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Instructions:
Medicare Certification for Ambulatory Surgery Centers (ASCs)
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 (PDF,
103 KB)
IMPORTANT
NOTE TO APPLICANTS: Interim
Survey Guidance (PDF 29 KB)
The
following forms and documents pertinent to ASCs are accessible on the
Internet:
- CMS
855 http://www.cms.hhs.gov/CMSforms/downloads/cms855b.pdf
- CMS
377 - Request to Establish Eligibility (exit
DHS; PDF, 63 KB)
- CMS
370 - Health Insurance Benefit Agreement (exit DHS; PDF, 19 KB) (2 originals)
- State
Operations Manual, Appendix L - Guidance to Surveyors: Ambulatory
Surgical Services - (Rev. 1, 05-21-04) (exit
DHS; PDF)
- Life
Safety Code Requirements (exit DHS)
- Part
416 of the Code of Federal Regulations 42 CFR Part 416 (exit
DHS)
- ASC's-Citations
and Descriptions - State Operations Manual Chapter 2. (exit
DHS; PDF) - on the left side select Bookmarks, then scroll
down to 2210- ASCs
- Provider-Based
Questionnaire (PDF, 275 KB)
An ASC applicant must:
1.
Enroll in the Medicare program with the
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 (leaving DHS) 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. Complete
the Provider Based Questionnaire
5. Complete Supporting Documentation
·
Copy
of the ASC’s contract(s) with transferring hospital [42 CFR 416.41]
·
Copy
of the ASC’s policy/procedures [42 CFR 416.42]
·
Structure
of the ASC’s Quality Assurance Program [42 CFR 416.43]
·
Copy
of the ASC’s 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 ASC’s radiology services [42 CFR 416.49]
·
List
of the ASC’s surgical procedures and anticipated length of surgery [42
CFR 416.65]
·
Statement
of anticipated patient payment source
·
Sketch
of the ASC’s physical plant
layout. If inside a medical
office building, identify ASC hours of operation.
·
Status
of the ASC’s building project: date received by Department of Commerce:
date of DQA inspection if applicable.
6. Submit the
following items as specified
The
original CMS 377, the two CMS 370 original forms, the provider-based
questionnaire and supporting documentation to:
Sandy
Wasilewski
Bureau of Technology, Licensing & Education
Division of Quality Assurance
P.O. Box 2969
Madison,
WI 53701-2969
7.
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. You may also contact the DQA Health Services Section
at (608) 243-2088 regarding this process.
8.
Consider AAAHC, JCAHO, AAAAFS
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, or AAAFS
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: Sandy Wasilewski.
9.
Submit a “Full Operation
Letter”
If
the ASC applicant is not seeking accreditation with deemed status under
one of the national accrediting bodies (see #8 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 Sandy Wasilewski, Human Services Program
Coordinator, Division of Quality Assurance, P.O. Box 2969, Madison,
WI 53701-2969
Initial Certification Survey
The
DQA will schedule an unannounced on-site survey. 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
the ASC is seeking accreditation and deemed status under one of the
national accrediting bodies, and meets all Conditions for Coverage, the
DQA will forward to CMS a copy of the accrediting body's confirmation
letter and survey report along with the Life Safety Code survey report
with our recommendation for initial Medicare certification. (See #8 above)
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.
Change
of Ownership
If
operation of the ASC is later transferred to another owner, ownership
group, or to a lessee, the provider agreement will be transferred. You are
required to notify the DQA at the time you are planning such a transfer.
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, 6406 Bridge Road,
Madison,
WI 53784 -006, or by calling 1-800-947-9627 (in state toll-free) or (608)
221-4746.
For
assistance in completing forms for certification, please call the
Ambulatory Surgery Center Licensing Specialist at (608) 266-0582. Questions
regarding the conditions for coverage survey process should be directed to
the Health Services Section at (608) 243-2028.
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