Providers must be operational when applications submitted

First Coast has seen an increase in applications being submitted that fail site visits due to not being operational, even though the site visit occurred after the effective date listed on the application. It is important you submit the correct effective date on your application and submit the application when the provider or supplier is operational. Here’s a couple of reminders for application guidelines related to the effective date and a provider or supplier being operational.

• Applications may be submitted up to 60 days prior to the effective date. If the application is received more than 60 days prior to the effective date listed, then the application may be returned. For more information about reasons for returning applications, review CMS IOM Pub. 100-08 Medicare Program Integrity Manual, Chapter 10, section 10.4.1.4.2.
• Applications may be denied if the processing contractor finds a legal basis for denying an application. The CMS IOM Pub. 100-08 Medicare Program Integrity Manual, Chapter 10, section 10.4.2.2 provides a list of reasons an application may be denied. Denial reason five is specific to on-site reviews stating the application may be denied if during on-site review it is determined that the provider or supplier is not operational.
  • Additionally, the CMS IOM Pub. 100-08 Medicare Program Integrity Manual, Chapter 10, section 10.6.20 discusses the expectations of the provider or supplier for the site visit. During the site visit, the site visit contractor will determine if specific criteria are met, to include (1) the facility is open, (2) personnel are at the facility, (3) customers are at the facility, and (4) the facility appears to be operational.
• Enrolled providers or suppliers may have their enrollment revoked and the CMS IOM Pub. 100-08 Medicare Program Integrity Manual, Chapter 10, section 10.4.7.3 provides a list of reasons for revocation. Revocation reason five state that a provider or supplier may be revoked if during on-site review it is determined that the provider or supplier is not operational.

To prevent processing impacts to your application, ensure your application is submitted timely, with the correct effective date, and when the provider or supplier is operational.