Commonwealth Coordinated Care Plus (CCC Plus) NETWORK SUBMISSION REQUIREMENTS
NETWORK SUBMISSION REQUIREMENTS MANUAL (NSRM)
DMAS
3/30/20174/26/2017
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 7
Health Plan API 8
Provider NPI 9
Provider Last Name 11
Provider First Name 12
Group Affiliation 13
Hospital Affiliation 14
Provider Taxonomy Code 15
Primary Taxonomy Code Indicator 16
Provider Designation 17
Provider Designation Sub-Classification 20
Address Line 1 21
Address Line 2 22
City 23
FIPS Code 24
State 25
Zipcode 26
24 HR Access 27
Other Language Spoken1 28
Other Language Spoken2 29
CSB Satellite Office 30
ADA Compliant 31
Accepting New Patients 32
Servicing FIPS Codes 33
Exhibit 1 – Taxonomy Codes (Use latest list released by Washington Publishing Company (WPC)) 34
Exhibit 2 – Examples for Primary Designation of Specialist 55
Exhibit 3 – Long Term Services & Supports (LTSS) Waiver Procedure Codes 56
Exhibit 4 – Addiction, Recovery and Treatment Services (ARTS) 57
Exhibit 5 – Community Mental Health Rehabilitation Services (CMHRS) Procedure Codes 58
Exhibit 6a – Virginia City and County FIPS Codes 59
Exhibit 6b – State FIPS Codes 61
Exhibit 7 – Other Language Spoken 62
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 10th of each month unless otherwise directed by DMAS. Full CCC Plus line of business network submission is required for all monthly submissions. Final readiness network that will be used to determine network adequacy for each regions is the file submitted three month 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 (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: United022017NS.xlsx. NOTE: “.xlsx” extension is included in the example to ensure that only Excel files are submitted. PDF, Word, Text or any other file type will not be accepted.
· Format the Excel spreadsheet using the EXACT Data Element Names as column headings. Follow the Data Specifications provided as mentioned in the detailed section of each Field Name. Do not abbreviate and do not add any other characters. NOTE: Files will fail if the column headings are not labeled correctly.
· The entire network shall be in one file, formatted as shown below.
· Do NOT submit separate files or separate worksheets within one file.
· If a provider has more than one physical office location, each location should be submitted; however, list each provider location separately.
· If a provider has more than one provider designation, each designation should be submitted; however, list each designation separately. (See example on page 13.)
· If a provider has more than one taxonomy in one location, each taxonomy should be submitted; however, list each provider taxonomy separately.
· Please ensure the primary taxonomy is labeled properly. If a provider only has one taxonomy, this record should be labeled as the primary taxonomy.
· List each separate location on a separate row in the spreadsheet.
· Fields labeled as a “Required Field” must be included for every record in the file
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.
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) not needed until readiness review for transition of CMHRS into CCC Plus, effective 1/1/2018.
10 = Hospital – Psychiatric
11 = Hospital – General
12 = Hospital – Physical Rehabilitation
13 = Urgent Care
14 = Nursing Facility – Skilled
15 = Nursing Facility – Intermediate Care
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
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
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
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
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:
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.