DEPARTMENT
OF HEALTH AND HUMAN SERVICES
Health Resources and
Services Administration
CHECKLIST FOR ADDING A
SITE (CHKLST003)
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Grantee
Name:
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Grantee
Number:
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CIS
Tracking Number:
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Questions
for Addition of Site
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Site
Name
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Site
Address
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When
do you plan to start providing services at the site?
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1.
NEED
Clearly
address why and how the addition of the proposed site
will address unmet need and further the mission of the
health center by maintaining
or increasing access
and maintaining
or improving quality of care
for the target population.
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1a.
How was the need for the proposed site identified (check
all applicable reasons)?
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UDS
Trend Data (e.g. Patient Origin Data) and/or a needs
assessment indicated a high need for a site at this
location (e.g. health center is exceeding patient
capacity at existing sites, health center is seeing
significant number of patients from the proposed
area).
UDS Data Year (20
) Needs assessment completed on (mm/dd/yyyy):
The
site is located in a Medically Underserved Area (MUA).
The site is located in a Medically Underserved Area
(MUA).
Health center verified MUA Designation is
current in HRSA
Database
on (mm/dd/yyyy):
The
site will serve a Medically Underserved Population (MUP).
The site will serve a Medically Underserved Population
(MUP).
Health center verified MUP Designation is
current in HRSA
Database
on (mm/dd/yyyy):
An
existing health center site (section 330 grantee or FQHC
Look-Alike) in the proposed area is closing and/or
another safety net provider(s) is no longer offering
services to our target population in this area.
One
or more of my current sites is under renovation and we
need to add a temporary site to scope where we will
provide services until the current site(s) under
renovation are ready. Once the health center re-opens the
existing site in scope that is currently under
renovation, if they will no longer be utilizing the
temporary site added through this change in scope, they
will need to submit a change in scope to REMOVE the
temporary site from scope via a Site Deletion
request.
The
site will replace a site I have already removed from
scope and/or plan to remove from scope in the future, and
these two actions (closure of original site and opening
of new site to replace the original site) will NOT be
accomplished within 120 days or less.
Other
(Describe in the space provided below):
Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
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1b.
Using the most recent UDS data and/or other data specific
to your target population and/or service area, describe
the:
specific
access barriers
(e.g. Ratio of Population to One FTE Primary Care
Physician, Distance (miles) OR Travel Time (minutes) to
Nearest Primary Care Provider Accepting New Medicaid
and/or Uninsured Patients: private practitioner, health
center, etc.) and
specific
risk factors
(e.g., occupational, environmental, behavioral,
social/cultural, or housing status) of the patient
population to be served at the proposed site that
supports
the need for and/or benefit of the proposed site.
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Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
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1c.
Provide evidence that the proposed site will
appropriately serve the current patient and/or target
population by providing the following information about
the population that will utilize the new site.
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Number
of patients projected to be served annually
This
is the anticipated number of patients that will utilize
the proposed site in the coming calendar year.
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Number:
(Format:
99)
Data
Source Used for Projection:
Maximum paragraph(s)
allowed approximately: 3 (3000 character(s) remaining)
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Percentage
of projected patients at or below 200% of Federal Poverty
Guidelines
This
is the anticipated % of patients with incomes at or below
200% of the Federal Poverty Guidelines that will utilize
the proposed site in the coming calendar year.
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Percentage:
%
(Format:
9 or 9.99)
Data
Source Used for Projection:
Maximum paragraph(s)
allowed approximately: 3 (3000 character(s) remaining)
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Percentage
of projected uninsured patients
This
is the anticipated % of uninsured patients that will
utilize the proposed site in the coming calendar year.
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Percentage:
%
(Format:
9 or 9.99)
Data
Source Used for Projection:
Maximum paragraph(s)
allowed approximately: 3 (3000 character(s) remaining)
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1d.Provide
a brief narrative description on how the projections in
1c. were derived.
