
OUD Care Team: The OUD multi-disciplinary care team hired or contracted to furnish
demonstration services, per the PA.
Status: The status of each OUD care team member(s) for Value in Treatment, which include
"active", "inactive", or "New Member" as of the submission of this report to CMS. "Active"
refers to a team member that is actively furnishing Value in Treatment services. “Inactive” refers
to a team member that was furnishing Value in Treatment services but is no longer doing so.
“New Member” refers to a newly added team member that will be or is already furnishing Value
in Treatment services, and that was not previously listed in the roster.
Directions under OUD Care Team tab
Directions:
1) Please verify the Participant Name and billing information listed in rows 20 to 24.
a. Any changes to the Participant Name or billing information (TIN, NPI, PTAN, CCN) must
be communicated with CMS at [email protected], per the PA. Changes
approved by CMS will be reflected in the next iteration of this financial report, if not
already captured.
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
complete.
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:
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 “PCPRequired”, “Addiction Provider- Required”, and “Prescriber- Required” drop down
options.
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
Provider- Required” drop down options. The third row must separately list the provider
authorized to prescribe narcotics and have “Prescriber- Required” drop down option

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selected.
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 “Prescriber- Required” drop
down option selected. The third row may be left blank.
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 “PrescriberRequired” drop down options, where applicable.
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 selected in Column B. There are no limits to how many care team members
are listed.
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.
a. To add new care team members, add another row with requested information and
select the “New Member” status. The next iteration of this roster submitted to
participants by CMS will reflect this newly added team member as “Active”.
b. OUD care team members no longer rendering Value in Treatment services should be
reflected as “Inactive” status. DO NOT delete 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.
III. Financial Report
Overview and Definitions tab
Overview: This tab summarizes total Value in Treatment payments and services. Specifically, it lists the
number of unique beneficiaries for whom the participant submitted a claim for the Value in Treatment
CMF, total claims billed for such services, and total CMF payments made by CMS to participants, as
indicated through Medicare claims. Total Payments will be generated by CMS and its contractors, and
provided to each participant via this Annual Financial Report Template. Value in Treatment services
furnished under the demonstration, and estimated cost, including staffing and services furnished, are to
be populated by participants by the requested due date.
Definitions:
# Beneficiaries: number of unique beneficiaries for whom Value in Treatment claims were
submitted by the participant. This number is generated by CMS using claims and is cumulative
over time (quarterly). Thus, the Q4 figure reflects the cumulative total number of unique
beneficiaries for whom a claim was reflected between January 1 to December 31 of the

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performance year.
CMF Rate: the amount paid for the Care Management Fee, minus the quality withhold, per
applicable beneficiary per month, as specified in the PA.
# Paid Claims: number of Value in Treatment claims that were paid to a participant during the
performance period. Numbers are broken down by claims paid per quarter and in total. The
total # Paid Claims for the entire year is the sum of quarterly figures.
CMF Payments: the total Value in Treatment payments made to a participant based on # Paid
Claims and the CMF Rate. Please refer to the PA for calculation formulas.
Incentive Payment: the total amount of any annual performance-based incentive payment
made to a participant based on quality performance, per the PA. Incentive payments are
calculated in the second quarter following the end of a PY, and paid in the third quarter.
Quality Withhold (%): percentage of the CMF withheld from each quarterly payment (5% in PY1
and 10% in each performance year thereafter).
Staffing: The actual staff involved in furnishing or administering Value in Treatment services,
and its associated staffing cost.
Number of Staff: the number of medical and non-medical staff involved in furnishing or
administering Value in Treatment services each quarter. The staff furnishing Value in
Treatment services should be an OUD Care Team member. Each person should be
counted as one regardless of staff time allocations.
Staffing Cost: actual cost associated with the number of staff identified as having
furnished or administered Value in Treatment services. Quarterly expenses are summed
to reflect the actual staffing cost of providing such services during the PY. You may enter
‘0’ for any category, where applicable.
Physicians: physicians and physician assistants who are licensed under state law to
furnish medical care, and are enrolled in Medicare. This may include primary care
physicians, addiction treatment physicians, and physicians authorized to prescribe
narcotics who are furnishing Value in Treatment OUD treatment services.
Nurse Practitioners: nurse practitioners (NPs) licensed under state law who are
furnishing Value in Treatment OUD treatment services.
Counseling & Psychology: practitioner licensed under state law to furnish psychiatric,
psychological, and counseling services to applicable beneficiaries. These may include
auxiliary personnel who furnish services incident to a physician or non-physician
provider, including licensed professional counselors, licensed clinical alcohol and drug
counselors, or licensed marriage and family therapists who are permitted to furnish
such services by state law within their scope of practice.
Social Support Providers: non-healthcare providers furnishing OUD treatment services
under Value in Treatment, such as social support, care management, and care

