Wisconsin Home Health Agency
Application and Certification Processes
TO APPLICANTS: INITIAL SURVEYS FOR MEDICARE PARTICIPATION:
08-03: Initial Surveys for New Medicare Providers (PDF,
NOTE: This application process is for entities
providing skilled nursing and other therapeutic services. Please review
DHS 133 via Rules_&_Regulations
for requirements before seeking this application.
NOTE: Do not complete a Home Health Agency application
if the intent is to provide only personal care services that
include assistance with activities of daily living, housekeeping activities,
and/or accompanying client to medical appointments.
Home health agencies have a three-step licensing/certification
process: State licensure, Medicare certification, and
OPTIONAL FIRST STEP
DQA has developed a webcast that we encourage you to
review prior to beginning the licensing process.
This webcast is designed for all potential
new home health care agency providers. It complements the more in
depth information available online. Presenters familiar with all
aspects necessary to establish a successful home health care business will
lead viewers through the application process, outline regulatory
requirements and provide an overview of certification.
This webcast is an excellent tool for
self-assessment. It will assist viewers in gauging their own
readiness and resources for submitting an application and ultimately
succeed in its operation. When you have completed viewing the webcast
contact the Division of Quality Assurance (DQA) for an application.
The link will take you to the DQA
webcasts. Scroll down to the Home Health Application Process
Webcast, dated December 13, 2007. Be sure to select the handouts and
print and/or retain a copy of the Home Health State Rules and Federal
Conditions of Participation.
You must complete the state licensure process at the same
time or before you complete the Medicare and Medicaid certification
processes. Similarly, you must complete the Medicare certification at the
same time or before you complete that for Medicaid.
The issuance of a license to operate a home health agency
in the state of Wisconsin is not part of the Medicare provider enrollment
process and therefore will not automatically assure either
certification in the Medicare program or Medicare payment.
IMPORTANT NOTE TO APPLICANTS: Interim
Survey Guidance (PDF 29 KB)
APPLICATION FOR LICENSE
PROBATIONARY LICENSE: As a home health applicant, you are required to complete an application,
pay fees and submit supporting documentation in the form of policies and
procedures that will demonstrate your compliance with Wisconsin
Administrative Rule DHS 133 for Home Health Agencies before a license will
The following must be completed:
must complete an application which may be obtained from the Home
Health Licensing Specialist who can be reached at (608)266-7297.
compliance with Caregiver Background Check process.
compliance with Wisconsin
Stats., Chapter 50.49(6) Licensing Requirement for fit &
required application fees
via submission of agency policies and procedures and patient care
documentation, your compliance with Wisconsin Administrative Rule
DHS 133 for Home Health Agencies
via submission of agency policies and procedures, your compliance with
Wisconsin Administrative Rule
DHS 13: Reporting & Investigation
of Caregiver Misconduct
A nonrefundable fee of $300.00 must be
included with your application as required under DHS 133.03(3). Your
check should be made payable to the: Division of Quality
Caregiver Background Check Process - A caregiver background
check (CBC) is required to be completed for all applicants/legal
representatives prior to the approval of any new license,
certification or registration of a DQA regulated entity.
information for Licensee Applicants/License Holder Background
Checks found on the
Caregiver Background Check Process web page for the completion
of the Background Information Disclosure (BID) form and Appendix.
Complete either the Online Caregiver Background Check (CBC) process
or the manual application process.
Also review information on the requirement for Employee
Background Checks found on the
Caregiver Background Check Process web page.
Wisconsin has a two-tier probationary license application review process.
The first tier review determines whether an applicant is fit and
qualified and includes an analysis of a variety of factors including
financial solvency, personnel qualifications, criminal background
clearance, payment of required fees, history of operating home health
agencies in other states, and documentation that demonstrates the
provision of the following required services to patients in their homes:
- Skilled nursing, and
- Therapeutic Services (physical therapy, speech therapy, occupational
therapy, medical social services or home health aide)
Following a determination the applicant meets the fit and qualified
criteria, the second tier review is completed by a Registered Nurse (RN)
who will review the applicants policies and procedures to determine
whether they meet administrative rule requirements of DHS 133 and DHS 13.
The RN will consult with the applicant during this review process
if needed. When tier one and
tier two reviews are complete and a determination is made that the
applicant satisfies all policy code requirements, a 90-day probationary
license will be recommended.
Regular, Non-Expiring License:
Following issuance of the probationary license, the licensee has up to 90 days in which to receive an on-site survey that is used
to evaluate the level of care provided to patients.
