How To Obtain Medicare & Medicaid Certifications for Your Facility

Getting certified for Medicare and Medicaid is a critical step for skilled nursing facilities (SNFs), home health providers, and post-acute care centers looking to serve more patients and ensure steady reimbursements.

However, the process can be complex, with federal and state requirements to navigate. Whether you're applying for the first time or need a refresher, this guide explains it all.

In this article, we’ll cover:

• Eligibility criteria for Medicare and Medicaid certifications

• How to obtain Medicare and Medicaid certifications

• How to become a Medicare-certified provider

• Best practices to maintain compliance and streamline operations

Understanding Medicare and Medicaid Certifications

Medicare and Medicaid licenses allow healthcare providers to serve beneficiaries of these federal programs and receive reimbursements for covered services. These certifications ensure that facilities meet regulatory, clinical, and operational standards.

Medicare vs. Medicaid certifications: What’s the difference?

While both programs provide essential healthcare funding, they have different eligibility requirements and oversight structures, as shown in this chart:

|                                                   Medicare Certification                                                  |                          Medicaid Certification                         |
|:-------------------------------------------------------------------------------------------------------------------------:|:-----------------------------------------------------------------------:|
|                              Overseen by the Centers for  Medicare & Medicaid Services (CMS)                              |            Administered at the state level with CMS oversight           |
|            Available to hospitals, skilled nursing facilities,  home health agencies, and other provider types            |       Available to providers meeting  state-specific requirements       |
|                          Requires compliance with  Conditions of Participation (CoPs) set by CMS                          |       Must follow state Medicaid regulations,  which vary by state      |
|                   Providers apply through the Provider Enrollment,  Chain, and Ownership System (PECOS)                   |           Requires an agreement with the state Medicaid agency          |
| Reimburses services for Medicare beneficiaries  (primarily seniors 65+ and certain younger individuals with disabilities) | Covers low-income individuals, families,  and certain disability groups

Facilities planning to accept both Medicare and Medicaid patients must complete separate certification processes for each program.

Medicare certification follows federal guidelines, while Medicaid requirements depend on state-specific regulations, making it important to review your state’s enrollment criteria before applying.

Medicare eligibility requirements

Medicare certification is overseen by the Centers for Medicare & Medicaid Services (CMS) and applies to healthcare providers that serve Medicare beneficiaries, primarily seniors aged 65 and older and certain younger individuals with disabilities. Many patients also use Medicare to help pay for SNF expenses. 

To qualify, providers must meet the following requirements:

• Provider type: Your facility must be an eligible provider type, such as skilled nursing facilities (SNFs), home health agencies, hospitals, physician groups, outpatient rehabilitation centers, and durable medical equipment (DME) suppliers.
  
  

• State licensure: Your facility must hold an active state license for the services provided. Licensing requirements vary by state, so it's important to check with your state health department.
  
  

• Compliance with conditions of participation (CoPs): CMS sets CoPs that outline health, safety, and operational standards for Medicare providers. These must be met to qualify for certification.

Medicare certification process

1. Verify eligibility: Ensure your facility meets all the Medicare provider-type qualifications.
   
   

2. Obtain a national provider identifier (NPI): Apply through the National Plan and Provider Enumeration System (NPPES).
   
   

3. Enroll in Medicare through PECOS: The Provider Enrollment, Chain, and Ownership System (PECOS) is the electronic system used for Medicare provider enrollment.
   
   

4. Complete the Medicare enrollment application: Submit the correct CMS-855 form for your provider type.
   
   

5. Undergo a state survey or accreditation: Some provider types require an on-site survey by the state survey agency or an approved CMS-accredited organization, such as the Joint Commission, CHAP, or ACHC.
   
   

6. Receive Medicare certification: If approved, your facility will receive a Medicare provider number and can begin billing for services.

Maintaining Medicare certification requires ongoing compliance with CoPs, regular surveys, and adherence to updated CMS regulations.

Medicaid eligibility requirements

Medicaid certification allows healthcare providers to serve low-income individuals, families, and people with disabilities. Unlike Medicare, Medicaid is administered at the state level, meaning eligibility and certification requirements vary by location.

However, most providers must meet the following general criteria:

• State-specific requirements: Each state runs its own Medicaid program, setting unique eligibility and regulatory standards for providers. These include licensing, operational, and billing requirements.
  
  

• Provider agreement with state Medicaid agency: To participate in Medicaid, facilities must enter into a formal agreement with their state’s Medicaid agency, outlining compliance obligations and reimbursement terms.
  
  

• Compliance with state regulations: Medicaid providers must follow state-specific patient care, billing, and documentation guidelines to maintain certification and avoid penalties.

Medicaid license process

1. Confirm state-specific requirements: Check your state Medicaid agency’s website for provider eligibility details and application guidelines.
   
   

2. Obtain necessary licensure: Your facility must have a valid state license that meets Medicaid requirements.
   
   

3. Sign a provider agreement: Enter into a formal agreement with your state Medicaid agency to define service expectations and reimbursement terms.
   
