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1
Managed Care Organization Reports Companion Guide 11/1/2013
South Carolina Dept of Health and Human Services
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2
Contents
MCO REPORTS TO SCDHHS
.............................................................................................................
3
MODEL ATTESTATION LETTER
............................................................................
4 NEW COUNTY OR VALIDATION OF COUNTY NETWORK
.......................................... 5 MONTHLY-REPORTS
NETWORK PROVIDER SPREADSHEET REQUIREMENTS ........ 100
MONTHLY-REPORTS SUBCONTRACT UPDATES
.................................................. 11
MONTHLY-MANAGED CARE Q&A GRID
............................................................ 36
MONTHLY- MATERNITY KICKER REPORTING
....................................................... 37 MONTHLY-
INCENTIVE REPORTING
....................................................................
37 MONTHLY-FRAUD &ABUSE REPORTING
............................................................ 46
QUARTERLY-GRIEVANCE AND APPEALS LOG WITH SUMMARY INFORMATION
........ 46 QUARTERLY-FQH/RHC WRAP DETAIL AND SUMMARY INFORMATION
................. 47 Quarterly-FRAUD &ABUSE REPORTING
............................................................. 56
CAPITATION RATE CALCULATION SHEET (CRCS)
.............................................. 56 ENCLOSURE 1
.............................................................................................
70 ENCLOSURE 2
.............................................................................................
75 ENCLOSURE 3
.............................................................................................
88 ENCLOSURE 4
.............................................................................................
95
FORMS
..................................................................................................................................................
97
PROVIDER FRAUD AND ABUSE MCO REFERRAL FORM…………..….……………..98
Member Fraud and Abuse MCO Referral Form…………………………….100
UNIVERSAL MEDICATION PRIOR AUTHORIZATION FORM
................................... 101 UNIVERSAL NEWBORN PRIOR
AUTHORIZATION FORM....................................... 102
UNIVERSAL 17-P AUTHORIZATION FORM
......................................................... 103
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3
MCO REPORTS TO SCDHHS
This reports companion guide is specifically designated for
reporting formats that are required by the division of managed
care. There may be other agency required reports that are not
specifically addressed within this guide. The requirements for
these types of reports are contained within P&P if you have
questions about reporting formats please contact your program
manager and they will direct you to the correct area for follow
up.
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4
Model Attestation Letter To be attached to all reports
(Company Letter Head) Attestation for Reports
Date______________ I, ________________, as (Title) for (Name of
Company), do hereby attest, based upon my best knowledge,
information and belief, that the data provided in the _________
Report(s) is accurate, true, and complete. I understand that should
SCDHHS determine the submitted information is inaccurate, untrue,
or incomplete, (Name of company) may be subject to liquidated
damages as outlined in Section 13.3 of the contract or sanctions
and/or fines as outlined in Section 13 of the contract.
__________________________ ______________________ Signature/Title
Date
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5
New County or Validation of County Network Frequency –As Needed
(Please see section 2-11 of the P&P guide)
NETWORK PROVIDER AND SUBCONTRACTOR LISTING SPREADSHEET
SERVICE STATUS SCDHHS COMMENTS
ANCILLARY SERVICES:
Ambulance Services 3
Durable Medical Equipment 1
Orthotics/Prosthetics 1
Home Health 1
Infusion Therapy** 1 Follow proximity guidelines for
specialists
Laboratory/X-Ray 1
Pharmacies* 1 Follow proximity guidelines for Primary Care
Providers
Hospitals 1 Follow proximity guidelines for specialists
PRIMARY CARE PROVIDERS:
Family/General Practice 1
Internal Medicine 1
RHC's/FQHC's 2 Not required but may be utilized as a PCP
provider
Pediatrics 1
OB/GYN 1 Serving as PCP for pregnant women, follow Proximity
Guidelines for Primary Care Providers
SPECIALISTS
Allergy/Immunology 1
Anesthesiology 3
Audiology 3
Cardiology 1
Chiropractic 3
Dental 4
Dermatology 1
Emergency Medical 3
Endocrinology and Metab 1
Gastroenterology 1
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6
NETWORK PROVIDER AND SUBCONTRACTOR LISTING SPREADSHEET
SERVICE
SPECIALISTS
Hematology/Oncology 1
Infectious Diseases 1
Licensed Independent Social Worker
1
Licensed Professional Counselor
1
Licensed Marriage & Family Therapist
1
Neonatology 3
Nephrology 1
Neurology 1
Nuclear Medicine 3
OB/GYN 1
Ophthalmology 1
Optician 4
Optometry 1
Orthopedics 1
Otorhinolaryngology 1
Pathology 3
Pediatrics, Allergy 3
Pediatrics, Cardiology 3
Podiatry 3
Psychiatry (private) 1
Psychologist 1
Pulmonary Medicine 1
Radiology, Diagnostic 3
Radiology, Therapeutic 3
Rheumatology 1
Surgery - General 1
Surgery - Thoracic 3
Surgery - Cardiovascular 3
Surgery - Colon and Rectal 3
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7
NETWORK PROVIDER AND SUBCONTRACTOR LISTING SPREADSHEET
SERVICE
SPECIALISTS
Surgery - Neurological 3
Surgery - Pediatric 3
Surgery - Plastic 3
Urology 1
Private Physical Therapy 1
Private Speech Therapy 1
Private Occupational Therapy
1
Hospital Based Physical Therapy***
1
Hospital Based Speech Therapy***
1
Hospital Based Occupational Therapy***
1
Long-Term Care 3 MCO responsibility begins once the Medicaid MCO
Member has been approved for, and admitted to the LTC facility. If
the Medicaid MCO Member stays in the facility for 90 consecutive
days, the Medicaid MCO Member will be disenrolled from the MCO at
the earliest opportunity by SCDHHS. The MCO financial
responsibility will not exceed 120 days total.
