LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2012-10 Update PIM-Part IX; Out of state Practices, CHOW & more

General Update to Chapter 15 of the Program Integrity Manual (PIM) – Part IX
  • MLN Matters® Number: MM 8019 Related Change Request (CR) #: CR 8019 Related CR Release Date: October 19, 2012 Effective Date: November 20, 2012 Related CR Transmittal #: R435PI Implementation Date: November 20, 2012
  • Provider Types Affected
    This MLN Matters® article is intended for physicians, providers and suppliers submitting claims to Medicare Contractors (Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs), Carriers and A/B Medicare Administrative Contractors (MACs)) for services to Medicare beneficiaries.
  • What You Need to Know
    This article is based on Change Request (CR) 8019, which updates Chapter 15 of the Medicare Program Integrity Manual (PIM). That chapter deals with Medicare provider enrollment. The majority of the revisions are editorial in nature. However, there are several policy updates in this CR related to:
    Correspondence addresses
    Out-of-state practice locations
    Submission of Change of Ownership (CHOW) applications after an initial or CHOW application has been submitted
    The scope of revocations and re-enrollment bars
    Make sure that your enrollment staffs are aware of these manual updates. See the Background Section for more details on the policy changes.
  • Background
    The key changes made to Chapter 15 of the PIM are as follows:

Correspondence Addresses

  • The correspondence address must be one where the Medicare Contractor can contact the applicant to resolve any issues once the provider is enrolled in the Medicare program. It can be any address the provider chooses, including that of a billing agency, management services organization, chain home office, or the provider’s representative (e.g., attorney, financial advisor). The provider, however, remains ultimately responsible for all Medicare enrollment-related correspondence that the contractor sends to him/her/it at this address. For instance, if a provider uses its chain home office as the correspondence address, the provider is still the party responsible for replying to revalidation letters, requests for information, etc.
    Also, an e-mail address listed on your enrollment application can be a generic e-mail address. It need not be that of a specific individual. Note that the contractor may accept a particular e-mail address if it has no reason to suspect that it does not belong to or is not somehow associated with the provider.

Out-of-State Practice Locations – Form CMS-855A

  • If a provider is adding a practice location in another state that is within the provider’s current contractor’s jurisdiction, a separate, initial Form CMS-855A enrollment application is not required if the following five conditions are met:
    The location is not part of a separate organization (e.g., a separate corporation, partnership)
    The location does not have a separate Tax Identification Number (TIN) and Legal Business Name (LBN)
    The State in which the new location is being added does not require the location to be surveyed
    The applicable Medicare Regional Office (RO) does not require the new location or its owner to sign a separate provider agreement
    The location is not a Federally Qualified Health Center (FQHCs are required to separately enroll each site)
  • Consider the following examples:
    The Medicare Contractor’s jurisdiction consists of States X, Y and Z. Jones Skilled Nursing Facility (JSNF), Inc., is enrolled in State X with three sites. It wants to add a fourth site in State Y. The new site will be under JSNF, Inc. JSNF will not be establishing a separate corporation, LBN or TIN for the site, and – per the State and RO – a separate survey and provider agreement are not necessary. Since all five conditions above are met, JSNF can add the fourth location via a change of information request, rather than an initial application. The change request must include all information relevant to the new location (e.g., licensure, new managing employees). To the extent required, the contractor shall create a separate Provider Enrollment, Chain and Ownership System (PECOS) enrollment record for the State Y location.
    The contractor’s jurisdiction consists of States X, Y and Z. JSNF, Inc., is enrolled in State X with three locations. It wants to add a fourth location in State Y but under a newly created, separate legal entity – JSNF, LP. The fourth location must be enrolled via a separate, initial Form CMS-855A.
    The contractor’s jurisdiction consists of States X, Y and Z. Jones Hospice (JH), Inc., is enrolled in State X with 1 location. It wants to add a second location in State Z under JH, Inc. However, it has been determined that a separate survey and certification of the new location are required. A separate, initial Form CMS-855A for the new location is required.

