SA Identifying Eligible Providers and Suppliers

2012 - SA Identifying Eligible Providers and Suppliers (Rev. 1, 05-21-04) Initial certifications of providers or suppliers involve steps, including enrollment, to survey applying providers/suppliers and confirm their eligibility. These steps are not repeated on cyclical recertification if the basic eligibility factors have not changed. Since the requirements in the statute and regulations differ for specific provider/supplier categories, the initial identification and screening procedures are unique to each type of provider or supplier. For Medicare purposes, the SA initial certification of compliance occurs before the RO makes its official determination that the provider/supplier meets all necessary requirements. The SA may contact the RO for advice if some aspect of Medicare eligibility is in dispute. Ordinarily, the SA develops as much information on the issue as is appropriate, completes the certification, and forwards the documentation to the RO for its decision. The SA should use the following criteria: • If the provider/supplier meets the CoPs, Conditions for Coverage, or in substantial compliance with the Requirements for SNFs, and is in full compliance with all other requirements, i.e., no deficiencies, send the Certification and Transmittal (Form CMS-1539) and all other documents to the RO within 10 calendar days of the survey; or • When the provider/supplier meets the CoPs or Conditions for Coverage, but it fails to meet other requirements, i.e., it has deficiencies below the Condition level, transmit all documentation to the RO within 45 calendar days of the survey. A provider/supplier found to be deficient with one or more standards, or other requirements below the Condition level may participate if it has submitted an approved PoC for achieving compliance within a reasonable period of time. A PoC must be submitted within 10 calendar days of the facility’s receipt of the official Form CMS-2567. The entity may be granted additional time if the plan is complex. (See Chapter 7 for SNFs and NFs.) Provider institutions are often complex health care delivery institutions centered around primary short-term hospitals. Although a totally new hospital may be rare, provider complexes frequently re-combine and reform or merge. This may or may not create new certification entities. In general, if the statute or regulations provide for separate certification of related or satellite components, they must be separately certified, e.g., a distinct part SNF in a hospital. In some instances a satellite’s certification depends upon the primary provider being approved to participate, e.g., a hospital-based hospice or an ESRD transplant center. The SA should recognize and act upon organizational combinations, and complete Form CMS- 1539 to reflect a change. A provider is the party having ultimate responsibility and liability for the operational decisions of the institution. Consequently, the SA should know what components are under the control of the provider’s governing body (as opposed to being loosely affiliated), and when the governing body’s control of a component has changed.