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Rural Health Clinic - 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.

      Following are the requirements and procedures through which your agency may be approved to participate in Medicare as a provider of Rural Health Clinic 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 for Medicare & 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.

      At the end of this narrative are links to 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.   

      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, you will receive 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, 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 Rural Health Clinic 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 G

Fiscal Intermediaries List

CMS 855 Enrollment Application Information
CMS 855 Application Fee Information

Occupancy approval - To insure the safety of patients, personnel, and the public, the physical plant should be maintained consistent with appropriate State and local building, fire, and safety codes.  Please submit a copy of reports prepared by State and local personnel responsible for insuring that the appropriate codes are met (occupancy approval).
Provider/Supplier Enrollment Forms and List (855 Application, etc.)

Request to Establish Eligibility to Participate in the Health Insurance for the Aged and Disabled Program to Provide Rural Health Clinic Services (CMS-29)

Office of Civil Rights

(This section applies to only provider-based Rural Health Clinics.)

Office of Civil Rights:

If you are a healthcare provider seeking initial Medicare Part A certification and/or undergoing a change of ownership (CHOW), you need a civil rights clearance.

To receive a civil rights clearance, you must complete the Civil Rights Information Request for Medicare Certification Package. To guide you through completing the Package, we have created this portal that will help you develop/submit polices that meet your civil right requirements.

You may submit hard copies of the civil rights package to the Wyoming Healthcare Licensing and Surveys OR you may choose to submit the civil rights package online directly into the OCR intake queue at

If you opt to submit online, you will receive an e-mail from OCR stating that you have completed the civil rights submission. The e-mail will contain an OCR number, which is critical to OCR’s ability to access your submission from the OCR intake queue. You must submit a copy of this e-mail to Healthcare Licensing and Surveys in lieu of the completed hard copy package.

Healthcare Licensing and Surveys will include the hard copy package or the OCR number, along with the initial or Change of Ownership (CHOW) certification paperwork, to the Centers for Medicare and Medicaid Services (CMS) Regional Office. The Centers for Medicare and Medicaid Services (CMS) will not certify you as a Medicare provider if you do not receive a clearance from OCR.