Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 19

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SECTION 4: PRACTICE LOCATION INFORMATION
INSTRUCTIONS
• Report all practice locations within the jurisdiction of the Medicare fee-for-service contractor to which
you will submit this application.
• If the provider is adding a practice location in the same State and the location requires a separate
provider agreement, a separate, complete CMS-855A must be submitted for that location. The
location is considered a separate provider for purposes of enrollment, and is not considered a practice
location of the main provider. If a provider agreement is not required, the location can be added as a
practice location.
• If the provider is adding a practice location in another State and the location requires a separate provider
agreement, a separate, complete CMS-855A must be submitted for that location. (This often happens
when a home health agency wants to perform services in an adjacent State.)
• If the provider is adding a practice location within another fee-for-service contractor’s jurisdiction and
the provider is not already enrolled with that fee-for-service contractor, the provider must submit a
full, complete CMS-855A to that fee-for-service contractor—regardless of whether a separate provider
agreement is required. It cannot add the location as a mere practice location.
• Provide the specific street address as recorded by the United States Postal Service. Do not furnish a
P.O. Box.
The provider should list its primary practice location first in Section 4A. The “primary
IMPORTANT:
practice location” must be associated with the NPI that the provider intends to use to bill for
Medicare services.
If you have any questions as to whether the practice location requires a separate State survey or provider
agreement, contact your fee-for-service contractor.
(CMHCs) must report all alternative sites where core services are
Community Mental Health Centers
provided (proposed alternative sites for initial enrollment and actual alternative sites for those CMHCs
already participating in Medicare). In accordance with provisions of the Public Health Service Act, a
CMHC is required to provide mental health services principally to individuals who reside in a defined
geographic area (service area). Therefore, CMHCs must service a distinct and definable community. Those
CMHCs operating or proposing to operate outside of this specific community must have a separate provider
agreement/number, submit a separate enrollment application, and individually meet the requirements
to participate. CMS will determine if the alternative site is permissible or whether the site must have a
separate agreement/number. CMS will consider the actual demonstrated transportation pattern of CMHC
clients within the community to ensure that all core services and partial hospitalization services are
available from each location within the community. A CMHC patient must be able to access and receive
services he/she needs at the parent CMHC site or the alternative site within the distinct and definable
community served by the parent.
CMS-855A (07/11)
18

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