Value in Opioid Use Disorder Treatment Demonstration Program

Centers for Medicare & Medicaid Services
Center for Medicare & Medicaid Innovation
Prevention and Population Health Group
7500 Security Blvd.
Mail Stop WB-06-05
Baltimore, MD 21244

Value in Treatment
Participation Agreement

Last Updated: March 25, 2021

Table of Contents
PARTICIPATION AGREEMENT .............................................................................................................. 3
I.

Agreement Term; Model Performance Period; Performance Years ................................................ 3

II.

Definitions .................................................................................................................................. 4

III. Participant Requirements ............................................................................................................ 5
IV. OUD Care Team ........................................................................................................................... 7
V.

Participation of Applicable Beneficiaries and Beneficiary Protections............................................ 9

VI. Payments .................................................................................................................................. 11
VII. ViT Monitoring and Evaluation................................................................................................... 14
VIII. Data Sharing and Reports .......................................................................................................... 16
IX. Overlap Policy ........................................................................................................................... 21
X.

Other Government Authorities .................................................................................................. 21

XI. Agreement to Comply with Laws................................................................................................ 21
XII. Certification of Data and Information......................................................................................... 22
XIII. Audits and Record Retention ..................................................................................................... 22
XIV. Remedial Action ........................................................................................................................ 23
XV. Termination .............................................................................................................................. 24
XVI. Miscellaneous ........................................................................................................................... 25
APPENDIX A: VALUE IN TREATMENT PROGRAMMATIC WAIVERS ....................................................... 31
APPENDIX B: VALUE IN TREATMENT CMF AND PBIP PAYMENT METHODOLOGY ................................. 32
APPENDIX C: VALUE IN TREATMENT HIPAA-COVERED DISCLOSURE REQUEST ATTESTATION and DATA
SPECIFICATION WORKSHEET ...................................................................................................... 39

ii

PARTICIPATION AGREEMENT
This Participation Agreement (“Agreement”) is between the Centers for Medicare &
Medicaid Services (“CMS”) and
(“Participant”) (each a “Party”
and collectively the “Parties”).
CMS is the agency within the U.S. Department of Health and Human Services (HHS) that is
charged with administering the Medicare, Medicaid, and the Children’s Health Insurance
Program (CHIP) programs.
The Participant is an entity or individual that is enrolled in Medicare and that is a physician (as
defined in section 1861(r)(1) of the Social Security Act (the “Act”)); a group practice comprising
at least one physician; a nurse practitioner; a group practice comprising at least one nurse
practitioner; a hospital outpatient department; a federally qualified health center (FQHC) (as
defined in section 1861(aa)(4) of the Act); a rural health clinic (RHC) (as defined in section
1861(aa)(2) of the Act); a community mental health center (as defined in section 1861(ff)(3)(B)
of the Act); a clinic certified as a certified community behavioral health clinic pursuant to section
223 of the Protecting Access to Medicare Act of 2014, P.L. 113–93; an opioid treatment program
(OTP) (as defined in section 1861(jjj)(2) of the Act); or a critical access hospital (as defined in
section 1861(mm)(1) of the Act).
CMS is implementing the Value in Opioid Use Disorder Treatment Demonstration Program
(ViT), a 4-year demonstration program authorized under section 1866F of the Act, which was
added by section 6042 of the Substance Use-Disorder Prevention that Promotes Opioid
Recovery and Treatment for Patients and Communities Act (the SUPPORT Act), P.L. 115-271,
enacted on October 24, 2018.
The purpose of ViT, as stated in the statute, is to “increase access of applicable beneficiaries to
opioid use disorder treatment services, improve physical and mental health outcomes for such
beneficiaries, and to the extent possible, reduce [Medicare program expenditures].”
The Participant submitted an application to participate in ViT and CMS selected the
Participant for participation in ViT pursuant to the application and selection process
established under “Value in Opioid Use Disorder Treatment Demonstration Program, Request
for Applications (RFA)”, published November 19, 2020.
The Parties, intending to be legally bound, therefore agree as follows:
I.

Agreement Term; Model Performance Period; Performance Years
A. Effective Date
The effective date of this Agreement (“Effective Date”) is the date this Agreement is
signed by the last Party to sign it (as indicated by the date associated with that Party’s
signature).
B. Agreement Term
The term of this Agreement (“Agreement Term”) begins on the Effective Date and
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expires two years after the last Day of the Demonstration Performance Period, unless
this Agreement is sooner terminated by either Party in accordance with Section XV of
the Agreement, in which case the Agreement Term shall expire on the effective date
of termination.
C. Demonstration Performance Period, Performance Years
The performance period for this Agreement (“Demonstration Performance Period”)
begins on the later of April 1, 2021 or the Effective Date (“Start Date”) and ends on
December 31, 2024, unless the Agreement is sooner terminated by either Party in
accordance with Section XV, in which case the Demonstration Performance Period
ends immediately upon the effective date of such termination. The Demonstration
Performance Period includes the following four performance years (each a
“Performance Year”):
Performance Year 2021: Start Date through December 31, 2021
Performance Year 2022: January 1, 2022 through December 31, 2022
Performance Year 2023: January 1, 2023 through December 31, 2023
Performance Year 2024: January 1, 2024 through December 31, 2024
II. Definitions
In this Agreement, the following definitions apply:
“Applicable Beneficiary” means an individual who: is entitled to, or enrolled for,
benefits under Medicare Part A and enrolled for benefits under Medicare Part B; is
not enrolled in a Medicare Advantage plan under Medicare Part C; and has a current
diagnosis for an OUD. An Applicable Beneficiary may include an individual who is
dually eligible for benefits under Medicare and Medicaid if such individual satisfies all
of these criteria.
“Beneficiary Agreement Form” means the form used by the Participant to obtain consent
from an Applicable Beneficiary: (1) for the Applicable Beneficiary to participate in ViT and to
receive OUD Treatment Services from the Participant; and (2) if applicable, for CMS to share
the Applicable Beneficiary’s health care information with the Participant.
“C.F.R.” means the Code of Federal Regulations, as may be amended from time to time.
“CMF” refers to the care management fee and means a per-Participating Beneficiary
per-month fee paid to the Participant by CMS pursuant to this Agreement. The CMF
shall be paid in addition to any other amount otherwise payable to the health care
practitioners in the Participant’s OUD Care Team or, if applicable, to the Participant
under title XVIII of the Act.
“Day” means calendar day unless otherwise specified.
“Eligible Practitioner” means a physician or other health care practitioner, such as a nurse
practitioner, who: (1) is enrolled under section 1866(j)(1) of the Act; (2) is authorized to
prescribe or dispense narcotic drugs to individuals for maintenance treatment or
detoxification treatment; and (3) has in effect a waiver in accordance with section 303(g) of
the Controlled Substances Act (21 U.S.C. § 823(g)) for such purpose and is otherwise in
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compliance with regulations promulgated by the Substance Abuse and Mental Health
Services Administration to carry out such section.
“OUD” stands for opioid use disorder, including opioid abuse, opioid dependence, and opioid
use.
“OUD Care Team” means a team of health care practitioners established by the Participant in
accordance with Section IV.A.1 that furnishes OUD Treatment Services to Participating
Beneficiaries.
“OUD Treatment Services” means, with respect to an Applicable Beneficiary, services
that are furnished for the treatment of OUD and that utilize drugs approved under
section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. § 355) for the
treatment of OUD in an outpatient setting, and includes: medication-assisted
treatment; treatment planning; psychiatric, psychological, or counseling services (or
any combination of such services), as appropriate; social support services, as
appropriate; and care management and care coordination services, including
coordination with other providers of services and suppliers not on an OUD Care
Team.
“Participant Survey” means a survey instrument conducted securely online to obtain
qualitative information on execution of the Participant’s Implementation Plan (as such term
is defined in section III.B) and the Participant’s experience implementing ViT.
“Participating Beneficiary” means an Applicable Beneficiary who has agreed to receive OUD
Treatment Services from the Participant by signing the Beneficiary Agreement Form.
“PBIP” refers to the performance based incentive payment and means a payment made to
the Participant by CMS based on the Participant’s performance with respect to the quality
and cost criteria specified in Appendix B of this Agreement.
“Per-Participating Beneficiary Cap” means the maximum number of Participating
Beneficiaries to whom the Participant is permitted to furnish OUD Treatment Services under
this Agreement in any given quarter, calculated in accordance with Section VI.C.
“PHI” means protected health information as defined in 45 C.F.R § 160.103.
“Program Integrity Screening” means a review of an individual’s or entity’s program
integrity history, which may include a review of the individual’s or entity’s history of
exclusion or other sanctions imposed with respect to participation in Medicare,
Medicaid, or CHIP; history of failure to pay Medicare debts in a timely manner;
current or prior law enforcement investigations or administrative actions; affiliations
with individuals or entities that have a history of program integrity issues; and other
information pertaining to the trustworthiness of the individual or entity.
“TIN” means a federal Taxpayer Identification Number, which in some cases may be
a Social Security Number.
“U.S.C.” means the United States Code, as may be amended from time to time.
III.

Participant Requirements
A.

General
1.

The Participant shall be a separate and unique legal entity identified by a TIN
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that is formed under applicable federal, state, or tribal law and authorized to
conduct business in each state in which it operates.

B.

2.

The Participant shall ensure compliance with the requirements of ViT as set
forth in this Agreement, including by establishing mechanisms to report
quality measures and other data to CMS.

3.

The Participant shall notify CMS in writing of any noncompliance or
deficiencies that would result in the Participant losing eligibility to
participate in ViT within 15 Days of discovery, unless a different timeframe
for notification is specified in this Agreement.

4.

The Participant shall notify CMS of any administrative or other action that
may affect the Participant’s Medicare enrollment status, or the Medicare
enrollment status of a member of the Participant’s OUD Care Team, within
30 Days of the Participant’s receipt of notice of such action.

5.

The Participant and the Participant’s OUD Care Team members must continue
participation in all applicable CMS quality reporting initiatives for the duration of
their participation in ViT.

Implementation Plan
The Parties acknowledge that the Participant submitted a plan for implementing
ViT (“Implementation Plan”) together with its application to participate in ViT
pursuant to the application and selection process established under the ViT RFA.

C.

OUD Treatment Services
1.

The Participant shall furnish OUD Treatment Services through its OUD Care
Team, or arrange for such services to be furnished, to Participating Beneficiaries
according to the terms of this Agreement. The Participant shall ensure that all
OUD Treatment Services furnished to Participating Beneficiaries under ViT are
furnished in an outpatient setting.

2.

The Participant shall furnish OUD Treatment Services to each Participating
Beneficiary, or arrange for such services to be furnished, based on the
Participating Beneficiary’s individualized OUD treatment plan, in alignment with
other services furnished to the Participating Beneficiary for purposes of treating
his or her OUD, and with a reasonable expectation that such services will
improve the overall health and function of the Participating Beneficiary.

3.

The Participant shall ensure that OUD Treatment Services are furnished to
Participating Beneficiaries on a face-to-face basis, with the exception of the
following services, which may be furnished on a non-face-to-face basis using
telecommunications technology:
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i.

