CMS-10803 Appendix A

Issuer ID:*
SADP Only?*
Source System:*
State:*

^Validation Status

Incomplete

Current Tabs	Number of Rows per Tab	Number of Validation Errors
Network Adequacy Provider	0	0

National Provider Identifier (NPI)*

Provider Name (First Name, Last Name or Facility Name)*

Specialty Type (area of medicine) of Individual Provider or Facility*

Does this provider offer telehealth?*

Street Address*

Street Address 2

City*

State*

County*

Zip*

Network IDs*

	Instructions for populating the Specialty/Facility Types without using the drop-down menu
	Important Notes The lists below show the individual and facility provider specialty types that can be entered in the NA template. Column C shows the Individual Provider Specialty Types. Column D shows the Facility Providers Specialty Types. Both Individual Providers Specialty Types and Facility Providers Specialty Types should be entered on the Network Adequacy Provider tab. If you would like to enter more than 1 specialty type for a record, please comma separate each type. For example, if you would like to assign 001 General Practice and 002 Family Medicine specialty types to a provider, please enter the types as "001 General Practice, 002 Family Medicine". Entering multiple specialty types using any other convention will result in a validation error. The same comma separation technique can be used to assign multiple Network IDs to the same provider. For example, an issuer in Virginia with 3 Network IDs could assign network 1 and network 3 to the same provider by entering "VAN001, VAN003".
	All providers and facilities must be appropriately licensed, accredited, or certified to provide services in their state, as applicable, and must have in-person services available.
	Individual Provider Specialty Types	Facility Specialty Types
	001 General Practice	040 Acute Inpatient Hospitals (Must have Emergency services available 24/7)
	002 Family Medicine	041 Cardiac Surgery Program
	003 Internal Medicine	042 Cardiac Catheterization Services
	004 Geriatrics	043 Critical Care Services - Intensive Care Units (ICU)
	005 Primary Care - Physician Assistant	045 Surgical Services (Ambulatory Surgical Centers and Outpatient Hospital)
	006 Primary Care - Advanced Registered Nurse Practitioner	046 Skilled Nursing Facilities
	007 Allergy and Immunology	047 Diagnostic Radiology (Free-standing; hospital outpatient; ambulatory health facilities with Dx Radiology)
	008 Cardiology	048 Mammography
	010 Chiropractor	052 Inpatient Psychiatry (Free-standing inpatient behavioral health facility and behavioral health beds within an Acute Care Hospital)
	011 Dermatology	057 Outpatient Infusion/Chemotherapy
	012 Endocrinology	072 Substance Use Disorder Rehabilitation Facility (Hospital unit and residential treatment facility)
	013 ENT/Otolaryngology	076 Mental Health Residential Treatment Facility (Mental Illness; Psychiatric)
	014 Gastroenterology	080 Urgent Care
	015 General Surgery	P072 Children's Substance Use Disorder Rehabilitation Facility
	016 Gynecology (OB/GYN)	P076 Children's Residential Treatment Facility (Mental Illness; Psychiatric)
	017 Infectious Diseases
	018 Nephrology
	019 Neurology
	020 Neurosurgery
	021 Oncology - Medical & Surgical
	022 Oncology - Radiation
	023 Ophthalmology
	025 Orthopedic Surgery
	026 Physical Medicine & Rehabilitation
	027 Plastic Surgery
	028 Podiatry
	029 Psychiatry
	030 Pulmonology
	031 Rheumatology
	033 Urology
	034 Vascular Surgery
	035 Cardiothoracic Surgery
	037 Emergency Medicine

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1415. This information collection requires QHP issuers, including SADP issuers, to ensure access to a sufficient number and geographic distribution of essential community providers (ECPs), where available, that serve predominantly low-income, medically underserved individuals. The time required to complete this information collection is estimated to average less than 1,458 hours per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is mandatory under 2702(c) of the Public Health Service Act and will be kept private in accordance with regulations at 45 CFR 155.260, Privacy and Security of Personally Identifiable Information. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850 and [email protected], Attention: Information Collections Clearance Officer.

