In order to complete hospital licensure, Medicare certification, and Medicaid certification, the following processes will need to be completed. Although state licensure is ultimately required for final approval for Medicare and Medicaid certification, many of the certification steps involved can be performed concurrently with the state licensure process.
Submit the information identified below to:
Division of Quality Assurance
Bureau of Health Services
Attn: Thomas Rylander
PO Box 2969
1 W. Wilson St. Rm. 455
Madison, WI 53701-2969
- Letter of intent: detailed statement of proposed hospital facility on business letterhead.
- Signed Hospital Certificate of Approval Application, F-62092 (hospital licensure application form).
- Hospital licensed bed fee ($18 per bed) as required in Wis. Stat. § 50.135(2)(a). The check should be made out to the Division of Quality Assurance.
- Copies of contracts for all hospital services provided via contracted organizations (all services marked with a “2” or “3” on the hospital licensure application form, Section H).
- Documentation that the hospital will be staffed for 24-hour coverage seven days per week at the time of opening, including:
- staffing full-time equivalent (FTE): list of registered or licensed nurses with current registration or license number
- list of active physician staff
- registered nurse staff pattern for 24-hour coverage seven days per week
- Facility floor plan
- A copy of the resume and/or professional licensure, as appropriate, for the following individuals:
- hospital administrator/CEO
- substitute administrator/CEO
- medical director
- director of nursing
- medical record administrator or accredited record technician
- staff or consulting pharmacist
- registered dietician
- CLIA qualified laboratory director and CLIA certificate number
- Medical social worker
- Patient rights and responsibilities policies established by governing board (Wis. Stat. § 50.36(1)).
- Governing body by-laws (Wis. Stat. § 50.36(1)).
- Medical staff by-laws including the various committees (Wis. Stat. § 50.36(1)).
- Hospital policies and procedures for:
- quality assessment and performance improvement program
- nursing services
- medical record services
- physical environment
- infection control
- all departments and services marked with a “1” or “3” in section H of the hospital licensure application
- Type of organization – provide documentation
- Corporation: provide copy of articles of incorporation
- Limited liability company (LLC): provide copy of articles of organization and operation agreement
- Limited liability partnership (LLP): provide copies of partnership agreement
- Organizational chart (identify any other entities or the parent company related to the applicant).
- If the applicant has health care facilities in other states a statement is required from each state’s licensing agency verifying each facility’s current licensure and certification status.
- A Model Balance Sheet, F-62674A (Word) or other document showing a proposed operating budget for the first 90 days of operation.
- Financial reference: proof of ability to provide 90 days' worth of finances for operations which may include the following documentation:
- bank statements for checking/savings accounts
- evidence verifying stock/bond/certificate of deposit ownership
- verification of outside employment and salary
- verification of income from another business
- credit reports
- letter(s) from financial institutions indicating the extent of the applicant’s line-of-credit and financial reference
- Lease agreements and management contracts provided if applicable.
- Internal Revenue Service (IRS) Employer Identification Number (EIN) document.
- Entity Caregiver Background Checks completed online including $10 per individual.
- Final approval of new construction from DQA’s Office of Plan Review and Inspection (OPRI). Please contact OPRI to review your planned construction before it begins.
Once the licensing specialist has all required documentation, your application can be forwarded to a nurse surveyor within the Division of Quality Assurance (DQA) for further review. Please allow for up to 90 days for this review to take place. Upon successful desk review of these materials, state licensure will be granted.
Although state licensure is required for final approval for Medicare certification, many of the steps involved can be performed concurrently with the state licensure process. Provide the following to the hospital licensing specialist:
- CMS-855 Medicare Enrollment Application: contact your Medicare Administrative Contractor (MAC) for more information on this process. The MAC will send documentation to the state agency and hospital upon approval.
- CMS-1572 Hospital Survey and Deficiencies Report from the Medicare certification survey (generated by your accrediting organization). This survey cannot be performed by the State Agency. Refer to CMS memo S&C-08-03 for additional information.
- CMS 1561 Health Insurance Benefits Agreement
Refer to the following resources for additional information related to Medicare certification:
- CMS Medicare Provider-Supplier Enrollment website
- 42 CFR 482, Code of Federal Regulations, Conditions of Participation for Hospitals
Once the hospital licensing and certification specialist has received these forms, they can make a recommendation for Medicare certification to the CMS regional office in Chicago, who are ultimately responsible for approving or denying this request. Once approved, your hospital will be assigned a 6-digit Medicare number starting with “52.”
Medicaid enrollment is not handled directly by DQA. Please contact Forward Health to begin the Medicaid enrollment process.
- For assistance in completing forms for hospital licensure and certification, please contact Thomas Rylander, Hospital Licensing Specialist at 608-266-7297.
- Questions regarding federal Conditions of Participation and the survey process should be directed to the Bureau of Health Services at 608-266-0269.