Status 1 = Required
2 = Not required unless serving as PCP for the county
3 = Attestation
4 = Attest, if offered
Proximity Guidelines
*Primary Care Providers should be within a maximum of 30 miles
of the Medicaid MCO Member’s place of residence
**Specialty Care Providers should be within a maximum of 50
miles of the Medicaid MCO Member’s place of residence
SCDHHS considers all the facts and circumstances in reviewing
Subcontracts and networks. SCDHHS may grant exceptions to its’
stated criteria on case-by-case basis.
***Therapies are in-patient or out-patient based.
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New County or Validation of County Network Continued Frequency
–As Needed (Please see section 2-11 of the P&P guide)
SERVICES STATUS
NAME (or Attest) if no
contract
GROUP OR PRACTICE
NAME STREET ADDRESS ADDRESS 2 CITY COUNTY STATE ZIP
TELEPHONE
NUMBER(S) MEDICAID #
ACCEPTING
NEW CLIENTS
Y/N AGE LIMITS
DAYS OF
OPERATION
HOURS OF
OPERATION
CONTRACT
DATES (START-
END)
ANCILLARY SERVICESAmbulance Services 3
Durable Medical Equipment 1
Orthotics/Prostetics 1
Home Health 1
Infusion Therapy 1
Follow Proximity Guidelines for
Specialists
Laboratory/X-Ray 1
Pharmacies 1
Follow Proximity Guidelines for
Primary Care Providers
HOSPITALS 1
Follow Proximity Guidelines for
Specialists
PRIMARY CAREFamily/Gen. Practice 1
Internal Medicine 1
RHC's/FQHC's 2
Not Required, but may be utilized as
a PCP provider
Pediatrics 1
OB-GYN 1
Serving as PCP for pregnant women,
follow Proximity Guidelines for
Primary Care Providers
SPECIALISTSAllergy/Immunology 1
Anesthesiology 3
Audiology 3
Cardiology 1
Chiropractic 3
Dental 4
Dermatology 1
Emergency Medical 3
Endocrinology and Metab 1
Gastroenterology 1
Hematology/Oncology 1
Infectious Diseases 1
Licensed Independent Social Worker 1
Licensed Professional Counselor 1
Licensed Marriage and Family Therapist 1
Neonatology 3
Nephrology 1
Neurology 1
Nuclear Medicine 3
Version Dated March 1, 2013
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9
New County or Validation of County Network Continued Frequency
–As Needed (Please see section 2-11 of the P&P guide)
SERVICES STATUS
NAME (or Attest) if no
contract
GROUP OR PRACTICE
NAME STREET ADDRESS ADDRESS 2 CITY COUNTY STATE ZIP
TELEPHONE
NUMBER(S) MEDICAID #
ACCEPTING
NEW CLIENTS
Y/N AGE LIMITS
DAYS OF
OPERATION
HOURS OF
OPERATION
CONTRACT
DATES (START-
END)
OB/GYN 1
Ophthalmology 1
Optician 4
Optometry 1
Orthopedics 1
Otorhinolryngology 1
Pathology 3
Pediatrics, Allergy 3
Pediatrics, Cardiology 3
Podiatry 3
Psychiatry (private) 1
Psychologists 1
Pulmonary Medicine 1
Radiology, Diagnostic 3
Radiology, Therapeutic 3
Rheumatology 1
Surgery - General 1
Surgery - Thoracic 3
Surgery - Cardiovascular 3
Surgery - Colon and Rectal 3
Sugery - Neurological 3
Surgery - Pediatric 3
Surgery - Plastic 3
Urology 1
Private Physical Therapy 1
Private Speech Therapy 1
Private Occupational Therapy 1
Hospital Based Physical Therapy *** 1
Hospital Based Speech Therapy *** 1
Hospital Based Occupational Therapy *** 1
Long Term Care 3
1 = Required
2 = Not required unless serving as PCP for the county
3 = Attestation
4 = Attestation, if offered
*** Therapies are in-patient or out-patient based
Attestation - The MCO attests that the service will be arranged
and
provided through any necessary means, including
out-of-network
providers.
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10
Network Provider and MCO Listing Spreadsheet Requirements
Frequency – Monthly
Provide the following information regarding all network
physician providers: 1. Practitioner Last Name, First Name and
Title - For types of service such as primary care
providers and specialist, list the practitioner’s name and
practitioner title such as MD, NP (Nurse Practitioner), PA
(Physician Assistant), etc.
