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 Community Health (MDCH) and the Centers for Medicare & Medicaid Services (CMS) Regional Office.

3.

Completed application forms listed below must be sent to MDCH 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.

MDCH is not at this time authorized by CMS to conduct initial surveys for Medicare certification of hospice agencies due to federal budgetary constraints. Provider applicants are therefore responsible for initiating contact with one of the three accrediting organizations (shown below) approved by CMS to conduct initial surveys incorporating Medicare hospice requirements. Results of the survey indicating compliance with the accrediting organization's standards must be submitted to MDCH.

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 MDCH.