Offering Participating Beneficiaries, with the Participant serving as the
originating site, telehealth visits with an OUD treatment center of
excellence or “hub”;

ii.

Assisting Participating Beneficiaries to arrange for transportation or legal
assistance;

iii.

Crisis intervention;

iv.

Psychotherapy

v.

Naloxone training;

vi.

Contingency management, defined as a behavior modification
intervention that establishes a connection between new, targeted
behavior and the opportunity to obtain a desired reward; and

vii.

Other care management activities that do not include direct beneficiary
interaction.

D. Participant Changes
1.

Legal Name Change

The Participant shall provide written notice to CMS at least 60 Days before any
change in the Participant’s legal name. The notice of legal name change must include
a copy of any legal document effecting the name change, authenticated by the
appropriate state official (if applicable), and the Parties must execute an agreement
reflecting the change of the Participant’s legal name.
2.

Identifier Change

The Participant shall provide written notice to CMS as soon as practicable, but no
later than 30 Days after any change in TIN, National Provider Identifier (NPI), or
other identifier specified by CMS with respect to the Participant or a member of the
Participant’s OUD Care Team. After review of such notice, CMS may terminate this
Agreement, demand immediate payment of any amount owed by the Participant to
CMS under this Agreement, or may take any other actions consistent with the terms
of this Agreement.
IV.

OUD Care Team
A. General
1.

The Participant shall establish an OUD Care Team by employing or contracting
with heath care practitioners to include, at a minimum:
i.

at least one physician (as defined in section 1861(r)(1) of the Act) who will
furnish primary care services or addiction treatment services to one or
more Participating Beneficiaries; and

ii.

at least one Eligible Practitioner who will furnish primary care services or
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addiction treatment services to one or more Participating Beneficiaries.
2.

The Participant may include in its OUD Care Team other practitioners licensed
under state law to furnish psychiatric, psychological, counseling, and social
services to Applicable Beneficiaries.

3.

The Participant shall have a collaborative, integrated relationship with each OUD
Care Team member.

B. OUD Care Team List
1.

The Participant shall maintain and update a list of OUD Care Team members in
accordance with this Section IV.B.

2.

The Parties acknowledge that the Participant submitted with its application to
participate in ViT, pursuant to the application and selection process established
under the ViT RFA, an initial list of OUD Care Team members, identified by
name, address, and NPI.

3.

The Participant shall report to CMS, in a form and manner and by a deadline
specified by CMS, any changes to its list of OUD Care Team members at least
biannually.

4.

Notwithstanding the prohibition in Section IX.A, the Participant may include
physicians and non-physician practitioners who participate in Comprehensive
Primary Care Plus (CPC+), Primary Care First (PCF), or the Maryland Primary Care
Program (MDPCP) on its list of OUD Care Team members.

C. OUD Care Team Arrangements
1.

The Participant shall have a written arrangement with each OUD Care Team
member who is not employed by the Participant (each an “OUD Care Team
Member Arrangement”).

2.

Each OUD Care Team Member Arrangement must be in writing and the only
parties to the arrangement must be the Participant and the OUD Care Team
member.

3.

Each OUD Care Team Member Arrangement must require that the OUD Care
Team member:
i.

Be available to provide OUD Treatment Services to Participating
Beneficiaries on a face-to-face basis except as permitted under Section
III.C.3;

ii.

Comply with all applicable laws and regulations, including those specified
in Section XI.A;

iii.

Comply with the applicable provisions of this Agreement;
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V.

iv.

Update his or her Medicare enrollment information on a timely basis in
accordance with Medicare program requirements, and notify the
Participant of any changes to its Medicare enrollment information, name,
address, or NPI; and

v.

Notify the Participant within 7 Days of becoming aware that he or she is
under investigation or has been sanctioned (including, without limitation,
the imposition of program exclusion, debarment, civil monetary penalties,
loss of medical license or equivalent, corrective action plans, and
revocation of Medicare billing privileges) by the federal, state or local
government, or any licensing authority.

4.

Each OUD Care Team Member Arrangement must permit the Participant to take
remedial action against the OUD Care Team member, including termination of
the OUD Care Team Member Arrangement, to address noncompliance with the
terms of ViT as set forth in this Agreement or any program integrity issues
identified by CMS or the Participant.

5.

CMS provides no opinion on the legality of any contractual or other arrangement
that the Participant, any of its OUD Care Team members, or any other individual
or entity involved in the Participant’s implementation of ViT has proposed,
implemented, or documented. The receipt by CMS of any such documentation
over the course of the application process or otherwise shall not be construed as
a waiver or modification of any applicable laws, rules or regulations, and will not
preclude CMS, HHS, or its Office of Inspector General, a law enforcement
agency, or any other federal or state agency from enforcing any and all
applicable laws, rules, and regulations.

Participation of Applicable Beneficiaries and Beneficiary Protections
A. Voluntary Participation by Applicable Beneficiaries
1.

Participation in ViT is voluntary for Applicable Beneficiaries. The Participant and
its OUD Care Team members are prohibited from providing gifts or other
remuneration to, and from withholding anything from Applicable Beneficiaries
to induce them to agree to participate in ViT and receive OUD Treatment
Services from the Participant and its OUD Care Team, or to agree for CMS to
share their data with the Participant. The Participant must permit an Applicable
Beneficiary to terminate his or her participation in ViT at any time.

2.

The Participant must use the Beneficiary Agreement Form to obtain consent
from an Applicable Beneficiary: (1) for the Applicable Beneficiary to participate
in ViT and receive OUD Treatment Services from the Participant; and (2) for CMS
to share the Applicable Beneficiary’s data with the Participant in accordance
with Section VIII. A signature by the Applicable Beneficiary or his or her
authorized representative on the Beneficiary Agreement Form is required to
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confirm the Applicable Beneficiary’s agreement to participate in ViT and receive
OUD treatment services from the Participant and, if applicable, to confirm the
Applicable Beneficiary’s agreement to share his or her data with the Participant.
The Participant shall not complete, and shall prohibit its OUD Care Team
members from completing the Beneficiary Agreement Form on behalf of an
Applicable Beneficiary.
3.

The Participant may distribute the Beneficiary Agreement Form to an Applicable
Beneficiary only together with the CMS-provided beneficiary notice and patient
FAQs, and only as permitted by this Section V.A.

4.

CMS will provide the Participant with templates for the Beneficiary Agreement
Form and for the accompanying beneficiary notice and patient FAQs. The
Participant shall make no changes to these CMS-provided templates, except as
expressly permitted by CMS in writing. The Participant shall submit the
completed templates to CMS, in a form and manner specified by CMS, for review
and approval. Completed templates are deemed approved 10 business days
following their submission to CMS unless CMS disapproves the completed
templates. CMS may issue a written notice of disapproval of at any time,
including after the expiration of the 10-buinsess day review period.

5.

The Participant shall not use, and shall prohibit its OUD Care Team members
from using, the Beneficiary Agreement Form, beneficiary notice, and patient
FAQs until completed by the Participant and approved by CMS. The Participant
shall, and shall require its OUD Care Team members to, immediately discontinue
use of any Beneficiary Agreement Form, beneficiary notice, or patient FAQs
disapproved by CMS.

6.

The Participant shall retain copies of all Beneficiary Agreement Forms,
beneficiary notices, and patient FAQs distributed to Applicable Beneficiaries in
accordance with Section XIII.B.

B. Access to Services and Beneficiary Cost Sharing
1.

The Participant shall make, and shall require its OUD Care Team members to
make, medically necessary covered services available to an Applicable Beneficiary,
regardless of whether the Applicable Beneficiary agrees to participate in ViT or to
receive OUD Treatment Services from the Participant.

2.

The Participant shall not require an Applicable Beneficiary to relinquish access to
any Medicare benefit as a condition of receiving services from the Participant.

3.

Participation in ViT by a Participating Beneficiary shall not affect coverage of or
payment under Medicare for any other item or service furnished to the
Participating Beneficiary, except that Medicare will pay 100 percent of the CMF
and PBIP payments made for services furnished under ViT, and 100 percent of the
bundled payments under 42 C.F.R. § 410.67 for opioid use disorder treatment
services furnished by opioid treatment programs, physicians and non-physician
practitioners to Participating Beneficiaries while such beneficiaries are
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participating in ViT. Accordingly, the Participant shall not collect any monies, such
as coinsurance, copayments, or deductibles, from a Participating Beneficiary for
such services, and shall return any such monies erroneously collected.
C. Prescription Drug Monitoring Program (PDMP)
If a PDMP exists in the state in which the Participant is furnishing OUD
Treatment Services, to the extent permitted under applicable state law, the
Participant shall query the state’s PDMP for each new Participating Beneficiary
prior to initiating treatment under ViT, and at least quarterly thereafter through
the course of the Participating Beneficiary’s participation in ViT.
D. HIPAA Requirements

VI.

1.

The Participant acknowledges that it is a covered entity or a business associate, as
those terms are defined in 45 C.F.R. § 160.103, of OUD Care Team members who
are covered entities.

2.

The Participant shall have all appropriate administrative, technical, and physical
safeguards in place before the Start Date to protect the privacy and security of
PHI in accordance with 45 C.F.R. § 164.530(c).

3.

The Participant shall maintain the privacy and security of all ViT-related
information that identifies individual beneficiaries in accordance with the Health
Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules
and all relevant HIPAA Privacy and Security guidance applicable to the use and
disclosure of PHI of covered entities, as well as applicable state laws and
regulations.

Payments
A. General
1.

On a quarterly basis, CMS shall pay the Participant a CMF for each month during
the quarter, subject to the limitations in Sections VI.B and VI.E.

2.

In order to incentivize the Participant to achieve quality and cost outcomes under
ViT, subject to the limitation in Section VI.D.1 and the limitations in Section VI.E,
CMS shall pay Participant a PBIP based on the Participant’s performance on the
quality and cost measures specified in Appendix B during a Performance Year.
CMS shall calculate the amount of the PBIP in accordance with Section VI.D and
Appendix B.

B. CMF
1.

CMS will pay the Participant the CMF on quarterly basis, as detailed in Appendix
B.

2.

The amount of the CMF is set at a flat rate of $125 per Participating Beneficiary
per month, minus the applicable PBIP quality withhold and any applicable
Medicare sequestration adjustments; the adjusted monthly amount is multiplied
by 3 to determine the quarterly payment amount, as described in Appendix B.

3.

Claims for the CMF under ViT must be submitted to the Medicare Administrative
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Contractor (MAC) appropriate to the Participant using the ViT-specific G-code
specified by CMS (ViT Code). No other billing or procedure codes may be
included on the claim.
4.

Only the Participant may submit a claim with the ViT Code.

5.

An ICD-10-CM diagnosis code for an OUD diagnosis specified by CMS must be
present on the claim in order for the claim to be eligible for a CMF payment under
ViT.

6.

