The applicant completes and submits a Medicare Enrollment Application (CMS-855A) form and all supporting documentation noted in the application to its Fiscal Intermediary.

2.

The Fiscal Intermediary reviews the CMS-855A application and determines if there is any evidence that the application should be denied with notification to the State Survey Agency, the Michigan Department of Licensing and Regulatory Affairs (LARA) and the CMS Regional Office.

3.

Completed application forms listed below must be sent to LARA at the address shown below at the same time the CMS-855A is submitted to the Fiscal Intermediary.
-- two signed originals of the CMS-1561 form ( Health Insurance Benefits Agreement)
-- Civil Rights information request forms
-- One original Medicare Intermediary Information form (BHS-LC-152)
-- One original CMS-417 form (Hospice Request For Certification In The Medicare Program)

4.

LARA is not at this time authorized by CMS to conduct initial surveys for Medicare certification of hospice agencies. Applicants are therefore responsible for initiating contact with one of the 3 accrediting organizations (shown below) approved by CMS to conduct initial surveys. Results of the survey indicating compliance with the accrediting organization's standards must be submitted to LARA.

5.

The application documents are then paired with the survey results and a recommendation to CMS for approval or denial of the certification request is made by LARA.