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Virginia Department of Medical Assistance Services Commonwealth Coordinated Care Plus (CCC Plus) NETWORK SUBMISSION REQUIREMENTS NETWORK SUBMISSION REQUIREMENTS MANUAL (NSRM) DMAS 11/7/2017

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Page 1: Commonwealth Coordinated Care Plus (CCC Plus) …dmasva.dmas.virginia.gov/Content_atchs/mltss/CCC Plu…  · Web viewVirginia Department of Medical Assistance Services. Commonwealth

Virginia Department of Medical Assistance Services

Commonwealth Coordinated Care Plus (CCC Plus) NETWORK SUBMISSION REQUIREMENTS

NETWORK SUBMISSION REQUIREMENTS MANUAL (NSRM)

DMAS11/7/2017

Page 2: Commonwealth Coordinated Care Plus (CCC Plus) …dmasva.dmas.virginia.gov/Content_atchs/mltss/CCC Plu…  · Web viewVirginia Department of Medical Assistance Services. Commonwealth

Table of ContentsCommonwealth Coordinated Care Plus (CCC Plus).....................................................................................3

Overview.................................................................................................................................................3

Network Submission Requirements Manual (NSRM)..................................................................................3

Network Submission General Information..............................................................................................3

NSRM Data File Layout Specifications.....................................................................................................4

Health Plan Name................................................................................................................................9

Health Plan API..................................................................................................................................10

Provider NPI......................................................................................................................................11

Provider Last Name...........................................................................................................................13

Provider First Name...........................................................................................................................14

Group Affiliation................................................................................................................................15

Hospital Affiliation.............................................................................................................................16

Provider Taxonomy Code..................................................................................................................17

Primary Taxonomy Code Indicator....................................................................................................18

Provider Designation.........................................................................................................................19

Provider Designation Sub-Classification............................................................................................22

Address Line 1...................................................................................................................................23

Address Line 2...................................................................................................................................24

City....................................................................................................................................................25

FIPS Code...........................................................................................................................................26

State..................................................................................................................................................27

Zipcode..............................................................................................................................................28

24 HR Access.....................................................................................................................................29

Other Language Spoken1..................................................................................................................30

Other Language Spoken2..................................................................................................................31

CSB Satellite Office............................................................................................................................32

ADA Compliant..................................................................................................................................33

Accepting New Patients.....................................................................................................................34

Servicing FIPS Codes..........................................................................................................................35

Exhibit 1 – Taxonomy Codes (Use latest list released by Washington Publishing Company (WPC))..36

Exhibit 2 – Examples for Primary Designation of Specialist...............................................................58

Exhibit 3 – Long Term Services & Supports (LTSS) Waiver Procedure Codes.....................................59

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Exhibit 4 – Addiction, Recovery and Treatment Services (ARTS).......................................................60

Exhibit 5 – Community Mental Health Rehabilitation Services (CMHRS) Procedure Codes..............61

Exhibit 6a – Virginia City and County FIPS Codes...............................................................................62

Exhibit 6b – State FIPS Codes.............................................................................................................64

Exhibit 7 – Other Language Spoken...................................................................................................65

Exhibit 8 –Network Adequacy Standards...........................................................................................67

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Commonwealth Coordinated Care Plus (CCC Plus)Overview

The Commonwealth Coordinated Care Plus (CCC Plus) program is a mandatory managed care program that operates statewide and provides services to members with complex care needs. CCC Plus populations include members who are aged, blind, or disabled, including members who are dually eligible for Medicare and Medicaid and members who receive long term services and supports (LTSS) through a home and community based care waiver or nursing facility.

For the purpose of assuring network adequacy at CCC Plus program go live and during the CCC Plus program implementation, the CCC Plus managed care organization (MCO) Contractors must submit their provider network to the Department electronically in a MS-Excel spreadsheet as part of the readiness review and ongoing CCC Program reporting requirements. The Contractor shall submit those providers with whom it has a signed contract. A complete list shall include all providers that are contracted directly with the Contractor and providers that are contracted through a subcontractor of the Contractor for the purpose of rendering services to CCC Plus members. Hereafter referred to as “Contractors network”.

Network Submission Requirements Manual (NSRM)The CCC Plus Network Submission Requirements Manual (NSRM) identifies DMAS’ data submission requirements for network submission by contracted MCOs.

Network Submission General Information

1. Submission Format

The Contractor’s network submission must be submitted electronically in a MS Excel format.

2. Submission Frequency

Network Files will be submitted monthly starting from March 2017. Files are due by the 20th of each month unless otherwise directed by DMAS. Full CCC Plus line of business network submission is required for all monthly submissions. Final readiness network that will be used to determine network adequacy for each regions is the file submitted three months ahead of the go live date for a specific region. For example, May network file will be used to determine Tidewater region final network readiness and June network file will be used to determine Central regional final network readiness, etc.

For the May 2017 submission, submit the entire CCC Plus Network. The entire network will be reviewed for Statewide adequacy; however, network determination will be phased in.

3. Comprehensive Services Assessment

DMAS uses data from the Contractor’s network submission to assess whether the Contractor has signed contracts with an appropriate range of primary care practitioners, clinical specialists, nursing facilities, and service facilities (hospitals, labs, behavioral health care providers, adult day care centers, waiver services providers, home health care providers, physicians, etc.) within the Contractor’s service area. Only providers within the State of Virginia and its neighboring States (West Virginia, Tennessee, Kentucky, North Carolina, Maryland, and the District of Columbia (Washington, D.C.)) should be included on the network file. Exceptions: Providers in Designations 06 (LTSS), 17 (DME), 20 (Labs) and 21

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(Pharmacy) may be included even if outside of Virginia and the neighboring States. Evaluations are completed on Contractors serving CCC Plus members.

4. Network Analysis

The Contractor’s network submission is analyzed and evaluated by DMAS to determine network adequacy.

NSRM Data File Layout SpecificationsThe Contractor shall strictly follow all layout specifications from naming conventions for the file name and column header names, to actual data and value set within each data element. In addition, the Contractor shall ensure:

The file name should be composed of the Contractor’s abbreviated name + month and year of the submission + NS+xlsx. For example, February 2017 submission from United should be named as: United022017NS.xlsx. NOTE: “.xlsx” extension is included in the example to ensure that only Excel files are submitted. PDF, Word, Text or any other file type will not be accepted.

Format the Excel spreadsheet using the EXACT Data Element Names as column headings. Follow the Data Specifications provided as mentioned in the detailed section of each Field Name. Do not abbreviate and do not add any other characters. NOTE: Files will fail if the column headings are not labeled correctly.

The entire network shall be in one file, formatted as shown below. Do NOT submit separate files or separate worksheets within one file. If a provider has more than one physical office location, each location should be submitted;

however, list each provider location separately. If a provider has more than one provider designation, each designation should be submitted;

however, list each designation separately. (See example on page 13). If a provider has more than one taxonomy in one location, each taxonomy should be submitted;

however, list each provider taxonomy separately. Please ensure the primary taxonomy is labeled properly. If a provider only has one taxonomy,

this record should be labeled as the primary taxonomy. List each separate location on a separate row in the spreadsheet. Fields labeled as a “Required Field” must be included for every record in the file.

5. Critical and Key Provider Designations

Critical Provider Designations – used by DMAS management to make Go/No Go decisions and includes: 01 – Primary Care Provider (PCP) 02 - Pediatrician 25 - OB/GYN 07 - Outpatient Mental Health 21 - Pharmacy 11 – General Hospital

Key Provider Designations – Health Plan will need to submit exception requests, if network adequacy standards are not going to be met:

01 – Primary Care Provider (PCP) 02 - Pediatrician 25 - OB/GYN 07 - Outpatient Mental Health

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21 - Pharmacy 11 – General Hospital 14 - Nursing Facility (Skilled and Intermediate) 03 - Specialist 06 – Long Term Services & Supports (LTSS), Adult Day Health Center (S5102)

NOTE: As the program matures, the above Critical and Key Provider Designations are subject to change.

Submissions not meeting these requirements will be rejected and returned. To be evaluated, a corrected file must be returned within ten (10) calendar days; otherwise, the network requirements will be rated unsatisfactory.

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Format the Excel spreadsheet using the following Data Element Names as column headings and formats mentioned in the detailed section of each Field name.

Data Element Name

Field Name, Long Description

Required Field

Data Specification – Variations and Examples

HEALTHPLAN HEALTH PLAN NAME Yes Health plan name acronymHEALTHPLANAPI HEALTH PLAN API No Health Plan API assigned by DMASPROVIDERNPI PROVIDER NPI Yes All providers listed must include an NPIPROVIDERLN PROVIDER LAST NAME Yes Provider Last NamePROVIDERFN PROVIDER FIRST NAME No Provider First NameGROUPAFFIL GROUP AFFILIATION No Medical or Provider Group AffiliationHOSPITALAFFIL HOSPITAL AFFILIATION No If provider is affiliated with a hospital. Valid value

is ‘1’ for Yes or ‘0’ for No.TAXONOMYCODE PROVIDER TAXONOMY

CODEYes Unique ten-character alphanumeric code that

enables providers to identify their specialty at the claim level. See Exhibit 1.

PRIMARYTAX PRIMARY TAXONOMY CODE INDICATOR

Yes If provider taxonomy is primary or not. Valid value is ‘1’ for Yes or ‘0’ for No.

PROVDESG PROVIDER DESIGNATION

Yes Must contain a valid value01 = PCP (Primary Care Provider) – All Ages02 = Pediatrician03 = Specialist (See Exhibit 2)04 = Health Department05 = Hospice06 = Long Term Services & Supports Waiver Provider (See Exhibit 3)07 = Outpatient Mental Health – Traditional Services08 = Addiction, Recovery and Treatment Services

(ARTS) (See Exhibit 4)09 = Community Mental Health Rehabilitation Services (CMHRS) Private Provider – Community Based (See Exhibit 5) Health Plans should begin submitting CMHRS providers with their September 2017 submission.10 = Hospital – Psychiatric11 = Hospital – General12 = Hospital – Physical Rehabilitation13 = Urgent Care14 = Nursing Facility16 = Outpatient Rehabilitation (PT/OT/ST)17 = Durable Medical Equipment (DME) and Supplies18 = Radiology 19 = Home Health20 = Laboratory21 = Pharmacy22 = Vision23 = Transportation24 = Other25 = OB/GYN26 = FQHC 27 = CSB28 = RHC

SUBCLASS PROVIDER DESIGNATION SUB-CLASSIFICATION

Yes *If the provider is a Long Term Services & Supports (LTSS) provider, refer to valid value list in Exhibit 3. If the provider is an ARTS provider, please refer to valid value list in Exhibit 4. If the

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Data Element Name

Field Name, Long Description

Required Field

Data Specification – Variations and Examples

NOTE: Only fill this field with the list of values listed in the Exhibits if the provider is for LTSS, ARTS, or CMHRS. All other providers fill the field as NA.

provider is a Community Mental Health Rehabilitation (CMHRS) provider, please refer to valid value list in Exhibit 5. For all other provider designations, please leave this filed blank.

List of values for provider designations 06, 08, and 09 shall be required with all network submissions during readiness and ongoing network adequacy monitoring.Example: If the provider listed will be contracted to provide LT Services & Supports Code “S5102”, then the valid value for this field is “S5102”. If the provider listed will be contracted to provide SUD ‘H0006’, then the valid value for this field is ‘H0006’. If the provider listed will be contracted to provide Community Mental Health Rehabilitation ‘H0046’, then the valid value for this field is ‘H0046’. If there is more than one procedure code for same provider, repeat the information in all columns.

ADDRESSLINE1 ADDRESS LINE 1 Yes Physical location Address required. P.O. Box cannot be used as a service location. If there are multiple service locations for this provider, please list each new service location address on a separate row. Therefore, if a specific provider has 5 different service location addresses, then there needs to be 5 separate rows. One for each address on a separate row.

ADDRESSLINE2 ADDRESS LINE 2 No Provider Suite or Room NumberCITY CITY Yes Physical location City.

Same practice as the ‘Address Line1’ field; if there are 5 different service locations, please repeat the information for each on a separate row for the City.

