CMS Pub. 100-08, ch. 10, § 10.2.1.8

(This section 10.2.1.8 applies to “standard” hospitals (as the term “hospital” is defined in §

1861(e)(1)), psychiatric hospitals, hospital units, and transplant programs. It does not apply to

critical access hospitals, which are a separate provider type and are not “transitioning.”)

A. General Background Information

Hospitals and hospital units are a provider type that enrolls via the Form CMS-855A. An

exception to this is when the hospital is requesting enrollment to bill for practitioner services for

hospital departments, outpatient departments, outpatient locations, and/or hospital clinics; in this

circumstance, a new Form CMS-855B enrollment application is required.

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

1. Receipt of Application

Upon receipt of a hospital 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 hospital has submitted all documentation otherwise required per this chapter.

For hospital 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.)

(An authorized official (as defined in § 424.502) must complete, sign, date, and include the Form

CMS-1561, though the hospital need not complete those sections of the form reserved for CMS.)

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 10.2.1.8(B) prohibits the contractor from returning or rejecting the

hospital 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 10.2.1.8(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 hospital, 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

10.2.1.8(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 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, and (3) enter the

applicable 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 hospital; (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. Additional Enrollment Information

1. Swing-Bed Designation

A “swing-bed” hospital is one that is approved by CMS to furnish post-hospital skilled nursing

facility (SNF) services. That is, hospital (or critical access hospital (CAH)) patients’ beds can

“swing” from furnishing hospital services to providing SNF care without the patient necessarily

being moved to another part of the building. It receives a separate survey and certification from

that of the hospital. Thus, if swing-bed designation is terminated, the hospital still maintains its

certification. In addition, the hospital is given an additional CCN to bill for swing-bed services.

(The third digit of the CCN will be the letter U, W, Y or Z.)

In general, and as stated in 42 CFR § 482.58, in order to obtain swing-bed status the hospital

must, among other things: (1) have a Medicare provider agreement; (2) be located in a rural area;

and (3) have fewer than 100 non-newborn or intensive care beds. Swing-bed hospitals,

therefore, are generally small hospitals in rural areas where there may not be enough SNFs, and

the hospital is thus used to furnish SNF services.

A separate provider agreement and enrollment for the swing-bed unit is not required. (The

hospital’s provider agreement incorporates the swing-bed services.) The hospital can add the

swing-bed unit as a practice location via the Form CMS-855A.

Additional data on “swing-bed” units can be found in Pub. 100-07, chapter 2, sections 2036 –

2040.

2. Psychiatric and Rehabilitation Units

Though these units receive a state survey, a separate provider agreement and enrollment is not

required. (The hospital’s provider agreement incorporates these units.) The hospital can add the

unit as a practice location to the Form CMS-855A.

3. Multi-Campus Hospitals

A multi-campus hospital (MCH) has two or more hospital campuses operating under one CCN.

The MCH would report its various units/campuses as practice locations on the Form CMS-855A.

For additional information on multi-campus hospitals, see Pub. 100-07, chapter 2, section 2024.

4. Physician-Owned Hospitals

As defined in 42 CFR § 489.3, a physician-owned hospital (POH) means any participating

hospital (as defined in 42 CFR §489.24) in which a physician or an immediate family member of

a physician has an ownership or investment interest in the hospital. The ownership or investment

interest may be through equity, debt, or other means, and includes an interest in an entity that

holds an ownership or investment interest in the hospital. (This definition does not include a

hospital with physician ownership or investment interests that satisfy the requirements at 42 CFR

§ 411.356(a) or (b).)

Section 2(A)(4) of the Form CMS-855A asks the applicant to identify whether it is a physician-owned hospital. If the applicant indicates in Section 2(A)(2) that it is a hospital, it must

complete Section 2(A)(4). Applicants that are not hospitals need not complete Section 2(A)(4).

