Instructions: Medicare Certification for
Ambulatory Surgery Centers (ASCs)
These are instructions for enrollment as a
certified supplier in the Medicare ASC program.
There are no state Licensure or Certificate of
Need requirements for ASCs in Wisconsin.
TO APPLICANTS: Initial Surveys for Medicare Participation:
S&C Memo 08-03: Initial
Surveys for New Medicare Providers (exit DHS)
following forms and documents pertinent to ASCs are accessible on the
855 (exit DHS)
377 - Request to Establish Eligibility (exit DHS)
370 - Health Insurance Benefit Agreement (exit DHS) (2 originals)
Operations Manual, Appendix L - Guidance to Surveyors: Ambulatory
Surgical Services (exit DHS)
Safety Code Requirements (exit DHS)
Fire Protection Association (NFPA)
416 of the Code of Federal Regulations 42 CFR Part 416 (exit DHS)
and Descriptions - State Operations Manual Chapter 2.
- on the left side select Bookmarks, then scroll
down to 2210- ASCs (exit DHS)
Office for Civil Rights forms;
Hard copies or complete/submit
On line (exit DHS):
- Data Request Checklist-Civil Rights Information Request
- HHS 690- Assurance of Compliance form (two signed copies if completing
An ASC applicant must
interested in Medicare certification must:
Enroll in the Medicare program with the
Enroll in the Medicare program with the
carrier will distribute Medicare enrollment applications (CMS-855B) for new applicant suppliers that they enroll. An
applicant must complete this
enrollment application (exit
DHS; PDF, 615 KB) and
submit it directly to the Carrier, Wisconsin Physicians Service (WPS) at:
WPS - Medicare
PO Box 8248
completion of their review, the carrier will forward a copy of the application
with their written recommendation to the Division or Quality Assurance (DQA).
CMS 377 and 370
IT IS VERY IMPORTANT TO INCLUDE YOUR FISCAL YEAR ENDING DATE ON THE
APPLICATION WHERE IT IS REQUESTED.
person signing form CMS 370, the Health Insurance Benefit Agreement, must
be someone who has the Life Safety Code Survey authorization of the owner
of the center to enter into this agreement. Sign and return two original
AAAHC, JCAHO, AAAASF, HFAP
Accrediting Organizations Information
ASC applicant may seek accreditation and deemed status under one of the
national accrediting bodies who would complete the initial on-site
DQA will hold our recommendation for Medicare certification until we have
received a copy of the confirmation letter from AAAHC, JCAHO, AAAASF, or
along with a copy of their survey report indicating your agency has been
surveyed and meets the applicable Medicare conditions.
Note: the ASC applicant is responsible for sending this information
to DQA, attention: Angela K. Mack.
ASC seeking accreditation and deemed status must also complete the
Review Life Safety Code
DQA engineers may provide ďAdvisoryĒ plan reviews of the Life Safety
Code requirements for ASC
providers at no charge.
order for this office to conduct an Advisory plan review, the ASC must
submit construction plans.
required forms, instructions and names of contacts are available at the Plan
Submit a ďFull Operation
the ASC applicant is not seeking accreditation with deemed status under
one of the national accrediting bodies (see #4 above) they will be
surveyed by the DQA after the application is considered complete.
application is considered complete once the FI has approved the CMS-855
and the CMS forms and the supporting documents are satisfactorily
submitted to DQA. The DQA will
notify the applicant that the application is complete and will ask for a
full operations letter. This written notice of full operations is required
before DQA surveyors can initiate a required on-site survey to determine
if all conditions for coverage are met.
content of a full operations letter must demonstrate:
facility has provided different types of anesthesia and different
types of surgery to at least 5 patients and
facility has patient records to review and
facility is prepared for survey of all Conditions for Coverage and
specified effective date of operation
of an anticipated date of full operation is not sufficient. The full
operations letter should be sent to Angela K. Mack, Division of Quality Assurance, P.O. Box 2969, Madison,
Complete Supporting Documentation if State will be conducting Medicare
of the ASCís contract(s) with transferring hospital [42 CFR 416.41]
of the ASCís policy/procedures [42 CFR 416.42]
of the ASCís Quality Assurance Program [42 CFR 416.43]
of the ASCís policy on infection control [42 CFR 416.44(a)3]
of staff credentialing for the ASC [42 CFR 416.45(a)]
for the ASCís radiology services [42 CFR 416.49]
of the ASCís surgical procedures and anticipated length of surgery [42
of anticipated patient payment source
of the ASCís physical plant
layout. If inside a medical
office building, identify ASC hours of operation.
of the ASCís building project: date received by Department of Commerce:
date of DQA inspection if applicable.
following items as specified
original CMS 377, the two CMS 370 original forms, civil rights forms and
policies, the provider-based
questionnaire and supporting documentation to:
Angela K. Mack
Division of Quality Assurance
P.O. Box 2969
Initial Certification Survey
the State Agency (DQA) conducts the initial Medicare survey it will be
should be noted that survey scheduling by DQA will be in accordance with
available staffing resources and will be dependent upon prior scheduling
commitments. Completion of this initial survey and the certification
process could take several months.
DQA will make a certification recommendation to the Center for Medicare
and Medicaid Services (CMS) based on the outcome of the survey.
CMS will notify the ASC applicant of their effective date of
participation in the Medicare program.
CMS certifies your facility for Medicare participation, one copy of the
Health Insurance Benefits Agreement will be countersigned and sent to you
along with the formal notification of approval.
that are denied Medicare approval are sent notification giving the reasons
for denial, and information about their rights to appeal the decision.
Wisconsin Medical Assistance (Medicaid) Program (WMAP)
a separate application for Medicaid certification in addition to any
application materials required for Medicare certification.
interested in becoming certified with
the WMAP, you are encouraged to apply at the same time that you apply
application is made to the WMAP and Medicare concurrently, and the
completed application for the WMAP is returned within thirty (30) days of
the date it is mailed to the applicant, the certification effective date
with the WMAP will be the same as the effective date with the Medicare
in applying to the WMAP may result in assignment of a later certification
materials can be obtained by writing to EDS: Attention: Provider
Maintenance, ForwardHealth, 313 Blettner Blvd., Madison WI 53784,
1-800-947-9627 (in state toll-free) or (608)
assistance in completing forms for certification, please call Angela K.
Mack at (608) 266-7485. Questions
regarding the conditions for coverage survey process should be directed to
the Bureau of Health Services at (608) 266-8481.
July 14, 2014