Effective Date of Certified Provider or Supplier Agreement or Approval
MLN Matters® Number: MM7232
Provider Types Affected
This article is for providers and suppliers subject to survey and certification requirements.
Provider Action Needed: Impact to You
This article is based on Change Request (CR) 7232 which clarifies instructions regarding the determination of the effective date of certified provider agreement or supplier approval.
What You Need to Know
The Code of Federal Regulations (42 CFR 489.13) has been revised to make it clearer that the date of a Medicare provider agreement or supplier approval may not be earlier than the latest date on which all applicable federal requirements have been met, and that such requirements include review and verification of an application to enroll in the Medicare program by the Centers for Medicare & Medicaid Services (CMS) legacy fiscal intermediary (FI), legacy carrier, or Medicare Administrative Contractor (MAC).
What You Need to Do
See the Background and Additional Information Sections of this article for further details regarding these changes.
The Fiscal Year (FY) 2011 Inpatient Prospective Payment System (IPPS) final rule was published on August 16, 2010 (75 FR50042) and was effective October 1, 2010 (see the FY 2011 IPPS final rule at http://edocket.access.gpo.gov/2010/2010-19092.htm on the Internet). Several provisions in the FY 2011 IPPS final rule amend Section 489.13 of the Code of Federal Regulations (42 CFR 489.13) which governs the determination of the effective date of a Medicare provider agreement or supplier approval for health care facilities that are subject to survey and certification. The revised Section 489.13 makes it clearer that:
You can review revised 489.13 of the CFR at http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr;sid=cbe4615ac0d1730fe7871c78553897f9;rgn=div2;view=text;node=20100816%3A1.77;idno=42;cc=ecfr;start=1;size=25 on the Internet.
These clarifications were necessary because a September 28, 2009, decision of the Appellate Division of the Departmental Appeals Board (DAB) interpreted Section 489.13 as not including enrollment application processing among Federal requirements that must be met. You can review the DAB Decision No. 2271 at http://www.hhs.gov/dab/decisions/dabdecisions/dab2271.pdf on the Internet.
In that case a State Agency had:
The CMS Regional Office (RO) issued a provider approval effective November 21, 2007 (the date the FI recommended the applicant's enrollment approval), consistent with our traditional interpretation of Section 489.13. However, the DAB ruled that the effective date must be July 6, 2007 (the date the survey was conducted).
The DAB agreed with the applicant in this case that the requirement for the Medicare contractor to verify and determine whether an application should be approved is
In accordance with Section 2003B of the State Operations Manual (SOM), State Agencies and accreditation organizations are aware that they should perform a survey of a new facility after the MAC/legacy FI/legacy carrier has provided notice that:
However, circumstances do occur when the sequence is reversed, i.e., the survey occurs prior to enrollment verification activities. Accreditation organizations, in particular, often find it challenging to confirm whether the MAC, FI, RHHI, or carrier has completed its review and made a recommendation, since they are dependent upon the applicant providing copies of the pertinent notices.
When the survey occurs prior to the enrollment verification activities, CMS believes it is essential that the provider agreement or supplier approval date be based on the later date, i.e., the date the contractor determined that the enrollment application was verified and recommends approval.
There are other Federal requirements not related to a facility's survey, such as the provision of required Office for Civil Rights documentation. Accordingly, the revised rule explicitly states in Section 489.13(b) that:
"Federal requirements include, but are not limited to –
The official instruction, CR 7232, issued to your carriers, FIs, MACs, and RHHIs regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R372PI.pdf on the CMS website.
If you have any questions, please contact the Provider Contact Center at their toll-free number, (866) 590-6703.
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
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