Information regarding Licensure and Certification of a New Skilled Nursing Facility (SNF)

License Application Procedure

In order to apply for a license with the Division of Health Service Regulation to operate a nursing home as required under General Statute § 131E-102, you must do the following:

  1. Complete these forms and submit prior to licensure date.
    1. Initial License Application (PDF, 60 KB)
    2. Alzheimer's Special Care Unit Required Disclosures Data Supplement (PDF, 20 KB), if applicable
    3. Breakdown of Room Numbers and Beds Within Those Rooms, DHSR-4504 (PDF, 21 KB)
  2. Include the nonrefundable initial license fees of $470.00 per facility plus $19.00 per bed (G.S. 131E-272). 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.
  3. Notify this office immediately if any of the information contained in the application changes prior to opening, e.g., the administrator, facility name, ownership. Inform this office in writing of the date you begin full operation or if the completion of your project is ahead of schedule.
  4. Contact Becky Wertz at 919-855-4580 at least 90 days prior to the anticipated licensure date to discuss the off-site initial licensure review. The Section will review policies and procedures and other documentation prior to licensure approval. 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.

Medicare Certification Procedure

  1. In order to apply for Medicare certification, you must complete the following forms:
    1. Long Term Care Facility Application for Medicare and Medicaid, CMS-671 (PDF, 367 KB)
    2. Health Insurance Benefits Agreement, CMS-1561 (PDF, 415 KB)
    3. Assurance of Compliance with Title VI, HHS-690 (PDF, 7 KB)
  2. Submit the Medicare Provider Enrollment Application, CMS-855A (PDF, 1.04 MB) to the appropriate Medicare Administrative Contractor (PDF, 205 KB). This process is used to insure that providers 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 North Carolina is responsible for processing your enrollment application. Both the enrollment process and the survey/certification process are required for Medicare certification and payment. 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 designated MAC or to the MAC that serves the chain home office. The MAC will approve or deny the provider for Medicare enrollment. The MAC will notify DHSR in writing of its recommendation.
  3. Decide how to submit the Office of Civil Rights (OCR) information by selecting one of two options.
    1. Complete the following forms.
    2. Submit the civil rights clearance package online at https://ocrportal.hhs.gov/ocr/pgportal. The submission will go directly into the OCR intake queue, and you will receive an e-mail from OCR stating that you completed the civil rights submission. You need to print a copy of this e-mail and submit it to the Nursing Home Licensure & Certification Section.

Where to Submit Forms

Check all forms for accuracy and completeness and make a copy of the licensure application for your files. Submit all of the forms except the CMS-855A form with the license fee to:

Becky Wertz, Nurse Consultant
Department of Health and Human Services
Division of Health Service Regulation, Nursing Home Licensure and Certification Section
2711 Mail Service Center
Raleigh, NC 27699-2711

Send the CMS-855A to the appropriate Medicare Administrative Contractor (PDF, 205 KB).

Contact Becky Wertz at Becky.Wertz@dhhs.nc.gov or 919-855-4580 for further assistance.