Certified Providers and Certified Suppliers That Enroll Via the Form CMS-855A
Community Mental Health Centers (CMHCs)
A. General Background Information
A community mental health center (CMHC) is a facility that provides mental health services. A CMHC must perform certain “core services.” These are:
1. Outpatient services (This includes services for (1) children, (2) the elderly, (3) persons who are chronically mentally ill, and (4) certain persons who have been discharged from a mental health facility for inpatient treatment.)
2. 24-hour-a-day emergency psychiatric services;
3. Day treatment or other partial hospitalization (PH) services, or psychosocial rehabilitation services; and
4. Screening for patients being considered for admission to State mental health facilities.
NOTE: Partial hospitalization is the only core service for which a CMHC can bill Medicare as a CMHC. Thus, while a facility must furnish certain “core” services in order to qualify as a CMHC, it can only get reimbursed for one of them – partial hospitalization. However, the facility may still be able to enroll in Medicare as a Part B clinic if it does not perform partial hospitalization services.
In some instances, these core services can be furnished under arrangement. This generally means that the facility can arrange for another facility to perform the service if, among other things, CMS determines that the following conditions are met:
• The CMHC arranging for the particular service is authorized by State law to perform the service itself;
• The arranging CMHC accepts full legal responsibility for the service; and
• There is a written agreement between the two entities.
While the CMHC generally has the option to furnish services under arrangement, there is actually an instance where the facility must do so. If the CMHC is located in a State that prohibits CMHCs from furnishing screening services (service #4 above), it must contract with another entity to have the latter perform the services. Any such arrangement must be approved by the regional office (RO). (See Pub. 100-07, State Operations Manual (SOM), chapter 2, section 2250, for additional information on core services and arrangements.)
A CMHC must provide mental health services principally to individuals who reside in a defined geographic area (service area); that is, it must service a distinct and definable community. A CMHC (or CMHC site) that operates outside of this specific community must – unless the RO holds otherwise - have a separate provider agreement/number and enrollment, and must individually meet all Medicare requirements.
B. Initial Enrollment and Certification
1. Policy through October 28, 2014
Unlike most certified providers and certified suppliers, CMHCs are not surveyed by the State agency to determine the CMHC’s compliance with Medicare laws (although the State may do a survey to verify compliance with State laws). Instead, the RO (or CMS-contracted personnel) will perform a site visit. The RO will not approve the CMHC unless the latter demonstrates that it is furnishing the core services to a sufficient number of patients. In addition, CMS reserves the right to request at any time documentation from the CMHC verifying the provision of core services.
If the RO or CMS-contracted personnel plans to perform a site visit of an existing, enrolled CMHC, the contractor shall furnish all background information that the RO requests. All inquiries and correspondence relating to the site visit shall be directed to the RO.
Prior to making a recommendation for approval, the contractor shall ensure that the provider has submitted a completed and signed CMHC attestation statement. If the CMHC cannot submit one, the contractor shall deny the application. (The attestation requirement also applies to new owners in a CHOW.) The CMHC attestation statement typically serves as the provider agreement.
If the contractor issues a recommendation for approval, it shall send a copy of the Form CMS-855A to the State agency (or, for contractors in RO 9, the contractor’s RO) with its recommendation. The contractor shall also contact the appropriate RO to initiate a site visit of the CMHC applicant; a copy of this request should be sent to the State agency.
2. Conditions of Participation
Effective October 29, 2014, CMHCs will be required to meet the conditions of participation outlined in 42 CFR Part 485, subpart J. CMHCs, like many other types of certified providers and certified suppliers, will therefore be required to undergo a State survey as part of the certification and enrollment process. The RO will no longer be performing the site visit discussed in section (B)(1) nor will be above-referenced attestation statement be required. Except as otherwise noted in this chapter 15 or in another CMS directive, CMHC initial applications shall – on and after October 29, 2014 - be processed in the same manner as those for all other certified providers.
C. Post-Tie-In Notice Site Visit
(The policies in this section (C) apply before, on, and after October 29, 2014)
The contractor shall order a site visit through the Provider Enrollment, Chain and Ownership System (PECOS) after the contractor receives the tie-in notice (or approval letter) from the RO but before the contractor conveys Medicare billing privileges to the CMHC. This is to ensure that the provider is still in compliance with CMS’s enrollment requirements. The scope of the site visit will be consistent with section 15.19.2.2(B) of this chapter. The National Site Visit Contractor (NSVC) will perform the site visit. The contractor shall not convey Medicare billing privileges to the provider prior to the completion of the NSVC’s site visit and the contractor’s review of the results.
D. Revalidations
If the CMHC submits a Form CMS-855A revalidation application, the contractor shall order a site visit through PECOS. This is to ensure that the provider is still in compliance with CMS’s enrollment requirements. The scope of the site visit will be consistent with section 15.19.2.2(B) of this chapter. The NSVC will perform the site visit. The contractor shall not make a final decision regarding the revalidation application prior to the completion of the NSVC’s site visit and the contractor’s review of the results.
