CMS Requirements for Clinic Signage

Does the sign on your front door match what you are telling everyone else?

Complete and accurate signage of a Rural Health Clinic (RHC) is important to the community and patients in that it provides the name of the clinic and hours of operation. Did you know that it also required by the Centers of Medicare & Medicaid Services?

RHCs are required to post their hours of operations at or near the entrance in a manner that clearly states the days of the week and the hours that RHC services are furnished.  The clinic can include days of the week and the hours that the building is open solely for administrative or other purposes, if applicable.

In addition, as part of the process to participate in Medicare, the RHC will fill out an enrollment application (CMS 855).  This application is then reviewed by a Medicare contractor who will verify that the RHC and administrative locations listed on the application exist. The contractor shall also verify that the reported telephone number is operational and connects to the clinic practice location/business listed on the application.

Once the application is reviewed and found complete, the clinic receives a CMS 855 approval letter that notifies them that they need to be surveyed by a CMS approved accreditation organization like The Compliance Team or the State survey agency to determine if the clinic is complying with the Medicare requirements.  Part of the survey includes reviewing the basic characteristics of the RHC, hours of operation and number of exam rooms.  It also includes the following:

• Reviewing the CMS 855 approval letter to ensure the clinic’s documents match either the legal business name or dba listed on the CMS 855 approval letter.
• Reviewing the CLIA to ensure the address matches the CMS 855 approval letter.
• Review the CMS 29 and ensure legal business name and dba if applicable are listed.  Ensure the CMS 29 address matches the CMS 855 approval letter.  Does the documented Medical Director match the existing Medical Director?

Thus, if you are planning on a change of location or changing your name, always make sure the sign on the front door of the clinic matches the name on all of your newly submitted paperwork.   In absence of such notification, CMS has no way to carry out its statutorily mandated obligation of determining whether an RHC is meeting all of the participation requirements.

Lastly, the information as given to your accreditation organization is reported to CMS, so if the two do not match, it leaves another fragmented piece in the true game of “who is that clinic?”