May 16, 2019
Provider Enrollment Ask the Contractor Teleconference (ACT) April 23, 2019
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- Can you explain the 36 month rule evaluation process that goes on at the MAC, then CMS regional? Who interprets this rule?
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For HHA providers, the MAC reviews ownership from initial enrollment to the current ownership changes submitted on an application to determine if there was a violation of the HHA 36 month rule meaning was there a more than a 50% change in direct ownership over any 36 month period. If there was, we look to ensure if an exception was met, ie, filed 2 full year Medicare cost reports, owner didn't die, or a reorganization. Once we complete our review, we send it to the CMS central office for review and approval.
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- Could you give a review of the new 855I application?
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The changes are outlined in detail on slides 14-28 of the presentation. Please contact customer service if you have additional questions.
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- Who do we contact if our changes in name or address have not been processed? How long do we wait before we contact someone?
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Ties in to the overview of the Average application processing times. You can also monitor the status of your application by clicking on the link in the acknowledgement letter which will tell you the status of your application http://www.cgsmedicare.com/medicare_dynamic/PE/Login.asp (enter the application reference number and the contact persons 5 digit zip code). If the website states for Part B we complete the processing of the application within 25 days, there is no need to call about the status until 25 days have elapsed. If the timeframe has passed, then please call customer service to request a status.
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- When checking USPS for address verification, the address verifies but PECOS indicates it does not. How do we handle?
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Add a comment as to why you feel the USPS verification may be incorrect. We also suggest going out to the USPS website and looking at the DPV tab as this is the process PECOS uses to validate an address. If you see DPV indicated on the USPS page:
Then click on Show Mailing Industry Details to see specific message:
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- Does an 855 application ever expire while waiting for follow up?
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A CMS-855 sent for approval to the CMS RO can expire if more than 6 months have passed and the delay in completing the survey is due to the provider. This normally only happens with initial enrollments requiring a State survey. In these cases, the State would request the MAC to send a letter asking the provider to validate if any information on the original application has changed and update if needed.
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- Can you describe how the capitalization amount is determined/approved for home health?
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Capitalization is only for Initial HHA's and is determined by looking at like providers in the same geographical area with the same business structure and similar visit projections. Please refer to 42 CFR §489.28(a) and §424.510(d)(9).
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- Can you tell me who reviews transactions for violation of the 36-month rule for home health?
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For HHA providers, the MAC reviews ownership from initial enrollment to the current ownership changes submitted on an application to determine if there was a violation of the HHA 36 month rule meaning was there a more than a 50% change in direct ownership over any 36 month period. If there was, we look to ensure if an exception was met, ie, filed 2 full year Medicare cost reports, owner didn't die, or a reorganization. Once we complete our review, we send it to the CMS central office for review and approval.
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