E. Practice Locations/Alternative Sites
A CMHC must list in Section 4 of its Form CMS-855A all alternative sites where core services are provided (i.e., proposed alternative sites for initial applicants and actual alternative sites for those CMHCs already participating in Medicare). The RO will decide whether the site in question: (1) can be part of the CMHC’s enrollment (i.e., a practice location), or (2) should be enrolled as a separate CMHC with a separate provider agreement. The practice location could be out-of-state if the RO determines that the location services the same “defined geographic area” as the main location. In all cases, the RO makes the final determination as to whether a particular practice location qualifies as an alternative site or whether a separate enrollment, provider agreement, etc., is required. If the contractor is unsure as to whether the location requires a separate enrollment and provider agreement, it may contact the RO for clarification.
If a CMHC is (1) adding a new location or (2) changing the physical location of an existing location, the contractor shall order a site visit of the new/changed location through PECOS after the contractor receives notice of approval from the RO but before the contractor switches the provider’s enrollment record to “Approved.” This is to ensure that the new/changed location is in compliance with CMS’s enrollment requirements. The scope of the site visit will be consistent with section 15.19.2.2(B) of this chapter. The NSVC will perform the site visit. The contractor shall not switch the provider’s enrollment record to “Approved” prior to the completion of the NSVC’s site visit and the contractor’s review of the results.
The contractor may refer to Pub. 100-07, SOM, chapter 2, section 2252, for additional information on CMHC alternative sites. Particular attention should be paid to the following provisions in section 2252I, regarding alternative sites:
• If a CMHC operates a CMS-approved alternative site, the site is not required to provide all of the core services. However, a patient must be able to access and receive the services he/she needs at the approved primary site, or at an alternative site that is within the distinct and definable community served by the CMHC.
• RO approvals of such alternative sites should be very limited because (1) CMHCs must serve a distinct and definable community, and (2) CMS has not limited the number of CMHCs an entity may submit for Medicare approval as long as these proposed CMHCs serve different communities.
• The RO will inform the CMHC if it determines that the proposed alternative site must be separately approved because it is not a part of the community where the CMHC is located.
F. Additional Information
For more information on CMHCs, refer to:
• Section 1861(ff) of the Social Security Act
• 42 CFR Sections 410.2, 410.43, and 410.110
• Pub. 100-07, chapter 2, sections 2250 – 2252P
Community Mental Health Centers (CMHCs)
A. General Background Information
A community mental health center (CMHC) is a facility that provides mental health services. A CMHC must perform certain “core services.” These are:
1. Outpatient services (This includes services for (1) children, (2) the elderly, (3) persons who are chronically mentally ill, and (4) certain persons who have been discharged from a mental health facility for inpatient treatment.)
2. 24-hour-a-day emergency psychiatric services;
3. Day treatment or other partial hospitalization (PH) services, or psychosocial rehabilitation services; and
4. Screening for patients being considered for admission to State mental health facilities.
NOTE: Partial hospitalization is the only core service for which a CMHC can bill Medicare as a CMHC. Thus, while a facility must furnish certain “core” services in order to qualify as a CMHC, it can only get reimbursed for one of them – partial hospitalization. However, the facility may still be able to enroll in Medicare as a Part B clinic if it does not perform partial hospitalization services.
In some instances, these core services can be furnished under arrangement. This generally means that the facility can arrange for another facility to perform the service if, among other things, CMS determines that the following conditions are met:
• The CMHC arranging for the particular service is authorized by State law to perform the service itself;
• The arranging CMHC accepts full legal responsibility for the service; and
• There is a written agreement between the two entities.
While the CMHC generally has the option to furnish services under arrangement, there is actually an instance where the facility must do so. If the CMHC is located in a State that prohibits CMHCs from furnishing screening services (service #4 above), it must contract with another entity to have the latter perform the services. Any such arrangement must be approved by the regional office (RO). (See Pub. 100-07, State Operations Manual (SOM), chapter 2, section 2250, for additional information on core services and arrangements.)
A CMHC must provide mental health services principally to individuals who reside in a defined geographic area (service area); that is, it must service a distinct and definable community. A CMHC (or CMHC site) that operates outside of this specific community must – unless the RO holds otherwise - have a separate provider agreement/number and enrollment, and must individually meet all Medicare requirements.
B. Initial Enrollment and Certification
1. Policy through October 28, 2014
Unlike most certified providers and certified suppliers, CMHCs are not surveyed by the State agency to determine the CMHC’s compliance with Medicare laws (although the State may do a survey to verify compliance with State laws). Instead, the RO (or CMS-contracted personnel) will perform a site visit. The RO will not approve the CMHC unless the latter demonstrates that it is furnishing the core services to a sufficient number of patients. In addition, CMS reserves the right to request at any time documentation from the CMHC verifying the provision of core services.
