Tuesday, 15 November 2016

Enrolling Indian Health Service (IHS) Facilities as DMEPOS Suppliers

Enrolling Indian Health Service (IHS) Facilities as DMEPOS Suppliers 

A. Background  

The National Supplier Clearinghouse (NSC) shall enroll IHS facilities as DMEPOS suppliers in accordance with (a) the general enrollment procedures cited in chapter 15, (b) the statement of work contained in the NSC contract with Medicare, and (c) the special procedures cited in this section.  

For enrollment purposes, Medicare recognizes two types of IHS facilities: 

(1) facilities wholly owned and operated by the IHS, and (2) facilities owned by the IHS but tribally operated or totally owned and operated by a tribe.  

CMS will provide the NSC with a list of IHS facilities that distinguishes between these two types.  On the list, the NSC shall use the column entitled, “FAC OPERATED BY”, for this purpose.   
B. Enrollment  

The provider/supplier shall complete the Form CMS-855S shall be completed in accordance with the instructions shown therein.  

NOTE:  Facilities that are:  

• Totally owned and operated by the IHS are considered governmental organizations.  An Area Director of the IHS must sign section 15 of the Form CMS–855S, be listed in section 6 of the form, and sign the letter required under section 5 of the form that attests that the IHS will be legally and financially responsible in the event there is any outstanding debt owed to CMS.  

• Tribally operated are considered tribal organizations. Section 15 of the Form CMS–855S must be signed by a tribal official who meets the definition of an “authorized official” under 42 CFR § 424.502.  The individual must also be listed in section 6 of the form, and must sign the letter required under section 5 of the form that attests that the tribe will be legally and financially responsible in the event there is any outstanding debt owed to CMS. 

C. Supplier Standards, Exceptions and Site Visits

All IHS facilities, whether operated by the IHS or a tribe:  

• Shall meet all required standards, with the exception of:  

• The comprehensive liability insurance requirements under 42 CFR 424.57(c)(10).  
• The requirement to provide State licenses for their facility / business. For example, if the DMEPOS supplier indicates on its application that it will be providing hospital beds and is located in a State that requires a bedding license, such licensure is not required. 

However, if it provides a DMEPOS item that requires a licensed professional in order to properly provide the item, it shall provide a copy of the professional license. 

The licensed professional can be licensed in any State or have a Federal license (e.g., a pharmacy does not need a pharmacy license, but shall have a licensed pharmacist).

• Shall, like all other DMEPOS suppliers, undergo site visits in accordance with section through of this chapter. (This includes all hospitals and pharmacies enrolling as DMEPOS suppliers.) 

D. Provider Education for IHS Facilities 

The NSC shall ensure that its Web site includes the information contained in this section 15.21.2 that is specific to enrollment of IHS facilities (whether operated by the IHS or a tribe).  

E. Specialty Codes  

The NSC shall apply the specialty code A9 (IHS) to all IHS enrollments (whether operated by the IHS or a tribe). However, the specialty code A9/A0 shall be applied to facilities that are IHS/tribal hospitals.  Other specialty codes should be applied as applicable (e.g., pharmacies).  

Development and Use of Fraud Level Indicators 

The National Supplier Clearinghouse (NSC) shall perform a fraud potential analysis of all DMEPOS applicants and current DMEPOS suppliers.  The fraud level indicator shall represent the potential for fraud and/or abuse.  The NSC shall use four fraud level indicator codes as follows:  

1. Low Risk (e.g., national drug store chains)  
2. Limited Risk (e.g., prosthetist in a low fraud area) 
3. Medium Risk (e.g., midsize general medical supplier in a high fraud area) 
4. High Risk (e.g., very small space diabetic supplier with low inventory in a high fraud area whose owner has previously had a chapter 7 bankruptcy). High fraud areas shall be determined by contractor analysis with concurrence of the NSC project officer. 

(NOTE:  These risk categories are in addition to, and not in lieu of, those specified in section 15.19.2 of this chapter.)  In assessing a fraud level indicator, the NSC shall consider such factors as:  

1. Experience as a DMEPOS supplier with other payers 
2. Prior Medicare experience 
3. The geographic area 
4. Fraud potential of products and services listed 
5. Site visit results 
6. Inventory observed and contracted 
7. Accreditation of the supplier 

After a fraud level indicator is assigned and the DMEPOS supplier is enrolled, the NSC shall establish a DMEPOS Review Plan based on the fraud level assessment.  

The DMEPOS Review Plan shall contain information regarding:  

1. Frequency of unscheduled site visits 
2. Maximum billing amounts before recommendation for prepay medical review 
3. Maximum billing spike amounts before recommendation for payment suspensions/prepay medical review, etc.  

The fraud level indicator shall be updated based upon information obtained through the Medicare enrollment process, such as reported changes of information.  Information obtained by the Office of Inspector General (OIG), CMS (including CMS satellite office) and/or a Zone Program Integrity Contractor (ZPIC) shall be reported to the NSC project officer.  

The NSC shall update the fraud level indicator based on information obtained by the OIG, CMS (including CMS satellite office) and/or a ZPIC only after the review and concurrence of the NSC project officer.  

In addition, the NSC shall monitor and assess geographic trends which indicate or demonstrate that one geographic area has a higher potential for having fraudulent suppliers.   Fraud Prevention and 


The NSC shall have documented evidence that it has, as a minimum, met the following requirements:  

• Assign an appropriate fraud level indicator for at least 95 percent of all DMEPOS suppliers, upon initial enrollment or revalidation. The fraud level indicator shall accurately reflect the risk the supplier poses to the Medicare program based on pre-defined criteria above.  

• Update the DMEPOS fraud level indicator for each enrolled DMEPOS supplier on an annual basis.  

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