Crosswalk

REQUEST FOR CERTIFICATION IN THE MEDICARE AND/OR MEDICAID PROGRAM

TO PROVIDE OUTPATIENT PHYSICAL THERAPY (OPT) AND/OR SPEECH PATHOLOGY SERVICES (OSP)- INITIAL AND EXTENSION SITE REQUESTS

(CMS-381)

CROSSWALK OF UPDATES

CMS 381 New Form Section	From which Original Form	Updates Made	Notes- Justification
Part I- A	CMS-1856	Added selection if the OPT is requesting deemed status Added name of Accrediting Organization Remaining information is the same as on the current 1856 form	Aligns with Admin Info 22-02 transition instructions. Greater clarity for the MACs processing of initial or extension site requests
Part I- B	NA	Added new for request of an extension site, however, context is based on the CMS-381 form and as a result of combining the two forms	Greater clarity for the MACs processing of request for certification activity. Outlines upfront the request being submitted.
Part II- I to V	CMS-1856	Added in DBA field Remainder of information pulled from 1856 form without change	DBA added for MAC’s clarification per MAC request Avoids inconsistencies in enrollment
Part II- VI	CMS-381	Added hours/information from CMS 381 form to be identified for both primary and extension site locations.	Needed info by SA/AOs for both primary and extension sites Ensures SA/AO knowledge if unannounced survey needs to be scheduled.
Part II-VII	CMS-1856	No change in content, pulled from CMS-1856 form and as a result of combining the two forms	Needed info by SA/AOs for both primary and extension sites
Part III- I & II	CMS-1856	Information pulled from 1856 form, but adjusted this as needed for primary sites as well as extension sites	Needed info by SA/AOs for primary and extension sites Ensures SA/AO knowledge if unannounced survey needs to be scheduled.
Part III- III	CMS-381	Added hours/information from CMS 381 form to be identified for both primary and extension site locations.	Needed info by SA/AOs for both primary and extension sites Ensures SA/AO knowledge if unannounced survey needs to be scheduled.
Part IV	NA	Added new for greater clarification for processing	Aligns with Admin Info 22-02 transition instructions. Greater clarity for the MACs processing and identification of which action to take. Ensures that if an extension site with different CCN (with identifier) is closed, the primary site and CCN is not inadvertently deleted/terminated.
Part V	NA	Added new to identify if there is a conversion occurring	Aligns with Admin Info 22-02 transition instructions. Greater clarity for the MACs processing. Added new for greater clarification for processing by the SA or AO
Part VI	CMS-381	Added additional areas as current 381 requests organizations to submit a supplementary sheet with extension sites	Cleaned up for ease of use by the provider Assists in organization at SA/AO level
Part VII	CMS-381	No change, info pulled from 381 form	Signature information does not require changes and should still be required on the forms.