FIPSCD FIPS CODE Yes Physical location FIPS Code.Submit five-digit FIPS Code appropriate for each unique service location(s). See Exhibit 6a for the valid values for County FIPS codes and Exhibit 6b for the valid values for State FIPS codes.

STATE STATE Yes Physical location State Code.2 character State abbreviation for each unique service location(s).

ZIP ZIPCODE Yes 5-digit zip code for each unique service location(s).

24HRACCESS 24 HR ACCESS No Valid Value '1' for Yes or '0' for NoOTH_LANG1 OTHER LANGUAGE

SPOKEN1No See Exhibit 7 for valid value list of other language

spoken.OTH_LANG2 OTHER LANGUAGE

SPOKEN2No See Exhibit 7 for valid value list.

CSBSAT CSB Satellite Office No Valid Value ‘1’ for Yes or ‘0’ for No

ADA ADA COMPLIANT Yes Valid Value ‘1’ for Yes or ‘0’ for No

NEWPTS ACCEPTING NEW PATIENTS

Yes Valid Value ‘1’ for Yes or ‘0’ for No

SVCFIPS Servicing FIPS Code No Required for specific provider designation

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Data Element Name

Field Name, Long Description

Required Field

Data Specification – Variations and Examplessubclasses – refer to Data Element Detail Rules for more information

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Health Plan Name Data Element Name: HEALTHPLAN Required for: IdentificationFormat: Character Length: 50

Definition:

Please use the official health plan name acronym for this field.

Edit Applications:

1. This is a required data element. An entry for health plan name must be on the record in order for the record to be accepted.

2. Records from the same health plans should contain the same health plan name acronym under this field.

Example:

1. Anthem

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Health Plan APIData Element Name: HEALTHPLANAPI Required for: IdentificationFormat: Numeric Length: 10

Definition:

Please use the API number assigned by DMAS for your CCC Plus line of business once it is available. Health plan should leave this field blank until the API is assigned by DMAS.

Edit Applications:

1. This is an optional data element

2. Records from the same health plans should contain the same health plan API number under this field

Example:

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Provider NPIData Element Name: PROVIDERNPI Required for: IdentificationFormat: Numeric Length: 10

Definition:

The National Provider Identifier (NPI) is a unique identification number for covered health care providers. The Federal Government mandated the use of only NPI for electronic healthcare transactions. The NPI number is issued under the direction of the Centers for Medicare & Medicaid Services (CMS). All providers must report the NPI of all their participating providers for the quarterly or annual Provider Network Data submission. For additional information on NPI, visit www.cms.hhs.gov/NationalProvIdentStand/. NPI is required; API nor a default value will be accepted. If the provider does not have an NPI, leave this field blank while an NPI is being obtained. Please be advised, that providers without an NPI will not be included in the analysis.

The current network analysis will not validate the NPI number(s) submitted. However, at some point in the future, DMAS will use the National Plan and Provider Enumeration System (NPPES) to validate that the NPI number submitted is on the national database and is still effective.

Edit Applications:

1. Must be a valid National Provider Identifier (NPI) number. The NPI is a 10-position numeric identifier (10-digit number).

2. This is a required data element. An entry must be made for every participating provider record in order for the record to be accepted. Leave blank, if an NPI is not yet available.

3. The NPI is validated for each record on the entire submission. If you’re NPI error percentage is higher than the allowable threshold of 10%, your entire submission will be rejected.

4. No provider is exempt from the NPI requirement for CCC Plus. This includes transportation providers. The recommended process for providers to obtain and NPI is as follows: See paragraph D of the NPI application (https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS10114.pdf); follow the link in paragraph D to the “Health Care Provider Taxonomy” (http://www.wpc-edi.com/reference/codelists/healthcare/health-care-provider-taxonomy-code-set/); find the category that fits the service provided in order for NPPES to issue the NPI. Examples: Non-emergency Medical Transport (VAN) - 343900000X, Private Vehicle - 347C00000X, Secured Medical Transport (VAN) - 343800000X, Taxi - 344600000X, Transportation Broker - 347E00000X.

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Example:

1. Dr. Yucha participates in Medicaid & Medicare and his NPI is 1789654320. Enter “1789654320” in this field.

2. Dr. Phil participates in Commercial & Child Health Plus and her NPI is 1334445555. Enter “1334445555” in this field.

3. Dr. Kelleher participates in Medicaid, HIV SNP and Commercial & Child Health Plus but has not yet received an NPI. Leave this field blank until the NPI is assigned.

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Provider Last Name Data Element Name: PROVIDERLN Required for: IdentificationFormat: Character Length: 50

Definition:

The last name of an individual provider, the practice name, or the facility name of the provider contracted with the health plan to provide services to enrollees.

Edit Applications:

1. Last name is a required data element. An entry for last name must be on the record in order for the record to be accepted.

2. Must be left justified.

Example:

2. The last name "Smith" occupies five character positions.

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Provider First NameData Element Name: PROVIDERFN Required for: IdentificationFormat: Character Length: 50

Definition:

The first name of an individual provider contracted with the health plan to provide services to enrollees.

Edit Applications:

1. The first name is a required data element. However, leave blank if a facility or practice name is listed above. An entry for first name must be on the record unless a facility or practice name is listed in order for the record to be accepted.

2. If in the rare instance a provider does not have a first name, ‘NONAME’ should be entered in the first name data field.

3. Must be left justified.

Example:

The first name "David" occupies five character positions.

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Group AffiliationData Element Name: GROUPAFFIL Required for: PracticeFormat: Character Length: 25

Definition:

The Group Affiliation identifies the medical or provider group that the provider is affiliated with.

Edit Applications:

1. Not a required element

Example:1. Dr. Valentine is affiliated with VCU health system hospital or Dr. Valentine is affiliated with Richmond Primary Care. His affiliation would be entered for this data element.

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Hospital AffiliationData Element Name: HOSPITALAFFIL Required for: PracticeFormat: Character Length: 1

Definition:

The Hospital Affiliation identifies if the medical or provider group is affiliated with a hospital.

Edit Applications:

1. Valid Value is ‘1’-Yes or ‘0’-No.

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Provider Taxonomy CodeData Element Name: TAXONOMYCODE Required for: PracticeFormat: Alphanumeric Length: 10

Definition:

Unique ten-character alphanumeric code that enables providers to identify their specialty at the claim level. Current taxonomy code values are listed on the DMAS Taxonomy Code Set list. See Exhibit 1.

For provider with more than one taxonomy included in the signed contract between a CCC Plus Health Plan and that provider, multiple records (rows) should be submitted with one for each taxonomy.

Edit Applications:1. Taxonomy code is a required field.

Example 1:207L00000X Anesthesiology207Q00000X Family Medicine

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Primary Taxonomy Code IndicatorData Element Name: PRIMARYTAX Required for: LocationFormat: Character Length: 1

Definition:This data element determines if the taxonomy is primary or not. DMAS will continue counting providers with primary taxonomies for CCC Plus network adequacy analysis. In parallel, DMAS will evaluate and research a better way to consider network adequacy based on all multiple taxonomies under a single provider.

Edit Applications:1. Valid Value '1'-Yes or '0'-No

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Provider DesignationData Element Name: PROVDESG Required for: PracticeFormat: Numeric Length: 2

Definition:

Provider Designation of the Service Provider

Edit Applications:

1. This is a required data element.

2. Must use valid codes:01 = PCP (Primary Care Provider) – All Ages02 = Pediatrician03 = Specialist (See Exhibit 2)04 = Health Department05 = Hospice06 = Long Term Services & Supports (LTSS) Waiver Provider (See Exhibit 3)07 = Outpatient Mental Health – Traditional Services08 = Addiction, Recovery, and Treatment Services (ARTS) – (See Exhibit 4)09 = Community Mental Health Rehabilitation Services (CMHRS) (See Exhibit 5)10 = Hospital – Psychiatric11 = Hospital – General12 = Hospital – Physical Rehabilitation13 = Urgent Care14 = Nursing Facility16 = Outpatient Rehabilitation (PT/OT/ST)17 = Durable Medical Equipment (DME) and Supplies18 = Radiology19 = Home Health20 = Laboratory21 = Pharmacy22 = Vision23 = Transportation24 = Other25 = OB/GYN26 = FQHC27 = CSB28 = RHC

Example:1. Dr. Smith is a primary care doctor working with members of all ages. His primary designation

would be "01".2. Dr. Phillips is a pediatrician and his patients are all children. He should be coded as a primary

designation as “02”.3. Examples of Specialists are listed in Exhibit 2. They (and any others not listed) should be coded

as a primary designation as “03”.

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4. Fairfax County Health Department is a health department; therefore, the primary designation would be "04".

5. Heartland Hospice is a hospice facility; therefore, the primary designation would be a "05".6. Jane Johnson is a LPN that provides PERS Nursing services and bills code H2021. Her primary

designation would be “06”.7. Dr. Foster is a mental health psychologist. Her primary designation would be “07”.8. XYZ Facility provides substance use partial hospitalization services. The facility’s primary

designation would be “08”.9. Keith Woods provides Community based Crisis Intervention and bills H0036 for his services. His

primary designation would be “09”.10. Poplar Springs is a Psychiatric Hospital. Its primary designation would be “10”.11. St. Mary’s is a general hospital. Its primary designation would be “11”.12. HealthSouth is a physical rehabilitation hospital. Its primary designation would be “12”.13. BetterMed Urgent Care is an urgent care provider; therefore, its designation would be “13”.14. LakeWood Manor is a skilled nursing facility. Its primary designation would be “14”.15. The Hermitage at Cedarfield is an intermediate care nursing facility. Its primary designation

would be “14”.16. Alliance Physical Therapy is an outpatient rehabilitation facility. Its primary designation would

be “16”.17. Advanced Home Medical provides durable medical equipment. Its primary designation would

be “17”.18. Radiology Associates of Richmond provides radiology services. Its primary designation would be

“18”.19. Bon Secours Home Care provides home health services. Its primary designation would be “19”.20. LabCorp provides lab services. Its primary designation would be “20”.21. CVS provides pharmaceuticals to individuals. Its primary designation would be “21”.22. Dr. Carey is an ophthalmologist. His primary designation would be “22”.23. Newby’s Cab Service is a transportation provider. Its primary designation would be “23”.24. Any other providers not reflected above or below may be listed here, including providers of

Enhanced Services. Please provide primary designation of “24”.25. Dr. Jefferson is an Obstetrician. Her primary designation would be “25”.26. Bland County Medical Clinic is an FQHC. Their primary designation would be “26”.27. District 19 is an CSB. Their primary designation would be “27”.28. Eastern Shore Rural Health is an RHC. Their primary designation would be “28”.

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Explanation:If the provider listed provides mental health (provider designation 07) and substance use disorder community based (provider designation 08) services, repeat provider information on a separate row; however, the provider designation code will be different, and procedure code is required for provider designation 08. See example below.

Example

PROV_NPIPROV_LAST _NM

PROV_FIRST _NM

GRP_ AFFIL

HSP_ AFFIL PRIM_TXNY

PROV_ DESIG

PROC_CD ADDRESS1 ADDRESS2 CITY

FIPS_CD STATE

1234567890 ANY NAME Y 103TC1900X 07 123 ANY SUITE 121 RICHMOND 51760 VA

1234567890 ANY NAME Y 103TA0400X 08 H0006 123 ANY SUITE 121 RICHMOND 51760 VA

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Provider Designation Sub-ClassificationData Element Name: SUBCLASS Required for: Provider Designation 06, 08 & 09Format: Character Length: 5

Definition:

If the provider is a Long Term Care Waiver Service Provider, please refer to valid value list in Exhibit 3.If the provider is a Substance Use Disorder (ARTS) Provider, please refer to valid value list in Exhibit 4.If the provider is a Community Based Mental Health Service Provider, please refer to valid value list in Exhibit 5.

Edit Applications:

1. Codes must be valid value from the procedure code list.2. Do not leave blank for provider designations 06, 08, and 09. This is a required data element for all 06, 08, and 09 providers. For all other provider designations, this section can be left blank or filled with NA.3. Valid codes are in following table: See Exhibit 3, Exhibit 4 and Exhibit 5.Preliminary networks submitted by Offerors with the RFP are not required to include the procedure codes. Procedure codes for provider designations 06, 08, and 09 shall be required with final network submissions during readiness and as part of the Contractor’s on-going network submission.