At this time, POHs are not required to submit a completed Form CMS-855POH or a completed

Attachment 1 of the Form CMS-855A. As stated in the March 12, 2015 announcement in MLN

Connects Provider eNews, CMS has extended the deadline for the POH Initial Annual

Ownership/Investment Report due to concerns about the accuracy of the data collected in the

report. Future instruction regarding the reporting of POH ownership and investment will be

provided on the CMS physician self-referral website.

5. Critical Access Hospitals

Critical access hospitals (CAHs) are not considered to be a hospital sub-type for enrollment

purposes. CAHs instead must be enrolled as a separate, distinct provider type. Thus, if an

existing hospital wishes to convert to a CAH, it must submit a Form CMS-855A as an initial

enrollment.

6. Hospital Addition of Practice Location

In situations where a hospital is adding a practice location, the contractor shall notify the

provider in writing that its recommendation for approval does not constitute approval of the

facility or group as provider-based under 42 CFR § 413.65.

If the contractor makes a recommendation for approval of the provider’s request to add a hospital

unit, the contractor shall forward the package to the state agency as described in this chapter.

7. Transplant Programs

A transplant program is a component within a transplant hospital that provides transplantation of

a particular type of organ to include: heart, lung, liver, kidney, pancreas, or intestine. All organ

transplant programs must be located in a hospital that has a Medicare provider agreement. The

transplant program will receive a CCN that is separate and distinct from the hospital.

For purposes of Medicare enrollment, a hospital transplant program is treated similarly to a

hospital sub-unit. If the hospital wishes to add a transplant program, it must check the “other”

box in Section 2A2 of the Form CMS-855A, write “transplant program” (and the type(s) thereof,

such as liver transplant program, kidney transplant program, etc.) on the space provided, and

follow the standard instructions for adding a hospital sub-unit. (If multiple types of transplant

programs are listed, the contractor shall (a) treat each as a separate sub-unit for enrollment

purposes and (b) process the application in the same fashion it would a hospital application that

is reporting/adding multiple sub-units.) No separate enrollment in PECOS need or will be

created for the transplant center.

D. Section 4 of the Form CMS-855A

Regarding Section 4 of the Form CMS-855A, the hospital 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 hospital’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. 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 an enrolled hospital seeks to add or delete a rehabilitation, psychiatric, or swing-bed unit, it

should submit a Form CMS-855 change of information request and not, respectively, an initial

enrollment application or a voluntary termination application.

E. Non-Participating Emergency Hospitals, Veterans Administration (VA) Hospitals, and

Department of Defense (DOD) Hospitals

Non-participating emergency hospitals, VA hospitals and DOD hospitals no longer need to

complete a Form CMS-855A enrollment application in order to bill Medicare.

F. Form CMS-855B Applications Submitted by Hospitals

1. Group Practices

If an entity is enrolling via the Form CMS-855B as a hospital-owned clinic/physician practice,

the contractor shall contact the applicant to determine whether the latter will be billing any of the

listed locations as provider-based. If the applicant will not be billing as provider-based, the

contractor shall process the application normally. If, however, the applicant will bill as provider-based, the contractor shall notify the applicant that the hospital must report any changed practice

locations to its contractor via the Form CMS-855A.

If the supplier is enrolling as a hospital department (under the “Clinic/Group Practice” category

on the Form CMS-855B) or an existing hospital department is undergoing a change of ownership

(CHOW), the contractor shall only issue the necessary billing numbers upon notification that a

provider agreement has been issued – or, in the case of a CHOW, the provider agreement has

been transferred to the new owner. If, however, the supplier is enrolling as a group practice that

is merely owned by a hospital (as opposed to being a hospital department), the contractor need

not wait until the provider agreement is issued before conveying billing privileges to the group.

2. Individual Billings

Assume an individual physician works for a hospital and will bill for services as an individual

(i.e., not as part of the hospital service/payment). However, the physician wants to reassign these

benefits to the hospital. The hospital will need to enroll with the contractor via the Form CMS-

855B (e.g., as a hospital department, outpatient location).