A. Background
Effective October 29, 2014, under § 485.918(b)(1) a CMHC must provide at least 40 percent of its items and services to individuals who are not eligible for benefits under title XVIII of the Social Security Act, as measured by the total number of CMHC clients treated by the CMHC for whom services are not paid for by Medicare, divided by the total number of clients treated by the CMHC in the applicable timeframe.
Pursuant to this requirement, a CMHC is required to submit to CMS a certification statement provided by an independent entity (such as an accounting technician). The document must certify that:
• The entity has reviewed the CMHC’s client care data
• For:
• Initial enrollments: The CMHC meets the 40 percent requirement for the prior 3 months.
• Revalidations: The CMHC meets the 40 percent requirement for each of the intervening 12-month periods between initial enrollment and revalidation.
The statement must be submitted as part of any initial enrollment or revalidation (including off-cycle revalidations).
B. Processing
The contractor shall abide by the following:
1. The contractor does not receive the certification with the Form CMS-855 -- The contractor shall develop for the certification as it would with any other form of required supporting documentation. If the CMHC fails to submit the certification within the applicable time period, the contractor shall follow the instructions in section 15.8.2 of this chapter.
2. The contractor receives the certification with the Form CMS-855 or timely receives the certification as part of a development request -- The contractor shall review the certification to ensure that it complies with § 485.918(b)(1) and the provisions of this section 15.4.1.1.1. If the certification is compliant, the contractor shall continue processing the application; if the certification is not compliant, the contractor shall deny the application or, if it chooses, develop for a revised certification.
Sections (B)(1) and (2) above do not apply if the contractor determines that the Form CMS-855 can be returned under section 15.8.1 of this chapter.
If the contractor exceeds applicable timeliness standards due to the instructions in this section 15.4.1.1.1, the contractor shall accordingly document the provider file consistent with section 15.10 of this chapter.
C. Special Guidelines
1. An appropriate official of the certifying entity must sign the document. (Notarization is not required unless CMS requests it.) Such persons may include accounting technicians, CEOs, officers, directors, etc.
2. The certification should be on the certifying entity’s letterhead or should otherwise indicate that the document is clearly from the entity.
3. The contractor shall include the certification in the recommendation package it sends to the state agency.
4. Unless CMS instructs the contractor otherwise, the appropriate denial bases for failing to comply with § 485.918(b)(1) are §§ 424.530(a)(1) and 485.918(b)(1). The appropriate revocation bases are §§ 424.535(a)(1) and 485.918(b)(1). In cases involving the latter, CMS will determine the appropriate re-enrollment bar length under § 424.535(c) and will notify the contractor thereof.
Effective October 29, 2014, under § 485.918(b)(1) a CMHC must provide at least 40 percent of its items and services to individuals who are not eligible for benefits under title XVIII of the Social Security Act, as measured by the total number of CMHC clients treated by the CMHC for whom services are not paid for by Medicare, divided by the total number of clients treated by the CMHC in the applicable timeframe.
Pursuant to this requirement, a CMHC is required to submit to CMS a certification statement provided by an independent entity (such as an accounting technician). The document must certify that:
• The entity has reviewed the CMHC’s client care data
• For:
• Initial enrollments: The CMHC meets the 40 percent requirement for the prior 3 months.
• Revalidations: The CMHC meets the 40 percent requirement for each of the intervening 12-month periods between initial enrollment and revalidation.
The statement must be submitted as part of any initial enrollment or revalidation (including off-cycle revalidations).
B. Processing
The contractor shall abide by the following:
1. The contractor does not receive the certification with the Form CMS-855 -- The contractor shall develop for the certification as it would with any other form of required supporting documentation. If the CMHC fails to submit the certification within the applicable time period, the contractor shall follow the instructions in section 15.8.2 of this chapter.
2. The contractor receives the certification with the Form CMS-855 or timely receives the certification as part of a development request -- The contractor shall review the certification to ensure that it complies with § 485.918(b)(1) and the provisions of this section 15.4.1.1.1. If the certification is compliant, the contractor shall continue processing the application; if the certification is not compliant, the contractor shall deny the application or, if it chooses, develop for a revised certification.
Sections (B)(1) and (2) above do not apply if the contractor determines that the Form CMS-855 can be returned under section 15.8.1 of this chapter.
If the contractor exceeds applicable timeliness standards due to the instructions in this section 15.4.1.1.1, the contractor shall accordingly document the provider file consistent with section 15.10 of this chapter.
C. Special Guidelines
1. An appropriate official of the certifying entity must sign the document. (Notarization is not required unless CMS requests it.) Such persons may include accounting technicians, CEOs, officers, directors, etc.
2. The certification should be on the certifying entity’s letterhead or should otherwise indicate that the document is clearly from the entity.
3. The contractor shall include the certification in the recommendation package it sends to the state agency.
4. Unless CMS instructs the contractor otherwise, the appropriate denial bases for failing to comply with § 485.918(b)(1) are §§ 424.530(a)(1) and 485.918(b)(1). The appropriate revocation bases are §§ 424.535(a)(1) and 485.918(b)(1). In cases involving the latter, CMS will determine the appropriate re-enrollment bar length under § 424.535(c) and will notify the contractor thereof.
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