Medicaid State Agencies
Medicaid State agencies do not have a National Provider Identifier and are not otherwise eligible to enroll in the Medicare program.
If a Medicaid State agency is enrolled or seeks enrollment as a provider or supplier in the Medicare program, the contractor shall deny or revoke its Medicare billing privileges using, respectively, §424.530(a)(5) (denials) and § 424.535(a)(3) (revocations) as the basis.
Section 4 of the Form CMS-855A
A. General Information
A hospital or other provider must list all addresses where it - and not a separately enrolled provider or supplier it owns or operates, such as a nursing home - furnishes services. The provider’s primary practice location should be the first location identified in section 4A and the contractor shall treat it as such – unless there is evidence indicating otherwise - for purposes of entry into the Provider Enrollment, Chain and Ownership System (PECOS). NOTE: Hospital departments located at the same address as the main facility need not be listed as practice locations on the Form CMS-855A.
If a practice location (e.g., hospital unit) has a CMS Certification Number (CCN) that is in any way different from that of the main provider, the contractor shall create a separate enrollment record in PECOS for that location; this does not apply, however, to home health agency (HHA) branches, outpatient physical therapy/outpatient speech pathology (OPT/OSP) extension sites and transplant centers.
An HHA should complete section 4A with its administrative address.
If the provider’s address and/or telephone number cannot be verified, the contractor shall request clarifying information from the provider. If the provider states that the facility and its phone number are not yet operational, the contractor may continue processing the application. However, it shall indicate in its recommendation letter that the address and telephone number of the facility could not be verified. For purposes of PECOS entry, the contractor can temporarily use the date the certification statement was signed as the effective date.
B. Verification of HHA Sites
If the contractor receives an application from an HHA that has the same general practice location address as another enrolled (or enrolling) HHA and the contractor has reason to suspect that the HHAs may be concurrently operating out of the same suite or office, the contractor shall notify the National Site Visit Contractor of this at the time the contractor orders the required site visit through PECOS.
C. Out-of-State Practice Locations
If a provider is adding a practice location in another State that is within the contractor’s jurisdiction, a separate, initial Form CMS-855A enrollment application is not required if the following 5 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 provider agreement, and
• The location is not a federally qualified health center (FQHCs are required to separately enroll each site)
Consider the following examples:
1. The contractor’s jurisdiction consists of States X, Y and Z. Jones Skilled Nursing Facility (JSNF), Inc., is enrolled in State X with 3 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 5 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 PECOS enrollment record for the State Y location.
2. The contractor’s jurisdiction consists of States X, Y and Z. JSNF, Inc., is enrolled in State X with 3 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.
3. 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.
Medicaid State agencies do not have a National Provider Identifier and are not otherwise eligible to enroll in the Medicare program.
If a Medicaid State agency is enrolled or seeks enrollment as a provider or supplier in the Medicare program, the contractor shall deny or revoke its Medicare billing privileges using, respectively, §424.530(a)(5) (denials) and § 424.535(a)(3) (revocations) as the basis.
Section 4 of the Form CMS-855A
A. General Information
A hospital or other provider must list all addresses where it - and not a separately enrolled provider or supplier it owns or operates, such as a nursing home - furnishes services. The provider’s primary practice location should be the first location identified in section 4A and the contractor shall treat it as such – unless there is evidence indicating otherwise - for purposes of entry into the Provider Enrollment, Chain and Ownership System (PECOS). NOTE: Hospital departments located at the same address as the main facility need not be listed as practice locations on the Form CMS-855A.
If a practice location (e.g., hospital unit) has a CMS Certification Number (CCN) that is in any way different from that of the main provider, the contractor shall create a separate enrollment record in PECOS for that location; this does not apply, however, to home health agency (HHA) branches, outpatient physical therapy/outpatient speech pathology (OPT/OSP) extension sites and transplant centers.
An HHA should complete section 4A with its administrative address.
If the provider’s address and/or telephone number cannot be verified, the contractor shall request clarifying information from the provider. If the provider states that the facility and its phone number are not yet operational, the contractor may continue processing the application. However, it shall indicate in its recommendation letter that the address and telephone number of the facility could not be verified. For purposes of PECOS entry, the contractor can temporarily use the date the certification statement was signed as the effective date.
B. Verification of HHA Sites
If the contractor receives an application from an HHA that has the same general practice location address as another enrolled (or enrolling) HHA and the contractor has reason to suspect that the HHAs may be concurrently operating out of the same suite or office, the contractor shall notify the National Site Visit Contractor of this at the time the contractor orders the required site visit through PECOS.
C. Out-of-State Practice Locations
If a provider is adding a practice location in another State that is within the contractor’s jurisdiction, a separate, initial Form CMS-855A enrollment application is not required if the following 5 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 provider agreement, and
• The location is not a federally qualified health center (FQHCs are required to separately enroll each site)
Consider the following examples:
1. The contractor’s jurisdiction consists of States X, Y and Z. Jones Skilled Nursing Facility (JSNF), Inc., is enrolled in State X with 3 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 5 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 PECOS enrollment record for the State Y location.
2. The contractor’s jurisdiction consists of States X, Y and Z. JSNF, Inc., is enrolled in State X with 3 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.
3. 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.
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