Licensure and Medicare / Medicaid Certification for
Completion of Forms
a. Complete CMS 1561 (two copies), Form CMS 690 and the necessary
Office of Civil Rights documents.
b. The person signing the Health Insurance Benefits Agreement (the CMS
1561 form) must be someone who has the authorization of the owners of the
agency to enter into this agreement.
c. Also, include two copies of your Utilization Review Plan.
d. All completed forms must be sent to:
Division of Quality Assurance
Bureau of Health Services
P. O. Box 2969, Room 455
Madison, WI 53701-2969
Full Operation Letter
The following process applies for those hospitals that are not
initially applying for accreditation through a national accrediting
organization (i.e. JCAHO or AOA):
Once the hospital is operational and the fiscal intermediary has
approved the CMS-855, a surveyor must conduct an onsite survey to
determine if all conditions of participation are met.
To expedite this
process, you are required to provide the state agency with a written
notice that your program is in "full operation," i.e. the
hospital is providing services to patients, has records to review and is
prepared for survey for all conditions of participation.
anticipated date of full operation is not sufficient. The letter should be
sent to the attention of Tracy Ellingson, at the above address. It is
important to remember that a survey will not be scheduled until the
notification is received.
Medicare Certification Survey Process
PLEASE NOTE: It is very important that this office be informed if the
facility will be applying to become a member of a national accrediting
program (i.e. JCAHO or AOA). This information should be stated in the
cover letter attached to the initial application packet.
In this case, the
accrediting organization should be conducting the initial certification
Upon completion of the survey, this office will require a copy of
the accrediting organization's confirmation letter along with a copy of
their most current survey report indicating this facility has been
surveyed and meets the standards required for Medicare certification.
recommendation to CMS (Centers for Medicare and Medicaid Services) for
Medicare certification will be based on the accrediting organization's
If the facility will not be applying for accreditation through a national
accrediting organization, the following process will apply:
a. The surveyor will inspect the facility, interview you and members of
your staff, review documents, and perform other procedures necessary to
evaluate your agency's compliance with the Conditions of Participation.
b. Following the survey, the Department of Health Services
will recommend to the Centers for Medicare and Medicaid Services (CMS)
whether your facility should be certified in the Medicare Program.
c. If it is determined that all requirements of Medicare and Civil
Rights are met, the Health Insurance Benefits Agreement will be
countersigned by CMS. One copy of the agreement will be returned to you
along with the notification that your agency has been approved.
Hospitals that are denied certification into the Medicare Program will
be sent a notification, together with the reasons for the denial and
information about their rights to appeal the decision.
Certification with the Wis. Medical Assistance (Medicaid) Program (WMAP)
a. You will need to submit an application for Medicaid certification in
addition to any application materials required for Medicare certification.
b. If you are interested in becoming a certified provider with the
Wisconsin Medicaid Program, you are encouraged to apply at the same time
that you apply to Medicare.
- If application is made to Medicaid and
Medicare concurrently, and the completed application for the Medicaid
program is returned within thirty (30) days of the date it is mailed to
the applicant, the certification effective date with Medicaid will be the
same as the effective date with Medicare.
- Delays in applying to the
Medicaid program may result in assignment of a later certification
c. Application materials can be obtained by writing to EDS- Attention:
Provider Maintenance, 6406 Bridge Road, Madison, WI 53784-0006, or by
calling 1-800-947-9627 (in state toll-free), or (608) 221-4746.
For assistance in completing forms for hospital licensure and
certification, please call Tracy L. Ellingson at
(608) 266-7297. Questions regarding the Conditions of Participation survey
process should be directed to the Bureau of Health Services at (608)
PDF: The free Acrobat Reader®
software is needed to view and print portable document format (PDF) files. Learn
August 26, 2013