Ambulatory Surgical Center (ASC)

Certification Application Process

1. 855 application submitted and approved by the ASC’s Fiscal Intermediary.
2. CMS 377 form completed and submitted to HSS.
3. CMS 370 completed in triplicate (each form must have original signatures) and submitted to HSS.
4. All licensed ASC facilities seeking initial Medicare certification must apply to one of the following accreditation organizations for an "initial deemed status Medicare survey" :
   
       a. TJC - The Joint Commission
   
       b. AAAHC - Accreditation Association of Ambulatory Care
   
       c. AAAASF - American Association for the Accreditation of Ambulatory Surgery Facilities, Inc.
   
       d. AOA - American Osteopathic Association
5. After the initial deemed status Medicare survey has been completed, LDH-HSS must receive a copy of the "deemed status" award letter.

Initial License Application

Louisiana has a licensing law for ambulatory surgical centers (ASCs) (La. R.S. 40:2131-2141) for those facilities requesting to be licensed as such. The law specifically excludes hospitals, nursing homes, abortion clinics and any facilities used for or relating to abortion procedures. The Louisiana Department of Health and Hospitals, Health Standards Section issues Ambulatory Surgical Center licenses. Once a license has been issued it shall be valid until its expiration date, unless otherwise revoked, suspended, or terminated. 

To submit electronically: ASC Initial Licensing Application and License Renewals

To submit via e-mail/mail:

1. License Application Checklist
2. Licensing Application Form
3. Applicable licensing fees ($600) 
   • HSS Payment Procedure web page
   • This fee is not refundable in the event the facility fails to meet the licensing requirements and HSS determines that a license could not be issued.
4. A  Letter of Intent must accompany each licensing application describing the DBA name of the facility to be licensed, the geographic address of the ASC requesting to be licensed, the anticipated date of completion of the ASC or the anticipated date by which the facility would be ready for licensing, and the types of surgical specialties to be provided in the ASC.
5. Notification to Health Standards Section that application has been filed with the La. Board of Pharmacy for the ASC’s Controlled Dangerous Substance (CDS) license.

An on-site announced licensing survey will only be scheduled and conducted by HSS after completion of above.

License Renewal

To submit electronically: ASC Initial Licensing Application and License Renewals

To submit via e-mail/mail:

1. A renewal letter will be mailed to the provider from Health Standards Section approximately 75 days in advance of the license expiration date .
2. Items that shall be submitted to Health Standards Section for a license renewal:
   1. Licensing Application (HSS-AS-01)
   2. Licensing fee: There has been a change in the HSS Payment Procedure web page; please follow the link for instructions.
   3. Copy of the current Fire Marshall Inspection
   4. Copy of the current Health Inspection Report
3. Once all requirements have been met, a new license will be mailed to the provider on the 20th or 21st  of the month before the current license expires.

Name Change

Providers licensed by Health Standards Section (HSS) must notify the department of any name change for the ASC. Providers shall pay the $25.00 application fee for a change in license, a completed license renewal application to reflect the new name, notification and name change with the Secretary of State, and a revised 855 reflecting the name change. Notification shall be in writing, on facility or agency letterhead. 
Click here for the name change checklist HSS-AS-0101 form

Change of Ownership Information

Providers must complete this document when they have a change in their ownership structure. This document would be used for both a change of ownership (CHOW) as defined by state and/or federal regulations, or a change of ownership information (CHOI) that does not meet the state and/or federal regulations CHOW definition.

 For Health Standards to make a CHOW/CHOI determination, all providers must submit the following documents:

1. *Letter of Intent (including d/b/a and entity name of the previous and the new owner, the effective date of transfer of ownership, address and phone number)
2. *A diagram showing the ownership structure “before” and “after” the change
3. *Copy of the executed Bill of Sale
4. *CHOW/CHOI License Application
5. *855A/B approval letter for the following providers: Home health, hospice, hospitals, RHCs, ASCs,   

ESRDs, portable x-ray, community mental health and OPT.

Note: If this action is a CHOI, the documents above are the only documents you need to submit, however the Department may, at its discretion, request additional documentation in support of the CHOI. If so, you will be contacted for any of said additional documents. There is no fee for a CHOI. 

If this action is a CHOW, the following documents are also needed:

1. Does your facility have a CLIA Certificate? If yes, contact the CLIA program.
2. *Licensing Fee: Click here for the link for the Health Standards Fee Schedule

The fee for a CHOW is usually the same as a license renewal unless the facility is making additional changes. For the providers completing an acquisition/merger, please contact the program desk for assistance.

Additional Documents Required:

1. License Application
2. Checklist for ASC CHOW
3. License Application Addendum Emergency Preparedness
4. Disclosure of Ownership
5. Attestation Letter
6. Fiscal-Year-End Deadline
7. Plan Review Attestation 

For all other Change of Ownership Information, please contact the HSS Ownership Group