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Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
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2.
Service Area Analysis:
Describe
how the health center has analyzed the service area,
utilizing UDS Mapper and/or other similar resources,
where the proposed site will be located. (Attach analysis
documentation) Responses
should be consistent with data and narrative on unmet
need and projected patients provided in Question 1.
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Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
Service
Area Analysis (Maximum 6 attachments)
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Purpose
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Document
Name
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Description
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No
attached document exists.
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Service
Area Analysis Resources
Service
Area Overlap Policy and Process:
http://bphc.hrsa.gov/policiesregulations/policies/pin200709.html
UDS
Mapper: http://www.udsmapper.org
HRSA
Data Warehouse: http://datawarehouse.hrsa.gov
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2a.
Select the appropriate statement. The proposed site is
being added to:
For
the purposes of this question:
Service
area is defined by the service area zip codes associated
with your Form 5B sites.
Patient
population is defined by your current UDS Patient Origin
Data.
Target
population is defined in your most recent approved
application.
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provide
increased access and/or capacity for the existing
patient/target population
within the existing
service area.
Continue
to Question 3.
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provide
increased access in whole or in part to a new
patient/target population
and/or a new
service area
that is not
currently served by your health center.
Continue
to Question 2b.
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Provide
comments related to selection
Maximum paragraph(s)
allowed approximately: 3 (3000 character(s) remaining)
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2b.
Will the proposed site serve all
or part of the service area of another health center
(section 330 grantee or Look-Alike) and/or of another
primary care safety
net provider
(rural health clinics, critical access hospitals, health
departments, etc.)?
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If
Yes,
list these other health centers and/or safety net
providers and discuss how the proposed site will
complement
these existing primary care resources so as to
minimize the potential for unnecessary duplication and/or
overlap
in services, sites, or programs. Continue
to 2c only if the site will serve all or part of the
service area of another health
center
(section 330 grantee or Look-Alike). Otherwise,
continue to Question 3.
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If
No,
continue directly to Question
3.
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Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
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2c.
As the proposed site will serve all
or part of the service area of another health center,
discuss if and how one or more of the following apply to
your proposal (See PIN
2007-09: Service Area Overlap Policy and Process
for more information on HRSA’s principles for
assessing individual situations of service area overlap):
The
proposed site will serve a
newly identified sub-group of underserved people
within a community already served by another health
center(s) site(s) (e.g., homeless people, populations
with limited English proficiency within the service
area), where the health care needs
of the relevant medically underserved population group
within the new service area are not being met by another
health center’s site(s).
The
proposed site will serve an area where unmet
need exceeds the capacity of the existing health
center's site(s)
in the new service area.
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Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
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Once
completed, continue to Question
3.
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3.
Service Area Collaboration
For
the purpose of this question:
Collaborative
relationships are those that assist in contributing to
one or both of the following goals relative to the
proposed site:
(1) maximizing access to required
and additional services within the scope of the health
center project to the target population that will be
served at the proposed site; and/or
(2) promoting
continuity of care to health care services for health
center patients served at the proposed site beyond the
scope of the project.
Collaboration
Resources
Collaboration
PAL:
http://bphc.hrsa.gov/policiesregulations/policies/pal201102.html
UDS
Mapper: http://www.udsmapper.org
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3a.
Describe established
collaboration and new collaborative efforts under
development with existing health centers
(section 330 grantee and Look-Alikes) within or adjacent
to the service area of the proposed site. In addition,
list the names and addresses of these health centers
and/or refer to the attached Service Area Analysis from
Question 2 if listed there). If
service area collaboration has already been discussed in
Service Area Analysis Question 2b, refer back to these
responses.
If a formal affiliation (e.g. MOA, MOU,
contract, etc.) and/ or letter of collaboration or
support from the neighboring health center(s) is
available, attach these documents below. Only documents
that speak to the proposed change in scope request for
the site addition should be included.