Modifiers:

For any Sub-Class code that include a modifier, format the code and modifier with no spaces or symbols. See examples below:

H0035HB H0035HA H0035HAUG H0035HAU7

Explanation:If the provider listed provides LTC Waiver Service Code “S5102”, then the valid value for this field is “S5102”. If the provider listed provides Community Mental Health Rehabilitation service code ‘H’, then the valid value is “T1019”. If there is more than one procedure code for same provider, repeat the information on a separate row; however, the procedure code will be different. See example below.

Example:

PROV_NPIPROV_LAST _NM

PROV_FIRST _NM

GRP_ AFFIL

HSP_ AFFIL PRIM_TXNY

PROV_ DESIG

PROC_CD ADDRESS1 ADDRESS2 CITY

FIPS_CD STATE

1234567890 ANY NAME Y 163WG0600X 06 S5102 123 ANY SUITE 121 RICHMOND 51760 VA

1234567890 ANY NAME Y 103TA0400X 08 H0006 123 ANY SUITE 121 RICHMOND 51760 VA

1234567890 ANY NAME N 251S00000X 09 H0023 123 ANY SUITE 121 RICHMOND 51760 VA

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Address Line 1Data Element Name: ADDRESSLINE1 Required for: LocationFormat: Character Length: 50

Definition:

The street number and street name associated with the individual provider’s location. If the provider has more than one location, each location should be listed separately.

Edit Applications: 1. This is a required data element.

2. Should never include room or suite number.

3. Must be left justified.

4. PO Box is not an acceptable or valid street address.

Example:

1. Dr. Mosby is located at 5972 Western Blvd would be entered as “5972 Western Boulevard".

2. Dr. Saunders is located at 329 West Seventh Street would be entered as "329 West 7th Street".

3. Dr. Little is located at 1646 Third Street would be entered as "1646 3rd Street".

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Address Line 2Data Element Name: ADDRESSLINE2 Required for: LocationFormat: Character Length: 50

Definition:

The room or suite number associated with the individual provider’s address. Most often the room or suite number coincides with the providers who are located in an office or professional building. List each location separately.

Edit Applications:

1. Room or suite number is not a required data element; however, please include if applicable.

2. Room or suite number information should never go in the street address field. If the room or suite number does not fit in the appropriate record positions, additional information can be added to the site name field.

3. If Not Applicable enter “NA”.

Example:

1. Dr. Luke Smith is located in Suite 610 of the St. Luke’s Professional Building. The entry for this data element would be "Suite 610" or "Room 610" (other location information could be entered: e.g., floor, wing, etc.).

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CityData Element Name: CITY Required for: LocationFormat: Character Length: 25

Definition:

The name of the town or city associated with the service location of the provider. There should be one record for each provider location.

Edit Applications:

1. This is a required data element.

2. Must be left justified.

Example:

1. Dr. Smith’s office is located in Richmond, VA. Dr. Smith’s city should be entered as "Richmond".

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FIPS CodeData Element Name: FIPSCD Required for: LocationFormat: Character Length: 5

Definition:

The federal government has identified a code for each State and county in the United States. The Federal Information Processing Standards (FIPS) code is a five-digit code for each State and county. DMAS will use all five-digits of the FIPS code to distinguish the State and counties for the provider.

Edit Application:

1. Must be a valid State and FIPS county code. This is a required data element.

2. Submit five-digit FIPS Code appropriate for each unique service location(s). See Exhibit 6a for a valid value of County FIPS codes and Exhibit 6b for a valid list of State FIPS codes.

3. Check to assure that zip code is included in the FIPS Code submitted.

Example:

1. Dr. Roofer’s office is located in Henrico County and the office zip code is 23229. The State code for Virginia is “51”. The county FIPS code for Henrico County is “087”. 51087 is the code/number that should be entered in the FIPS Code field.

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StateData Element Name: STATE Required for: LocationFormat: Character Length: 2

Definition:

The name of the state in which the service provider is located; and it is a 2-character state abbreviation for each unique service location(s). These providers must be under contract to serve Virginia State residents.

Edit Applications:

1. Should be a valid U.S. Postal Service state code.

“DC” – District of Columbia“KY” – Kentucky"MD" – Maryland"NC" – North Carolina"TN" – Tennessee "VA" - Virginia"WV" – West Virginia

2. Do not leave blank. This is a required data element for all providers for all records.

Example:

1. Dr. Smith has one office in Virginia and another office across the Virginia state line in North Carolina. There should be one record with the state of "VA" and another separate record for Dr. Smith that has his North Carolina address and the state as "NC".

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ZipcodeData Element Name: ZIP Required for: LocationFormat: Numeric Length: 5

Definition:

5-digit zip code for each unique service location(s); the zip code associated with the provider service address. The zip code is assigned by the United States Postal Service for the location of the provider’s service location. There should be one record for each provider location.

Edit Applications:

1. Must be a valid zip code.

2. Check to assure that zip code is valid for FIPS Code submitted.

Example:

1. Dr. Smith’s zip code is “23219”; this should be entered in the appropriate positions for the zip code.

Edit Applications:

1. Do not leave blank. This is a required data element for all providers for all records.

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24 HR AccessData Element Name: 24HRACCESS Required for: LocationFormat: Character Length: 1

Definition:

This data element determines if the provider has 24-hour access.

Edit Applications:

1. Valid Value '1'-Yes or '0'-No

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Other Language Spoken1Data Element Name: OTH_LANG1 Required for: AccessFormat: Numeric Length: 2

Definition:This data element determines what language(s) that a provider or clinical staff can speak to a member.

Edit Applications:

1. Valid Values are numeric. See Language Valid Value Code list in Exhibit 7.

2. Enter in the first language spoken for the practice. If English is the language spoken, then enter in Valid Value “01”.

Example:

1. In addition to speaking English, Dr. Tango’s staff speaks Spanish. You should enter "01" in Other Language Spoken1 and "02" in Other Language Spoken2 (See next data element for Other Language Spoken2).

Edit Applications:

1. Language Valid Value List-Exhibit 7.

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Other Language Spoken2Data Element Name: OTH_LANG2 Required for: AccessFormat: Numeric Length: 2

Definition:

This data element determines what language(s) that a provider or clinical staff can speak to a member.

Edit Applications:

1. Valid value is numeric. See Language Valid Value Code list in Exhibit 7.

2. Enter in the Other Language Spoken2 for the practice. If Spanish is the second language spoken, then enter in “02”.

Example:

1. The English language is Dr. Tango’s first language spoken; Dr. Tango’s Other Language Spoken2 is Spanish. Enter "02" in Other Language Spoken2.

Edit Applications:

1. Language Valid Value List-Exhibit 7.

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CSB Satellite OfficeData Element Name: CSBSAT Required for: CSBFormat: Character Length: “1”

Definition:

This data element identifies that the CSB office sent is a satellite office.

Edit Applications:

1. This field is required if the CSB is a satellite office.

Edit Applications:

1. Valid Value ‘1’-Yes or ‘0’- No.

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ADA CompliantData Element Name: ADA Required for: LocationFormat: Character Length: “1”

Definition:

This data element identifies that the providers office meets ADA compliance.

Edit Applications:

1. Valid Value '1'-Yes or '0'-No

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Accepting New PatientsData Element Name: NEWPTS Required for: LocationFormat: Character Length: “1”

Definition:

This data element identifies if the provider is accepting new patients.

Edit Applications:

1. Valid Value ‘1’-Yes or ‘0’- No.

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Servicing FIPS CodesData Element Name: SVCFIPS Required for: Format: Numeric Length: 5 for each FIPSDefinition:

This data element will identify the FIPS code(s) that are serviced by this provider.

Edit Application:

1. Must be a valid Virginia State and FIPS county code. EXCEPTION: If the provider services the entire State of Virginia, send on one line using the following default code in the Servicing FIPS Code column: 99999. For all other providers, include a unique row for each FIPS code that the provider services.

2. Submit five-digit FIPS Code appropriate for each unique service location(s). See Exhibit 6a for a valid value of County FIPS codes and Exhibit 6b for a valid list of State FIPS codes.

3. Check to assure that the provider’s zip code is included in the FIPS Code submitted.4. Required ONLY when Provider Designation sub-classification has been identified as any of the

following:a. Provider Designation (PD) 06 – Personal Care, Respite Care and Respite Care LPNb. PD 06 – Skilled Nursing, Congregate Nursing and Congregate Respite Nursingc. PD 06 – Service Facilitationd. PD 06 – Assistive Technology Onlye. PD 06 – PERSf. PD 06 – Environmental Modificationsg. Home Healthh. Durable Medical Equipment and Supplies (DME)i. Transportationj. Provider Designation (PD) 09 - Community Mental Health Rehabilitation Services (CMHRS)

reference Exhibit 5, but only the following services: H2019 - Crisis Stabilization H0036 - Crisis Intervention H2012 - Intensive In-Home (IIH) H0046 - Mental Health Skill-building Services (MHSS) H0023 - Mental Health Case Management H2033 – Behavioral Therapy H0024 – Peer Support Services, Individual Mental Health H0025 – Peer Support Services, Group Mental Health H0039 – Intensive Community Treatment (ICT)

Example:

1. Dr. Roofer’s office is located in Henrico County and the office zip code is 23229. The State code for Virginia is “51”. The county FIPS code for Henrico County is “087”. 51087 is the code/number that should be entered in the FIPS Code field.

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Exhibit 1 – Taxonomy Codes (Use latest list released by Washington Publishing Company (WPC))

The following list was downloaded from WPC and should not be utilized as a master list of all valid values. Use the National Code list, as published by WPC, for the most updated list of taxonomy codes.

Code Classification Specialization101Y00000X Counselor

101YA0400X CounselorAddiction (Addiction, Recovery, and Treatment Services)

101YM0800X Counselor Mental Health101YP1600X Counselor Pastoral101YP2500X Counselor Professional101YS0200X Counselor School102L00000X Psychoanalyst102X00000X Poetry Therapist103G00000X Clinical Neuropsychologist103GC0700X Clinical Neuropsychologist Clinical103K00000X Behavioral Analyst103T00000X Psychologist

103TA0400X PsychologistAddiction (Addiction, Recovery, and Treatment Services)

103TA0700X Psychologist Adult Development & Aging103TB0200X Psychologist Cognitive & Behavioral103TC0700X Psychologist Clinical103TC1900X Psychologist Counseling103TC2200X Psychologist Clinical Child & Adolescent103TE1000X Psychologist Educational103TE1100X Psychologist Exercise & Sports103TF0000X Psychologist Family103TF0200X Psychologist Forensic103TH0004X Psychologist Health103TH0100X Psychologist Health Service103TM1700X Psychologist Men & Masculinity103TM1800X Psychologist Mental Retardation & Developmental Disabilities103TP0016X Psychologist Prescribing (Medical)103TP0814X Psychologist Psychoanalysis103TP2700X Psychologist Psychotherapy103TP2701X Psychologist Group Psychotherapy103TR0400X Psychologist Rehabilitation103TS0200X Psychologist School103TW0100X Psychologist Women104100000X Social Worker1041C0700X Social Worker Clinical1041S0200X Social Worker School106H00000X Marriage & Family Therapist111N00000X Chiropractor111NI0013X Chiropractor Independent Medical Examiner

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Code Classification Specialization111NI0900X Chiropractor Internist111NN0400X Chiropractor Neurology111NN1001X Chiropractor Nutrition111NP0017X Chiropractor Pediatric Chiropractor111NR0200X Chiropractor Radiology111NR0400X Chiropractor Rehabilitation111NS0005X Chiropractor Sports Physician111NT0100X Chiropractor Thermography111NX0100X Chiropractor Occupational Health111NX0800X Chiropractor Orthopedic122300000X Dentist1223D0001X Dentist Dental Public Health1223D0004X Dentist Dentist Anesthesiologist1223E0200X Dentist Endodontics1223G0001X Dentist General Practice1223P0106X Dentist Oral and Maxillofacial Pathology1223P0221X Dentist Pediatric Dentistry1223P0300X Dentist Periodontics1223P0700X Dentist Prosthodontics1223S0112X Dentist Oral and Maxillofacial Surgery1223X0008X Dentist Oral and Maxillofacial Radiology1223X0400X Dentist Orthodontics and Dentofacial Orthopedics122400000X Denturist124Q00000X Dental Hygienist125J00000X Dental Therapist

