Open Door Forum: Next Generation ACO Model - Completing Model Participant List Deep Dive

Next Generation ACO Model Open Door
Forum
Submission of Initial CY
2018 Next Generation
Participant Lists by 2018
NGACO Applicants
April 25, 2017

4:00-5:00pm ET

Disclaimer
The comments made on this call are offered only for general
informational and educational purposes. As always, the agency’s
position on matters may be subject to change. CMS’ comments
are not offered as, and do not constitute legal advice or legal
opinions, and no statement made on this call will preclude the
agency and/or its law enforcement partners from enforcing any
and all applicable laws, rules and regulations. ACOs are
responsible for ensuring that their actions fully comply with
applicable laws and regulations, and we encourage you to consult
with your own legal counsel to ensure such compliance.
Furthermore, to the extent that we may seek to gather facts and

information from you during this call, we intend to gather your

individual input. CMS is not seeking group advice.

2

Housekeeping
Slides will be made

available online!

3

Agenda
• Review:
– Provider definitions (CMMI)
– Provider overlap rules (CMMI)
• Policies & Procedures: Changes after initial
submission, accuracy of data, Legacy TINs, CCNs
(CMMI)
• PLST Demo (RTI)
• PLST Tips (RTI)
• Provider list processing timeline (CMMI)
• Q&A Session (CMMI & RTI)
4

A “Next Generation Participant” is defined as an individual or
Definition: Next Generation
Participant
entity that:
• is a Medicare-enrolled provider or supplier,
• is identified on the Participant List,
• bills for items and services it furnishes to beneficiaries under a
Medicare billing number assigned to a TIN in accordance with
applicable Medicare regulations,
• is not a Preferred Provider,
• is not a Prohibited Participant, and
• has agreed to participate in the Model, to report quality data
through the ACO, and to comply with care improvement
objectives and Model quality performance standards pursuant
to a written agreement with the ACO.
5

“Next Generation Professional” is defined as a Next Generation Participant
Definition: Next Generation
Professional
who is either:
A. A physician (as defined in section 1861(r) of the Act); or
B. One of the following non-physician practitioners:
1. Physician assistant who satisfies the qualifications set forth at 42 CFR
§ 410.74(a)(2)(i)-(ii);
2. Nurse practitioner who satisfies the qualifications set forth at 42 CFR
§ 410.75(b);
3. Clinical nurse specialist who satisfies the qualifications set forth at 42 CFR
§ 410.76(b);
4. Certified registered nurse anesthetist (as defined at 42 CFR § 410.69(b));
5. Certified nurse midwife who satisfies the qualifications set forth at 42 CFR
§ 410.77(a);
6. Clinical psychologist (as defined at 42 CFR § 410.71(d));
7. Clinical social worker (as defined at 42 CFR § 410.73(a)); or
8. Registered dietician or nutrition professional (as defined at 42 CFR
§ 410.134). 6

Definition: Prohibited Participant
• A “Prohibited Participant” is defined as an
individual or entity that is:
1. A Durable Medical Equipment, Prosthetics, Orthotics
and Supplies (DMEPOS) Supplier
2. An ambulance supplier,
3. A drug or device manufacturer, or
4. Excluded or otherwise prohibited from participation
in Medicare or Medicaid.
7

Definition: Preferred Provider
“Preferred Provider” means an individual or entity
that:
A. Is a Medicare-enrolled provider (as defined at 42 CFR §
400.202) or supplier (as defined at 42 CFR § 400.202);
B. Is identified on the Preferred Provider List in accordance
with Section IV;
C. Bills for items and services it furnishes to Beneficiaries
under a Medicare billing number assigned to a TIN in
accordance with applicable Medicare regulations;
D. Is not a Next Generation Participant;
E. Is not a Prohibited Participant; and
F. Has agreed to participate in the Model pursuant to a
written agreement with the ACO. 8

Participant Overlap Rules: ACO
Overlap
An NGACO may not simultaneously participate

in any other Medicare shared savings initiatives

(e.g., Medicare Shared Savings Program (MSSP),

Comprehensive ESRD Care (CEC) Initiative).