If the RO or CMS-contracted personnel plans to perform a site visit of an existing, enrolled CMHC, the contractor shall furnish all background information that the RO requests. All inquiries and correspondence relating to the site visit shall be directed to the RO.
Prior to making a recommendation for approval, the contractor shall ensure that the provider has submitted a completed and signed CMHC attestation statement. If the CMHC cannot submit one, the contractor shall deny the application. (The attestation requirement also applies to new owners in a CHOW.) The CMHC attestation statement typically serves as the provider agreement.
If the contractor issues a recommendation for approval, it shall send a copy of the Form CMS-855A to the State agency (or, for contractors in RO 9, the contractor’s RO) with its recommendation. The contractor shall also contact the appropriate RO to initiate a site visit of the CMHC applicant; a copy of this request should be sent to the State agency.
2. Conditions of Participation
Effective October 29, 2014, CMHCs will be required to meet the conditions of participation outlined in 42 CFR Part 485, subpart J. CMHCs, like many other types of certified providers and certified suppliers, will therefore be required to undergo a State survey as part of the certification and enrollment process. The RO will no longer be performing the site visit discussed in section (B)(1) nor will be above-referenced attestation statement be required. Except as otherwise noted in this chapter 15 or in another CMS directive, CMHC initial applications shall – on and after October 29, 2014 - be processed in the same manner as those for all other certified providers.
C. Post-Tie-In Notice Site Visit
(The policies in this section (C) apply before, on, and after October 29, 2014)
The contractor shall order a site visit through the Provider Enrollment, Chain and Ownership System (PECOS) after the contractor receives the tie-in notice (or approval letter) from the RO but before the contractor conveys Medicare billing privileges to the CMHC. This is to ensure that the provider is still in compliance with CMS’s enrollment requirements. The scope of the site visit will be consistent with section 15.19.2.2(B) of this chapter. The National Site Visit Contractor (NSVC) will perform the site visit. The contractor shall not convey Medicare billing privileges to the provider prior to the completion of the NSVC’s site visit and the contractor’s review of the results.
D. Revalidations
If the CMHC submits a Form CMS-855A revalidation application, the contractor shall order a site visit through PECOS. This is to ensure that the provider is still in compliance with CMS’s enrollment requirements. The scope of the site visit will be consistent with section 15.19.2.2(B) of this chapter. The NSVC will perform the site visit. The contractor shall not make a final decision regarding the revalidation application prior to the completion of the NSVC’s site visit and the contractor’s review of the results.
E. Practice Locations/Alternative Sites
A CMHC must list in Section 4 of its Form CMS-855A all alternative sites where core services are provided (i.e., proposed alternative sites for initial applicants and actual alternative sites for those CMHCs already participating in Medicare). The RO will decide whether the site in question: (1) can be part of the CMHC’s enrollment (i.e., a practice location), or (2) should be enrolled as a separate CMHC with a separate provider agreement. The practice location could be out-of-state if the RO determines that the location services the same “defined geographic area” as the main location. In all cases, the RO makes the final determination as to whether a particular practice location qualifies as an alternative site or whether a separate enrollment, provider agreement, etc., is required. If the contractor is unsure as to whether the location requires a separate enrollment and provider agreement, it may contact the RO for clarification.
If a CMHC is (1) adding a new location or (2) changing the physical location of an existing location, the contractor shall order a site visit of the new/changed location through PECOS after the contractor receives notice of approval from the RO but before the contractor switches the provider’s enrollment record to “Approved.” This is to ensure that the new/changed location is in compliance with CMS’s enrollment requirements. The scope of the site visit will be consistent with section 15.19.2.2(B) of this chapter. The NSVC will perform the site visit. The contractor shall not switch the provider’s enrollment record to “Approved” prior to the completion of the NSVC’s site visit and the contractor’s review of the results.
The contractor may refer to Pub. 100-07, SOM, chapter 2, section 2252, for additional information on CMHC alternative sites. Particular attention should be paid to the following provisions in section 2252I, regarding alternative sites:
• If a CMHC operates a CMS-approved alternative site, the site is not required to provide all of the core services. However, a patient must be able to access and receive the services he/she needs at the approved primary site, or at an alternative site that is within the distinct and definable community served by the CMHC.
• RO approvals of such alternative sites should be very limited because (1) CMHCs must serve a distinct and definable community, and (2) CMS has not limited the number of CMHCs an entity may submit for Medicare approval as long as these proposed CMHCs serve different communities.
• The RO will inform the CMHC if it determines that the proposed alternative site must be separately approved because it is not a part of the community where the CMHC is located.
F. Additional Information
For more information on CMHCs, refer to:
• Section 1861(ff) of the Social Security Act
• 42 CFR Sections 410.2, 410.43, and 410.110
• Pub. 100-07, chapter 2, sections 2250 – 2252P
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