Licensure and Medicare / Medicaid Certification for Hospitals - Part 2

Initial Licensure Review Process

Upon receipt in the Division of Quality Assurance (DQA), the application materials will be reviewed for completeness.

If any documents are missing or if there is information that needs further clarification, DQA will contact the applicant either by telephone or in writing. The application process may be suspended until the packet is considered to be complete.

As a part of the initial licensure review process, a Registered Nurse (RN) from DQA will assist in analyzing the application materials submitted to this office.

The RN's approval of the DHS 124 written application materials, along with the results of the engineer/registered architect's approval of the building construction plans and on-site inspection will determine whether the facility can be issued a Certificate of Approval (COA) to conduct business.

The engineer/registered architect will be the bureau's agent to authorize the provider when the facility can be opened and can begin admitting patients.

The engineer will notify the Bureau of Health Services when the COA should be issued. It will be mailed to the facility under separate cover.

Please note that the hospital will not be required to have received the actual certificate prior to admitting patients. The COA should be framed and posted in a conspicuous place at the facility such as a lobby, admitting or business office.

For assistance in completing forms for hospital licensure and certification, please call DQA at 608-266-7485. Questions regarding the Conditions of Participation survey process should be directed to the Bureau of Health Services at 608-266-8481.

Medicare Certification Application Process

1. The State of Wisconsin, Department of Health Services (DHS) has an agreement to assist the U.S. Department of Health & Human Services (DHHS) in determining whether health care facilities meet, and continue to meet, the Conditions of Participation.

2. Refer to the Conditions for Participation for all Title XVIII Medicare program requirements.

3. In order to qualify for Medicare reimbursement, your hospital must be in compliance with the Medicare Conditions of Participation, reimbursement requirements, including financial solvency and the requirements of Title VI of the Civil Rights Act of 1964.

4. CMS-855(A) or CMS-855(B) Form:

  • Only the fiscal intermediary (FI) or carrier will distribute enrollment applications for providers/suppliers that they enroll.
  • The provider/supplier should complete the application and submit it directly to the intermediary or carrier.
  • Within 10 calendar days of receipt of the CMS-855A or CMS-855B, the FI/carrier will send a copy of the application to the state agency or the regional office, as applicable.
  • The Centers for Medicare and Medicaid Services (CMS) Provider-Supplier website is designed to provide Medicare enrollment information for providers, physicians, non-physician practitioners, and other suppliers.
  • You will also find list of FIs and carriers by state and specialty. If the provider/supplier needs to select an FI or carrier, it may access this website.
  • In Wisconsin, the fiscal intermediary is National Government Services in Milwaukee unless your facility is affiliated with a CMS-designated chain, in which case, it may have a designated single U.S. fiscal intermediary.
  • New free-standing providers are no longer permitted to express a preference for a particular fiscal intermediary (FI). New providers must be assigned to the designated local FI. The FI/carrier will answer any applicant inquiries concerning completion of the enrollment application.
  • The provider/supplier must still contact the state agency for the other required Medicare and/or Medicaid certification forms for their provider/supplier type.
  • If the FI recommends approval of the enrollment application, it will provide the state agency and relevant Regional Office with a written recommendation for approval.
  • Please be reminded that the issuance of a license to a new operator cannot guarantee the new applicant automatic federal Medicare certification until the CMS-855 approval process has been completed and confirmed by the fiscal intermediary.
Last Revised: February 15, 2017