9

Participant Overlap Rules: Next Generation
Participant and Preferred Provider Overlap
• A Next Generation Participant may not also be an
ACO participant, ACO provider/supplier and/or ACO
professional in an accountable care organization in
the Medicare Shared Savings Program.
• A Next Generation Professional who is a primary
care specialist may not:
(a) be identified as a Next Generation Participant by a
different accountable care organization in the Model;
(b) be an ACO participant, ACO provider/supplier or ACO
professional in the Medicare Shared Savings Program;
or
(c) participate in another Medicare ACO model, except as
expressly permitted by CMS.
10

In the NGACO model a Next Generation Professional
who is a primary care specialist is defined as a physician
or non-physician practitioner whose principal specialty
code is one of the following:
Code Specialty
1 General Practice
8 Family Medicine
11 Internal Medicine
38 Geriatric Medicine
50 Nurse Practitioner
97 Physician Assistant 11

A Next Generation Participant who is a non-
primary care specialist may be a Next
Generation Participant in another NGACO or
serve in an equivalent role in any other model
or program in which such non-primary care
specialists are not required to be exclusive to
one participating entity.
12

• The NGACO Model does not require full TIN
Provider Overlap Rules: SSP & Full-TIN
Exclusivity
participation. In other words, the NGACO Model
does not require that all individuals/organizations in
an NGACO-participating TIN be a part of the NGACO.
• MSSP requires that all eligible professionals in ACO-
participating TIN be part of the MSSP ACO.
• If one individual or entity under a TIN is an approved
Next Generation Participant, then all
individuals/entities who bill under that TIN are
precluded from participating as an ACO participant,
ACO provider/supplier and/or ACO professional in
the MSSP ACO Model.
13

Policies & Procedures: Changes after
Initial Participant Submission
• After submission of your proposed/initial CY 2018 Next
Generation Participant lists on June 9, 2017, 2018 NGACO
Applicants are not permitted, at any time prior to the
Performance Year, to:
A) Add new proposed Next Generation Participants, and/or
B) Change/correct/amend identifiers associated with previously-
submitted proposed Next Generation Participants
• NGACOs will be able to remove proposed Next Generation
Participants from their lists, prior to the PY, at a designated
time
• It is incumbent upon the ACO to ensure accurate data &
provider identifiers are submitted 14

Provider Type
Practitioner at a
Solo Practice
Taxpayer ID
Number
Required
Individual NPI
Required
Organization
NPI
Optional
CMS
Certification
Number
Prohibited
Practitioner at a
Group Practice
Required Required Optional Prohibited
Practitioner at
an FQHC, RHC,
or CAH2
Required Required Required Required
Facility or
Institution
Required Prohibited Required Required
[Provider Identifiers for Provider
Types ]
15

Policies & Procedures: Accuracy of
Provider Data
• CMMI does not verify the accuracy of provider identifiers (CCNs, TINs, individual NPIs,
organizational NPIs, individual provider names, organizational names) submitted by
NGACOs.
• CMMI does not verify that a TIN submitted by an NGACO on behalf of a proposed
provider is the actual, correct and/or accurate TIN through which the individual provider
bills Medicare for services rendered to beneficiaries.
• CMMI verifies ONLY if the format of certain provider identifiers is/are correct.
• It is incumbent upon the applicant NGACO to ensure all provider identifiers are accurate
BEFORE submitting their proposed/initial Next Generation Participant lists to CMMI.
• It is incumbent upon the NGACO to verify that the correct TIN (the TIN the provider
uses/has authorized to bill Medicare) is submitted on behalf of providers. It is incumbent
upon the NGACO to verify that an individual provider has reassigned their billing rights to
whichever TIN they submit. This information is stored in PECOS (Provider Enrollment
Chain and Ownership System).
– https://pecos.cms.hhs.gov/pecos/login.do
– “Who should I call?” CMS Provider Enrollment Assistance Guide:
https://www.cms.gov/Medicare/Provider-Enrollment-and
Certification/MedicareProviderSupEnroll/downloads//CMSProviderEnrollmentAssist
anceGuide.pdf 16

[Provider Identifiers]
• Providers (individual or organizations) should
update their information in the National Plan
and Provider Enumeration System (NPPES)
– National Provider Identifier (NPI)
– Specialist designation
• Program Integrity Checks (CPI)
– Ensures that individual suppliers can bill Medicare
and are not sanctioned
17

Definition: Legacy TIN
• A Legacy TIN is defined as a taxpayer identification
number that was used by a proposed Next
Generation Participant when billing for primary care
services during the 24-month Alignment Period but
will not be used by that Next Generation Participant
to bill for primary care services during the
Performance Year.
• The Alignment Period is the 24-month period that is
used when identifying whether Next Generation
Participants were the principal source of primary care
services received by a beneficiary.
• The 2-year alignment period for CY2018/PY3 is July 1,
2015 through June 30, 2017. 18

Legacy TINs: Types & Purpose
• Two types of Legacy TINs: “sunsetted” Legacy TINs and “active”
Legacy TINs.
• Sunsetted Legacy TIN= a TIN that was used by a Next Generation
Participant to bill for services during the Alignment Period but is
no longer used by any Medicare providers/suppliers.
• Active Legacy TIN= a TIN that was used by a Next Generation
Participant to bill for services during the Alignment Period but
will no longer used by that same Next Generation Participant to
bill for services during the PY. However, that TIN is still used by
other Medicare providers/suppliers to bill for services.
– For example, in the past, a Next Generation Participant billed using
TIN 123. The Next Generation Participant now bills under TIN 456,
but TIN 123 is still used by a group of Medicare providers and
suppliers that are not Next Generation Participants. This Legacy TIN
would be considered an “active Legacy TIN.”
19

