CMS Pub. 100-08, ch. 10, § 10.2.1.14

A. General Background Information

As stated in Pub. 100-07, chapter 7, section 7004.2, a SNF is a facility that:

• Is primarily engaged in providing to residents skilled nursing care and related services for

residents who require medical or nursing care; or

• Is primarily engaged in providing to residents skilled rehabilitation services for the

rehabilitation of injured, disabled, or sick persons; while the care and treatment of mental

disease is not the primary action of SNFs, the ability to provide appropriate resources and

support for these beneficiaries is necessary;

• Has in effect a transfer agreement (meeting the requirements of §1861(1) of the Social

Security Act with one or more hospitals having agreements in effect under § 1866 of the

Social Security Act); and

• Meets the requirements for a skilled nursing facility described in subsections (b), (c), and (d)

of §1819 of the Social Security Act.

Like other certified providers, SNFs receive a state survey and sign a provider agreement.

SNFs cannot have multiple practice locations under one Form CMS-855A enrollment.

Effective January 1, 2023, SNFs that are initially enrolling or undergoing a change in ownership

(as described in sections 10.6.15 and 10.6.21(E)(3) of this chapter) fall within the “high”

screening category under 42 CFR § 424.518. SNF revalidations are processed at the “moderate”

screening level.

B. Processing Instructions for SNF Initial Form CMS-855A Applications

1. Receipt of Application

Upon receipt of a SNF initial Form CMS-855A application, the contractor shall undertake the

following (in whichever order the contractor prefers unless directed otherwise in this chapter):

(i) Perform all data validations otherwise required per this chapter.

(ii) Ensure that the application(s) is complete consistent with the instructions in this chapter.

(iii) Ensure that the SNF has submitted all documentation otherwise required per this chapter.

For SNF initial enrollment, this also includes the following:

• Form CMS-1561 (Health Insurance Benefit Agreement, also known as a “provider

agreement”)

• Evidence of successful electronic submission of the Form HHS-690 through the Office of

Civil Rights (OCR) portal, as applicable. (Evidence should be either written or electronic

documentation.) (See https://www.hhs.gov/sites/default/files/forms/hhs-690.pdf for more

information.)

• A signed SNF patient transfer agreement. (See https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Downloads/Facility-Transfer-

Agreement-Example.pdf for an example.)

(The SNF must complete, sign, date, and include the Form CMS-1561 and transfer agreement

described above, though the SNF need not complete those sections of the forms reserved for

CMS. For organizational SNFs, an authorized official (as defined in § 424.502) must sign the

forms; for sole proprietorships, the sole proprietor must sign.)

Notwithstanding the foregoing, if the Form CMS-1561, Form HHS-690 evidence, or SNF

transfer agreement is missing, unsigned, undated, or otherwise incomplete, the contractor need

not develop for the form(s) or the information thereon; the contractor shall instead notify the

state in its recommendation letter which document(s) was/were missing or otherwise incomplete.

For all other missing or incomplete required documentation, the contractor shall follow the

normal development instructions in this chapter.

2. Conclusion of Initial Contractor Review

(Nothing in this section 10.2.1.14(B) prohibits the contractor from returning or rejecting the SNF

application if otherwise permitted to do so per this chapter. When returning or rejecting the

application, the contractor shall follow this chapter’s procedures for doing so.)

a. Approval Recommendation

If, consistent with the instructions in section 10.2.1.14(B) and this chapter, the contractor

believes an approval recommendation is warranted, the contractor shall send the

recommendation to the state pursuant to existing practice and this chapter’s instructions. (This

includes sending recommendations via hard copy mail if the state only accepts this method of

transmission.) The contractor need not copy the SOG Location or PEOG on the

recommendation. Unless CMS directs otherwise, the contractor shall also send to the provider

the notification letter in section 10.7.5.1(E) of this chapter.