125K00000XAdvanced Practice Dental Therapist

125Q00000X Oral Medicinist126800000X Dental Assistant126900000X Dental Laboratory Technician132700000X Dietary Manager133N00000X Nutritionist133NN1002X Nutritionist Nutrition, Education133V00000X Dietitian, Registered133VN1004X Dietitian, Registered Nutrition, Pediatric133VN1005X Dietitian, Registered Nutrition, Renal133VN1006X Dietitian, Registered Nutrition, Metabolic

136A00000XDietetic Technician, Registered

146D00000XPersonal Emergency Response Attendant

146L00000XEmergency Medical Technician, Paramedic

146M00000XEmergency Medical Technician, Intermediate

146N00000XEmergency Medical Technician, Basic

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Code Classification Specialization152W00000X Optometrist152WC0802X Optometrist Corneal and Contact Management152WL0500X Optometrist Low Vision Rehabilitation152WP0200X Optometrist Pediatrics152WS0006X Optometrist Sports Vision152WV0400X Optometrist Vision Therapy152WX0102X Optometrist Occupational Vision156F00000X Technician/Technologist156FC0800X Technician/Technologist Contact Lens156FC0801X Technician/Technologist Contact Lens Fitter156FX1100X Technician/Technologist Ophthalmic156FX1101X Technician/Technologist Ophthalmic Assistant156FX1201X Technician/Technologist Optometric Assistant156FX1202X Technician/Technologist Optometric Technician156FX1700X Technician/Technologist Ocularist156FX1800X Technician/Technologist Optician156FX1900X Technician/Technologist Orthoptist163W00000X Registered Nurse

163WA0400X Registered NurseAddiction (Addiction, Recovery, and Treatment Services)

163WA2000X Registered Nurse Administrator163WC0200X Registered Nurse Critical Care Medicine163WC0400X Registered Nurse Case Management163WC1400X Registered Nurse College Health163WC1500X Registered Nurse Community Health163WC1600X Registered Nurse Continuing Education/Staff Development163WC2100X Registered Nurse Continence Care163WC3500X Registered Nurse Cardiac Rehabilitation163WD0400X Registered Nurse Diabetes Educator163WD1100X Registered Nurse Dialysis, Peritoneal163WE0003X Registered Nurse Emergency163WE0900X Registered Nurse Enterostomal Therapy163WF0300X Registered Nurse Flight163WG0000X Registered Nurse General Practice163WG0100X Registered Nurse Gastroenterology163WG0600X Registered Nurse Gerontology163WH0200X Registered Nurse Home Health163WH0500X Registered Nurse Hemodialysis163WH1000X Registered Nurse Hospice163WI0500X Registered Nurse Infusion Therapy163WI0600X Registered Nurse Infection Control163WL0100X Registered Nurse Lactation Consultant163WM0102X Registered Nurse Maternal Newborn163WM0705X Registered Nurse Medical-Surgical163WM1400X Registered Nurse Nurse Massage Therapist (NMT)163WN0002X Registered Nurse Neonatal Intensive Care163WN0003X Registered Nurse Neonatal, Low-Risk

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Code Classification Specialization163WN0300X Registered Nurse Nephrology163WN0800X Registered Nurse Neuroscience163WN1003X Registered Nurse Nutrition Support163WP0000X Registered Nurse Pain Management163WP0200X Registered Nurse Pediatrics163WP0218X Registered Nurse Pediatric Oncology163WP0807X Registered Nurse Psych/Mental Health, Child & Adolescent163WP0808X Registered Nurse Psych/Mental Health163WP0809X Registered Nurse Psych/Mental Health, Adult163WP1700X Registered Nurse Perinatal163WP2201X Registered Nurse Ambulatory Care163WR0006X Registered Nurse Registered Nurse First Assistant163WR0400X Registered Nurse Rehabilitation163WR1000X Registered Nurse Reproductive Endocrinology/Infertility163WS0121X Registered Nurse Plastic Surgery163WS0200X Registered Nurse School163WU0100X Registered Nurse Urology163WW0000X Registered Nurse Wound Care163WW0101X Registered Nurse Women's Health Care, Ambulatory163WX0002X Registered Nurse Obstetric, High-Risk163WX0003X Registered Nurse Obstetric, Inpatient163WX0106X Registered Nurse Occupational Health163WX0200X Registered Nurse Oncology163WX0601X Registered Nurse Otorhinolaryngology & Head-Neck163WX0800X Registered Nurse Orthopedic163WX1100X Registered Nurse Ophthalmic163WX1500X Registered Nurse Ostomy Care164W00000X Licensed Practical Nurse164X00000X Licensed Vocational Nurse

167G00000XLicensed Psychiatric Technician

170100000XMedical Genetics, Ph.D. Medical Genetics

170300000X Genetic Counselor, MS171000000X Military Health Care Provider1710I1002X Military Health Care Provider Independent Duty Corpsman1710I1003X Military Health Care Provider Independent Duty Medical Technicians171100000X Acupuncturist

171M00000XCase Manager/Care Coordinator

171R00000X Interpreter171W00000X Contractor171WH0202X Contractor Home Modifications171WV0202X Contractor Vehicle Modifications172A00000X Driver172M00000X Mechanotherapist172P00000X Naprapath

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Code Classification Specialization172V00000X Community Health Worker173000000X Legal Medicine173C00000X Reflexologist173F00000X Sleep Specialist, PhD174200000X Meals174400000X Specialist1744G0900X Specialist Graphics Designer1744P3200X Specialist Prosthetics Case Management1744R1102X Specialist Research Study1744R1103X Specialist Research Data Abstracter/Coder174H00000X Health Educator174M00000X Veterinarian174MM1900X Veterinarian Medical Research174N00000X Lactation Consultant, Non-RN174V00000X Clinical Ethicist175F00000X Naturopath175L00000X Homeopath175M00000X Midwife, Lay175T00000X Peer Specialist176B00000X Midwife176P00000X Funeral Director177F00000X Lodging183500000X Pharmacist1835C0205X Pharmacist Critical Care1835G0000X Pharmacist General Practice1835G0303X Pharmacist Geriatric1835N0905X Pharmacist Nuclear1835N1003X Pharmacist Nutrition Support

1835P0018X PharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist

1835P0200X Pharmacist Pediatrics1835P1200X Pharmacist Pharmacotherapy1835P1300X Pharmacist Psychiatric1835P2201X Pharmacist Ambulatory Care1835X0200X Pharmacist Oncology183700000X Pharmacy Technician193200000X Multi-Specialty193400000X Single Specialty

202C00000XIndependent Medical Examiner

202K00000X Phlebology

204C00000XNeuromusculoskeletal Medicine, Sports Medicine

204D00000XNeuromusculoskeletal Medicine & OMM

204E00000X Oral & Maxillofacial Surgery204F00000X Transplant Surgery

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Code Classification Specialization204R00000X Electrodiagnostic Medicine207K00000X Allergy & Immunology207KA0200X Allergy & Immunology Allergy207KI0005X Allergy & Immunology Clinical & Laboratory Immunology207L00000X Anesthesiology207LA0401X Anesthesiology Addiction Medicine207LC0200X Anesthesiology Critical Care Medicine207LH0002X Anesthesiology Hospice and Palliative Medicine207LP2900X Anesthesiology Pain Medicine207LP3000X Anesthesiology Pediatric Anesthesiology207N00000X Dermatology207ND0101X Dermatology MOHS-Micrographic Surgery207ND0900X Dermatology Dermatopathology207NI0002X Dermatology Clinical & Laboratory Dermatological Immunology207NP0225X Dermatology Pediatric Dermatology207NS0135X Dermatology Procedural Dermatology207P00000X Emergency Medicine207PE0004X Emergency Medicine Emergency Medical Services207PE0005X Emergency Medicine Undersea and Hyperbaric Medicine207PH0002X Emergency Medicine Hospice and Palliative Medicine207PP0204X Emergency Medicine Pediatric Emergency Medicine207PS0010X Emergency Medicine Sports Medicine207PT0002X Emergency Medicine Medical Toxicology207Q00000X Family Medicine207QA0000X Family Medicine Adolescent Medicine207QA0401X Family Medicine Addiction Medicine207QA0505X Family Medicine Adult Medicine207QB0002X Family Medicine Obesity Medicine207QG0300X Family Medicine Geriatric Medicine207QH0002X Family Medicine Hospice and Palliative Medicine207QS0010X Family Medicine Sports Medicine207QS1201X Family Medicine Sleep Medicine207R00000X Internal Medicine207RA0000X Internal Medicine Adolescent Medicine207RA0001X Internal Medicine Advanced Heart Failure and Transplant Cardiology207RA0201X Internal Medicine Allergy & Immunology207RA0401X Internal Medicine Addiction Medicine207RB0002X Internal Medicine Obesity Medicine207RC0000X Internal Medicine Cardiovascular Disease207RC0001X Internal Medicine Clinical Cardiac Electrophysiology207RC0200X Internal Medicine Critical Care Medicine207RE0101X Internal Medicine Endocrinology, Diabetes & Metabolism207RG0100X Internal Medicine Gastroenterology207RG0300X Internal Medicine Geriatric Medicine207RH0000X Internal Medicine Hematology207RH0002X Internal Medicine Hospice and Palliative Medicine

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Code Classification Specialization207RH0003X Internal Medicine Hematology & Oncology207RH0005X Internal Medicine Hypertension Specialist207RI0001X Internal Medicine Clinical & Laboratory Immunology207RI0008X Internal Medicine Hepatology207RI0011X Internal Medicine Interventional Cardiology207RI0200X Internal Medicine Infectious Disease207RM1200X Internal Medicine Magnetic Resonance Imaging (MRI)207RN0300X Internal Medicine Nephrology207RP1001X Internal Medicine Pulmonary Disease207RR0500X Internal Medicine Rheumatology207RS0010X Internal Medicine Sports Medicine207RS0012X Internal Medicine Sleep Medicine207RT0003X Internal Medicine Transplant Hepatology207RX0202X Internal Medicine Medical Oncology207SC0300X Medical Genetics Clinical Cytogenetic207SG0201X Medical Genetics Clinical Genetics (M.D.)207SG0202X Medical Genetics Clinical Biochemical Genetics207SG0203X Medical Genetics Clinical Molecular Genetics207SG0205X Medical Genetics Ph.D. Medical Genetics207SM0001X Medical Genetics Molecular Genetic Pathology207T00000X Neurological Surgery207U00000X Nuclear Medicine207UN0901X Nuclear Medicine Nuclear Cardiology207UN0902X Nuclear Medicine Nuclear Imaging & Therapy207UN0903X Nuclear Medicine In Vivo & In Vitro Nuclear Medicine207V00000X Obstetrics & Gynecology207VB0002X Obstetrics & Gynecology Obesity Medicine207VC0200X Obstetrics & Gynecology Critical Care Medicine207VE0102X Obstetrics & Gynecology Reproductive Endocrinology207VF0040X Obstetrics & Gynecology Female Pelvic Medicine and Reconstructive Surgery207VG0400X Obstetrics & Gynecology Gynecology207VH0002X Obstetrics & Gynecology Hospice and Palliative Medicine207VM0101X Obstetrics & Gynecology Maternal & Fetal Medicine207VX0000X Obstetrics & Gynecology Obstetrics207VX0201X Obstetrics & Gynecology Gynecologic Oncology207W00000X Ophthalmology207WX0200X Ophthalmology Ophthalmic Plastic and Reconstructive Surgery207X00000X Orthopedic Surgery207XP3100X Orthopedic Surgery Pediatric Orthopedic Surgery207XS0106X Orthopedic Surgery Hand Surgery207XS0114X Orthopedic Surgery Adult Reconstructive Orthopedic Surgery207XS0117X Orthopedic Surgery Orthopedic Surgery of the Spine207XX0004X Orthopedic Surgery Foot and Ankle Surgery207XX0005X Orthopedic Surgery Sports Medicine207XX0801X Orthopedic Surgery Orthopedic Trauma207Y00000X Otolaryngology