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coordination. This may include social workers, community health workers, care
managers, certified peer specialists, and qualified clergy.
Administrative: includes program directors/managers, schedulers, and any other
administrative staff supporting the administrative, operations, and management
activities of Value in Treatment. These individuals may or may not be listed as part of
the OUD Care Team.
Other: any other staff supporting Value in Treatment that was not otherwise captured.
This may include volunteers not employed or contracted by the participant that were
rewarded with Value in Treatment funds for their dedicated time.
Services Furnished by Service Type: The actual Value in Treatment services furnished directly or
through contracts/vendors, and its associated cost. These services are categorized as “Delivery
Settings/Modalities”, “Recovery Social Support”, and “Treatment Initiation & Engagement,”
each of which is defined below.
Service Type Cost: The cost associated with furnishing Value in Treatment services. Note
that associated service type cost is different from staffing cost. For example, if the Value
in Treatment service furnished was providing meals, the service would be categorized as
“Nutrition”, and only capture non-labor expenses like the cost of the actual meal,
supplies for packaging the meal, facility expenses (equipment and space used for
cooking and preparing meals), and travel expenses (mileage to and from), if applicable.
Staff time spent preparing and providing meals would be separately captured under
staffing related expenses. Quarterly expenses are summed to reflect the actual cost of
providing such services during the PY. You may enter ‘0’ for any category, where
applicable.
Delivery Settings/Modalities: the setting or modalities in which Value in Treatment
services were furnished. “Office Visits/Consults” are those that occurred in-person at
office location. “Home Visits/Consults” are those that occurred in-person at the
beneficiary, family, or caregiver’s home. “Remote Consults” includes any
visit/consultation that were not in-person but were offered remotely via telephone or
other telecommunication technology during or after office hours. “Care Delivery- Other”
are all other that do not fall in the other categories, which may include mobile outreach
(e.g., text reminders or encouragement).
Recovery Social Support: recovery-enabling social support services offered on a limited
or extended duration in-house (if appropriate) or in coordination with state/local
agencies and community-based organization that through existing evidence has shown
to have a “reasonable expectation of improving or maintaining the health or overall
function of applicable beneficiaries,” and that comply with applicable fraud and abuse
laws. For monitoring and evaluation purposes, CMS has categorized and defined social
support services, as listed below. Categorization is also intended to ensure standard use
among participants under this financial report. Please note that the listed social support
services under each category definition are examples only and not intended to be CMS
endorsement or suggested services. Social support services furnished under the

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demonstration should align with the PA.
Assessments/referrals: the use of social needs assessment tools to identify
social needs for the purpose of referring beneficiaries to appropriate resources
and/or confirming eligibility for select social needs interventions being provided
by the participant. Assessments and referrals may only be listed as Value in
Treatment expenses if not already covered by Medicare or other program for
applicable beneficiaries.
Housing: housing support, which may include housing navigation services, rent
subsidies, utility subsidies, transitional housing, permanent supportive housing,
recovery housing, home-based modifications to improve mobility, accessibility,
and safety, etc.
Employment: employment support services for applicable beneficiaries seeking
to enter the workforce, which may include employment navigation services or
referrals to employment support programs, vocational assessments, resume
writing, interviewing skills, job placement, etc.
Nutrition: nutrition support, which may include navigation services to enroll
beneficiary in SNAP, referrals to other community programs, food and nutrition
case management, medically and/or non-medically tailored meals (delivered or
for pick-up), groceries (delivered or for pick-up), etc.
Transportation: non-emergency transportation support for medical or nonmedical needs, which may include public transportation subsidies or private
transportation (shuttles, taxi, ride-sharing services, etc.).
Recovery Social Support- Other: other recovery-enabling social support services
not otherwise captured in other sub-categories, such needle exchange programs
or services addressing interpersonal violence/toxic stress, education, legal,
social isolation/loneliness, etc.
Treatment Initiation & Engagement: recovery-enabling treatment initiation and
engagement support services offered on a limited or extended duration in-house (if
appropriate) or in coordination with state/local agencies and community-based
organization that through existing evidence has shown to have a “reasonable
expectation of improving or maintaining the health or overall function of applicable
beneficiaries,” and that comply with applicable fraud and abuse laws. For monitoring
and evaluation purposes, CMS has categorized OUD treatment initiation and
engagement services, as listed below. Categorization is also intended to ensure standard
use among participants under this financial report. Please note that the listed OUD
treatment initiation and engagement services are examples only and not intended to be
CMS endorsement or suggested services. OUD treatment initiation and engagement
services furnished under the demonstration should align with the PA.
Medication-assisted treatment (MAT): MAT services not otherwise covered by
Medicare or other programs. MAT is the use of medications (buprenorphine,

