Virginia Department of Medical Assistance Services

Virginia Department of Medical Assistance Services

Commonwealth Coordinated Care Plus (CCC Plus) NETWORK SUBMISSION REQUIREMENTS NETWORK SUBMISSION REQUIREMENTS MANUAL (NSRM)

DMAS 9/18/2018

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Table of Contents Commonwealth 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

ZIP ....................................................................................................................................................... 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

CONTROL LOG ......................................................................................................................................... 72

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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. Post Network Files to SharePoint in the “Networks Adequacy” folder. 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 Specifications The 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: UHC022017NS.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. Acceptable Contractor abbreviations are:

o AET – Aetna o ANT – Anthem o MCC – Magellan o OPT – Optima o UHC – United o VAP – Virginia Premier

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

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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

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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6. File Layout Requirements 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 acronym

HEALTHPLANAPI HEALTH PLAN API No Health Plan API assigned by DMAS

PROVIDERNPI PROVIDER NPI Yes All providers listed must include an NPI

PROVIDERLN PROVIDER LAST NAME Yes Provider Last Name

PROVIDERFN PROVIDER FIRST NAME No Provider First Name

GROUPAFFIL GROUP AFFILIATION No Medical or Provider Group Affiliation

HOSPITALAFFIL HOSPITAL AFFILIATION No If provider is affiliated with a hospital. Valid value is ‘1’ for Yes or ‘0’ for No.

TAXONOMYCODE PROVIDER TAXONOMY CODE

Yes 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 value 01 = PCP (Primary Care Provider) – All Ages 02 = Pediatrician 03 = Specialist (See Exhibit 2) 04 = Health Department 05 = Hospice 06 = Long Term Services & Supports Waiver Provider (See Exhibit 3) 07 = Outpatient Mental Health – Traditional Services 08 = 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 – Psychiatric 11 = Hospital – General 12 = Hospital – Physical Rehabilitation 13 = Urgent Care 14 = Nursing Facility 16 = Outpatient Rehabilitation (PT/OT/ST) 17 = Durable Medical Equipment (DME) and Supplies 18 = Radiology 19 = Home Health 20 = Laboratory 21 = Pharmacy 22 = Vision 23 = Transportation 24 = Other 25 = OB/GYN 26 = FQHC 27 = CSB 28 = RHC 29 = Dental

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Data Element Name


Required Field


SUBCLASS PROVIDER DESIGNATION SUB-CLASSIFICATION 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.

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 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 Number

CITY 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 No

OTH_LANG1 OTHER LANGUAGE SPOKEN1

No See Exhibit 7 for valid value list of other language spoken.

OTH_LANG2 OTHER LANGUAGE SPOKEN2

No See Exhibit 7 for valid value list.

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

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Data Element Name


Required Field


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 subclasses – refer to Data Element Detail Rules for more information

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7. Data Element Definitions with Examples

Health Plan Name

Data Element Name: HEALTHPLAN Required for: Identification Format: 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 API

Data Element Name: HEALTHPLANAPI Required for: Identification Format: 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 NPI

Data Element Name: PROVIDERNPI Required for: Identification Format: 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.

http://www.cms.hhs.gov/NationalProvIdentStand/

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS10114.pdf

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS10114.pdf

http://www.wpc-edi.com/reference/codelists/healthcare/health-care-provider-taxonomy-code-set/

http://www.wpc-edi.com/reference/codelists/healthcare/health-care-provider-taxonomy-code-set/

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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: Identification Format: 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 Name

Data Element Name: PROVIDERFN Required for: Identification Format: 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 Affiliation

Data Element Name: GROUPAFFIL Required for: Practice Format: 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 Affiliation

Data Element Name: HOSPITALAFFIL Required for: Practice Format: 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 Code

Data Element Name: TAXONOMYCODE Required for: Practice Format: 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 Anesthesiology 207Q00000X Family Medicine

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Primary Taxonomy Code Indicator

Data Element Name: PRIMARYTAX Required for: Location Format: 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 Designation

Data Element Name: PROVDESG Required for: Practice Format: 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 Ages 02 = Pediatrician 03 = Specialist (See Exhibit 2) 04 = Health Department 05 = Hospice 06 = Long Term Services & Supports (LTSS) Waiver Provider (See Exhibit 3) 07 = Outpatient Mental Health – Traditional Services 08 = Addiction, Recovery, and Treatment Services (ARTS) – (See Exhibit 4) 09 = Community Mental Health Rehabilitation Services (CMHRS) (See Exhibit 5) 10 = Hospital – Psychiatric 11 = Hospital – General 12 = Hospital – Physical Rehabilitation 13 = Urgent Care 14 = Nursing Facility 16 = Outpatient Rehabilitation (PT/OT/ST) 17 = Durable Medical Equipment (DME) and Supplies 18 = Radiology 19 = Home Health 20 = Laboratory 21 = Pharmacy 22 = Vision 23 = Transportation 24 = Other 25 = OB/GYN 26 = FQHC 27 = CSB 28 = RHC 29 = Dental

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-TE. 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

PROVIDERNPI PROVIDERLN PROVIDERFN GROUPAFFIL

HOSPITALAFFIL

TAXONOMYCODE

PROVDESG SUBCLASS

ADDRESSLINE1

ADDRESSLINE2 CITY FIPSCD 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-Classification

Data Element Name: SUBCLASS Required for: Provider Designation 06, 08 & 09 Format: 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:

PROVIDERNPI PROVIDERLN PROVIDERFN GROUPAFFIL

HOSPITALAFFIL

TAXONOMYCODE

PROVDESG SUBCLASS

ADDRESSLINE1

ADDRESSLINE2 CITY FIPSCD 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 1

Data Element Name: ADDRESSLINE1 Required for: Location Format: 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 2

Data Element Name: ADDRESSLINE2 Required for: Location Format: 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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City Data Element Name: CITY Required for: Location Format: 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 Code

Data Element Name: FIPSCD Required for: Location Format: 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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State

Data Element Name: STATE Required for: Location Format: 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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ZIP

Data Element Name: ZIP Required for: Location Format: 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 Access

Data Element Name: 24HRACCESS Required for: Location Format: 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 Spoken1

Data Element Name: OTH_LANG1 Required for: Access Format: 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 Spoken2

Data Element Name: OTH_LANG2 Required for: Access Format: 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 Office

Data Element Name: CSBSAT Required for: CSB Format: 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 Compliant

Data Element Name: ADA Required for: Location Format: 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 Patients

Data Element Name: NEWPTS Required for: Location Format: 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 Codes

Data Element Name: SVCFIPS Required for: Format: Numeric Length: 5 for each FIPS

Definition: 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 LPN b. PD 06 – Skilled Nursing, Congregate Nursing and Congregate Respite Nursing c. PD 06 – Service Facilitation d. PD 06 – Assistive Technology Only e. PD 06 – PERS f. PD 06 – Environmental Modifications g. Home Health h. Durable Medical Equipment and Supplies (DME) i. Transportation j. 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 Specialization

101Y00000X Counselor

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

101YM0800X Counselor Mental Health

101YP1600X Counselor Pastoral

101YP2500X Counselor Professional

101YS0200X Counselor School

102L00000X Psychoanalyst 102X00000X Poetry Therapist 103G00000X Clinical Neuropsychologist 103GC0700X Clinical Neuropsychologist Clinical

103K00000X Behavioral Analyst 103T00000X Psychologist

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

103TA0700X Psychologist Adult Development & Aging

103TB0200X Psychologist Cognitive & Behavioral

103TC0700X Psychologist Clinical

103TC1900X Psychologist Counseling

103TC2200X Psychologist Clinical Child & Adolescent

103TE1000X Psychologist Educational

103TE1100X Psychologist Exercise & Sports

103TF0000X Psychologist Family

103TF0200X Psychologist Forensic

103TH0004X Psychologist Health

103TH0100X Psychologist Health Service

103TM1700X Psychologist Men & Masculinity

103TM1800X Psychologist Mental Retardation & Developmental Disabilities

103TP0016X Psychologist Prescribing (Medical)

103TP0814X Psychologist Psychoanalysis

103TP2700X Psychologist Psychotherapy

103TP2701X Psychologist Group Psychotherapy

103TR0400X Psychologist Rehabilitation

103TS0200X Psychologist School

103TW0100X Psychologist Women

104100000X Social Worker 1041C0700X Social Worker Clinical

1041S0200X Social Worker School

106E00000X Assistant Behavior Analyst

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106H00000X Marriage & Family Therapist 106S00000X Behavior Technician

