Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 10

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SECTION 2: IDENTIFYING INFORMATION
NEW ENROLLEES
Submit separate CMS-855A enrollment applications if the types of providers for which this
application is being submitted are separately recognized provider types with different rules regarding
Medicare participation. For example, if a provider functions as both a hospital and an end-stage renal
disease (ESRD) facility, the provider must complete two separate enrollment applications (CMS-855A)—
one for the hospital and one for the ESRD facility. If a hospital performs multiple types of services, only
one enrollment application (CMS-855A) is required.
For example, a hospital that has a swing-bed unit need only submit one enrollment application
(CMS– 855A). This is because the provider is operating as a single provider type—a hospital—that
happens to have a distinct part furnishing different/additional services.
SPECIAL ENROLLMENT NOTES
• If you are adding a psychiatric or rehabilitation unit to a hospital, check the appropriate subcategory
under the “Hospital” heading. (A separate enrollment for the psychiatric/rehabilitation unit is not
required). The unit should be listed as a practice location in Section 4.
• If you are adding a home health agency (HHA) branch, list it as a practice location in Section 4. A
separate enrollment application is not necessary.
• If you are changing hospital types (e.g., general hospital to a psychiatric hospital), indicate this in
Section 2. A new/separate enrollment is not necessary.
• If you are adding an HHA sub-unit (as opposed to a branch), this requires an initial enrollment
application for the sub-unit.
• If the hospital will focus on certain specialized services, the applicant should analyze whether the
facility will be a general hospital or will fall under the category of a specialty hospital. A specialty
hospital is defined as a facility that is primarily engaged in cardiac, orthopedic, or surgical care. Based
upon Diagnosis Related Group/Major Diagnosis Category (DRG/MDC) and type (medical/surgical), the
applicant should project all inpatient discharges expected in the first year of the hospital’s operation.
Those applicants that project that 45% or more of the hospital’s inpatient cases will fall in either cardiac
(MDC-5), orthopedic (MDC-8), or surgical care should check the Hospital—Specialty Hospital block in
Section 2A2.
• Physician-owned hospital means any participating hospital (as defined in 42 CFR § 489.24) in which
a physician, or an immediate family member of a physician has an ownership or investment interest in
the hospital. The ownership or investment interest may be through equity, debt, or other means, and
includes an interest in an entity that holds an ownership or investment interest in the hospital. This
definition does not include a hospital with physician ownership or investment interests that satisfy the
requirements at 42 CFR § 411.356(a) or (b).
CMS-855A (07/11)
9

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