	Taxonomy Codes
	Important Notes The 'Taxonomy Codes' tab serves the following purposes: (1) serves as a reference file that identifies the provider taxonomy codes that issuers can include in their network adequacy data submissions; (2) filters the taxonomy codes into each individual provider and facility specialty type, so that issuers know which providers to include in which individual provider and facility specialty categories; and (3) crosswalks provider types into their respective categories for time and distance standards. For brevity purposes, when discussing provider types for network adequacy, we will use the term “behavioral health” to encompass mental health and substance use disorders. Under the circumstances described below, advanced practice registered nurses (APRNs) and physician assistants (PAs) could be included as primary care providers. Under the circumstances below, APRNs who specialize in behavioral health services could be included in the outpatient clinical behavioral health provider category. The purpose of including APRNs and PAs is to inform CMS of the rare instances in which an issuer contracts with non-MD/DO primary care and behavioral health services providers in underserved counties to serve as the major source of these types of care for enrollees. In these instances, organizations may include submissions under the non-MD/DO primary care and outpatient clinical behavioral health specialty codes if the contracted APRN or PA satisfies the following conditions: currently licensed in the state; meets the state’s requirements governing the qualifications of that provider type; fully credentialed by the organization as a provider of primary care or behavioral health services; functions in accordance with state law as the primary source for the enrollee’s primary care or behavioral health services (i.e., not to supplement a physician’s care); and practices in or renders services to enrollees residing in a Health Professional Shortage Area. For Acute Inpatient Hospitals (facility specialty type code 040), issuers must report these hospitals within their network adequacy submissions as "Acute Inpatient Hospitals" (rather than a taxonomy code), which are defined as hospitals that provide all-day, year-round emergency services. Due to known data integrity issues (e.g., a high number of hospital outpatient facilities being incorrectly reported as acute inpatient hospitals, etc.), issuers may not use the National Uniform Claim Committee (NUCC) hospital taxonomy code to report such hospitals for network adequacy submissions. For Cardiac Surgery Programs (facility specialty type code 041), Cardiac Catheterization Services (facility specialty type code 042), and Critical Care Services - Intensive Care Units (ICU) (facility specialty type code 043), issuers must report within their network adequacy submissions the respective provider types that filter into these facility specialty types. Since these are services rather than facility types, there are no specific taxonomy codes that align completely with these specialty codes.
	Individual/Facility	NUCC Taxonomy Code	Specialty Group Description	Specialty Code	Specialty Type Descriptions	Time and Distance Category	NUCC Display Name (For reference only of more comprehensive description)
	Individual	207K00000X	Allergy and Immunology	007	Allergy and Immunology	Allergy and Immunology	Allergy & Immunology Physician
	Individual	207KA0200X	Allergy and Immunology	007	Allergy and Immunology	Allergy and Immunology	Allergy Physician
	Individual	207KI0005X	Allergy and Immunology	007	Allergy and Immunology	Allergy and Immunology	Clinical & Laboratory Immunology (Allergy & Immunology) Physician
	Individual	207RA0201X	Allergy and Immunology	007	Allergy and Immunology	Allergy and Immunology	Allergy & Immunology (Internal Medicine) Physician
	Individual	207RI0001X	Allergy and Immunology	007	Allergy and Immunology	Allergy and Immunology	Clinical & Laboratory Immunology (Internal Medicine) Physician
	Individual	2080P0201X	Allergy and Immunology	007	Allergy and Immunology	Allergy and Immunology	Pediatric Allergy/Immunology Physician
	Individual	207RA0001X	Cardiology	008	Cardiology	Cardiology	Advanced Heart Failure and Transplant Cardiology Physician
	Individual	207RA0002X	Cardiology	008	Cardiology	Cardiology	Adult Congenital Heart Disease Physician
	Individual	207RC0000X	Cardiology	008	Cardiology	Cardiology	Cardiovascular Disease Physician
	Individual	207RI0011X	Cardiology	008	Cardiology	Cardiology	Interventional Cardiology Physician
	Individual	2080P0202X	Cardiology	008	Cardiology	Cardiology	Pediatric Cardiology Physician
	Individual	208G00000X	Cardiothoracic Surgery	035	Cardiothoracic Surgery	Cardiothoracic Surgery	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
	Individual	111N00000X	Chiropractor	010	Chiropractor	Chiropractor	Chiropractor
	Individual	111NI0900X	Chiropractor	010	Chiropractor	Chiropractor	Internist Chiropractor
	Individual	111NN0400X	Chiropractor	010	Chiropractor	Chiropractor	Neurology Chiropractor
	Individual	111NN1001X	Chiropractor	010	Chiropractor	Chiropractor	Nutrition Chiropractor
	Individual	111NP0017X	Chiropractor	010	Chiropractor	Chiropractor	Pediatric Chiropractor
	Individual	111NR0200X	Chiropractor	010	Chiropractor	Chiropractor	Radiology Chiropractor
	Individual	111NR0400X	Chiropractor	010	Chiropractor	Chiropractor	Rehabilitation Chiropractor
	Individual	111NS0005X	Chiropractor	010	Chiropractor	Chiropractor	Sports Physician Chiropractor
	Individual	111NT0100X	Chiropractor	010	Chiropractor	Chiropractor	Thermography Chiropractor
	Individual	111NX0100X	Chiropractor	010	Chiropractor	Chiropractor	Occupational Health Chiropractor
	Individual	111NX0800X	Chiropractor	010	Chiropractor	Chiropractor	Orthopedic Chiropractor
	Individual	1223E0200X	Dental	204	Dental - Endodontist	Dental	Endodontist
	Individual	122300000X	Dental	201	Dental - General	Dental	Dentist
	Individual	1223G0001X	Dental	201	Dental - General	Dental	General Practice Dentistry

