CMS Pub. 100-06, ch. 6, § 420

Exhibit - Participating Physician/Supplier Report - Screen 1

PARTICIPATING PHYSICIAN/SUPPLIER REPORT

SPECIALTY CODES

01 General Practice

02 General Surgery

03 Allergy/Immunology

04 Otolaryngology

05 Anesthesiology

06 Cardiology

07 Dermatology

08 Family Practice

09 Interventional Pain Management

10 Gastroenterology

11 Internal Medicine

Participants

Non-Participants

Par

Drop-Out

Current

(6)

Non-Par

Sign-Up

Current

(7)

Par

Disenrolls

(8)

SPECIALTY

CODE/GROUP

Prior

(1)

Current

(2)

Contin.

(3)

Prior

(4)

Current

(5)

01-PHY

02-PHY

03-PHY

04-PHY

05-PHY

06-PHY

07-PHY

08-PHY

09-PHY

10-PHY

11-PHY

Exhibit 1 - Participating Physician/Supplier Report - Screen 2

PARTICIPATING PHYSICIAN/SUPPLIER REPORT

SPECIALTY CODES

12 Osteopathic Manipulative Medicine

13 Neurology

14 Neurosurgery

15 Speech Language Pathologist in Private Practice

16 Obstetrics/Gynecology

17 Hospice and Palliative Care

18 Ophthalmology

19 Oral Surgery (Dentists only)

20 Orthopedic Surgery

21 Cardiac Electrophysiology

22 Pathology

23 Sports Medicine

24 Plastic and Reconstructive Surgery

SPECIALTY

CODE/GROUP

Participants

Non-Participants

Par

Drop-Out

Current

(6)

Non-Par

Sign-Up

Current

(7)

Par

Disenrolls

(8)

Prior

(1)

Current

(2)

Contin.

(3)

Prior

(4)

Current

(5)

12-PHY

13-PHY

14-PHY

15-NPP

16-PHY

17-PHY

18-PHY

19-LLP

20-PHY

21-PHY

22-PHY

23-PHY

24-PHY

Exhibit 1 - Participating Physician/Supplier Report - Screen 3

PARTICIPATING PHYSICIAN/SUPPLIER REPORT

SPECIALTY CODES

25 Physical Medicine and Rehabilitation

26 Psychiatry

27 Geriatric Psychiatry

28 Colorectal Surgery (formerly Proctology)

29 Pulmonary Disease

30 Diagnostic Radiology

31 Intensive Cardiac Rehabilitation (ICR)

32 Anesthesiologist Assistant

33 Thoracic Surgery

34 Urology

35 Chiropractic

36 Nuclear Medicine

37 Pediatric Medicine

SPECIALTY

CODE/GROUP

Participants

Non-Participants

Par

Drop-Out

Current

(6)

Non-Par

Sign-Up

Current

(7)

Par

Disenrolls

(8)

Prior

(1)

Current

(2)

Contin.

(3)

Prior

(4)

Current

(5)

25-PHY

26-PHY

27-PHY

28-PHY

29-PHY

30-PHY

31-SUP

32-NPP

33-PHY

34-PHY

35-LLP

36-PHY

37-PHY

Exhibit 1 - Participating Physician/Supplier Report - Screen 4

PARTICIPATING PHYSICIAN/SUPPLIER REPORT

SPECIALTY CODES

38 Geriatric Medicine

39 Nephrology

40 Hand Surgery

41 Optometry

42 Certified Nurse Midwife

43 Certified Registered Nurse Anesthetist (CRNA)

44 Infectious Disease

45 Mammography Screening Center

46 Endocrinology

47 Independent Diagnostic Testing Facility (IDTF)

48 Podiatry

49 Ambulatory Surgical Center

50 Nurse Practitioner

SPECIALTY

CODE/GROUP

Participants

Non-Participants

Par

Drop-Out

Current

(6)

Non-Par

Sign-Up

Current

(7)

Par

Disenrolls

(8)

Prior

(1)

Current

(2)

Contin.

(3)

Prior

(4)

Current

(5)

38-PHY

39-PHY

40-PHY

41-LLP

42-NPP

43-NPP

44-PHY

45-SUP

46-PHY

47-SUP

48-LLP

49-SUP

50-NPP

Exhibit 1 - Participating Physician/Supplier Report - Screen 5

PARTICIPATING PHYSICIAN/SUPPLIER REPORT

SPECIALTY CODES

59 Ambulance Service Supplier

60 Public Health/Welfare Agency

61 Volunteer Health/Charitable Agency

62 Psychologist (Billing Independently)

63 Portable X-Ray Supplier (Billing Independently)

64 Audiologist (Billing Independently)

65 Physical Therapist in Private Practice

66 Rheumatology

67 Occupational Therapist in Private Practice

68 Clinical Psychologist

69 Clinical Laboratory (Billing Independently.)

70 Single or Multispecialty Clinic or Group Practice

71 Registered Dietitian/Nutrition Professional

SPECIALTY

CODE/GROUP

Participants

Non-Participants

Par

Drop-Out

Current

(6)

Non-Par

Sign-Up

Current

(7)

Par

Disenrolls

(8)

Prior

(1)

Current

(2)

Contin.