The state will: (1) review the recommendation package for completeness; (2) review the

contractor’s recommendation for approval; (3) perform any state-specific functions; and (4)

contact the contractor with any questions. The contractor shall respond to any state inquiry in

Item (4) within 5 business days. If the inquiry involves the need for the contractor to obtain

additional data, documentation, or clarification from the SNF, however, the timeframe is 15

business days; if the provider fails to respond to the contractor within this timeframe, it shall

notify the state thereof. The contractor may always contact its PEOG BFL should it need the

latter’s assistance with a particular state inquiry.

b. Denial

If the contractor determines that a denial is warranted, it shall follow the denial procedures

outlined in this chapter. This includes: (1) using the appropriate denial letter format in section

10.7.5.1 of this chapter; and (2) if required under section 10.6.6 (or another CMS directive) of

this chapter, referring the matter to PEOG for review prior to denying the application.

3. Completion of State Review

The state will notify the contractor once it has completed its review. There are two potential

outcomes:

a. Approval Not Recommended

If the state does not recommend approval, it will notify the contractor thereof. (The contractor

may accept any notification that is in writing (e-mail is fine).) No later than 5 business days after

receiving this notification, therefore, the contractor shall commence the actions described in

section 10.2.1.14(B)(2)(b) above.

b. Approval Recommended

If the state recommends approval, it will typically (though not always) do so via a Form CMS-

1539; the contractor may accept any documentation from the state signifying that the latter

recommends approval. (Note that the contractor will not receive a formal tie-in notice.)

No later than 5 business days after receipt of the recommendation from the state, the contractor

shall order the site visit described in subsection (D)(1) below.

If the SNF fails the site visit, the contractor shall follow the denial procedures addressed in

subsection (B)(2)(b) above. If the SNF passes the site visit, the contractor shall (within 3

business days of completing its review of the results) send an e-mail to

MedicareProviderEnrollment@cms.hhs.gov with the following information and documents:

• The Form CMS-855 application (or PECOS Application Data Report) and all application

attachments

• A copy of the Form CMS-1539 or similar documentation received from the state.

• A copy of the provider-signed Form CMS-1561.

• A copy of the provider-signed SNF transfer agreement.

• A copy of the draft approval letter, with the effective date shown on the Form CMS-1539 (or

similar documentation) included in the draft letter. (See section 10.7.5.1 for the model

approval letter.)

PEOG will countersign the provider agreement. Based on the information received from the

contractor, PEOG will also (1) assign an effective date, (2) assign a CCN, (3) enter the

applicable data into ASPEN, and (4) approve (with possible edits) the approval letter.

Within 5 business days of receiving from PEOG the signed provider agreement, transfer

agreement, effective date, and CCN, the contractor shall: (1) send the approval letter and a copy

of the CMS-countersigned provider agreement to the SNF; (2) send a copy of both the letter and

the provider agreement sent to the state and/or AO (as applicable)); (3) switch the PECOS record

from “approval recommended” to “approved” consistent with existing instructions; and (3) retain

the provider-signed transfer agreement (which CMS does not counter-sign) on file.

C. SNF Distinct Parts

A SNF can be a separate institution or a “distinct part” of an institution. The term “distinct part”

means an area or portion of an institution (e.g., a hospital) that is certified to furnish SNF

services. The hospital and the SNF distinct part will each receive a separate CCN. Also:

• A hospital may have only one SNF distinct part.

• “Distinct part” designation is not equivalent to being “provider-based.”

A SNF distinct part unit must enroll separately (i.e., it cannot be listed as a practice location on

the hospital’s Form CMS-855A), be separately surveyed, and sign a separate provider

agreement. (Note how this is different from “swing-bed” units, which do not enroll separately

and do not sign separate provider agreements.)

D. Site Visits

1. Initial application - The scope of the site visit shall be consistent with sections 10.6.20(A) and

10.6.20(B) of this chapter. The 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.

2. Revalidation – If a SNF submits a 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 shall be consistent with sections 10.6.20(A)

and 10.6.20(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.

(See sections 10.6.15 and 10.6.21(E)(3) for instructions regarding site visits for ownership

changes.)

E. Additional Information

For more information on SNFs, refer to:

• Section 1819 of the Social Security Act

• Pub. 100-07, chapter 7

• Pub. 100-02, chapter 8