CMS-10728 OUD Care Team Roster Guidance & Template

Value in Opioid Use Disorder Treatment Demonstration (CMS-10728)

ViTOUDCareTeam_Attachment 1.xlsx

OMB: 0938-1388

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Overview

Overview
1. Data Dictionary
2. OUD Care Team


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.


Sheet 2: 1. Data Dictionary

Table 1. Participant ViT OUD Care Team Roster




blank blank
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

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





















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































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