Provider Based Determinations

Table of Contents

• Provider Based Determinations
• Processing of Provider-Based Determinations
• MAC Provider-Based Designation Checklist
• Related Content

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Provider Based Determinations

On 4/18/2003, CMS issued a Program Memorandum to contractors, Transmittal A-03-030 (341 KB) on 4/18/2003 to address provider-based status on or after 10/1/2002. This transmittal includes a sample attestation form that CMS has developed that providers 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 PPS final rule published on 8/1/2002, (67 FR 50078) revised those regulations effective on 10/1/2002 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 7/1/2003. This 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 PRM, Part I, Section 2446, and the State Operations Manual, Section 2004, that apply to any facility for periods before the regulations at 42 CFR 413.65 become applicable to it.

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Processing of Provider-Based Determinations

PBAs are processed by NGS with a recommendation for approval or denial sent to the appropriate CMS RO.

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

Note: Please see the CMS Provider Based Determination (PBD) Checklist below to be completed by the contractor. Ensure supporting data submitted will allow the contractor to properly support the questions on the checklist. If you have any questions please send them to ngsprovbaseddeterminations@anthem.com.

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MAC Provider-Based Designation Checklist

The MAC Provider-Based Designation Checklist is used to review provider-based determination requests. The intended use is for MACs only and is made available to providers as a reference for guidance only; providers are not required to fill in and submit the information.

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Related Content

• MAC Provider-Based Designation Checklist

Reviewed 5/9/2024