CMS Pub. 100-08, ch. 10, § 10.2.2.1

ASCs are a certified supplier type that enroll via the Form CMS-855B.

A. Background

An ASC is defined in 42 CFR § 416.2 as any distinct entity that operates exclusively for the

purpose of providing surgical services to patients not requiring hospitalization and in which the

expected duration of services would not exceed 24 hours following an admission; the entity must

have an agreement with CMS to participate in Medicare as an ASC and must meet the conditions

set forth in 42 CFR Part 416, subparts B and C (The ASC supplier agreement (Form CMS-370)

is similar to the provider agreement signed by Part A providers.)

An ASC satisfies the criterion of being a “distinct” entity when it is separate and clearly

distinguishable from any other healthcare facility or office-based physician practice. Thus,

distinct entity means that surgical services may only be provided at the single location listed in

the Medicare supplier agreement. Medicare-certified ASCs are not permitted to have multiple

locations under the same supplier agreement. If an entity owns multiple surgical locations and

wishes them to participate in Medicare as an ASC, each location must seek separate participation

and enrollment and must demonstrate independent compliance with the ASC conditions of

coverage, for the regulations do not permit configurations of multiple ASC locations under one

Medicare agreement. (Each location would be considered a new, initial enrollment; thus, if an

enrolled ASC wishes to add a second practice location, the transaction would constitute a new,

initial enrollment rather than the addition of a practice location to an existing enrollment.) ASCs

may only have one surgical location per CMS Certification Number (CCN). See also CMS

Publication (Pub. 100-07), State Operations Manual, chapter 2, section 2210 for more

information.

As stated in § 416.26(a), CMS may deem an ASC to be in compliance with any or all of the ASC

conditions of coverage set forth in 42 CFR Part 416, subpart C if:

• The ASC is accredited by a national accrediting body, or licensed by a state agency, that

CMS determines provides reasonable assurance that the conditions are met;

• In the case of deemed status through accreditation by a national accrediting body, where state

law requires licensure, the ASC complies with state licensure requirements; and

• The ASC authorizes the release to CMS of the findings of the accreditation survey.

Unless CMS deems the ASC to be in compliance with the ASC conditions of coverage in 42

CFR Part 416, subpart C, the state survey agency must survey the facility to ascertain

compliance with those conditions. (See 42 CFR § 416.26(b).)

B. Processing Instructions for ASC Initial Form CMS-855B Applications

1. Receipt of Application

Upon receipt of an ASC initial Form CMS-855B application, the contractor shall undertake the

following (in whichever order the contractor prefers unless directed otherwise in this chapter):

(A) Perform all data validations otherwise required per this chapter.

(B) Ensure that the application(s) is complete consistent with the instructions in this chapter.

(C) Ensure that the ASC has submitted all documentation otherwise required per this chapter.

For ASC initial enrollment, this also includes the Form CMS-370 (ASC supplier agreement).

(The ASC must complete, sign, date, and include the Form CMS-370, though the ASC need not

complete those sections of the form reserved for CMS. For organizational ASCs, an authorized

official (as defined in § 424.502) must sign the form; for sole proprietorships, the sole proprietor

must sign.)

Notwithstanding the foregoing, if the Form CMS-370 or the Form HHS-690 evidence is missing,

unsigned, undated, or otherwise incomplete, the contractor need not develop for the form(s) or

the information thereon; the contractor shall instead notify the state in its recommendation letter

which document(s) was/were missing or otherwise incomplete. For all other missing or

incomplete required documentation, the contractor shall follow the normal development

instructions in this chapter.

2. Conclusion of Initial Contractor Review

(Nothing in this section 10.2.2.1(B) prohibits the contractor from returning or rejecting the ASC

application if otherwise permitted to do so per this chapter. When returning or rejecting the

application, the contractor shall follow this chapter’s procedures for doing so.)

(A) Approval Recommendation

If, consistent with the instructions in section 10.2.2.1(B) and this chapter, the contractor believes

an approval recommendation is warranted, the contractor shall send the recommendation to the

state pursuant to existing practice and this chapter’s instructions. The contractor need not copy

the SOG Location or PEOG on the recommendation. Unless CMS directs otherwise, the

contractor shall also send to the provider the notification letter in section 10.7.5.1(E) of this

chapter.

The state will: (1) review the recommendation package for completeness; (2) review the

contractor’s recommendation for approval; (3) perform any state-specific functions; and (4)

contact the contractor with any questions. The contractor shall respond to any state inquiry in

Item (4) within 5 business days. If the inquiry involves the need for the contractor to obtain

additional data, documentation, or clarification from the ASC, however, the timeframe is 15

business days; if the provider fails to respond to the contractor within this timeframe, it shall

notify the state thereof. The contractor may always contact its PEOG BFL should it need the

latter’s assistance with a particular state inquiry.