111N00000X Chiropractor 111NI0013X Chiropractor Independent Medical Examiner

111NI0900X Chiropractor Internist

111NN0400X Chiropractor Neurology

111NN1001X Chiropractor Nutrition

111NP0017X Chiropractor Pediatric Chiropractor

111NR0200X Chiropractor Radiology

111NR0400X Chiropractor Rehabilitation

111NS0005X Chiropractor Sports Physician

111NT0100X Chiropractor Thermography

111NX0100X Chiropractor Occupational Health

111NX0800X Chiropractor Orthopedic

122300000X Dentist 1223D0001X Dentist Dental Public Health

1223D0004X Dentist Dentist Anesthesiologist

1223E0200X Dentist Endodontics

1223G0001X Dentist General Practice

1223P0106X Dentist Oral and Maxillofacial Pathology

1223P0221X Dentist Pediatric Dentistry

1223P0300X Dentist Periodontics

1223P0700X Dentist Prosthodontics

1223S0112X Dentist Oral and Maxillofacial Surgery

1223X0008X Dentist Oral and Maxillofacial Radiology

1223X0400X Dentist Orthodontics and Dentofacial Orthopedics

122400000X Denturist 124Q00000X Dental Hygienist 125J00000X Dental Therapist

125K00000X Advanced Practice Dental Therapist

125Q00000X Oral Medicinist 126800000X Dental Assistant 126900000X Dental Laboratory Technician 132700000X Dietary Manager 133N00000X Nutritionist 133NN1002X Nutritionist Nutrition, Education

133V00000X Dietitian, Registered 133VN1004X Dietitian, Registered Nutrition, Pediatric

133VN1005X Dietitian, Registered Nutrition, Renal

133VN1006X Dietitian, Registered Nutrition, Metabolic

136A00000X Dietetic Technician, Registered

146D00000X Personal Emergency Response Attendant

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146L00000X Emergency Medical Technician, Paramedic

146M00000X Emergency Medical Technician, Intermediate

146N00000X Emergency Medical Technician, Basic

152W00000X Optometrist 152WC0802X Optometrist Corneal and Contact Management

152WL0500X Optometrist Low Vision Rehabilitation

152WP0200X Optometrist Pediatrics

152WS0006X Optometrist Sports Vision

152WV0400X Optometrist Vision Therapy

152WX0102X Optometrist Occupational Vision

156F00000X Technician/Technologist 156FC0800X Technician/Technologist Contact Lens

156FC0801X Technician/Technologist Contact Lens Fitter

156FX1100X Technician/Technologist Ophthalmic

156FX1101X Technician/Technologist Ophthalmic Assistant

156FX1201X Technician/Technologist Optometric Assistant

156FX1202X Technician/Technologist Optometric Technician

156FX1700X Technician/Technologist Ocularist

156FX1800X Technician/Technologist Optician

156FX1900X Technician/Technologist Orthoptist

163W00000X Registered Nurse

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

163WA2000X Registered Nurse Administrator

163WC0200X Registered Nurse Critical Care Medicine

163WC0400X Registered Nurse Case Management

163WC1400X Registered Nurse College Health

163WC1500X Registered Nurse Community Health

163WC1600X Registered Nurse Continuing Education/Staff Development

163WC2100X Registered Nurse Continence Care

163WC3500X Registered Nurse Cardiac Rehabilitation

163WD0400X Registered Nurse Diabetes Educator

163WD1100X Registered Nurse Dialysis, Peritoneal

163WE0003X Registered Nurse Emergency

163WE0900X Registered Nurse Enterostomal Therapy

163WF0300X Registered Nurse Flight

163WG0000X Registered Nurse General Practice

163WG0100X Registered Nurse Gastroenterology

163WG0600X Registered Nurse Gerontology

163WH0200X Registered Nurse Home Health

163WH0500X Registered Nurse Hemodialysis

163WH1000X Registered Nurse Hospice

163WI0500X Registered Nurse Infusion Therapy

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163WI0600X Registered Nurse Infection Control

163WL0100X Registered Nurse Lactation Consultant

163WM0102X Registered Nurse Maternal Newborn

163WM0705X Registered Nurse Medical-Surgical

163WM1400X Registered Nurse Nurse Massage Therapist (NMT)

163WN0002X Registered Nurse Neonatal Intensive Care

163WN0003X Registered Nurse Neonatal, Low-Risk

163WN0300X Registered Nurse Nephrology

163WN0800X Registered Nurse Neuroscience

163WN1003X Registered Nurse Nutrition Support

163WP0000X Registered Nurse Pain Management

163WP0200X Registered Nurse Pediatrics

163WP0218X Registered Nurse Pediatric Oncology

163WP0807X Registered Nurse Psych/Mental Health, Child & Adolescent

163WP0808X Registered Nurse Psych/Mental Health

163WP0809X Registered Nurse Psych/Mental Health, Adult

163WP1700X Registered Nurse Perinatal

163WP2201X Registered Nurse Ambulatory Care

163WR0006X Registered Nurse Registered Nurse First Assistant

163WR0400X Registered Nurse Rehabilitation

163WR1000X Registered Nurse Reproductive Endocrinology/Infertility

163WS0121X Registered Nurse Plastic Surgery

163WS0200X Registered Nurse School

163WU0100X Registered Nurse Urology

163WW0000X Registered Nurse Wound Care

163WW0101X Registered Nurse Women's Health Care, Ambulatory

163WX0002X Registered Nurse Obstetric, High-Risk

163WX0003X Registered Nurse Obstetric, Inpatient

163WX0106X Registered Nurse Occupational Health

163WX0200X Registered Nurse Oncology

163WX0601X Registered Nurse Otorhinolaryngology & Head-Neck

163WX0800X Registered Nurse Orthopedic

163WX1100X Registered Nurse Ophthalmic

163WX1500X Registered Nurse Ostomy Care

164W00000X Licensed Practical Nurse 164X00000X Licensed Vocational Nurse

167G00000X Licensed Psychiatric Technician

170100000X Medical Genetics, Ph.D. Medical Genetics

170300000X Genetic Counselor, MS 171000000X Military Health Care Provider 1710I1002X Military Health Care Provider Independent Duty Corpsman

1710I1003X Military Health Care Provider Independent Duty Medical Technicians

171100000X Acupuncturist

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171M00000X Case Manager/Care Coordinator

171R00000X Interpreter 171W00000X Contractor 171WH0202X Contractor Home Modifications

171WV0202X Contractor Vehicle Modifications

172A00000X Driver 172M00000X Mechanotherapist 172P00000X Naprapath 172V00000X Community Health Worker 173000000X Legal Medicine 173C00000X Reflexologist 173F00000X Sleep Specialist, PhD 174200000X Meals 174400000X Specialist 1744G0900X Specialist Graphics Designer

1744P3200X Specialist Prosthetics Case Management

1744R1102X Specialist Research Study

1744R1103X Specialist Research Data Abstracter/Coder

174H00000X Health Educator 174M00000X Veterinarian 174MM1900X Veterinarian Medical Research

174N00000X Lactation Consultant, Non-RN 174V00000X Clinical Ethicist 175F00000X Naturopath 175L00000X Homeopath 175M00000X Midwife, Lay 175T00000X Peer Specialist 176B00000X Midwife 176P00000X Funeral Director 177F00000X Lodging 183500000X Pharmacist 1835C0205X Pharmacist Critical Care

1835G0000X Pharmacist General Practice

1835G0303X Pharmacist Geriatric

1835N0905X Pharmacist Nuclear

1835N1003X Pharmacist Nutrition Support

1835P0018X Pharmacist Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist

1835P0200X Pharmacist Pediatrics

1835P1200X Pharmacist Pharmacotherapy

1835P1300X Pharmacist Psychiatric

1835P2201X Pharmacist Ambulatory Care

1835X0200X Pharmacist Oncology

183700000X Pharmacy Technician

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193200000X Multi-Specialty 193400000X Single Specialty

202C00000X Independent Medical Examiner

202K00000X Phlebology

204C00000X Neuromusculoskeletal Medicine, Sports Medicine

204D00000X Neuromusculoskeletal Medicine & OMM

204E00000X Oral & Maxillofacial Surgery 204F00000X Transplant Surgery 204R00000X Electrodiagnostic Medicine 207K00000X Allergy & Immunology 207KA0200X Allergy & Immunology Allergy

207KI0005X Allergy & Immunology Clinical & Laboratory Immunology

207L00000X Anesthesiology 207LA0401X Anesthesiology Addiction Medicine

207LC0200X Anesthesiology Critical Care Medicine

207LH0002X Anesthesiology Hospice and Palliative Medicine

207LP2900X Anesthesiology Pain Medicine

207LP3000X Anesthesiology Pediatric Anesthesiology

207N00000X Dermatology 207ND0101X Dermatology MOHS-Micrographic Surgery

207ND0900X Dermatology Dermatopathology

207NI0002X Dermatology Clinical & Laboratory Dermatological Immunology

207NP0225X Dermatology Pediatric Dermatology

207NS0135X Dermatology Procedural Dermatology

207P00000X Emergency Medicine 207PE0004X Emergency Medicine Emergency Medical Services

