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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES Form Approved OMB No. 0938-0581 CLINICAL LABORATORY IMPROVEMENT AMENDMENTS CLIA APPLICATION FOR CERTIFICATION I. The valid OMB control number for this information collection is 0938-0581. The time required to complete this information collection is estimated to average 30 minutes to 2 hours per response including the time to review instructions search existing data resources gather the data needed and complete and...
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How to fill out CMS-116

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How to fill out CMS-116

01
Gather necessary information about the program and beneficiaries.
02
Download the CMS-116 form from the official CMS website.
03
Start by filling out the top section with your organization’s name and address.
04
Provide your National Provider Identifier (NPI) and Medicare number if applicable.
05
Indicate the type of service provided by your organization.
06
Complete the sections regarding the geographical area served.
07
Fill in the details related to the services offered according to the guidelines.
08
Ensure all information is accurate and complete to avoid delays.
09
Review the form for any errors or missing information.
10
Submit the completed CMS-116 form according to the specified submission guidelines.

Who needs CMS-116?

01
Healthcare providers aiming to participate in Medicare programs.
02
Organizations that provide health services and require Medicare certification.
03
Entities looking to report service information to CMS.

Who needs a CMS Form 116?

According to the United States Federal Law, every facility which deals with doing laboratory testings on humans (excluding basic researches and clinical trials) must comply with CIA standards. To be legally allowed to perform this type of activities, a laboratory facility has to be officially acknowledged as a clinical laboratory. The results achieved by such facilities are to be used for establishing diagnoses, preventing and treating diseases, and making general health condition assessments.

CIA regulations should be fulfilled even in case a laboratory performs one of few basic test free of charge.

What is the CIA Application for Certification Form for?

The Clinical Laboratory Improvement Amendments Application for Certification has been created to collect operation data about a laboratory facility. It will be used for defining the type of certificate to issue and fees to charge.

As for the types of CIA Certificates, they can be as follows:

    Certificate of Waiver

    Certificate for Provider-Performed Microscopy Procedures (PPM)

    Certificate of Compliance

    Certificate of Accreditation

However, typically if the CMS Form 116 is filed for the first time as an initial application, the laboratory in most will be issued a Certificate of Registration. Right after an inspection is conducted, another type of certificate will be provided.

Is Form CMS-116 accompanied by other forms?

It is strongly recommended that the applying facility contacts their State Agency for additional requirements as for supporting documentation, forms or statements as they vary from one state to another. In fact, this is true not only regarding the state of laboratory operation, but also regarding the type of CIA Certificate applied for. For instance, supervising personnel of laboratory where nonwaived tests and PPM procedures are performed must comply with certain requirements as for educational and training background and experience. Therefore, in such a case, the confirmation of these requirements being met must be attached to a completed CMS-116 form.

When is CMS Form 116 due?

A process of the CMS-116 application revision is quite time-consuming, as it can take up to two months. Nevertheless, a laboratory facility can start its work as soon as their payment of a registration fee is credited. And in about two weeks, the requested Certificate will be delivered.

The CIA Certificate is valid for two years. To renew the certificate in a timely manner, it is necessary to file a new CMS-116 form with no less than nine months prior to the effective certificate's expiration date. And if the form is filed and payment made until the due date, the renewed Certificate will be received one month before the current Certificate’s expiration date.

How do I fill out the CIA Application for Certification Form?

The application should provide relevant information on the following items:

    Facility’s general information (type of application, name, address, email, name of director, etc.);

    Type of requested certificate and appropriate testing (indicated further);

    Type of laboratory;

    Hours of testing;

    Single/multiple sites;

    Type of control;

    Director affiliation with other laboratories;

    Owner/director’s signature and date

Where do I send CMS Form 116?

The completed Clinical Laboratory Improvement Amendments Application for Certification must be submitted to the local State Agency in the State where the laboratory testing will be performed. The full list of addresses and other contact information can be found in this online PDF document.

