CMS Pub. 100-08, ch. 10, § 10.6.20

The contractor shall review section 10.3 of this chapter for special instructions regarding site

visits. In the event of a conflict, those instructions take precedence over those in this section

10.6.20.

A. DMEPOS Suppliers and IDTFs

The scope of site visits of DMEPOS suppliers and IDTFs shall continue to be conducted in

accordance with existing CMS instructions and guidance.

(For purposes of this section 10.6.20, the term “contractor” refers to the Medicare Administrative

Contractor; the term “SVC” refers to the site visit contractor.)

B. Provider and Supplier Types Other Than DMEPOS Suppliers and IDTFs

For provider/supplier types other than DMEPOS suppliers and IDTFs – that must undergo a site

visit pursuant to this section 10.6.20 and § 424.518, the SVC will perform such visits consistent

with the procedures in this section 10.6.20. This includes all of the following:

(1) Documenting the date and time of the visit, and including the name of the individual

attempting the visit.

(2) Photographing the provider/supplier’s business for inclusion in the provider/supplier’s

file. All photographs will be date/time stamped.

(3) Fully documenting observations made at the facility, which could include facts such as

(a) the facility was vacant and free of all furniture, (b) a notice of eviction or similar

documentation is posted at the facility, and (c) the space is now occupied by another

company.

(4) Writing a report of the findings regarding each site verification.

(5) Including a signed site visit report stating the facts and verifying the completion

of the site verification.

In terms of the extent of the visit, the SVC will determine whether the following criteria are met:

(i) the facility is open; (ii) personnel are at the facility; (iii) customers are at the facility (if

applicable to that provider or supplier type); and (iv) the facility appears to be operational. This

will require the site visitor(s) to enter the provider/supplier’s practice location/site rather than

simply conducting an external review. If any of the four elements ((i) through (iv)) listed above

are not met, the contractor will, as applicable - and using the procedures outlined in this chapter

and in existing CMS instructions - deny the provider’s enrollment application pursuant to §

424.530(a)(5)(i) or (ii) or revoke the provider’s Medicare billing privileges under §

424.535(a)(5)(i) or (ii).

C. Operational Status

When conducting a site verification to determine whether a practice location is operational, the

SVC shall make every effort to limit its verification to an external review of the location. If the

SVC cannot determine whether the location is operational based on this external review, it shall

conduct an unobtrusive site verification by limiting its encounter with provider or supplier

personnel or medical patients.

The contractor must review and evaluate the site visit results received from the SVC prior to

making a final determination. If it is determined (during the review and evaluation process) that

the location is non-operational based on the site visit results but there is reason to proceed with

the enrollment, the contractor shall provide the appropriate justification in the comment section

of the Validation Checklist in PECOS. (For example, a second site visit determined the location

to be operational; the provider only renders services in patient’s homes; etc.).

If the contractor is unsure of how to proceed based on its evaluation of the site visit results, it

shall contact its PEOG BFL and copy its contracting officer's representative (COR).

D. Timing

Site verifications should be done Monday through Friday (excluding holidays) during their

posted business hours. If there are no hours posted, the site verification should occur between 9

a.m. and 5 p.m. If, during the first attempt, there are obvious signs that the facility is no longer

operational, no second attempt is required. If, on the first attempt, the facility is closed but there

are no obvious indications that the facility is non-operational, a second attempt on a different day

during the posted hours of operation should be made.

E. Documentation

As indicated previously, when conducting site verifications to determine whether a practice

location is operational, the SVC shall:

(i) Document the date and time of the attempted visit and include the name of the individual

attempting the visit.

(ii) As appropriate, photograph the provider/supplier’s business for inclusion in the

provider/supplier’s file on an as-needed basis. All photographs should be date/time stamped.

(iii) Fully document all observations made at the facility (e.g., the facility was vacant and free of

all furniture, a notice of eviction or similar documentation was posted at the facility, the space is

now occupied by another company, etc.).

(iv) Write a report of its findings regarding each site verification.

F. Determination

(In the event an instruction in this subsection F is inconsistent with guidance in section 10.6.6,

10.4.7 et seq., or 10.4.8, the latter three sections of instructions shall take precedence.)

If a provider/supplier is determined not to be operational or in compliance with the regulatory

requirements for its provider/supplier type, the contractor shall revoke the provider/supplier’s

Medicare billing privileges - unless the provider/supplier has submitted a change of information

request that notified the contractor of a change in practice location. Within 7 calendar days of

CMS or the contractor determining that the provider/supplier is not operational, the contractor

shall update PECOS or the applicable claims processing system (if the provider/supplier does not

have an enrollment record in PECOS) to revoke Medicare billing privileges and issue a

revocation notice to the provider/supplier. The contractor shall afford the provider/supplier

applicable appeal rights in the revocation notification letter.

For non-operational status revocations, the contractor shall use either 42 CFR § 424.535(a)(5)(i)

or 42 CFR § 424.535(a)(5)(ii) as the legal basis for revocation. Consistent with 42 CFR §

424.535(g), the date of revocation is the date on which CMS or the contractor determines that the

provider/supplier is no longer operational. The contractor shall establish a 2-year reenrollment

bar for providers/suppliers that are not operational.

For regulatory non-compliance revocations, the contractor shall use 42 CFR § 424.535(a)(1) as

the legal basis for revocation. Consistent with 42 CFR § 424.535(g), the date of revocation is the

date on which CMS or the contractor determines that the provider/supplier is no longer in

compliance with regulatory provisions for its provider/supplier type. The contractor shall

establish a 2-year enrollment bar for providers/suppliers that are not in compliance with

provisions for their provider/supplier type.

G. Multiple Site Visits

Notwithstanding any other instruction to the contrary in this chapter, the contractor shall not

order a site visit if the specific location to be visited has already passed a site visit within the last

12 months and the applicable provider/supplier is in an approved status.

Consider the following illustrations:

Example 1 - A single-site home health agency (HHA) undergoes a revalidation site visit on

February 1. The HHA submits a change of information request on July 1 to add a branch

location. The contractor shall order this site visit because the visit will occur at a location (i.e.,

the branch location) different from the main location (i.e., the location that underwent the

February 1 revalidation visit).

Example 2 - A DMEPOS supplier undergoes a revalidation site visit on April 1. It submits an

initial Form CMS-855S application on May 1 to enroll a second location. The new location shall

undergo a site visit because: (1) it is different from the first (revalidated) location; and (2) it

is/will be separately enrolled from the first location.

Example 3 - A physical therapy (PT) group has three locations – X, Y, and Z. As part of a

revalidation, the contractor elects to order a site visit of Location Y rather than X or Z. The visit

was performed on June 1. On October 4, the group submits a Form CMS-855B to report a

change of ownership, thus requiring a site visit under this chapter. However, the contractor shall

not order a visit for Location Y because this site has been visited within the past 12

months. Location X or Location Z must instead be visited.

Example 4 - An IDTF undergoes an initial enrollment site visit on July 1. On September 24, it

submits a Form CMS-855B application to change its practice location; this mandates a site visit

under this chapter. The site visit shall be performed even though the initial visit took place

within the past 12 months. This is because the second visit will be of the new location, whereas

the first visit was of the old location.

H. Certified Providers/Suppliers – Address Validation Error

Notwithstanding any other instruction to the contrary in this chapter, the contractor need not

order a site visit for a certified provider/supplier prior to making a recommendation to the state if

an address validation error is received in PECOS. The contractor shall override the error

message and notate in the referral package that the address was unverifiable. This avoids

multiple site visits being performed (that is, pre-enrollment, survey, and post enrollment).