✓
If
no other health centers exist within or adjacent to the
service area state this.
✓
If documentation of collaboration or support from service
area health centers cannot be obtained, include
documentation of efforts made to obtain such documents
and an explanation for why they could not be obtained.
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Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
Collaboration
Documentation (Maximum 6 attachments)
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attached document exists.
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3b.
Describe established collaboration and new collaborative
efforts under development with other
safety net providers
(e.g. rural health clinics, critical access hospitals,
health departments, etc.) within or adjacent to the
service area of the proposed site. In addition, list the
names and addresses of these other safety net providers
and/or refer to the attached Service Area Analysis from
Question 2 if listed there). If
service area collaboration has already been discussed in
Service Area Analysis Question 2b, refer back to these
responses.
If
a formal affiliation (e.g. MOA, MOU, contract, etc.)
and/or letter of collaboration or support relevant
to the proposed site addition is available,
attach these documents below. Only
documents that speak to the proposed change in scope
request for the site addition should be included.
✓
If no other safety net providers exist within or adjacent
to the service area state this.
✓
If documentation of collaboration or support from service
area safety net providers cannot be obtained, include
documentation of efforts made to obtain such documents
and an explanation for why they could not be obtained.
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Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
Collaboration
Documentation (Maximum 6 attachments)
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Name
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No
attached document exists.
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4.
Governance
Discuss
whether the addition of the proposed site will have any
impact on the health center’s ability to maintain
compliance with the Health Center Program Board
Composition Governance
Requirements.
Consider and discuss any plans to address,
the following applicable aspects of the Board Composition
Requirement that may be impacted by a site addition:
Will
the addition of the new site significantly change the
overall demographics of the patients served by the
health center as a whole (i.e. across all sites) in
terms of race, ethnicity and sex and thus potentially
impact the representativeness of the composition of the
health center’s current patient majority governing
board (unless
waived for Health Center Program grantees funded and
look-alikes designated only
under sections 330(g), (h), and/or (i) of the Public
Health Service (PHS) Act)?
Will
the addition of the new site significantly change the
size and complexity of the overall health center
organization and potentially create the need to recruit
additional patient and/or non-patient board members
(i.e. increase the board’s size)?
Will
the addition of the new site impact the need to recruit
additional non-patient board members with expertise in
areas not currently reflected on the board?
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Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
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5.
Site Ownership and Operation:
For
sites that will be operated through a contractual or
subrecipient arrangement (i.e. not directly by the health
center):
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Will
services at the contracted or subrecipient operated site
be provided
on behalf of the health center to health center patients?
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Yes
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No
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Will
the health center’s governing
board retain control and authority
over the provision of the services to health center
patients at the contracted or subrecipient operated site?
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Yes
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No
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Briefly
justify why the health center has chosen to operate the
site through such third party arrangements.
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Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
Health
centers are reminded of their responsibilities to obtain
any required prior approval from HRSA for aspects of the
program conducted by subrecipients or contractors before
a subrecipient or contractor can undertake an activity or
make a budget change requiring that approval e.g.,
approval to extend the period of performance of a
subaward to a subrecipient if it would extend beyond the
end of the grant’s project period).
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5a.
FOR SITES OPERATED BY CONTRACT:
If the proposed site is owned and/or operated by a third
party on behalf of the health center through a written
contractual agreement between the health center and the
third party (i.e. the health center is purchasing a
specific set of goods and services from the third
party-such as the operation of a site), does
the contract state, address or include:
The activities to be performed by the
contractor in the operation of the site, specifically
including:
How
the services provided at the site will be documented in
the health center patient record?
How
the health center will bill and/or pay for the services
provided to health center patients at the site?
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Yes
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No
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List
Page #(s):
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The
time schedule for such activities (e.g. hours of site
operation)?