207PE0005X Emergency Medicine Undersea and Hyperbaric Medicine

207PH0002X Emergency Medicine Hospice and Palliative Medicine

207PP0204X Emergency Medicine Pediatric Emergency Medicine

207PS0010X Emergency Medicine Sports Medicine

207PT0002X Emergency Medicine Medical Toxicology

207Q00000X Family Medicine 207QA0000X Family Medicine Adolescent Medicine

207QA0401X Family Medicine Addiction Medicine

207QA0505X Family Medicine Adult Medicine

207QB0002X Family Medicine Obesity Medicine

207QG0300X Family Medicine Geriatric Medicine

207QH0002X Family Medicine Hospice and Palliative Medicine

207QS0010X Family Medicine Sports Medicine

207QS1201X Family Medicine Sleep Medicine

207R00000X Internal Medicine 207RA0000X Internal Medicine Adolescent Medicine

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207RA0001X Internal Medicine Advanced Heart Failure and Transplant Cardiology

207RA0201X Internal Medicine Allergy & Immunology

207RA0401X Internal Medicine Addiction Medicine

207RB0002X Internal Medicine Obesity Medicine

207RC0000X Internal Medicine Cardiovascular Disease

207RC0001X Internal Medicine Clinical Cardiac Electrophysiology

207RC0200X Internal Medicine Critical Care Medicine

207RE0101X Internal Medicine Endocrinology, Diabetes & Metabolism

207RG0100X Internal Medicine Gastroenterology

207RG0300X Internal Medicine Geriatric Medicine

207RH0000X Internal Medicine Hematology

207RH0002X Internal Medicine Hospice and Palliative Medicine

207RH0003X Internal Medicine Hematology & Oncology

207RH0005X Internal Medicine Hypertension Specialist

207RI0001X Internal Medicine Clinical & Laboratory Immunology

207RI0008X Internal Medicine Hepatology

207RI0011X Internal Medicine Interventional Cardiology

207RI0200X Internal Medicine Infectious Disease

207RM1200X Internal Medicine Magnetic Resonance Imaging (MRI)

207RN0300X Internal Medicine Nephrology

207RP1001X Internal Medicine Pulmonary Disease

207RR0500X Internal Medicine Rheumatology

207RS0010X Internal Medicine Sports Medicine

207RS0012X Internal Medicine Sleep Medicine

207RT0003X Internal Medicine Transplant Hepatology

207RX0202X Internal Medicine Medical Oncology

207SC0300X Medical Genetics Clinical Cytogenetic

207SG0201X Medical Genetics Clinical Genetics (M.D.)

207SG0202X Medical Genetics Clinical Biochemical Genetics

207SG0203X Medical Genetics Clinical Molecular Genetics

207SG0205X Medical Genetics Ph.D. Medical Genetics

207SM0001X Medical Genetics Molecular Genetic Pathology

207T00000X Neurological Surgery 207U00000X Nuclear Medicine 207UN0901X Nuclear Medicine Nuclear Cardiology

207UN0902X Nuclear Medicine Nuclear Imaging & Therapy

207UN0903X Nuclear Medicine In Vivo & In Vitro Nuclear Medicine

207V00000X Obstetrics & Gynecology 207VB0002X Obstetrics & Gynecology Obesity Medicine

207VC0200X Obstetrics & Gynecology Critical Care Medicine

207VE0102X Obstetrics & Gynecology Reproductive Endocrinology

207VF0040X Obstetrics & Gynecology Female Pelvic Medicine and Reconstructive Surgery

207VG0400X Obstetrics & Gynecology Gynecology

207VH0002X Obstetrics & Gynecology Hospice and Palliative Medicine

207VM0101X Obstetrics & Gynecology Maternal & Fetal Medicine

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207VX0000X Obstetrics & Gynecology Obstetrics

207VX0201X Obstetrics & Gynecology Gynecologic Oncology

207W00000X Ophthalmology 207WX0009X Ophthalmology Glaucoma Specialist

207WX0107X Ophthalmology Retina Specialist

207WX0108X Ophthalmology Ureitis and Ocular Inflammatory Disease

207WX0109X Ophthalmology Neuro-Ophthalmology

207WX0110X Ophthalmology Pediatric Ophthalmology and Strabismus Specialist

207WX0120X Ophthalmology Cornea and External Diseases Specialist

207WX0200X Ophthalmology Ophthalmic Plastic and Reconstructive Surgery

207X00000X Orthopedic Surgery 207XP3100X Orthopedic Surgery Pediatric Orthopedic Surgery

207XS0106X Orthopedic Surgery Hand Surgery

207XS0114X Orthopedic Surgery Adult Reconstructive Orthopedic Surgery

207XS0117X Orthopedic Surgery Orthopedic Surgery of the Spine

207XX0004X Orthopedic Surgery Foot and Ankle Surgery

207XX0005X Orthopedic Surgery Sports Medicine

207XX0801X Orthopedic Surgery Orthopedic Trauma

207Y00000X Otolaryngology 207YP0228X Otolaryngology Pediatric Otolaryngology

207YS0012X Otolaryngology Sleep Medicine

207YS0123X Otolaryngology Facial Plastic Surgery

207YX0007X Otolaryngology Plastic Surgery within the Head & Neck

207YX0602X Otolaryngology Otolaryngic Allergy

207YX0901X Otolaryngology Otology & Neurotology

207YX0905X Otolaryngology Otolaryngology/Facial Plastic Surgery

207ZB0001X Pathology Blood Banking & Transfusion Medicine

207ZC0006X Pathology Clinical Pathology

207ZC0008X Pathology Clinical Informatics

207ZC0500X Pathology Cytopathology

207ZD0900X Pathology Dermatopathology

207ZF0201X Pathology Forensic Pathology

207ZH0000X Pathology Hematology

207ZI0100X Pathology Immunopathology

207ZM0300X Pathology Medical Microbiology

207ZN0500X Pathology Neuropathology

207ZP0007X Pathology Molecular Genetic Pathology

207ZP0101X Pathology Anatomic Pathology

207ZP0102X Pathology Anatomic Pathology & Clinical Pathology

207ZP0104X Pathology Chemical Pathology

207ZP0105X Pathology Clinical Pathology/Laboratory Medicine

207ZP0213X Pathology Pediatric Pathology

208000000X Pediatrics 2080A0000X Pediatrics Adolescent Medicine

2080B0002X Pediatrics Obesity Medicine

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2080C0008X Pediatrics Child Abuse Pediatrics

2080H0002X Pediatrics Hospice and Palliative Medicine

2080I0007X Pediatrics Clinical & Laboratory Immunology

2080N0001X Pediatrics Neonatal-Perinatal Medicine

2080P0006X Pediatrics Developmental – Behavioral Pediatrics

2080P0008X Pediatrics Neurodevelopmental Disabilities

2080P0201X Pediatrics Pediatric Allergy/Immunology

2080P0202X Pediatrics Pediatric Cardiology

2080P0203X Pediatrics Pediatric Critical Care Medicine

2080P0204X Pediatrics Pediatric Emergency Medicine

2080P0205X Pediatrics Pediatric Endocrinology

2080P0206X Pediatrics Pediatric Gastroenterology

2080P0207X Pediatrics Pediatric Hematology-Oncology

2080P0208X Pediatrics Pediatric Infectious Diseases

2080P0210X Pediatrics Pediatric Nephrology

2080P0214X Pediatrics Pediatric Pulmonology

2080P0216X Pediatrics Pediatric Rheumatology

2080S0010X Pediatrics Sports Medicine

2080S0012X Pediatrics Sleep Medicine

2080T0002X Pediatrics Medical Toxicology

2080T0004X Pediatrics Pediatric Transplant Hepatology

208100000X Physical Medicine & Rehabilitation

2081H0002X Physical Medicine & Rehabilitation Hospice and Palliative Medicine

2081N0008X Physical Medicine & Rehabilitation Neuromuscular Medicine

2081P0004X Physical Medicine & Rehabilitation Spinal Cord Injury Medicine

2081P0010X Physical Medicine & Rehabilitation Pediatric Rehabilitation Medicine

2081P0301X Physical Medicine & Rehabilitation Brain Injury Medicine

2081P2900X Physical Medicine & Rehabilitation Pain Medicine

2081S0010X Physical Medicine & Rehabilitation Sports Medicine

208200000X Plastic Surgery 2082S0099X Plastic Surgery Plastic Surgery Within the Head and Neck

2082S0105X Plastic Surgery Surgery of the Hand

2083A0100X Preventive Medicine Aerospace Medicine

2083B0002X Preventive Medicine Obesity Medicine

2083C0008X Preventive Medicine Clinical Informatics

2083P0011X Preventive Medicine Undersea and Hyperbaric Medicine

2083P0500X Preventive Medicine Preventive Medicine/Occupational Environmental Medicine

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2083P0901X Preventive Medicine Public Health & General Preventive Medicine