(3)

Prior

(4)

Current

(5)

59-SUP

60-SUP

61-SUP

62-NPP

63-SUP

64-NPP

65-NPP

66-PHY

67-NPP

68-NPP

69-SUP

70-PHY

71-NPP

Exhibit 1 - Participating Physician/Supplier Report - Screen 6

PARTICIPATING PHYSICIAN/SUPPLIER REPORT

SPECIALTY CODES

72 Pain Management

73 Mass Immunization Roster Biller

74 Radiation Therapy Centers

75 Slide Preparation Facilities

76 Peripheral Vascular Disease

77 Vascular Surgery

78 Cardiac Surgery

79 Addiction Medicine

80 Licensed Clinical Social Worker

81 Critical Care (Intensivist)

82 Hematology

83 Hematology/Oncology

84 Preventative Medicine

SPECIALTY

CODE/GROUP

Participants

Non-Participants

Par

Drop-Out

Current

(6)

Non-Par

Sign-Up

Current

(7)

Par

Disenrolls

(8)

Prior

(1)

Current

(2)

Contin.

(3)

Prior

(4)

Current

(5)

72-PHY

73-SUP

74-SUP

75-SUP

76-PHY

77-PHY

78-PHY

79-PHY

80-NPP

81-PHY

82-PHY

83-PHY

84-PHY

Exhibit 1 - Participating Physician/Supplier Report - Screen 7

PARTICIPATING PHYSICIAN/SUPPLIER REPORT

SPECIALTY CODES

85 Maxillofacial Surgery

86 Neuropsychiatry

88 Unknown Provider

89 Certified Clinical Nurse Specialist

90 Medical Oncology

91 Surgical Oncology

92 Radiation Oncology

93 Emergency Medicine

94 Interventional Radiology

95 Unknown Supplier

97 Physician Assistant

98 Gynecological Oncology

99 Unknown Physician Specialty

SPECIALTY

CODE/GROUP

Participants

Non-Participants

Par

Drop-Out

Current

(6)

Non-Par

Sign-Up

Current

(7)

Par

Disenrolls

(8)

Prior

(1)

Current

(2)

Contin.

(3)

Prior

(4)

Current

(5)

85-LLP

86-PHY

88-NPP

89-NPP

90-PHY

91-PHY

92-PHY

93-PHY

94-PHY

95-SUP

97-NPP

98-PHY

99-PHY

Exhibit 1 - Participating Physician/Supplier Report - Screen 8

PARTICIPATING PHYSICIAN/SUPPLIER REPORT

SPECIALTY CODES

A5 Pharmacy

C0 Sleep Medicine

C1 Centralized Flu

C2 Indirect Payment Procedure

C3 Interventional Cardiology

C4 Restricted Use

C5 General Dentist

C6 Hospitalist

C7 Advanced Heart Failure and Transplant Cardiology

C8 Medical Toxicology

C9 Hematopoietic Cell Transplantation and Cellular Therapy

D1 Medicare Diabetes Prevention Program

D2 Restricted Use

D3 Medical Genetics and Genomics

D4 Undersea and Hyperbaric Medicine

D5 Opioid Treatment Program

D6 Home Infusion Therapy Services

D7 Micrographic Dermatologic Surgery

D8 Adult Congenital Heart Disease

E1 Marriage and Family Therapist

E2 Mental Health Counselors

E3 Dental Anesthesiology

E4 Dental Public Health

E5 Endodontics

E6 Oral and Maxillofacial Pathology

E7 Oral and Maxillofacial Radiology

E9 Oral Medicine

F1 Orofacial Pain

F2 Orthodontics and Dentofacial Orthopedics

F3 Pediatric Dentistry

F4 Periodontics

F5 Prosthodontics

F6 Epileptologists

SPECIALTY

CODE/GROUP

Participants

Non-Participants

Par

Drop-Out

Current

(6)

Non-Par

Sign-Up

Current

(7)

Par

Disenrolls

(8)

Prior

(1)

Current

(2)

Contin.

(3)

Prior

(4)

Current

(5)

A5-SUP

C0-PHY

C1-NPP

C2-NPP

C3-PHY

C4-RES

C5-PHY

C6-PHY

C7-PHY

C8-PHY

C9-PHY

D1-SUP

D2-RES

D3-PHY

D4-PHY

D5-SUP

D6-SUP

D7-PHY

D8-PHY

E1-PHY

E2-PHY

E3-PHY

E4-PHY

E5-PHY

E6-PHY

E7-PHY

E9-PHY

F1-PHY

F2-PHY

F3-PHY

F4-PHY

F5-PHY

F6-PHY

Exhibit 1 - Participating Physician/Supplier Report - Screen 9

PARTICIPATING PHYSICIAN/SUPPLIER REPORT

SPECIALTY CODES

Total Physicians - The contractor reports in the appropriate column the total of all specialty codes

applicable to physicians.

Total LLPs - The contractor reports in the appropriate column the total of all specialty codes

applicable to limited license physicians.

Total NPPs - The contractor reports in the appropriate column the total of all specialty codes

applicable to non-physician practitioners.

Total Physicians/LLPs/NPPs - The contractor reports in the appropriate column the sum of all

physicians, LLPs and NPPs.

Total Suppliers - The contractor reports in the appropriate column the total of all specialty codes

applicable to suppliers.

SPECIALTY

CODE/GROUP

Participants

Non-Participants

Par

Drop-Out

Current

(6)

Non-Par

Sign-Up

Current

(7)

Par

Disenrolls

(8)

Prior

(1)

Current

(2)

Contin.

(3)

Prior

(4)

Current

(5)

TOTALs

PHYs*

LLPs*

NPPs*

PHYs/LLPS/NPPs*

SUPs*

* These lines do not represent specific specialty codes. They are the totals of the specialty sub-groups.