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Yes
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No
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List
Page #(s):
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The
policies and requirements that apply to the contractor,
including those required by 45 CFR 74.48 or 92.36(i) and
other terms and conditions of the grant? These
may be incorporated by reference where feasible –
See the HHS Grants Policy Statement for more information
on public policy requirements applicable to contractors
at: http://www.hrsa.gov/grants/hhsgrantspolicy.pdf
pages II-2 to II-6
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Yes
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No
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List
Page #(s):
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The
maximum amount of money for which the health center may
become liable to the third party under the agreement?
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Yes
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No
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List
Page #(s):
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Provisions
consistent with the health center’s board approved
procurement policies and procedures in accordance with
45CFR Part 74.41-48?
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Yes
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No
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List
Page #(s):
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Assurances
that no provisions will affect the health center’s
overall responsibility for the direction of the site and
services to be provided there and accountability to the
Federal government by reserving sufficient rights and
control to the health center to enable it to fulfill its
responsibilities?
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Yes
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No
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List
Page #(s):
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Requirements
that the contractor maintain appropriate financial,
program and property management systems and records and
provides the health center, HHS and the U.S. Comptroller
General with access to such records, including the
submission of financial and programmatic reports to the
health center if applicable and comply with any other
applicable Federal procurement standards set forth in
45CFR Part 74 (including conflict of interest standards)?
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Yes
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No
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List
Page #(s):
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Provision
that such agreement is subject to termination (with
administrative, contractual and legal remedies) in the
event of breach by the contractor?
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Yes
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No
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List
Page #(s):
It
is the responsibility of the health center to ensure that
the contract does NOT inappropriately imply the
conference of the benefits and/or privileges of the
Health Center Program grantees or FQHC Look-Alikes such
as 340B Drug Pricing or FQHC reimbursement, on the other
party.
Attach
the contract for the site (draft agreements are
acceptable) here.
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Contract
for the site (Maximum 6 attachments)
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Select
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Purpose
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Document
Name
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Size
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Description
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No
attached document exists.
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5b.
FOR SITES OPERATED BY SUBRECIPIENTS:
If the proposed site is owned and/or operated by
subrecipient on behalf of the health center through a
written subrecipient agreement between the health center
and the subrecipient organization to perform a
substantive portion of the grant-supported program or
project, respond
to all of the following questions.
A
subrecipient is an organization that “(ii)(I) is
receiving funding from such a grant under a contract with
the recipient of such a grant, and (II) meets the
requirements to receive a grant under section 330 of such
Act . . .” (§1861(aa)(4) and §1905(l)(2)(B)
of the Social Security Act).
Subrecipients
must be compliant with all of the requirements of
section 330 to be eligible to receive FQHC reimbursement
from both Medicare and Medicaid.
The
subrecipient arrangement must be documented through a
formal written agreement (Section 330(a)(1) of the PHS
Act)
The
health center (grantee of record) named on the NoA is the
entity legally accountable to HRSA for performance of the
project or program, the appropriate expenditure of funds
by all parties including subrecipients, and other
requirements placed on the health center (grantee of
record), regardless of the involvement of others in
conducting the project or program.
Has
the health center’s key management staff confirmed
that the subrecipient meets all
applicable section 330 requirements
and does the health center’s key management staff
and its governing board have a plan in place to monitor
the subrecipient's compliance over time?
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Yes
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No
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Does
the board-approved subrecipient agreement state, address
or include the following elements necessary for meeting
the programmatic, administrative, financial, and
reporting requirements of the grant, including those
necessary to ensure compliance with all applicable
Federal regulations and policies:
Identification
of the PI/PD and individuals responsible for the
programmatic activity at the subrecipient organization
along with their roles and responsibilities?
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Yes
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No
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List
Page #(s):
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Procedures
for directing and monitoring the programmatic effort?
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Yes
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No
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List
Page #(s):
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Procedures
to be followed in providing funding to the subrecipient,
including dollar ceiling, method and schedule of payment,
type of supporting documentation required, and procedures
for review and approval of expenditures of grant funds?
