Provider-Based Attestation
Regulations in 42 Code of Federal Regulations (CFR) 413.65 describe the criteria and procedures for determining whether a facility or organization is provider-based. Change Request 2411 provides information on the background of the regulations and actions to implement these regulations.
Attestation Forms / Information
- Attestation Statement (Example to use in attesting to Palmetto GBA) (PDF)
- List of Documentation to Include with Attestation (PDF)
- Provider Based Checklist (CMS issued checklist for reviewing attestations) (PDF)
- Location Change — Provider-Based Facility Form (PDF)
Regulations and Publications
- 42 CFR 413.65 — Requirements for ... provider-based status
- Change Request 2411 Provider-based Status On or After October 1, 2002 (PDF)
Although, attesting is voluntary, providers are encouraged to attest and document they have met the criteria. MACs review the attestation and supporting documentation and submit a recommendation to the CMS Regional Office, which approves/denies and issues a notification of their decision.
Please include supporting documentation for both on-campus and off-campus location submissions – this enables review to be completed in timely manner.
On the first page of the sample attestation are listed the provider types and facilities for which an attestation is not needed. Generally, determinations are not made unless there is a reimbursement (payment) impact between how the facility would bill (and be paid) as provider-based versus freestanding.
Before Submitting a Provider-Based Attestation
- Ensure the provider-based facility/entity has enrolled (and been approved) as an additional location using CMS-855A form
- For a provider based RHC, ensure the tie-in has been received from CMS containing the RHC provider number
- The attestation is signed by an authorized official of the main provider
The following terms used in the context of provider-based determinations.
Provider-based status — means the relationship between a main provider and a provider-based entity or a department of a provider, remote location of a hospital, or satellite facility, that complies with the provisions of this section.
Main provider — a provider (typically a hospital) that either creates, or acquires ownership of, another entity to deliver additional health care services under its name, ownership, and financial and administrative control.
Provider-based entity — a provider of health care services that is either created by, or acquired by, a main provider for purpose of furnishing health care services of a different type from those of the main provider (typical example is a physician clinic or physician practice).
Department of a provider — a facility that is either created by, or acquired by, a main provider for the purpose of furnishing health care services of the same type as those furnished by the main provider.
Remote location of a hospital — furnishes inpatient hospital services under the name, ownership, and financial and administrative control of the main provider (often referred to as a separate campus).
Satellite facility — part of a hospital that provides inpatient services in a building also used by another hospital.
Campus — means the physical area immediately adjacent to the provider’s main building.
- On-campus locations are buildings or structures within 250 yards from the main building
- Off-campus locations are Not on the main campus or 250 yards from the main building or a remote location of the hospital (but generally within 35 miles)
Provider-Based Attestation requests may be submitted through email (preferred) or physical mail.
Email for Ala., Ga., Tenn. Locations: JJIRR@palmettogba.com.
| Postal Service Address | Overnight Address |
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Palmetto GBA |
Palmetto GBA |