This on-site survey will consist of a review of patient care,
review of records and documentation, interviews with staff, and
observation of cares being given in the home setting.
No on-site survey will be conducted
unless the licensee can demonstrate they meet the following criteria:
Admitted and cared for at least ten (10) skilled nursing level patients; and
retain on active service seven (7) skilled nursing patients at the time the
written request for on-site survey is requested.
- If licensee is seeking Medicare certification, have the CMS 855
enrollment application completed
- Capitalization requirements completed
- Fiscal intermediary approval received
NOTE: If you are
seeking Medicare certification, you are advised to submit application
materials and supporting documentation at the same time you seek Wisconsin
Failure to meet these minimum on-site state licensure survey standards,
by the expiration date of the 90-day probationary license, may result in
When the applicant can demonstrate readiness for the on-site survey,
send a written request for the survey that includes the following:
Full Operation Letter - Prepare and submit a written
notification once you are in "full operation," i.e., the
agency has provided services to patients and has records to review. Do
- once the agency is operational
- has served at least ten (10) patients requiring skilled nursing
- at least seven (7) skilled nursing patients remain active
- the CMS 855 enrollment application has been completed
- capitalization requirements have been completed
- agency has been approved by the fiscal intermediary
This notification does not have to be provided with the federal application
materials, but may be submitted via a separate letter at a time
feasible to the provider.
This notification is required in order to signal that your agency
is ready for a state and federal onsite survey to determine if all conditions of
participation and compliance with DHS 133 are met.
- It is important to remember that a
survey will not be scheduled until the notification is received.
Send the written request for the on-site survey to:
Home Health Licensing
Specialist, Division of Quality Assurance, Post
Office Box 2969, Madison, WI 53701-2969.
Compliance Review Tools
You may find the following forms useful in conducting an agency
self-evaluation of compliance with Wisconsin administrative rule
requirements. These forms are used by surveyors during on-site
Prelicensure Desk Review Checklist
Licensure Survey Entrance Conference Guide
Licensure Survey Exit Conference Guide
F-62601 Rights of
Home Health Agency Patients
Patient Rights Statement Review
Calendar Worksheet - Prescribed Visits
Contract Review Worksheet
Program Evaluation Review Worksheet
Clinical Record Review
Personnel Record Review
Caregiver Program Compliance Check
Licensure Survey Home Visit Guide
Medicare Certification (Optional)
In order to become certified in the Medicare Program,
a home health agency must
first meet State of Wisconsin licensing requirements and obtain a
probationary license. The medicare home health agency requirements are:
Federal Conditions of Participation for Home Health Agencies, 42 CFR 484,
via Code of Federal
Regulations (exit DHS)
Home Health Prospective Payment System (PPS) (exit
Health Information Resource for Medicare (exit
Contact your Fiscal Intermediary to have a Medicare
General Enrollment Health Care Provider/Supplier Application (CMS-
855A) completed and submitted.
This separate enrollment
requirement must precede survey and certification.
- In Wisconsin, the fiscal intermediary is United
Government Services (exit DHS) in Milwaukee unless your
facility is affiliated with a CMS-designated chain, in which case,
it may have a designated single U.S. fiscal intermediary.
Submit the following federal forms (see "Forms"
section in Medicare
- CMS 1572
Two copies of CMS 1561
-The person signing the Health Insurance
Benefits Agreement (CMS 1561) must be someone who has the
authorization of the owners of the agency to enter into this
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
All forms to be submitted to Division of Quality
Assurance (address in "Forms" section in Medicare
Certification Materials) - Ignore any other send-to
addresses on the forms.
Certification Materials for links to the necessary items.
Medicaid Certification with the
Wisconsin Medical Assistance (Medicaid) Program (WMAP) (Optional):
If you are interested in becoming a certified provider with the WMAP,
you are encouraged to apply at the same time that you apply to Medicare.
See Wisconsin Medicaid provider certification packets on the Wisconsin
Application materials can be obtained by writing to EDS, Attention:
Provider Maintenance, 6406 Bridge Road, Madison, WI 53713, or by calling 1-800-947-9627 (in-state toll free) or (608) 221-9883.
Change of Ownership - If operation of the
home health agency is later transferred to another owner,
ownership group, or to a lessee, the Health Insurance Benefits Agreement
will be transferred.
You are required to notify the
Division of Quality Assurance at the time
you are planning a change-of-ownership transfer as your license is
Complete all applicable sections of
application, including Section B.
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August 26, 2013