Exception Requests
Exception requests (ERs) are a critical component of the review process. ERs were introduced into the network adequacy process to address instances where meeting criteria may not be feasible. Plans have had problems providing a clear rationale for their ERs and in many cases submit an ER when it is not necessary (criteria passed). While there are a number of options in CMS’s ER template, plans need to clearly make their case for the need of an ER. For example, “Provider not willing to contract” is not an acceptable rationale for an ER. Retium Health helps MAOs evaluate the need and rationale for an ER and will help develop the appropriate justification.
Analysis of Deficiencies: Retium Health will work with your team reviewing the ACC and Zip-Code deficiency reports to determine not only in which counties your network may not be meeting adequacy criteria, but also in which specific areas/zip codes you are deficient
Validation of the CMS Supply File and Identification of Alternative Providers: CMS determines feasibility to meet network criteria based on its supply file which is available to all plans submitting bids. This file can help identify providers where your organization is deficient (not meeting network criteria) and should also be validated since errors in the file can assist with the development of ERs (e.g. criteria can not be met since the provider included is no longer providing services at this location).
Mapping: the team will also provide mapping as needed to show alternative providers that can cover the areas where an incorrect provider (not practicing at the stated location or in the specialty type assigned) is located.
Exception Request (ER) Justification: Retium Health will work with your team to provide the rationale for an ER, including identifying an alternative provider in your HSD table that is closest to the “incorrect” one. The justification may include: a) Provider listed in supply file is no longer practicing at this location; b) Provider listed is included in the wrong specialty type (physician X is an oncologist but is concluded as a PCP); c) Provider is only contracting with one organization and is not willing to contract with any other plan.
Members of our team Helped CMS develop the MA Network Adequacy Criteria and Exception Request templates
For over 10 years, our people worked with CMS to establish the current criteria, the CMS review process and the exception request approach