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Initial Medicare Certification Process for Ambulatory Surgical Centers
To become Medicare certified, the facility must first be licensed. Notify MDH if you plan on having a Region V Office of CMS Approved Accrediting Organization conduct the initial Medicare certification survey or MDH conduct the initial Medicare certification survey. See list of CMS-Approved Accreditation Organizations (PDF).
Complete and send to MDH the following federal forms:
- Health Insurance Benefits Agreement (CMS-370) (PDF)
- Request to Establish Eligibility (CMS-377) (PDF)
- Medicare Enrollment Application (CMS 855B) (PDF)
CMS-855 application and all supporting documentation will be sent to the designated fiscal intermediary. See Medicare Fee-for-Service Provider Enrollment Contact List (PDF).
MDH will not proceed with the initial Medicare certification process until after we have received a copy of the 855B and approval letter from the fiscal intermediary.
Email or mail completed documents to:
Minnesota Department of Health
Health Regulation Division
Licensing and Certification Program
P.O. Box 64900
St. Paul, Minnesota 55164-0900
Attn: Certification Specialist
Email address: health.HRD-FedLCR@state.mn.us
On-site Medicare survey
- If you choose to have MDH conduct the initial certification survey, it is required a minimum of 10 procedures be performed before the initial certification survey. Part of the survey process is to review medical records from 10 procedures completed and follow current procedures(s) from admission through discharge. Since this survey is unannounced, we will need a schedule of procedures, before the initial certification survey is done so we may schedule the survey on a day that surgery will be performed.
- If no deficiencies are issued at the time of the initial certification survey, MDH will recommend Medicare certification to Region V Office of CMS effective the date of the survey.
- If deficiencies are issued at the time of the initial certification survey, a plan of correction is required. If the plan of correction is accepted, MDH will recommend Medicare certification to Region V Office of CMS effective the date the acceptable plan of correction is received in this office.
- If at the time of the initial certification survey you have not met the Conditions of Participation, we will recommend denial of Medicare certification to Region V Office of CMS. Region V Office of CMS will deny certification and you will need to reapply.
MDH will process the initial certification survey documents, the approved 855B and federal forms with our recommendation to Region V Office of CMS. Region V Office of CMS will review the application. If approved, Region V Office of CMS will send a letter to the facility including the CMS Certification Number (CCN).
If you choose to have the Region V Office of CMS-approved Accrediting Organization conduct the initial survey, MDH will need a copy of the approval letter from the Accrediting Organization. MDH will forward the approval letter from the Accrediting Organization, the approved 855B and federal forms to Region V Office of CMS with our recommendation. Region V Office of CMS will review the application and if approved, Region V Office of CMS will send a letter to the facility including the CMS Certification Number (CCN).