2083S0010X Preventive Medicine Sports Medicine

2083T0002X Preventive Medicine Medical Toxicology

2083X0100X Preventive Medicine Occupational Medicine

2084A0401X Psychiatry & Neurology Addiction Medicine

2084B0002X Psychiatry & Neurology Obesity Medicine

2084B0040X Psychiatry & Neurology Behavioral Neurology & Neuropsychiatry

2084D0003X Psychiatry & Neurology Diagnostic Neuroimaging

2084F0202X Psychiatry & Neurology Forensic Psychiatry

2084H0002X Psychiatry & Neurology Hospice and Palliative Medicine

2084N0008X Psychiatry & Neurology Neuromuscular Medicine

2084N0400X Psychiatry & Neurology Neurology

2084N0402X Psychiatry & Neurology Neurology with Special Qualifications in Child Neurology

2084N0600X Psychiatry & Neurology Clinical Neurophysiology

2084P0005X Psychiatry & Neurology Neurodevelopmental Disabilities

2084P0015X Psychiatry & Neurology Psychosomatic Medicine

2084P0301X Psychiatry & Neurology Brain Injury Medicine

2084P0800X Psychiatry & Neurology Psychiatry

2084P0802X Psychiatry & Neurology Addiction Psychiatry

2084P0804X Psychiatry & Neurology Child & Adolescent Psychiatry

2084P0805X Psychiatry & Neurology Geriatric Psychiatry

2084P2900X Psychiatry & Neurology Pain Medicine

2084S0010X Psychiatry & Neurology Sports Medicine

2084S0012X Psychiatry & Neurology Sleep Medicine

2084V0102X Psychiatry & Neurology Vascular Neurology

2085B0100X Radiology Body Imaging

2085D0003X Radiology Diagnostic Neuroimaging

2085H0002X Radiology Hospice and Palliative Medicine

2085N0700X Radiology Neuroradiology

2085N0904X Radiology Nuclear Radiology

2085P0229X Radiology Pediatric Radiology

2085R0001X Radiology Radiation Oncology

2085R0202X Radiology Diagnostic Radiology

2085R0203X Radiology Therapeutic Radiology

2085R0204X Radiology Vascular & Interventional Radiology

2085R0205X Radiology Radiological Physics

2085U0001X Radiology Diagnostic Ultrasound

208600000X Surgery 2086H0002X Surgery Hospice and Palliative Medicine

2086S0102X Surgery Surgical Critical Care

2086S0105X Surgery Surgery of the Hand

2086S0120X Surgery Pediatric Surgery

2086S0122X Surgery Plastic and Reconstructive Surgery

2086S0127X Surgery Trauma Surgery

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2086S0129X Surgery Vascular Surgery

2086X0206X Surgery Surgical Oncology

208800000X Urology 2088F0040X Urology Female Pelvic Medicine and Reconstructive Surgery

2088P0231X Urology Pediatric Urology

208C00000X Colon & Rectal Surgery 208D00000X General Practice

208G00000X

Thoracic Surgery (Cardiothoracic Vascular Surgery)

208M00000X Hospitalist 208U00000X Clinical Pharmacology 208VP0000X Pain Medicine Pain Medicine

208VP0014X Pain Medicine Interventional Pain Medicine

209800000X Legal Medicine 211D00000X Assistant, Podiatric 213E00000X Podiatrist 213EG0000X Podiatrist General Practice

213EP0504X Podiatrist Public Medicine

213EP1101X Podiatrist Primary Podiatric Medicine

213ER0200X Podiatrist Radiology

213ES0000X Podiatrist Sports Medicine

213ES0103X Podiatrist Foot & Ankle Surgery

213ES0131X Podiatrist Foot Surgery

221700000X Art Therapist 222Q00000X Developmental Therapist 222Z00000X Orthotist 224900000X Mastectomy Fitter 224L00000X Pedorthist 224P00000X Prosthetist 224Y00000X Clinical Exercise Physiologist

224Z00000X Occupational Therapy Assistant

224ZE0001X Occupational Therapy Assistant Environmental Modification

224ZF0002X Occupational Therapy Assistant Feeding, Eating & Swallowing

224ZL0004X Occupational Therapy Assistant Low Vision

224ZR0403X Occupational Therapy Assistant Driving and Community Mobility

225000000X Orthotic Fitter 225100000X Physical Therapist 2251C2600X Physical Therapist Cardiopulmonary

2251E1200X Physical Therapist Ergonomics

2251E1300X Physical Therapist Electrophysiology, Clinical

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2251G0304X Physical Therapist Geriatrics

2251H1200X Physical Therapist Hand

2251H1300X Physical Therapist Human Factors

2251N0400X Physical Therapist Neurology

2251P0200X Physical Therapist Pediatrics

2251S0007X Physical Therapist Sports

2251X0800X Physical Therapist Orthopedic

225200000X Physical Therapy Assistant 225400000X Rehabilitation Practitioner 225500000X Specialist/Technologist 2255A2300X Specialist/Technologist Athletic Trainer

2255R0406X Specialist/Technologist Rehabilitation, Blind

225600000X Dance Therapist 225700000X Massage Therapist 225800000X Recreation Therapist 225A00000X Music Therapist

225B00000X Pulmonary Function Technologist

225C00000X Rehabilitation Counselor 225CA2400X Rehabilitation Counselor Assistive Technology Practitioner

225CA2500X Rehabilitation Counselor Assistive Technology Supplier

225CX0006X Rehabilitation Counselor Orientation and Mobility Training Provider

225X00000X Occupational Therapist 225XE0001X Occupational Therapist Environmental Modification

225XE1200X Occupational Therapist Ergonomics

225XF0002X Occupational Therapist Feeding, Eating & Swallowing

225XG0600X Occupational Therapist Gerontology

225XH1200X Occupational Therapist Hand

225XH1300X Occupational Therapist Human Factors

225XL0004X Occupational Therapist Low Vision

225XM0800X Occupational Therapist Mental Health

225XN1300X Occupational Therapist Neurorehabilitation

225XP0019X Occupational Therapist Physical Rehabilitation

225XP0200X Occupational Therapist Pediatrics

225XR0403X Occupational Therapist Driving and Community Mobility

226000000X Recreational Therapist Assistant

226300000X Kinesiotherapist

227800000X Respiratory Therapist, Certified

2278C0205X Respiratory Therapist, Certified Critical Care

2278E0002X Respiratory Therapist, Certified Emergency Care

2278E1000X Respiratory Therapist, Certified Educational

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2278G0305X Respiratory Therapist, Certified Geriatric Care

2278G1100X Respiratory Therapist, Certified General Care

2278H0200X Respiratory Therapist, Certified Home Health

2278P1004X Respiratory Therapist, Certified Pulmonary Diagnostics

2278P1005X Respiratory Therapist, Certified Pulmonary Rehabilitation

2278P1006X Respiratory Therapist, Certified Pulmonary Function Technologist

2278P3800X Respiratory Therapist, Certified Palliative/Hospice

2278P3900X Respiratory Therapist, Certified Neonatal/Pediatrics

2278P4000X Respiratory Therapist, Certified Patient Transport

2278S1500X Respiratory Therapist, Certified SNF/Subacute Care

227900000X Respiratory Therapist, Registered

2279C0205X Respiratory Therapist, Registered Critical Care

2279E0002X Respiratory Therapist, Registered Emergency Care

2279E1000X Respiratory Therapist, Registered Educational

2279G0305X Respiratory Therapist, Registered Geriatric Care

2279G1100X Respiratory Therapist, Registered General Care

2279H0200X Respiratory Therapist, Registered Home Health

2279P1004X Respiratory Therapist, Registered Pulmonary Diagnostics

2279P1005X Respiratory Therapist, Registered Pulmonary Rehabilitation

2279P1006X Respiratory Therapist, Registered Pulmonary Function Technologist

2279P3800X Respiratory Therapist, Registered Palliative/Hospice

2279P3900X Respiratory Therapist, Registered Neonatal/Pediatrics

2279P4000X Respiratory Therapist, Registered Patient Transport

2279S1500X Respiratory Therapist, Registered SNF/Subacute Care

229N00000X Anaplastologist

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231H00000X Audiologist 231HA2400X Audiologist Assistive Technology Practitioner

231HA2500X Audiologist Assistive Technology Supplier

235500000X Specialist/Technologist 2355A2700X Specialist/Technologist Audiology Assistant

2355S0801X Specialist/Technologist Speech-Language Assistant

235Z00000X Speech-Language Pathologist 237600000X Audiologist-Hearing Aid Fitter 237700000X Hearing Instrument Specialist 242T00000X Perfusionist

