Provider-Based Determinations

2004 - Provider-Based Determinations (Rev. 193, Issued: 09-20-19, Effective: 09-20-19, Implementation: 09-20-19) “Distinct Part” and “Provider-Based” are not synonymous terms. When a location, department, remote location or satellite is established as being provider-based, it is an integral part of the provider, covered by the provider’s Medicare agreement, and therefore subject to the same Medicare conditions of participation as any other part of that provider. Unless covered by a specific exception listed in the rule, the provider-based regulations at §413.65 apply to any provider of services under the Medicare program, as well as to physicians’ practices or clinics or other suppliers that are not themselves providers, but which the provider asserts are an integral part of that provider. Providers are not required to seek a determination from CMS that all of their provider- based components satisfy the provider-based rules at 42 CFR 413.65, but they may voluntarily seek such determinations. The RO Division of Financial Management makes provider-based determinations in response to a specific request. If a provider requests the SA for a provider-based determination under the Medicare program for one or more of its component services, the SA must notify the RO immediately so that the request can be routed appropriately to the RO Division of Financial Management. In the case of a request concerning an off-campus department, remote location or satellite, the provider’s survey and certification file about the locations included under its provider agreement must not be revised to add the new location until and unless the provider is issued a positive determination about its request. For Critical Access Hospitals (CAHs) adding a provider-based location – also see SOM Chapter 2, Section 2256H – Off-Campus CAH Facilities – Process Requirements.