Long Term Care Program
Medicare Certification Process

  1. Contact the West Virginia Health Care Authority. As set forth at W. Va. C.S.R. ' 65-7-25, a long term care facility which desires to seek Medicare certification for any or all of its beds must request a ruling on the reviewability of the action from the West Virginia Health Care Authority.

    Ruling on Reviewability

  2. Contact the Fiscal Intermediary of Preference. The fiscal intermediary will provide the facility with a CMS-855A Enrollment Application. A copy of the CMS-855A Enrollment Form can also be obtained by going to http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp and selecting the appropriate form.

    For a list of fiscal intermediaries serving the State of West Virginia, go to http://cms.hhs.gov/providers/enrollment/contacts/ and click on A WV@.

    The fiscal intermediary will also be able to answer any questions regarding the application and enrollment process. The CMS-855A should be completed and submitted to the fiscal intermediary. Do not submit the completed CMS-855A to the state survey agency.

    For additional information regarding the Medicare enrollment process for skilled nursing facilities, go to www.cms.hhs.gov/providers/enrollment/providers/enroll.asp and click on A Skilled Nursing Facility@.

  3. Contact the Office of Health Facility Licensure and Certification (OHFLAC). Notify OHFLAC of the facility's intention to apply for Medicare certification. If the facility is seeking Medicare certification of a part of the facility, rather than the entire facility, the facility must also submit a floor plan identifying which beds will be Medicare certified. All beds in the Medicare certified part of the facility must be contiguous; the beds cannot be scattered throughout the facility. OHFLAC will also provide the facility with four (4) forms that need to be completed, in addition to the CMS-855A Enrollment Application. Each of the following forms needs to be completed in duplicate, each with an original signature, and returned to OHFLAC:

    1. Statement of Financial Solvency (Form CMS-2572)
    2. Health Insurance Benefit Agreement (Form CMS-1561)
    3. Assurance of Compliance (Form HHS-690)
    4. Expression of Intermediary Preference

  4. After the fiscal intermediary has recommended the facility for approval, OHFLAC may conduct an initial Medicare certification survey. OHFLAC may then recommend the facility for Medicare certification to the local Centers for Medicare & Medicaid Services (CMS) Regional Office.

  5. The CMS Regional Office will contact the facility concerning issuance of a formal signed provider agreement. Upon completion of the agreement, the facility will be given a provider number and be permitted to submit billings.

  6. If the facility has already submitted an application and is having a problem with the fiscal intermediary, the facility should contact the CMS Regional Office where the fiscal intermediary is located. The Regional Office is responsible for monitoring the fiscal intermediary performance and is available to provide assistance.

    To contact the CMS Regional Office responsible for a fiscal intermediary located in another state, go to http://cms.hhs.gov/providers/enrollment/contacts/ and click on the appropriate state.