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Provider-Based Status Determinations

CMS issued a Program Memorandum (PM) to contractors, Transmittal A-03-030 on April 18, 2003 that addresses Provider-Based Status On or After October 1, 2002.  This transmittal includes a sample attestation form. CMS has developed a Provider-Based Attestation Statement that the provider can complete when submitting a request for provider-based status.  This will assist the provider by ensuring the necessary requirements are met and that all appropriate supporting documentation is submitted with the request.

The regulations in 42 CFR Section 413.65, describe the criteria and procedures for determining whether a facility or organization is provider-based.  The Medicare Hospital Inpatient Prospective Payment System (PPS) final rule published on August 1, 2002 (67 FR 50078) revised those regulations effective on October 1, 2002 for facilities and organizations that are not grandfathered as provider-based, and in the case of grandfathered facilities, effective for main provider cost reporting period that began on or after July 1, 2003.  This PM provides background information on the provider-based regulations and notification of the actions providers are to take to implement the revised regulations.  This information supersedes provider-based status instructions in the Provider Reimbursement Manual (PRM), Part I, Section 2446, and the State Operations Manual (SOM), Section 2004, that apply to any facility for periods before the regulations at 42 CFR 413.65 become applicable to it.

This page addresses the CMS Regional Office and MAC’s responsibility in relation to the reviewing provider-based requests and making determinations on them.

Processing of Provider-Based Determinations

Provider-Based Attestations (PBA) are processed by Cahaba with a recommendation for approval or denial sent to the appropriate CMS Regional Office (RO) and copied to appropriate State surveying agency.

Please send completed attestations to Provider Audit and Reimbursement: ngsprovbaseddeterminations@anthem.com.

Note: Effective October 1, 2002 the attestation process is voluntary. In the event the provider chooses to follow a specific format for making a request, the Cahaba Provider-Based Attestation Statement should be used. PM A-03-030 also contains a sample form and additional provider-based instructions. Please see the CMS Provider Based Determination (PBD) Checklist to be completed by the contractor. Ensure supporting data submitted will allow the contractor to properly support the questions on the checklist.

Please do not send the Provider-Based Attestation until the 855 has been approved.  PBAs will be returned to the provider if the 855 enrollment application has not been approved.  No consideration will be given to applications until the 855 has been approved.

Provider Enrollment Coordination

Please note that a CMS-855A Federal Healthcare Provider/Supplier Enrollment Application must be completed in the following situations:

  • the change in status to provider-based is the result of a change of ownership
  • the change in status to provider-based is the result of an additional location
  • the provider-based facility is a rural health clinic (RHC) requesting initial enrollment.  The state agency will conduct a survey and CMS will issue a Medicare provider number in this situation.
  • the provider-based facility is converting from freestanding to provider-based.  CMS will issue a new Medicare provider number in this situation.

Provider-Based Educational Resources

  • CMS Program Memorandum, April 18, 2003, addressing Provider-Based Status on or after October 1, 2002. Transmittal A-03-030.
  • 42 CFR Section 413.65, describes criteria and procedures for determining whether a facility is provider-based.
  • The August 1, 2002, Federal Register can be found on the CMS website. Scroll down to the Centers for Medicare & Medicaid Services to obtain the TEXT or PDF format.
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