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Code Classification Specialization207YP0228X Otolaryngology Pediatric Otolaryngology207YS0012X Otolaryngology Sleep Medicine207YS0123X Otolaryngology Facial Plastic Surgery207YX0007X Otolaryngology Plastic Surgery within the Head & Neck207YX0602X Otolaryngology Otolaryngic Allergy207YX0901X Otolaryngology Otology & Neurotology207YX0905X Otolaryngology Otolaryngology/Facial Plastic Surgery207ZB0001X Pathology Blood Banking & Transfusion Medicine207ZC0006X Pathology Clinical Pathology207ZC0008X Pathology Clinical Informatics207ZC0500X Pathology Cytopathology207ZD0900X Pathology Dermatopathology207ZF0201X Pathology Forensic Pathology207ZH0000X Pathology Hematology207ZI0100X Pathology Immunopathology207ZM0300X Pathology Medical Microbiology207ZN0500X Pathology Neuropathology207ZP0007X Pathology Molecular Genetic Pathology207ZP0101X Pathology Anatomic Pathology207ZP0102X Pathology Anatomic Pathology & Clinical Pathology207ZP0104X Pathology Chemical Pathology207ZP0105X Pathology Clinical Pathology/Laboratory Medicine207ZP0213X Pathology Pediatric Pathology208000000X Pediatrics2080A0000X Pediatrics Adolescent Medicine2080B0002X Pediatrics Obesity Medicine2080C0008X Pediatrics Child Abuse Pediatrics2080H0002X Pediatrics Hospice and Palliative Medicine2080I0007X Pediatrics Clinical & Laboratory Immunology2080N0001X Pediatrics Neonatal-Perinatal Medicine2080P0006X Pediatrics Developmental – Behavioral Pediatrics2080P0008X Pediatrics Neurodevelopmental Disabilities2080P0201X Pediatrics Pediatric Allergy/Immunology2080P0202X Pediatrics Pediatric Cardiology2080P0203X Pediatrics Pediatric Critical Care Medicine2080P0204X Pediatrics Pediatric Emergency Medicine2080P0205X Pediatrics Pediatric Endocrinology2080P0206X Pediatrics Pediatric Gastroenterology2080P0207X Pediatrics Pediatric Hematology-Oncology2080P0208X Pediatrics Pediatric Infectious Diseases2080P0210X Pediatrics Pediatric Nephrology2080P0214X Pediatrics Pediatric Pulmonology2080P0216X Pediatrics Pediatric Rheumatology2080S0010X Pediatrics Sports Medicine2080S0012X Pediatrics Sleep Medicine2080T0002X Pediatrics Medical Toxicology

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Code Classification Specialization2080T0004X Pediatrics Pediatric Transplant Hepatology

208100000XPhysical Medicine & Rehabilitation

2081H0002XPhysical Medicine & Rehabilitation Hospice and Palliative Medicine

2081N0008XPhysical Medicine & Rehabilitation Neuromuscular Medicine

2081P0004XPhysical Medicine & Rehabilitation Spinal Cord Injury Medicine

2081P0010XPhysical Medicine & Rehabilitation Pediatric Rehabilitation Medicine

2081P0301XPhysical Medicine & Rehabilitation Brain Injury Medicine

2081P2900XPhysical Medicine & Rehabilitation Pain Medicine

2081S0010XPhysical Medicine & Rehabilitation Sports Medicine

208200000X Plastic Surgery2082S0099X Plastic Surgery Plastic Surgery Within the Head and Neck2082S0105X Plastic Surgery Surgery of the Hand2083A0100X Preventive Medicine Aerospace Medicine2083B0002X Preventive Medicine Obesity Medicine2083C0008X Preventive Medicine Clinical Informatics2083P0011X Preventive Medicine Undersea and Hyperbaric Medicine

2083P0500X Preventive MedicinePreventive Medicine/Occupational Environmental Medicine

2083P0901X Preventive Medicine Public Health & General Preventive Medicine2083S0010X Preventive Medicine Sports Medicine2083T0002X Preventive Medicine Medical Toxicology2083X0100X Preventive Medicine Occupational Medicine2084A0401X Psychiatry & Neurology Addiction Medicine2084B0002X Psychiatry & Neurology Obesity Medicine2084B0040X Psychiatry & Neurology Behavioral Neurology & Neuropsychiatry2084D0003X Psychiatry & Neurology Diagnostic Neuroimaging2084F0202X Psychiatry & Neurology Forensic Psychiatry2084H0002X Psychiatry & Neurology Hospice and Palliative Medicine2084N0008X Psychiatry & Neurology Neuromuscular Medicine2084N0400X Psychiatry & Neurology Neurology

2084N0402X Psychiatry & NeurologyNeurology with Special Qualifications in Child Neurology

2084N0600X Psychiatry & Neurology Clinical Neurophysiology2084P0005X Psychiatry & Neurology Neurodevelopmental Disabilities2084P0015X Psychiatry & Neurology Psychosomatic Medicine2084P0301X Psychiatry & Neurology Brain Injury Medicine2084P0800X Psychiatry & Neurology Psychiatry2084P0802X Psychiatry & Neurology Addiction Psychiatry2084P0804X Psychiatry & Neurology Child & Adolescent Psychiatry

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Code Classification Specialization2084P0805X Psychiatry & Neurology Geriatric Psychiatry2084P2900X Psychiatry & Neurology Pain Medicine2084S0010X Psychiatry & Neurology Sports Medicine2084S0012X Psychiatry & Neurology Sleep Medicine2084V0102X Psychiatry & Neurology Vascular Neurology2085B0100X Radiology Body Imaging2085D0003X Radiology Diagnostic Neuroimaging2085H0002X Radiology Hospice and Palliative Medicine2085N0700X Radiology Neuroradiology2085N0904X Radiology Nuclear Radiology2085P0229X Radiology Pediatric Radiology2085R0001X Radiology Radiation Oncology2085R0202X Radiology Diagnostic Radiology2085R0203X Radiology Therapeutic Radiology2085R0204X Radiology Vascular & Interventional Radiology2085R0205X Radiology Radiological Physics2085U0001X Radiology Diagnostic Ultrasound208600000X Surgery2086H0002X Surgery Hospice and Palliative Medicine2086S0102X Surgery Surgical Critical Care2086S0105X Surgery Surgery of the Hand2086S0120X Surgery Pediatric Surgery2086S0122X Surgery Plastic and Reconstructive Surgery2086S0127X Surgery Trauma Surgery2086S0129X Surgery Vascular Surgery2086X0206X Surgery Surgical Oncology208800000X Urology2088F0040X Urology Female Pelvic Medicine and Reconstructive Surgery2088P0231X Urology Pediatric Urology208C00000X Colon & Rectal Surgery208D00000X General Practice

208G00000X

Thoracic Surgery (Cardiothoracic Vascular Surgery)

208M00000X Hospitalist208U00000X Clinical Pharmacology208VP0000X Pain Medicine Pain Medicine208VP0014X Pain Medicine Interventional Pain Medicine209800000X Legal Medicine211D00000X Assistant, Podiatric213E00000X Podiatrist213EG0000X Podiatrist General Practice213EP0504X Podiatrist Public Medicine213EP1101X Podiatrist Primary Podiatric Medicine213ER0200X Podiatrist Radiology213ES0000X Podiatrist Sports Medicine213ES0103X Podiatrist Foot & Ankle Surgery

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Code Classification Specialization213ES0131X Podiatrist Foot Surgery221700000X Art Therapist222Q00000X Developmental Therapist222Z00000X Orthotist224900000X Mastectomy Fitter224L00000X Pedorthist224P00000X Prosthetist224Y00000X Clinical Exercise Physiologist

224Z00000XOccupational Therapy Assistant

224ZE0001XOccupational Therapy Assistant Environmental Modification

224ZF0002XOccupational Therapy Assistant Feeding, Eating & Swallowing

224ZL0004XOccupational Therapy Assistant Low Vision

224ZR0403XOccupational Therapy Assistant Driving and Community Mobility

225000000X Orthotic Fitter225100000X Physical Therapist2251C2600X Physical Therapist Cardiopulmonary2251E1200X Physical Therapist Ergonomics2251E1300X Physical Therapist Electrophysiology, Clinical2251G0304X Physical Therapist Geriatrics2251H1200X Physical Therapist Hand2251H1300X Physical Therapist Human Factors2251N0400X Physical Therapist Neurology2251P0200X Physical Therapist Pediatrics2251S0007X Physical Therapist Sports2251X0800X Physical Therapist Orthopedic225200000X Physical Therapy Assistant225400000X Rehabilitation Practitioner225500000X Specialist/Technologist2255A2300X Specialist/Technologist Athletic Trainer2255R0406X Specialist/Technologist Rehabilitation, Blind225600000X Dance Therapist225700000X Massage Therapist225800000X Recreation Therapist225A00000X Music Therapist

225B00000XPulmonary Function Technologist

225C00000X Rehabilitation Counselor225CA2400X Rehabilitation Counselor Assistive Technology Practitioner225CA2500X Rehabilitation Counselor Assistive Technology Supplier225CX0006X Rehabilitation Counselor Orientation and Mobility Training Provider225X00000X Occupational Therapist225XE0001X Occupational Therapist Environmental Modification

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Code Classification Specialization225XE1200X Occupational Therapist Ergonomics225XF0002X Occupational Therapist Feeding, Eating & Swallowing225XG0600X Occupational Therapist Gerontology225XH1200X Occupational Therapist Hand225XH1300X Occupational Therapist Human Factors225XL0004X Occupational Therapist Low Vision225XM0800X Occupational Therapist Mental Health225XN1300X Occupational Therapist Neurorehabilitation225XP0019X Occupational Therapist Physical Rehabilitation225XP0200X Occupational Therapist Pediatrics225XR0403X Occupational Therapist Driving and Community Mobility

226000000XRecreational Therapist Assistant

226300000X Kinesiotherapist

227800000XRespiratory Therapist, Certified

2278C0205XRespiratory Therapist, Certified Critical Care

2278E0002XRespiratory Therapist, Certified Emergency Care

2278E1000XRespiratory Therapist, Certified Educational

2278G0305XRespiratory Therapist, Certified Geriatric Care

2278G1100XRespiratory Therapist, Certified General Care

2278H0200XRespiratory Therapist, Certified Home Health

2278P1004XRespiratory Therapist, Certified Pulmonary Diagnostics

2278P1005XRespiratory Therapist, Certified Pulmonary Rehabilitation

2278P1006XRespiratory Therapist, Certified Pulmonary Function Technologist

2278P3800XRespiratory Therapist, Certified Palliative/Hospice

2278P3900XRespiratory Therapist, Certified Neonatal/Pediatrics

2278P4000XRespiratory Therapist, Certified Patient Transport

2278S1500XRespiratory Therapist, Certified SNF/Subacute Care

227900000XRespiratory Therapist, Registered

2279C0205XRespiratory Therapist, Registered Critical Care

2279E0002XRespiratory Therapist, Registered Emergency Care

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Code Classification Specialization

2279E1000XRespiratory Therapist, Registered Educational

2279G0305XRespiratory Therapist, Registered Geriatric Care

2279G1100XRespiratory Therapist, Registered General Care

2279H0200XRespiratory Therapist, Registered Home Health

2279P1004XRespiratory Therapist, Registered Pulmonary Diagnostics

2279P1005XRespiratory Therapist, Registered Pulmonary Rehabilitation

2279P1006XRespiratory Therapist, Registered Pulmonary Function Technologist

2279P3800XRespiratory Therapist, Registered Palliative/Hospice

2279P3900XRespiratory Therapist, Registered Neonatal/Pediatrics

2279P4000XRespiratory Therapist, Registered Patient Transport

2279S1500XRespiratory Therapist, Registered SNF/Subacute Care

229N00000X Anaplastologist231H00000X Audiologist231HA2400X Audiologist Assistive Technology Practitioner231HA2500X Audiologist Assistive Technology Supplier235500000X Specialist/Technologist2355A2700X Specialist/Technologist Audiology Assistant2355S0801X Specialist/Technologist Speech-Language Assistant235Z00000X Speech-Language Pathologist237600000X Audiologist-Hearing Aid Fitter237700000X Hearing Instrument Specialist242T00000X Perfusionist