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Yes
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No
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List
Page #(s):
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If
different from those of the recipient, a determination of
policies to be followed in such areas as travel
reimbursement and salaries and fringe benefits (the
policies of the subrecipient may be used as long as they
meet HHS requirements)?
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Yes
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No
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List
Page #(s):
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Incorporation
of applicable public policy requirements and provisions
indicating the intent of the subrecipient to comply,
including submission of applicable assurances and
certifications? See
the HHS Grants Policy Statement for more information on
public policy requirements applicable to subrecipients
at: http://www.hrsa.gov/grants/hhsgrantspolicy.pdf
pages II-2 to II-6
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Yes
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No
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List
Page #(s):
Attach
the subrecipient agreement documentation (draft
documents are acceptable) here.
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Subrecipient
Agreement (Maximum 6 attachments)
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Subrecipients
are eligible to receive FQHC reimbursement as well as
many of the other benefits and privileges of the Health
Center Program grantees and Look-Alikes such as 340B Drug
Pricing, FTCA coverage (section 330 grantees
only).However, the health center AND subrecipient
organization are reminded that such benefits are not
automatically conferred and may require additional steps
and updates (e.g. updating the FTCA deeming folder to
ensure that the subrecipient is deemed via the grantee of
record’s FTCA coverage).
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6.
SERVICES:
Are
all the services that will be offered at the proposed
site already included within the approved scope of
project as documented on your health center’s Form
5A
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Yes
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No,
but a separate CIS Request will be submitted to add
all new services to scope.
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7.
LIMITED SERVICE SITES
Is
this a limited service sites that will not offer
comprehensive primary care or will not be open to the
entire health center patient population (e.g. sites that
offer only oral or behavioral health services, sites that
are only open to school-aged children, etc.):
How
will patients seen at this proposed site be assured
access to the full scope of existing required and
additional services the health center provides? Please
explain
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Yes
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No
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If
Yes, explain and address all of the following points as
applicable.
If
the site is limited to a certain segment of the health
center’s patient population (e.g. school-aged
children), how will individuals who present for services
at this site be referred to another appropriate health
center site for services?
If
the site offers only limited services (e.g.
dental-only), how will individuals seen at this site
access the full scope of existing required and
additional services the health center provides?
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Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
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8.
SLIDING FEE DISCOUNT PROGRAM:
Will
the health center offer its current sliding fee discount
program (sliding fee discount schedule, including any
nominal fees and related implementing policies and
procedures) at the proposed site to patients with incomes
at or below 200 percent of the Federal Poverty
Guidelines, and ensure that no patients will be denied
access to the service due to inability to pay?
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Yes
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No
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If
No, briefly explain your response:
Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
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9.
Financial Impact Analysis
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Template
Name
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Template
Description
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Action
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Financial
Impact Analysis
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Template
for Financial Impact Analysis
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Instructions
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Instructions
for Financial Impact Analysis
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Attach
Financial Impact Analysis Document here.
Financial
Impact Analysis (Maximum 6 attachments)
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9a.
Explain how the addition of the proposed site to scope
will
be accomplished and sustained without additional section
330 Health Center Program funds.
Specifically (referencing the attached Financial Impact
Analysis, as necessary) describe how adequate
revenue will be generated to cover all expenses as well
as an appropriate share of overhead costs
incurred by the health center in administering the new
site.
The Financial Impact Analysis must at a
minimum show a break-even scenario or the potential for
generating additional revenue.
Additional
revenue (program income) obtained through the addition of
a new site must be invested in activities that further
the objectives of the approved health center project,
consistent with and not specifically prohibited by
statute or regulations.
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Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
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9b.
Is this change in scope dependent on any special grant,
foundation or other funding that is time-limited, e.g.,
will only be available for 1 or 2 years?