(B) Denial

If the contractor determines that a denial is warranted, it shall follow the denial procedures

outlined in this chapter. This includes: (1) using the appropriate denial letter format in section

10.7.8 of this chapter; and (2) if required under section 10.6.6 (or another CMS directive) of this

chapter, referring the matter to PEOG for review prior to denying the application.

3. Completion of State Review

The state will notify the contractor once it has completed its review. There are two potential

outcomes:

(A) Approval Not Recommended

If the state does not recommend approval, it will notify the contractor thereof. (The contractor

may accept any notification that is in writing (e-mail is fine).) No later than 5 business days after

receiving this notification, the contractor shall commence the actions described in section

10.2.2.1(B)(2)(B) above.

(B) Approval Recommended

If the state recommends approval, it will typically (though not always) do so via a Form CMS-

1539; the contractor may accept any documentation from the state signifying that the latter

recommends approval. (Note that the contractor will not receive a formal tie-in notice.)

No later than 5 business days after receipt of the recommendation from the state, the contractor

shall send an e-mail to MedicareProviderEnrollment@cms.hhs.gov with the following

information and documents:

• The Form CMS-855 application (or PECOS Application Data Report) and all application

attachments

• A copy of the Form CMS-1539 or similar documentation received from the state

• A copy of the supplier Form CMS-370

• A copy of the draft approval letter, with the effective date shown on the Form CMS-1539 (or

similar documentation) included in the draft letter. (See section 10.7.5.1 for the model

approval letter.)

PEOG will countersign the supplier agreement. Based on the information received from the

contractor, PEOG will also (1) assign an effective date, (2) assign a CCN, and (3) enter the

applicable data into ASPEN, and (4) approve (with possible edits) the approval letter. Within 5

business days of receiving from PEOG the signed supplier agreement, effective date, and CCN,

the contractor shall: (1) send the approval letter and a copy of the CMS-countersigned supplier

agreement to the ASC; (2) send a copy of both the approval letter and the supplier agreement to

the state and/or AO; and (3) switch the PECOS record from “approval recommended” to

“approved” consistent with existing instructions.

C. Additional Enrollment Information

The contractor shall ensure that, as applicable, all licenses, certifications, and accreditations

submitted by ASCs are included in the enrollment package that is forwarded to the state.

If the ASC applicant’s address or telephone number cannot be verified, the contractor shall

contact the applicant for further information. If the supplier states that the facility or its phone

number is not yet operational, the contractor shall continue processing the application. However,

it shall indicate in its recommendation letter to the state agency (“state”)/SOG Location that the

address and telephone number of the facility could not be verified.

When enrolling the ASC, and except as otherwise stated in this chapter or as otherwise instructed

by PEOG, the contractor shall use the effective date indicated on the state approval notice/letter

(e.g. CMS-1539). This is the date from which the supplier can bill for services.

D. ASCs and Reassignment

Physicians and non-physician practitioners who meet the reassignment exceptions in 42 CFR §

424.80, and CMS Pub. 100-04, Claims Processing Manual, chapter 1, sections 30.2.6 and 30.2.7

may reassign their benefits to an ASC. In such a reassignment, the individual and the ASC must

sign the Form CMS-855R. However, the ASC need not separately and additionally enroll as a

group practice in order to receive benefits. It can accept reassignment as an ASC.

E. ASCs Changes of Ownership (CHOWs) and Changes of Information

Though ASCs are not mentioned in 42 CFR § 489.18, CMS generally applies the CHOW

provisions of § 489.18 to them. CHOWs involving ASCs are thus handled in accordance with

the principles in § 489.18 and Pub. 100-07, chapter 3, sections 3210 through 3210.5(C). For

ASC CHOW processing instructions, see section 10.6.1.1 of this chapter.

The contractor shall process ASC changes of information in accordance with section 10.6.1.2 of

this chapter.

F. Additional General ASC Information

For more information on ASCs, refer to:

• 42 CFR Part 416

• Pub. 100-07, chapter 2, section 2210 and Appendix L. (See Pub. 100-07, chapter 2, section

2210 for information regarding the sharing of space between ASCs and other providers and

suppliers.)

• Pub. 100-02, Benefit Policy Manual, chapter 15, sections 260 – 260.5.3

• Pub. 100-04, chapter 14

G. ASCs and Hospitals

See the following instructions for guidance regarding hospital-operated/affiliated ASCs:

• Pub. 100-04, chapter 14, section 10.1

• Pub. 100-02, chapter 15, section 260.1