Licensure and Medicare / Medicaid Certification for
Initial Licensure Review Process
Upon receipt in the Division of Quality Assurance (DQA), the application
materials will be reviewed for completeness.
If any documents are missing
or if there is information that needs further clarification, the bureau
will contact the applicant either by telephone or in writing. The
application process may be suspended until the packet is considered to be
As a part of the initial licensure review process, a Registered Nurse
(RN) from the bureau will assist in analyzing the application materials
submitted to this office.
The RN's approval of the HFS 124 written
application materials, along with the results of the engineer/registered
architect's approval of the building construction plans and on-site
inspection will determine whether the facility can be issued a Certificate
of Approval (COA) to conduct business.
The engineer/registered architect
will be the bureau's agent to authorize the provider when the facility can
be opened and can begin admitting patients.
The engineer will notify the Bureau of Health Services when the COA should be issued. It will be mailed to
the facility under separate cover.
Please note that the hospital will not
be required to have received the actual certificate prior to admitting
patients. The COA should be framed and posted in a conspicuous place at
the facility such as a lobby, admitting or business office.
For assistance in completing forms for hospital licensure and
certification, please call Angela K. Mack at
(608) 266-7485. Questions regarding the Conditions of Participation survey
process should be directed to the Bureau of Health Services at (608)
Medicare Certification Application Process
1. The State of Wisconsin, Department of Health Services
(DHS) has an agreement to assist the U.S. Department of Health & Human
Services (DHHS) in determining whether health care facilities meet, and
continue to meet, the Conditions of Participation.
2. Refer to the Conditions for Participation for all Title XVIII
Medicare program requirements.
3. In order to qualify for Medicare reimbursement, your hospital must
be in compliance with the Medicare Conditions of Participation,
reimbursement requirements, including financial solvency and the
requirements of Title VI of the Civil Rights Act of 1964.
4. CMS-855(A) or CMS-855(B) Form:
- Beginning November 1, 2001, only the fiscal intermediary (FI) or
carrier will distribute enrollment applications for providers/suppliers
that they enroll.
- The provider/supplier should complete the application
and submit it directly to the intermediary or carrier.
- Within 10 calendar
days of receipt of the CMS-855A or CMS-855B, the FI/carrier will send a
copy of the application to the state agency or the regional office, as
- The Centers for Medicare and Medicaid Services (CMS) website located
is designed to provide Medicare enrollment information for providers,
physicians, non-physician practitioners, and other suppliers.
- You will also find list of FIs and carriers by state and specialty.
If the provider/supplier needs to select an FI or carrier, it may
access this website.
- 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.
- New free-standing providers are no longer permitted to express a
preference for a particular fiscal intermediary (FI). New providers
must be assigned to the designated local FI. The FI/carrier will answer any applicant inquiries concerning
completion of the enrollment application.
- The provider/supplier must still contact the state agency for the
other required Medicare and/or Medicaid certification forms for their
- If the FI recommends approval of
the enrollment application, it will provide the state agency and relevant
Regional Office with a written recommendation for approval.
- Please be reminded that the issuance of a license to a new operator
cannot guarantee the new applicant automatic federal Medicare
certification until the CMS-855 approval process has been completed and
confirmed by the fiscal intermediary.
June 25, 2014