DHSR requires the following to proceed with licensure:
Unless there are special circumstances, the DHSR office must receive the application for licensure prior to the anticipated licensure date. You must notify our office immediately if any of the information contained in the application changes prior to opening, e.g., the administrator, facility name, ownership, etc. To assist us in the timely processing of your request for licensure and certification, please inform this office in writing of the date you begin full operation or if the completion of your project is ahead of schedule.
Pursuant to G.S. 131E-272, the Division of Health Service Regulation (DHSR) charges an initial nonrefundable license fee to the applicant in the amount of $470.00 plus a nonrefundable per-bed fee of $19.00 per facility. The license fee must accompany the license application prior to the issuance of the nursing home license. Payment should be in the form of check, money order or certified check and must be payable to "The Division of Health Service Regulation." A separate check is required for each licensed entity. The legislation (SB 622, Session Law 2005-276) prohibits DHSR from issuing a license if the provider has not paid the fee.
We will be conducting an off-site review of policies and procedures and other documentation prior to licensure approval. Please contact Becky Wertz at 919-855-4580 at least 30 days prior to anticipated licensure to discuss the off-site initial licensure review. The actual date of licensure will be contingent upon state construction inspection and approval. Facilities cannot admit residents to a facility until the initial off-site review is completed and DHSR approves the license.
DHSR requires the following forms to proceed with Medicare certification
As part of the certification application process, applicants requesting enrollment in the Medicare program must complete a Medicare Provider Enrollment Application, CMS-855A (PDF, 1.04 MB). This process is used to insure that providers/suppliers meet the requirement of Sections 1814(a)(1) and 1833(e) of Title XVIII of the Social Security Act, which authorizes collection of information to determine Medicare program payments. The Medicare contractor that serves your state or practice location is responsible for processing your enrollment application. Applicants must submit their application to the appropriate Medicare fee-for-service contractor. Both the enrollment process and the survey/certification process are required for Medicare certification and payment.
In addition, new providers must be assigned to the designated local medicare administrative contractor (MAC) and are no longer permitted to express a preference for a particular MAC. In addition, providers may no longer request a change of MAC and must continue with the MAC to which they have been assigned. New providers that belong to CMS-recognized chains have the option of being assigned to the local designed MAC or to the MAC that serves the chain home office.
The MAC will approve or deny the provider/supplier for Medicare enrollment. The MAC will notify DHSR in writing of its recommendation.
Check all forms for accuracy and completeness and make a copy of the licensure application for your files before submitting all with the license fee to:
Ms. Becky Wertz
Department of Health and Human Services
Division of Health Service Regulation
2711 Mail Service Center
Raleigh, NC 27699-2711
Contact Becky Wertz at Becky.Wertz@dhhs.nc.gov or 919-855-4580 for further assistance.
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