virginia department of medical assistance services
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Virginia Department of Medical Assistance Services
Commonwealth Coordinated Care Plus (CCC Plus) NETWORK SUBMISSION REQUIREMENTS NETWORK SUBMISSION REQUIREMENTS MANUAL (NSRM)
DMAS 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
Field Name, Long Description
Required Field
Data Specification – Variations and Examples
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
Field Name, Long Description
Required Field
Data Specification – Variations and Examples
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.
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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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Code Classification Specialization
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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Code Classification Specialization
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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Code Classification Specialization
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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Code Classification Specialization
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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Code Classification Specialization
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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Code Classification Specialization
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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Code Classification Specialization
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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Code Classification Specialization
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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Code Classification Specialization
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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Code Classification Specialization
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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Code Classification Specialization
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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Code Classification Specialization
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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Code Classification Specialization
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
Code Classification Specialization
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
Code Classification Specialization
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
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Code Classification Specialization
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
Code Classification Specialization
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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Code Classification Specialization
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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Code Classification Specialization
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
3418M1120X Military/U.S. Coast Guard Transport
Military or U.S. Coast Guard Ambulance, Air Transport
3418M1130X Military/U.S. Coast Guard 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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Code Classification Specialization
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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Code Classification Specialization
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
At least 2 Pediatricians w/in 15
miles
At least 2 Pediatricians w/in 30
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
At least 2 Providers w/in 60 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 75 minutes
At least 1 Provider w/in 30 miles
At least 1 Provider w/in 60 miles
06 – Long Term Services & Supports (LTSS) Waiver Provider
S5109-Service Facilitation Consumer Training Visit
H2000-Service Facilitation Comprehensive Visit
S5116-Service Facilitation Management Training Hours
T1028-Service Facilitation Reassessment Visit
T1002-Skilled Nursing Services/RN
T1003-Skilled Nursing Services/LPN
Yes – Provider travels to member
¹Choice of at least 2 Providers for any service area locality
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Provider Designation (PD)
Regulations and/or Contract include
Time and Distance Requirements?
Time (Urban) Time (Rural) Distance or Travel
(Urban) Distance or Travel
(Rural)
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
06 – Long Term Services & Supports (LTSS) Waiver Provider
T1999-Assistive Technology Only
T1999-U5-Assistive Technology Maintenance Costs Only
S5165-Environmental Modification Only
99199-U4- Environmental Modification, Maintenance Costs Only
S5160- PERS Installation
S5160-U1- PERS and Medication Monitoring Installation
Yes – Provider travels to member
NOTE for the following, Health Plans can have 1 Provider that covers a specific service area/locality:
Assistive Technology Only
Environmental Modification
Personal Emergency Response Systems (PERS)
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Provider Designation (PD)
Regulations and/or Contract include
Time and Distance Requirements?
Time (Urban) Time (Rural) Distance or Travel
(Urban) Distance or Travel
(Rural)
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
At least 2 Providers w/in 75 minutes
At least 2 Providers w/in 30 miles
At least 2 Providers w/in 60 miles
08 – Addiction, Recovery and Treatment Services (ARTS), excluding Residential & Inpatient Detox
Yes At least 2 Providers w/in 45 minutes
At least 2 Providers w/in 75 minutes
At least 2 Providers w/in 30 miles
At least 2 Providers w/in 60 miles
08 – Addiction, Recovery and Treatment Services (ARTS), Residential ONLY
Yes At least 1 Provider w/in 45 minutes
At least 1 Provider w/in 75 minutes
At least 1 Provider w/in 30 miles
At least 1 Provider w/in 60 miles
08 – Addiction, Recovery and Treatment Services (ARTS), Inpatient Detox ONLY
Yes At least 1 Provider w/in 45 minutes
At least 1 Provider w/in 75 minutes
At least 1 Provider w/in 30 miles
At least 1 Provider w/in 60 miles
09 – Community Mental Health Rehabilitation Services (CMHRS)
H2017 - Psychosocial Rehab
H0035-HB - Day Treatment/Partial Hospitalization, Adults
H0035-HA - Therapeutic Day Treatment (TDT) School Day, Child
H0035-HA & UG - TDT Afterschool, Child
H0035-HA & U7 - TDT Summer Program, Child
Yes – Member travels to provider
At least 2 Providers w/in 45 minutes
At least 2 Providers w/in 75 minutes
At least 2 Providers w/in 30 miles
At least 2 Providers w/in 60 miles
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Provider Designation (PD)
Regulations and/or Contract include
Time and Distance Requirements?