• If applicable to a given ACO provider, you can and should submit
Submitting Legacy TINs on Initial Next
Generation Participant List
both types of Legacy TINs on behalf of proposed Next Generation
Participants to ensure that the services provided by those
providers during the Alignment Period are accurately captured and
reflected in the execution of the beneficiary alignment algorithm.
• When completing your Initial Next Generation Participants list, you
must indicate if a provider record submitted contains a legacy TIN.
• If an ACO submits an active or sunsetted legacy TIN on behalf of a
Next Generation Participant on its initial 2018 Next Generation
Participant list for alignment purposes, the ACO must submit two
records for that provider on the list according to the example in
the table on the next slide. One record contains the provider’s
non-legacy, current TIN that will be used for billing during 2018
while the second record contains the active/sunsetted Legacy TIN.20

ACO
ID
V000
V000
Provider
Class
PART
PART
Legacy
Record
Y
Billing

TIN

012345678

012345680

Org

NPI

CCN
Ind NPI

1234567891

1234567891

OrgName

Erewhon PC
Erewhon PC
Last

Name

Chase
Chase
First
Name
Samuel
Samuel
City
Boston
Boston
State
MA
MA
Zip
02108
02108
Example
21

Policies & Procedures: CCNs
• A CMS Certification Number (CCN) is a 6 character code
issued by CMS when an institutional provider applies to
become a Medicare participating provider. The CCN should
not be confused with a PTAN or other identifier that may be
used by the provider when submitting claims to a Medicare
Administrative Contractor.
• Review the CMS State Operations Manual (Chapter 2
Certification Process) for information on how CCNs are
assigned. https://www.cms.gov/Regulations-and
Guidance/Guidance/Manuals/Downloads/som107c02.pdf
• https://www.resdac.org/sites/resdac.umn.edu/files/Provide
r%20Number%20Table.txt
22

Policies & Procedures: CCNs
A CCN is a required identifier for institutional
providers/facilities, including but not limited to
Federally-Qualified Health Centers (FQHCs), critical
access hospitals (CAHs), critical access hospitals that
elect payment under Method 2 (CAH2s) , home health
agencies (HHAs), acute care hospitals (ACHs), skilled
nursing facilities (SNFs) and skilled nursing units of
acute care hospitals including swing-beds, hospices,
rural health clinics (RHCs), inpatient rehabilitation
facilities, long-term care hospitals (LTCHs), psychiatric
hospitals, etc.
23

Provider List Submission Tool (PLST)
Demonstration
• The Provider List Submission Tool (PLST) is a
macro-enabled Excel workbook with several
worksheets
• The PLST is designed to facilitate submission
of acceptable provider lists
• It is updated periodically
• Documentation (information packet) is also
provided
24

[The Provider List Submission Tool]
CERTIFICATION worksheet
Incomplete certification worksheet Complete certification worksheet
26

LIST_STAGING worksheet: The LIST_STAGING
worksheet is a “scratch pad” on which you can
prepare records for submission. In general you
are advised to copy data first onto the
LIST_STAGING worksheet so that you can correct
errors as they are identified.
27

ACO_PROVIDER_LIST_VALIDATION worksheet

NGACO Participating & Preferred Provider List Validation
5 Total provider records checked
0 Pass format validation
5 Fail format validation and will not be processed
0 Duplicate records will not be processed
0 Participating provider records checked
0 Participating provider records pass format validation
Import Transfer Run Validation Export
0 Unique Individual (Professional/Practitioner) NPIs
0 DATA ARE READY TO SUBMIT FOR CMMI REVIEWView List
0 Unique Individual (Professional/Practitioner) NPIs
5 DO NOT SUBMIT DATA UNTIL ALL ERRORS ARE CORRECTED!View List
28

ACO_PROVIDER_LIST worksheet
• The ACO_PROVIDER_LIST worksheet displays your data. After
running the validation algorithm it will also highlight and describe
the errors that it encountered and that need to be corrected. Cells
containing errors are highlighted in light/bright blue and contain
comments describing the error.
• Column T provides “response codes” indicating whether the record
passed validation and, if not, the general reason that the record did
not pass validation.
• Column W through Z are populated by the PLST validation algorithm
with data that are used as part of the validation process or that will
be added by CMMI’s contractor after the data have been received
and processed.
• Columns AA through AE are populated by the PLST validation
algorithm.
29

