CMS-10728 OUD Care Team Roster Guidance & Template

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Overview

Overview
1. Data Dictionary
2. OUD Care Team

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Sheet 1: Overview

blank	Center for Medicare & Medicaid Services Innovation logo
	Value in Treament (ViT) Demonstration
	OUD Care Team Roster Guidance & Template
	Version 1.0
	Last updated: October 9, 2020
	Overview
	What is the ViT Opioid Use Disorder (OUD) Care Team Roster: a list of participant's OUD Care Team members composed of health care practitioners established by the Participant in accordance with demonstration requirements and other practitioners licensed under state law to furnish psychiatric, psychological, counseling, and social services. The OUD Care Team is to furnish OUD Treatment Services to Participating Beneficiaries as part of the demonstration.
	Completing and updating the OUD Care Team List: As part of the RFA, the applicant is required to submit an initial list of OUD Care Team members in accordance to this guidance. Selected applicants, "The Participant", shall maintain and update this list in accordance to this guidance, and submit to CMS the updated list every time updates are made and as requested by CMS to the demonstration inbox ([email protected]).
	1) RFA submission: As part of the RFA application, applicants must submit the OUD Care Team roster as an attachment along with the application package. Please submit this attachment using the following naming convention (case-sensitive): <'DemoID'>_ViTOUDCareTeam_Attachment1.xlsx
	DemoID'> = ShortName-ID (Example: CMMI-1234), where ShortName is a 7 character name with no space (abbreviation, initials, acronyms, other short name identified by applicant/participant), and ID is the last four digits of the 9-digit Tax ID Number (TIN)
	2) Subsequent updates: Updates to the initial list submitted as part of the RFA or other previous versions may be submitted using the following naming convention (case-sensitive): <'DemoID'>_ViTOUDCareTeam_Attachment1_v#.xlsx
	DemoID'> = ShortName-ID (Example: CMMI-1234), where ShortName is a 7 character name with no space (abbreviation, initials, acronyms, other short name identified by applicant/participant), and ID is the last four digits of the 9-digit Tax ID Number (TIN)
	Table of Contents
	1. Data Dictionary: lists each of the data fields included in the ViT Participant OUD Care Team Roster, along with definitions and data requirements.
	2. OUD Care Team: A blank OUD Care Team roster template that must be completed/updated. Instructions are found at the top of the template.

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Sheet 2: 1. Data Dictionary

Table 1. Participant ViT OUD Care Team Roster
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Field Name	Descriptive Field Name	Field Description	Required Value	Data Type (Length)	Valid Values
DemoID	Demonstration Identification	A demonstration ID developed by demonstration applicants/ participants. The DemoID developed as the applicant will be the same expected to be used as a Participant, once selected.	Yes	TEXT (12)	Format: <'DemoID'> = ShortName-ID, where ShortName is a 7 character name with no space (abbreviation, initials, acronyms, other short name identified by aplicant/participant), and ID is the last four digits of the 9-digit Tax ID Number (TIN) Example: CMMI-1234
Participant_Type	Participant Type	The type of entity/provider allowed to participate in the demonstration.	Yes	STRING (1)	N = 1 - 9, where: 1 = Physician 2 = Group Practice 3 = Hospital Outpatient Department 4 = Federally Qualified Health Center 5 = Rural Health Clinic 6 = Community Mental Health Center 7 = Certified Community Behavioral Health Clinic 8 = Opioid Treatment Program 9 = Critical Access Hospital
Member_Type	Member Type	The OUD care team member type.	Yes	STRING (1)	N = 1 - 12, where: 1 = Applicant/Participant 2 = Medicare-enrolled Primay Care Provider (PCP) 3 = Medicare-enrolled Addiction Provider 4 = Medicare-enrolled Provider Authorized to Prescribe/Dispense Narcotics 5 = Counselor 6 = Clinical Alcohol and Drug Counselor 7 = Marriage/Family Therapist 8 = Peer Specialist 9 = Community Health Worker 10 = Qualified Clergy 11 = Care Manager 12 = Other
Relationship	Relationship to Applicant/Participant	The OUD care team member's relationship to the applicant/participant.	Yes	STRING (1)	N = 1 - 4, where: 1 = Employed 2 = Contracted 3 = Self (Owner) 4 = Other
Business_Name	Legal Business Name	The applicant/participant's full legal business name, as reported to the IRS.	Yes	TEXT (100)	Format: NameNameNameName (Full Name; no spaces; no longer than 100 characters with no spaces)
Last Name	Last Name	OUD care team member's last name	Yes	TEXT
First Name	First Name	OUD care team member's first name	Yes	TEXT
Middle Name	Middle Name	OUD care team member's middle name	Yes	TEXT
Title/Position	Title/Position	OUD care team member's title	Yes	TEXT
Credentials	Credentials	OUD care team member's credentials	Yes	TEXT
Street Address	Street Address	Full street address	Yes	TEXT
City	City	City	Yes	TEXT
State	State	Abbreviated state name	Yes	TEXT (2)	Format: 2 letter state postal code abbreviation, no spaces (XX)
Nine Digit Zip Code	Nine Digit Zip Code	The first part is the first five digits of the zip code which indicates the destination post office or delivery area. The last 4 digits of the nine-digit ZIP Code represents a specific delivery route within that overall delivery area.	Yes	NUM (9)	Format: 9-digit number (XXXXX-XXXX)
Phone Number	Phone Number		Yes	NUM (10)	Format: 10-digit number (XXX-XXX-XXXX)
TIN	Tax Identification Number (TIN)	A Tax Identification Number (TIN) is a nine-digit number used as a tracking number by the U.S. Internal Revenue Service (IRS).	Yes
NPI	National Provider Identifier (NPI)	The NPI is a unique identification number for covered health care providers.	Yes, if applicable	NUM (10)	Format: 10-position, intelligence-free numeric identifier (10-digit number)
CCN	CMS Certification Number (CCN)	The CCN is used to identify each separately certified Medicare provider or supplier. The NPI and PTAN is tied to the CCN.	Yes, if applicable	CHAR (6)	Format: Any valid six digit number. The first two digits identify the State in which the provider is located. The last four digits identify the type of facility.
PTAN	Provider Transaction Access Number (PTAN)	A Medicare-only number issued to providers by MACs upon enrollment to Medicare. When a MAC approves enrollment and issues an approval letter, the letter will contain the PTAN assigned to the provider or supplier (linked to their NPI).	Yes, if applicable	CHAR (9)	Format: XXX-XX-XXXX
DEA	DEA Registration Number	A DEA number (DEA Registration Number) is an identifier assigned to a health care provider (such as a physician, physician assistant, nurse practitioner, optometrist, dentist, or veterinarian) by the United States Drug Enforcement Administration allowing them to write prescriptions for controlled substances.	Yes, if applicable	CHAR (9)	Format: XXXXXXXXX Every DEA number is made up of two letters, six numbers, and one check digit. The first letter is a code to identify the type of prescriber (i.e., a hospital, a practitioner, a manufacturer, etc.). The second letter is the first letter of the prescriber's last name.
DEA_PatientNumber	Maximum number of patients DEA health care provider is allowed to treat.	Maximum number of patients DEA health care provider is allowed to treat.	Yes, if applicable	NUM (3)	Format: maximum of three digit number.
START_DATE	Effective Start Date	Effective start date the OUD Care Team member is expected to start furnishing ViT demonstration services.	Yes	DATE (10)	Format: YYYY-MM-DD
END_DATE	Effective End Date	Effective end date the OUD Care Team member is expected to stop furnishing ViT demonstration services.	Yes, if applicable	DATE (10)	Format: YYYY-MM-DD

