36C10G20R0014-029.docx

Appendix E: Waiver Request Template (For detailed CCN Waiver Request process see CCN PWS Section 3.1)

CCN WAIVER REQUEST

(File naming convention: CCN Region 5 Alaska_Date_<Borough>_<Specialty>)

Part I: Waiver Information

Please enter the Contract ID, Borough/SSA Code, County Name, State, Provider Specialty Code, and Specialty Name for which you are requesting a Waiver.

Borough/SSA Code

Borough Name

Specialty Code

Specialty Name

Part II: Rationale for Waiver

Please respond "Yes" or "No" to the questions below.

Question 1: Does the Contractor attest that it has reviewed publicly available databases and other sources to determine availability of providers/facilities with respect to the Waiver being requested and all information pertained herein is accurate?

Question 2: If the Contractor responded “yes” to Question 1, above, did the contractor’s review identify providers/facilities within or nearby the borough and providing the specialty referenced in this Waiver, and with which the contractor has not contracted?

Question 3: Are there other non-contracted providers/facilities outside the borough and providing the specialty referenced in this Waiver who provide the specialty referenced in the Waiver?

Part III: Sources

In the rows below, please enter any sources (up to five) you used to identify provider/facilities within or nearby CCN’s Network Access Standards. If you have more than five sources, please describe the additional sources in the Part IV: Narrative Text section below. The options for the sources are:

-Physician Compare -Hospital Compare -Nursing Home Compare -Dialysis Compare -NPI file/NPPES -Provider of Services (POS) file -Direct outreach to provider -Provider website -State licensing data -Online mapping tool -Other (Note to the Contractor: Please describe the other source(s) in the “Part IV: Narrative Text” section) Additionally, if you select “Other,” please describe the other sources in the Part IV: Narrative Text section below.

Source 1

Source 2

Source 3

Source 4

Source 5

Part IV: Narrative Text (Optional)

Please use the below box to enter any additional text to justify your Waiver request. This section may also be used to explain “Other” and additional sources from the Part III: Sources section.

Part V: Table of Non-Contracted Providers

Please list below any providers/facilities you have identified within or nearby CCN’s Network Access Standards with whom you have not contracted. Each additional provider/facility should be listed on a separate row. For each additional provider, please complete all columns. In the “Reason for Not Contracting” field, you can select one of the following options:

-Provider is no longer practicing (e.g., deceased, retired), -Provider does not provide services at the office/facility address listed in database, -Provider does not provide services in the specialty type listed in the database and for which this Waiver is being requested, -Provider does not contract with any organization, -Sanctioned provider on List of Excluded Individuals and Entities, -Inability to contract with provider (Note to the contractor: This is not a valid sole rationale for submitting a Waiver), -In the process of negotiating a contract with provider, -Provider is at capacity and is not accepting new patients, -Other If you select “Other” from the “Reason for Not Contracting” list, please elaborate on this reason in the “Additional Notes” field.

Provider/ Facility Name

Provider Street Address

Provider City

Provider State

Provider ZIP Code

NPI #

Provider Phone Number

Reason for Not Contracting

Additional Notes

Part VI: Recommendation

Please use the below box to enter the recommendation on how the Contractor intends to provide Veterans in the borough access to specialty referenced in the Waiver. Include required changes to the Network Access Standards and QASP Standards for this borough and specialty. The format must be consistent with existing QASP network access standards

SOURCE SELECTION INFORMATION--SEE FAR 2.101 AND 3.104

SOURCE SELECTION INFORMATION--SEE FAR 2.101 AND 3.104