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naltrexone, or methadone) in combination with counseling and behavioral
therapies, which is effective in the treatment of opioid use disorders (OUD) and
can help some people to sustain recovery.
Non-Opioid Pain Management: patient-centered non-opioid pain management
services not otherwise covered by Medicare or other programs, which may
include non-opioid medication options (e.g., analgesics, select anticonvulsants,
select antidepressants, topical agents, etc.) and nonpharmacological treatment
(e.g., exercise therapy, cognitive behavioral therapy, multimodal and
multidisciplinary therapies, etc.).
Naloxone: access to naloxone, a medication that rapidly reverses the effects of
opioid overdose and is the standard treatment for overdose.
Treatment Planning & Education: individualized, patient-centered treatment
plans, and/or treatment education provided to the applicable beneficiary and
family/caregiver.
Care Transition & Coordination: partnerships and coordination with inpatient
hospitals and emergency departments to transition an applicable beneficiary to
receive Value in Treatment services through the participant’s OUD care team.
Treatment Follow-Up: regular patient treatment outreach/follow-up.
Social/Peer Support: addiction support groups and/or one-on-one peer support
services through certified peer counselors to motivate recovery.
Contingency Management (CM): CM provides incentives to OUD patients
contingent upon treatment attendance and/or verified drug abstinence in order
to increase likelihood of these behaviors.
Treatment Initiation & Engagement- Other: other OUD treatment initiation and
engagement services not otherwise captured in other sub-categories.
Other: broadly, any other service type offered in Value in Treatment that did
not fit the definition for “Delivery Settings/Modalities”, “Recovery Social
Support”, and “Treatment Initiation & Engagement.”
Directions under Financial Report tab
Directions:
1) Performance Year (PY) dates are from January 1 to December 31. All figures in this Financial
Report should be applicable to the previous PY, as noted in row 21.
2) Sections 1 and 2 are calculated and generated by CMS, and are reflected in green-filled color.
CMS generated fields are locked and may not be edited by participants.
a. It is the participant's responsibility to verify that the payment rate, # of Payments, Total
Payments, and number of unique beneficiaries indicated in Sections 1 and 2 align with

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actual figures.
b. Please refer to the “Overview & Definitions” tab for definitions of each populated field.
Some calculation notes are also reflected under each table.
c. If participant has any questions or identifies any discrepancies, please though email CMS
at [email protected]. Because payments are calculated using Medicare
billed claims through the demonstration G-code, any errors or discrepancies in CMS
generated figures may be due to billing issues or misunderstandings with the MACs.
d. Unique beneficiaries in Section 2 reflect cumulative totals each quarter and by the end
of the performance year (Q4). For example, if there were 10 unique beneficiaries in Q1,
15 in Q2, 20 in Q3, and 25 in Q4, the Q1 total figure would be 10, 25 in Q2, 45 in Q3, and
70 by the end of Q4.
3) Section 3 is to be populated and completed by participants. These fields are indicated in greyfilled color.
a. For subsection a, please indicate the number of staff involved, and the associated
staffing cost. Please refer to the “Overview & Definitions” tab for staffing definitions.
Some calculation notes are also reflected under each table.
i. Please calculate total figures by summing the cost and number of staff from
each quarter.
ii. All staff listed, except administrative and other, who are furnishing
demonstration services should be reflected in the OUD care team roster. Please
update the roster, as needed, to ensure the count is accurately aligned.
b. For subsection b, please indicate the number of unique beneficiaries furnished Value in
Treatment services, and identify the types of services furnished.
i. Please calculate total figures. The cost total is the sum from each quarter. The #
Beneficiaries is calculated in accordance to the definition (refer to “Overview &
Definitions” tab). A given beneficiary may receive more than one type of service,
and thus should be counted as a unique beneficiary under each row. You may
enter "0" (zero) for any rows, where applicable.
ii. It is the participants’ responsibility to accurately track the number of unique
beneficiaries furnished each type of Value in Treatment services.
iii. It is also the participants’ responsibility to estimate associated cost. The
estimated cost is collected for evaluation purposes only, and is not intended to
be collected for reconciliation or recoupment purposes.
iv. If rows 84, 91, 101, and 102 have figures greater than "0" (zero) in any given
quarter, participants must explain in the text box starting in row 109, as
requested. Applicant must specify what the “other” service was. If more than
one service falls under “other”, please break the numbers down in the
explanation. For example, if two “other” recovery social support services were
provided to a total of 20 unique beneficiaries, participant will need to specify
the number of unique beneficiaries that received each of the two “other”

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services by the end of the performance period.
According the Paperwork Reduction Act of 1995 (PRA), no persons are required to respond to a collection of
information unless such a collection displays a valid OMB Control number. CMS/CMMI is required by the PRA to
inform demonstration participants that the collection of this financial reporting information is required and take
approximately 30 minutes to review the instructions and to complete and submit the financial report. Any
comments regarding the burden or other aspects of this collection of information, including suggestions for
reducing burden, must be sent to Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop
WB-06-05 Baltimore, Maryland 21244.

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