CMS Pub. 100-08, ch. 10, § 10.2.1.7

A. General Background Information

A hospice is a public agency or private organization or subdivision of either of these that is

primarily engaged in providing a comprehensive set of services such as the assessment and

management of pain. Typically, the need for services is identified and coordinated by an

interdisciplinary group to provide for the physical, psychosocial, spiritual, and emotional needs

of a terminally ill patient and/or family members, as delineated in a specific patient plan of care.

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

1. Receipt of Application

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

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

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

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

(C) Ensure that the hospice has submitted all documentation otherwise required per this chapter.

For hospice 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.)

(The hospice must complete, sign, date, and include the Form CMS-1561, though the hospice

need not complete those sections of the form reserved for CMS. For organizational hospices, an

authorized official (as defined in § 424.502) must sign the form; for sole proprietorships, the sole

proprietor must sign.)

Notwithstanding the foregoing, if the Form CMS-1561 or the Form HHS-690 evidence 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 10.2.1.7(B) prohibits the contractor from returning or rejecting the

hospice 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 10.2.1.7(B)(2) 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. 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 hospice, 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).) The site visit described in

subsection (D)(1) below need not be performed. No later than 5 business days after receiving

this notification, the contractor shall commence the actions described in section

10.2.1.7(B)(2)(B) above.

(B) Approval Recommended

If the state recommends approval, it will typically do so via a Form CMS-1539; however, 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 hospice fails the site visit, the contractor shall follow the denial procedures addressed in

subsection (B)(2)(B) above. If the hospice passes the site visit, the contractor (within 3 business

days of completing its review of the results) shall 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 from the state or similar documentation received from the

accrediting organization.

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

• 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 relevant

data into the applicable national database, and (4) approve (with possible edits) the approval

letter. Within 5 business days of receiving from PEOG the signed provider agreement, effective

date, and CCN, the contractor shall: (1) send the approval letter and a copy of the CMS-countersigned provider agreement to the hospice; (2) send a copy of both the approval letter and

the provider agreement to the state and/or accrediting organization (as applicable)); and (3)

switch the PECOS record from “approval recommended” to “approved” consistent with existing

instructions.

C. Multiple Practice Locations

Hospices are not precluded from having multiple practice locations if permitted by the state. If

the state disapproves an additional practice location, the location must seek Medicare approval as

a separate hospice with its own enrollment and provider agreement. (See Pub. 100-07, chapter 2,

section 2088 for the policies regarding multiple hospice locations.)

If the hospice submits a change of information application to add or relocate a practice location,

the contractor shall process the application consistent with section 10.6.1.2 of this chapter. The

contractor should be aware, however, that the state may not approve the location

addition/change.

D. Site Visits

1. Initial application - The scope of the site visit will 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 hospice 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 will 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.

3. New/changed location - If a hospice 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 no later than 5 business days after the contractor receives the approval

recommendation from the state but before the contractor sends to PEOG the applicable e-mail

described in section 10.6.1.2(A)(3) of this chapter. (See the latter section for more information.)

This is to ensure that the new/changed location complies with CMS’s enrollment requirements.

The scope of the site visit will 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 change of information application prior to the completion of the NSVC’s site visit

and the contractor’s review of the results.

E. Out-of-State Hospice Operations

Pub. 100-07, chapter 2, section 2085 states that when a hospice furnishes services across state

lines:

• It must be certified by the state in which its CCN is based.

• The involved states must have a written reciprocal agreement permitting the hospice to

provide services in this manner. In those states that have a reciprocal agreement, hospices

need not be separately enrolled in each state; consequently, they would not have to obtain a

separate Medicare provider agreement/number in each state. Hospices residing in a state that

does not have a written reciprocal survey agreement with a contiguous state are precluded

from providing services across state lines; the hospice must establish a separate location in

the state in which it wishes to provide services.

See section 10.3.1.1.4(D) of this chapter for additional information regarding the enrollment of

out-of-state hospice locations. In the event of any inconsistency between the instructions in

sections 10.3.1.1.4(D) and 10.2.1.7(E), the latter takes precedence.

F. Recommendation Before New Hospice Location Established

If a hospice is adding a new location or changing the site of an existing one, the contractor can

make a recommendation for approval to the state prior to the establishment of the new/changed

location (notwithstanding any other instruction in this chapter to the contrary) in accordance with

Pub. 100-07, chapter 2, section 2088. If the contractor opts to make such a recommendation

prior to the location’s establishment or movement, it shall note in its recommendation letter that

the location is not yet established or has not yet moved.

G. Practice Locations and Mergers/Acquisitions

Notwithstanding section 10.2.1.7(C) above, hospices cannot merge and allow the other locations

to become multiple locations of the hospice because this hinders CMS and/or the state in

evaluating compliance with 42 CFR § 418.100(f). The hospice will need to file a CHOW or a

voluntary termination of the non-surviving site; the surviving hospice can then submit a Form

CMS-855A to add a new multiple location in accordance with Pub. 100-07, chapter 2, section

2088.

H. Additional Information:

For more information on hospices, refer to:

• Sections 1861(u) and 1861(dd) of the Social Security Act

• 42 CFR Part 418

• Pub. 100-07, chapter 2, sections 2080 – 2089

• Pub. 100-04, chapter 11

• Pub. 100-02, chapter 9