These are instructions for enrollment as a certified supplier in the Medicare ASC program.
There are no state Licensure or Certificate of Need requirements for ASCs in Wisconsin.
NOTE TO APPLICANTS: Initial Surveys for Medicare Participation: S&C Memo 08-03: Initial Surveys for New Medicare Providers
The following forms and documents pertinent to ASCs are accessible on the Internet:
- CMS 855
- CMS 377 - Request to Establish Eligibility
- CMS 370 - Health Insurance Benefit Agreement (2 originals)
- State Operations Manual, Appendix L - Guidance to Surveyors: Ambulatory Surgical Services
- Life Safety Code Requirements
- National Fire Protection Association (NFPA)
- 42 CFR Part 416 of the Code of Federal Regulations
- ASC's-Citations and Descriptions - State Operations Manual Chapter 2. - on the left side select Bookmarks, then scroll down to 2210- ASCs
- Office for Civil Rights forms; Complete/Submit Online:
- Data Request Checklist-Civil Rights Information Request
- HHS 690- Assurance of Compliance form (two signed copies if completing hard copies)
An ASC applicant interested in Medicare certification must:
1. 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, 615 KB) and submit it directly to the Carrier, Wisconsin Physicians Service (WPS) at:
WPS - Medicare
Provider Enrollment Unit
PO Box 8248
Madison WI 53708-8248
Upon completion of their review, the carrier will forward a copy of the application with their written recommendation to the Division or Quality Assurance (DQA).
2. Complete CMS 377 and 370
NOTE: IT IS VERY IMPORTANT TO INCLUDE YOUR FISCAL YEAR ENDING DATE ON THE APPLICATION WHERE IT IS REQUESTED.
3. Sign All Forms
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 two original forms.
4. 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.
The DQA will hold our recommendation for Medicare certification until we have received a copy of 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: Angela K. Mack.
An ASC seeking accreditation and deemed status must also complete the following:
- Office of Civil Rights (OCR) Assurance of Compliance Form HHS-690 (TWO originals)
- Office for Civil Rights (OCR) Civil Rights Information Request for Medicare Certification including applicable attachments
5. 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.
6. 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. The 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 and
- the facility has patient records to review and
- the facility is prepared for survey of all Conditions for Coverage and
- 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 Angela K. Mack, Division of Quality Assurance, P.O. Box 2969, Madison, WI 53701-2969
7. Complete Supporting Documentation if State will be conducting Medicare Survey
- Copy of the ASCs contract(s) with transferring hospital [42 CFR 416.41]
- Copy of the ASCs policy/procedures [42 CFR 416.42]
- Structure of the ASCs Quality Assurance Program [42 CFR 416.43]
- Copy of the ASCs 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 ASCs radiology services [42 CFR 416.49]
- List of the ASCs surgical procedures and anticipated length of surgery [42 CFR 416.65]
- Statement of anticipated patient payment source
- Sketch of the ASCs physical plant layout. If inside a medical office building, identify ASC hours of operation.
- Status of the ASCs building project: date received by Department of Commerce: date of DQA inspection if applicable.
8. Submit the following items as specified
The original CMS 377, the two CMS 370 original forms, civil rights forms and policies, the provider-based questionnaire and supporting documentation to:
Angela K. Mack
Division of Quality Assurance
P.O. Box 2969
Madison, 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 thirty (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 608-266-7485. Questions regarding the conditions for coverage survey process should be directed to the Bureau of Health Services at 608-266-8481.