State of Michigan s4

Dear :

The LTC Reimbursement and Rate Setting Section has received notice of the prospective Medicaid Program participation of the nursing home operation. The Section must receive written notification of certain information in order for the Provider Enrollment office to issue a Provider Agreement.

Primary Data Submission: The LTC-20A requested information should be submitted as soon as possible so that the Medical Services Administration can proceed with the new Medicaid provider number assignment. This office will provide the appropriate submitted data to the Provider Enrollment Unit, Payment Initiation Section, Payment Processing Division (517) 335-5492, which will be responsible for issuing the provider billing number.

Secondary Data Submission: The LTC-21 and Medicaid Long Term Care Plant Cost Certification will be needed for calculation of the new operation’s Medicaid per diem rate. The plant cost component of the per diem rate will not be established until the following data is received: a. Completion of the LTC-21 certification page and related plant cost certification detail for either, the purchase or new construction, renovation/addition. b. Submission of documents requested including an asset value appraisal in accordance with Medicare/Medicaid guidelines where a facility purchase is involved.

The Medicaid policy regarding change of ownership is contained in policy bulletins 04–07 and 05–14. These bulletins have been incorporated into the Medicaid Provider Manual http://www.mdch.state.mi.us/dch- medicaid/manuals/MedicaidProviderManual.pdf. The individual policy bulletins are also available on line at www.michigan.mdch | Medicaid Policy Bulletins. If you have any questions, please do not hesitate to contact our Lansing Office at (517) 335–5356.

Sincerely,

Mark R. West, Section Manager LTC Reimbursement and Rate Setting Section LTC Reimbursement and Audit Division Bureau of Audit, Reimbursement and Quality Assurance Financial Operations Administration

Enclosures

CAPITOL COMMONS CENTER  400 SOUTH PINE  LANSING, MICHIGAN 48913 www.michigan.gov/mdhhs  1-517-335-5356