The following information is required for Provider Type 12 (Nursing Facility): Bed Type, Beds Per Room, Prefix, First Room Number, Last Room Number, Bed Suffix, Total Number of Rooms, Total Certified Beds, and Certified for Either Medicare or Medicaid. The Effective Date defaults from Requested Effective Date and End Date defaults as Open Ended (12/31/2299)
For Provider Type 12 (Nursing Facility) with specialty of ”Brain Injury”: Total Certified Beds, and Certified for Either Medicare or Medicaid. The Effective Date is default from Requested Effective Date and End Date defaults as Open Ended (12/31/2299)
For Provider Type 12 (Nursing Facility), with specialty of “Hospital Swing”: Total Certified Beds and Certified for Either Medicare or Medicaid. The Effective Date is default from Requested Effective Date and End Date defaults as Open Ended (12/31/2299)
For all other Provider Types (01, 02, 11, 92 & 93), regardless of specialty, the following information is required: Bed Type, Total Certified Beds, and Certified for Either Medicare or Medicaid. The Effective Date is default from Requested Effective Date and End Date defaults as Open Ended (12/31/2299)
Bed Data
Bed Data information is required for these Provider Types:
(01) General Hospital
(02) Psychiatric Hospital
(04) PRTF-Psychiatric Residential Treatment Facilities
(11) ICF(Intermediate Care Facility)/MR/DD
(12) Nursing Facility
(92) Psychiatric Distinct Part Unit
(93) Rehabilitation Distinct Part Unit
Bed Type
Bed Type is required for all the above listed provider types
Select Bed Type from the Dropdown box
Additional Bed Type details are required for Provider Type 12
If “Other” is chosen, provide a description in the comment box as this is required
Beds Per Room
Enter the number of beds per room
Certified Beds
Enter the number of Certified beds from your approved Certification and Transmittal with Bed Listing from OIG (Office of Inspector General)
Bed Effective Date
Bed Effective Date will default to enrollment requested effective date
Bed End Date
Bed end date should be open ended and is not a required field
First Room Number
Enter the first room number
Last Room Number
Enter the last room number
Total Rooms
Enter the total number of rooms
Rooms Suffix
Enter all Room Suffixes
Number Medicare Rooms
Enter the total number of Medicare Rooms
Number Medicaid Rooms
Enter the total number of Medicaid Rooms
Both
Enter the total number of beds that can be used for both Medicare AND Medicaid
Substance Use Disorder (SUD) PT 03 Behavioral Health Service Organization (BHSO) Tier Selections and PT 66 Behavioral Health Multi-Specialty Group:
There are three tiers available for selection: Tier 1 Mental Health, Tier 2 Outpatient SUD, and Tier 3 Residential SUD. PT 66: No tier selections. Bed data only required for Tier 3 PT 03 Residential SUD.
At least one bed data record is required.
Bed data must be entered for each Residential Facility. Residential Facility will be selected from drop down menu based on addresses entered on screen 1.7 Address Information
Enter Bed Type (select Residential). No overlapping bed records for the same Bed Type.
Enter Bed Effective/End Dates
Enter Total Beds. Total beds cannot exceed 999.
Special Characters:
The following Special Characters cannot be used in the situations below. Field properties will not allow the following characters in the box:
For First Name, Business Name, Other name (if any): | + \ '
For Last Name field: | + \ ', and numbers are not allowed
For Comment Boxes: < > ^ ~ ` + | \ / ¬ £
For Address fields: | + ! @ # $ ^ * ( ) ? / \ " < > & : ; _
If you copy and paste an excluded special character, an error message will display after clicking Save & Next
Remove excluded characters from pasted information or uploaded text in the document
Save & Next:
When finished, click Save & Next to save the information and proceed to the next page
Click Back to go to the previous screen without saving
Click Exit to return to the dashboard without saving
Note that if the information is not saved, you will lose the data on the current page