2. Practice Name/Provider Name - Indicate the name of the
provider. For practitioners indicate the professional
association/group name, if applicable.
3. Street Address, City, County, State, Zip Code, Telephone
Number of Practice/Provider 4. Office hours- the hours the
physician is actually available to see the MCO Member (i.e. 8-5) 5.
Days of Operation-state what day the physician is actually in the
office. (i.e. Monday through
–Friday or Tuesday and Thursday , or any variations etc) 6.
License Number - Indicate the provider/practitioner license number,
if appropriate. 7. NPI National Provider ID – Indicated the
provider/practitioner’s Medicaid provider number, if
they are a Medicaid provider. 8. Restrictions - Indicate any
restrictions or limitations of a provider’s scope of service.
For
instance, for a physician who only sees patients up to age 18,
indicate < 18; Should an OB/GYN not accept high risk patients,
indicate this clearly in a short descriptive narrative.
9. County Served – Indicate which county or counties the
provider serves. Do so by listing all
alphabetically
On separate tabs to the spreadsheet, please provide listings of
all 1) new 2) terminated and 3) Current network providers for the
month. New providers are defined as those that are newly contracted
in the first month of participation. Terminated providers are those
who are no longer contracted in the month. The second month that
the provider has been terminated they would no longer be reported
on the file. Current providers are those that are ongoing and
contracted any new providers in their second month of contracting
would be reported on this tab. For these tabs, please provide the
information requested in items 1-9 above.
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11
Monthly Reports Worksheet Tab 1- New PCP
Worksheet Tab 2- Terminated PCP
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Primary Care Physicians: Family/General Practice
Primary Care Physicians: Internal Medicine
Primary Care Physicians: Pediatrics
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Primary Care Physicians: Family/General Practice
Primary Care Physicians: Internal Medicine
Primary Care Physicians: Pediatrics
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12
Worksheet Tab 3- Current Network
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Primary Care Physicians: Family/General Practice
Primary Care Physicians: Internal Medicine
Primary Care Physicians: Pediatrics
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13
Excel Spreadsheet Worksheet Tab 1- New Specialty Physicians
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Specialty Physicians: Certified NurseMidwife/Licensed
Midwife
Specialty Physicians: Chiropractor
Specialty Physicians: Dermatologist
Specialty Physicians: Endrocrinologist
Specialty Physicians: Pediatric Endrocrinologist
Specialty Physicians: Gastroenterologist
Specialty Physicians: Allergist
Specialty Physicians: Anesthesiologist
Specialty Physicians: Cardiologist
Specialty Physicians: Pediatric Cardiologist
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14
Excel Spreadsheet Worksheet Tab 1- New Specialty Physicians
Continued
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Specialty Physicians: Pediatric Neurologist
Specialty Physicians: Neurosurgeon
Specialty Physicians: Obstetrics/Gynecology
Specialty Physicians: Oncologist
Specialty Physicians: Opthamologist
Specialty Physicians: Optometrist
Specialty Physicians: General Surgery
Specialty Physicians: Infectious Disease/AIDS
Specialty Physicians: Nephrologist
Specialty Physicians: Pediatric Nephrologist
Specialty Physicians: Neurologist
Specialty Physicians: General Surgery
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15
Excel Spreadsheet Worksheet Tab 1- New Specialty Physicians
Continued
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Specialty Physicians: Pulmonologist
Specialty Physicians: Radiologist
Specialty Physicians: Urologist
Specialty Physicians: Occupational
Specialty Physicians: Occupational Pediatric
Specialty Physicians: Othopedist
Specialty Physicians: Pediatric Orthopedist
Specialty Physicians: Otolaryngologist
Specialty Physicians: Pathologist
Specialty Physicians: Podiatrist
Specialty Physicians: Psychiatrist
Specialty Physicians: Oral Surgeon
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Specialty Physicians: Urologist
Specialty Therapist: Occupational
Specialty Therapist: Occupational - Pediatric
Specialty Physicians: Podiatrist
Specialty Physicians: Psychiatrist
Specialty Physicians: Pulmonologist
Specialty Physicians: Radiologist
Specialty Physicians: Oral Surgeon
Specialty Physicians: Orthopedist
Specialty Physicians: Pediatric Orthopedist
Specialty Physicians: Otolaryngologist
Specialty Physicians: Pathologist
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16
Excel Spreadsheet Worksheet Tab 1- New Specialty Physicians
Continued
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Specialty Therapist: Physical Pediatric
Specialty Therapist: Speech
Specialty Therapist: Speech Pediatric
Specialty Therapist: Physical
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Specialty Therapist: Speech - Pediatric
Specialty Therapist: Physical - Pediatric
Specialty Therapist: Respiratory
Specialty Therapist: Respiratory - Pediatric
Specialty Therapist: Speech
Specialty Therapist: Physical
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17
Excel Spreadsheet Worksheet Tab 2- Terminated Specialty
Physicians
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Specialty Physicians: Certified NurseMidwife/Licensed
Midwife
Specialty Physicians: Chiropractor
Specialty Physicians: Dermatologist
Specialty Physicians: Endrocrinologist
Specialty Physicians: Pediatric Endrocrinologist
Specialty Physicians: Gastroenterologist
