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September 23, 2011 - Updated 10.07.14

Provider-Based: General Information

CMS issued a Program Memorandum (PM) on April 18, 2003, which gives instructions on implementing the provider-based regulations. The regulations are in 42 CFR §413.65 and describe the criteria and procedures for determining whether a facility or organization is provider-based.

These regulations were effective October 1, 2002, for facilities or organizations that are not 'grandfathered' as provider-based. For 'grandfathered' facilities, the regulations are effective for cost reporting periods beginning on or after July 1, 2003. The Program Memorandum (PM) provides background information on the provider-based regulations and information on the attestation process.

In general, this is a voluntary attestation process. Providers are no longer required to apply for and receive a provider-based determination prior to billing as provider-based. Although not required, there are significant benefits to self-attesting. As a result of submitting an attestation, a review and determination will be performed. For specific information on the attestation process refer to Provider-Based: Attestation Process.

Topics:

  1. Background information on the provider-based regulations
  2. Information on the attestation process that began on October 1, 2002 and addresses the following questions.
    1. Is an attestation required?
    2. Should grandfathered facilities submit self-attestations?
    3. What are the benefits of self-attesting?
    4. Who is responsible for processing the attestations and making provider-based determinations?
    5. Is there a required form that must be used for attestations?
    6. What should be included in the attestation?
  3. Content of attestations for On-campus facilities
  4. Content of attestations for Off-campus facilities
  5. Additional issues to consider for attestations

The following items offer general information on the types of providers impacted by the provider-based requirements and the attestation process.

  1. What provider types are impacted by the provider-based regulations?

    Provider types impacted are those for which provider-based status affects the Medicare payment. The common situation is outpatient clinics of hospitals. If considered provider-based, the clinic would bill a facility charge under the hospital number to the intermediary and the physician's professional services to the carrier. If not considered provider-based, the clinic services would only be billed to the carrier.

  2. Many provider types are NOT impacted because provider-based status does not affect the amount of payment.

    Specifically, provider-based determinations are NOT made for following facilities. This means no attestation statement needs to be submitted for these provider types.

    1. Ambulatory surgical centers (ASCs);
    2. Comprehensive outpatient rehabilitation facilities (CORFs);
    3. Home health agencies (HHAs);
    4. Skilled nursing facilities (SNFs);
    5. Hospices;
    6. Inpatient rehabilitation units that are excluded from the inpatient prospective payment system for acute hospital services;
    7. Independent diagnostic testing facilities furnishing only services paid under a fee schedule;
    8. Facilities other than those operating as parts of critical access hospitals (CAHs) that furnish only physical, occupational, or speech therapy to ambulatory patients (as long as the $1500 annual cap is suspended);
    9. ESRD facilities (42 CFR 413.174 applies);
    10. Departments of providers that perform functions necessary for the successful operation of the providers but do not furnish services of a type for which separate payment could be claimed under Medicare or Medicaid (for example, laundry or medical records departments);
    11. Ambulances.
  3. Campus Criteria

    For purposes of these regulations, the definition of 'campus' affects the criteria that applies. Campus means the physical area immediately adjacent to the provider's main buildings. A facility within 250 yards of the main buildings is generally considered to be on-campus. A facility outside of the 250 yard criteria but within 35 miles of the campus is generally considered to be off-campus.

  4. Attestation Requirements

    To be considered provider-based, the on-campus criteria must be met. For off-campus facilities additional requirements must be met. Please refer to the attestation statement located under Provider-Based: Attestation Process.

  5. Supporting Documentation

    On-campus facilities are to maintain documentation supporting the attestation responses, but do not have to submit it with the attestation statement. Off-campus facilities must submit documentation supporting the responses when the attestation is submitted.

    The attestation statements can be sent to the Provider Reimbursement Department (changed from Part A Provider Enrollment) at the following addresses:

    Regular Mail: CGS
    J15 Part A Provider Reimbursement
    PO Box 20020
    Nashville, TN 37202
    Courier Service (FedEx/UPS): CGS
    J15 Part A Provider Reimbursement
    Two Vantage Way (AG-720)
    Nashville, TN 37228

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