An Ambulatory Surgery Center is limited to any distinct entity that operates exclusively for the purpose of providing surgical services to patients who do not require hospitalization (i.e., an inpatient stay in a hospital).
To establish Centers for Medicare/Medicaid Services (CMS) Medicare Certification of an ASC, an applicant must request, complete, and submit an application packet. Application materials are located below or requested through the Bureau of Facility Standards at 208-334-6626.
The application packet includes what must be submitted and approved by the Bureau of Facility Standards prior to an initial survey (items 1 - 3) and resource information related to ASCs (items 4 - 9) as follows:
- Health Insurance Benefits Agreement - CMS form 370, (two originals required),
- ASC Request for Certification - CMS form 377,
- “Office of Civil Rights Clearance for Medicare Certification” (OCR) Request Form and Technical Assistance Packet. (Additional information is available at https://www.hhs.gov/civil-rights/for-providers/index.html.). This form may be answered and submitted, on line, via https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf
The OCR intake queue, and the provider will receive an e-mail from OCR stating that the provider completed the civil rights submission. The e-mail will contain an OCR number, which is critical to OCR’s ability to access the provider’s submission from the OCR intake queue.
- Fiscal year ending date form,
- Appendix L - Guidance to Surveyors: ASCs
- CMS Letter - S&C-11-06-ASC, Clarification of H&P Assessments
- Appendix Q - Guidelines For Determining Immediate Jeopardy,
- CMS Letter - S&C-08-03 Initial Surveys,
- ASC Fire Safety Survey Report - CMS form 2786U.
When you have completed the application, you may send all documents by mail to:
Department of Health and Welfare
Bureau of Facility Standards
P.O. Box 83720
Boise, ID 83720-0009
To become an Idaho Medicaid provider, you must submit an Idaho Medicaid provider enrollment application to Gainwell, Idaho’s Medicaid Management Information Systems (MMIS) Vendor. To submit an Idaho Medicaid provider enrollment application, go to www.idmedicaid.com and register for a trading partner account. A step-by-step user guide can be found by selecting Reference Material, User Guides, New Provider Enrollment Guide. Additional provider enrollment help is available by contacting your Provider Relations Consultant or Provider Services. Contact information can be found at www.idmedicaid.com or call 866-686-4272.
Applying to be an Idaho Medicaid provider is a separate process from federal certification and state licensure.
Medicare/Medicaid reimbursement is not retroactive and usually becomes effective only after your enrollment application is approved, the survey is completed, and you are in compliance with all regulations or have submitted an acceptable plan of correction.
- Processes - PowerPoint presentation
- Applied Quality Assurance-Performance Improvement (QAPI)
- Administration of Drugs - Q181
- Submission and Investigation of Grievances - Q225
- Infection Control - Q241 and Q242
- Infection Prevention and Survey Readiness
- Plan of Correction (PoC) Review Checklist
- Understanding the form 2567 and Writing Acceptable PoCs - PowerPoint Presentation