Provider Application and Related Resources
This section provides information on the application process for becoming a PACE permanent provider. Included below is the provider application and appendices, a suggested format template for reflecting Participant Rights in the application, the Application Review Guide used by CMS to evaluate provider applications, and the Program Agreement template, the three-party contract governing provider operations signed by CMS, the State Administering Agency, and the Provider Organization.
PACE Provider Application - Revised as of August 2007
The PACE Provider Application and Appendices, available in the Downloads area of the page, provides an electronic version of the application that States and PACE Provider Sites utilize to complete and submit the Provider Application. This Provider Application has been updated to reflect the provisions of the December 2006 final PACE regulation, and has been revised to remove the Medicare Contractor Form, which is no longer required. This file is in a zipped rich text format so States can download a writeable version for submission.
It also contains appendices (including the Provider Arrangements File, Insurance Coverage File, and Payment Information Form ) that must be submitted to CMS as part of the PACE Provider Application, along with a file describing the various attachments (README).
Patient Rights Template for PACE organizations - Revised as of March 2007
The Patient Rights Template available below is a model tool developed by CMS to guide potential PACE providers in developing their application for permanent provider status. Use of this model is suggested only and is not required for application for permanent provider status.
CMS Central and Regional Office Addresses for Application Submission
Also available below is a file (Provider Application Mailing Addresses.PDF) containing a list of mailing addresses for use by State Administering Agencies when submitting provider applications to CMS. Please submit applications to Central Office and the appropriate Regional Office simultaneously.
PACE Application Review Guide Tool - Modified March 2004
The PACE Application Review Guide Tool,available below, has been developed by the CMS staff members as an informal tool to assist them in reviewing applications submitted by entities seeking to be permanent PACE providers. CMS has made an abbreviated version of this tool available below to potential PACE applicants, to serve as a clarifying reference as entities prepare a PACE Application for CMS review.
PACE Program Agreement - Revised as of March 2007
The Program Agreement, available below, is executed between CMS, the State Administering Agency, and the PACE organization upon approval of a permanent PACE provider application. Included in the Program Agreement are required data elements to be reported by the PACE organization.