ACO_SERVICE_AREA worksheet
• The NGACO will use the ACO_SERVICE_AREA worksheet to identify
the counties in which its primary care providers maintain office
locations. These counties comprise the “core service area” (CSA) of
the NGACO. Counties adjacent to the core service area counties are
part of the extended service area.
• The ACO_SERVICE_AREA worksheet consists of three
fields/columns:
– State: The postal abbreviation of the state in which the county is
located.
– County Name: The name of the county.
– NGACO Core Service Area County: An indicator that the county is
included in the NGACO’s core service area
30

Data Validation Algorithm
• The algorithm checks for:
– Formatting errors
– Duplicate records
• Any records that are submitted with formatting or duplication
errors will not be processed.
• To ensure initial processing of all records, run validation on the
ACO_PROVIDER_LIST_VALIDATION tab before submitting any
provider lists.
31

[Handling “Errors” Flagged by the
PLST]
ASK BEFORE YOU SUBMIT DATA CONTAINING ERRORS

32

PLST Tips
• ALL data should be treated as characters, NOT NUMBERS

• Therefore when cutting and pasting you should “cut and
paste values”
– Do not simply cut and paste
– Excel will treat an identifier (TIN ) as a number
• Do NOT include accented characters
– Maria not María
– Nunez not Nuñez
• Do NOT include carriage returns or tabs in any cells.
• The validation routine will replace “illegal” characters
although it may flag the errors
33

On the Initial CY 2018 Next Generation
Participant PLST due June 9, 2017:
• Do not submit Alternative Payment Arrangements or
Benefit Enhancement elections in PLST
• Do NOT change the PLST Purpose, Provider Class, or Alt.

Payment settings on the CERTIFICATION worksheet.

• Make sure that:
– PLST Purpose = Add
– Provider Class = PART
– Alt. Payment = None
• Where the PLST asks for ACO ID, NG-301 would use N301

• Applicants MUST specify their core service area on this
PLST
34

PLST Tips Continued..
• The columns in the PLST “as shipped” are all formatted as text.

• 0, 1, 2, 3, 4, 5, 6, 7, 8 and 9 cannot be entered as numbers.
• Excel “treats” anything that looks like a number as a number
unless the user/programmer takes steps to prevent that. This is
important for identifiers that can begin with a zero.
• For example a valid ORG_TIN is 012345678. The ACO must not
omit the initial zero. Similarly a valid ORG_CCN is 010024. The
ACO must not omit the initial zero.
• When these data are entered (manually) the initial zero will be
preserved.
• If an ACO copies and pastes from another Excel workbook of
their own design it is possible that the leading zero will be
dropped.
35

• August 2017:
Looking Ahead: Tentative Provider
Processing Timeline
– CMS Selection Decisions Communicated to Applicant NGACOs
– Proposed CY2018 Next Generation Participant List response files sent
to applicants
• September 2017:
– Certification and Submission of Final CY 2018 Participant List due to
CMS
– NGACOs resolve provider overlap issues
– Selected ACOs and their Proposed Next Generation Participants
decide which Medicare shared savings initiative they will participate
in for CY 2018
– Selected NGACOs should begin staging/preparing data for submission
of their proposed Preferred Providers, associated Preferred Provider
benefit enhancement (BE) and alternative payment mechanism
elections, and Participant BE and payment mechanism elections for
CY 2018 36

• October 2017:
Processing Timeline
– CMS sends Final CY2018 Next Generation Participant
Response Files to NGACOs who will participate in the
NGACO Model for CY2018
• November 2017:
– NGACOs submit proposed CY2018 Preferred Providers &
associated benefit enhancement and payment
mechanism elections (Population-Based Payments or All-
Inclusive Population-Based Payment indicators) to CMS
– NGACOs submit benefit enhancement and alternative
payment elections (Population-Based Payments or All-
Inclusive Population-Based Payment indicators) on behalf
of their final CY2018 Participants
37

• December 2017:
Processing Timeline
– CMS sends an updated provider list, in the form of a Response
File, to NGACOs reflecting approved/rejected Preferred
Providers, approved/rejected benefit enhancement and
alternate payment mechanism elections for proposed
Preferred Providers, and approved/rejected benefit
enhancement and alternate payment mechanism elections for
final Next Generation Participants
– Certification of Final CY 2018 Preferred Provider List due to
CMS
– NGACOs remove Preferred Providers from its final list before
the Performance Year
– NGACOs remove Next Generation Participants from its final list
prior to the PY 38

Questions?
Next Generation ACO Model Webpage:
http://innovation.cms.gov/initiatives/Next-Generation-ACO-Model/
E-mail: NextGenerationACOModel@cms.hhs.gov

Technical Support: CMMIForceSupport@cms.hhs.gov

39

Reviewed
by: Luis

Open Door Forum: Next Generation ACO Model - Completing Model Participant List Deep Dive

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