Ambulatory Surgical Centers (ASCs)

10.2.2.1 – Ambulatory Surgical Centers (ASCs) (Rev. 12209; Issued: 08-17-23; Effective: 09-18-23; Implementation: 09-18-23) 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