CMS shall pay the CMF to the Participant in addition to any amount that may
otherwise be made under Medicare, including:

i.

payment for existing care management codes in the Medicare Physician Fee
Schedule, unless the Participant is an FQHC or RHC, in which case the
Participant is prohibited from billing HCPCS codes G0511 (general care
management) or G0512 (psychiatric collaborative care model) within a
calendar quarter period of having billed the ViT Code for the same
beneficiary; and

ii.

bundled payments for opioid use disorder treatment services furnished by
opioid treatment programs made pursuant to 42 C.F.R. § 410.67.

C. Per Participating Beneficiary Cap
1.

In order to ensure compliance with the requirements of section 1866F(h)(2) of
the Act, in a given calendar quarter of a Performance Year, the Participant shall
not furnish services to Participating Beneficiaries under this Agreement in excess
of the number of Participating Beneficiaries included in the Participant’s Per
Participating Beneficiary Cap.

2.

The Parties acknowledge that CMS notified the Participant of the Participant’s
Per Participating Beneficiary Cap prior to the Effective Date, which was
calculated based on the Participant’s historical claims and a projection of
beneficiary cost sharing amounts.

3.

The Participant may submit a request, in a form and manner specified by CMS,
that CMS increase the number of Participating Beneficiaries included in the
Participant’s Per Participating Beneficiary Cap.

4.

In response to the Participant’s request or for such other reasons determined by
CMS, CMS may, at CMS’s sole discretion, adjust the number of Participating
Beneficiaries included in the Participant’s Per Participating Beneficiary Cap in
accordance with this Section VI.C.4 to ensure ViT is serving the maximum number
of Participating Beneficiaries without exceeding the limitations set forth in
sections 1866F(d)(2) and (h)(2) of the Act.

i.

CMS may reduce the number of Participating Beneficiaries included in the
Participant’s Per Participating Beneficiary Cap for a subsequent calendar
quarter if CMS determines that the Participant has furnished OUD Treatment
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Services, or arranged for such services to be furnished, to at least 5% fewer
Participating Beneficiaries than the number of Participating Beneficiaries
included in the Participant’s Per Participating Beneficiary Cap for two or more
consecutive quarters.
ii.

CMS may increase the number of Participating Beneficiaries included in the
Participant’s Per Participating Beneficiary Cap for a subsequent calendar
quarter if: (1) the Participant submits a request pursuant to Section VI.C.3; (2)
the Participant has consistently furnished OUD Treatment Services, or
arranged for such services to be furnished, to the number of Participating
Beneficiaries already included in the Participant’s Per Participating
Beneficiary Cap; and (3) CMS determines, at CMS’s sole discretion, that there
are sufficient funds under section 1866F(h)(2) of the Act to make CMF and
PBIP payments to the Participant for furnishing OUD Treatment Services to
the additional number of Participating Beneficiaries requested by the
Participant for inclusion in the Participant’s Per Participating Beneficiary Cap.

5.

CMS shall provide the Participant with written notice of any adjustments to the
Participant’s Per Participating Beneficiary Cap at least 30 Days prior to the start
of the calendar quarter in which such adjustments will take effect.

6.

The Per Participating Beneficiary Cap is specific to ViT, and in no way restricts a
beneficiary’s freedom of choice or ability to access other items and services
from the Participant.

D. Performance-Based Incentive Payment (PBIP)
1.

CMS shall pay the Participant a PBIP for a Performance Year only if the Participant
has complied with the data reporting requirements set forth in Section VII.B.

2.

CMS will calculate the amount of the Participant’s PBIP, if any, for the
Performance Year based on the total amount withheld from the CMF payments
made to the Participant for the Performance Year in accordance with Section
VI.B.2 and Appendix B.

3.

CMS will pay the Participant a PBIP for a Performance Year only if the Participant’s
performance on the cost and quality measures specified in Appendix B during the
Performance Year meets or exceeds the applicable performance threshold as
determined by CMS in accordance with the methodology specified in Appendix B.

4.

CMS will assess the Participant’s performance on the cost and quality measures
specified in Appendix B during the Performance Year after one quarter claims run
out following the Performance Year.

5.

If CMS determines that the Participant is entitled to a PBIP for a Performance
Year, CMS shall make the PBIP to the Participant no later than the third quarter
following the Performance Year.

E. Denial of Payment
1.

CMS shall make a CMF payment to no more than one individual or entity
13

participating in ViT for a given Participating Beneficiary under ViT during a
calendar quarter. If two or more individuals or entities participating in ViT submit
a claim for the CMF under ViT to a single Participating Beneficiary during a single
calendar quarter, CMS shall determine which individual or entity will receive a
CMF for that Participating Beneficiary based on the date of claim submission.
That is, CMS will pay a CMF to the individual or entity that submits the first valid
CMF claim for that Participating Beneficiary during the calendar quarter,
irrespective of whether that claim had the earliest date of service.
2.

CMS shall not pay the Participant a CMF or PBIP for an individual who does not
meet the definition of a Participating Beneficiary.

3.

CMS shall not pay the Participant a CMF or PBIP for any Participating Beneficiaries
in excess of the number of Participating Beneficiaries included in the Participant’s
Per Participating Beneficiary Cap.

F. Payment to CMS

VII.

1.

If CMS determines that a payment made by CMS pursuant to this Section VI was
made in error or was otherwise inconsistent with the terms of this Agreement,
CMS shall send the Participant a demand letter for the amount of such payment,
and may take a remedial action as described in Section XIV. The Participant shall
pay any such amount within 30 Days of the date of the demand letter.

2.

If CMS does not receive payment of the full amount owed by the date specified in
the demand letter, CMS may assess interest at the rate applicable to other
Medicare debts pursuant to 42 C.F.R. §405.378 on any outstanding unpaid
amounts. Interest will be calculated in 30-Day periods and assessed for each 30Day period that payment is not made in full.

3.

If the Participant fails to pay CMS the full amount owed by the date specified in
the demand letter, CMS will recoup monies owed from present and future
Medicare payments otherwise owed to the Participant. If CMS is unable to recoup
the full amount owed via Medicare payments, CMS will invoke all legal means to
collect the debt, including referral of the remaining debt to the United States
Department of Treasury, pursuant to 31 U.S.C. 3711(g).

ViT Monitoring and Evaluation
A. CMS Monitoring and Evaluation
1.

CMS will monitor the Participant’s maintenance of additional services specified in
the Participant’s Implementation plan, the Participant’s performance under ViT,
the Participant’s experience implementing ViT, and qualitative information on the
functional, physical, mental, and overall health status of Participating
Beneficiaries in order to detect non-compliance with ViT requirements as set
forth in this Agreement, inappropriate care furnished to Participating
Beneficiaries, overutilization, inappropriate reductions in care, cost-shifting to
other payers or populations, and any other program integrity risks.

2.

CMS will contract with an independent evaluator to study the design and
implementation of the Demonstration. The Participant agrees to support the
14

independent evaluation by providing requested data to assess the impact of the
Demonstration and by participating in check-in calls and/or phone interviews with
the independent evaluation contractor during the Demonstration and at least a
year after the Demonstration officially ends. CMS will conduct an independent
evaluation of the ViT to assess the extent that the demonstration program:

3.

i.

Reduces hospitalizations and emergency department visits;

ii.

Increases use of medication-assisted treatment for OUD;

iii.

Improves health outcomes of individuals with OUD, including reducing the
incidence of infectious diseases (such as Hepatitis C and HIV);

iv.

Does not increase the total Medicare spending on items and services;

v.

Reduces deaths from opioid overdose; and

vi.

Reduces the utilization of inpatient residential treatment.

In addition, the evaluation findings will include the extent to which the PBIP:
i.

Increased retention in treatment;

ii.

Increased use of pharmacotherapy for OUD;

iii.

Increased follow-ups after an emergency department visit for alcohol and
other drug abuse or dependence; and

iv.

Initiated as well as increased engagement in alcohol and other drug
dependence treatment.

B. Participant Cooperation
1.

As a condition of payment under Section VI, the Participant shall submit to CMS
or its designees, in such form, manner, and frequency specified by CMS, with
respect to each Participating Beneficiary to whom the Participant furnishes OUD
Treatment Services through its OUD Care team, or for whom the Participant
arranges for such services to be furnished, data and such other information as
CMS determines appropriate to monitor and evaluate ViT.

2.

The Participant shall prepare and submit a financial report for each Performance
Year to CMS in a form and manner and by a date specified by CMS.
i.

CMS shall provide the Participant with a template for the financial report in
which CMS will pre-fill the CMF and PBIP payments received by the
Participant from CMS under ViT during that Performance Year;

ii.

The Participant shall confirm whether the CMF and PBIP amounts pre-filled
by CMS are correct and shall report any discrepancies in the payment
amounts or eligibility for such payments to CMS.

iii.

Each financial report must include a summary of the Participant’s
expenditures of such CMF and PBIP payments, including the approximate
clinical labor, non-clinical labor, non-labor expenses, service types as
specified in the financial report template provided by CMS.
15

3.

The Participant shall respond, and shall require the members of its OUD Care
Team to respond to any survey or interview conducted by CMS or its designees to
monitor and evaluate ViT to include, without limitation, the Participant Survey.

4.

The Participant shall cooperate, and shall require its OUD Care Team members to
cooperate, with audits conducted by CMS and its designees to determine
compliance with the requirements of ViT as set forth in this Agreement, to include
without limitation the submission of medical charts, medical records, Beneficiary
Agreement Forms, and other data pertaining to Participating Beneficiaries.

5.

The Participant shall cooperate, and shall require its OUD Care Team members to
cooperate, with CMS efforts to conduct the independent evaluation of ViT, to
include:

i.

Engagement and cooperation with site visits and focus groups; and

ii.

Other activities that CMS determines appropriate to conduct a
comprehensive evaluation of ViT.

6.

If the Participant submits any PHI to CMS or its designees pursuant to this Section
VII, the Participant shall submit such PHI via a secure method specified by CMS
and in accordance with the requirements of Section V.D. The Participant shall not
disclose PHI to CMS or its designees in response to a survey or interview
conducted by CMS or its designees described in Section VII.B.3.

C. Program Integrity Screening
CMS may, at its sole discretion, subject the Participant and its OUD Care Team
members to periodic Program Integrity Screening throughout the Demonstration
Performance Period.
VIII. Data Sharing and Reports
A. General
1.

Subject to the limitations discussed in this Agreement, and in accordance with
applicable law, in advance of each Performance Year and at any other time
deemed necessary by CMS, CMS will offer the Participant an opportunity to
request certain data and reports, which are described in Section VIII.B and
Appendix C of this Agreement.

2.

The data and reports provided to the Participant under the preceding paragraph
will omit individually identifiable data for each Participating Beneficiary who has
not agreed for CMS to share his or her data with the Participant as described in
Section V.A, and for each Participating Beneficiary who has elected to terminate
his or her consent for CMS to share his or her data with the Participant as
described in Section VIII.D.

3.