	County Names used in the Network Adequacy Template
	The list below shows the county names that are used and accepted in the Network Adequacy template. If you aren't using the drop-down menus, please ensure that your county names match the names below. A different version of a county name will result in a validation error. The county names below are the same as those in the Service Area template. Only include the county name in the county field, do not include the FIPS code.
	State	County Name	FIPS Code
	AK	Aleutians East	02013
	AK	Aleutians West	02016
	AK	Anchorage	02020
	AK	Bethel	02050
	AK	Bristol Bay	02060
	AK	Chugach	02063
	AK	Copper River	02066
	AK	Denali	02068
	AK	Dillingham	02070
	AK	Fairbanks North Star	02090
	AK	Haines	02100
	AK	Hoonah Angoon	02105
	AK	Juneau	02110
	AK	Kenai Peninsula	02122
	AK	Ketchikan Gateway	02130
	AK	Kodiak Island	02150
	AK	Kusilvak	02158
	AK	Lake And Peninsula	02164
	AK	Matanuska Susitna	02170
	AK	Nome	02180
	AK	North Slope	02185
	AK	Northwest Arctic	02188
	AK	Petersburg	02195
	AK	Prince Of Wales Hyder	02198
	AK	Sitka	02220
	AK	Skagway	02230
	AK	Southeast Fairbanks	02240
	AK	Wrangell	02275
	AK	Yakutat	02282
	AK	Yukon Koyukuk	02290
	AL	Autauga	01001

Below are the validation errors that were identified in the submitted data. Please correct these errors. You must have a valid template before you can export data to XML files. Select the Cell address that is underlined and highlighted in blue to navigate to the specified error. Important Note: If one or more rows are deleted in a provider tab or data is reorganized, cell hyperlinks in that tab may no longer be accurate. Please re-run the data validation on the 'User Control' tab to refresh the hyperlinks if this occurs.
Tab	Cell	Validation Error Message