What Order Do License, Accreditation, Payer Enrollment, and Operating Go In?
There is no single universal order. For provider types Medicare certifies through survey, the federal sources below set a sequence, and provider type, state, and payer change it.
For a provider type Medicare certifies through survey, those sources set these fixed points: any applicable state license and the Medicare enrollment application come first; the State Survey Agency's certification survey follows the Medicare Administrative Contractor's recommendation of approval (unless the applicant takes the deemed-status route) and requires the applicant to be operational and providing care; the Medicare participation effective date is the survey-completion date (or the effective date of the accreditation decision) if all applicable federal requirements are met that day, and otherwise a later date (42 CFR 489.13(b)). Medicaid enrollment and commercial payer contracting follow rules set by each state agency and each payer.
The order is not fully yours to choose. CMS's rule is that the effective date of a Medicare provider agreement or supplier approval "may not be earlier than the latest of the dates on which CMS determines that each applicable Federal requirement is met," and those requirements expressly include the enrollment requirements in 42 CFR part 424 subpart P alongside the health and safety standards (42 CFR 489.13(b)). The slowest item sets your date, not the last one you started. There is also an operating-before-certification requirement in the middle of the chain, and a plan has to account for it early.
Which of the four is a prerequisite for which?
State licensure feeds everything downstream. Medicare enrollment requires submission of "All applicable Federal and State licenses, certifications" with the enrollment application (42 CFR 424.510(d)(2)(iii)(A)). Medicaid runs its own check: the state Medicaid agency must have a method for verifying that a provider claiming a state license is licensed, and must confirm that the license has not expired and carries no current limitations (42 CFR 455.412).
The enrollment application then feeds the survey. CMS enrolls a provider once it "successfully completes the enrollment process, including, if applicable, a State survey and certification or accreditation process" (42 CFR 424.510(a)(1)). CMS's operational guidance is more specific: the State Survey Agency surveys the applicant "after it receives the recommendation of approval from the MAC" (unless the applicant takes the deemed-status route), and "when an applicant is denied enrollment by the MAC, no survey is conducted" (State Operations Manual, Ch. 2, §§2005A1-2005A2). For ESRD facilities: once the MAC reviews and approves the CMS-855A, "it will notify the SA/RO that a survey may be scheduled" (CMS State Operations Manual §2280).
Commercial payers set their own credentialing requirements. Confirm each payer's requirements directly; no federal rule fixes their order.
Where does the sequence require you to operate before certification?
The operating requirement is operational history. CMS states that "the applicant must be operational and providing care to patients/residents in order for a certification survey to be conducted" (State Operations Manual, Ch. 2, §2005A2). You cannot receive a certification survey until you are running, and your Medicare participation date cannot precede the survey.
In this page's reading, the period between opening the doors and the effective date is operating time that the Medicare agreement does not yet cover.
For some provider types the requirement is quantified. CMS requires each home health agency applicant "to have provided skilled home health services to a minimum of 10 patients before a survey is conducted," and states that "At least 7 of the 10 required patients should be receiving care from the HHA at the time of the initial Medicare survey"; new HHAs "must demonstrate that they can transmit OASIS data prior to the initial certification survey" (CMS State Operations Manual §§2008B, 2202.10). An ESRD applicant must have "provided services to at least one patient for each modality or service for which they are applying" (CMS State Operations Manual §2280).
In this page's reading, the other steps are applications and reviews, while this one is calendar time with patients in care.
Does accreditation replace the state survey?
Sometimes, for some provider types, through some accreditors. CMS states that Section 1865(a) of the Social Security Act "allows most health care facilities to demonstrate their compliance with the Medicare conditions through accreditation by a CMS-approved AO program, instead of being surveyed by SAs for certification."
CMS calls this deemed status, and grants it where the accreditor's standards "meet or exceed those of Medicare" and its survey processes are "comparable to those of SAs" (CMS, Accrediting Organizations).
Four scoping points decide whether deeming is available to you.
CMS approval is granted per accreditation program and per provider or supplier type; an accreditor's application must specify "The type of provider or supplier accreditation program for which the organization is requesting approval or re-approval" (42 CFR 488.5(a)(2)). CMS states that "at this time only certain AOs have requested CMS approval of Medicare accreditation programs, and those programs are only for some of these provider/supplier types" (State Operations Manual, Ch. 2, §2003C).
Accreditation from a body holding no CMS-approved program for your provider type confers no deemed status. CMS notes that "AOs may also offer accreditation activities outside of CMS deeming authority." Those accreditations do not substitute for certification.