Specialty Physicians: Allergist
Specialty Physicians: Anesthesiologist
Specialty Physicians: Cardiologist
Specialty Physicians: Pediatric Cardiologist
-
18
Excel Spreadsheet Worksheet Tab 2- Terminated Specialty
Physicians Continued
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Specialty Physicians: Pediatric Neurologist
Specialty Physicians: Neurosurgeon
Specialty Physicians: Obstetrics/Gynecology
Specialty Physicians: Oncologist
Specialty Physicians: Opthamologist
Specialty Physicians: Optometrist
Specialty Physicians: General Surgery
Specialty Physicians: Infectious Disease/AIDS
Specialty Physicians: Nephrologist
Specialty Physicians: Pediatric Nephrologist
Specialty Physicians: Neurologist
Specialty Physicians: General Surgery
-
19
Excel Spreadsheet Worksheet Tab 2- Terminated Specialty
Physicians Continued
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Specialty Physicians: Pulmonologist
Specialty Physicians: Radiologist
Specialty Physicians: Urologist
Specialty Physicians: Occupational
Specialty Physicians: Occupational Pediatric
Specialty Physicians: Othopedist
Specialty Physicians: Pediatric Orthopedist
Specialty Physicians: Otolaryngologist
Specialty Physicians: Pathologist
Specialty Physicians: Podiatrist
Specialty Physicians: Psychiatrist
Specialty Physicians: Oral Surgeon
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Specialty Physicians: Urologist
Specialty Therapist: Occupational
Specialty Therapist: Occupational - Pediatric
Specialty Physicians: Podiatrist
Specialty Physicians: Psychiatrist
Specialty Physicians: Pulmonologist
Specialty Physicians: Radiologist
Specialty Physicians: Oral Surgeon
Specialty Physicians: Orthopedist
Specialty Physicians: Pediatric Orthopedist
Specialty Physicians: Otolaryngologist
Specialty Physicians: Pathologist
-
20
Excel Spreadsheet Worksheet Tab 2- Terminated Specialty
Physicians Continued
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Specialty Therapist: Physical Pediatric
Specialty Therapist: Speech
Specialty Therapist: Speech Pediatric
Specialty Therapist: Physical
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Specialty Therapist: Speech - Pediatric
Specialty Therapist: Physical - Pediatric
Specialty Therapist: Respiratory
Specialty Therapist: Respiratory - Pediatric
Specialty Therapist: Speech
Specialty Therapist: Physical
-
21
Excel Spreadsheet Worksheet Tab 3- Current Specialty
Physicians
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Specialty Physicians: Certified NurseMidwife/Licensed
Midwife
Specialty Physicians: Chiropractor
Specialty Physicians: Dermatologist
Specialty Physicians: Endrocrinologist
Specialty Physicians: Pediatric Endrocrinologist
Specialty Physicians: Gastroenterologist
Specialty Physicians: Allergist
Specialty Physicians: Anesthesiologist
Specialty Physicians: Cardiologist
Specialty Physicians: Pediatric Cardiologist
-
22
Excel Spreadsheet Worksheet Tab 3- Current Specialty Physicians
Continued
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Specialty Physicians: Pediatric Neurologist
Specialty Physicians: Neurosurgeon
Specialty Physicians: Obstetrics/Gynecology
Specialty Physicians: Oncologist
Specialty Physicians: Opthamologist
Specialty Physicians: Optometrist
Specialty Physicians: General Surgery
Specialty Physicians: Infectious Disease/AIDS
Specialty Physicians: Nephrologist
Specialty Physicians: Pediatric Nephrologist
Specialty Physicians: Neurologist
Specialty Physicians: General Surgery
-
23
Excel Spreadsheet Worksheet Tab 3- Current Specialty Physicians
Continued
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Specialty Physicians: Pulmonologist
Specialty Physicians: Radiologist
Specialty Physicians: Urologist
Specialty Physicians: Occupational
Specialty Physicians: Occupational Pediatric
Specialty Physicians: Othopedist
Specialty Physicians: Pediatric Orthopedist
Specialty Physicians: Otolaryngologist
Specialty Physicians: Pathologist
Specialty Physicians: Podiatrist
Specialty Physicians: Psychiatrist
Specialty Physicians: Oral Surgeon
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Specialty Physicians: Urologist
Specialty Therapist: Occupational
Specialty Therapist: Occupational - Pediatric
Specialty Physicians: Podiatrist
Specialty Physicians: Psychiatrist
Specialty Physicians: Pulmonologist
Specialty Physicians: Radiologist
Specialty Physicians: Oral Surgeon
Specialty Physicians: Orthopedist
Specialty Physicians: Pediatric Orthopedist
Specialty Physicians: Otolaryngologist
Specialty Physicians: Pathologist
-
24
Excel Spreadsheet Worksheet Tab 3- Current Specialty Physicians
Continued
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Last Name First Name
License
Number Credential Practice Name Address City Zip
Phone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Office
Hours
Days Of
Operation
Specialty Therapist: Physical Pediatric
Specialty Therapist: Speech
Specialty Therapist: Speech Pediatric
Specialty Therapist: Physical
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Last Name First Name Credential Address City ZipPhone
Number
Provider
County
Age
Restrictions
Hospital
Affiliation
Specialty Therapist: Speech - Pediatric
Specialty Therapist: Physical - Pediatric
Specialty Therapist: Respiratory
Specialty Therapist: Respiratory - Pediatric
Specialty Therapist: Speech
Specialty Therapist: Physical
-
25
Provide the following information regarding all hospital
providers: 1. Name – Hospital Name
2. Street Address, City, Zip Code, Telephone Number 3. County
Served – Indicate which county or counties the provider serves. Do
so by listing all
alphabetically On separate tabs to the spreadsheet, please
provide listings of all 1) new 2) terminated and 3) Current network
providers for the month. New providers are defined as those that
are newly contracted in the first month of participation.
