Licensure and Medicare / Medicaid Certification for Hospitals - Part 3

Completion of Forms

a. Complete CMS 1561 (two copies), Form CMS 690 and the necessary Office of Civil Rights documents.

b. The person signing the Health Insurance Benefits Agreement (the CMS 1561 form) must be someone who has the authorization of the owners of the agency to enter into this agreement.

c. Also, include two copies of your Utilization Review Plan.

d. All completed forms must be sent to:

Division of Quality Assurance
Bureau of Health Services
P.O. Box 2969, Room 455
Madison, WI 53701-2969

Full Operation Letter

The following process applies for those hospitals that are not initially applying for accreditation through a national accrediting organization (i.e. JCAHO or AOA):

Once the hospital is operational and the fiscal intermediary has approved the CMS-855, a surveyor must conduct an onsite survey to determine if all conditions of participation are met.

To expedite this process, you are required to provide the state agency with a written notice that your program is in "full operation," i.e. the hospital is providing services to patients, has records to review and is prepared for survey for all conditions of participation.

Notification of anticipated date of full operation is not sufficient. The letter should be sent to the attention of  Angela K. Mack, at the above address. It is important to remember that a survey will not be scheduled until the notification is received.

Medicare Certification Survey Process

PLEASE NOTE: It is very important that this office be informed if the facility will be applying to become a member of a national accrediting program (i.e. JCAHO or AOA). This information should be stated in the cover letter attached to the initial application packet.

In this case, the accrediting organization should be conducting the initial certification survey.

Upon completion of the survey, this office will require a copy of the accrediting organization's confirmation letter along with a copy of their most current survey report indicating this facility has been surveyed and meets the standards required for Medicare certification.

Our recommendation to CMS (Centers for Medicare and Medicaid Services) for Medicare certification will be based on the accrediting organization's survey.

If the facility will not be applying for accreditation through a national accrediting organization, the following process will apply:

a. The surveyor will inspect the facility, interview you and members of your staff, review documents, and perform other procedures necessary to evaluate your agency's compliance with the Conditions of Participation.

b. Following the survey, the Department of Health Services will recommend to the Centers for Medicare and Medicaid Services (CMS) whether your facility should be certified in the Medicare Program.

c. If it is determined that all requirements of Medicare and Civil Rights are met, the Health Insurance Benefits Agreement will be countersigned by CMS. One copy of the agreement will be returned to you along with the notification that your agency has been approved.

Certification Denial

Hospitals that are denied certification into the Medicare Program will be sent a notification, together with the reasons for the denial and information about their rights to appeal the decision.

Certification with the Wis. Medical Assistance (Medicaid) Program (WMAP)

a. You will need to submit an application for Medicaid certification in addition to any application materials required for Medicare certification.

b. If you are interested in becoming a certified provider with the Wisconsin Medicaid Program, you are encouraged to apply at the same time that you apply to Medicare.

  • If application is made to Medicaid and Medicare concurrently, and the completed application for the Medicaid program is returned within thirty (30) days of the date it is mailed to the applicant, the certification effective date with Medicaid will be the same as the effective date with Medicare.
  • Delays in applying to the Medicaid program may result in assignment of a later certification effective date.

c. Application materials can be obtained by writing to EDS- Attention: Provider Maintenance, 6406 Bridge Road, Madison, WI 53784-0006, or by calling 1-800-947-9627 (in state toll-free), or (608) 221-4746.

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.

Last Revised: November 20, 2014