A valid state license is required prior to providing care to any clients.
Following are the requirements and procedures through which your agency may be approved to be licensed as a provider of Psychiatric Hospital Facility services.
Click below for a license application for State licensure. Please fill out the application in its entirety and submit to our office, along with the required fee. After reviewing the regulations, please contact one of our engineers at (307) 777-7123 to discuss the building requirements and any construction review approval process. Once we have approved these items, a provisional license will be issued, and you will be able to start providing services to clients/patients/residents.
When you have clients for which you are providing services, your agency must request, in writing, that a health survey be conducted. An unannounced survey will be provided by state surveyors as soon as scheduling permits.
A valid license permits an applicant to operate a healthcare facility in Wyoming. It does not enroll or certify a provider or supplier of healthcare services to participate in federal certification programs (Medicare/Medicaid).
State Initial-CHOW License Application Instructions
State Initial-CHOW License Application
State Change of Information Application Instructions
State Change of Information Application
State Miscellaneous Update of Information Application
Psychiatric Hospital Facility Rule
Chapter 15 (Licensure) – 06-18-1999
Healthcare Facility Construction Rule/Guidelines – click here
Life Safety Code Standards – click here
The Centers for Medicare & Medicaid Services (CMS) has issued revised survey priorities due to very substantial federal resource limitations. In light of the federal Medicare resource constraints, initial surveys for most provider and supplier types have been classified at the lowest priority level. For facilities that qualify for deemed status there is an alternate route to obtain certification and this may well be the fastest way to obtain certification this year. However, there are other types of facilities for which deemed status is not an option. The Survey and Certification Letter S&C-08-03 can be accessed for additional information.
Following are the requirements and procedures through which your agency may be approved to participate in Medicare as a provider of hospital services. Healthcare Licensing and Surveys (HLS) certifies and, periodically, recertifies providers of services to assure Medicare Conditions of Participation are met. This assists the Centers for Medicare and Medicaid Services (CMS) in determining if agencies can participate in Medicare. Such approval is prerequisite to qualifying to participate in the state Medicaid program as well.
You are subject to complete an HCFA-855A or HCFA-855B. The HCFA-855A is the Medicare Federal Health Care Provider/Supplier Application for Health Care Providers that will Bill Medicare Fiscal Intermediaries, and the HCFA-855B is the Medicare Federal Health Care Provider/Supplier Application for Health Care Suppliers that will Bill Medicare Carriers. Please see application link and fee information link below.
It is your responsibility to contact the appropriate fiscal intermediary (FI) or carrier (see link below) for the appropriate enrollment application. Please be aware your FI of preference does not automatically guarantee you will be assigned to that FI. Questions regarding this enrollment application must be directed to the FI or carrier. Once you have received and completed this enrollment application form, you must submit it directly to the FI or carrier. Our office will be notified by the FI or carrier of their review and recommendations to CMS with regard to your application. Until such time the state agency will not perform the federal survey.
Below are links to the survey and certification forms which are necessary to complete if you desire to participate. Please complete and submit them promptly in order to avoid unnecessarily delaying approval, since your facility cannot claim provider reimbursement for services furnished prior to approval. If the forms are not self-explanatory, you may telephone (307) 777-7123 for assistance. Submit ALL COPIES OF THE FORMS.
On the second line of the Health Insurance Benefits Agreement, after the term Social Security Act, enter the entrepreneurial name of the enterprise, followed by the trade name (if different from the entrepreneurial name). Ordinarily, this is the same as the business name used on all official IRS correspondence concerning payroll withholding taxes, such as the W-3 or 941 forms. For example, the ABC Corporation, owner of the Community General Hospital, would enter on the agreement, ABC Corporation d/b/a Community General Hospital. A partnership of several persons might complete the agreement to read: Robert Johnson, Louis Miller and Paul Allen, ptr., Easy Care Home Health Services. A sole proprietorship could complete the agreement to read: John Smith d/b/a Mercy Hospital. The person signing the Health Insurance Benefits Agreement must be someone who has the authorization of the owners of the enterprise to enter into this agreement.