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Yes
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No
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If
Yes, how will the new site be supported and sustained
when these funds are no longer available? Describe a
clear plan for sustaining the site.
Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
All
time-limited or special one-time funds should be clearly
identified as such in the Financial Impact Analysis.
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10.
STAFFING:
Provide
a clear and comprehensive description of the relevant
staffing arrangements made to support the proposed new
site and to ensure staffing is/will be sufficient to meet
any projected patient/visit increases. The discussion of
“staffing” should include non-health center
employees if the site will be operated via contract or
subrecipient arrangement. In addition, describe any
potential impact on the overall organization’s
staffing plan (reference the Financial Impact Analysis as
applicable). Specifically describe any key management
staff that will supervise/oversee site operations and who
they will report to within the larger health center
organizational structure (e.g. CMO, COO, etc.).
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Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
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11.
HEALTH CENTER STATUS: Discuss
any major changes in the health center’s staffing,
financial position, governance, and/or other operational
areas, as well as any unresolved areas of non-compliance
with Program Requirements (e.g. active Progressive Action
conditions) in the past 12 months that might impact the
health center’s ability to implement the proposed
change in scope.
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Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
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12.
CREDENTIALING AND PRIVILEGING:
How
has the health center planned for the appropriate
credentialing and privileging of all
provider(s)
that will staff the proposed site in accordance with PIN
2002-22?
In responding, consider the following:
It
is the responsibility of the health center to ensure
that all credentialing and privileging of providers has
been completed BEFORE providing services at the new site
as part of their Federal scope of project. This includes
services provided either Directly (Form 5A: Column I) OR
via a (Form 5A: Column II) Formal Written Agreement
(e.g. contract). For services provided via a Formal
Written Referral Arrangement (Column III), the referral
provider should be able to assure to the health center
that all their providers are appropriately credentialed
and privileged individually.
The
health center’s current board-approved policy must
cover the required verification of credentials and
establishment of privileges to perform any new
activities and procedures expected of providers by the
health center or be updated to do so (for services
provided at the new site either Directly (Form 5A:
Column I) OR via a (Form 5A: Column II) Formal Written
Agreement.
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Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
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Click
"Save" button to save all information within
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13.
QUALITY IMPROVEMENT/ASSURANCE PLAN:
How
will the proposed new site be integrated into and
assessed via the health center’s quality
improvement/assurance and risk management plans?
In
responding, address the following:
Will
it be integrated into the current QI/QA plan?
Are
board-approved peer and chart review policies in place
by which all provider(s) at the proposed site will be
assessed?
Are
risk management plans in place to assure the new site
has appropriate liability coverage (e.g.
non-medical/dental professional liability coverage,
general liability coverage, automobile and collision
coverage, fire coverage, theft coverage, etc.).
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Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
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Additional
Considerations for Adding a Site to Scope
While
the following areas are not specific factors
or criteria that will impact the CIS approval process,
these are key elements that health centers should have
considered or actively planned to address prior to adding
a new site to scope.
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A.
Medical Malpractice Coverage:
Your health center must develop plans for any providers
that will provide services on behalf of the health center
at the new site (e.g., extension of FTCA coverage,
private malpractice coverage). Respond the following as
applicable:
For
grantees deemed under the FTCA, have you reviewed the
FTCA Health Center Policy Manual or if appropriate,
consulted with BPHC to assure the applicability of FTCA
coverage?
The
FTCA Health Center Policy Manual is available
at:
http://www.bphc.hrsa.gov/policiesregulations/policies/pin201101.html
For specific questions, contact the BPHC HelpLine at:
1-877-974-BPHC (2742) or Email: [email protected].
Available Monday to Friday (excluding Federal holidays),
from 8:30 AM – 5:30 PM (ET), with extra hours
available during high volume periods.
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Yes
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Not
Applicable, health center is not deemed or FTCA
coverage does not apply.
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If
you selected "Not Applicable" respond to the
question below.
