Provider-Based Application
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PROVIDER-BASED STATUS APPLICATION
The following is in accordance with the rules codified in 42 Code of Federal Regulations (CFR) §413.65 and 42 CFR §413.174 for hospital-based ESRD facilities.
Please review the provider-based instructions and definitions (Attachment A) prior to completing this application.
General Information
Please check one of the following that best describes the entity that is requesting provider-based status (refer to Attachment A):
_____ Department of the hospital
_____ Remote location of a hospital
_____ Satellite facility
_____ Other, please specify
List the specific medical services the entity requesting provider-based status will provide.
Main Provider Name:
Main Medicare Provider Number:
Main Provider Address (include county):
Name of Requested Provider-Based Entity:
Entity Provider Number (if applicable):
Entity Address (include county):
Please check whether the entity requesting provider-based status was acquired by the main provider as:
_____ a new facility_____ a change of ownership
_____other (please explain)
Date when main provider established or
assumed ownership of the entity.
Application Contact Name:
Contact Phone Number:
Is the entity owned by two or more providers engaged in a joint venture (e.g., a hospital has jointly purchased or jointly created free-standing facilities under a joint venture arrangement)? Yes _____ No _____
If yes, the entity cannot be considered provider-based since neither party to the joint
venture arrangement can claim the free-standing facility as a provider-based entity. The 42 CFR §413.65(e) prohibits provider-based status for entities owned by two or more providers engaged in a joint venture
An entity must meet all of the following requirements to be determined by CMS to have provider-based status. Please respond to the following questions. Where your response is “NO” or when indicated, provide a brief explanation. Attach additional sheets for explanations if necessary.
Hospitals seeking provider-based status for ESRD facilities should complete sections II, III, IV, and V only.
I. Licensure and Certification
The entity requesting provider-based status should be operated under the same license as the main provider, except in areas where the State requires a separate license or State law does not permit licensure of the main provider and entity under a single license.
1.Is the entity requesting provider-based status operated under the same license as the main provider? Yes _____ No _____
If yes, please provide the State license number and expiration date:______
If no:
Does the State where the entity is located require a separate license for the entity requesting provider-based status? Yes _____ No _____
Does the State where the entity is located permit licensure of the main provider and entity under a single license? Yes _____ No _____
Comments:
I. Licensure and Certification (continued)
2.Is the entity included under the accreditation of the provider where it is based (if the provider is accredited by a national accrediting body) and does the accrediting body recognize the entity as part of the parent provider?
Yes_____No_____
JCAHO expiration date: ______
If not JCAHO accredited, date of last Medicare certification survey ______
Comments:
II. Operation under the ownership and control of the main provider
The facility or organization seeking provider-based status must be operated under the ownership and control of the main provider.
1.Is the business enterprise that constitutes the facility or organization 100 percent owned and operated by the provider? Yes _____ No _____
Comments:
2.Does the main provider and the facility or organization seeking provider-based status have the same governing body? Yes _____ No _____
Comments:
3.Is the entity operated under the same organizational documents as the main provider? For example, is the entity seeking provider-based status subject to the common bylaws and operating decisions of the governing body of the provider where it is based? Yes _____ No _____
Comments:
II. Operation under the ownership and control of the main provider (continued)
4.Are the main provider and entity seeking provider-based status sister subsidiaries?
Yes_____No_____
Comments:
5.Does the main provider have:
Final responsibility for administrative decisions for the entity?
Yes_____No_____
Final approval for contracts with outside parties for the entity?
Yes_____No_____
Final approval for personnel policies for the entity (such as fringe benefits/code of conduct)? Yes _____ No _____
Final approval for medical staff appointment in the facility or organization for the entity? Yes _____ No _____
Comments:
III. Administration and Supervision
The reporting relationship between the facility or organization seeking provider-based status and the main provider must have the same frequency, intensity, and level of accountability that exists in the relationship between the main provider and one of its departments. The facility or organization should be operated under the same monitoring and oversight by the provider as any other department of the provider and should be operated just as any other department of the provider with regard to supervision and accountability.
1.Is the facility or organization under the direct supervision of the main provider?
Yes_____No_____
Comments:
Please provide a list of key administrative staff (position/titles only) at the main provider and the entity requesting provider-based status that have a reporting relationship.
III. Administration and Supervision (continued)
2.Does the facility or organization director or individual responsible for daily operations at the entity maintain a reporting relationship with a manager at the main provider that has the same frequency, intensity, and level of accountability that exists in the relationship between the main provider and its other departments? Yes _____ No _____
Please furnish a copy of the main provider’s organizational chart. The organizational chart must include the main provider and the entity requesting provider-based status and show which department of the main provider the entity is included.
Comments:
3.Is the facility or organization director or individual responsible for daily operations at the entity accountable to the governing body of the main provider, in the same manner as any other department head of the main provider?
Yes_____No_____
Please provide a written description of the entity director’s reporting requirements and accountability procedures for day to day operations.
Comments:
- Are the following administrative functions of the entity requesting provider-based status integrated with those of the main provider?
