These are instructions for enrollment as a certified supplier in the Medicare Ambulatory Surgery Center (ASC) program.
There are no state licensure or Certificate of Need requirements for ASCs in Wisconsin.
The following forms and documents pertinent to ASCs are accessible on the Internet:
- CMS 855 (PDF)
- CMS 377 – Request to Establish Eligibility (PDF)
- CMS 370 – Health Insurance Benefit Agreement (PDF)
- State Operations Manual, Appendix L – Guidance to Surveyors: Ambulatory Surgical Services (PDF)
- Life Safety Code Requirements (PDF)
- National Fire Protection Association (NFPA)
- 42 CFR Part 416 of the Code of Federal Regulations
- ASCs - Citations and Descriptions - State Operations Manual Chapter 2 (PDF) (2210- ASCs)
An ASC applicant interested in Medicare certification must:
Enroll in the Medicare program with the carrier
The carrier will distribute Medicare enrollment applications (CMS-855B) for new applicant suppliers that they enroll. An applicant must complete this Medicare enrollment application (PDF) and submit it directly to National Government Services.
Upon completion of their review, the carrier will forward a copy of the application with their written recommendation to the Division of Quality Assurance (DQA).
Complete CMS 377 and CMS 370
NOTE: IT IS VERY IMPORTANT TO INCLUDE YOUR FISCAL YEAR ENDING DATE ON THE APPLICATION WHERE IT IS REQUESTED.
The 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 both original forms.
Consider AAAHC, JCAHO, AAAASF, HFAP Accrediting Organizations Information
An ASC applicant may seek accreditation and deemed status under one of the national accrediting bodies who would complete the initial on-site certification survey.
DQA will hold recommendations for Medicare certification until receiving the confirmation letter from AAAHC, JCAHO, AAAASF, or HFAP 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: Tommy Rylander.
Review Life Safety Code Information
The DQA engineers may provide Advisory plan reviews of the Life Safety Code requirements for ASC providers at no charge.
In order for this office to conduct an Advisory plan review, the ASC must submit construction plans.
All required forms, instructions and names of contacts are available at the Plan Review website.
Submit a "Full Operation Letter"
If 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.
The 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. 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.
The content of a full operations letter must demonstrate:
- The facility has provided different types of anesthesia and different types of surgery to at least 5 patients.
- The facility has patient records to review.
- The facility is prepared for survey of all Conditions for Coverage.
- A specified effective date of operation.
Notification of an anticipated date of full operation is not sufficient. The full operations letter should be sent to Tommy Rylander, Division of Quality Assurance, PO Box 2969, Madison, WI 53701-2969
Complete supporting documentation if State will be conducting Medicare survey
- Copy of the ACS's contract(s) with transferring hospital (42 CFR 416.41)
- Copy of the ACS's policy/procedures (42 CFR 416.42)
- Structure of the ACS's Quality Assurance Program (42 CFR 416.43)
- Copy of the ACS's policy on infection control (42 CFR 416.44[a]3)
- Evidence of staff credentialing for the ASC (42 CFR 416.45([a])
- Policy for the ACS's radiology services (42 CFR 416.49)
- List of the ACS's surgical procedures and anticipated length of surgery (42 CFR 416.65)
- Statement of anticipated patient payment source
- Sketch of the ACS's physical plant layout. If inside a medical office building, identify ASC hours of operation.
- Status of the ACS's building project: date received by Department of Commerce: date of DQA inspection if applicable.
Submit the following items as specified
The CMS-377, CMS-370, and any supporting documentation should be submitted to:Division of Quality AssurancePO Box 2969Madison, WI 53701-2969
Initial Certification Survey
If the State Agency (DQA) conducts the initial Medicare survey it will be unannounced. It 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.
Post Survey Process
The 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.
If 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.
Applicants that are denied Medicare approval are sent notification giving the reasons for denial, and information about their rights to appeal the decision.
Certification with the Wisconsin Medical Assistance (Medicaid) Program (WMAP)
- Submit a separate application for Medicaid certification in addition to any application materials required for Medicare certification.
- If interested in becoming certified with the WMAP, you are encouraged to apply at the same time that you apply to Medicare.
If application is made to the WMAP and Medicare concurrently, and the completed application for the WMAP is returned within 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 program.
Delays in applying to the WMAP may result in assignment of a later certification effective date.
- Application 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 608-221-4746.
For assistance in completing forms for certification, please call 608-266-7297. Questions regarding the conditions for coverage survey process should be directed to the Bureau of Health Services at 608-266-8481.