  • Out-of-State Practice Locations – Form CMS-855B
    If a supplier is adding a practice location in another State that is within the contractor’s jurisdiction, a separate, initial Form CMS-855B enrollment application is not required if the following five conditions are met:
    The location is not part of a separate organization (e.g., a separate corporation, partnership)
    The location does not have a separate Tax Identification Number (TIN) and Legal Business Name (LBN)
    The State in which the new location is being added does not require the location to be surveyed
    The applicable RO does not require the new location or its owner to sign a separate supplier agreement
    The location is not an Independent Diagnostic Testing Facility (IDTFs are required to separately enroll each site)
  • Consider the following examples:
    The contractor’s jurisdiction consists of States X, Y and Z. Jones Group Practice (JGP), Inc., is enrolled in State X with three locations. It wants to add a fourth location in State Y. The new location will be under JGP, Inc. JGP will not be establishing a separate corporation, LBN or TIN for the fourth location. Since there is no State or RO involvement with group practices, all five conditions are met. JGP can add the fourth location via a change of information request, rather than an initial application. The change request must include all information relevant to the new location (e.g., licensure, new managing employees). To the extent required, the contractor shall create a separate enrollment record in the Provider Enrollment, Chain, and Ownership System (PECOS) for the State Y location.
    The contractor’s jurisdiction consists of States X, Y and Z. Jones Group Practice (JGP), Inc., is enrolled in State X with three locations. It wants to add a fourth location in State Y, but under a newly created, separate entity – Jones Group Practice, LP. The fourth location must be enrolled via a separate, initial Form CMS-855B.
    The contractor’s jurisdiction consists of States X, Y and Z. Jones Group Practice (JGP), Inc., is enrolled in State X with three locations. It wants to add a fourth location in State Q. Since State Q is not within the contractor’s jurisdiction, a separate initial enrollment for the fourth location is necessary.
    The contractor’s jurisdiction consists of States X, Y and Z. Jones Ambulatory Surgical Center (JASC), Inc., is enrolled in State X with three locations. It wants to add a fourth location in State Z under JASC, Inc. However, it has been determined that a separate survey and certification of the new site are required. A separate, initial Form CMS-855B is therefore necessary.
  • Out-of-State Practice Locations – Form CMS-855I
    If a supplier is adding a practice location in another State that is within the contractor’s jurisdiction, a separate, initial Form CMS-855I enrollment application is not required if the following conditions are met:
    The location is not part of a separate organization (e.g., a separate solely-owned corporation)
    The location does not have a separate Tax Identification Number (TIN) and Legal Business Name (LBN)
  • Consider the following examples:
    The contractor’s jurisdiction consists of States X, Y and Z. Dr. Jones, a sole proprietor, is enrolled in State X with two locations. He wants to add a third location in State Y under his social security number and his sole proprietorship’s employer identification number. He can add the third location via a change of information request, rather than an initial application. The change request must include all information relevant to the new location (e.g., licensure). To the extent required, the contractor shall create a separate PECOS enrollment record for the State Y location.
    The contractor’s jurisdiction consists of States X, Y and Z. Dr. Jones, LLC (a solely-owned limited liability company) is enrolled in State X with 2 locations. Dr. Jones wants to add a third location in State Y but as a sole proprietorship, not as part of Dr. Jones, LLC. Since the new location is not part of the same organizational entity, it must be enrolled via a separate, initial Form CMS-855I.

Submission of CHOW Applications after an Initial or CHOW Application has been Submitted

(This section does not apply to Home Health Agencies.)

  • In situations where: 1) the provider submits a Form CMS-855A initial application or CHOW application; and 2) a Form CMS-855A CHOW application is subsequently submitted but before the Medicare contractor has received the tie-in notice from the RO, the contractor shall abide by the following:
    Situation 1 – The provider submitted an initial application followed by a CHOW application, and a recommendation for approval has not yet been made with respect to the initial application – The contractor shall reject both applications and require the provider to re-submit an initial application with the new owner’s information.
    Situation 2 – The provider submitted a CHOW application followed by another CHOW application, and a recommendation for approval has not been made for the first application – The contractor shall process both applications – preferably in the order in which they were received – and shall, if recommendations for approval are warranted, refer both applications to the State/RO in the same package. The accompanying notice/letter to the State/RO shall explain the situation.
    Situation 3 – The provider submitted an initial application followed by a CHOW application, and a recommendation for approval of the initial application has been made – The contractor shall:
    Reject the CHOW application
    Notify the State/RO via letter (sent via mail or email) that there has been a change of ownership (the new owner should be identified) and that the contractor will be requiring the provider to resubmit a new initial application containing the new owner’s information
    Request via letter that the provider submit a new initial Form CMS-855A application containing the new owner’s information within 30 days of the date of the letter. If the provider fails to do so, the contractor shall reject the initial application and notify the provider and the State/RO of this via letter. If the provider submits the application, the contractor shall process it as normal and, if a recommendation for approval is made, send the revised application package to the State/RO with an explanation of the situation; the initially submitted application becomes moot. If the newly submitted application is denied, however, the initially submitted application is denied as well; the contractor shall notify the provider and the State/RO accordingly.
    Situation 4 – The provider submitted a CHOW application followed by another CHOW application, and a recommendation for approval has been made for the first application
    Notify the State/RO via e-mailed letter that a CHOW application has been submitted (the new owner should be identified) and that the contractor will be requiring the provider to resubmit a new initial application containing the new owner’s information. The contractor shall:
    Process the new CHOW application as normal. If a recommendation for approval is made, the contractor shall send the revised CHOW package to the State/RO with an explanation of the situation; the first CHOW application becomes moot. If the newly submitted CHOW application is denied, the first application is denied as well; the contractor shall notify the provider and the State/RO accordingly.

Scope of Revocation and Reenrollment Bar
A chart has been added to chapter 15 of the PIM that outlines the extent to which: 1) a particular revocation generally applies to the provider’s other locations; and 2) the re-enrollment bar applies. The chart is in Section 15.27.2.F of that chapter.

Additional Information
The official instruction, CR 8019, issued to your FI, RHHI, Carrier and A/B MAC regarding this change, may be viewed on the CMS website. The entire revised Chapter 15 of the PIM is attached to that CR.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2011 American Medical Association.