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Sheet 3: 2. OUD Care Team

Value in Opioid Use Disorder Treatment Demonstration Program (Value in Treatment)

OUD Care Team Roster

Instructions

1) One of the rows must correspond to the applicant/participant ("1 = Applicant/Participant" must be indicated under Member_Type column). The legal business name associated with the billing TIN and the provider contact name associated with the billing NPI must be provided for the applicant/participant. This TIN-NPI combo will be used for billing purposes. No other TIN-NPI combo may bill for the demonstration g-code.

2) The OUD Care Team roster must include a Medicare-enrolled primary care provider (PCP) or addiction treatment provider.

2(a) If one provider is both (a PCP and an addiction treatment provider), this individual must be listed in two separate rows, with PCP selected under Member_Type for one row and Medicare-enrolled Addiction Provider selected in the other.

3) The OUD Care Team roster must include a Medicare-enrolled provider authorized to prescribe/dispense narcotic drugs.

3(a) This individual must be listed in its own row, even if it is the same provider who is also a PCP and/or addiction treatment provider.

4) All columns for each listed OUD care team member must be completed, including columns indicated as "Required, if applicable". If not applicable, "N/A" must be inserted. For example, if the Member_Type is any of the 5 to 12 drop down selections, that member may not have an NPI, PTAN, CCN, or DEA, in which case "N/A" is appropriate.

5) If listed OUD care team member is associated with more than one TIN, please list and separate with a comma (,).

6) Copy and paste the same DemoID and Participant_Type to all listed OUD Care Team members, as there is only one DemoID and one Participant Type applicable to the entity applying to the demonstration.

7) For any OUD Care Team members that stop furnishing ViT demonstration services (as indicated by the End Date column), but later come back to join the team, a new row must be added for them. Please do not delete any inactive (those with an End Date indicated) OUD care team members from this roster.

8) Please reference the Data Dictionary to ensure all requested information follows the noted format.

Same ID for all listed members (specific to entity applying)

Drop Down Selection (specific to the entity applying; apply same type for all listed members)

Drop Down Selection (specific to each individual)

Drop Down Selection

Required, if applicable

Required, if applicable

Required, if applicable

Required, if applicable

Required, if applicable

Required, if applicable

DemoID

Participant_Type

Member_Type

Relationship

Business_Name

Last Name

First Name

Middle Name

Title/Position

Credentials

Street Address

City

State

Nine Digit Zip Code

Phone Number

TIN

NPI

PTAN

CCN

DEA

DEA_PatientNumber

START_DATE

END_DATE