(Practice Location Information) - Form CMS-855A

10.3.1.1.4 – Section 4 (Practice Location Information) - Form CMS-855A (Rev. 12639; Issued: 05-16-24; Effective: 06-17-24; Implementation: 06-17-24) A. General Background Unless CMS specifies otherwise, any change in the provider’s phone number or address that the provider did not cause (i.e., area code change, municipality renames the provider’s street) must still be updated via the Form CMS-855. Any provider submitting a Form CMS-855A application must submit the 9-digit ZIP Code for each practice location listed. (For paper applications only - If a practice location (e.g., hospital unit) has a CMS Certification Number (CCN) that is in any way different from that of the main provider, the contractor shall create a separate enrollment record in PECOS for that location. (This does not apply, however, to home health agency (HHA) branches, outpatient physical therapy/outpatient speech pathology (OPT/OSP) extension sites, and transplant centers.)) The contractor shall verify that the practice locations listed on the application actually exist and are valid addresses with the United States Postal Service (USPS). PECOS includes a USPS Address Matching System Application Program Interface (API), which validates address information entered and flags the address if it is determined to be invalid, unknown, undeliverable, vacant, unlikely to deliver mail (No-Stat), a CMRA (i.e., UPS Store, mailboxes, etc.), or a known invalid address false positive. These address types are not permitted in PECOS and are flagged upon entry. The contractor need not verify the provider’s telephone number listed on the application, though the provider must report one. If it does not, the contractor shall develop for a phone number using the procedures outlined in this chapter. If the contractor cannot verify the provider’s address, the contractor shall request clarifying information from the provider. If the provider states that the facility is not yet operational, the contractor may continue processing the application. However, it shall indicate in its recommendation letter that the address of the facility could not be verified. For purposes of PECOS entry, the contractor can temporarily use the date the certification statement was signed as the effective date. (For paper applications only: In Section 4A of the Form CMS-855A, if the “type of practice location” checkbox is blank, the contractor can confirm the information via the PCV, e-mail, or fax.) B. Do Not Forward (DNF) Unless instructed otherwise in another CMS directive, the contractor shall follow the DNF initiative instructions in Pub. 100-04, chapter 1, section 80.5. Returned paper checks, remittance notices, or EFT payments shall be flagged if returned from the post office or banking institution, respectively, as this may indicate that the provider’s “special payment” address (in the Practice Location Information section of the Form CMS-855A) or EFT information has changed. The provider should submit a Form CMS-855A to change this address; if the provider does not have an established enrollment record in PECOS, it must complete an entire Form CMS-855A and Form CMS-588. If the provider is closing its business and has a termination date, the contractor will likely need to make payments for prior services rendered. Since the practice location has been terminated, the contractor may encounter a DNF message. If so, the contractor should request the provider to complete the “special payment” address section of the Form CMS-855A and to sign the certification statement. The contractor, however, shall not collect any other information unless there is a need to do so or unless an instruction in this chapter states otherwise. (See section 10.6.1.3(C)(5) of this chapter for additional information.) C. Remittance Notices/Special Payments For new enrollees, all payments must be made via EFT. The contractor shall thus ensure that the provider has completed and signed the Form CMS-588 and shall verify that the bank account complies with Pub. 100-04, chapter 1, section 30.2. If an enrolled provider that currently receives paper checks submits a Form CMS-855A change request (no matter what the change involves), the provider must also submit a Form CMS-588 that switches its payment mechanism to EFT. (The change request cannot be processed until the Form CMS-588 is submitted.) All future payments (excluding special payments) must be made via EFT; once a provider changes its method of payment from paper checks to EFT, it must continue using EFT. A provider cannot switch from EFT to paper checks. The contractor shall verify that the bank account complies with Pub. 100-04, chapter 1, section 30.2. The “special payment” address may only be one of the following: (i) One of the provider’s practice locations (ii) A P.O. Box (iii) The provider’s billing agent. (The contractor shall request additional information if it has any reason to suspect that the arrangement – at least with respect to any special payments that might be made – may violate the Payment to Agent rules in Pub. 100-04, chapter 1, section 30.2.) (iv) The chain home office address. Per Pub.100-04, chapter 1, section 30.2, a chain organization may have payments to its providers sent to the chain home office. The provider must list the chain home office’s LBN on the Form CMS-588. The TIN on the Form CMS-588 should be that of the provider. (v) Correspondence address (vi) A lockbox. (The contractor shall request additional information if it has any reason to suspect that the arrangement, at least with respect to any special payments that might be made, may violate the Payment to Agent rules in Pub. 100-04, chapter 1, section 30.2.) D. Out-of-State Practice Locations If a provider is adding a practice location in another state that is within the contractor’s jurisdiction -- and, for PECOS applications, to the extent PECOS permits it --- a separate, initial Form CMS-855A enrollment application is not required if all of the following conditions are met: (i) The location is not part of a separate organization (e.g., a separate corporation, partnership); (ii) The location does not have a separate TIN and LBN; (iii) The state in which the new location is