Billing ServicesYes_____No_____
LaundryYes_____No_____
Housekeeping/JanitorialYes_____No_____
RecordsYes_____No_____
Human ResourcesYes_____No_____
PayrollYes_____No_____
Employee Benefit PackageYes_____No_____
Salary StructureYes_____No_____
Purchasing ServicesYes_____No_____
Comments:
III. Administration and Supervision (continued)
5.Do the same employees or group of employees handle the above administrative functions for both the entity that is requesting provider-based status and the main provider? Yes _____ No _____
If the answer to the previous question is “NO”, are the administrative functions for both the main provider and the entity:
Contracted out under the same contract agreement?
Yes_____No_____
Handled under different contract agreements, with the contract of the entity being managed by the main provider?
Yes_____No_____
Please provide copies of any contracts for administrative functions that are completed under arrangements for the main provider and/or entity.
Comments:
IV. Clinical Services
The clinical services of the facility or organization seeking provider-based status and the main provider must be integrated.
1.Are staff members of the entity employees of the main provider?
Yes_____No_____
Comments:
2.Do professional staff of the facility or organization have clinical privileges at the main provider? Yes _____ No _____
Comments:
IV. Clinical Services (continued)
3.Does the main provider maintain the same monitoring and oversight of the facility or organization as it does for any other department of the provider?
Yes_____No_____
Comments:
4.Does the entity seeking provider-based status have a Medical Director?
Yes_____No_____
If yes:
Does the medical director of the entity seeking provider-based status maintain a reporting relationship with the Chief Medical Officer (CMO) or other similar official of the main provider that has the same frequency, intensity, and level of accountability that exists in the relationship between the medical director of the department of the main provider and the CMO or other similar official of the main provider, and is it under the same type of supervision and accountability as any other director, medical or otherwise, of the main provider?
Yes_____No_____
Comments:
5.Are medical staff committees or other professional committees at the main provider responsible for medical activities in the facility or organization?
Yes_____No_____
Comments:
6.Does the above include:
Quality assuranceYes_____No_____
Utilization ReviewYes_____No_____
Coordination and integration of services, to the extent practicable, between the entity and the main provider?
Yes_____No_____
Comments:
IV. Clinical Services (continued)
7.Are medical records for patients treated in the entity integrated into a unified retrieval system (or cross-reference) of the main provider?
Yes_____No_____
Comments:
8.Are inpatient and outpatient services of the entity and the main provider integrated? Yes _____ No _____
Comments:
9.Do patients treated at the entity who require further care have full access to all services of the main provider and are they referred, where appropriate, to the corresponding inpatient or outpatient department or service of the main provider?
Yes_____No_____
Comments:
10.Are patients at the entity considered patients of the main provider?
Yes_____No_____
Comments:
V. Financial Integration
The financial operations of the entity should be fully integrated within the financial system of the main provider.
1.Are income and expenses shared between the main provider and the entity?
Yes_____No_____
Comments:
V. Financial Integration (continued)
2.Are the costs of the entity reported in a cost center of the provider?
Yes_____No_____
Comments:
3.Is the financial status of the entity incorporated and readily identified in the main provider’s trial balance? Yes _____ No _____
Please provide a copy of the appropriate section of the main provider’s chart of accounts or trial balance that will show the location of the entity’s revenues and expenses.
Comments:
VI. Public Awareness
The facility or organization seeking provider-based status is held out to the public and other payers as part of the main provider.
1.When patients enter the provider-based entity, are they aware that they are entering the main provider and are they billed accordingly?
Yes_____No_____
Please attach examples that show that the entity is clearly identified as part of the main provider (i.e. patient registration forms, letterhead, advertisements, signage, etc.). Advertisements that show the facility of be part of or affiliated with the main provider’s network or healthcare system only are not acceptable.
Comments:
VII. Location in Immediate Vicinity
A rural health clinic that is otherwise qualified as a provider-based entity of a hospital that is located in a rural area and has fewer than 50 beds is not subject to the criteria in this section.
1.Is the entity a rural health clinic that meets the stated criteria?
Yes_____ Skip the rest of this section.
No_____Go to next question.
A facility is treated as meeting the geographic location requirements if it is owned and operated by a hospital that: (1) is owned and operated by a state or local government, or is a private hospital with a contract with state or local government to operate off-campus clinics serving a low-income population; and (2) has a disproportionate share adjustment percentage greater than 11.75 percent.
2.Does the facility meet the above criteria:
Yes_____ Skip the rest of this section. Provide documentation
No_____Go to next question.
3.Is the entity and main provider located on the same campus (See definition of campus on Attachment A)? Yes _____ No _____
If no, how many miles is the entity from the parent provider?______
Please submit a map that identifies the main provider and the entity that supports the mileage.
4.Is the entity more than 35 miles from the main provider?
Yes_____No_____
If yes, please submit records showing that during the 12 month period immediately preceding the first day of the month in which the application for provider-based status is filed with CMS, and for each subsequent 12 month period that:
- at least 75 percent of the patients served by the entity reside in the same zip code areas as at least 75 percent of the patients served by the main provider,
- at least 75 percent of the patients served by the entity who required the type of care furnished by the main provider received that care from that provider (for example, at least 75 percent of the patients of an RHC seeking provider-based status received inpatient hospital services from the hospital that is the main provider), or
VII. Location in Immediate Vicinity
- if the entity is not able to meet the criteria in 1 or 2 because it was not in operation during all of the 12 month period previously described, the facility or organization is located in a zip code area included among those that, during all of the 12 month period described previously, accounted for at least 75 percent of the patient served by the main provider.
