CONVERSION (MEDICARE) APPLICATION
(MEDICAID TO MEDICARE)
From the Program Director-Provider Services
As set forth in the Centers for Medicare and Medicaid Services (“CMS”)
State Operations Manual (“SOM”), Section 2777, when a Medicaid (Title
19 NF) facility wishes to participate as a Medicare (Title 18 SNF or Title
18 SNF/19 NF) provider, that facility must request and submit a "Conversion"
application to the Indiana State Department of Health (“Department”).
A new survey is not required for participation in the Medicare program.
Information obtained during the most recent Medicaid survey and other
documentation required for an initial certification of a Skilled Nursing
Facility (SNF) will be submitted to CMS for their determination of approval
or denial. This documentation includes the annual recertification survey,
post-survey revisit reports (if applicable), paper compliance reports
(if applicable), life safety code inspection (and any post-survey reports
and/or waiver thereof), Civil Rights Data Needs, etc.
Prior to forwarding the complete packet to CMS for their determination
of your request for participation in the Medicare Program, the latest
annual recertification survey, post-survey reports and life safety code
inspection report have to be completely processed through the Department
as well as the Indiana Family and Social Services Administration Office
of Medicaid Policy and Planning. The annual recertification survey and
life safety code survey must also be reviewed and approved by the Surveyor
Supervisor, Quality Review, and Enforcement Teams of the Department. In
addition, the Medicare Health Care Provider/Supplier Enrollment Application
(CMS-855A) must be reviewed and approved by the Fiscal Intermediary before
the conversion application can be forwarded to CMS.
Upon completion of the internal and external processing of your recent
recertification survey, your application for participation in the Medicare
Program will be forwarded to CMS. To completely process your application
will take approximately three (3) to six (6) months from the date of your
annual recertification survey. You will receive a letter from the Department
notifying you that the application has been forwarded to CMS.
You will receive notification directly from CMS (normally within 3-4
weeks from the date your application was sent to CMS) regarding the final
determination of your participation in the Medicare Program.
As directed by CMS, if your facility is due for its annual recertification
survey within the next 3-4 months, your application must be held until
after completion of your forthcoming survey, including all internal and
external processing as mentioned above. Because of the timeframes and
processing procedures involved for conversion applications, it is recommended
that facilities submit their conversion applications approximately four
(4) months after its most recent survey.
The recommend effective date for your facility’s participation in the
Medicare Program is the date that your Fiscal Intermediary recommended
approval of your Medicare/Federal Health Care Provider/Supplier Enrollment
Application (CMS-855A) form, or the date requested by the facility in
writing (if after approval date of the CMS-855A form), and as approved
by the CMS.
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