Terminated providers are those who are no longer contracted in the
month. The second month that the provider has been terminated they
would no longer be reported on the file. Current providers are
those that are ongoing and contracted any new providers in their
second month of contracting would be reported on this tab. For
these tabs, please provide the information requested in items 1-3
above. Excel Spreadsheet Worksheet Tab 1- New Inpatient
Services
Name Address City Zip Phone Number Provider County
Name Address City Zip Phone Number Provider County
Name Address City Zip Phone Number Provider County
Name Address City Zip Phone Number Provider County
Name Address City Zip Phone Number Provider County
Name Address City Zip Phone Number Provider County
Name Address City Zip Phone Number Provider County
NICU Level 3
Hospital
Birth Delivery Facility/Hospital with birth deliviery
facilities
Birthing Center
RPICC
Hospital Pedatric Beds
Emergency Services and Emergency Services Facilities
-
26
Excel Spreadsheet Worksheet Tab 2- Terminated Inpatient
Services
Name Address City Zip Phone Number Provider County
Name Address City Zip Phone Number Provider County
Name Address City Zip Phone Number Provider County
Name Address City Zip Phone Number Provider County
Name Address City Zip Phone Number Provider County
Name Address City Zip Phone Number Provider County
Name Address City Zip Phone Number Provider County
NICU Level 3
Hospital
Birth Delivery Facility/Hospital with birth deliviery
facilities
Birthing Center
RPICC
Hospital Pedatric Beds
Emergency Services and Emergency Services Facilities
-
27
Excel Spreadsheet Worksheet Tab 3- Current Inpatient
Services
Provide the following information regarding all ancillary
providers: 1. Provider Name – Name of provider
2. Street Address, City, Zip Code, Telephone Number 3. County
Served – Indicate which county or counties the provider serves. Do
so by listing all
alphabetically On separate tabs to the spreadsheet, please
provide listings of all 1) new 2) terminated and 3) Current network
providers for the month. New providers are defined as those that
are newly contracted in the first month of participation.
Terminated providers are those who are no longer contracted in the
month. The second month that the provider has been terminated they
would no longer be reported on the file. Current providers are
those that are ongoing and contracted any new providers in their
second month of contracting would be reported on this tab. For
these tabs, please provide the information requested in items 1-3
above.
Name Address City Zip Phone Number Provider County
Name Address City Zip Phone Number Provider County
Name Address City Zip Phone Number Provider County
Name Address City Zip Phone Number Provider County
Name Address City Zip Phone Number Provider County
Name Address City Zip Phone Number Provider County
Name Address City Zip Phone Number Provider County
NICU Level 3
Hospital
Birth Delivery Facility/Hospital with birth deliviery
facilities
Birthing Center
RPICC
Hospital Pedatric Beds
Emergency Services and Emergency Services Facilities
-
28
Excel Spreadsheet Tab 1- New Ancillary Providers
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
School Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Dental Services
Hearing Services
Vision Services
Transportation
School-based Services (In counties in which school-based
services exist)
County Public Health Departments
Durable Medical Equipment
Home Health Services
Laboratory Services
Licensed Pharmacy/Pharmacist
Portable X-ray Services
Freestanding Dialysis Center
-
29
Excel Spreadsheet Tab 2- Terminated Ancillary Providers
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
School Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Dental Services
Hearing Services
Vision Services
Transportation
School-based Services (In counties in which school-based
services exist)
County Public Health Departments
Durable Medical Equipment
Home Health Services
Laboratory Services
Licensed Pharmacy/Pharmacist
Portable X-ray Services
Freestanding Dialysis Center
-
30
Excel Spreadsheet Tab 3- Current Ancillary Providers
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
School Name Address Zip Phone Number Provider County
Provider Name Address Zip Phone Number Provider County
Dental Services
Hearing Services
Vision Services
Transportation
School-based Services (In counties in which school-based
services exist)
County Public Health Departments
Durable Medical Equipment
Home Health Services
Laboratory Services
Licensed Pharmacy/Pharmacist
Portable X-ray Services
Freestanding Dialysis Center
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31
Subcontract Update Report Frequency: Monthly (Please see section
2-8 of the P&P guide for explanation) 1. Original Date of
Contract: The date of the original executed contract. 2. Name of
Contract: Name of the Contract 3. Address: Primary address of
subcontractor 4. City: City of subcontractor 5. County: Counties
the subcontractor services 6. Date Mailed: Mailing date to
subcontractor. 7. Status: Please indicate if the contract is
complete or incomplete 8. Comments: Next steps to complete process
with the subcontractor. 9. Completed or Signed: Date that the
contract was executed between contractor and
subcontractor. Worksheet Tab 1- 2011
Worksheet Tab 2- 2012
Worksheet Tab 3- 2013
Worksheet Tab 4- 2014
Original Date of Contract Name of Contract Address City County
Date Mailed Status Comments
Completed or
Signed
Original Date of Contract Name of Contract Address City County
Date Mailed Status Comments
Completed or
Signed
Original Date of Contract Name of Contract Address City County
Date Mailed Status Comments
Completed or
Signed
Original Date of Contract Name of Contract Address City County
Date Mailed Status Comments
Completed or
Signed
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32
Worksheet Tab 5- 2015
Worksheet Tab 6- 2016
Original Date of Contract Name of Contract Address City County
Date Mailed Status Comments
Completed or
Signed
Original Date of Contract Name of Contract Address City County
Date Mailed Status Comments
Completed or
Signed
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33
Managed Care Question and Answer Grid Frequency: As Needed On
occasion the MCO’s may need to ask questions of SCDHHS. SCDHHS has
developed the following form to allow plans the ability to ask
questions of SCDHHS. 1. Number: Number of the question.