243U00000XRadiology Practitioner Assistant

246Q00000X Spec/Tech, Pathology246QB0000X Spec/Tech, Pathology Blood Banking246QC1000X Spec/Tech, Pathology Chemistry246QC2700X Spec/Tech, Pathology Cytotechnology246QH0000X Spec/Tech, Pathology Hematology246QH0401X Spec/Tech, Pathology Hemapheresis Practitioner246QH0600X Spec/Tech, Pathology Histology246QI0000X Spec/Tech, Pathology Immunology246QL0900X Spec/Tech, Pathology Laboratory Management246QL0901X Spec/Tech, Pathology Laboratory Management, Diplomate246QM0706X Spec/Tech, Pathology Medical Technologist246QM0900X Spec/Tech, Pathology Microbiology246R00000X Technician, Pathology

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Code Classification Specialization246RH0600X Technician, Pathology Histology246RM2200X Technician, Pathology Medical Laboratory246RP1900X Technician, Pathology Phlebotomy246W00000X Technician, Cardiology246X00000X Spec/Tech, Cardiovascular246XC2901X Spec/Tech, Cardiovascular Cardiovascular Invasive Specialist246XC2903X Spec/Tech, Cardiovascular Vascular Specialist246XS1301X Spec/Tech, Cardiovascular Sonography246Y00000X Spec/Tech, Health Info246YC3301X Spec/Tech, Health Info Coding Specialist, Hospital Based246YC3302X Spec/Tech, Health Info Coding Specialist, Physician Office Based246YR1600X Spec/Tech, Health Info Registered Record Administrator246Z00000X Specialist/Technologist, Other246ZA2600X Specialist/Technologist, Other Art, Medical246ZB0301X Specialist/Technologist, Other Biomedical Engineering246ZB0302X Specialist/Technologist, Other Biomedical Photographer246ZB0500X Specialist/Technologist, Other Biochemist246ZB0600X Specialist/Technologist, Other Biostatistician246ZC0007X Specialist/Technologist, Other Surgical Assistant246ZE0500X Specialist/Technologist, Other EEG246ZE0600X Specialist/Technologist, Other Electroneurodiagnostic246ZG0701X Specialist/Technologist, Other Graphics Methods246ZG1000X Specialist/Technologist, Other Geneticist, Medical (PhD)246ZI1000X Specialist/Technologist, Other Illustration, Medical246ZN0300X Specialist/Technologist, Other Nephrology246ZS0410X Specialist/Technologist, Other Surgical Technologist246ZX2200X Specialist/Technologist, Other Orthopedic Assistant

247000000XTechnician, Health Information

2470A2800XTechnician, Health Information Assistant Record Technician

247100000X Radiologic Technologist2471B0102X Radiologic Technologist Bone Densitometry2471C1101X Radiologic Technologist Cardiovascular-Interventional Technology2471C1106X Radiologic Technologist Cardiac-Interventional Technology2471C3401X Radiologic Technologist Computed Tomography2471C3402X Radiologic Technologist Radiography2471M1202X Radiologic Technologist Magnetic Resonance Imaging2471M2300X Radiologic Technologist Mammography2471N0900X Radiologic Technologist Nuclear Medicine Technology2471Q0001X Radiologic Technologist Quality Management2471R0002X Radiologic Technologist Radiation Therapy2471S1302X Radiologic Technologist Sonography2471V0105X Radiologic Technologist Vascular Sonography2471V0106X Radiologic Technologist Vascular-Interventional Technology247200000X Technician, Other2472B0301X Technician, Other Biomedical Engineering

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Code Classification Specialization2472D0500X Technician, Other Darkroom2472E0500X Technician, Other EEG2472R0900X Technician, Other Renal Dialysis2472V0600X Technician, Other Veterinary247ZC0005X Pathology Clinical Laboratory Director, Non-physician251300000X Local Education Agency (LEA)251B00000X Case Management

251C00000X

Day Training, Developmentally Disabled Services

251E00000X Home Health251F00000X Home Infusion

251G00000XHospice Care, Community Based

251J00000X Nursing Care251K00000X Public Health or Welfare251S00000X Community/Behavioral Health251T00000X PACE Provider Organization251V00000X Voluntary or Charitable251X00000X Supports Brokerage

252Y00000XEarly Intervention Provider Agency

253J00000X Foster Care Agency253Z00000X In Home Supportive Care261Q00000X Clinic/Center261QA0005X Clinic/Center Ambulatory Family Planning Facility261QA0006X Clinic/Center Ambulatory Fertility Facility261QA0600X Clinic/Center Adult Day Care261QA0900X Clinic/Center Amputee261QA1903X Clinic/Center Ambulatory Surgical261QA3000X Clinic/Center Augmentative Communication261QB0400X Clinic/Center Birthing261QC0050X Clinic/Center Critical Access Hospital261QC1500X Clinic/Center Community Health261QC1800X Clinic/Center Corporate Health261QD0000X Clinic/Center Dental261QD1600X Clinic/Center Developmental Disabilities261QE0002X Clinic/Center Emergency Care261QE0700X Clinic/Center End-Stage Renal Disease (ESRD) Treatment261QE0800X Clinic/Center Endoscopy261QF0050X Clinic/Center Family Planning, Non-Surgical261QF0400X Clinic/Center Federally Qualified Health Center (FQHC)261QG0250X Clinic/Center Genetics261QH0100X Clinic/Center Health Service261QH0700X Clinic/Center Hearing and Speech261QI0500X Clinic/Center Infusion Therapy261QL0400X Clinic/Center Lithotripsy

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Code Classification Specialization

261QM0801X Clinic/CenterMental Health (Including Community Mental Health Center)

261QM0850X Clinic/Center Adult Mental Health261QM0855X Clinic/Center Adolescent and Children Mental Health261QM1000X Clinic/Center Migrant Health261QM1100X Clinic/Center Military/U.S. Coast Guard Outpatient

261QM1101X Clinic/CenterMilitary and U.S. Coast Guard Ambulatory Procedure

261QM1102X Clinic/CenterMilitary Outpatient Operational (Transportable) Component

261QM1103X Clinic/CenterMilitary Ambulatory Procedure Visits Operational (Transportable)

261QM1200X Clinic/Center Magnetic Resonance Imaging (MRI)261QM1300X Clinic/Center Multi-Specialty261QM2500X Clinic/Center Medical Specialty261QM2800X Clinic/Center Methadone Clinic261QM3000X Clinic/Center Medically Fragile Infants and Children Day Care261QP0904X Clinic/Center Public Health, Federal261QP0905X Clinic/Center Public Health, State or Local261QP1100X Clinic/Center Podiatric261QP2000X Clinic/Center Physical Therapy261QP2300X Clinic/Center Primary Care261QP2400X Clinic/Center Prison Health261QP3300X Clinic/Center Pain261QR0200X Clinic/Center Radiology261QR0206X Clinic/Center Radiology, Mammography261QR0207X Clinic/Center Radiology, Mobile Mammography261QR0208X Clinic/Center Radiology, Mobile261QR0400X Clinic/Center Rehabilitation

261QR0401X Clinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)

261QR0404X Clinic/Center Rehabilitation, Cardiac Facilities

261QR0405X Clinic/CenterRehabilitation, Addiction, Recovery, and Treatment Services

261QR0800X Clinic/Center Recovery Care261QR1100X Clinic/Center Research261QR1300X Clinic/Center Rural Health261QS0112X Clinic/Center Oral and Maxillofacial Surgery261QS0132X Clinic/Center Ophthalmologic Surgery261QS1000X Clinic/Center Student Health261QS1200X Clinic/Center Sleep Disorder Diagnostic261QU0200X Clinic/Center Urgent Care261QV0200X Clinic/Center VA261QX0100X Clinic/Center Occupational Medicine261QX0200X Clinic/Center Oncology261QX0203X Clinic/Center Oncology, Radiation273100000X Epilepsy Unit

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Code Classification Specialization273R00000X Psychiatric Unit273Y00000X Rehabilitation Unit

275N00000XMedicare Defined Swing Bed Unit

276400000XRehabilitation, Substance Use Disorder Unit

281P00000X Chronic Disease Hospital281PC2000X Chronic Disease Hospital Children282E00000X Long Term Care Hospital

282J00000XReligious Nonmedical Health Care Institution

282N00000X General Acute Care Hospital282NC0060X General Acute Care Hospital Critical Access282NC2000X General Acute Care Hospital Children282NR1301X General Acute Care Hospital Rural282NW0100X General Acute Care Hospital Women283Q00000X Psychiatric Hospital283X00000X Rehabilitation Hospital283XC2000X Rehabilitation Hospital Children284300000X Special Hospital286500000X Military Hospital2865C1500X Military Hospital Community Health2865M2000X Military Hospital Military General Acute Care Hospital

2865X1600X Military HospitalMilitary General Acute Care Hospital. Operational (Transportable)

287300000X Christian Science Sanitarium

291900000XMilitary Clinical Medical Laboratory

291U00000X Clinical Medical Laboratory292200000X Dental Laboratory293D00000X Physiological Laboratory

302F00000XExclusive Provider Organization

302R00000XHealth Maintenance Organization

305R00000XPreferred Provider Organization

305S00000X Point of Service310400000X Assisted Living Facility3104A0625X Assisted Living Facility Assisted Living, Mental Illness3104A0630X Assisted Living Facility Assisted Living, Behavioral Disturbances

310500000XIntermediate Care Facility, Mental Illness

311500000XAlzheimer Center (Dementia Center)

311Z00000X Custodial Care Facility311ZA0620X Custodial Care Facility Adult Care Home

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Code Classification Specialization

313M00000XNursing Facility/Intermediate Care Facility

314000000X Skilled Nursing Facility3140N1450X Skilled Nursing Facility Nursing Care, Pediatric315D00000X Hospice, Inpatient315P00000X Intermediate Care Facility,

Mentally Retarded317400000X Christian Science Facility320600000X Residential Treatment Facility, Mental Retardation and/or Developmental

Disabilities320700000X Residential Treatment Facility,

Physical Disabilities320800000X Community Based Residential Treatment Facility, Mental Illness320900000X Community Based Residential Treatment, Mental Retardation and/or

Developmental Disabilities322D00000X Residential Treatment Facility, Emotionally Disturbed Children323P00000X Psychiatric Residential

Treatment Facility324500000X Substance Abuse

Rehabilitation Facility3245S0500X Substance Abuse

Rehabilitation FacilitySubstance Abuse Treatment, Children

331L00000X Blood Bank332000000X Military/U.S. Coast Guard

Pharmacy332100000X Department of Veterans

Affairs (VA) Pharmacy332800000X Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy332900000X Non-Pharmacy Dispensing

Site332B00000X Durable Medical Equipment &

Medical Supplies332BC3200X Durable Medical Equipment &

Medical SuppliesCustomized Equipment

332BD1200X Durable Medical Equipment & Medical Supplies

Dialysis Equipment & Supplies

332BN1400X Durable Medical Equipment & Medical Supplies

Nursing Facility Supplies

332BP3500X Durable Medical Equipment & Medical Supplies

Parenteral & Enteral Nutrition

332BX2000X Durable Medical Equipment & Medical Supplies

Oxygen Equipment & Supplies

332G00000X Eye Bank332H00000X Eyewear Supplier (Equipment,

not the service)332S00000X Hearing Aid Equipment332U00000X Home Delivered Meals333300000X Emergency Response System

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Code Classification SpecializationCompanies

333600000X Pharmacy3336C0002X Pharmacy Clinic Pharmacy3336C0003X Pharmacy Community/Retail Pharmacy3336C0004X Pharmacy Compounding Pharmacy3336H0001X Pharmacy Home Infusion Therapy Pharmacy3336I0012X Pharmacy Institutional Pharmacy3336L0003X Pharmacy Long Term Care Pharmacy3336M0002X Pharmacy Mail Order Pharmacy3336M0003X Pharmacy Managed Care Organization Pharmacy3336N0007X Pharmacy Nuclear Pharmacy3336S0011X Pharmacy Specialty Pharmacy335E00000X Prosthetic/Orthotic Supplier335G00000X Medical Foods Supplier