The Participant shall not require an Applicable Beneficiary to agree to share his
or her data with the Participant in order to participate in ViT and receive OUD
Treatment Services from the Participant.
16

B. Provision of Certain Claims Data
1.

CMS believes that the care coordination and quality improvement work of the
Participant (acting on its own behalf as a HIPAA covered entity (“CE”) or as a
business associate (“BA”) acting on behalf of its OUD Care Team members who
are HIPAA CEs) would benefit from the receipt of certain beneficiary-identifiable
claims data on Participating Beneficiaries. CMS will therefore offer to the
Participant an opportunity to request specific beneficiary-identifiable claims
data by completing the HIPAA-Covered Disclosure Request Attestation and Data
Specification Worksheet (Appendix C). All requests for beneficiary-identifiable
claims data will be granted or denied at CMS’ sole discretion based on CMS’
available resources, the limitations in this Agreement, and applicable law.

2.

In offering this beneficiary-identifiable claims data which omits individually
identifiable data for each Participating Beneficiary who has not agreed for CMS
to share his or her data with the Participant as described in Section V.A, CMS
does not represent that the Participant has met all applicable HIPAA
requirements for requesting data under 45 CFR § 164.506(c)(4). The Participant
and its OUD Care Team members should consult with their own counsel to make
those determinations prior to requesting this data from CMS.

3.

The beneficiary-identifiable claims data available is the data described in
Appendix C.

4.

The Parties mutually agree that, except for data covered by Section VIII.B.15
below, CMS retains all ownership rights to the data files referred to in Appendix
C, and the Participant does not obtain any right, title, or interest in any of the
data furnished by CMS.

5.

The Participant represents, and in furnishing the data files specified in Appendix
C, CMS relies upon such representation, that such data files will be used solely
for the purposes described in this Agreement. The Participant agrees not to
disclose, use or reuse the data except as specified in this Agreement or except as
CMS shall authorize in writing or as otherwise required by law. The Participant
further agrees not to sell, rent, lease, loan, or otherwise grant access to the data
covered by this Agreement.

6.

The Participant intends to use the requested information as a tool to conduct
quality improvement activities and deliver seamless, coordinated care for
Participating Beneficiaries. Information derived from the CMS files specified in
Appendix C may be shared and used within the legal confines of the Participant
and its OUD Care Team members in a manner consistent with Section VIII.B.7 to
enable the Participant to improve access to OUD Treatment Services and care
integration, and be a patient-centered organization.

7.

The Participant may reuse original or derivative data without prior written
17

authorization from CMS for clinical treatment, care management and
coordination, and quality improvement activities but shall not disseminate
individually identifiable original or derived information from the files specified in
Appendix C to anyone who is not a HIPAA CE OUD Care Team member in a
treatment relationship with the subject Participating Beneficiaries; a HIPAA BA
of such an OUD Care Team member; the Participant’s BA, where the Participant
is itself a HIPAA CE; the Participant’s sub-BA, which is hired by the Participant to
carry out work on behalf of the CE OUD Care Team members; or a nonparticipant HIPAA CE in a treatment relationship with the subject Participating
Beneficiary(ies). When using or disclosing PHI or personally identifiable
information (“PII”), obtained from files specified in Appendix C, the Participant
must make “reasonable efforts to limit” the information to the “minimum
necessary” to accomplish the intended purpose of the use, disclosure, or
request. The Participant shall further limit its disclosure of such information to
the types of disclosures that CMS itself would be permitted make under the
“routine uses” in the applicable systems of records listed in Appendix C.
8.

Subject to the limits specified above and elsewhere in this Agreement and
applicable law, the Participant may link individually identifiable information
specified in Appendix C (including directly or indirectly identifiable data) or
derivative data to other sources of individually-identifiable health information,
such as other medical records available to the Participant and its OUD Care
Team members. The Participant may disseminate such data that has been linked
to other sources of individually identifiable health information provided such
data has been de-identified in accordance with HIPAA requirements in 45 CFR §
164.514(b).

9.

The Participant agrees to establish appropriate administrative, technical, and
physical safeguards to protect the confidentiality of the data and to prevent
unauthorized use or access to it. The safeguards shall provide a level and scope
of security that is not less than the level and scope of security requirements
established for federal agencies by the Office of Management and Budget (OMB)
in OMB Circular No. A-130, Appendix I--Responsibilities for Protecting and
Managing Federal Information Resources
(https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/circulars/A130/a
130revised.pdf) as well as Federal Information Processing Standard 200 entitled
“Minimum Security Requirements for Federal Information and Information
Systems” (https://nvlpubs.nist.gov/nistpubs/FIPS/NIST.FIPS.200.pdf); and, NIST
Special Publication 800-53 “Recommended Security Controls for Federal
Information Systems”
(https://nvlpubs.nist.gov/nistpubs/SpecialPublications/NIST.SP.800-53r4.pdf).

10.

The Participant acknowledges that the use of unsecured telecommunications,
including the Internet, to transmit directly or indirectly individually identifiable
18

information from the files specified in Appendix C, or any such derivative data
files is strictly prohibited. Further, the Participant agrees that the data specified
in Appendix C, must not be physically moved, transmitted, or disclosed in any
way from or by the site of the Custodian indicated in Appendix C, other than as
provided in this Agreement without written approval from CMS, unless such
movement, transmission, or disclosure is required by a law.
11.

The Participant agrees to grant access to the data and/or the facility(ies) in
which the data is maintained to the authorized representatives of CMS or HHS
Office of Inspector General, including at the site of the custodian indicated in
Appendix C, for the purpose of inspecting to confirm compliance with the terms
of this Agreement.

12.

The Participant agrees that any use of CMS data in the creation of any document
concerning the purpose specified in this section and Appendix C, of the
Agreement must adhere to CMS’ current cell size suppression policy. This policy
stipulates that no cell (e.g., admittances, discharges, patients, services)
representing 10 or fewer beneficiaries may be displayed. Also, no use of
percentages or other mathematical formulas may be used if they result in the
display of a cell representing 10 or fewer beneficiaries.

13.

The Participant agrees to report any breach of PHI or PII from or derived from
the CMS data files, loss of these data or improper use or disclosure of such data
to the CMS Action Desk by telephone at (410) 786-2850 or by email notification
at [email protected] within one hour. Furthermore, the
Participant agrees to cooperate fully in any federal incident security process that
results from such improper use or disclosure.

14.

The Parties mutually agree that the individual named in Appendix C is
designated as Custodian of the CMS data files on behalf of the Participant and
will be responsible for the observance of all conditions of use and disclosure of
such data and any derivative data files, and for the establishment and
maintenance of security arrangements as specified in this Agreement to prevent
unauthorized use or disclosure. Furthermore, such Custodian is responsible for
contractually binding any downstream recipients of such data to the terms and
conditions in this Agreement as a condition of receiving such data. The
Participant agrees to notify CMS within fifteen (15) Days of any change of
custodianship. The parties mutually agree that CMS may disapprove the
appointment of a custodian or may require the appointment of a new custodian
at any time.

15.

Data disclosed to the Participant pursuant to Appendix C may be retained by the
Participant until the conclusion or termination of this Agreement. The
Participant is permitted to retain any individually identifiable health information
from such data files or derivative data files after the conclusion or termination of
19

the Agreement if the Participant is a HIPAA CE, and the data has been
incorporated into the subject Participating Beneficiaries’ medical records that
are part of a designated record set under HIPAA. Furthermore, any HIPAA CE to
whom the Participant provides such data in the course of carrying out ViT may
also retain such data if the recipient entity is a HIPAA CE or BA and the data is
incorporated into the subject Participating Beneficiaries’ medical records that
are part of a designated record set under HIPAA. The Participant shall destroy all
other data and send written certification of the destruction of the data files
and/or any derivative data files to CMS within 30 Days following the expiration
or termination of the Agreement or except as CMS shall authorize in writing or
as otherwise required by law. Except for disclosures for treatment purposes, the
Participant shall bind any downstream recipients to these terms and conditions
as a condition of disclosing such data to downstream entities and permitting
them to retain such records under this paragraph. These retention provisions
survive the expiration or termination of the Agreement.
C. De-Identified Reports
CMS will provide the following reports to the Participant, which will be deidentified in accordance with HIPAA requirements in 45 CFR § 164.514(b):
1.

Annual Financial Reports -These reports will include year-to-date information on
total ViT Medicare payments to individuals and entities participating in ViT. This
aggregate information will not include individually identifiable health
information and will incorporate de-identified data from Participating
Beneficiaries who have not opted in for data sharing.

2.

Other Reports - CMS will periodically provide reports to the Participant
regarding the Participant’s financial performance throughout the Performance
Year. The reports will not contain individually identifiable health information and
will incorporate de-identified data from Participating Beneficiaries who have
opted out of data sharing.

D. Beneficiary Rights to Opt in to or Terminate Data Sharing
1.

The Participant shall provide Participating Beneficiaries who inquire about or
wish to modify their preferences regarding claims data sharing for care
coordination and quality improvement purposes with information about how to
modify their data sharing preferences. Such communications shall note that,
even if a Participating Beneficiary has elected to decline claims data sharing,
CMS may still engage in certain limited data sharing for quality improvement
purposes.

2.

The Participant shall allow Participating Beneficiaries to reverse a data sharing
preference at any time by calling 1-800-MEDICARE.

3.

CMS will maintain the data sharing preferences of Participating Beneficiaries.
20

4.

IX.

The Participant may affirmatively contact a Participating Beneficiary who has
elected to decline claims data sharing no more than once in a given Performance
Year to provide information regarding data sharing. Such contact includes
mailings, phone calls, electronic communications, or other methods of
communicating with beneficiaries outside of a clinical setting.

Overlap Policy
A. Prohibition
1.

The Participant shall not concurrently participate in ViT and any of the following
Innovation Center initiatives: PCF, CPC+, or MDPCP.

2.

CMS reserves the right to potentially include additional requirements, revise
initiative parameters, or ultimately prohibit simultaneous participation in other
CMS initiatives, based on a number of factors, including CMS’s capacity to avoid
counting savings twice in interacting initiatives and to conduct a robust evaluation
of each such initiative.

B. Permitted Overlap and Notification

X.

1.

The Participant may concurrently participate in ViT and certain other CMS
initiatives, including shared savings, total cost of care, and medical home
initiatives.

2.

The Participant must give written notice to CMS if the Participant is selected to
participate in any other CMS initiative after the Effective Date. Such notice must
be given within 30 Days of receiving notification that the Participant has been
selected to participate in the initiative.

Other Government Authorities
None of the provisions of this Agreement limit or restrict any other federal government
agency that is permitted by law to audit, evaluate, investigate, or inspect the Participant
or its OUD Care Team members.

XI.