   

4. Submit the Medicaid provider enrollment application: States have different application procedures, but most require submission through an online portal.
   
   

5. Complete background checks and screening: Some states require fingerprinting, criminal background checks, and site visits before approval.
   
   

6. Receive Medicaid certification: Once approved, your facility will receive a Medicaid provider number, allowing you to bill Medicaid for services.

Since Medicaid programs are state-specific, providers should regularly review state policies to stay compliant with evolving regulations.

5-step application process: How to obtain Medicare and Medicaid certifications

Getting certified for Medicare and Medicaid involves multiple steps, each designed to ensure your facility meets the necessary legal, operational, and quality standards. While the process may seem complex, breaking it down into clear, actionable steps can help you navigate it with confidence.

Step 1: Get a National Provider Identifier (NPI)

Before you can enroll in Medicare or Medicaid, your facility needs an NPI, a unique 10-digit identification number required for healthcare providers. This number is used across all healthcare transactions, including billing and claims submission.

To apply:

• Go to the National Plan and Provider Enumeration System (NPPES) website.
  
  

• Complete the online application with your facility’s details, including tax identification information and provider type.
  
  

• Submit your application and wait for approval. Processing usually takes a few days, and you’ll receive your NPI via email once approved.

Without an NPI, you won’t be able to proceed with Medicare or Medicaid enrollment, so this should be your first step.

Step 2: Enroll in the Provider Enrollment, Chain, and Ownership System (PECOS)

Once you have an NPI, the next step is enrolling in PECOS — Medicare’s online provider enrollment system. PECOS allows providers to submit applications electronically, track enrollment progress, and make updates to their Medicare enrollment when needed.

To enroll in PECOS:

• Visit the PECOS website and log in using your NPPES credentials.
  
  

• Select the appropriate enrollment application for your provider type.
  
  

• Enter your facility’s details, including ownership information, practice location, and licensure.
  
  

• Upload any required supporting documents.
  
  

• Submit your application and track its progress.

Submitting your enrollment through PECOS is generally faster than mailing paper applications, reducing processing delays.

Step 3: Complete the Medicare enrollment application

Medicare requires providers to fill out a CMS-855 enrollment form, which varies depending on your provider or supplier type. This form is crucial because it establishes your facility as a Medicare provider and allows you to receive reimbursements.

To complete this step:

• Identify the correct CMS-855 form for your facility type. Common options include CMS-855A for hospitals, home health agencies, and SNFs, CMS-855B for clinics and group practices, or CMS-855I for individual practitioners.
  
  

• Carefully fill out the application, providing accurate facility and ownership details.
  
  

• Submit the form through PECOS or mail it to your local Medicare Administrative Contractor (MAC).
  
  

• Pay any applicable fees for provider screening, if required.

Errors or missing documentation can delay your approval, so double-check your application before submission.

Step 4: Undergo a State Survey or Accreditation

To complete Medicare certification, most facilities need to pass an on-site survey conducted by the State Survey Agency or an approved CMS-accreditation organization. This survey ensures that your facility meets Medicare’s conditions of participation (CoPs) — a set of federal standards related to patient care, safety, and facility operations.

Here’s how the process works:

• Once your application is submitted, your State Survey Agency or accreditation organization (e.g., Joint Commission, CHAP, or ACHC) will contact you to schedule an inspection.
  
  

• Inspectors will review policies, patient care procedures, staffing qualifications, and safety protocols.
  
  

• If your facility passes the survey, you’ll receive approval for Medicare certification.
  
  

• If deficiencies are found, you’ll be given a timeframe to correct them and schedule a follow-up review.

Facilities that are already accredited by a CMS-approved organization may not need a state survey, but requirements vary depending on the provider type and location.

Step 5: Enroll in Medicaid (if applicable)

Medicaid enrollment is handled separately by each state Medicaid agency, and the requirements can vary significantly. If your facility plans to accept Medicaid patients, you’ll need to complete a Medicaid provider agreement and follow state-specific enrollment procedures.

To enroll:

• Contact your state Medicaid agency or visit their website to review provider eligibility and application guidelines.
  
  

• Submit an application, which may require additional forms beyond what was submitted for Medicare.
  
  

• Some states require fingerprinting, background checks, or additional screening before approval.
  
  

• Once approved, you’ll receive a Medicaid provider number, allowing you to bill Medicaid for services.

Because Medicaid programs are state-run, it’s essential to verify your state’s specific enrollment requirements to avoid delays.

Final steps

Once your facility completes these steps and receives approval, you’ll be officially Medicare and/or Medicaid certified. At this point, you can begin billing for services, but it’s important to stay compliant with CMS and state Medicaid regulations to maintain your certification.

Regular audits, ongoing training, and internal compliance checks can help ensure your facility continues to meet the necessary standards.

Enrollment procedures

Once your Medicare or Medicaid application is submitted, it goes through a detailed review process to ensure your facility meets all regulatory requirements. This step is crucial to verify eligibility, compliance, and operational readiness before approval.

Application review

CMS and state Medicaid agencies carefully review each application to check for completeness, accuracy, and compliance with federal and state regulations. If any required information is missing or incorrect, they may request additional documentation, which can delay processing.