5.If the entity is not located in the same State as the main provider, is the entity located, where consistent with the laws of both States, in an adjacent state?
Yes_____No_____
If yes, please provide supporting documentation.
Comments:
VIII. Management Contracts
1.Is the entity operated under a management contract?
Yes_____Submit a copy of any management contracts and go to next question.
No_____Skip this section.
- Is the staff of the facility or organization, other than management staff, employed by the provider or by another organization, other than the management company, which also employees the staff of the main provider?
Yes_____No_____
3.Are the administrative functions of the facility or organization integrated with those of the main provider (please reference the administration and supervision section)? Yes _____ No _____
4.Does the main provider have significant control over the operations of the facility or organization? Yes _____ No _____
5.Is the management contract held by the main provider itself, not by a main organization that has control over both the main provider and the facility or organization? Yes _____ No _____
Comments:
IX. Obligations of Hospital-Based Entities and Departments
Hospital outpatient departments and hospital-based entities have obligations that must be met.
- If the entity is a hospital outpatient department, located either on or off the hospital campus, does the entity comply with the anti-dumping rules as set forth in 42 CFR 489.20(l), (m), (q), as well as 489.24? Yes _____ No _____ N/A _____
- If the entity is a hospital-based outpatient department or a provider-based entity (including an RHC) located on the main campus, is any patient seeking emergency care ensured of treatment by the hospital in accordance with the anti-dumping rules in 42 CFR 489.24? Yes _____ No _____ N/A _____
- Are physician services furnished in hospital-based entities (other than RHCs) billed with the correct site-of-service indicator, so that applicable site-of-service reductions to physician and practitioner payment amounts can be applied?
Yes _____No _____N/A _____
- Are physicians who provide services in the hospital outpatient departments or provider-based entity obligated to comply with the non-discrimination provisions set forth in 42 CFR 489.10(b)? Yes _____ No _____ N/A _____
- If the entity is a hospital outpatient department, does the entity comply with all of the terms of the hospital’s provider agreement?
Yes _____No _____N/A _____
- If a patient is admitted to the hospital as an inpatient after receiving treatment in the provider-based entity, are payments for services in the hospital-based entity subject to the payment window provisions applicable to PPS hospitals and to PPS excluded hospitals and units found in 42 CFR §412.2(c)(5) and §413.40(c)(2)?
Yes _____No _____N/A _____
- Does the hospital provide written notification to a Medicare beneficiary prior to the delivery of services in a hospital-based entity not located on the main provider’s campus of the amount of the Medicare beneficiary’s potential financial liability?
Yes _____No _____N/A _____
Please furnish an example of the written notification provided to Medicare beneficiaries that shows the amount of the beneficiary’s potential financial liability.
IX. Obligations of Hospital-Based Entities and Departments (continued)
- Does the entity meet applicable hospital health and safety rules for Medicare participating hospitals found in 42 CFR §482?
Yes _____No _____N/A _____
Comments:
An officer or administrator of the main provider should sign and date as follows to certify that all information contained in this application is true, correct, and complete.
______
Signature of Officer or Administrator Date
______
Title
______
Please Print Name of Officer or Administrator
.
PROVIDER-BASED STATUS INSTRUCTIONS
The provider-based regulations can be found in 42 Code of Federal Regulations (CFR) §413.65. These regulations are effective for cost reporting periods beginning on or after January 10, 2001. Provider-based regulations for ESRD facilities can be found in 42 CFR §413.174.
Responsibility for obtaining provider-based determinations
A facility or organization is NOT entitled to be treated as provider-based simply because it or the main provider believe it is provider-based.
A main provider or a facility or organization must contact the Centers for Medicare & Medicaid Services (CMS) to obtain notification that it will recognize the operation as provider-based. The facility or organization must be determined by CMS to be provider-based before the main provider bills for services of the facility or organization as if it were provider-based, or before it includes costs of those services on its cost report. Please contact your servicing claims processing contractor to determine the appropriate procedures for filing the provider based application.
A facility that is not located on the campus of a hospital and is used as a site of physician services of the kind ordinarily furnished in physician offices will be presumed to be a free-standing facility, unless it is determined by CMS to have provider-based status.
CMS will not make determinations of provider-based status for facilities or organizations if by law their status (freestanding or provider-based) would not affect either Medicare payment levels or beneficiary liability. Provider-based determinations will not be made with respect to Ambulatory Surgical Centers (ASCs), Comprehensive Outpatient Rehabilitation Facilities (CORFs), Home Health Agencies (HHAs), Skilled Nursing Facilities (SNFs), hospices, inpatient rehab units, facilities that furnish only clinical diagnostic laboratory tests, or facilities that furnish only physical, occupational, or speech therapy (as long as the $1500 annual cap on coverage remains suspended).