Agreement to Comply with Laws
A. The Participant shall comply with, and shall require all OUD Care Team members to
comply with the applicable terms of this Agreement and all applicable statutes and
regulations, including without limitation: (a) federal criminal laws; (b) the False Claims
Act (31 U.S.C. § 3729 et seq.); (c) the anti-kickback statute (42 U.S.C. § 1320a-7b(b)); (d)
the civil monetary penalties law (42 U.S.C. § 1320a-7a); and (e) the physician self-referral
law (42 U.S.C. § 1395nn).
B. This Agreement does not waive any obligation of the Participant or its OUD Care Team
members to comply with the terms of any other CMS contract, agreement, model, or
demonstration.
C. The failure by CMS to require performance of any provision of this Agreement does not
affect CMS’s right to require performance at any time thereafter, nor does a waiver of
any breach or default of this Agreement constitute a waiver of any subsequent breach or
default or a waiver of the provision itself.
21

XII.

Certification of Data and Information
With respect to data and information that CMS requires to be certified when
submitted to CMS by the Participant, the Participant shall ensure that an
individual with the authority to legally bind the individual or entity submitting
such data or information certifies the accuracy, completeness, and truthfulness
of that data and information to the best of his or her knowledge information,
and belief.

XIII.

Audits and Record Retention
A. Right to Audit
1.

The Participant agrees, and must require all OUD Care Team members to agree,
that the government, including CMS, HHS, and the Comptroller General or their
designees, has the right to audit, inspect, investigate, and evaluate any books,
contracts, records, documents and other evidence of the Participant and OUD
Care Team members that pertain to the following:
i.

The Participant’s compliance with the terms of this Agreement, including
provisions that require the Participant to impose duties or requirements
on its OUD Care Team members;

ii.

Whether the OUD Care Team members complied with the duties and
requirements imposed on them by the Participant pursuant to the terms
of this Agreement;

iii.

The quality of the OUD Treatment Services performed under this
Agreement; and

iv.

The Participant’s right to CMF and PBIP.

B. Maintenance of Records
The Participant agrees, and must require all OUD Care Team members to agree, to
the following:
1. To maintain and give the government, including CMS, HHS, and the Comptroller
General or their designees, access to all books, contracts, records, documents, and
other evidence (including data related to Medicare utilization and costs, quality
performance measures, and other financial arrangements) sufficient to enable the
audit, evaluation, inspection, or investigation of the following:
i.

the Participant’s compliance with the terms of this Agreement, including
provisions that require the Participant to impose duties or requirements
on OUD Care Team members;

ii.

whether the OUD Care Team members complied with the duties and
requirements imposed on them by the Participant pursuant to the terms
of this Agreement;

iii.

the quality of services furnished under this Agreement; and
22

iv.

the Participant’s right to CMF and PBIP.

2. To maintain such books, contracts, records, documents, and other evidence for a
period of 10 years from the expiration or termination of this Agreement or from the
date of completion of any audit, evaluation, inspection, or investigation, whichever
is later, unless:
i.

CMS determines there is a special need to retain a particular record or
group of records for a longer period and notifies the Participant at least 30
Days before the normal disposition date; or

ii.

There has been a termination, dispute, or allegation of fraud or similar
fault against the Participant, or its OUD Care Team members in which case
the records shall be maintained for an additional six years from the date
of any resulting final resolution of the termination, dispute, or allegation
of fraud or similar fault.

XIV. Remedial Action
A. Remedial Action
1.

If CMS determines that the Participant has failed to meet one or more ViT
requirements as set forth in this Agreement, or that the Participant or a member
of its OUD Care Team has past or present program integrity issues, CMS may
take one or more of the following actions:
i.

Notify the Participant and, if appropriate, the OUD Care Team member of
the violation;

ii.

Require the Participant to provide additional information to CMS or its
designees;

iii.

Place the Participant on a monitoring and/or auditing plan developed by
CMS;

iv.

Require the Participant to remove an OUD Care Team member from the
Participant’s list of OUD Care Team members and to terminate its OUD
Care Team Member Arrangement, immediately or within a timeframe
specified by CMS, with that OUD Care Team member;

v.

Request that the Participant submit a proposed Corrective Action Plan
(“CAP”), subject to CMS review and approval, which the Participant must
implement once approved by CMS;

vi.

Amend this Agreement without the consent of the Participant to provide
that any and all waivers of existing law made pursuant to Section 1866F(i)
of the Act will be inapplicable;

vii.

Discontinue the provision of data sharing and reports to the Participant
under Section VIII;
23

viii.
2.

Require the repayment of any CMF or PBIP.

CMS may impose additional remedial actions or terminate this Agreement
pursuant to Section XV if CMS determines that remedial actions were insufficient
to correct noncompliance with the terms of this Agreement or other program
integrity issues.

B. Further action
CMS and its contractors will work with CMS’ Center for Program Integrity and
the HHS Office of Inspector General to report and refer any suspected noncompliance, fraud, or abuse for further investigative or administrative action as
appropriate under existing law.
XV.

Termination
A. Termination by CMS
CMS reserves the right to terminate this Agreement, or to require the Participant to
terminate its OUD Care Team Member Arrangement with one or more OUD Care Team
Members, for reasons including but not limited to:
1.

CMS determines that the Agency no longer has funds to support ViT.

2.

CMS determines that the Participant or, if applicable, a member of the
Participant’s OUD Care Team has:
i.

Failed to comply with any term of this Agreement or any other Medicare
program requirement, rule, or regulation;

ii.

Failed to comply with a monitoring plan and/or auditing plan imposed
pursuant to Section XIV.A;

iii.

Failed to implement a CMS-approved CAP imposed pursuant to Section
XIV.A;

iv.

Failed to demonstrate improved performance following any remedial
action;

v.

Taken any action that threatens the health or safety of a Participating
Beneficiary or other patient;

vi.

Failed to repay money owed to the Medicare program as required under
the Agreement or any audit issued pursuant thereto;

vii.

Consistently failed to meet quality performance thresholds or benchmarks
required under the Agreement;

viii.

Failed to meet reporting requirements specified in the Agreement,
including failure to report to CMS quality measures or information CMS has
determined appropriate to monitor and evaluate ViT;

ix.

Unreasonably interfered with or impeded CMS’s and its designees’
monitoring and evaluation activities;
24

x.

Submitted false data or made false representations, warranties, or
certifications in connection with any aspect of ViT.

3.

CMS determines that the Participant or any member of its OUD Care Team is
subject to sanctions or other actions of an accrediting organization or a federal
state, or local governmental agency, to include action by the Department of
Health and Human Services (HHS) or the Department of Justice involving
violations of applicable laws, statutes, and regulations, including but not limited
to: federal criminal laws, the federal False Claims Act, antitrust laws, the federal
anti-kickback statute, the federal civil monetary penalties law, the federal
physician self-referral law or any other applicable Medicare laws, rules or
regulations that are relevant to ViT.

4.

CMS determines that the Participant is unable to implement its participation in
ViT due to federal, state, or local laws or scope of practice barriers.

B. Termination by Participant
The Participant may terminate this Agreement upon advance written notice to
CMS. Such notice must specify the effective date of the termination; which date
may be no sooner than 30 Days following the date of that notice.
C. Notification Requirements
1.

Upon termination of the Agreement by the Participant or CMS, the Participant
shall provide written notice of such termination to all members of its OUD Care
Team. The Participant shall deliver such written notice in a time and

manner determined by CMS. The Participant shall include in such notices
any content specified by CMS, including information regarding data
destruction and record keeping, as applicable.
2.

Upon termination of the Agreement by the Participant or CMS, the Participant
shall provide written notice of such termination to each Participating Beneficiary.
The Participant shall deliver such written notice in a time and manner determined
by CMS. The Participant shall include in such notices any content specified by
CMS. Any notice to Participating Beneficiaries is subject to review and approval by
CMS.

XVI. Miscellaneous
A. Agency Notifications and Submission of Reports
Unless otherwise stated in writing after the Effective Date, all notifications and reports
required under this Agreement shall be submitted to the Parties at the addresses set
forth below:

CMS:
Value In Treatment
Centers for Medicare & Medicaid Services
Center for Medicare and Medicaid Innovation
25

7500 Security Boulevard
Mailstop: WB-06-05XX
Baltimore, MD 21244
Email: [email protected]

Participant:
Organization Name:
Address:

Email:
Phone Number:
B. Notice of Bankruptcy
In the event the Participant enters into proceedings relating to bankruptcy, whether
voluntary or involuntary, the Participant agrees to furnish, by certified mail, written
notification of the bankruptcy to CMS. This notification shall be furnished within 5 Days of
the initiation of the proceedings relating to bankruptcy filing. This notification shall include
the date on which the bankruptcy petition was filed, the identity of the court in which the
bankruptcy petition was filed, and a listing of all federal government contracts, project
agreements, contract officers, and project officers for all government contracts and project
agreements against which final payment has not been made. This obligation remains in
effect until the expiration or termination of this Agreement and final payment under this
Agreement has been made.
C. Severability
In the event that one or more of the provisions contained herein shall, for any reason, be
held to be invalid, illegal or unenforceable in any respect, such invalidity, illegality or
unenforceability shall not affect any other provisions of this Agreement, but this
Agreement shall be construed as if such invalid, illegal or unenforceable provisions had
never been contained herein, unless the deletion of such provision or provisions would
result in such a material change so as to cause completion of the transactions
contemplated herein to be unreasonable.
D. Entire Agreement: Amendment
This Agreement, including all Appendices, constitutes the entire agreement between the
26

Parties. The Parties may amend this Agreement or any Appendix hereto at any time by
mutual written agreement; provided, however, that CMS may unilaterally amend this
Agreement or any Appendix hereto as specified in this Agreement including its Appendices,
or for good cause or as necessary to comply with applicable federal or state law, regulatory
requirements, accreditation standards or licensing guidelines or rules. To the extent
practicable, CMS shall provide the Participant with 30 Days advance written notice of any
such unilateral amendment, which notice shall specify the amendment’s effective date.
E. Survival
Termination or expiration of this Agreement by any party shall not affect the rights and
obligations of the Parties accrued prior to the effective date of the termination or
expiration of this Agreement, except as provided in this Agreement. The data privacy and
security requirements articulated in this Agreement survive for the duration that CMS data
remains in the possession of the Participant. The rights and duties under the following
Sections of this Agreement shall also survive termination of this Agreement and apply
thereafter:
1. Section III.D [Participant Changes]
2. Section V.D [HIPAA Requirements]
3. Section VI [Payments];
4. Section VII [ViT Monitoring and Evaluation];
5. Section VIII [Data Sharing and Reports];
6. Section XII [Certification of Data and Information];
7. Section XIII [Audits and Record Retention];
8. XV.C [Notification Requirements];
9. Section XVI.B [Notice of Bankruptcy]; Section XVI.E [Survival];
10. Section XVI.G [Prohibition on Assignment];
11. Section XVI.H [Change of Control]; and
12. Appendix B [Value in Treatment CMF and PBIP Payment Methodology].
F. Precedence
If any provision of this Agreement conflicts with a provision of any document incorporated
herein by reference, the provision of this Agreement shall prevail.
G. Prohibition on Assignment
Except with the prior written consent of CMS, the Participant shall not transfer, including
by merger (whether the Participant is the surviving or disappearing entity), consolidation,
dissolution, or otherwise: (1) any discretion granted it under this Agreement; (2) any right
that it has to satisfy a condition under this Agreement; (3) any remedy that it has under this
Agreement; or (4) any obligation imposed on it under this Agreement. The Participant shall
27

provide CMS 90 Days advance written notice of any such proposed transfer. This obligation
remains in effect until the expiration or termination of this Agreement and final payment
by the Participant under this Agreement has been made. CMS may condition its consent to
such transfer on full or partial reconciliation of any monies owed to CMS under the terms
of this Agreement. Any purported transfer in violation of this Section is voidable at the
discretion of CMS.
H. Change of Control
CMS may terminate this Agreement or require immediate payment of any monies owed
under this Agreement if the Participant undergoes a Change of Control. For purposes of
this paragraph, a “Change of Control” shall mean: (1) the acquisition by any “person” (as
such term is used in Sections 13(d) and 14(d) of the Securities Exchange Act of 1934) of
beneficial ownership (within the meaning of Rule 13d-3 promulgated under the Securities
Exchange Act of 1934), directly or indirectly, of voting securities of the Participant
representing more than 50% of the Participant’s outstanding voting securities or rights to
acquire such securities; (2) upon any sale, lease, exchange or other transfer (in one
transaction or a series of transactions) of all or substantially all of the assets of the
Participant; or (3) a plan of liquidation of the Participant or an agreement for the sale or
liquidation of the Participant is approved and completed. The Participant shall provide CMS
90 Days advance written notice of a Change of Control. This obligation remains in effect
until the expiration or termination of this Agreement and final payment by the Participant
under this Agreement has been made.
I.

