How long does the accreditation and certification process take?

The surgery center accreditation process is simple.  Depending on the organization you choose to grant you with accreditation you can fill out an online application or call the organization and they will email you or mail to you the application.  The advantage to the online application is that when you are finished it is just a matter of a click and the application is submitted.

The organization will notify you immediately when they received the application whether online or by mail.  They will inform you in the application receipt letter that the application is in the process of being reviewed.  Applications for surgery center accreditation can be approved in as little as two weeks.  If it takes longer it is probably due to the fact that some answers to questions or supporting documents have been left out of the application.  If this has happened do not worry the accrediting organization will let you know within that time frame.  They will either request that you provide them with the information before they approve the application for a survey, or they will approve the application for survey and request that you have the documents or an explanation and provide it to the on-site surveyor.  Some missing documents left out of the application process that can halt the approval process for survey is:

Missing copy of Fire Marshal Clearance

Leaving out details regarding the Ownership of the facility

Once the application is approved the accrediting organization will ask you about an open window for you to be surveyed.  The good news about accreditation is that you know when the surveyor is coming.  You can usually get a surveyor for accreditation within 30-45 days.  It has happened sooner than that.

Don’t Forget:

During the time that you are preparing your application you need to work on getting the facility compliant to the standards of the accrediting organization.  It is mandatory that you purchase and have on-site a copy of the organization of choice standards manual.  If you hire a consultant, that person will prep your facility based on those standards but will also advise you to have a copy on hand for the facility.

Don’t Forget:

The Fees.  There are fees to pay for this process, application and survey fees.

The surgery center certification or licensing process can be simple but it is more time consuming.  There is a two phase application process.  The first phase is the Medicare enrollment application process for the facility.  Once this application is submitted to your Medicare enrollment provider it can take up to 60 days or more to get the approval letter in which denotes that they have made their preliminary assessment and have forwarded the information to CMS regional office and you are ready to proceed to the next step of the enrollment process which involves an on-site survey to be conducted by the state (licensing) or deemed accrediting authority (certification deem status).

The next step or second phase is the application process for the on-site survey.  This process relatively flows in the same direction for accreditation but make sure you request to be sent via mail or email or file on-line the proper application in which denotes you are filing for a Medicare deemed status survey. If you are filing with DHS licensing you can download the pdf forms on your state’s DHS website.  You will be answering and providing the same documents you would for accreditation so please refer back to accreditation process.  You will also have to provide documentation for certification such as a copy of your approval letter from your Medicare provider, physical environment checklist reflecting the conditions of NFPA, floor plan highlighting the separation walls, etc…  Again refer back to the accreditation time line approval because it is relatively the same approval process.  There is just more paperwork to be added to this process.

Once this application is approved you will be provided with a 90 day window for an on-site survey.  This means that the surveyor and there are 2 for this survey can and will show up un-announced within that three month time frame so you better be ready.  Again don’t forget about the fees for application and survey fee.

For more information I am available for consultation and for service if you need assistance on the surgery center initial enrollment process.  You can reach me at

Here’s to your success


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