Your clinic can add home dialysis or self-care dialysis by following the steps below to comply with the federal Medicare Conditions for Coverage for End Stage Renal Disease.
Conditions for Coverage
- Conditions for Coverage for End-Stage Renal Disease Facilities; Final Rule
- Conditions for Coverage for End-Stage Renal Disease Facilities: Interpretive Guidance, Interim Final Version 1.1
Required forms and documentation
1. Download a copy of CMS form 855a, and follow the instructions to fill it out.
2. Submit the completed CMS-855a to your fiscal intermediary (FI). Your FI can answer any questions you have before you submit the form so it is accurate.
- Fiscal intermediaries by state (on-line table) - 1) choose your state; 2) for "Contact Type", choose "all contact types"; 3) and for "Contacts whose organization type is", choose "Fiscal Intermediary"; 4) then search.
3. Promptly contact your local State Survey Agency. They will provide you with any additional forms you need and information they require (License, CON, etc.), and help you if you want to apply for Medicaid enrollment. You will need to fill out a CMS-3427 form: the End Stage Renal Disease Application and Survey and Certification Report.
- State Survey Agency Directory
- Survey and Certification Regional and Central Office Management
- Medicare Fee-for-Service Claims Contact Directory
4. After the FI recommends you for approval, the stage agency will conduct a state survey, on average within 60 days of receiving your application (assuming your forms were complete and you provided the FI with any information they requested).
5. If you pass the state survey, the local CMS regional office will contact you about issuance of a formal signed agreement. Upon completion of the agreement, you will be given a Centers for Medicare & Medicaid Certification Number (CCN, formerly provider number) and allowed to submit billings.
6. If you have already submitted an application and have a problem with the FI, contact the CMS regional office in the state where the FI is located. The regional office has responsibility for monitoring the FI’s performance, and will be glad to assist you.