Certification
The individual signing this Agreement on behalf of the Participant certifies to the best of his
or her knowledge, information, and belief that the information contained in this Agreement
(inclusive of Appendices), is accurate, complete, and truthful and that he or she is
authorized by the Participant to execute this Agreement and to legally bind the Participant
on whose behalf he or she is executing this Agreement to its terms and conditions.

J.

Interpretation of the Agreement
The Participant has been represented (or has had the opportunity to be represented) by
their attorneys throughout the transactions contemplated by this Agreement in connection
with the execution of this Agreement and any agreements and instruments executed in
connection herewith. As a consequence, the Parties do not intend that the presumptions of
laws or rules relating to the interpretation of contracts against the drafter of any particular
clause should be applied to this Agreement or any document or instrument executed in
connection herewith, and therefore waive their effects.

K. Execution in Counterpart
This Agreement and any amendments thereto may be executed in counterparts, each of
which shall be deemed to be an original, but all of which, taken together, shall constitute
one and the same Agreement. This Agreement and any amendments hereto may be
28

signed by autopen or electronic signature (e.g., DocuSign or similar electronic signature
technology) and may be transmitted by electronic means. Copies of this Agreement and
any amendments hereto that are so executed and delivered have the same force and
effect as if executed with handwritten signatures and physically delivered.

[SIGNATURE PAGE FOLLOWS]

29

Each Party is signing this Agreement on the date stated opposite that Party’s signature. If a Party signs
but fails to date a signature, the date that the other Party receives the signing Party’s signature will be
deemed to be the date that the signing Party signed this Agreement.

PARTICIPANT:
Date:
By:
Name of authorized signatory
Title

CMS:
Date:
By:
Name of authorized signatory
Title

30

APPENDIX A: VALUE IN TREATMENT PROGRAMMATIC WAIVERS
I.

Waiver
Under the authority of 1866F(i) of the Act, CMS finds it necessary solely for purposes of
carrying out ViT to waive the following requirements:
A.

B.

Waivers of Beneficiary Cost Sharing:
1.

As necessary to carry out ViT, CMS waives the requirements of sections
1833(a)(1)(F), 1833(a)(1)(L), 1833(a)(1)(N), 1833(a)(1)(U), 1833(a)(1)(CC), and
1833(b) of the Act to the extent otherwise applicable for Medicare Part B payment
systems and for OTPs permitted to submit claims on CMS form 835A, such that
Medicare will pay 100 percent of the cost of services related to highly coordinated
and integrated OUD Treatment Services furnished through ViT to Participating
Beneficiaries. This waiver applies on a uniform basis without regard to patientspecific factors and shall be applied to ViT Code claims.

2.

As necessary to carry out ViT, CMS waives the requirements of sections
1833(a)(1)(F), 1833(a)(1)(L), 1833(a)(1)(N), 1833(a)(1)(U), 1833(a)(1)(CC), and
1833(b) of the Act to the extent otherwise applicable for Medicare Part B payment
systems, such that Medicare will pay 100 percent of the bundled payment for
opioid use disorder treatment services furnished to Participating Beneficiaries by
OTPs under 42 C.F.R. 410.67(d), and for OTPs permitted to submit claims on CMS
form 835A. This waiver applies on a uniform basis without regard to patientspecific factors and shall be applied to claims for HCPCS codes G2067 through
G2080, and any other HCPCS codes specified by CMS for use by OTPs in billing for
opioid use disorder treatment services.

3.

As necessary to carry out ViT, CMS waives the requirements of sections
1833(a)(1)(F), 1833(a)(1)(L), 1833(a)(1)(N), 1833(a)(1)(U), 1833(a)(1)(CC), and
1833(b) of the Act to the extent otherwise applicable for Medicare Part B payment
systems, such that Medicare will pay 100 percent of the bundled payment for an
episode of OUD treatment furnished to Participating Beneficiaries by physicians
and other practitioners in the office setting. This waiver applies on a uniform basis
without regard to patient-specific factors and shall be applied to claims for HCPCS
codes G2086 through G2088 submitted for services furnished to Participating
Beneficiaries.

Waiver of Conditions of Payment for Medicare Telehealth Services:
As necessary to carry out ViT, CMS waives the requirements of section 1834(m) of the
act, as necessary to allow payment to be made for services furnished to a patient
remotely using telecommunications technology in accordance with the terms of this
Agreement.
31

APPENDIX B: VALUE IN TREATMENT CMF AND PBIP PAYMENT METHODOLOGY
I.

Payments
During the 4 Performance Years of the ViT, CMS will pay the Participant a CMF on a quarterly
basis. CMS will also pay the Participant a PBIP annually. The payment timeline and
methodology for each of these two payments are detailed in the following subsections of this
Appendix B.

II.

Timeline
CMS will pay the CMF and PBIP in accordance with the timeline outlined in Table 1. The CMF
will be paid as a per Participating Beneficiary per quarter payment for the calendar quarter in
which the Participant furnishes and submits a ViT Code claim and will be paid after the claim is
processed. The PBIP for a given Performance Year will be paid annually no later than Q3 of the
year following the Performance Year.
Table 1: Care Management Fee (CMF) Payments and Performance-Based Incentive Payments (PBIP) Timeline
Calendar
Year
2021

CMF Payments
Calendar Quarter
Q2 (04/01/2021 – 06/30/2021)
Q3 (07/01/2021 – 09/30/2021)
Q4 (10/01/2021 – 12/31/2021)

CMF will be paid after the
claim is processed

Performance
Year 1
04/01/2021 2
– 12/31/2021

PBIP Payments
Claims Runout
Period
01/01/2022 –
03/31/2022

Payment Date

Payment
Date
None

2022

Q1 (01/01/2022 – 03/31/2022)
Q2 (04/01/2022 – 06/30/2022)
Q3 (07/01/2022 – 09/30/2022)
Q4 (10/01/2022 – 12/31/2022)

CMF will be paid after the
claim is processed

01/01/2022 –
12/31/2022

01/01/2023 –
03/31/2023

No later
than Q3
2023

2023

Q1 (01/01/2023 – 03/31/2023)
Q2 (04/01/2023 – 06/30/2023)
Q3 (07/01/2023 – 09/30/2023)
Q4 (10/01/2023 – 12/31/2023)

CMF will be paid after the
claim is processed

01/01/2023 –
12/31/2023

01/01/2024 –
03/31/2024

No later
than Q3
2024

2024

Q1 (01/01/2024 – 03/31/2024)
Q2 (04/01/2024 – 06/30/2024)
Q3 (07/01/2024 – 09/30/2024)
Q4 (10/01/2024 – 12/31/2024)

CMF will be paid after the
claim is processed

01/01/2024 –
12/31/2024

01/01/2025 –
03/31/2025

No later
than Q3
2025

III.

Care Management Fee (CMF)
The amount of the CMF is calculated as $125 per Participating Beneficiary per month (PBPM),

Performance year 1 will be abbreviated and will consist of 9 months.
In the event that the Effective Date of this Agreement is a date after April 1, 2021, the start of this
Performance Year will be the Effective Date.

1
2

32

adjusted by subtracting the applicable PBIP quality withhold percentage and then applying
Medicare sequestration. The adjusted amount is multiplied by three to determine the
quarterly payment amount. Claims for the CMF must be billed to the Medicare Administrative
Contractor (MAC) appropriate to the Participant.
The MAC will verify that all CMF payment policies outlined in Section VI of the Agreement, and
further described below, are met with respect to each CMF claim submitted by the Participant.
A.
Payment Policy
CMS will make a CMF payment to the Participant only if the CMF payment policies outlined in
Section VI of this Agreement, and further described below, are met. CMS will monitor CMF
payments for compliance with these policies. In addition, the Participant may not
simultaneously participate in ViT and the MDPCP, CPC+, or PCF and is therefore ineligible for
CMF payments under ViT while also participating in these initiatives. The MAC will verify the
absence of such participation overlaps to process CMF claims.
The MAC will deny claims that do not meet the applicable payment policies. CMS will seek
repayment of CMF payments that have been made in error or inconsistent with applicable
payment policies in accordance with Section VI.F of this Agreement.
1.

Claim contains the ViT Code and is a standalone claim

The Participant must submit a claim that includes only the ViT Code.
No other billing or procedure codes may be included on the same claim, including the codes
used to bill for the bundled payment for opioid use disorder treatment services furnished by
OTPs and the codes used to bill for the bundled payment for an episode of OUD treatment
furnished by physicians and other practitioners in the office setting.
The MAC will deny any claim that includes the ViT Code and any other billing or procedure
code. In such a case, the ViT Code claim for the services furnished to a Participating Beneficiary
under ViT must be resubmitted as a standalone claim for the CMF payment to be processed
and paid.
2.

Claim is from a Participant

Only the Participant may submit a claim with the ViT Code. This means that the billing
information on the claim must match the billing information provided to CMS by the
Participant, including the Participant’s unique Taxpayer Identification Number (TIN), for the
claim to be processed. Other individuals and entities, including the Participant’s OUD Care
Team members, may not bill the ViT Code.
3.

