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. Submit all of the above to: DHHS/DHSR/Nursing Home Licensure & Certification Section, Susan Kane, Nurse Consultant, 2711 Mail Service Center, Raleigh, NC 27699.
  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 Susan Kane at 919-855-4558 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 issues 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) Submit to Nursing Home Licensure & Certification Section.
    2. Health Insurance Benefits Agreement, CMS-1561 (PDF, 415 KB) Submit to Nursing Home Licensure & Certification Section.
  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. Submit an attestation of compliance with all applicable civil rights laws enforced by Office of Civil Rights (OCR) electronically via OCR's online Assurance of Compliance portal. Enclose a copy of evidence of successful electronic submission (e-mail) to the Nursing Home Section.

Contact Susan.Kane@dhhs.nc.gov or Becky.Wertz@dhhs.nc.gov for further assistance.