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Medicare Deemed Status Accreditation

Earn Medicare Deemed Status with AAAHC

AAAHC holds “deeming authority” from the Centers for Medicare & Medicaid Services (CMS) to conduct deemed status accreditation for ambulatory surgical centers (ASCs).

MDS accreditation may only be requested by a currently Medicare certified ASC or one that is seeking Medicare certification. Any other associated entity must request accreditation separately from the ASC seeking MDS.

MDS surveys are unannounced. Specific survey date and surveyor names are not provided for Medicare Deemed Status surveys.

*Application fees are non-refundable. MDS surveys are unannounced. Specific survey date and surveyor names are not provided for AAAHC/MDS surveys.

Make your commitment to accreditation readiness

At the core of our mission and vision is the 1095 Strong, quality every day philosophy. This commitment to ongoing education and quality improvement demonstrates survey readiness not only on the day of the survey but all 1,095 days of the accreditation term. A complete list of the AAAHC Policies and Procedures can be found within the Accreditation Handbook for Medicare Deemed Status.

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Surveys tailored to your organization

AAAHC tailors your accreditation survey to the type, size, and range of services offered by your organization. AAAHC determines the length of the onsite visit and the number of surveyors based on your Application for Survey and supporting documents. These factors determine your survey fee.

We welcome questions regarding the scope of your survey or the estimated survey cost. Application fees are non-refundable.

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For additional details regarding scheduling and cancellation policies, review the current version of the handbook applicable to your program.

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Qualify for accreditation

An organization is considered for accreditation by AAAHC on an individual basis and is eligible for accreditation if it meets all of the following criteria.

The organization

1. Has been providing health care services for at least six months before the onsite survey, excluding organizations seeking accreditation through an Early Option Survey (EOS)/Initial Medicare Deemed Status Survey.

2. Is either a formally organized and legally constituted entity that primarily provides health care services, or a sub-unit that primarily provides such services within a formally organized and legally constituted entity that may be, but need not be, health related.

3. Attests to its compliance with the AAAHC Survey Eligibility Criteria and to the definition of an ASC set forth by CMS, which can be found in the Code of Federal Regulations Title 42 Chapter IV Subchapter B Part 416.2 Definitions, which states:

Ambulatory surgical center or ASC means any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following an admission. The entity must have an agreement with CMS to participate in Medicare as an ASC, and must meet the conditions set forth in subparts B and C of this part.

ASC services means, for the period before January 1, 2008, facility services that are furnished in an ASC, and beginning January 1, 2008, means the combined facility services and covered ancillary services that are furnished in an ASC in connection with covered surgical procedures.

Covered ancillary services means items and services that are integral to a covered surgical procedure performed in an ASC as provided in §416.164(b), for which payment may be made under §416.171 in addition to the payment for the facility services.

Covered surgical procedures means those surgical procedures furnished before January 1, 2008, that meet the criteria specified in §416.65 and those surgical procedures furnished on or after January 1, 2008, that meet the criteria specified in §416.166.

Facility services means for the period before January 1, 2008 , services that are furnished in connection with covered surgical procedures performed in an ASC, and beginning January 1, 2008, means services that are furnished in connection with covered surgical procedures performed in an ASC as provided in §416.164(a) for which payment is included in the ASC payment established under §416.171 for the covered surgical procedure.

4. Is in compliance with applicable federal, state, and local laws and regulations, or, for organizations operating outside of the United States, all applicable laws and regulations.

5. Is licensed by the state in which it is located, if the state requires licensure for that organization, unless the organization is applying for a survey that will be used to obtain licensure in a state that recognizes AAAHC accreditation for this purpose.

6. Provides health care services under the direction of one of the following health care professionals; (these individuals or groups of professionals must accept responsibility for the health care provided by the organization and must be licensed in accordance with applicable state laws).

  • Doctor of medicine or osteopathy (MD/DO)
  • Doctor of dental surgery or dental medicine
  • (DDS/DMD)
  • Doctor of podiatric medicine (DPM)
  • Doctor of optometry (OD)
  • Doctor of chiropractic (DC)

7. Shares the facilities, equipment, business management, and records involved in patient care among the members of the organization.

8. Operates in compliance with U.S. Equal Employment Opportunity Commission laws.

9. Submits the completed, signed Application for Survey, all supporting documents, and the nonrefundable application fee in advance of the survey.

10. Pays the appropriate fees in accordance with AAAHC policies.

11. Acts in good faith in providing complete and accurate information to AAAHC during the accreditation process and throughout a term of accreditation.

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Earn your accreditation term

AAAHC awards accreditation for three years when it concludes that the organization is in substantial compliance with the Standards, and when AAAHC has no reservations about the organization’s continuing commitment to provide high-quality patient care and services consistent with the Standards. Organizations may receive a three-year term with intracycle activities required for continued assessment of ongoing compliance with the Standards.

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Post your public notice of survey

AAAHC reminds all organizations that the policy requires that a Notice of Accreditation Survey be posted prominently throughout the organization for (30) calendar days prior to the scheduled survey date(s), with the exception of random and discretionary surveys.

For Medicare Deemed Status surveys, the Notice must be posted immediately after the invoice packet containing a copy of the notice is received by the organization. The Notice must be posted at least until the end of the survey or for a minimum of 30 calendar days, even if that period extends beyond the end of the survey.

Click here to access the notice and additional instructions.

Understand a denial or revocation of accreditation

AAAHC denies accreditation to an organization when it concludes that the organization is not in substantial compliance with AAAHC Standards and/or policies and procedures.

AAAHC reserves the right to revoke or deny the accreditation of any organization at any time without prior notice. Your AAAHC account manager will help you navigate the requirements to remain in good standing.

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Achieving Accreditation

Strengthen your accreditation readiness

Achieving Accreditation is an interactive, immersive event designed to help you learn and prepare for your AAAHC survey while developing a deeper understanding of AAAHC Standards. We are facing the future together…1095 Strong!

Learn more about Achieving Accreditation

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Kershner Quality Improvement Award

Check out exemplary studies

Kershner QI Awards recognize excellence in quality improvement methodology and outcomes for AAAHC-accredited organizations in both the surgical/procedural and primary care space.

Learn more about QI innovation