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Medicare Application Process and Forms

The Centers for Medicare and Medicaid Services (CMS) determines whether a provider can participate in the Medicare program with the help of its regional home health intermediary.  The Ohio Department of Health (ODH) also assists CMS in making this determination by compiling information and, based on the information ODH collects, recommending to CMS whether the provider should be approved to participate.  ODH uses the application process described below to compile information and make the recommendation.  This approval is also a prerequisite for participation in the State Medicaid program as well.  Please note that you cannot claim provider reimbursement for services furnished prior to your approval.

MEDICAID CERTIFICATION is administered by the Ohio Department of Medicaid (ODM).  An application for Medicaid certification can be requested by calling ODM at (800) 686-1516.

Submit the Following to the Fiscal Intermediary

CMS-855A Provider/Supplier Enrollment Application

The Provider/Supplier Enrollment Application Form (CMS-855A) is a requirement of the application process.  To obtain this form, click on the “CMS-855” link above or call the fiscal intermediary at (855) 696-0705 or visit their website at www.palmettogba.com/medicare.  The CMS-855A form, along with its required documentation, and proof of payment of the application fee, are to be returned directly to Palmetto GBA, not ODH.  ODH cannot process your application until this approval has been received from the Fiscal Intermediary.  It may take up to 6 months for ODH to receive this approval. 

Submit the Following Forms to ODH at the Address Below

  • CMS-1572(a) Home Health Agency Survey and Deficiencies Report
  • CMS-1561 Health Insurance Benefit Agreement
  • Civil Rights Verification or Package
  • HHS 690 Assurance of Compliance forms

Ohio Department of Health
Bureau of Regulatory Operations, HHA
246 North High Street, 3rd Floor
Columbus, OH 43215  

CMS-1572A Home Health Agency Survey and Deficiencies Report

Click on the “CMS-1572A” link above, complete the first 2 pages of the form and submit one (1) original.  DO NOT COMPLETE Items #7, #8, #11, #12, #21, #22 and #23.  ALL OTHER information on page 1 and 2 should be completed.  When completing questions #18 and #19; if you put a “2” in any of the boxes in question #18, then the corresponding staffing in question #19 should be “0”.  If you put a “1” or “3” in any of the boxes in question #18, then there must be a number in the corresponding staffing box in question #19.

CMS-1561 Health Insurance Benefit Agreement

Click on the “CMS-1561” link above, complete form and submit two (2) signed originals. 

On the second line after the term “Social Security Act”, enter the entrepreneurial name of the enterprise, followed by the trade name (if different from the entrepreneurial name).  Ordinarily, this is the same as the business name used on all official IRS correspondence concerning payroll withholding taxes, such as the W-3 or 941 forms.  For example, the ABC Corporation, owner of the Community General Hospital, would enter on the agreement, "ABC Corporation D/B/A Community General Hospital."  A partnership of several persons might complete the agreement to read:  "Robert Johnson, Louis Miller and Paul Allen, partners, D/B/A Easy Care Home Health Services."  A sole proprietorship would complete the agreement to read:   "John Smith D/B/A Mercy Hospital."  The person signing the Health Insurance Agreement must be someone who has the authorization of the owners of the enterprise to enter into this agreement. NOTE:  Complete the form in its entirety and sign & date under “Accepted For The Provider of Services By”.  No other signatures are required on the form at this time.

Civil Rights Package

Medicare Part A providers will be required to sign an attestation of their compliance with all applicable civil rights laws enforced by OCR (including Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972, the Age Discrimination Act of 1975, and Section 1557 of the Affordable Care Act). This attestation is referred to as an Assurance of Compliance and it can be found on the HHS website (Form HHS-690).   

New applicants for Medicare funding and current providers undergoing a CHOW will be responsible for submitting this attestation electronically to the OCR via OCR’s online Assurance of Compliance portal at https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf. The provider will receive electronic verification from OCR of successful submission of the attestation.

Providers forwarding notification of a CHOW must submit evidence of successful electronic submission of the above attestation (Form HHS-690) through the OCR portal before an initial survey may be conducted or the CHOW may be processed.

If the OCR receives complaints of discrimination subsequent to an initial certification or a CHOW, it may utilize any of its enforcement tools, including compliance reviews, technical assistance, new policy guidance and educational opportunities to assist an entity in coming into compliance with relevant civil rights laws. In the event the provider/supplier does not regain compliance, the OCR will notify the applicable CMS RO and termination of the provider agreement will be initiated.

Please submit the screen shot that confirms the HHS 690 attestation submission back to the Ohio Department of Health along with the civil rights application (policy/procedures).

The Following Documents are Available on the ODH Webpage For Your Information

Office of Civil Rights HIV/AIDS Information Sheet

Click on the link above to obtain documentation referencing Civil Rights and AIDS or AIDS-related conditions.

Conditions of Participation

The Conditions of Participation are set forth in 42 CFR Part 484.  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 home health agencies. The home health agency must first contact an Accreditation Organization (ACHC, CHAP,CIHQ, or Joint Commission), and become accredited.

Accrediting Organization contacts:

Application Approval Process

CMS Requires the following completed and signed documents: 1) 855A, 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 8 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 Benefit 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 Bureau of Regulatory Operations -  Certification Unit at liccert@odh.ohio.gov or call (614) 644-8118.

If you have questions about the status of your CMS-855 form, contact Palmetto Government Benefits Administration at (855) 696-0705 or visit their website at www.palmettogba.com/medicare.