2. Question: The MCO’s question of SCDHHS.
3. Contract or Policy Section Page: The section of either the
P&P or the contract that caused
the original question to SCDHHS.
4. Submitted by: The person submitting the question.
5. Date Submitted: The date that the question was submitted.
6. SCDHHS Answer: The answer submitted by SCDHHS.
7. Answered by: The individual at SCDHHS submitting the final
answer to the MCO.
8. Date Answered: The date that the individual at SCDHHS
answered the question.
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34
Question and Answer Grid Format
NUMBER QUESTION
Contract or Policy and
Procedure Guide
Section/Page
SUBMITTED
BY (Name )
DATE
SUBMITT
ED SCDHHS ANSWER
ANSWERED
BY
DATE
ANSWERED
Question and Answer Grid
Plan Name
Health Plan DHHS
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35
Adjustment Maternity Kicker Notification Payment Log Definitions
Frequency: Monthly as necessary SCDHHS automated the maternity
kicker process in 2010. If the MCO finds that a maternity kicker
has not been processed through automated adjustments within the
fourth month after the birth (birth month is month one) then the
MCO must submit the form below to their program manager. After the
fourth month the MCO shall submit any maternity kickers that they
are seeking manual adjustments for within six months of the child’s
birth. SCDHHS at its discretion may consider circumstances beyond
this timeframe. Stillborn births do not require a waiting period to
be reported since no Medicaid ID number is assigned to a stillborn.
The baby must be alive at the time of birth to be Medicaid
eligible. Indicate with an “X” for multiple births. Otherwise, do
not fill in this column. Count: Numerical count of lines reported -
1, 2, 3…. Newborns Date of Birth: date of birth of newborn format –
00/00/00 Mother’s Last Name: Add the mothers last name Mother’s
First Name: Add the mother first name Mother’s Medicaid ID Number:
Mother’s Medicaid ID number – 10 digits Newborn’s Last Name: Add
the newborn’s last name. If name is not known, use “Baby Boy” or
“Baby Girl” Newborn’s First Name: Add the newborn’s first name. Not
applicable if name is not known Newborn’s Sex: Use M for male, F
for female Multiple Births: Please place an “X” in this column for
any multiple birth situations. Regardless of how many births you
will only be reimbursed for one maternity kicker. * These columns
reserved for SCDHHS use
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36
Adjustment Maternity Kicker Payment Notification Log Frequency –
Monthly as necessary
Mother's Information Newborn's Information
Count
Newborn's
DOB
(mm/dd/yy) Last Name First Name
Mother's
Medicaid ID Last Name First Name
Child's
Medicaid ID
NB
Sex
(M/F)
Multiple
Birth?
(X=Yes) Y/N $ amt
Total $0.00
Stillborn Deliveries Below This Line
MCO Name (MCO Number)
Maternity Kicker Payment Notification Log
Date (Unpaid Through Date)
Reserved for
SCDHHS use
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37
Monthly- Incentive Reporting
Patient Centered Medical Home (PCMH) Form Completing the PCMH
Form: There are five (5) worksheet tabs to this report. Worksheet
one (1) is a review of the instructions, worksheet two (2) is the
spreadsheet utilized for providers in the application phase.
Worksheet three (3) is utilized for level 1 PCMH providers,
worksheet four (4) is for the level 2 PCMH providers, worksheet
five (5) is for the level 3 PCMH providers. PCMH Application:
a. Please add those providers and their members that are still
under application to the worksheet tab labeled Application. b.
Please include the members Medicaid ID, their last name, first
name, date assigned to the PCMH, accredited site, and accredited
site address, accredited site phone number and primary care
physician first and last name, and the months in the quarter the
member was enrolled with the site. c. Space has been provided for
75 members on the excel file, if there are more members than this
please insert a row or rows for the extra members. d. For anyone
still in the application process you will need to include with
their contracts a copy of the application and a defined timeline
with an update provided quarterly. See appendix 5 of the P&P
for more details.