Background checks

As part of the screening process, some providers must undergo background checks or fingerprinting, particularly if they are classified as high-risk by CMS or their state Medicaid agency. This step helps prevent fraud and ensures that all participating providers meet ethical and legal standards.

Final approval notification

Once your application is approved, you will receive official certification from CMS or your state Medicaid agency. This includes a Medicare provider number and/or a Medicaid provider number, allowing your facility to start billing for services provided to program beneficiaries.

If your application is denied, you will receive instructions on how to appeal or correct any deficiencies.

Maintaining compliance

Medicare and Medicaid providers must stay compliant with all federal and state regulations to continue receiving reimbursements. Failing to meet compliance requirements can result in penalties, payment delays, or even loss of certification.

How to stay compliant

• Provide regular staff training on Medicare and Medicaid billing practices to prevent errors and fraudulent claims.
  
  

• Conduct internal audits to catch compliance risks before they become issues.
  
  

• Stay updated on policy changes that may affect reimbursement, documentation, and reporting requirements.

Common reasons for certification delays

Even if your facility qualifies for certification, several common issues can slow down the approval process:

• Incomplete documentation, such as missing forms or incorrect provider details
  
  

• Failure to meet state licensing requirements or Medicare’s conditions of participation (CoPs)
  
  

• Delays in background check processing or scheduling of required surveys or inspections

Taking a proactive approach by double-checking applications, preparing for inspections, and keeping up with policy changes can help avoid delays and ensure smooth certification and continued compliance.

Frequently asked questions

How long does the certification process take?

Medicare certification typically takes 60 to 90 days, while Medicaid processing times depend on state regulations and can take anywhere from a few weeks to several months. The timeline for Medicare and Medicaid certification varies based on provider type, state requirements, and whether a facility needs an on-site survey.

Delays often occur due to incomplete applications, background checks, or scheduling surveys.

Can I apply for Medicare and Medicaid certifications simultaneously?

Yes, facilities can apply for both Medicare and Medicaid certifications at the same time. However, since Medicare is federally regulated and Medicaid is state-administered, each program has separate application processes and requirements.

Some states may require providers to complete Medicare certification first before enrolling in Medicaid, so it’s important to check with your state Medicaid agency.

What happens if my application is denied?

If your Medicare or Medicaid certification application is denied, you will receive a notice explaining the reason for the denial and any corrective actions you can take.

Depending on the issue, you may be able to submit additional documentation, correct deficiencies, or appeal the decision through a formal reconsideration process. Reviewing application requirements carefully and ensuring all necessary documents are included can help avoid denials.

Are there fees associated with the application process?

Medicare certification requires a provider enrollment fee, which is updated annually by CMS. Some provider types may also need to pay for accreditation if required by Medicare. 

Medicaid application fees vary by state, and certain providers may be exempt from fees depending on state-specific policies. Checking with your Medicare Administrative Contractor (MAC) and state Medicaid agency will provide the most accurate cost information.

How to use technology to maintain Medicare and Medicaid compliance

Staying compliant with Medicare and Medicaid regulations requires constant oversight, accurate documentation, and adherence to changing policies.

Technology can help streamline compliance efforts by automating key processes, reducing human error, and ensuring that facilities meet federal and state requirements.

Here’s how ExaCare helps skilled nursing facilities and post-acute care providers maintain compliance:

• Centralized documentation: ExaCare integrates with major EHR and referral platforms, ensuring that all patient information, referral packets, and supporting documents are stored in one place. This reduces errors, improves documentation accuracy, and simplifies audits.
  
  

• AI-powered decision support: Medicare and Medicaid eligibility depends on strict patient assessment criteria. ExaCare’s AI-driven screening extracts key clinical and financial data from referral packets, helping providers make informed decisions about patient admissions while ensuring compliance with reimbursement guidelines.
  
  

• Automated financial analysis: ExaCare flags high-cost medications and provides reimbursement estimates, helping facilities avoid financial risks associated with Medicaid’s state-specific coverage rules and Medicare’s reimbursement limitations.
  
  

• Real-time compliance tracking: ExaCare’s analytics tools help track key performance indicators (KPIs) related to admissions, response times, and regulatory adherence. This allows facilities to identify potential compliance gaps before they become issues.

Is your facility ready to manage more referrals?

Knowing how to obtain Medicare and Medicaid certifications is just one part of the equation — your facility also needs a fast, efficient admissions process to handle incoming referrals without delays.

Even with strong marketing, slow response times and manual processes can cause missed opportunities and strain hospital relationships.

Many SNFs still rely on disconnected referral systems and time-consuming manual reviews, creating bottlenecks in admissions. Hospitals expect quick, informed decisions, and if your facility isn’t keeping up, you risk losing referrals to competitors with more efficient systems.

ExaCare transforms your admissions process by using AI to streamline referrals, automate document review, and help you make faster, more informed decisions.

Ready to see how ExaCare can help your facility win more referrals? Talk with our team to learn more.

Schedule a demo.