Hospital Medicare Certification

PLEASE NOTE: The Illinois Department of Public Health (IDPH) is no longer able to conduct initial Medicare Certification Surveys. You must now contact an Accreditation Agency such as AOA/HFAP, CIHQ, DNV Healthcare or JC to do your survey. However, you are still required to complete an 855A* and other Medicare forms to enroll and receive a provider number from the Centers for Medicare and Medicaid Services (CMS).

THE FACILITY MUST FILL OUT THE FORM 855A AND RETURN THE ORIGINAL TO ITS FISCAL INTERMEDIARY. When the 855A is approved by the Fiscal Intermediary, a copy of the 855A will be forwarded to the Illinois Department of Public Health (IDPH). Questions regarding the 855A should be directed to the Fiscal Intermediary. The 855A can be found at the following website:

*PLEASE NOTE: When the 855A is approved by your Fiscal Intermediary, it will be forwarded to IDPH. Your intermediary will notify you by mail when the 855A has been sent to us.

All other forms (ORIGINALS) listed on this instruction sheet should be filled out and returned to IDPH at the address listed below. Please be advised, however, that these forms are only valid for six months from the date they are completed. Therefore, it is advised that you wait to submit your forms to IDPH until such time as you have contacted the Accreditation Agency, processed your application with them, and completed your Accreditation survey.

Upon completion of your Accreditation Survey, mail a copy of your accreditation approval letter and any other documentation received from your accrediting agency along with the Medicare forms listed below to:

Questions regarding Medicare Forms ONLY, should be directed to 217-782-0582.

CMS-1561 - Health Insurance Benefits Agreement form –(2 originals required) Make sure you sign/date/put your title in the section that says “Accepted for the provider of Services by”. ***DO NOT SIGN IN THE OTHER TWO SIGNATURE BLOCKS***

Medicare Intermediary Information – (1 original required)

Office for Civil Rights (OCR)Clearance Process – A health care provider that applies for participation in the Medicare Part A program must receive a civil rights clearance from OCR, as set forth in 42 CFR 480.10(b).

Initial Enrollment or CHOW- the Civil Rights Packet may be submitted on line- by submitting the attestation electronically to the OCR via OCR’s online Assurance of Compliance portal at the following website.
Your agency will receive an electronic verification from OCR of successful submission of the attestation. Submit to the Department a copy, demonstrating evidence of successful electronic submission of the attestation.

When all of the pertinent documents are received, they will be forwarded to CMS (Centers for Medicare and Medicaid Services) in Chicago.