Time (Urban) Time (Rural) Distance or Travel
(Urban) Distance or Travel
(Rural)
09 – Community Mental Health Rehabilitation Services (CMHRS)
H0039 - Intensive Community Treatment (ICT)
H2019 - Crisis Stabilization
H0036 - Crisis Intervention
H2012 - Intensive In-Home (IIH)
H0046 - Mental Health Skill-building Services (MHSS)
H2033 - Behavioral Therapy
H0024 - Peer Support Services, Individual Mental Health
H0025 - Peer Support Services, Group Mental Health
Yes – Provider travels to member
¹Choice of at least 2 Providers for any service area locality
09 – Community Mental Health Rehabilitation Services (CMHRS)
H0023 - Mental Health Case Management
Yes – Provider travels to member
Choice of the CSB in network in the locality in which the member is served. The CSB is currently the only option allowed to bill/perform this service due to regulations.
10 – Hospital – Psychiatric Yes At least 1 Provider w/in 45 minutes
At least 1 Provider w/in 75 minutes
At least 1 Provider w/in 30 miles
At least 1 Provider w/in 60 miles
11 – Hospital – General Yes At least 1 Provider w/in 45 minutes
At least 1 Provider w/in 75 minutes
At least 1 Provider w/in 30 miles
At least 1 Provider w/in 60 miles
12 – Hospital – Physical Rehabilitation
Yes At least 1 Provider w/in 45 minutes
At least 1 Provider w/in 75 minutes
At least 1 Provider w/in 30 miles
At least 1 Provider w/in 60 miles
13 – Urgent Care Yes At least 1 Provider w/in 45 minutes
At least 1 Provider w/in 75 minutes
At least 1 Provider w/in 30 miles
At least 1 Provider w/in 60 miles
14 – Nursing Facility Yes At least 2 Providers w/in 45 minutes
At least 2 Providers w/in 75 minutes
At least 2 Providers w/in 30 miles
At least 2 Providers w/in 60 miles
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Provider Designation (PD)
Regulations and/or Contract include
Time and Distance Requirements?
Time (Urban) Time (Rural) Distance or Travel
(Urban) Distance or Travel
(Rural)
16 – Outpatient Rehabilitation (PT/OT/SP)
Yes At least 2 Providers w/in 45 minutes
At least 2 Providers w/in 75 minutes
At least 2 Providers w/in 30 miles
At least 2 Providers w/in 60 miles
17 – Durable Medical Equipment (DME) and Supplies
Yes ¹Choice of at least 1 provider for any service area locality
18 – Radiology Yes At least 2 Providers w/in 45 minutes
At least 2 Providers w/in 75 minutes
At least 2 Providers w/in 30 miles
At least 2 Providers w/in 60 miles
19 – Home Health Agency Yes ¹Choice of a least 2 Providers for any service are locality
20 – Laboratory Yes At least 1 Provider w/in 45 minutes
At least 1 Provider w/in 75 minutes
At least 1 Provider w/in 30 miles
At least 1 Provider w/in 60 miles
21 – Pharmacy Yes At least 2 Providers w/in 45 minutes
At least 2 Providers w/in 75 minutes
At least 2 Providers w/in 30 miles
At least 2 Providers w/in 60 miles
22 – Vision Yes At least 2 Providers w/in 45 minutes
At least 2 Providers w/in 75 minutes
At least 2 Providers w/in 30 miles
At least 2 Providers w/in 60 miles
23 – Transportation No
24 – Other No
25 – OB/GYN Yes At least 2 Providers w/in 45 minutes
At least 2 Providers w/in 75 minutes
At least 2 Providers w/in 30 miles
At least 2 Providers w/in 60 miles
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 “,””
04/26/2017 7 - Servicing FIPS Codes
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”
08/30/2017 7 - Provider Designation
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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Date Section Information Updated
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
10/30/2017 7 - Servicing FIPS Codes
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
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)” 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.
11/03/2017 7 - Provider Designation
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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Date Section Information Updated
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
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