Application Requirements

40.4.2 - Application Requirements (Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 42 CFR §422.158 A private, national AO may seek deeming authority for any or all of the 9 categories listed in section 40.1 of this chapter. For each deeming category for which the AO is applying for deeming authority, it must, demonstrate that its standards and processes meet or exceed Medicare requirements within that particular category. A private, national AO applying for approval must furnish to CMS all of the following materials. When reapplying for approval, the organization need furnish only the particular information and materials requested by CMS. 1. The type(s) of MA coordinated care plans that they seek authority to deem; 2. A crosswalk that provides a detailed comparison of the organization’s accreditation requirements and standards with the corresponding Medicare requirements; 3. A detailed description of the organization’s survey process for each type of MAO it is seeking authority to deem, including: a. Frequency of surveys performed, whether the surveys are announced or unannounced, and how far in advance surveys are announced; b. Copies of survey forms and guidelines and instructions to surveyors; c. A description of the organization’s survey review and accreditation status decision making process; d. The procedures used to notify accredited MAOs of deficiencies and the procedures to monitor the correction of those deficiencies; and e. Procedures the organization uses to enforce compliance with their accreditation requirements; 4. Detailed information about the individuals who perform surveys for each type of MAO that the organization seeks authority to deem, including: a. The size and composition of and the methods of compensation for its accreditation survey teams; b. The education and experience requirements surveyors must meet to participate in its accreditation program; c. The content and frequency of the in-service training provided to survey personnel; d. The evaluation system used to monitor the performance of individual surveyors and survey teams; and e. The policies and practices with respect to participation in surveys or in the accreditation decision process pertaining to an individual who is professionally or financially affiliated with the entity being surveyed. 5. A description of the data management and analysis system with respect to surveys and accreditation decisions, including the kinds of reports, tables, and other displays generated by the organization’s data system; 6. The procedures it will use to respond to and investigate complaints or identify other problems with accredited organizations, including coordination of these activities with licensing bodies and ombudsmen programs; 7. The policies and procedures regarding withholding, denying and removal of accreditation for failure to meet the organization’s standards and requirements, and other actions the organization will take in response to non-compliance with their standards and requirements; 8. The policies and procedures regarding how the organization deals with accreditation of organizations that are acquired by another organization, have merged with another organization, or that undergo a change of ownership or management; 9. A description of all the types (full, partial, or denial) and categories (provisional conditional, or temporary) of accreditation offered by the organization, the duration of each category of accreditation, and a statement identifying the types and categories that would serve as a basis for accreditation if CMS grants the organization MA deeming authority; 10. A list of all the MAOs that the organization has currently accredited, by State an type, and the category of accreditation and expiration date of accreditation held by each organization; 11. A list of all the managed care organizations (MCOs) that the organization has surveyed in the past three years, the date each was accredited (if denied, the date it was denied), and the level (category) of accreditation it received; 12. A list of all managed care surveys scheduled to be performed by the organization within the next 3 months indicating organization type, date, state, and whether each MCO is an MAO; 13. The name and address of each person with an ownership or controlling interest in the AO; 14. A written presentation that demonstrates that it will be able to furnish data electronically, in a CMS compatible format; 15. A resource analysis that demonstrates that the organization’s staffing, funding, and other resources are adequate to perform the required surveys and related activities. The resource analysis should include financial statements for the past 3 years (audited if possible) and the projected number of deemed status surveys for the upcoming year; and 16. A statement acknowledging that, as a condition of approval, the organization agrees to comply with the ongoing responsibility requirements that are addressed in section 40 of this chapter. If CMS determines that it needs additional information for a determination to grant or deny the AO’s request for approval, it will notify the AO and allow it time to provide the additional information. As part of the application process, CMS may visit the AO’s offices to verify representations made by the organization in its application, including, but not limited to, reviewing documents, auditing meetings concerning the accreditation process, evaluating survey results or the accreditation status decision-making process, and interviewing the organization’s staff.