Claim is for a Participating Beneficiary

A ViT Code claim for services furnished under ViT must be for services furnished to a
Participating Beneficiary, as defined in Section II of this Agreement. That is, the Participating
33

Beneficiary must be an Applicable Beneficiary who has agreed to receive OUD Treatment
Services from the Participant by signing the Beneficiary Agreement Form.
The MAC will verify that the Participating Beneficiary included on each billed claim satisfies the
definition of an Applicable Beneficiary during their claims processing. This means that, on the
date of service included on the claim, the Participating Beneficiary must be entitled to, or
enrolled for, benefits under Medicare Part A and enrolled for benefits under Medicare Part B
(which may include a beneficiary dually-eligible for Medicare and Medicaid); not be enrolled in
a Medicare Advantage Plan under Medicare Part C; and have an OUD diagnosis. For purposes
of verifying that the Participating Beneficiary had an OUD diagnosis, the submitted claim must
contain at least one of the CMS specified ICD-10-CM diagnosis codes for an OUD diagnosis.
To satisfy the definition of a Participating Beneficiary, the beneficiary also must have agreed to
receive OUD Treatment Services from the Participant on or before the date of service on the
claim. The MAC will not collect proof of the signed Beneficiary Agreement Form for claims
processing. Proof that the Participating Beneficiary has signed a Beneficiary Agreement Form
agreeing to receive OUD Treatment Services from the Participant will be collected and verified
during audits conducted by CMS and its designees described in Sections VII.B.4 and XIII.A of
this Agreement.
4.

Claim is not duplicative

The ViT Code claim must not be duplicative of another ViT Code claim for services furnished to
the same Participating Beneficiary under ViT during the same calendar quarter. If two or more
individuals or entities submit a ViT Code claim for services furnished to the same Participating
Beneficiary under ViT during the same calendar quarter, only one such claim will be processed.
CMS will determine which individual or entity will receive a CMF for that Participating
Beneficiary based on the date of claim submission, not based on date of service. That is, CMS
will pay a CMF to the individual or entity that submits the first valid ViT Code claim for services
furnished to that Participating Beneficiary under ViT during the calendar quarter, irrespective
of whether that claim had the earliest date of service.
5.

Claim does not exceed the Participant’s Per-Participating Beneficiary Cap

The submitted claim must not exceed the Per-Participating Beneficiary Cap set for the
Participant in accordance with Section VI.C of this Agreement. The Participant is expected to
keep track of its billing to monitor its claims volume against the Per-Participating Beneficiary
Cap. ViT Code claims submitted for services furnished to any Participating Beneficiary in excess
of the number of Participating Beneficiaries included in the Participant’s Per-Participating
Beneficiary Cap will be denied by the MAC.
B.
Calculation of CMF Payments with Quality Withhold & Medicare Sequestration Adjustment
The CMF payment made to the Participant is subject to a PBIP quality withhold (No withhold in
PY1; 5% in PY2; 10% in each Performance Year thereafter) and, if a sequestration order is in
effect, an adjustment to account for sequestration (2%).
Specifically, the amount of the CMF for each ViT Code claim submitted for the calendar quarter
34

in which OUD Treatment Services were furnished to a Participating Beneficiary under ViT is
calculated as $125 per Participating Beneficiary per month, minus the applicable PBIP quality
withhold and any applicable Medicare sequestration adjustments. This adjusted amount is
then multiplied by three to reflect the three-month duration of the calendar quarter. The
calculation formulas applicable to each Performance Year are reflected below.
Performance Year 1 (2021)
𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷) =
$125 – ��𝑛𝑛𝑛𝑛 𝑤𝑤𝑤𝑤𝑤𝑤ℎℎ𝑜𝑜𝑜𝑜𝑜𝑜 ($0)� + (2% 𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠 𝑟𝑟𝑟𝑟𝑟𝑟𝑟𝑟 ((100% ($125)))� =
$125 − [($0) + ($2.50)] = $𝟏𝟏𝟏𝟏𝟏𝟏. 𝟓𝟓𝟓𝟓 PBPM
𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷)
= 𝐶𝐶𝐶𝐶𝐶𝐶 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 ∗ 3 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚ℎ𝑠𝑠 = $𝟑𝟑𝟑𝟑𝟑𝟑. 𝟓𝟓𝟓𝟓 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃

*Note that the 2% sequestration adjustment is applied only if sequestration is in effect for
the period in which the payment is made.
Performance Year 2 (2022)
𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷) =
$125 – [(5% 𝑤𝑤𝑤𝑤𝑤𝑤ℎℎ𝑜𝑜𝑜𝑜𝑜𝑜 ($125 )) +
(2% 𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠 𝑟𝑟𝑟𝑟𝑟𝑟𝑟𝑟 ((95%($125)))] = $125 − [($6.25) + ($2.38)] =
$𝟏𝟏𝟏𝟏𝟏𝟏. 𝟑𝟑𝟑𝟑 PBPM

𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷)
= 𝐶𝐶𝐶𝐶𝐶𝐶 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 ∗ 3 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚ℎ𝑠𝑠 = $𝟑𝟑𝟑𝟑𝟑𝟑. 𝟏𝟏𝟏𝟏 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃

*Note that the 2% sequestration adjustment is applied only if sequestration is in effect for
the period in which the payment is made.
Performance Year 3 to 4 (2023 to 2024)
𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷) =
$125 – [(10% 𝑤𝑤𝑤𝑤𝑤𝑤ℎℎ𝑜𝑜𝑜𝑜𝑜𝑜 ($125 )) +
(2% 𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠 𝑟𝑟𝑟𝑟𝑟𝑟𝑟𝑟 ((90%($125)))] = $125 − [($12.50) + ($2.25)] =
$𝟏𝟏𝟏𝟏𝟏𝟏. 𝟐𝟐𝟐𝟐 PBPM

𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷)
= 𝐶𝐶𝐶𝐶𝐶𝐶 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 ∗ 3 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚ℎ𝑠𝑠 = $𝟑𝟑𝟑𝟑𝟑𝟑. 𝟕𝟕𝟕𝟕 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃

*Note that the 2% sequestration adjustment is applied only if sequestration is in effect for
the period in which the payment is made.
IV.

Performance-Based Incentive Payments (PBIP)
To encourage the Participant to improve quality of care and reduce healthcare cost, CMS will
apply a PBIP quality withhold in calculating the amount of the quarterly CMF payments, as
specified in the previous section of this Appendix B. The Participant may earn back the PBIP
quality withhold in the form of a PBIP if the Participant meets or exceeds the applicable
35

performance threshold. The PBIP, if any, will be paid to the Participant on an annual basis in
accordance to the timeline specified in Table 1 of this Appendix B.
ViT employs the following PBIP design principles and features:
•

•
•

Quality withhold phased in during the Demonstration Performance Period, increasing from none
in the first Performance Year, to 5% during the second Performance Year, and to 10% for each of
the subsequent Performance Years.
Claim-based performance measures tied to payment are specific to OUD.
The Participant must meet or exceed the performance threshold in order to earn back PBIP
quality withhold in the form of a PBIP.

The following policies specify the PBIP quality withhold amount that Participants may earn back based on
performance, the quality measures tied to payment, and the quality performance calculation
methodology. CMS will notify the Participant of the performance threshold for each Performance Year
prior to the start of the Performance Year to which the performance threshold will apply. CMS will also
provide the Participant with more detailed information regarding the performance calculation
methodology.
A.
PBIP Quality Withhold Calculation
The PBIP quality withhold applied to the $125 PBPM amount used to calculate the CMF
payment rate will be 5% in Performance Year 2 (2022) and 10% in each of Performance Years 3
to 4 (2023 to 2024). The formulas and specific amount withheld per quarterly CMF payment
are reflected in Table 2.
Table 2: Performance-Based Incentive Payments (PBIP) Quality Withhold Amount
Performance
Year
PY 1 (2021)

PY 2 (2022)

PY 3 (2023)

PY 4 (2024)

Performance-Based Incentive Payments (PBIP)
Quality Withhold
Formula and Specific Amount Withheld
(%)
𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷) 𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾
Zero
= 0 𝑤𝑤𝑤𝑤𝑤𝑤ℎℎ𝑜𝑜𝑜𝑜𝑜𝑜 ∗ $125 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 = $𝟎𝟎
5%

10%

10%

𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷) 𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾
= 𝐶𝐶𝐶𝐶𝐶𝐶 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 ∗ 3 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚ℎ𝑠𝑠 = $𝟎𝟎
𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷) 𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾
= 5% 𝑤𝑤𝑤𝑤𝑤𝑤ℎℎ𝑜𝑜𝑜𝑜𝑜𝑜 ∗ $125 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 = $𝟔𝟔. 𝟐𝟐𝟐𝟐

𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷) 𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝒆𝒆𝒆𝒆𝒆𝒆
= 𝐶𝐶𝐶𝐶𝐶𝐶 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 ∗ 3 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚ℎ𝑠𝑠 = $𝟏𝟏𝟏𝟏. 𝟕𝟕𝟕𝟕
𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷) 𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾
= 10% 𝑤𝑤𝑤𝑤𝑤𝑤ℎℎ𝑜𝑜𝑜𝑜𝑜𝑜 ∗ $125 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 = $𝟏𝟏𝟏𝟏. 𝟓𝟓𝟓𝟓
𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷) 𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾
= 𝐶𝐶𝐶𝐶𝐶𝐶 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 ∗ 3 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚ℎ𝑠𝑠 = $𝟑𝟑𝟑𝟑. 𝟓𝟓𝟓𝟓
𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷) 𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾
= 10% 𝑤𝑤𝑤𝑤𝑤𝑤ℎℎ𝑜𝑜𝑜𝑜𝑜𝑜 ∗ $125 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 = $𝟏𝟏𝟏𝟏. 𝟓𝟓𝟓𝟓

36

Performance
Year

Performance-Based Incentive Payments (PBIP)
Quality Withhold
Formula and Specific Amount Withheld
(%)
𝑪𝑪𝑪𝑪𝑪𝑪 𝒑𝒑𝒑𝒑𝒑𝒑 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷 𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩𝑩 𝒑𝒑𝒑𝒑𝒑𝒑 𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸𝑸 (𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷) 𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾𝑾
= 𝐶𝐶𝐶𝐶𝐶𝐶 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 ∗ 3 𝑚𝑚𝑚𝑚𝑚𝑚𝑚𝑚ℎ𝑠𝑠 = $𝟑𝟑𝟑𝟑. 𝟓𝟓𝟓𝟓

B.
Quality Measures tied to Payment
For purposes of the PBIP, CMS will compare the Participant’s performance on the quality
measures specified in Table 3 to the performance of a national comparison group described
below to determine whether the Participant met or exceeded the PBIP performance threshold.
These measures are claim-based and require no reporting on the part of the Participant. In
addition to the measures modifications described in Table 3, CMS may in CMS’s sole discretion
make minor changes to the measures methodologies, including to adjust the numerator and
denominator, and to apply risk-adjustments, to ensure each measure is appropriate for use in
ViT. CMS will obtain licensing approval to do so, if required. Prior to the start of each
Performance Year CMS may also in CMS’s sole discretion opt to not use one or more of the
quality measures specified in Table 3. CMS will notify Participant of any changes to the quality
measures or measure specifications prior the start of the Performance Year in which such
changes will take effect.
Table 3: Performance-Based Incentive Payments (PBIP) Quality Measures
Measure Title
Use of pharmacotherapy for opioid
use disorder (OUD)

NQF ID
3400
(NQF endorsed)

Initiation and Engagement of
Alcohol and Other Drug Abuse or
Dependence Treatment
Continuity of Pharmacotherapy for
Opioid Use Disorder (OUD)
Emergency Department (ED) Use
Due to Opioid Overdose

0004
(NQF endorsed)
3175
(NQF endorsed)
N/A
(not NQF
endorsed)

Changes to Specifications for ViT?
Yes. Measure modified to be specific to Medicare
beneficiaries, as the NQF endorsed measure applies to
Medicaid beneficiaries ages 18 to 64 with an OUD diagnosis.
No. Will use specifications as defined. ViT will consider this
measure two separate measures, as it calculates two rates.
No. Will use specifications as defined.
CMS will develop specifications to capture the rate of ED
visits for opioid overdose events using ICD-9 or ICD-10
diagnosis codes for Medicare beneficiaries aged 18 and
older.

