Home Health Agencies (HHA)- Initial Medicare Certification.

A licensed Comprehensive Home Care Provider will complete the following forms:

• CMS-1572 (a and b) (PDF)
• CMS-1561 (PDF)
• Civil Rights Attestation and the Assurance of Compliance form  US Office of Civil Rights Assurance of Compliance.

Email above documents to: Health.HRD-FedLCR@state.mn.us

Submit application to the designated Medicare Administrative Contractor (MAC)

• CMS 855A Medicare Enrollment Application (PDF)

See link below for MAC contacts

 Medicare Fee-for-Service Provider Enrollment Contact List

*Important:  The MAC CMS-855 approval letter is NOT the final approval for Initial Medicare Certification.

• Contact a Centers for Medicare and Medicaid Services (CMS) approved National Accrediting Organization (AO) to conduct the initial Medicare survey. 

A list of CMS approved AOs can be found at the following link:

  CMS-approved Accrediting Organizations (PDF)

The Minnesota Department of Health (MDH) will proceed with this process when all required forms have been completed the CMS-855 has been approved by the MAC and the AO has completed the initial Medicare survey 

MDH will forward its recommendation for certification or denial to the MAC.  The MAC will forward the final determination to the facility.

Any questions please email:  Health.HRD-FedLCR@state.mn.us

Refer to Chapter 2 of the State Operations Manual – Home Health Agency - see link below:

The State Operations Manual - Chapter 2 - Organization of HHA - Chapter 2182 (PDF)