End-Stage Renal Dialysis Facility Initial Medicare Certification
This page contains instructions for initial Medicare certification for end-stage renal dialysis facilities in Minnesota.
- Submit CMS 855A application and all supporting documentation to the designated Medicare Administrative Contractor (MAC) for approval.
CMS 855A Medicare Enrollment Application (PDF)
(See Medicare Fee-for-Service Provider Enrollment Contact List)
- Send the following to MDH at the address below or submit via email:
- Provide written notice on facility letterhead including the name and address of facility.
- Complete the End-Stage Renal Dialysis Application and Survey and Certification Report (CMS-3427) (PDF)
- Complete the Life Safety Code Attestation for Exempt ESRD Facilities (PDF)
Unannounced Survey Process
When MDH has received the above documents, a Health Facility Identification (HFID) number will be assigned to the facility. MDH engineering and State Fire Marshal (SFM) inspection may be required based on Life Safety Code (LSC) attestation.
A request for survey will be sent to the MDH health supervisor to schedule the initial certification survey.
If no deficiencies are issued at the time of the survey, MDH will recommend Medicare Certification to Region V Office of CMS effective the date of the survey.
If standard level deficiencies are issued at the time of the survey, a plan of correction is required. With an acceptable plan of correction, MDH will recommend Medicare certification to Region V Office of CMS effective the date the acceptable plan of correction is received in this office.
If Conditions of Participation have not been met at the time of the survey, MDH will recommend denial of Medicare certification to Region V Office of CMS. Region V Office of CMS will deny the application. If denied a new initial Medicare application need to be completed.
Certification Recommendation to CMS
MDH will process the certification survey, approved 855 and federal forms with recommendation to Region V Office of CMS. Region V Office of CMS will review the application and will send a letter to the facility when approved including the CMS Certification Number (CCN) number.
Mail or email completed documents to:
Minnesota Department of Health
Health Regulation Division
Licensing and Certification Program
P.O. Box 64900
St. Paul, Minnesota 55164-0900
Attn: Certification Specialist