being added does not require the location to be surveyed; (iv) Neither the new location nor its owner is required to sign a separate provider agreement; and (v) The provider type in question is not required to separately enroll each of its practice locations. (For example, a federally qualified health center (FQHC) would not meet this criterion because FQHCs must separately enroll each location.) Consider the following examples: EXAMPLE 1 - The contractor’s jurisdiction consists of States X, Y and Z. Jones Health Care Facility (JHCF), Inc. is enrolled in State X with 3 sites. It wants to add a fourth site in State Y. The new site will be under JHCF, Inc. JHCF will not be establishing a separate corporation, LBN, or TIN for the site, and - per the state and CMS policy - a separate survey and provider agreement are not necessary; moreover, CMS policy does not require this provider type to separately enroll each of its practice locations. Since all 5 conditions above are met, JHCF, Inc. can add the fourth location via a change of information request, rather than an initial application. The change request must include all information relevant to the new location (e.g., licensure, new managing employees). (For paper applications only---and to the extent required---the contractor shall create a separate PECOS enrollment record for the State Y location.) EXAMPLE 2 - The contractor’s jurisdiction consists of States X, Y and Z. JHCF, Inc., is enrolled in State X with 3 locations. It wants to add a fourth location in State Y but under a newly created, separate legal entity - JHCF, LP. The fourth location must be enrolled via a separate, initial Form CMS-855A. EXAMPLE 3 - The contractor’s jurisdiction consists of States X, Y and Z. Jones Health Services (JHS), Inc., is enrolled in State X with 1 location. It wants to add a second location in State Z under JHS, Inc. However, it has been determined that a separate survey and certification of the new location are required. A separate, initial Form CMS-855A for the new location is required. E. Additional Practice Location Information 1. Special Payments In the “Practice Location Information/Where Do You Want Remittance Notices or Special Payments Sent” section, if neither box is checked and no address is furnished, the contractor can contact the provider by telephone, e-mail, the PCV, or fax to confirm the provider’s intentions. If the provider replies that the “special payments” address is the same as the practice location, no further development is needed. If, however, the provider wants payments sent to a different address, the provider must furnish this address in the “Where Do You Want Remittance Notices or Special Payments Sent” section of the Form CMS-855A. Note that the provider/supplier can only have one special payment address per enrollment for both PECOS and paper applications. See section 10.3(C)(2)(b) for more information. 2. Base of Operations In the Practice Location Information/Base of Operations section, if the “Check here” box is not checked and no address is furnished, the contractor can contact the provider by telephone, e- mail, the PCV, or fax to confirm the provider’s intentions. If the provider replies that the base of operations address is the same as the practice location, no further development is needed. If the provider indicates that the base of operations is at a different location, the provider must furnish this address in the Base of Operations section of the Form CMS-855A. 3. Vehicle Information In the Practice Location Information/Vehicle Information section, if the vehicle certificates are furnished but the applicable Form CMS-855A sections are blank, the contractor can verify via telephone, the PCV, e-mail, or fax that said vehicles are the only ones the provider has. 4. Primary Practice Location (PPL) Checkboxes The provider must identify one – but no more than one – of the practice locations it lists in Section 4(A) as its PPL. If the provider identifies multiple PPLs or no PPLs, the contractor shall develop for additional information/clarification consistent with the instructions in Chapter 10. If the provider lists multiple practice locations, identifies one of them (e.g., Location A) as its PPL, and fails to check the PPL boxes for the other listed locations (Locations B, C, and D), the contractor can assume --- absent evidence to the contrary -- that Location A is the PPL and need not require the provider to check “No” for the PPL checkboxes for Locations B, C, and D. 5. Date First Patient Seen For each practice location listed in Section 4(A), the provider must identify the date (month, day, and year) on which the first patient was or will be seen. If the provider fails to submit this data, the contractor shall develop for it consistent with the procedures in this chapter. 6. Medical Record Storage In Section 4(C)(2), the provider must check whether it stores its patient medical records electronically and, if it checks “Yes,” identify the service used to store these records. In the latter case, an actual website need not be disclosed. Only a general reference to the type of electronic storage is required (e.g., in-house software program, online service, vendor, etc.). It lies within the contractor’s discretion to determine whether the description – which, again, need only be general in nature – adequately identifies the type of electronic service; if an inadequate description is furnished, the contractor shall develop for it consistent with the procedures in this chapter. Moreover, if a website is listed, the contractor need not access it to verify that the link is indeed where the records are stored. 7. Provider-Based If the provider checks the “Outpatient Provider-Based Department” (PBD) box in Section 4(A), it must check one of the seven succeeding checkboxes that outlines the type of PBD involved. Except if CMS directs otherwise, the contractor need not verify any of the furnished PBD data in Section 4(A), including whether the department is indeed a PBD or the type of PBD involved. In addition, even if the contractor knows the department is provider-based, the provider need not check that it is a PBD. Only if the provider checks the PBD checkbox must it also identify the type.