Looking for a Cms Forms And Templates? Download it for free!

INSTRUCTIONS FOR FORM CMS-3427

PART 1 – DOCUMENTATION NEEDED TO PROCESS FACILITY APPLICATION/NOTIFICATION TO BE

COMPLETED BY APPLICANT

A completed request for approval as a supplier of End Stage Renal Disease (ESRD) services in the Medicare program (Part I – Form

CMS-3427) must include:



A narrative statement describing the need for the service(s) to be provided, and



A copy of the Certificate of Need approval, if such approval is required by the state.

TYPE OF APPLICATION (ITEM 1)

Check appropriate category. A “change of service” refers to an addition or deletion of services. “Expansion” refers to addition of stations. If

you relocate one of your services to a different physical location, you may be required to obtain a separate CCN for that service at the new

location.

IDENTIFYING INFORMATION (ITEMS 2-24)

Enter the name and address (actual physical location) of the ESRD facility where the services are performed. If the mailing address is

different, show the mailing address in Remarks (Item 33). Check the applicable blocks (Item 17 and Item 18) to indicate the facility’s

hospital and/or SNF/NF affiliation, if any. If so, enter the CCN of the hospital and/or SNF/NF. Check whether the facility is owned and/or

managed by a “multi-facility” organization (Item 19) and provide the name and address of the parent organization. A “multi-facility

organization” is defined as a corporation or a LLC that owns more than one facility.

TYPES OF SERVICE, DIALYSIS STATIONS, AND DAYS/HOURS OF OPERATION (ITEMS 20-28)

Provide information on current services offered (Item 20). Check N/A or each New service for which you are requesting approval (Item 21).

Note that facilities providing home therapies must provide both training and support. If you are requesting to offer home training and support

only (Item 21), you must have a functional plan/arrangement to provide backup dialysis as needed. A new “home training and support only”

service applies to initial applications. If you request any home training and support program (Item 21), you must also indicate “Yes” for a

training room (Item 24). If you provide or support dialysis within one or more a LTC facilities (SNF/NF), list all LTCs (name, CCN, and

address) participating in this service under Remarks (Item 33), and complete Item 22. Enter the number of stations for which you are asking

approval (Item 25). Provide information on isolation (Items 26-27). Facilities not existing prior to October 14, 2008 which do not have an

isolation room must attach evidence of CMS waiver and written agreement with geographically proximal facility with isolation room. Provide

all days and start time for the first shift of patients and end time for the last shift of patients (in military time) for each day of operation (Item

28). Provide information on dialyzer reprocessing (Item 29).

STAFFING (ITEM 30)

“Other” includes non-certified patient care technicians, administrative personnel, etc. To calculate the number of full-time equivalents of any

discipline (Item 30), add the total number of hours that all members of that discipline work at this facility and enter that number in the

numerator. Enter into the denominator the number of hours that facility policy defines as full-time work for that discipline. Report FTEs in

0.25 increments only. Example: An RD works 20 hours a week at Facility A. Facility A defines full time work as 40 hours/week. To calculate

FTEs for the RD, divide 20 by 40. The RD works 0.50 FTE at Facility A.

REMARKS (ITEM 33)

You may use this block for explanatory statements related to Items 1-32.

LICENSING AND CERTIFICATE OF NEED

If your state requires licensing for ESRD facilities, include your current license number in Item 31. If your state requires a Certificate of Need

(CON) for an initial ESRD or for the change you are requesting, mark the applicable box in Item 32 and include a copy of the documentation

of the CON approval.

Upon completion, forward a copy of form CMS-3427 (Part I) to the State agency.

PART II - SURVEY AND CERTIFICATION REPORT TO BE COMPLETED BY STATE AGENCY

The surveyor should review and verify the information in Part I with administrator or medical director and complete Part II of this form.

Recognize that CMS cannot issue a CCN for an initial survey until all required steps are complete, including CMS-855A approved by the

applicable MAC. Complete the Statement of Deficiencies (CMS Form 2567) in ASPEN. Complete the CMS-1539 in ASPEN entering

recommended action(s). All required information must be entered in ASPEN and uploaded in order for the survey to be counted in the

state workload.

FORM CMS-3427 (Revision 05/13)

Form Cms-3427 - End Stage Renal Disease Application And Survey And Certification Report Page 3

Related Articles

Related forms

Related Categories