These reports should be submitted on a monthly basis to ensure
that SCDHHS and its contractor can reimburse the plans timely and
accurately at the end of the quarter.
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38
PCMH Application Template (Tab 2)
Record
MedicaidMember
Num FirstName LastName
DateMember
Assigned
Accredited Group NPI
# AccreditedSiteName
AccreditedSiteStreet
Address
Accredited
SiteCity
Accredited
SiteState
Accredited
SiteZipcode
Accredited
SitePhone
Individual NPI #
of Individual
Physician
Physician
LastName
Physician
FirstName MonthEnrolled
1
2
3
4
5
6
[Insert Plan Name] Fiscal Year (insert year) - 1st Quarter
(July)
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39
PCMH1 Worksheet: a. Please add those providers and their members
that are in PCMH1 status to the worksheet tab labeled PCMH1. b.
Please include the members Medicaid ID, their last name, first
name, date assigned to the PCMH, accredited site, and accredited
site address, accredited site phone number and primary care
physician first and last name, and the months in the quarter the
member was enrolled with the site. c. Space has been provided for
75 members on the excel file, if there are more members than this
please insert a row or rows for the extra members.
PCMH Level I (tab 3)
Record
MedicaidMember
Num FirstName LastName
DateMember
Assigned
Accredited Group NPI
# AccreditedSiteName
AccreditedSiteStreet
Address
Accredited
SiteCity
Accredited
SiteState
Accredited
SiteZipcode
Accredited
SitePhone
Individual NPI #
of Individual
Physician
Physician
LastName
Physician
FirstName MonthEnrolled
1
2
3
4
5
6
[Insert Plan Name] Fiscal Year (insert year) - 1st Quarter
(July)
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40
PCMH2 Worksheet: a. Please add those providers and their members
that are in PCMH2 status to the worksheet tab labeled PCMH2. b.
Please include the members Medicaid ID, their last name, first
name, date assigned to the PCMH, accredited site, and accredited
site address, accredited site phone number and primary care
physician first and last name, and the months in the quarter the
member was enrolled with the site. c. Space has been provided for
75 members on the excel file, if there are more members than this
please insert a row or rows for the extra members.
PCMH Level II (tab 4)
Record
MedicaidMember
Num FirstName LastName
DateMember
Assigned
Accredited Group NPI
# AccreditedSiteName
AccreditedSiteStreet
Address
Accredited
SiteCity
Accredited
SiteState
Accredited
SiteZipcode
Accredited
SitePhone
Individual NPI #
of Individual
Physician
Physician
LastName
Physician
FirstName MonthEnrolled
1
2
3
4
5
6
[Insert Plan Name] Fiscal Year (insert year) - 1st Quarter
(July)
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41
PCMH3 Worksheet: a. Please add those providers and their members
that are in PCMH3 status to the worksheet tab labeled PCMH3. b.
Please include the members Medicaid ID, their last name, first
name, date assigned to the PCMH, accredited site, and accredited
site address, accredited site phone number and primary care
physician first and last name, and the months in the quarter the
member was enrolled with the site. c. Space has been provided for
75 members on the excel file, if there are more members than this
please insert a row or rows for the extra members.
PCMH Level III (tab 5)
Record
MedicaidMember
Num FirstName LastName
DateMember
Assigned
Accredited Group NPI
# AccreditedSiteName
AccreditedSiteStreet
Address
Accredited
SiteCity
Accredited
SiteState
Accredited
SiteZipcode
Accredited
SitePhone
Individual NPI #
of Individual
Physician
Physician
LastName
Physician
FirstName MonthEnrolled
1
2
3
4
5
6
[Insert Plan Name] Fiscal Year (insert year) - 1st Quarter
(July)
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42
INSTRUCTIONS MCO MONTHLY / QUARTERLY FRAUD AND ABUSE ACTIVITIES
REPORT
1. The format for the MCO Monthly Fraud and Abuse Activities
Report is an Excel spreadsheet with three different worksheets. The
first worksheet is for reporting the monthly fraud & abuse
activities as specified; the second worksheet, titled “Look-Up
Value,” establishes the values for the information in the drop down
boxes; the third worksheet, titled “Data Dictionary,” defines the
meaning of the column headings. 2. The monthly report is intended
to be a full replacement file each month. This means the
information is both cumulative and updated each month as new
information becomes available.
3. The MCO should list all provider integrity or SIU cases or
provider specific audits in the column for
provider/recipient name, as indicated. “Program Integrity
provider cases” means any provider under
review by the MCO, including:
Providers that are the subject of preliminary Investigations,
including any investigations that are
initiated through a REOMB response.
Providers referred to SCDHHS on the Fraud and Abuse Referral
Form.
Audits Performed by the MCO; this would include Recovery Audit
Contractor audits, pharmacy
audits, etc.
Providers identified through exception reports or fraud
algorithms conducted by the MCO SIU.
