We offer instructions for you to enroll 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 are for ASCs:
- CMS 855B—Medicare Enrollment Application (PDF)
- CMS 377—Request for Initial Certification or Update of Certification Information in the Medicare Program (PDF)
- CMS 370—Health Insurance Benefits Agreement (PDF)
- Code of Federal Regulations—42 CFR Part 416 Ambulatory Surgical Services
- Fire Safety Survey Report—Life Safety Code (PDF)
- National Fire Protection Association
- State Operations Manual, Appendix L – Guidance for Surveyors: Ambulatory Surgical Services (PDF)
- State Operations Manual, Chapter 2 – The Certification Process (PDF)
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). Submit it directly to National Government Services.
After review, the carrier will send a copy of the application with their written recommendation to the Wisconsin Division of Quality Assurance (DQA).
Complete CMS 377 and CMS 370.
IMPORTANT NOTE: Include your fiscal year ending date on the application where requested.
The person signing the Health Insurance Benefit Agreement (CMS form 370) must have the Life Safety Code Survey authorization of the owner of the center in order to enter into this agreement.
Sign and return both original forms.
Consider accrediting organizations information for:
- Accreditation Association for Ambulatory Health Care (AAAHC)
- The Joint Commission
- American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
- Healthcare Facilities Accreditation Program (HFAP)
An ASC applicant may seek accreditation and deemed status under one of the national accrediting bodies. That body would then complete the initial on-site certification survey.
DQA will hold recommendations for Medicare certification until receiving the confirmation letter from the accrediting body. The letter should include 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 Tommy Rylander at DQA via email: firstname.lastname@example.org.
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 on our Plan Review webpage.
Submit a full operations 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 complete.
The application is considered complete after:
- The Medicare Administrative Contractor (MAC) has approved the CMS-855.
- The CMS forms and the supporting documents are satisfactorily submitted to DQA.
DQA will notify the applicant that the application is complete. They also will ask for a full operations letter. This written notice of full operations is required before DQA surveyors can hold the required on-site survey to determine if all conditions for coverage are met.
The content of a full operations letter must show:
- The facility has provided different types of anesthesia and different types of surgery to at least five patients.
- The facility has patient records to review.
- The facility is prepared for the survey of all conditions for coverage.
- A specified effective date of operation.
Notification of an anticipated date of full operation is not sufficient.
Send the full operations letter to:Tommy RylanderDivision of Quality AssurancePO Box 2969
Madison, WI 53701-2969
Or you may email the letter to email@example.com.
- Complete supporting documentation if the state will be conducting a 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 416.51).
- 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 sent to:Tommy RylanderDivision of Quality AssurancePO Box 2969
Madison, WI 53701-2969
Or via email to firstname.lastname@example.org.
After submission of all materials
Initial certification survey
If DQA conducts the initial Medicare survey, it will be unannounced. Note that survey scheduling by DQA depends on available staffing resources and other factors. The initial survey and the certification process could take several months.
DQA will make a certification recommendation to CMS based on the outcome of the survey. CMS will notify you of your 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 signed and sent to you as well.
If you are denied Medicare approval, you'll be told the reasons for the denial. You also will be given information about how to appeal the decision.
Certification with the Wisconsin Medical Assistance 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 WMAP, we encourage you to apply at the same time that you apply to Medicare.
If application is made to WMAP and Medicare at the same time, and the completed application for WMAP is returned within 30 days of the date it's mailed to the applicant, the certification effective date with WMAP will be the same as the effective date with the Medicare program.
Delays in applying to WMAP may result in assigning a later certification effective date.
Application materials can be obtained by writing to:Attention: Provider Maintenance, ForwardHealth313 Blettner Blvd.
Madison WI 53784
You also can call 800-947-9627 (in state toll-free) or 608-221-4746.
- Call 608-266-7297 for help filling out forms for certification.
- Call the Bureau of Health Services at 608-266-8481 if you have questions about the conditions for coverage survey process.