End Stage Renal Disease (ESRD) is the stage of renal (kidney) impairment that appears irreversible and permanent and requires regular dialysis or kidney transplant to maintain life. An ESRD facility is a facility which provides dialysis services to patients.
To establish Medicare Certification of an ESRD facility, an applicant must complete and submit an application packet. Application materials can be found below or requested through the Bureau of Facility Standards at 208-334-6626, Option 4.
The application packet includes the documentation that must be submitted to, and approved by, the Bureau of Facility Standards prior to an initial survey (items #1 - #3), as well as resource information related to ESRD facilities (items #4 - #6) as follows:
1. ESRD Facility Survey Report - CMS form 3427
2. Narrative Report describing the planned provided services, which includes:
- A Plan of Operation specific to the provided services,
- The qualifications and responsibilities of the supervisory staff (physician, registered nurse in charge, dietician, social worker, etc.),
3. Fire, Life Safety, & Construction information
a. If the facility meets exemption requirements as stated in CMS Letter, S&C: 13-47-LSC/ESRD, then please complete and submit the Model Attestation Statement attached to the CMS Letter.
b. If the facility does not meet exemption requirements, please submit the following:
- Certificate of Occupancy,
- Fire Alarm/Sprinkler System Fire Watch
- Results of the most recent local Fire Department Inspection,
- A written plan for the protection of patients in an emergency,
4. ESRD Basic Technical Survey Training Interpretive Guidance (including part 494 Conditions for Coverage)
5. Appendix Q, Guidelines For Determining Immediate Jeopardy,
6. CMS Letter, S&C-08-03 Initial Surveys.
The application materials may be submitted by mail.
Please mail your application packet to:
Department of Health and Welfare
Bureau of Facility Standards
P.O. Box 83720
Boise, ID 83720-0009
PLEASE KEEP A COPY FOR YOUR RECORDS.
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.
PO Box 83720
Boise, ID 83720-0009