Provider-Based Status Determinations

The Centers for Medicare and Medicaid Services (CMS) issued a Program Memorandum (PM) to Intermediaries, 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. Cahaba has also 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 supercedes 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 Fiscal Intermediary’s responsibility in relation to the reviewing provider-based requests and making determinations on them.

See additional provider-based status background information for details.

Processing of Provider-Based Determinations

Provider-based attestations 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 the Provider Enrollment address on the Contact Us page.

Contact our Alabama office if your provider-based facility is located in the state of Alabama.

Note that 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 may be used. PM A-03-030 also contains a sample form and additional provider-based instructions

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.

For more information refer to our main provider enrollment page or contact the appropriate Provider Enrollment Helpline identified under Processing of Provider-Based Determinations above.

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 Web site. Scroll down to the Centers for Medicare & Medicaid Services to obtain the TEXT or PDF format.

Provider-based instruction and clarification is included in the Medicare A Newsline on a quarterly basis. Please refer to past articles for related information.

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