Instructions and Help about CMS-116

Welcome to go beyond learning experiences to code Metro our goal in creating this series is to provide you with tangible oftentimes little-known tips that you can apply to both your business and your career our topics will vary as will our speakers, and we welcome you to visit our website to get the latest edition of go beyond we appreciate your feedback and invite you to send us your thoughts and questions as well as any suggestions you might have for future topics our first edition of go beyond focuses on tips for completing the CMS 1500 form for faster payment our presenter today is our own chief operating officer Dr. Kim finger Kim has an extensive background in autism having served as a direct service provider in Connecticut many years ago after which she swayed into the world of executive coaching prior to joining code Metro Kim was the chief operating officer at autism spectrum therapies a large California-based autism services company Kim created the insurance billing department at code Metro and is here to share with you her tips on completing the 1500 form hello it's my pleasure to share with you our tips on how to successfully complete a CMS 1500 form a question were frequently asked by our customers is which fields on the 1500 form must be completed for the CMS form to be accepted and not rejected by the insurance carrier, so today we're going to answer this question as well as review which fields are optional to complete and which can be left blank we'll also be reviewing what information is entered in each of the mandatory and optional fields recognizing that the language on the 1500 form is foreign to most providers and a source of confusion when preparing the form okay let's take a look at the 1500 form there are 33 fields on the form of which two fields can always be left blank without worry and that's field 10d reserved for local use and field 15 if patient has had same or similar illness give first date now that we have those out of the way let's talk about the fields that must be completed to submit a clean claim before we go through the numbered fields let's start with entering the name and address of the insurance company in the top right-hand corner of the form, although you may be submitting the form electronically the name and address of the insurance carrier must be included in this space on the form itself field 1a is a required field in this field you will enter the patient's insurance policy number as indicated on their insurance card in some cases the card will be in the parents name and their policy number will be entered here the ID number though will reflect not the parent but the patient's insurance ID number fields 2 camp; 5 capture patient name and address and must be completed the only optional field is telephone number fields 4 camp; 7 will contain the same name and address as fields 2 camp; 5 although the name on the insurance card may be the mother or father's name recent changes dictate that the patient...

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People Also Ask about

For a change in certificate type you must complete the CLINICAL LABORATORY IMPROVEMENT AMENDMENTS (CLIA) APPLICATION FOR CERTIFICATION marked for a change in certificate type. Make sure you follow instructions to complete and submit all the requested information including the List of Tests Performed in the Facility.
Types of CLIA Certificates Certificate of Waiver. Certificate for Provider Performed Microscopy Procedures (PPM) Certificate of Registration. Certificate of Compliance. Certificate of Accreditation.
Can I transfer my CLIA certificate to the new owners? Yes. The new owners can request a transfer by completing a CMS-116 Application Form and a CLIA Ownership Information form" found under CERTIFICATION & FEES on webpage.
The CLIA application (Form CMS-116) collects information about your laboratory's operation which is necessary to determine the fees to be assessed, to establish baseline data and to fulfill the statutory requirements for CLIA. This information will also provide an overview of your facility's laboratory operation.
There are five different CLIA certificate types which all are effective for a period of two years. Except for the Certificate of Compliance and Certificate of Accreditation, renewal of each certificate is accomplished by payment of the certificate fees.
What is a Waived Test? Based on the complexity of the tests, CLIA tests are categorized into three levels: waived, moderate complexity, and high complexity tests. CLIA defines waived tests as “Simple laboratory examinations and procedures that have an insignificant risk of an erroneous result.”

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CMS-116 is a form used by healthcare providers to report and submit specific information related to the services they provide under the Medicare program.
Healthcare providers who offer services reimbursed by Medicare are required to file CMS-116, including hospitals, skilled nursing facilities, and home health agencies.
To fill out CMS-116, providers should gather required data, follow the instructions provided with the form, and accurately complete all sections, ensuring that all information is current and correct before submission.
The purpose of CMS-116 is to collect necessary information from healthcare providers to ensure compliance with Medicare regulations and to facilitate the processing of claims.
Information that must be reported on CMS-116 includes provider identification details, service descriptions, billing information, and any other data as specified in the form instructions.
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