Rural Health Clinics

State Operations Manual (SOM) Chapter 2

SOM Appendix G for Regulations

SOM Appendix Z for Emergency Preparedness

To voluntarily become a Medicare certified provider, you will need to complete the following steps and submit the paperwork electronically to LARA-BSCSupport@michigan.gov, unless otherwise noted in the instructions.

• Complete Provider Enrollment Application (CMS-855A) and submit to Medicare Administrative Contractor (MAC). The MAC will provide you a recommendation letter once the initial review is complete.
• An e-mail confirming a successful electronic submission of your Civil Rights Clearance for Medicare Provider Certification from the Office for Civil Rights (OCR). *This applies to only provider based clinics.
• A signed “Health Insurance Benefit Agreement” (CMS-1561A). *When completing the form, please include both the clinic name and the legal provider name.
• Currently, CMS has prioritized initial surveys as a lower tier work. Following the guidance of the CMS Mission and Priority Document, Michigan is currently not performing initial surveys. A provider can become accredited to obtain certification.
• Contact Accrediting Organization (AO) to schedule survey. *Once the deeming survey is complete, please ensure the Department of Licensing and Regulatory Affairs (LARA), Bureau of Survey and Certification (BSC) receives a copy of the survey report and final approval letter from your deeming authority.
• A completed “Verification of Clinic Data - Rural Health Clinic Program” form (CMS-29 and CMS-30E). If not provided by your accrediting organization.
• Once all of the above documents have been received your application will be deemed complete and our office will review and forward the packet to the MAC for final determination and issuance of the Medicare provider number.
• Please note, this process can take up to 30-60 days from the day of receipt by the MAC.

When a RHC is not able to meet its 50 percent staffing requirement for its nurse practitioner, physician assistant, or certified nurse-midwife, a one-year waiver for the staffing requirement can be obtained from the State Agency.

To apply for a waiver, the following protocol is required.

• The request must be made in writing.
• The facility must submit documentation demonstrating that it has been unable, despite reasonable efforts, to hire a physician assistant, nurse practitioner, or certified nurse midwife in the previous 90-day period;
• The facility is not making the request less than 6 months after the date of the expiration of any previous such waiver for the facility.
• The request and supporting documentation are to be submitted to LARA-BCSSupport@michigan.gov.
• The documentation will be reviewed by our office and then forwarded onto the CMS Chicago location for their approval.
• Once approved, the effective date of the one-year staffing waiver is the 61st day after the date the request is received by the SA.
• Once the RHC fills the vacant position, please notify our office at LARA-BSCSupport@michigan.gov.

Bureau Phone:  517-284-0193

Bureau Fax Number:  517-763-0214

Help for general questions:  LARA-BSCHelp@michigan.gov

Certification Support email (document submission):  LARA-BSCSupport@michigan.gov