Skip to Main Content

Print | Bookmark | Email | Font Size: + |

April 29, 2016

CGS Provider-Based Attestation Statement

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

  1. 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.
  2. 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.
  3. 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.
  4. 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.

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved