ࡱ> QSP{ K#bjbjzz 6c((4h$B,n___GIIIIII$HZm_____m_RG_GP{Gj30T bT T h___mm}N_______T _________( H:  TO: INITIAL OUTPATIENT PHYSICAL, OCCUPATIONAL OR SPEECH THERAPY PROVIDER FROM: HEALTH STANDARDS SECTION (HSS) RE: INITIAL MEDICARE CERTIFICATION PLEASE READ ALL INFORMATION CAREFULLY. ENCLOSED IS A LIST OF FORMS TO BE COMPLETED AND SENT TO THE STATE OFFICE. CONTACT THIS OFFICE IF FORMS IDENTIFIED ON THE LIST ARE MISSING. This application packet is designed to direct an applicant through the initial process as it relates to Medicare/Medicaid Certification. The Department of Health and Hospitals (DHH) shall not process any application until all completed forms and required applicable accompanying information are received. THE APPLICATION PROCESS WILL BE TERMINATED FOR APPLICANTS WHO HAVE NOT COMPLETED THE SUBMISSION OF ALL THE REQUIRED FORMS AND SUPPLEMENTAL INFORMATION WITHIN 90 DAYS OF THE INITIAL APPLICATION DATE. APPLICANTS WHO ARE STILL INTERESTED IN APPLYING MUST BEGIN THE INITIAL PROCESS WITH THE SUBMISSION OF A NEW APPLICATION. When all of the required forms and information have been received, the State Office will notify you in writing on how to proceed. The forms and information should be submitted to State Office approximately six (6) weeks prior to your anticipated opening date. For participation in the Medicare program, all providers/suppliers must complete the CMS 855 form, Medicare Federal Health Care Provider/Supplier Application for Health Care Providers or Suppliers. The application must be obtained from the provider/suppliers chosen fiscal intermediary or carrier. The Centers for Medicare and Medicaid Services (CMS) website located @  HYPERLINK "http://www.cms.hhs.gov/MedicareProviderSupEnroll/" http://www.cms.hhs.gov/MedicareProviderSupEnroll/, contains a list of FIs and carriers by state and specialty. The FI/Carrier will answer any inquiries concerning completion of the enrollment application. (revised February, 2009) Initial OUTPATIENT PHYSICAL/OCCUPATIONAL/SPEECH THERAPY Provider Page 2 Please note that an initial certification survey of a new provider/supplier will be conducted only after the state agency has received notice from the FI or Carrier that the CMS 855 form has been approved. New providers/suppliers must be in operation and providing services to patients when surveyed for certification. This means that at the time of the survey, the institution must have opened its doors to admissions, be furnishing all services necessary to meet the applicable provider/supplier definition and demonstrate the operational capability of all facets of its operations. In accordance with 42 CFR, 485.717 A,B, an Outpatient Physical Therapy (OPT), Outpatient Occupational Therapy (OOT), or Outpatient Speech Therapy (OSP) provider provides physical therapy, occupational therapy and/or speech therapy services and a rehabilitation program that in addition to PT, OT and/or ST services, it offers either social or vocational adjustment services by making provision for special, qualified staff to evaluate the social or vocational factors involved in a patient's rehabilitation, to counsel and advise on social or vocational problems arising from the patient's illness or injury, and to make appropriate referrals for required services. Therefore applicants must notify this agency of which services they intend to provide. Federal Regulations requires your building to have a fire alarm system. At a minimum, this system needs a pull station which activates an internally audible alarm that can be heard throughout the building. You will need to submit documentation of either its existence or an invoice for its installation. If a system has to be installed, the office of State Fire Marshal must approve your plans for installation. In that event, you will need to contact them at (225) 925-4916. An OPT/OOT/OSP provider may provide services from multiple locations which it controls (e.g., buildings or space it owns or rents). However, you must designate one location as your primary site for certification purposes and this primary site must provide the services that are provided at any extension location. Prior to relocating an office or extension unit, a facility must contact this agency for a determination of whether the new location meets the pertinent Medicare requirements. Each primary site and extension unit must have approval from the Office of the State Fire Marshal. Current regulations require that the effective date of the provider agreement can be no earlier than the completion date of the survey, assuming all requirements are met. In the event that a deficiency is cited at the initial survey, the effective date will be no earlier than the date that the facility provides an acceptable Plan of Correction. You are cautioned about accepting Medicare beneficiaries prior to confirmation by the Department of Health and Human Services Regional Office, in Dallas, Texas, of the effective date of the Health Insurance Benefits Agreement. You should notify the beneficiary or his representative, in writing, of beneficiary's financial responsibility in the program. Initial OUTPATIENT PHYSICAL/OCCUPATIONAL/SPEECH THERAPY Provider Page 3 This agency is responsible for determining compliance with Medicare/Medicaid regulations and certifying its findings to the CMS Regional Office, which will make the decision as to whether you qualify for participation in the Medicare program. A provider/supplier participating in the Medicare program under this approval will continue to be eligible to participate until a determination of noncompliance is made. If you have any additional questions, you may contact this office at (225)3423329. You may call 18005536847 to request the Federal Regulations and Interpretive Guidelines for your program. Information/forms included in this packet: Initial Provider Memorandum CMS 1561 - Health Agreement (3) CMS 1856  Request for Certification in Medicare and/or Medicaid Program Fiscal Intermediary Preference/Fiscal Year End Date HSS 1513L - Disclosure of Ownership and Control Interest Statement Office for Civil Rights Forms Memo Federal Regulations The following information/forms are to be returned to state office by all applicants: Letter of Intent (anticipated date of opening) CMS 1856  Request for Certification in Medicare and/or the Medicaid Program CMS 1561  Health Agreement (3) Fiscal Intermediary Preference/Fiscal Year End Date HSS 1513L - Disclosure of Ownership and Control Interest Statement Office for Civil Rights Forms Memo Fire approval from Office of State Fire Marshal Documentation of existence of fire alarm system      STATE OF LOUISIANA  DEPARTMENT OF HEALTH AND HOSPITALS OFFICE OF MANAGEMENT AND FINANCE ( BUREAU OF HEALTH SERVICES FINANCING ( HEALTH STANDARDS SECTION 500 LAUREL STREET SUITE 100 (70801-1811) ( P.O. 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