License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association website.
Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.

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CGS Provider-Based Attestation Statement

THE FOLLOWING STEPS ARE IMPORTANT TO AVOID A REJECTED PROVIDER-BASED ATTESTATION:

The Provider-Based Attestation MAY NOT be submitted until after the CMS Form 855A has been approved. Once the 855A has been submitted to the Provider Enrollment Area and approval received, the provider-based attestation may be submitted.
For a provider-based RHC, do not submit the provider-based attestation until after the tie in has been received from CMS with the number for the RHC.
Ensure that all supporting documentation has been included with the attestation. For example, if the license (or support for why there wouldn't be a separate license) is missing, a request will be made for such information. If the request is not fulfilled within the allotted time, the MAC must reject the submission and return to the main provider. The Attestation statement must be signed & dated by the authorized individual of the hospital.
Submit the provider-based Attestation Statement to CGS via email (preferred method) at J15reimbursement.cgsadmin.com, via CGS web portal or by mail at:

Regular Mail: CGS – J15 A Provider Reimbursement
PO Box 20020
Nashville, TN 37202

Courier Service: CGS – J15 A Provider Reimbursement
26 Century Blvd STE ST610 (AG-720)
Nashville, TN 37214-3685

(Please note that if you choose to email a hard copy, all mail received in Nashville is scanned and sent to us as an electronic version of your submission. If you are using tabs to identify exhibits, these tabs will be removed prior to the scanning process. Please use a title page in lieu of a tab for exhibit identifiers.)

Provider-based

SECTION I: ATTESTATION

If your facility is an ASC, submitted documentation that the facility Medicare ASC certification has been terminated. The ASC termination should include both the CCN and the ASC agreement number on Form 855B.
Include a description of how provider-based status will impact the Medicare payment levels or beneficiary liability.

SECTION II: LOCATION OF PROVIDER

For On-Campus facilities provide a straight line measurement map to verify the 250 yard requirement.
For Off-Campus facilities provide a map indicating the mileage separating the Provider-Based facility and the Main provider.

SECTION III: LICENSURE

Provide your Annual Registration Report
Provide a copy of the hospital license that lists the provider-based entity's address, or a letter from the State notifying the provider that the entity is included in the hospital's license. Note: If the State does not issue a separate license for the provider-based entity, please provide documentation that the State does not require the entity to be licensed separately (i.e., letter or e-mail from the state indicating a separate license is not issued for provider-based entities or a copy of the State regulation).

SECTION IV: CLINICAL SERVICES

Provide a list of key personnel (i.e. table of organization) working at the provider-based facility showing job titles.
Provide list of all clinical staff (i.e. physicians, nurses, physical therapists, radiology technicians, etc.) working at the facility or organization showing job titles and name of employer. Also include whether professional staff have clinical privileges at the main provider.
Provide a written description of the level of monitoring and oversight of the facility by the main provider
Provide a description of the responsibilities and relationship between the Medical Director of the provider-based facility, the Chief Medical Officer of the main provider, and the Medical Staff Committees at the main provider.
Provide a written explanation of how inpatient and outpatient services of the facility and the main provider are integrated.
Provide a copy of the written policy in place that is utilized in record retrieval from both the main provider and the provider-based facility

SECTION V: FINANCIAL INTEGRATION

Provide a copy of the appropriate section of the main provider's chart of accounts showing that the facility is integrated with the hospital's accounts and the entire trial balance that shows the location of the provider-based facility's revenues and expenses within the trial balance. Clearly identify the cost centers on the trial balance.
Provider a copy of the filed CMS Form 2552-10 cost report indicating the provider-based facility on worksheet A, line 90.

SECTION VI: PUBLIC AWARENESS

Provide documentation that demonstrates the facility is held out to the public as part of the main provider. Examples of documentation that could satisfy this requirement are pictures of outside signage, entrance door and interior. Mockup pictures are not acceptable. The pictures should be close enough to read the sign, yet far enough away to enable the viewer a concept of the entire environment.
Provide a copy of the detail floor plan of the facility with the provider-based space clearly marked as well as a floor plan of the building in which the provider-based facility is located.

SECTION VII: OBLIGATIONS OF HOSPITAL OUTPATIENT DEPARTMENTS & HOSPITAL-BASED ENTITIES.

Provide a copy of the main provider's EMTALA (anti-dumping) policies. Provide written policies with respect to the off-campus departments for appraisal of emergencies and referral when appropriate.
Provide staff policy to bill the site of service.
Provide documentation that physician services furnished at the Center are billed with the correct site-of-services so that appropriate physician and practitioner payment amounts can be determined. The Health Insurance Claim Form 1500 (OMB-0938-1197 Form 1500) is the preferred verification for site-of-service coding.
Provide a copy of the facility's nondiscrimination policy in accordance with the non-discrimination provisions in §489.10(b) of chapter IV of Title 42."
Provide the staff policy that all Medicare patients are billed as hospital outpatients and not as physician's office patients.
Provide the staff policy for patients who received services at the hospital outpatient department and were admitted to the hospital as an inpatient.
Please provide a notice of beneficiary co-insurance form with an estimated or actual co-insurance cost for services.
Provide a copy of the policy regarding distribution of the notice of beneficiary co-insurance for the subject facility. The form and policy need to support the statement: "if beneficiary for any reason is unable to read and understand notice, the notice is provided to the patient's authorized representative prior to the delivery of service and in situations where emergency service is required; notice is given as soon as possible after emergency situation is stabilized."
Provide a copy of the potential charges used to complete the beneficiary coinsurance financial form.
Provide written notice to the beneficiary of potential financial liability, and policy needs to support that: if the beneficiary is unconscious, under great duress, or for any other reason unable to read a written notice and understand and act on his or her own rights, the notice must be provided, before the delivery of services, to the beneficiary's authorized representative; and in situations where emergency service is required, notice is given as soon as possible after emergency situation is stabilized.

SECTION IX: OPERATION UNDER THE OWNERSHIP

Provide the articles of incorporation and bylaws for the main provider and provider-based facility if separate documents exist.
Provide a copy of the provider-based facility lease.

SECTION X: ADMINISTRATION AND SUPERVISION (OFF CAMPUS ONLY)

Provide a list of the key administrative staff (position/titles only) at the main provider and the provider-based facility that reflects a reporting relationship.
Provide a copy of the organizational chart. The chart must include the main provider and the entity requesting provider-based status showing which department of the main provider the entity is included.
Submit a written description of the facility director's reporting requirements and accountability procedures for day-to-day operation.