335U00000XOrgan Procurement Organization

335V00000X Portable X-ray and/or Other Portable Diagnostic Imaging Supplier341600000X Ambulance3416A0800X Ambulance Air Transport3416L0300X Ambulance Land Transport3416S0300X Ambulance Water Transport

341800000XMilitary/U.S. Coast Guard Transport

3418M1110XMilitary/U.S. Coast Guard Transport

Military or U.S. Coast Guard Ambulance, Ground Transport

3418M1120XMilitary/U.S. Coast Guard Transport

Military or U.S. Coast Guard Ambulance, Air Transport

3418M1130XMilitary/U.S. Coast Guard Transport

Military or U.S. Coast Guard Ambulance, Water Transport

343800000XSecured Medical Transport (VAN)

343900000XNon-emergency Medical Transport (VAN)

344600000X Taxi344800000X Air Carrier347B00000X Bus347C00000X Private Vehicle347D00000X Train347E00000X Transportation Broker363A00000X Physician Assistant363AM0700X Physician Assistant Medical363AS0400X Physician Assistant Surgical Technologist363L00000X Nurse Practitioner363LA2100X Nurse Practitioner Acute Care363LA2200X Nurse Practitioner Adult Health363LC0200X Nurse Practitioner Critical Care Medicine363LC1500X Nurse Practitioner Community Health

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Code Classification Specialization363LF0000X Nurse Practitioner Family363LG0600X Nurse Practitioner Gerontology363LN0000X Nurse Practitioner Neonatal363LN0005X Nurse Practitioner Neonatal, Critical Care363LP0200X Nurse Practitioner Pediatrics363LP0222X Nurse Practitioner Pediatrics, Critical Care363LP0808X Nurse Practitioner Psych/Mental Health363LP1700X Nurse Practitioner Perinatal363LP2300X Nurse Practitioner Primary Care363LS0200X Nurse Practitioner School363LW0102X Nurse Practitioner Women's Health363LX0001X Nurse Practitioner Obstetrics & Gynecology363LX0106X Nurse Practitioner Occupational Health364S00000X Clinical Nurse Specialist364SA2100X Clinical Nurse Specialist Acute Care364SA2200X Clinical Nurse Specialist Adult Health364SC0200X Clinical Nurse Specialist Critical Care Medicine364SC1501X Clinical Nurse Specialist Community Health/Public Health364SC2300X Clinical Nurse Specialist Chronic Care364SE0003X Clinical Nurse Specialist Emergency364SE1400X Clinical Nurse Specialist Ethics364SF0001X Clinical Nurse Specialist Family Health364SG0600X Clinical Nurse Specialist Gerontology364SH0200X Clinical Nurse Specialist Home Health364SH1100X Clinical Nurse Specialist Holistic364SI0800X Clinical Nurse Specialist Informatics364SL0600X Clinical Nurse Specialist Long-Term Care364SM0705X Clinical Nurse Specialist Medical-Surgical364SN0000X Clinical Nurse Specialist Neonatal364SN0800X Clinical Nurse Specialist Neuroscience364SP0200X Clinical Nurse Specialist Pediatrics364SP0807X Clinical Nurse Specialist Psych/Mental Health, Child & Adolescent364SP0808X Clinical Nurse Specialist Psych/Mental Health364SP0809X Clinical Nurse Specialist Psych/Mental Health, Adult364SP0810X Clinical Nurse Specialist Psych/Mental Health, Child & Family364SP0811X Clinical Nurse Specialist Psych/Mental Health, Chronically Ill364SP0812X Clinical Nurse Specialist Psych/Mental Health, Community364SP0813X Clinical Nurse Specialist Psych/Mental Health, Geropsychiatric364SP1700X Clinical Nurse Specialist Perinatal364SP2800X Clinical Nurse Specialist Perioperative364SR0400X Clinical Nurse Specialist Rehabilitation364SS0200X Clinical Nurse Specialist School364ST0500X Clinical Nurse Specialist Transplantation364SW0102X Clinical Nurse Specialist Women's Health364SX0106X Clinical Nurse Specialist Occupational Health364SX0200X Clinical Nurse Specialist Oncology

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Code Classification Specialization364SX0204X Clinical Nurse Specialist Oncology, Pediatrics

367500000XNurse Anesthetist, Certified Registered

367A00000X Advanced Practice Midwife367H00000X Anesthesiologist Assistant372500000X Chore Provider372600000X Adult Companion

373H00000XDay Training/Habilitation Specialist

374700000X Technician3747A0650X Technician Attendant Care Provider3747P1801X Technician Personal Care Attendant374J00000X Doula

374K00000XReligious Nonmedical Practitioner

374T00000XReligious Nonmedical Nursing Personnel

374U00000X Home Health Aide376G00000X Nursing Home Administrator376J00000X Homemaker376K00000X Nurse's Aide385H00000X Respite Care385HR2050X Respite Care Respite Care Camp385HR2055X Respite Care Respite Care, Mental Illness, Child

385HR2060X Respite CareRespite Care, Mental Retardation and/or Developmental Disabilities, Child

385HR2065X Respite Care Respite Care, Physical Disabilities, Child390200000X Student in an Organized Health Care Education/Training Program405300000X Prevention Professional

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Exhibit 2 – Examples for Primary Designation of Specialist

(This is not intended to be an all-inclusive list.)

Allergy and ImmunologyAudiologyEndocrinologyFamily MedicineGastroenterologyGeriatricGynecologic OncologyHospitalistInfectious DiseaseNephrologyOccupational MedicineOncology, HematologyOrthopedicsOtolaryngologyPathologyPediatric SpecialistPhysical MedicinePhysician ExtenderPulmonary MedicineRadiation OncologyRehabilitationSurgery (various)Transplant Surgery

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Exhibit 3 – Long Term Services & Supports (LTSS) Waiver Procedure Codes

REQUIRED FOR PROVIDER DESIGNATION 06

LTC Waiver Procedure Code

Modifier Description

S5102 Adult Day Health CareT1999 Assistive Technology OnlyT1999 U5 Assistive Technology Maintenance Costs OnlyT1000 U1 Congregate Nursing/RN T1001 U1 Congregate Nursing/LPNT1031 TE Congregate Respite Nursing/LPNT1030 TD Congregate Respite Nursing/RN99199 U4 Environmental Modification, Maintenance Costs OnlyS5165 Environmental Modifications OnlyS5160 PERS InstallationS5160 U1 PERS and Medication Monitoring InstallationS5185 PERS Medication MonitoringS5161 PERS MonitoringH2021 TD PERS Nursing Services/RNH2021 TE PERS Nursing Services/LPNT1019 Personal CareT1005 Respite Care

S9125TDTE Respite Care LPN

S5109 Service Facilitation Consumer Training VisitH2000 Service Facilitation Initial Comprehensive VisitS5116 Service Facilitation Management Training HoursT1028 Service Facilitation Reassessment Visit99509 Service Facilitation Routine VisitT1003 Skilled Nursing Services/LPNT1002 Skilled Nursing Services/RNH2015 Transition Coordination

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Exhibit 4 – Addiction, Recovery and Treatment Services (ARTS)

REQUIRED FOR PROVIDER DESIGNATION 08

ASAM Level of Care

Valid Value

s

ASAM Description

2.1 1 Intensive Outpatient Services2.5 2 Partial Hospitalization Services3.1 3 Clinically Managed Low-Intensity Residential Services3.3 4 Clinically Managed Population-Specific High-Intensity Residential Services

(Adult)3.5 5 Clinically Managed High-Intensity Residential Services (Adult)

Clinically Managed Medium Intensity (Adolescent)3.5 6 Specialty Unit3.7 7 Medically Monitored Intensive Inpatient Services (Adult)

Medically Monitored High Intensity Inpatient Services (Adolescent)3.7 8 Inpatient4.0 9 Medically Managed Intensive InpatientOTP 10 Opioid Treatment Program (OTP)

OBOT 11 Office-Based Opioid Treatment (OBOT)n/a 12 Substance Use Care Management

Procedure code corresponding to each of the ASAM level of care will be provided by DMAS in the future. In the meantime, please designate providers to each level based on the level of services they can provide under the contract with your health plan.

Place holder/reminder when all of the ARTS services are defined by procedure codes and their corresponding ASAM Level.

T1012 Peer Support Services, Individual Substance Use Disorder – effective 07/01/2017S9445 Peer Support Services, Group Substance Use Disorder – effective 07/01/2017

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Exhibit 5 – Community Mental Health Rehabilitation Services (CMHRS) Procedure Codes

REQUIRED FOR PROVIDER DESIGNATION 09

Service Procedure

CodeModifier Service Name

The following CMHRS services require member to travel to provider:H2017 Psychosocial RehabH0035 HB Day Treatment/Partial Hospitalization, AdultH0035 HA Therapeutic Day Treatment (TDT) School Day, ChildH0035 HA & UG TDT Afterschool, Child – effective 12/01/2016H0035 HA & U7 TDT Summer Program, Child – effective 12/01/2016

The following CMHRS services require the provider to travel to the member:H0039 Intensive Community Treatment (ICT)H2019 Crisis StabilizationH0036 Crisis InterventionH2012 Intensive In-Home (IIH)H0046 Mental Health Skill-building Services (MHSS)H0023 Mental Health Case Management, can be performed only by CSBsH2033 Behavioral TherapyH0024 Peer Support Services, Individual Mental Health – effective

07/01/2017H0025 Peer Support Services, Group Mental Health – effective 07/01/2017

Some of the above services require assessments before the service code is billed H0031 IIH AssessmentH0032 U6 Psychosocial Rehab AssessmentH0032 U7 Day Treatment/Partial Hospitalization Assessment, AdultH0032 U7 TDT Assessment, ChildH0032 U8 MHSS AssessmentH0032 U9 ICT AssessmentH0032 UA Behavioral Therapy Assessment

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Exhibit 6a – Virginia City and County FIPS Codes

CCC Plus REGIONS BY LOCALITY AND FIPSCENTRAL REGION

007 AMELIA 085 HANOVER 730 PETERSBURG025 BRUNSWICK 087 HENRICO 145 POWHATAN033 CAROLINE 670 HOPEWELL 147 PRINCE EDWARD036 CHARLES CITY 097 KING AND QUEEN 149 PRINCE GEORGE041 CHESTERFIELD 099 KING GEORGE 760 RICHMOND CITY570 COLONIAL HEIGHTS 101 KING WILLIAM 159 RICHMOND CO.049 CUMBERLAND 103 LANCASTER 175 SOUTHAMPTON053 DINWIDDIE 111 LUNENBURG 177 SPOTSYLVANIA595 EMPORIA 115 MATHEWS 179 STAFFORD057 ESSEX 117 MECKLENBURG 181 SURRY620 FRANKLIN CITY 119 MIDDLESEX 183 SUSSEX630 FREDERICKSBURG 127 NEW KENT 193 WESTMORELAND075 GOOCHLAND 133 NORTHUMBERLAND081 GREENSVILLE 135 NOTTOWAY

TIDEWATER REGION001 ACCOMACK 095 JAMES CITY CO. 740 PORTSMOUTH550 CHESAPEAKE 700 NEWPORT NEWS 800 SUFFOLK073 GLOUCESTER 710 NORFOLK 810 VIRGINIA BEACH650 HAMPTON 131 NORTHAMPTON 830 WILLIAMSBURG093 ISLE OF WIGHT 735 POQUOSON 199 YORK

NORTHERN & WINCHESTER REGION510 ALEXANDRIA 610 FALLS CHURCH 139 PAGE013 ARLINGTON 061 FAUQUIER 153 PRINCE WILLIAM043 CLARKE 069 FREDERICK 157 RAPPAHANNOCK047 CULPEPER 107 LOUDOUN 171 SHENANDOAH600 FAIRFAX CITY 683 MANASSAS CITY 187 WARREN059 FAIRFAX CO. 685 MANASSAS PARK 840 WINCHESTER