This same column can be used to list any members who were
referred to SCDHHS for suspected fraud. The column marked “Case
Type” will show whether the entry refers to a Provider or a
Recipient. 4. The format for the MCO Quarterly Fraud and Abuse
report is also an Excel spreadsheet, and has worksheets for look-up
values and data dictionary. The quarterly report, however, is
intended to capture only the activities that occurred in that
quarter. The first set of rows is summary data for the recoveries,
cost avoidance and other fraud and abuse results for the quarter.
The second set of rows should show the specific details, by
provider, any results during the quarter. The first seven columns
(A through G) should be copied from the monthly report for any
provider case for which the MCO had a recovery or administered a
provide sanction during the quarter. The MCO should file a separate
quarterly report each quarter – these reports are not cumulative.
5. Fill out the reports as completely as possible; use “NA” if no
information exists for a particular column. 6. The monthly reports
should be sent to SCDHHS via the secure portal. Requirements for
submitting the monthly and quarterly reports will be in the MCO
Policy and Procedure Guide. SCDHHS provides a secured Portal link
via the Internet for the individual MCO s to use for sharing
beneficiary/member and provider information in the context of fraud
and abuse reviews and referrals. The Program Integrity site
administrator will establish a password for the Plans to use to
upload or download data through the secured portal. In order to
receive the password for the link, each Plan must submit the
appropriate contact information to Larry Overbaugh, the SCDHHS Site
administrator, at [email protected]
mailto:[email protected]
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43
Monthly MCO Fraud and Abuse Report
MCO SIU COMPREHENSIVE LIST OF REVIEWS AND FRAUD REFERRALS
REPORT FREQUENCY: MONTHLY - FULL REPLACEMENT FILE REPORT
PREPARED BY: EMAIL:
DISTRIBUTION: SCDHHS MCO PI COORDINATOR REPT SUBMISSION DT:
TELEPHONE #:
********USE CAPS FOR ALL DATA ENTRY FIELDS*********
REC
NO MCO ID w NAME
CASE
TYPE
MCO
CASE NO
PROV/RECIP
NAME (L, F, M,
SUFFIX) NPI/MID
PROV
MCO ID
NPI
G/I PROV TYPE
PROV
CNTY REASON FOR REVIEW TYPE OF REVIEW COMPLAINT/ALLEGATION
ALGORITHM
NAME
ESTIMATED
DOLLARS AT
RISK
OVERPYMT
AMT
DETERMINED
REVIEW
PERIOD
BEGIN
REVIEW
PERIOD
END
CASE
OPENED
CASE
CLOSED
PYMT
SUSP
BEGIN
PYMT
SUSP
END
F&A
IND F&A BASIS
FIRST RPT
SCDHHS SCDHHS RESPONSE DLU
1 HM9998 FIRST MCO P 2001 DEAS, MICKEY, B, MD1234567890 AC9999 I
20 PHYSICIAN 02 AIKEN COMPLAINT FRM SCDHHSOVER PYMT
PROVIDER DOES NOT
INDICATE COB ON CLAIMS. NONE $150.00 $75.00 5/1/2013 5/2/2013
6/1/2013 6/30/2013 N
Z NOT FRAUD AND
ABUSE 6/15/2013 NOT APPLICABLE 7/1/2013
2 HM9998 FIRST MCO P 2002 RADIOLOGY R US 1234567880 AC9998 G 06
MIDWIFE 07 BEAUFORTEXCEPTION REPORT FRAUD AND ABUSE
GROUP IS BILLING ALL
PROCS WITH MOD 00 MODIFIER RPT A$60,000.00 $0.00 4/1/2012
5/30/2013 6/2/2013 7/1/2013 Y
L REPEATED PATTERNS
OF UP-CODING
AND/OR UNBUNDLING -
RESULTS IN LRG PROV
OVERPYMT 7/2/2013 REFFERAL TO OAG 7/2/2013
3 HM9998 FIRST MCO R 2003 SMITH, RADAR, M9876987001
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44
Monthly MCO Fraud and Abuse Report (Tab 2)
CASE
TYPE LEN
Key:
NPI
G/ I LEN
Key: Provider
Type LEN
Key: Reason for
Review LEN
Key:
Type of
Review LEN
Key: Sanction1-
4 LEN
Key:
F&A
Ind Key: F&A Basis LEN Key: Prov County LEN
SCDHHS
RESPONSE LEN
P 1 G 1
00 NURSING
HOME 15
EXCEPTION
REPORT 16
OVER
PYMT 9 1 TERMINATION FOR CAUSE23 Y
A NO DOCUMENTATION FOR
SERVICES 31 00 OUT OF STATE 15 REFFERAL TO OAG 15
R 1 I 1
01 INPATIENT
HOSPITAL 21
COMPLAINT
FRM SCDHHS 20
FRAUD
AND
ABUSE 15 2 SUSPENSION /WITHHOLD PAYMENT30 N
B MANUFACTURED OR ALTERED
DOCUMENTATION OR FORGED
SIGNATURES 60 01 ABBEVILLE 12
ACCEPTED FOR
SCDHHS ACTION 26
02 OUTPATIENT
HOSPITAL 22
OTHER
COMPLAIN
