Ambulatory Surgery Centers: Medicare Certification
Wisconsin will facilitate and provide information on the federal Medicare certification process for ambulatory surgical centers (ASC) that choose to seek it. There are no state licensure or certificate of need requirements for ASCs in Wisconsin.
An ASC applicant interested in Medicare certification must contact their Medicare Administrative Contractor (MAC) to begin the Medicare enrollment process using the CMS-855B form (PDF). This form must be submitted directly to the MAC. Wisconsin's designated MAC is National Government Services.
After the MAC reviews and approves the form, they will send a copy of the application with their written recommendation to the Division of Quality Assurance (DQA).
In addition to the CMS-855B, the following certification documents are needed by DQA:
- CMS 377 - Request for Initial Certification or Update of Certification Information in the Medicare Program (PDF)
- CMS 370 - Health Insurance Benefits Agreement (PDF)
- Initial Medicare certification survey final approval letter and full survey report from your chosen survey organization. See the "Seeking Medicare certification through state agency survey" and "Seeking Medicare certification through an outside accrediting organization" tabs below for more details on survey options.
These materials should be sent to:
- Email: dhsdqalccs@dhs.wisconsin.gov
Mailing address:
Division of Quality AssuranceATTN: BHS/ASC CertificationPO Box 2969
Once DQA has received all documents (CMS-855B, CMS-377, CMS-370, and survey report), a recommendation will be made for Medicare certification to the Center for Medicare and Medicaid Services (CMS), who will ultimately be responsible for granting certification.
If your organization decides to be surveyed by surveyors in DQA's Bureau of Health Services, please submit a full operations letter to DQA, which should indicate the ASC is ready to participate in the state survey process. This letter should include:
- The effective date of operation
- Days and hours of operation
- A copy of your ASC's surgical log (minus patient names/identifiers) from the date of opening to the date of the letter. The log should include the date, type of procedure, type of anesthesia, name of surgeon and name of anesthesia provider.
Once this letter is received by DQA, an unannounced survey will be scheduled within the hours listed on the full operations letter. The initial survey and the certification process may take several months.
CMS has approved the following accrediting organizations to perform ASC Medicare certification surveys:
- Accreditation Association for Ambulatory Health Care (AAAHC)
- The Joint Commission
- American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
- Accreditation Commission for Health Care (ACHC)
If your ASC has decided to be surveyed by one of these accrediting organizations, please reach out to one of these organizations and arrange to receive an initial Medicare certification deemed status survey. Please consult with these organizations regarding their timelines for survey, and any additional fees they may charge for services.
Engineers in DQA's Office of Plan Review and Inspection (OPRI) may provide advisory plan reviews of the Life Safety Code requirements for ASC providers at no charge. In order for OPRI to conduct an advisory plan review, the ASC must submit construction plans. All required forms, instructions and names of contacts are available on our Plan Review webpage.
The following forms and documents are for ASCs:
- CMS 855B - Medicare Enrollment Application (PDF)
- CMS 377 - Request for Initial Certification or Update of Certification Information in the Medicare Program (PDF)
- CMS 370 - Health Insurance Benefits Agreement (PDF)
- Code of Federal Regulations - 42 CFR Part 416 Ambulatory Surgical Services
- Fire Safety Survey Report - Life Safety Code (PDF)
- National Fire Protection Association
- State Operations Manual, Appendix L - Guidance for Surveyors: Ambulatory Surgical Services (PDF)
- State Operations Manual, Chapter 2 - The Certification Process (PDF)
Contact us
Questions?
- Call 608-266-7297 for help filling out forms for certification.
- Call the Bureau of Health Services at 608-266-8481 if you have questions about the conditions for coverage survey process.