Deeming is permissive. Under 42 CFR 488.4 as currently in force, the accreditor "may recommend that CMS grant deemed status"; CMS "may deem" the provider or supplier compliant, "excluding kidney transplant centers within a hospital and ESRD facilities"; and a deemed provider or supplier "is subject to validation surveys" (42 CFR 488.4; see also the deemed status definition at 42 CFR 488.1). CMS's June 16, 2026 final rule (91 FR 36370) revises 488.4 effective June 16, 2027; under the revised text, accreditation by a CMS-approved program "acts as a recommendation" that CMS deem the provider or supplier, and a provider or supplier granted deemed status remains subject to validation surveys. The revised text also drops the ESRD and kidney transplant exclusion. In the rule's preamble, CMS states that section 50403 of the Bipartisan Budget Act of 2018 "amended section 1865(a) of the Act to include renal dialysis facilities as provider entities allowed to participate in Medicare through a CMS-approved accreditation program," and that the existing exclusion of kidney transplant programs is "in direct conflict with the Bipartisan Budget Act of 2018 amendment." Check the section in force on the date you rely on it.
Accreditation under a CMS-approved Medicare accreditation program "is voluntary and is not required for Medicare participation" (CMS State Operations Manual §2003C). Taking that route rather than the state survey is a choice, not a compliance obligation.
How much of this varies by state?
Enough that this page cannot answer the licensure half of your question, and neither can any other national page. The State Operations Manual leaves the licensure content to each state, as the passages below show.
CMS's ESRD guidance notes that "State licensure requirements may include State Certificate of Need (CON) for ESRD facilities" (State Operations Manual §2280), and its home health guidance tells surveyors what to review "In States which license HHAs" (§2183.1), which implies that not every state licenses home health agencies.
What is federally uniform is the requirement itself: an ESRD applicant "must be in compliance with any applicable State Licensure requirements, in addition to the Federal requirements" (CMS State Operations Manual §2280). The content is a state-by-state research question.
How do you plan the sequence?
Work backward from two fixed points: the date you intend to be operating, and the date the first payer contract has to be live for the business to work. Everything between them is a dependency chain, and the planning task is finding which link is binding.
In this page's reading, the order of planning is: the state licensure question, since Medicare enrollment and Medicaid screening both read from it; then the operational-history requirement, since it consumes calendar time; then whether a CMS-approved accreditation program exists for your exact provider type, before building a plan around deeming.
What this is NOT
This page is not legal advice and not a substitute for your state's licensure rules. It describes federal Medicare and Medicaid sequencing that applies nationally; it does not tell you what your state requires.
It is not a timeline. No duration appears here; the sources cited set order and conditions, not durations.
It does not cover every provider type. The dependency shape above is drawn from Medicare survey-and-certification provider types. Provider types enrolled without a certification survey follow different paths.
It is not a claim that accreditation and certification are interchangeable. They are separate determinations by separate bodies, and accreditation substitutes for the state survey only where CMS has approved that accreditor's program for that provider type.
Frequently asked questions
Which accreditation programs can support a CMS deemed-status determination?
Only CMS-approved accreditation programs for your specific provider or supplier type; the accreditor recommends, and CMS grants deemed status. CMS publishes the current list and it changes, so verify it with CMS directly rather than any secondary summary, this page included.
Is the accreditation survey the step that sets the timeline?
Not necessarily. Under 42 CFR 489.13(b) the effective date can be no earlier than the latest date on which each applicable federal requirement is met, including enrollment. State licensure upstream, and the operational history CMS requires before a certification survey can be conducted, can each set the date instead.
Sources
42 CFR 488.1, Definitions (deemed status), https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-488/subpart-A/section-488.1
42 CFR 488.4, General rules for a CMS-approved accreditation program, https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-488/subpart-A/section-488.4
42 CFR 488.5, Application procedures for national accrediting organizations, https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-488/subpart-A/section-488.5
42 CFR 489.13, Effective date of agreement or approval, https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-489/subpart-A/section-489.13
42 CFR 424.510, Requirements for enrolling in the Medicare program, https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-424/subpart-P/section-424.510
42 CFR 455.412, Verification of provider licenses (Medicaid), https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-455/subpart-E/section-455.412
CMS, 91 FR 36370 (June 16, 2026), final rule revising 42 CFR 488.4, effective June 16, 2027, https://www.federalregister.gov/documents/2026/06/16/2026-12069/medicare-program-strengthening-oversight-of-accrediting-organizations-aos-and-preventing-ao
CMS, Accrediting Organizations (AOs), https://www.cms.gov/medicare/health-safety-standards/quality-safety-oversight-general-information/accrediting-organizations-aos
CMS State Operations Manual, Pub. 100-07, Ch. 2, The Certification Process (Rev. 227, issued 12-13-24), https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/som107c02.pdf
Last updated: October 17, 2026. Every source above was retrieved on that date (eCFR text current as of October 15, 2026). Accrediting organization approvals and state licensure requirements change; verify both directly before relying on them.