243U00000X Radiology Practitioner Assistant

246Q00000X Spec/Tech, Pathology 246QB0000X Spec/Tech, Pathology Blood Banking

246QC1000X Spec/Tech, Pathology Chemistry

246QC2700X Spec/Tech, Pathology Cytotechnology

246QH0000X Spec/Tech, Pathology Hematology

246QH0401X Spec/Tech, Pathology Hemapheresis Practitioner

246QH0600X Spec/Tech, Pathology Histology

246QI0000X Spec/Tech, Pathology Immunology

246QL0900X Spec/Tech, Pathology Laboratory Management

246QL0901X Spec/Tech, Pathology Laboratory Management, Diplomate

246QM0706X Spec/Tech, Pathology Medical Technologist

246QM0900X Spec/Tech, Pathology Microbiology

246R00000X Technician, Pathology 246RH0600X Technician, Pathology Histology

246RM2200X Technician, Pathology Medical Laboratory

246RP1900X Technician, Pathology Phlebotomy

246W00000X Technician, Cardiology 246X00000X Spec/Tech, Cardiovascular 246XC2901X Spec/Tech, Cardiovascular Cardiovascular Invasive Specialist

246XC2903X Spec/Tech, Cardiovascular Vascular Specialist

246XS1301X Spec/Tech, Cardiovascular Sonography

246Y00000X Spec/Tech, Health Info 246YC3301X Spec/Tech, Health Info Coding Specialist, Hospital Based

246YC3302X Spec/Tech, Health Info Coding Specialist, Physician Office Based

246YR1600X Spec/Tech, Health Info Registered Record Administrator

246Z00000X Specialist/Technologist, Other 246ZA2600X Specialist/Technologist, Other Art, Medical

246ZB0301X Specialist/Technologist, Other Biomedical Engineering

246ZB0302X Specialist/Technologist, Other Biomedical Photographer

246ZB0500X Specialist/Technologist, Other Biochemist

246ZB0600X Specialist/Technologist, Other Biostatistician

246ZC0007X Specialist/Technologist, Other Surgical Assistant

246ZE0500X Specialist/Technologist, Other EEG

50 | P a g e


246ZE0600X Specialist/Technologist, Other Electroneurodiagnostic

246ZG0701X Specialist/Technologist, Other Graphics Methods

246ZG1000X Specialist/Technologist, Other Geneticist, Medical (PhD)

246ZI1000X Specialist/Technologist, Other Illustration, Medical

246ZN0300X Specialist/Technologist, Other Nephrology

246ZS0410X Specialist/Technologist, Other Surgical Technologist

246ZX2200X Specialist/Technologist, Other Orthopedic Assistant

247000000X Technician, Health Information 2470A2800X Technician, Health Information Assistant Record Technician

247100000X Radiologic Technologist 2471B0102X Radiologic Technologist Bone Densitometry

2471C1101X Radiologic Technologist Cardiovascular-Interventional Technology

2471C1106X Radiologic Technologist Cardiac-Interventional Technology

2471C3401X Radiologic Technologist Computed Tomography

2471C3402X Radiologic Technologist Radiography

2471M1202X Radiologic Technologist Magnetic Resonance Imaging

2471M2300X Radiologic Technologist Mammography

2471N0900X Radiologic Technologist Nuclear Medicine Technology

2471Q0001X Radiologic Technologist Quality Management

2471R0002X Radiologic Technologist Radiation Therapy

2471S1302X Radiologic Technologist Sonography

2471V0105X Radiologic Technologist Vascular Sonography

2471V0106X Radiologic Technologist Vascular-Interventional Technology

247200000X Technician, Other 2472B0301X Technician, Other Biomedical Engineering

2472D0500X Technician, Other Darkroom

2472E0500X Technician, Other EEG

2472R0900X Technician, Other Renal Dialysis

2472V0600X Technician, Other Veterinary

247ZC0005X Pathology Clinical Laboratory Director, Non-physician

251300000X Local Education Agency (LEA) 251B00000X Case Management

251C00000X Day Training, Developmentally Disabled Services

251E00000X Home Health 251F00000X Home Infusion

251G00000X Hospice Care, Community Based

251J00000X Nursing Care 251K00000X Public Health or Welfare 251S00000X Community/Behavioral Health 251T00000X PACE Provider Organization 251V00000X Voluntary or Charitable 251X00000X Supports Brokerage

51 | P a g e


252Y00000X Early Intervention Provider Agency

253J00000X Foster Care Agency 253Z00000X In Home Supportive Care 261Q00000X Clinic/Center 261QA0005X Clinic/Center Ambulatory Family Planning Facility

261QA0006X Clinic/Center Ambulatory Fertility Facility

261QA0600X Clinic/Center Adult Day Care

261QA0900X Clinic/Center Amputee

261QA1903X Clinic/Center Ambulatory Surgical

261QA3000X Clinic/Center Augmentative Communication

261QB0400X Clinic/Center Birthing

261QC0050X Clinic/Center Critical Access Hospital

261QC1500X Clinic/Center Community Health

261QC1800X Clinic/Center Corporate Health

261QD0000X Clinic/Center Dental

261QD1600X Clinic/Center Developmental Disabilities

261QE0002X Clinic/Center Emergency Care

261QE0700X Clinic/Center End-Stage Renal Disease (ESRD) Treatment

261QE0800X Clinic/Center Endoscopy

261QF0050X Clinic/Center Family Planning, Non-Surgical

261QF0400X Clinic/Center Federally Qualified Health Center (FQHC)

261QG0250X Clinic/Center Genetics

261QH0100X Clinic/Center Health Service

261QH0700X Clinic/Center Hearing and Speech

261QI0500X Clinic/Center Infusion Therapy

261QL0400X Clinic/Center Lithotripsy

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

261QM0850X Clinic/Center Adult Mental Health

261QM0855X Clinic/Center Adolescent and Children Mental Health

261QM1000X Clinic/Center Migrant Health

261QM1100X Clinic/Center Military/U.S. Coast Guard Outpatient

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

261QM1102X Clinic/Center Military Outpatient Operational (Transportable) Component

261QM1103X Clinic/Center Military Ambulatory Procedure Visits Operational (Transportable)

261QM1200X Clinic/Center Magnetic Resonance Imaging (MRI)

261QM1300X Clinic/Center Multi-Specialty

261QM2500X Clinic/Center Medical Specialty

261QM2800X Clinic/Center Methadone Clinic

261QM3000X Clinic/Center Medically Fragile Infants and Children Day Care

261QP0904X Clinic/Center Public Health, Federal

261QP0905X Clinic/Center Public Health, State or Local

261QP1100X Clinic/Center Podiatric

52 | P a g e


261QP2000X Clinic/Center Physical Therapy

261QP2300X Clinic/Center Primary Care

261QP2400X Clinic/Center Prison Health

261QP3300X Clinic/Center Pain

261QR0200X Clinic/Center Radiology

261QR0206X Clinic/Center Radiology, Mammography

261QR0207X Clinic/Center Radiology, Mobile Mammography

261QR0208X Clinic/Center Radiology, Mobile

261QR0400X Clinic/Center Rehabilitation

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

261QR0404X Clinic/Center Rehabilitation, Cardiac Facilities

261QR0405X Clinic/Center Rehabilitation, Addiction, Recovery, and Treatment Services

261QR0800X Clinic/Center Recovery Care

261QR1100X Clinic/Center Research

261QR1300X Clinic/Center Rural Health

261QS0112X Clinic/Center Oral and Maxillofacial Surgery

261QS0132X Clinic/Center Ophthalmologic Surgery

261QS1000X Clinic/Center Student Health

261QS1200X Clinic/Center Sleep Disorder Diagnostic

261QU0200X Clinic/Center Urgent Care

261QV0200X Clinic/Center VA

261QX0100X Clinic/Center Occupational Medicine

261QX0200X Clinic/Center Oncology

261QX0203X Clinic/Center Oncology, Radiation

273100000X Epilepsy Unit 273R00000X Psychiatric Unit 273Y00000X Rehabilitation Unit

275N00000X Medicare Defined Swing Bed Unit

276400000X Rehabilitation, Substance Use Disorder Unit

281P00000X Chronic Disease Hospital 281PC2000X Chronic Disease Hospital Children

282E00000X Long Term Care Hospital

282J00000X Religious Nonmedical Health Care Institution

282N00000X General Acute Care Hospital 282NC0060X General Acute Care Hospital Critical Access

282NC2000X General Acute Care Hospital Children

282NR1301X General Acute Care Hospital Rural

282NW0100X General Acute Care Hospital Women

283Q00000X Psychiatric Hospital 283X00000X Rehabilitation Hospital 283XC2000X Rehabilitation Hospital Children

53 | P a g e


284300000X Special Hospital 286500000X Military Hospital 2865C1500X Military Hospital Community Health

2865M2000X Military Hospital Military General Acute Care Hospital

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

287300000X Christian Science Sanitarium

291900000X Military Clinical Medical Laboratory

291U00000X Clinical Medical Laboratory 292200000X Dental Laboratory 293D00000X Physiological Laboratory