C.
National Comparison Group
CMS will assess the Participant’s performance on the combined quality measures in Table 3 (or
such other measures specified by CMS) relative to a national comparison group’s averaged
composite score to determine whether the Participant has met or exceeded the performance
threshold.
CMS will identify the national comparison group as a group comparable to but excluding those
individuals and entities participating in ViT. CMS will assess the performance of this national
comparison group on the quality measures in Table 3 (or such other measures specified by
CMS) using Medicare Fee-for-Service claims data. CMS will combine the performance scores
for each of the quality measures across the national comparison group into an averaged
37

composite score.
D.
Quality Performance Calculation Methodology
The Participant’s performance scores for each of the quality measures in Table 3 will be
combined into an averaged composite score. CMS will then compare the Participant’s
averaged composite score (rounded to the second decimal) to the averaged composite score
for the national comparison group described above (rounded to the second decimal) to
establish a percentile score. Finally, CMS will determine whether the Participant’s percentile
score meets or exceeds the performance threshold. The performance threshold is an absolute
threshold that the Participant must meet or exceed to earn back the PBIP quality withhold
amount.
CMS will calculate the Participant’s quality performance on a given quality measure only if a
minimum of 125 Participating Beneficiaries are included in the measure. To ensure the
Participant has the opportunity to earn back the PBIP quality withhold in the form of a PBIP,
CMS will include the Participant in a pool with other ViT Participants to meet the minimum
Participating Beneficiary count. The quality performance calculation methodology used to
calculate PBIP payments is detailed in Table 4.
Table 4: Performance-Based Incentive Payments (PBIP) Quality Performance Calculation Methodology
ViT Participant with <125 unique Participating
Beneficiaries
• ViT Participants that don’t meet the minimum of
125 unique Participating Beneficiaries will be
pooled together. CMS may pool all ViT Participants
together or create separate pools based on similar
characteristics, depending on the number of ViT
Participants that don’t meet this minimum.
• ViT Participants pooled together will have their
Participating Beneficiaries, as identified through ViT
billed claims submitted during the relevant
Performance Year, pooled together for purposes of
calculating the quality measures numerator and
denominator.
• CMS calculates performance for each of the quality
measures tied to payment.
• CMS calculates the averaged composite score.
• The average composite score (rounded to the
second decimal) is compared to the composite
score for the national comparison group (rounded
to the second decimal) to attain a percentile score.
• If the percentile score meets or exceeds the
performance threshold, each of the ViT Participants
pooled together earn back 100% of their PBIP
quality withhold amount. None of the PBIP quality
withhold amount will be paid to the pooled ViT
Participants if performance does not meet or
exceed the performance threshold.

38

ViT Participant with 125+ unique Participating
Beneficiaries
• ViT Participants that meet the minimum of 125
unique Participating Beneficiaries will not be
pooled with other ViT Participants, and they will be
assessed independently.
• Each such ViT Participant will have its Participating
Beneficiaries, as identified through ViT billed claims
submitted during the relevant Performance Year,
included in the quality measures numerator and
denominator.
• CMS calculates performance for each of the quality
measures tied to payment.
• CMS calculates the averaged composite score.
• The average composite score (rounded to the
second decimal) is compared to the composite
score for the national comparison group (rounded
to the second decimal) to attain a percentile score.
• If the percentile score meets or exceeds the
performance threshold, the ViT Participant earns
back 100% of the PBIP quality withhold amount.
None of the PBIP quality withhold amount will be
paid if performance does not meet or exceed the
performance threshold.

APPENDIX C: VALUE IN TREATMENT HIPAA-COVERED DISCLOSURE REQUEST ATTESTATION and DATA
SPECIFICATION WORKSHEET
I.

Performance Year 2021 HIPAA-Covered Disclosure Request Attestation

The Participant requests the CMS data listed in the Data Specification Worksheet below for
Performance Year 2021 and makes the following assertions regarding its ability to meet the HIPAA
requirements for receiving such data:
The Participant is (select if applicable):
o A HIPAA Covered Entity (CE) as defined in 45 CFR § 160.103.
The Participant is seeking protected health information (PHI), as defined in 45 CFR § 160.103 (select
one):
o For its own use.
o On behalf of a CE for which the Participant is a BA.
o Other: Please attach a description of the intended purpose (e.g., for “research” purposes, for
“public health” purposes, etc.).
The Participant requests (select all that apply):
For the Participating Beneficiaries who have agreed, pursuant to a Beneficiary Agreement Form,
for CMS to share data with the Participant under ViT, for Performance Year 2021: (i) 1 years of
historical claims data files for the data elements identified in the Data Specification Worksheet;
and (ii) monthly claims data files for the data elements identified in the Data Specification
Worksheet, from the following CMS data files:

Data Elements

Source

Part A Claims Header

CCW

Part A Claims Revenue Center

CCW

Part B Physicians Header and Lines

CCW

Beneficiary Cross-Reference (XREF)

CCW

o Other: Please attach a detailed description of the data requested.
The Participant intends to use the requested data to carry out (select one):
o “Health care operations” that fall within the first and second paragraphs of the definition of that
phrase under the HIPAA Privacy Rule (45 CFR § 164.501).
o Other: Please attach a description of the intended purpose (e.g., for “research” purposes, for
“public health” purposes, etc.).
The data requested is (select one):
o The "minimum necessary" (as defined at 45 CFR § 164.502) to carry out the health care
operations activities described above.
o Other: Please attach a description of how (if applicable) the data requested exceeds what is
needed to carry out the work described above.
39

In making this request, the Value in Treatment participant names the following individual as the data
custodian. In providing this information, the Value in Treatment participant attests that this individual is
either an employee of the Value in Treatment Participant or an employee of a BA of the Value in
Treatment Participant that requires access to the requested data for the purpose indicated above. The
Participant’s data custodian for the requested data is as follows:
_____________________
(name of individual serving as data custodian)
_____________________
(data custodian organization)
_____________________
(data custodian phone number)
_____________________
(data custodian e-mail)
_____________________
(alternative contact #1 name)
_____________________
(alternative contact #1 organization)
_____________________
(alternative contact #1 phone number)
_____________________
(alternative contact #1 e-mail)

By:

Date:

Name of authorized signatory
Title

40

II.
Data
Element
Source

Data Specification Worksheet
Data Element
Claim From Date
Claim Thru Date

Part A
Claims

Claim Payment
Amount
Facility Provider
NPI Number
Claim Effective
Date
Claim Bill
Frequency Code
Calendar
Century Year
Month Number
Claim Line From
Date
Claim Line Thru
Date
Claim Line
Institutional
Revenue Center
Date

Part A
Claims
Revenue
Center
Details

HCPCS Code
Claim From Date
Claim Thru Date
Claim Line
Service Unit
Quantity
Claim Line
Covered Paid
Amount
Calendar
Century Year
Month Number

Data Element Description
The first day on the billing statement that covers services
rendered to the beneficiary.
The last day on the billing statement that covers services
rendered to the beneficiary.
Amount that Medicare paid on the claim.
Identifies the facility associated with the claim. Each facility is
assigned its own unique NPI.
Date the claim was processed and added to the NCH. Also
referred to as the NCH Weekly Processing Date.
The third digit of the type of bill (TOB3) code. It indicates the
sequence of the claim in the beneficiary's current episode of care
(e.g., interim or voided).
Find Claim Frequency Codes here: http://www.resdac.org/cmsdata/variables/Claim-Frequency-Code.
The year and calendar month number combination in the format
'YYYYMM'. e.g. 200701, 200702, etc.
The date the service associated with the line item began.
The date the service associated with the line item ended.
The date that applies to the service associated with the Revenue
Center code.
The HCPCS code representing the procedure, supply, product,
and/or service provided to the beneficiary.
The first day on the billing statement that covers services
rendered to the beneficiary.
The last day on the billing statement that covers services
rendered to the beneficiary.
The number of dosage units of medication that were dispensed in
this fill.
The amount Medicare reimbursed the provider for covered
services associated with the claim-line.
The year and calendar month number combination in the format
'YYYYMM'. e.g. 200701, 200702, etc.
41

Data
Element
Source

Data Element

Claim From Date
Provider Type
Code
Rendering
Provider FIPS
State Code
Claim Rendering
Federal Provider
Specialty Code
Claim Line From
Date
Claim Line Thru
Date
HCPCS Code
Claim Line
Covered Paid
Amount
Part B
Physicians

Claim Provider
Tax Number
Rendering
Provider NPI
Number
Claim Carrier
Payment Denial
Code
Claim Line
Processing
Indicator Code
Claim Effective
Date
Claim Line
Allowed Charges
Amount
Claim Line
Service Unit
Quantity
Calendar
Century Year
Month Number

Data Element Description
The first day on the billing statement that covers services
rendered to the beneficiary.
Identifies the type of Provider Identifier.
Identifies the state that the provider providing the service is
located in.
Indicates the CMS specialty code associated with the provider of
services. CMS used this number to price the service on the lineitem.
The date the service associated with the line item began.
The date the service associated with the line item ended.
The HCPCS code representing the procedure, supply, product,
and/or service provided to the beneficiary.
The amount Medicare reimbursed the provider for covered
services associated with the claim-line.
The SSN or Employee Identification Number (EIN) of the provider
of the indicated service. This number identifies who receives
payment for the indicated service.
A number that identifies the provider rendering the indicated
service on the claim line. Each provider is assigned its own unique
NPI.
Indicates to whom payment was made (e.g., physician,
beneficiary), or if the claim was denied.
Indicates whether the service indicated on the claim line was
allowed or the reason it was denied.
Date the claim was processed and added to the NCH.
The amount Medicare approved for payment to the provider.
The number of dosage units of medication that were dispensed in
this fill.
The year and calendar month number combination in the format
'YYYYMM'. e.g. 200701, 200702, etc.

42

Data
Element
Source

Beneficiary
XREF

Data Element

Data Element Description

Meta Process
Date

The date the CCLF process loaded the historical record in the table

Calendar
Century Year
Month Number

The year and calendar month number combination in the format
'YYYYMM'. e.g. 200701, 200702, etc.

Meta Process
Date

The date the CCLF process loaded the historical record in the table

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