Provider HSD Table Crosswalk

Number

Form

1

Provider HSD Table

2

Provider HSD Table

3

Provider HSD Table

4

Provider HSD Table

5

Provider HSD Table

Change

Removed column
"Specialty"
Removed column "Uses
CMS MA Contract
Amendment? (Y/N)"
Removed column "Name
of Medical Group
Affiliation or "DC""
Removed column
"Contract Type"
Revised Language in
column O "Letter of
Intent Signed by Both
Parties? (Y)" to include
language "Letter of
Intent? (Y/N) Only
applicable for MA
Applicants"

Current Location

Reason

Column D

The "Specialty" column required MAOs to
enter duplicative information already
captured in the "Specialty Code column". The
facility type name is not required for
processing in the NMM

Column M

Collected information no longer used as part
of network adequacy reviews

Column F

Collected information no longer used as part
of network adequacy reviews
Collected information no longer used as part
of network adequacy reviews

Column O

Column O is included in HSD table templates
for Applicants and non-applicants. Clarifying
languge was added to inform non-applicants
that Column O should not be completed with
network reviews.

Column L