302F00000X Exclusive Provider Organization

302R00000X Health Maintenance Organization

305R00000X Preferred Provider Organization

305S00000X Point of Service 310400000X Assisted Living Facility 3104A0625X Assisted Living Facility Assisted Living, Mental Illness

3104A0630X Assisted Living Facility Assisted Living, Behavioral Disturbances

310500000X Intermediate Care Facility, Mental Illness

311500000X Alzheimer Center (Dementia Center)

311Z00000X Custodial Care Facility 311ZA0620X Custodial Care Facility Adult Care Home

313M00000X Nursing Facility/Intermediate Care Facility

314000000X Skilled Nursing Facility 3140N1450X Skilled Nursing Facility Nursing Care, Pediatric

315D00000X Hospice, Inpatient

315P00000X Intermediate Care Facility, Mentally Retarded

317400000X Christian Science Facility 320600000X Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities

320700000X Residential Treatment Facility, Physical Disabilities

320800000X Community Based Residential Treatment Facility, Mental Illness

320900000X Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities

322D00000X Residential Treatment Facility, Emotionally Disturbed Children

323P00000X Psychiatric Residential Treatment Facility

324500000X Substance Abuse Rehabilitation Facility

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3245S0500X Substance Abuse Rehabilitation Facility Substance Abuse Treatment, Children

331L00000X Blood Bank

332000000X Military/U.S. Coast Guard Pharmacy

332100000X Department of Veterans Affairs (VA) Pharmacy

332800000X Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy

332900000X Non-Pharmacy Dispensing Site

332B00000X Durable Medical Equipment & Medical Supplies

332BC3200X Durable Medical Equipment & Medical Supplies Customized 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 Bank

332H00000X Eyewear Supplier (Equipment, not the service)

332S00000X Hearing Aid Equipment 332U00000X Home Delivered Meals

333300000X Emergency Response System Companies

333600000X Pharmacy 3336C0002X Pharmacy Clinic Pharmacy

3336C0003X Pharmacy Community/Retail Pharmacy

3336C0004X Pharmacy Compounding Pharmacy

3336H0001X Pharmacy Home Infusion Therapy Pharmacy

3336I0012X Pharmacy Institutional Pharmacy

3336L0003X Pharmacy Long Term Care Pharmacy

3336M0002X Pharmacy Mail Order Pharmacy

3336M0003X Pharmacy Managed Care Organization Pharmacy

3336N0007X Pharmacy Nuclear Pharmacy

3336S0011X Pharmacy Specialty Pharmacy

335E00000X Prosthetic/Orthotic Supplier 335G00000X Medical Foods Supplier

335U00000X Organ Procurement Organization

335V00000X Portable X-ray and/or Other Portable Diagnostic Imaging Supplier

341600000X Ambulance 3416A0800X Ambulance Air Transport

3416L0300X Ambulance Land Transport

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3416S0300X Ambulance Water Transport

341800000X Military/U.S. Coast Guard Transport

3418M1110X Military/U.S. Coast Guard Transport

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


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


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

343800000X Secured Medical Transport (VAN)

343900000X Non-emergency Medical Transport (VAN)

344600000X Taxi 344800000X Air Carrier 347B00000X Bus 347C00000X Private Vehicle 347D00000X Train 347E00000X Transportation Broker 363A00000X Physician Assistant 363AM0700X Physician Assistant Medical

363AS0400X Physician Assistant Surgical Technologist

363L00000X Nurse Practitioner 363LA2100X Nurse Practitioner Acute Care

363LA2200X Nurse Practitioner Adult Health

363LC0200X Nurse Practitioner Critical Care Medicine

363LC1500X Nurse Practitioner Community Health

363LF0000X Nurse Practitioner Family

363LG0600X Nurse Practitioner Gerontology

363LN0000X Nurse Practitioner Neonatal

363LN0005X Nurse Practitioner Neonatal, Critical Care

363LP0200X Nurse Practitioner Pediatrics

363LP0222X Nurse Practitioner Pediatrics, Critical Care

363LP0808X Nurse Practitioner Psych/Mental Health

363LP1700X Nurse Practitioner Perinatal

363LP2300X Nurse Practitioner Primary Care

363LS0200X Nurse Practitioner School

363LW0102X Nurse Practitioner Women's Health

363LX0001X Nurse Practitioner Obstetrics & Gynecology

363LX0106X Nurse Practitioner Occupational Health

364S00000X Clinical Nurse Specialist 364SA2100X Clinical Nurse Specialist Acute Care

364SA2200X Clinical Nurse Specialist Adult Health

364SC0200X Clinical Nurse Specialist Critical Care Medicine

364SC1501X Clinical Nurse Specialist Community Health/Public Health

364SC2300X Clinical Nurse Specialist Chronic Care

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364SE0003X Clinical Nurse Specialist Emergency

364SE1400X Clinical Nurse Specialist Ethics

364SF0001X Clinical Nurse Specialist Family Health

364SG0600X Clinical Nurse Specialist Gerontology

364SH0200X Clinical Nurse Specialist Home Health

364SH1100X Clinical Nurse Specialist Holistic

364SI0800X Clinical Nurse Specialist Informatics

364SL0600X Clinical Nurse Specialist Long-Term Care

364SM0705X Clinical Nurse Specialist Medical-Surgical

364SN0000X Clinical Nurse Specialist Neonatal

364SN0800X Clinical Nurse Specialist Neuroscience

364SP0200X Clinical Nurse Specialist Pediatrics

364SP0807X Clinical Nurse Specialist Psych/Mental Health, Child & Adolescent

364SP0808X Clinical Nurse Specialist Psych/Mental Health

364SP0809X Clinical Nurse Specialist Psych/Mental Health, Adult

364SP0810X Clinical Nurse Specialist Psych/Mental Health, Child & Family

364SP0811X Clinical Nurse Specialist Psych/Mental Health, Chronically Ill

364SP0812X Clinical Nurse Specialist Psych/Mental Health, Community

364SP0813X Clinical Nurse Specialist Psych/Mental Health, Geropsychiatric

364SP1700X Clinical Nurse Specialist Perinatal

364SP2800X Clinical Nurse Specialist Perioperative

364SR0400X Clinical Nurse Specialist Rehabilitation

364SS0200X Clinical Nurse Specialist School

364ST0500X Clinical Nurse Specialist Transplantation

364SW0102X Clinical Nurse Specialist Women's Health

364SX0106X Clinical Nurse Specialist Occupational Health

364SX0200X Clinical Nurse Specialist Oncology

364SX0204X Clinical Nurse Specialist Oncology, Pediatrics

367500000X Nurse Anesthetist, Certified Registered

367A00000X Advanced Practice Midwife 367H00000X Anesthesiologist Assistant 372500000X Chore Provider 372600000X Adult Companion

373H00000X Day Training/Habilitation Specialist

374700000X Technician 3747A0650X Technician Attendant Care Provider

3747P1801X Technician Personal Care Attendant

374J00000X Doula

374K00000X Religious Nonmedical Practitioner

374T00000X Religious Nonmedical Nursing Personnel

374U00000X Home Health Aide 376G00000X Nursing Home Administrator

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376J00000X Homemaker 376K00000X Nurse's Aide 385H00000X Respite Care 385HR2050X Respite Care Respite Care Camp

385HR2055X Respite Care Respite Care, Mental Illness, Child

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

385HR2065X Respite Care Respite Care, Physical Disabilities, Child

390200000X Student in an Organized Health Care Education/Training Program

405300000X 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 Immunology

Audiology

Endocrinology

Family Medicine

Gastroenterology

Geriatric

Gynecologic Oncology

Hospitalist

Infectious Disease

Nephrology

Occupational Medicine

Oncology, Hematology

Orthopedics

Otolaryngology

Pathology

Pediatric Specialist

Physical Medicine

Physician Extender

Pulmonary Medicine

Radiation Oncology

Rehabilitation

Surgery (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 Care

T1999 Assistive Technology Only

T1999 U5 Assistive Technology Maintenance Costs Only

T1000 U1 Congregate Nursing/RN

T1001 U1 Congregate Nursing/LPN

T1031 TE Congregate Respite Nursing/LPN

T1030 TD Congregate Respite Nursing/RN

99199 U4 Environmental Modification, Maintenance Costs Only

S5165 Environmental Modifications Only

S5160 PERS Installation

S5160 U1 PERS and Medication Monitoring Installation

S5185 PERS Medication Monitoring

S5161 PERS Monitoring

H2021 TD PERS Nursing Services/RN

H2021 TE PERS Nursing Services/LPN

T1019 Personal Care

T1005 Respite Care

S9125 TD Respite Care RN

S9125 TE Respite Care LPN

S5109 Service Facilitation Consumer Training Visit

H2000 Service Facilitation Initial Comprehensive Visit

S5116 Service Facilitation Management Training Hours

T1028 Service Facilitation Reassessment Visit

99509 Service Facilitation Routine Visit

T1003 Skilled Nursing Services/LPN

T1002 Skilled Nursing Services/RN

H2015 Transition Coordination

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Exhibit 4 – Addiction, Recovery and Treatment Services (ARTS) REQUIRED FOR PROVIDER DESIGNATION 08

