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Outpatient Physical Therapy/Speech Pathology - Federal Certification Information

Important Notice for New Facilities
Seeking Federal Medicare Certification

The Centers for Medicare & Medicaid Services (CMS) has issued revised survey priorities due to very substantial federal resource limitations. In light of the federal Medicare resource constraints, initial surveys for most provider and supplier types have been classified at the lowest priority level. For facilities that qualify for deemed status there is an alternate route to obtain certification and this may well be the fastest way to obtain certification this year. However, there are other types of facilities for which deemed status is not an option. The Survey and Certification Letter S&C-08-03 can be accessed for additional information.

The following are the requirements and procedures through which your agency may be approved to participate in Medicare as a provider of Outpatient Physical Therapy/Speech Pathology services.  The Office of Healthcare Licensing and Surveys (OHLS) certifies and periodically recertifies providers of services to assure Medicare Conditions of Participation are met.  This assists the Centers of Medicare and Medicaid Services (CMS) in determining if agencies can participate in Medicare.  Such approval is prerequisite to qualifying to participate in the state Medicaid program as well.

You are subject to complete a CMS-855A or CMS-855B.  The CMS-855A is the Medicare Federal Health Care Provider/Supplier Application for Health Care Providers that will bill Medicare Fiscal Intermediaries, and the CMS-855B is the Medicare Federal Health Care Provider/Supplier Application for Health Care Suppliers that will bill Medicare Carriers.  Please see application link and fee information link below. 

It is your responsibility to contact the appropriate fiscal intermediary (FI) or carrier (see link below) for the appropriate enrollment application. Please be aware your FI of preference does not automatically guarantee you will be assigned to that FI. Questions regarding this enrollment application must be directed to the FI or carrier. Once you have received and completed this enrollment application form, you must submit it directly to the FI or carrier. Our office will be notified by the FI or carrier of their review and recommendations to CMS with regard to your application. Until such time the state agency will not perform the federal survey.


Links are provided below for the survey and certification forms which are necessary to complete if you desire to participate.  Please complete and submit them promptly in order to avoid unnecessarily delaying approval, since your facility cannot claim provider reimbursement for services furnished prior to approval.  If the forms are not self-explanatory, you may telephone (307)777-7123 for assistance.  COMPLETE AND SUBMIT ALL COPIES OF THE FORMS. Please note that there are three (3) Health Insurance Benefits Agreements; submit all three (3) signed originals.


On the second line of the Health Insurance Benefits Agreement 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 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, ptr., Easy Care Home Health Services.  A sole proprietorship could complete the agreement to read: John Smith d/b/a Mercy Hospital.  The person signing the Health Insurance Benefits Agreement must be someone who has the authorization of the owners of the enterprise to enter into this agreement.


Please contact this office and speak with one of our engineers to find out about any environment and/or life safety code issues.  When you feel ready to participate, you must write to this office requesting a survey.  We will schedule an initial survey after receipt of the fiscal intermediary’s approval of your 855 Enrollment Application.  Our surveyors will inspect the agency, interview you and members of your staff, review documents, and undertake other procedures necessary to evaluate the extent to which your agency meets the Conditions of Participation.  If your agency has significant deficiencies in any of the Conditions, you will be informed and given an opportunity to correct them.


After we have completed the survey of your facility, we will forward with our recommendation, all documentation pertaining to your application to participate in the Medicare program to the Centers for Medicare & Medicaid Services (CMS), Division of Health Standards and Quality, Regional Office in Denver, Colorado.  They will review the documents, determine the effective date of your participation in the Medicare program, and will send you official notification.  Until you receive such notification, Medicare certification is not official.  Reimbursement cannot be made for services provided to Medicare beneficiaries prior to the effective date of participation.


After it is determined by CMS that all requirements are met, the Health Insurance Benefits Agreement will be countersigned.  One copy will be returned to you, along with the notification that your agency has been approved.  If operation of the entire agency is later transferred to another owner, ownership group, or to a lessee, the agreement will automatically be assigned to the successor.  You are required to notify OHLS and CMS at the time you are planning such a transfer.Those institutions and agencies that are denied approval to participate in the Medicare program are sent notification giving the reasons for the denial and information about their rights to appeal the decision.


It is to your benefit to read the Outpatient Physical Therapy/Speech Pathology Interpretive Guidelines and Conditions of Participation very carefully.  You must meet the minimum guideline qualifications to be eligible to participate.  Please do not hesitate to telephone the Office of Healthcare Licensing and Surveys at (307) 777-7123 if you have any questions.

Federal Certification Forms and Regulations

      Interpretive Guidelines (Regulations) - Appendix E

      Fiscal Intermediaries List

      CMS 855 Enrollment Application Information
      CMS 855 Application Fee Information

      Provider/Supplier Enrollment Forms and List (CMS-855 Application, etc.) 

      Health Insurance Benefit Agreement Form (CMS-1561 – 3 originals required)

Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy and/or Speech Pathology Services (CMS-1856)