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For
health centers not deemed under the FTCA or if FTCA
coverage is not applicable to the site, have you
developed a plan for medical malpractice coverage?
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Yes
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No
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Briefly
explain your response:
Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
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B.
Section 340B Drug Pricing Program Participation: Health
centers that participate in the 340B Drug Pricing Program
are reminded that changes to the scope of project
approved by BPHC do not automatically update within the
340B Program’s Database. Health centers should
contact the HRSA Office of Pharmacy Affairs to determine
whether any updates to the 340B Database are necessary by
contacting Apexus Answers at 888-340-2787, or
[email protected].
Will
your health center complete all necessary 340B Program
updates with the HRSA Office of Pharmacy Affairs?
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Yes
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Not
Applicable, health center does not participate in the
340B program
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Briefly
explain your response:
Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
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C.
Facility Requirements: Has
your health center assured that any/all Federal, State
and local standards/accreditation requirements of the
facility where the new site will be established have been
fully met (including those associated with CMS FQHC
certification)?
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Yes
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Not
Applicable
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Briefly
explain your response:
Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
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D.
Reimbursement as a Federally Qualified Health Center
(FQHC) under Medicare, Medicaid and CHIP:
Health
centers are required to submit a separate Medicare
enrollment application for each “permanent unit”
at which they provide services. This includes units
considered both “permanent sites” and
“seasonal sites” under their HRSA scope of
project, but not mobile vans. Health centers are also
required to bill each service to Medicare using the
unique Medicare Billing Number assigned to the site at
which it was provided. Specifically, health centers must
inform Medicare of the new site that has been added to
scope by submitting a new Medicare Enrollment
Application, Form 855A, to their Medicare Administrative
Contractor. Form 855A is available at
https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads//cms855a.pdf.
For
further information on the Medicare enrollment
application process, review Program Assistance Letter
2011-04: Process for Becoming Eligible for Medicare
Reimbursement under the FQHC Benefit available
at:http://www.bphc.hrsa.gov/policiesregulations/policies/pal201104.html.
In
addition, many state Medicaid programs also require all
permanent and seasonal sites to enroll individually and
bill using a site-specific billing number. For further
information about the requirements in a state, health
centers should contact their Primary Care Association or
State Medicaid Agency.
Will
your health center submit a separate Medicare enrollment
application for the new site to the appropriate Medicare
Administrative Contractor as soon as possible after
HRSA’s approval of the Change in Scope, and bill
for services provided at this new site using that site’s
unique Medicare Billing Number?
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Yes
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Not
Applicable
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Briefly
explain your response:
Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
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"Save" button to save all information within
this page.
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Will
your health center determine if a separate Medicaid
enrollment application is required for your new site, and
if so, submit it as soon as possible?
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Yes
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Not
Applicable
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Briefly
explain your response:
Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
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E.
National Health Service Corps Program Participation:
Health centers that participate in the National Health
Service Corps (NHSC) are reminded that all NHSC providers
must continue to work ONLY at an approved site within the
health center's scope of project. Note that there may be
some sites within a health center’s scope of
project that are not NHSC-eligible (see the Eligibility
Requirements and Qualification Factors section
of the NHSC Site Reference Guide at
http://nhsc.hrsa.gov/downloads/sitereference.pdf
for information on eligible and non-eligible NHSC sites).
NHSC
sites and participants may contact the NHSC through the
Customer Service Portal
(https://programportal.hrsa.gov/extranet/landing.seam)
or through the Customer Care Center by calling
1-800-221-9393.
In
adding this site to your scope, has your health center
assessed the impact on any NHSC participants that will be
asked to work at this site and advised them that they
will need to seek a site reassignment with the NHSC prior
to beginning work at this new site?
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Yes
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Not
Applicable, health center does not plan to place any
NHSC participants at this site.
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Briefly
explain your response:
Maximum
paragraph(s) allowed approximately: 3 (3000 character(s)
remaining)
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