ASAM Level of Care

Valid Values

ASAM Description

2.1 1 Intensive Outpatient Services

2.5 2 Partial Hospitalization Services

3.1 3 Clinically Managed Low-Intensity Residential Services

3.3 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 Inpatient Psychiatric Care, Specialty Unit

3.7 7 Medically Monitored Intensive Inpatient Services (Adult) Medically Monitored High Intensity Inpatient Services (Adolescent)

3.7 8 Intensive Inpatient

4.0 9 Medically Managed Intensive Inpatient

OTP 10 Opioid Treatment Program (OTP) (Licensed as such by DBHDS)

OBOT 11 Office-Based Opioid Treatment (OBOT)

n/a 12 Substance Use Care Management

BWP 13 Buprenorphine Waivered Prescribers (BWP) – in-network (non-preferred OBOT)

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 07/01/2017

S9445 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

Code Modifier Service Name

The following CMHRS services require member to travel to provider:

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 – effective 12/01/2016

H0035 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 Stabilization

H0036 Crisis Intervention

H2012 Intensive In-Home (IIH)

H0046 Mental Health Skill-building Services (MHSS)

H0023 Mental Health Case Management, can be performed only by CSBs

H2033 Behavioral Therapy

H0024 Peer Support Services, Individual Mental Health – effective 07/01/2017

H0025 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 Assessment

H0032 U6 Psychosocial Rehab Assessment

H0032 U7 Day Treatment/Partial Hospitalization Assessment, Adult

H0032 U7 TDT Assessment, Child

H0032 U8 MHSS Assessment

H0032 U9 ICT Assessment

H0032 UA Behavioral Therapy Assessment

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Exhibit 6a – Virginia City and County FIPS Codes

CCC Plus REGIONS BY LOCALITY AND FIPS CENTRAL REGION

007 AMELIA 085 HANOVER 730 PETERSBURG

025 BRUNSWICK 087 HENRICO 145 POWHATAN

033 CAROLINE 670 HOPEWELL 147 PRINCE EDWARD

036 CHARLES CITY 097 KING AND QUEEN 149 PRINCE GEORGE

041 CHESTERFIELD 099 KING GEORGE 760 RICHMOND CITY

570 COLONIAL HEIGHTS 101 KING WILLIAM 159 RICHMOND CO.

049 CUMBERLAND 103 LANCASTER 175 SOUTHAMPTON

053 DINWIDDIE 111 LUNENBURG 177 SPOTSYLVANIA

595 EMPORIA 115 MATHEWS 179 STAFFORD

057 ESSEX 117 MECKLENBURG 181 SURRY

620 FRANKLIN CITY 119 MIDDLESEX 183 SUSSEX

630 FREDERICKSBURG 127 NEW KENT 193 WESTMORELAND

075 GOOCHLAND 133 NORTHUMBERLAND

081 GREENSVILLE 135 NOTTOWAY

TIDEWATER REGION

001 ACCOMACK 095 JAMES CITY CO. 740 PORTSMOUTH

550 CHESAPEAKE 700 NEWPORT NEWS 800 SUFFOLK

073 GLOUCESTER 710 NORFOLK 810 VIRGINIA BEACH

650 HAMPTON 131 NORTHAMPTON 830 WILLIAMSBURG

093 ISLE OF WIGHT 735 POQUOSON 199 YORK

NORTHERN & WINCHESTER REGION

510 ALEXANDRIA 610 FALLS CHURCH 139 PAGE

013 ARLINGTON 061 FAUQUIER 153 PRINCE WILLIAM

043 CLARKE 069 FREDERICK 157 RAPPAHANNOCK

047 CULPEPER 107 LOUDOUN 171 SHENANDOAH

600 FAIRFAX CITY 683 MANASSAS CITY 187 WARREN

059 FAIRFAX CO. 685 MANASSAS PARK 840 WINCHESTER

CHARLOTTESVILLE/WESTERN REGION

003 ALBEMARLE 590 DANVILLE 125 NELSON

009 AMHERST 065 FLUVANNA 137 ORANGE

011 APPOMATTOX 079 GREENE 143 PITTSYLVANIA

015 AUGUSTA 083 HALIFAX 165 ROCKINGHAM

029 BUCKINGHAM 660 HARRISONBURG 790 STAUNTON

031 CAMPBELL 109 LOUISA 820 WAYNESBORO

037 CHARLOTTE 680 LYNCHBURG

540 CHARLOTTESVILLE 113 MADISON

ROANOKE/ALLEGHANY REGION

005 ALLEGHANY 067 FRANKLIN CO. 155 PULASKI

017 BATH 071 GILES 750 RADFORD

019 BEDFORD 089 HENRY 770 ROANOKE CITY

023 BOTETOURT 091 HIGHLAND 161 ROANOKE CO.

530 BUENA VISTA 678 LEXINGTON 163 ROCKBRIDGE

580 COVINGTON 690 MARTINSVILLE 775 SALEM

045 CRAIG 121 MONTGOMERY 197 WYTHE

063 FLOYD 141 PATRICK

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CCC Plus REGIONS BY LOCALITY AND FIPS SOUTHWEST REGION

021 BLAND 640 GALAX 169 SCOTT

520 BRISTOL 077 GRAYSON 173 SMYTH

027 BUCHANAN 105 LEE 185 TAZEWELL

035 CARROLL 720 NORTON 191 WASHINGTON

051 DICKENSON 167 RUSSELL 195 WISE

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Exhibit 6b – State FIPS Codes

Virginia

Neighboring States

State Abbreviation

FIPS Code

State Name State

Abbreviation FIPS Code

State Name

AL 01 ALABAMA NV 32 NEVADA

AK 02 ALASKA NH 33 NEW HAMPSHIRE

AZ 04 ARIZONA NJ 34 NEW JERSEY

AR 05 ARKANSAS NM 35 NEW MEXICO

CA 06 CALIFORNIA NY 36 NEW YORK

CO 08 COLORADO NC 37 NORTH CAROLINA

CT 09 CONNECTICUT ND 38 NORTH DAKOTA

DE 10 DELAWARE OH 39 OHIO

DC 11 DISTRICT OF COLUMBIA OK 40 OKLAHOMA

FL 12 FLORIDA OR 41 OREGON

GA 13 GEORGIA PA 42 PENNSYLVANIA

HI 15 HAWAII RI 44 RHODE ISLAND

ID 16 IDAHO SC 45 SOUTH CAROLINA

IL 17 ILLINOIS SD 46 SOUTH DAKOTA

IN 18 INDIANA TN 47 TENNESSEE

IA 19 IOWA TX 48 TEXAS

KS 20 KANSAS UT 49 UTAH

KY 21 KENTUCKY VT 50 VERMONT

LA 22 LOUISIANA VA 51 VIRGINIA

ME 23 MAINE WA 53 WASHINGTON

MD 24 MARYLAND WV 54 WEST VIRGINIA

MA 25 MASSACHUSETTS WI 55 WISCONSIN

MI 26 MICHIGAN WY 56 WYOMING

MN 27 MINNESOTA AS 60 AMERICAN SAMOA

MS 28 MISSISSIPPI GU 66 GUAM

MO 29 MISSOURI PR 72 PUERTO RICO

MT 30 MONTANA VI 78 VIRGIN ISLANDS

NE 31 NEBRASKA

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Exhibit 7 – Other Language Spoken

Other Language Spoken 01-English

02-Spanish

03-German

04-French

05-Vietnamese

06-Korean

07-Navajo

08-Tagalog

09-Portuguese

10-Italian

11-Arabic

12-Dakota

13-Yupik

14-Polish

15-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


miles


miles

03 – Specialist 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


04 – Health Department (HD) No

05 – Hospice No

06 – 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 30 miles



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

Yes – Provider travels to member

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

68 | P a g e






(Rural)

T1000-U1-Congregate 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-TD-Respite Care/RN

S9125-TE-Respite Care/LPN

99509-Service Facilitation Routine Visit

H2015-Transition Coordination


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


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)

69 | P a g e






(Rural)

S5185- PERS Medication Monitoring

S5161- PERS Monitoring

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




08 – Addiction, Recovery and Treatment Services (ARTS), excluding Residential & Inpatient Detox

Yes At least 2 Providers w/in 45 minutes




08 – Addiction, Recovery and Treatment Services (ARTS), Residential ONLY

Yes At least 1 Provider w/in 45 minutes




08 – Addiction, Recovery and Treatment Services (ARTS), Inpatient Detox ONLY





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





70 | P a g e






(Rural)


H0039 - Intensive Community Treatment (ICT)

