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Medicare Application Process and Forms

 

AMBULATORY SURGICAL CENTER MEDICARE APPLICATION TO PARTICIPATE IN
MEDICARE PROGRAM INSTRUCTIONS

This page explains the procedures in participating in the Medicare Program as an Ambulatory Surgical Center.  The Ohio Department of Health (ODH) has an agreement with the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) to assist in determining whether health care facilities meet, and continue to meet, the Conditions for Coverage.

An Ambulatory Surgical Center is defined in 42 CFR Subpart A, Section 416.2 as "...any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization..." The meaning of "exclusively" has been further defined as "physicians may not see non-surgical patients for workups or diagnostic visits in the ambulatory surgical center."

Your facility must be licensed as a nursing home with the State of Ohio prior to obtaining Medicare Certification.

SUBMIT THE FOLLOWING TO THE FISCAL INTERMEDIARY

CMS-855B Provider/Supplier Enrollment Application

The Provider/Supplier Enrollment Application Form (CMS-855B) is a requirement of the application process.  To obtain this form, click on the “CMS-855” link above or call the fiscal intermediary at (866) 276-9558 or visit their website at www.CGSmedicare.com.  The CMS-855B form, along with its required documentation, and proof of payment of the application fee, are to be returned directly to CGS, not ODH.  ODH cannot process your application until this approval has been received from the Fiscal Intermediary.  It may take up to six months for ODH to receive this approval. 

SUBMIT THE FOLLOWING FORMS TO ODH AT THE ADDRESS BELOW:

  • CMS-377 Ambulatory Surgical Center Application
  • CMS-370 Health Insurance Benefits Agreement

Ohio Department of Health
DQA/BIOS - Certification Unit
246 North High Street, 3rd Floor
Columbus, OH 43215  

CMS-377 Ambulatory Surgical Center Request for InitialCertification or Update Of Certification Information in The Medicare Program 

Click on the “CMS-377” link above, complete form and submit two (2) signed originals.

CMS-370 Health Insurance Benefits Agreement

Conditions of Participation

The Conditions of Participation are set forth in 42 CFR Part 416. A copy of the Conditions of Participation is available on the above link.

ACCREDITATION SURVEY

The Ohio Department of Health does not conduct initial Medicare Certification Surveys for ambulatory surgical centers. The center must first contact an Accreditation Organization (AAAHC, AAAASF, HFAP or Joint Commission), and become accredited.

Accrediting Organization contacts:

Accreditation Association for Ambulatory Health Care, Inc. (AAAHC)  (847)853-6060  http://www.aaahc.org/
The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) (847)775-7917 http://www.aaaasf.org/
Healthcare Facilities Accreditation Program (HFAP)  (312)202-8258 http://www.hfap.org/
The Joint Commission (JC)  (630)792-5286  http://www.jointcommission.org/

APPLICATION APPROVAL PROCESS

CMS Requires the following completed and signed documents: 1) 855B, 2) ODH application and 3) accrediting organization’s approval letter. Once ODH receives all of the above information the packet is forwarded to CMS.

CMS takes approximately eight weeks to determine whether the facility meets the requirements to participate in the Medicare program. CMS requires that the application documents be signed no more than 6 months prior to CMS’ review.  If the process takes more than 6 months, CMS may require the facility to submit updated forms. 

Once the process is complete, CMS will notify the facility of its determination.  If CMS approves the facility for participation in the Medicare program, CMS will send an approval letter containing the facility’s Medicare number and effective date, as well as a signed copy of the Health Insurance Benefits Agreement to the facility.

If CMS denies approval to participate in the Medicare program, CMS will send the facility notification of denial and provide the reasons for the denial, and provide information about the facility’s rights to appeal the decision.

CONTACT INFORMATION

If you have questions about the application process, you may contact the Certification Unit at liccert@odh.ohio.gov or call (614) 644-8118.

If you have questions about the status of your CMS-855B form, contact CGS at (866) 276-9558 or visit their website at www.CGSmedicare.com.

 

Last Updated: 02/02/2015

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