Criteria for Determining Whether a Facility Provider-Based

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.

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:
• Is an attestation required?
• Should grandfathered facilities submit self-attestations?
• What are the benefits of self-attesting?
• Who is responsible for processing the attestations and making provider-based determinations?
• Is there a required form that must be used for attestations?
  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

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.

a. Ambulatory surgical centers (ASCs)
b. Comprehensive outpatient rehabilitation facilities (CORFs)
c. Home health agencies (HHAs)
d. Skilled nursing facilities (SNFs)
e. Hospices
f. Inpatient rehabilitation units that are excluded from the inpatient prospective payment system for acute hospital services
g. Independent diagnostic testing facilities furnishing only services paid under a fee schedule
h. 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)
i. ESRD facilities (42 CFR 413.174 applies)
j. 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);
k. 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 address:

Part A Provider Reimbursement
Mail Code: AG-330 P.O. Box 100144
Columbia, SC 29202-3144