H2019 - Crisis Stabilization




H2033 - Behavioral Therapy

H0024 - Peer Support Services, Individual Mental Health

H0025 - Peer Support Services, Group Mental Health


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




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




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




12 – Hospital – Physical Rehabilitation





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




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




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(Rural)

16 – Outpatient Rehabilitation (PT/OT/SP)

Yes At least 2 Providers w/in 45 minutes




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




19 – Home Health Agency Yes ¹Choice of a least 2 Providers for any service are locality

20 – Laboratory Yes At least 1 Provider w/in 45 minutes




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




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




23 – Transportation No

24 – Other No

25 – OB/GYN Yes At least 2 Providers w/in 45 minutes




26 – Federal Qualified Health Center (FQHC)

No

27 – Community Service Board (CSB)

No

28 – Rural Health Center (RHC) No

29 – Dental No

Early Intervention (EI) Provider Yes ²Under development

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 DBHDS maintains a list of EI providers. Analysis is under development to analyze the EI providers submitted by the health plans against DBHDS list

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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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CONTROL LOG

Date Section Information Updated

04/26/2017 7 - Servicing FIPS Codes

Struck through “separated by a comma “,””


Under Edit Application, 1. – added “EXCEPTION: If the provider services the entire State of Virginia, send one line using the following default code in the Servicing FIPS Code column: 99999. For all other provider, include a unique row for each FIPS code that the provider services.”

04/26/2017 Exhibit 3 Added: “T1001 with a U1 modifier and description = Congregate Nursing/LPN”

07/10/2017 1 Changed due date of Network File from the 10th to the 20th

08/07/2017 1 Corrected three month to three months

08/30/2017 5 Added Section 5 – Critical and Key Provider Designations

08/30/2017 6 Changed description on Provider Designation 14 from “Nursing Facility – Skilled” to “Nursing Facility”

08/30/2017 6 Struck through Provider Designation 15 – Nursing Facility – Intermediate Care” (14 and 15 combined under “Nursing Facility”)

08/30/2017 7 - Provider Designation

Changed description on Provider Designation 14 from “Nursing Facility – Skilled” to “Nursing Facility”


Struck through Provider Designation 15 – Nursing Facility – Intermediate Care” (14 and 15 combined under “Nursing Facility”)

08/30/2017 Exhibit 4 Added place holder / reminder to also add the ARTS services by procedure codes

08/30/2017 Exhibit 5 Added: “H0035 with modifiers HA & HG and description = TDT Afterschool, Child – effective 12/01/2016”

08/30/2017 Exhibit 5 Added: “H0035 with modifiers HA & U7 and description = TDT Summer Program, Child – effective 12/01/2016”

08/30/2017 Exhibit 5 Struck through H0038, T1012, S9445 and S9446 and description = Mental Health

08/30/2017 Exhibit 5 Added: “H0024 with description = Peer Support Services, Individual Mental Health – effective 07/01/2017”

08/30/2017 Exhibit 5 Added: “Some of the above services require assessments before the service code is billed:

H0031 = IIH Assessment

H0032-U6 = Psychosocial Rehab Assessment

H0032-U7 = Day Treatment/Partial Hospitalization Assessment, Adult

H0032-U7 = TDT Assessment, Child

H0032-U8 = MHSS Assessment

H0032-U9 = ICT Assessment

H0032-UA = Behavioral Therapy Assessment

08/30/2017 Exhibit 5 Added: “H0025 with description = Peer Support Services, Group Mental Health – effective 07/01/2017”

08/30/2017 Exhibit 8 Added chart that outlines adequacy standards

09/01/2017 6 Struck through “not needed until readiness review for transition of CMHRS into CCC Plus effective 1/1/2018.” Added: “Health Plans should begin submitting CMHRS providers with their September 2017 submission.”

09/05/2017 Exhibit 5 Struck through “H2020 – Level B Group Home”

09/05/2017 Exhibit 5 Struck through “H2022 – Level A Group Home”

09/05/2017 Exhibit 5 Struck through “T1016 – Treatment Foster Care Case Management”

09/05/2017 Exhibit 8 Added Label “Exhibit 8 – Network Adequacy Standards” to inserted chart (above)

10/04/2017 Exhibit 3 Added column: “Modifier”

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10/04/2017 Exhibit 3 Added “T1999 with modifier U5 – Assistive Technology Maintenance Costs Only”

10/04/2017 Exhibit 3 Added “U1 modifier to code T1000” and struck through “or LPN” in Description

10/04/2017 Exhibit 3 Added “TE “ modifier to code T1031

10/04/2017 Exhibit 3 Added “TD” modifier to code T1030

10/04/2017 Exhibit 3 Added “U4” modifier to code 99199

10/04/2017 Exhibit 3 Added: “S5160 with modifier U1 and description = PERS and Medication Monitoring Installation”

10/04/2017 Exhibit 3 Added “TD” modifier to code H2021 and struck through “LPN or”

10/04/2017 Exhibit 3 Added: “H2021 with modifier TE and description = PERS Nursing Services/LPN”

10/04/2017 Exhibit 3 Added “TD modifier to code S9125


Under Edit Application, 4. – added: “j. Provider Designation (PD) 09 – Community Mental Health Rehabilitation Services (CMHRS) reference Exhibit 5, but only the following services:

H2019 - Crisis Stabilization





H2033 – Behavioral Therapy

H0024 – Peer Support Services, Individual Mental Health

H0025 – Peer Support Services, Group Mental Health

H0039 – Intensive Community Treatment (ICT)” 10/30/2017 Exhibit 5 Struck through “CMHRS SERVICES” on chart

10/30/2017 Exhibit 8 Added: “NOTE: For providers / members in the Roanoke/Southwest Regions, access standards will be based on Rural Time and Distance parameters.


Sub Classification

Added “Modifiers” and example how to include in file

11/06/2017 Exhibit 5 Added column “Modifier”

11/06/2017 Exhibit 5 Moved “HB” from column Service Procedure Code to new column, Modifier

11/06/2017 Exhibit 5 Moved “HA” from column Service Procedure Code to new column, Modifier

11/07/2017 Exhibit 5 Added: “can be performed only by CSB” to code H0023

05/10/2018 4 Added “Acceptable Contractor abbreviations” and corrected sample file name using the abbreviated name

05/10/2018 6 Added label: 6 – File Layout Requirements

05/10/2018 7 Added label: 7 – Data Element Definitions with Examples

05/10/2018 7 Added Provider Designation “29” defined as “Dental”

05/10/2018 Exhibit 3 On code S9125 – struck through “LPN” and added “RN”

05/10/2018 Exhibit 3 Added “S9125 with modifier TE and description = Respite Care LPN

05/10/2018 Exhibit 4 Inserted “Inpatient Psychiatric Care” to description for ASAM Level 3.5

05/10/2018 Exhibit 4 Inserted “Intensive” to description for ASAM Level 3.7

05/10/2018 Exhibit 4 Inserted “(Licensed as such by DBHDS)” to description for OTP

05/10/2018 Exhibit 4 Added value “13” to define BWP – Buprenorphine Waivered Prescribers

08/31/2018 Title Page Update Date

08/31/2018 2 Added “Post Network Files to SharePoint in the “Networks Adequacy” folder.”

08/31/2018 7 Example 6. Added “TE” modifier to code H2021

08/31/2018 Exhibit 1 Added the following Taxonomy codes:

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106E00000X - Assistant Behavior Analyst 106S00000X - Behavior Technician 207WX0009X - Ophthalmology - Glaucoma Specialist 207WX0107X - Ophthalmology - Retina Specialist 207WX0108X - Ophthalmology - Ureitis and Ocular Inflammatory Disease 207WX0109X - Ophthalmology - Neuro-Ophthalmology 207WX0110X - Ophthalmology - Pediatric Ophthalmology and Strabismus Specialist 207WX0120X - Ophthalmology - Cornea and External Diseases Specialist

08/31/18 Exhibit 8 Added: S9125-TD Respite Care/RN

08/31/18 Exhibit 8 Added “TE” to S9125-Respite Care/LPN

09/18/18 7 Page 19 – Added “29 = Dental” to the list of Provider Designations

09/18/18 Exhibit 8 08 – Addiction, Recovery and Treatment Services (ARTS) – added “Excluding Residential and Inpatient Detox” to first column and dropped the footnote

09/18/18 Exhibit 8 Added: 08 – Addiction, Recovery and Treatment Services (ARTS), Residential ONLY

09/18/18 Exhibit 8 Added: 08 – Addiction, Recovery and Treatment Services (ARTS), Inpatient Detox ONLY

09/18/18 Exhibit 8 Added: 29 – Dental

09/18/18 Exhibit 8 Early Intervention Time and Distance Requirements answer changed from No to Yes and marked as “under development”

09/18/18 Exhibit 8 Foot note 2 added regarding EI and DBHDS

Documents

Virginia Department of Medical Assistance Services