CHARLOTTESVILLE/WESTERN REGION003 ALBEMARLE 590 DANVILLE 125 NELSON009 AMHERST 065 FLUVANNA 137 ORANGE011 APPOMATTOX 079 GREENE 143 PITTSYLVANIA015 AUGUSTA 083 HALIFAX 165 ROCKINGHAM029 BUCKINGHAM 660 HARRISONBURG 790 STAUNTON031 CAMPBELL 109 LOUISA 820 WAYNESBORO037 CHARLOTTE 680 LYNCHBURG540 CHARLOTTESVILLE 113 MADISON

ROANOKE/ALLEGHANY REGION005 ALLEGHANY 067 FRANKLIN CO. 155 PULASKI017 BATH 071 GILES 750 RADFORD019 BEDFORD 089 HENRY 770 ROANOKE CITY023 BOTETOURT 091 HIGHLAND 161 ROANOKE CO.530 BUENA VISTA 678 LEXINGTON 163 ROCKBRIDGE580 COVINGTON 690 MARTINSVILLE 775 SALEM045 CRAIG 121 MONTGOMERY 197 WYTHE063 FLOYD 141 PATRICK

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CCC Plus REGIONS BY LOCALITY AND FIPSSOUTHWEST REGION

021 BLAND 640 GALAX 169 SCOTT520 BRISTOL 077 GRAYSON 173 SMYTH027 BUCHANAN 105 LEE 185 TAZEWELL035 CARROLL 720 NORTON 191 WASHINGTON051 DICKENSON 167 RUSSELL 195 WISE

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Exhibit 6b – State FIPS CodesState

AbbreviationFIPS Code State Name State

AbbreviationFIPS Code State Name

AL 01 ALABAMA NV 32 NEVADAAK 02 ALASKA NH 33 NEW HAMPSHIREAZ 04 ARIZONA NJ 34 NEW JERSEYAR 05 ARKANSAS NM 35 NEW MEXICOCA 06 CALIFORNIA NY 36 NEW YORKCO 08 COLORADO NC 37 NORTH CAROLINACT 09 CONNECTICUT ND 38 NORTH DAKOTADE 10 DELAWARE OH 39 OHIODC 11 DISTRICT OF COLUMBIA OK 40 OKLAHOMAFL 12 FLORIDA OR 41 OREGONGA 13 GEORGIA PA 42 PENNSYLVANIAHI 15 HAWAII RI 44 RHODE ISLANDID 16 IDAHO SC 45 SOUTH CAROLINAIL 17 ILLINOIS SD 46 SOUTH DAKOTAIN 18 INDIANA TN 47 TENNESSEEIA 19 IOWA TX 48 TEXASKS 20 KANSAS UT 49 UTAHKY 21 KENTUCKY VT 50 VERMONTLA 22 LOUISIANA VA 51 VIRGINIAME 23 MAINE WA 53 WASHINGTONMD 24 MARYLAND WV 54 WEST VIRGINIAMA 25 MASSACHUSETTS WI 55 WISCONSINMI 26 MICHIGAN WY 56 WYOMINGMN 27 MINNESOTA AS 60 AMERICAN SAMOAMS 28 MISSISSIPPI GU 66 GUAMMO 29 MISSOURI PR 72 PUERTO RICOMT 30 MONTANA VI 78 VIRGIN ISLANDSNE 31 NEBRASKA

VirginiaNeighboring States

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Exhibit 7 – Other Language Spoken

Other Language Spoken01-English02-Spanish03-German04-French05-Vietnamese06-Korean07-Navajo08-Tagalog09-Portuguese10-Italian11-Arabic12-Dakota13-Yupik14-Polish15-French Creole

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Exhibit 8 –Network Adequacy Standards

All provider designations must meet Network Adequacy Standards. The following chart shows Time and Distance Standards for those designations where Federal or State regulations require. This chart should not be interpreted as the sole evaluation method of Network Adequacy Standards.

Provider Designation (PD)

Regulations and/or Contract include

Time and Distance Requirements?

Time (Urban) Time (Rural) Distance or Travel (Urban)

Distance or Travel (Rural)

01 – Primary Care Provider (PCP) Yes At least 2 PCPs w/in 30 minutes

At least 2 PCPs w/in 45 minutes

At least 2 PCPs w/in 15 miles

At least 2 PCPs w/in 30 miles

02 – Pediatricians Yes At least 2 Pediatricians w/in 30

minutes

At least 2 Pediatricians w/in 45

minutes

At least 2 Pediatricians w/in 15

miles

At least 2 Pediatricians w/in 30

miles03 – Specialist Yes At least 2 Providers

w/in 45 minutesAt least 2 Providers

w/in 75 minutesAt least 2 Providers

w/in 30 milesAt least 2 Providers

w/in 60 miles04 – Health Department (HD) No05 – Hospice No06 – Long Term Services & Supports (LTSS) Waiver Provider S5102-Adult Day Care

Center

Yes – Member travels to provider

At least 1 Provider w/in 45 minutes

At least 1 Provider w/in 75 minutes

At least 1 Provider w/in 30 miles

At least 1 Provider w/in 60 miles

06 – Long Term Services & Supports (LTSS) Waiver Provider S5109-Service Facilitation

Consumer Training Visit H2000-Service Facilitation

Comprehensive Visit S5116-Service Facilitation

Management Training Hours T1028-Service Facilitation

Reassessment Visit T1002-Skilled Nursing

Services/RN T1003-Skilled Nursing

Services/LPN T1000-U1-Congregate

Yes – Provider travels to member

¹Choice of at least 2 Providers for any service area locality

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Provider Designation (PD)

Regulations and/or Contract include

Time and Distance Requirements?

Time (Urban) Time (Rural) Distance or Travel (Urban)

Distance or Travel (Rural)

Nursing/RN T1001-U1-Congregate

Nursing/LPN T1031-TE-Congregate

Respite Nursing/LPN T1030-TD-Congregate

Respite Nursing/RN T1019-Personal Care T1005-Respite Care S9125-Respite Care/LPN 99509-Service Facilitation

Routine Visit H2015-Transition

Coordination06 – Long Term Services & Supports (LTSS) Waiver Provider T1999-Assistive Technology

Only T1999-U5-Assistive

Technology Maintenance Costs Only

S5165-Environmental Modification Only

99199-U4- Environmental Modification, Maintenance Costs Only

S5160- PERS Installation S5160-U1- PERS and

Medication Monitoring Installation

S5185- PERS Medication Monitoring

S5161- PERS Monitoring

Yes – Provider travels to member

NOTE for the following, Health Plans can have 1 Provider that covers a specific service area/locality:

Assistive Technology Only Environmental Modification Personal Emergency Response Systems (PERS)

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Provider Designation (PD)

Regulations and/or Contract include

Time and Distance Requirements?

Time (Urban) Time (Rural) Distance or Travel (Urban)

Distance or Travel (Rural)

H2021-TD-PERS Nursing Services/RN

H2021-TE-PERS Nursing Services/LPN

07 – Outpatient Mental Health Yes At least 2 Providers w/in 45 minutes

At least 2 Providers w/in 75 minutes

At least 2 Providers w/in 30 miles

At least 2 Providers w/in 60 miles

08 – Addiction, Recovery and Treatment Services (ARTS)

²Yes At least 2 Providers w/in 45 minutes

At least 2 Providers w/in 75 minutes

At least 2 Providers w/in 30 miles

At least 2 Providers w/in 60 miles

09 – Community Mental Health Rehabilitation Services (CMHRS) H2017 - Psychosocial Rehab H0035-HB - Day

Treatment/Partial Hospitalization, Adults

H0035-HA - Therapeutic Day Treatment (TDT) School Day, Child

H0035-HA & UG - TDT Afterschool, Child

H0035-HA & U7 - TDT Summer Program, Child

Yes – Member travels to provider

At least 2 Providers w/in 45 minutes

At least 2 Providers w/in 75 minutes

At least 2 Providers w/in 30 miles

At least 2 Providers w/in 60 miles

09 – Community Mental Health Rehabilitation Services (CMHRS) H0039 - Intensive

Community Treatment (ICT) H2019 - Crisis Stabilization H0036 - Crisis Intervention H2012 - Intensive In-Home

(IIH) H0046 - Mental Health Skill-

building Services (MHSS) H2033 - Behavioral Therapy H0024 - Peer Support

Yes – Provider travels to member

¹Choice of at least 2 Providers for any service area locality

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Provider Designation (PD)

Regulations and/or Contract include

Time and Distance Requirements?

Time (Urban) Time (Rural) Distance or Travel (Urban)

Distance or Travel (Rural)

Services, Individual Mental Health

H0025 - Peer Support Services, Group Mental Health

09 – Community Mental Health Rehabilitation Services (CMHRS) H0023 - Mental Health Case

Management

Yes – Provider travels to member

Choice of the CSB in network in the locality in which the member is served. The CSB is currently the only option allowed to bill/perform this service due to regulations.

10 – Hospital – Psychiatric Yes At least 1 Provider w/in 45 minutes

At least 1 Provider w/in 75 minutes

At least 1 Provider w/in 30 miles

At least 1 Provider w/in 60 miles

11 – Hospital – General Yes At least 1 Provider w/in 45 minutes

At least 1 Provider w/in 75 minutes

At least 1 Provider w/in 30 miles

At least 1 Provider w/in 60 miles

12 – Hospital – Physical Rehabilitation

Yes At least 1 Provider w/in 45 minutes

At least 1 Provider w/in 75 minutes

At least 1 Provider w/in 30 miles

At least 1 Provider w/in 60 miles

13 – Urgent Care Yes At least 1 Provider w/in 45 minutes

At least 1 Provider w/in 75 minutes

At least 1 Provider w/in 30 miles

At least 1 Provider w/in 60 miles

14 – Nursing Facility Yes At least 2 Providers w/in 45 minutes

At least 2 Providers w/in 75 minutes

At least 2 Providers w/in 30 miles

At least 2 Providers w/in 60 miles

16 – Outpatient Rehabilitation (PT/OT/SP)

Yes At least 2 Providers w/in 45 minutes

At least 2 Providers w/in 75 minutes

At least 2 Providers w/in 30 miles

At least 2 Providers w/in 60 miles

17 – Durable Medical Equipment (DME) and Supplies

Yes ¹Choice of at least 1 provider for any service area locality

18 – Radiology Yes At least 2 Providers w/in 45 minutes

At least 2 Provider w/in 75 minutes

At least 2 Providers w/in 30 miles

At least 2 Providers w/in 60 miles

19 – Home Health Agency Yes ¹Choice of a least 2 Providers for any service are locality20 – Laboratory Yes At least 1 Provider

w/in 45 minutesAt least 1 Provider w/in 75 minutes

At least 1 Provider w/in 30 miles

At least 1 Provider w/in 60 miles

21 – Pharmacy Yes At least 2 Providers w/in 45 minutes

At least 2 Provider w/in 75 minutes

At least 2 Providers w/in 30 miles

At least 2 Providers w/in 60 miles

22 – Vision Yes At least 2 Providers w/in 45 minutes

At least 2 Provider w/in 75 minutes

At least 2 Providers w/in 30 miles

At least 2 Providers w/in 60 miles

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Provider Designation (PD)

Regulations and/or Contract include

Time and Distance Requirements?

Time (Urban) Time (Rural) Distance or Travel (Urban)

Distance or Travel (Rural)

23 – Transportation No24 – Other No25 – OB/GYN Yes At least 2 Providers

w/in 45 minutesAt least 2 Provider w/in 75 minutes

At least 2 Providers w/in 30 miles

At least 2 Providers w/in 60 miles

26 – Federal Qualified Health Center (FQHC)

No

27 – Community Service Board (CSB)

No

28 – Rural Health Center (RHC) NoEarly Intervention (EI) Provider No

¹For providers that travel to a members home to deliver services, in addition to meeting choice requirement if applicable, CCC Plus providers are those that are located in the same city/county where the Member lives. CCC Plus providers can also be those who are not located in the city/county of the Member’s residence and are willing and able to service residents of that city/county.² Does not apply to Residential

NOTE: For providers / members in the Roanoke/Alleghany and Southwest Regions access standards will be based on Rural Time and Distance parameters.

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