Our surveyors will inspect the agency, interview you and members of your staff, review documents, and undertake other procedures necessary to evaluate the extent to which your agency meets the Conditions of Participation. If your agency has significant deficiencies in any of the Conditions, you will be informed and given an opportunity to correct them. After we have completed the survey of your facility, we will forward, with our recommendation, all documentation pertaining to your application to participate in the Medicare program to the Centers for Medicare and Medicaid Services (CMS) Regional Office in Denver, Colorado. They will review the documents, determine the effective date of your participation in the Medicare program, and will send you official notification. Until you receive such notification, Medicare certification is not official. Reimbursement cannot be made for services provided to Medicare beneficiaries prior to the effective date of participation.
After it is determined by CMS that all requirements are met, the Health Insurance Benefits Agreement will be countersigned. One copy will be returned to you along with the notification that your agency has been approved. If operation of the entire agency is later transferred to another owner, ownership group, or to a lessee, the agreement will automatically be assigned to the successor. You are required to notify HLS and CMS at the time you are planning such a transfer.
Those institutions and agencies that are denied approval to participate in the Medicare program are sent notification giving the reasons for the denial and information about their rights to appeal the decision.
It is to your benefit to read the Hospice Facility Interpretive Guidelines and Conditions of Participation very carefully. You must meet the minimum guideline qualifications to be eligible to participate. Please do not hesitate to telephone this office if you have any questions.
Also, Psychiatric Hospital facilities are required to be licensed by the State of Wyoming.
Federal Forms and Regulations
Reporting of Hospital Death Associated with Restraint or Seclusion
S&C: 14-27-Hospital-CAH/DPU – Memorandum re Hospital Restraint/Seclusion Deaths to be Reported Using the Centers for Medicare and Medicaid Services Form CMS-10455 (memo dated 05/09/14)
WDSC-RO8-1c – Memorandum providing clarification to hospitals regarding the reporting of Restraint/Seclusion Deaths (memo dated 03/08/17)
Reporting Form CMS-10455 (11/13)
Interpretive Guidelines (Regulations) – Appendix AA
Fiscal Intermediaries List
CMS 855 Enrollment Application Information
CMS 855 Application Fee Information
Provider/Supplier Enrollment Forms and List (855 Application, etc.)
Health Insurance Benefit Agreement Form (CMS-1561)
Office of Civil Rights (OCR)
Office of Civil Rights: https://www.hhs.gov/ocr/civilrights/clearance/index.html
If you are a healthcare provider seeking initial Medicare Part A certification and/or undergoing a change of ownership (CHOW), you need a civil rights clearance.
To receive a civil rights clearance, you must complete the Civil Rights Information Request for Medicare Certification Package. To guide you through completing the Package, OCR has created a portal that will help you develop/submit polices that meet your civil right requirements.
You must submit the civil rights package online directly into the OCR intake queue at https://ocrportal.hhs.gov/ocr/pgportal. You will receive an e-mail from OCR stating that you have completed the civil rights submission. The e-mail will contain an OCR number, which is critical to OCR’s ability to access your submission from the OCR intake queue. You must submit a copy of this e-mail to Healthcare Licensing and Surveys.
CMS is aware that the HHS form 690 (assurance of compliance), link https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf, has been discontinued. In accordance with the Paperwork Reduction Act of 1995, as amended, a revised form is pending approval at the U.S. Office of Management and Budget. Providers need to be aware that even though the link is down, they are still held accountable to establish and maintain compliance with civil rights requirements. Additionally, the CMS approval of Initial or CHOW provider agreements will be contingent upon the Office for Civil Rights (OCR) approval of compliance with Civil Rights requirements. This site will be updated once further guidance regarding future OCR Clearance process had been determined.