CMS Pub. 100-11, ch. 17, § 20.1

Information requested in the provider application is based on Sections 1894 and 1934 of

the Social Security Act, and the regulations at 42 CFR § 460.2 thru 460.210.

An individual authorized to act for the entity must submit to CMS a complete application

that describes how the entity meets all requirements of Part 460. It is the responsibility of

the PACE organization and the State Administering Agency to validate the information

contained in each application. An entity’s application must be accompanied by an

assurance from the State Administering Agency of the State in which the program is

located indicating that the State considers the entity to be qualified to be a PACE

organization and is willing to enter into a PACE program agreement with the entity.

A completed application includes:

• Cover Sheet with the appropriate signatures;

• Table of Contents for the Narrative part;

• Table of Contents for Documents part;

• Narrative part, with each question copied and brief and precise answers,

divided into chapters;

• Documents part, arranged by chapters; this part should follow the Narrative.

Materials such as marketing brochures and booklets should be inserted in

envelopes in the appropriate places in the application. The envelope should be

numbered as a single page.

The PACE Provider Application and related resources are located on the CMS webpage

at: http://www.cms.hhs.gov/PACE/06_ProviderApplicationandRelatedResources.asp#To

pOfPage.

This Provider Application has been updated to reflect the provisions of the December

2006 final PACE regulation. This file is in a zipped rich text format so States can

download a writeable version for submission. It also contains appendices (including the

Provider Arrangements File, Insurance Coverage File, and Payment Information Form)

that must be submitted to CMS as part of the PACE Provider Application.

CMS evaluates an application for approval as a PACE organization on the basis of the

information contained in the application, information obtained through onsite visits

conducted by CMS or the State Administering Agency, and information obtained by the

State Administering Agency.

An entity must state in its application the service area it proposes for its program. CMS,

in consultation with the State Administering Agency, may exclude from designation an

area that is already covered under another PACE program agreement to avoid

unnecessary duplication of services and avoid impairing the financial and service

viability of an existing program.

A PACE application can be submitted at any time during the year. As stated in 42 CFR §

460.20, within 90 days after an organization submits a complete application to CMS,

CMS can (1) approve the application; (2) deny the application and notify the entity in

writing of the basis for denial and the process for requesting reconsideration of the denial;

or (3) request additional information needed to make a final determination. Upon receipt

of all of the responses to the request for additional information and the completed State

Readiness Review, CMS has an additional 90 days to either approve the application or

disapprove the application and notify the entity in writing of the basis for the denial and

the process for requesting reconsideration of the denial. An application is deemed

approved if CMS fails to act on the application within 90 days after the date the

application is submitted by the organization or the date CMS receives all requested

additional information. For purposes of the 90-day time limit, the date that an application

is submitted to CMS is the date on which the application is delivered to the address

designated by CMS.

[42 CFR §§ 460.12(a)(1) and (b), 460.18, 460.20, 460.22, 460.72]