This document is intended to provide guidance on the provider-based attestation review process and to avoid any unnecessary submissions.  Please read through this document before submitting an attestation to WPS Government Health Administrators.
   

Contact Information for Provider-Based Attestations

At WPS Government Health Administrators, our Audit Advisement team is responsible for reviewing and fielding questions on the provider-based attestation process. Below are the names and email addresses for the two main provider-based contacts for questions and submission of documentation. Providers may also submit documentation through our secure messaging tool File Exchange. You can find Instructions for the using the tool in Audit Secure-EDI/File Exchange Email Messaging Tool.
 
Name: Christine Blase 
Title: Provider-Based Attestation Coordinator in the Audit Advisement Area
Email: Provider.Based@wpsic.com 

Name: Brett Morton
Title: Quality Assurance Manager
Email: Provider.Based@wpsic.com 

Provider-Based Attestation Submission Address:
Delivery/Overnight Service:

WPS Government Health Administrators
Attn: Christine Blase
Medicare Audit Advisement
1717 W. Broadway
Madison, WI 53713-1834 

Regular Mail Service:

WPS Government Health Administrators
Attn: Christine Blase
Medicare Audit Advisement
P.O. Box 8696
Madison, WI 53708-8696 

Contact Information for the CMS Form 855A (Enrollment Application Form)

At WPS Government Health Administrators, our Provider Enrollment team is responsible for reviewing and fielding questions on the CMS Form 855A Enrollment process. Please call Provider Enrollment Customer Service at (866) 518-3285, option 2 for J5 providers, and (866) 234-7331, option 2 for J8 providers.

CMS Form 855A Enrollment Submission Address:
Delivery/Overnight Service: 

WPS Government Health Administrators
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834 

Regular Mail Service: 

WPS Government Health Administrators
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248

Provider Enrollment and Provider-Based are two different departments. To ensure the correct department receives the proper documentation, mail in two different packages.

Requirements to Bill Services as Provider-Based

Although there is no required certification or review, providers must comply with the requirements of 42 CFR 413.65 and all other applicable regulations. A facility is only allowed to bill as provider-based if they meet the various financial and clinical integration and other criteria as stated in the regulations. Although the attestation and review process to document that you have met those criteria is voluntary, the requirement that you meet all of the criteria is not optional. If later review determines that the criteria were not met, there is the possibility that additional money reimbursed due to billing as provider-based, rather than freestanding, will be recouped. 

Any time you add a new service location you are required to report it to us within 90 days of the effective date of change, regardless of whether you are filing a provider-based attestation or not. Per 42 CFR 424.520(b), failure to report such changes within 90 days may result in the deactivation or revocation of the provider's Medicare billing privileges. These changes must be reported by submitting a CMS form 855A. See later section regarding the CMS form 855A and the proper contacts for questions or submissions.

Billing Requirements for non-excepted outpatient services.  Related MLN Matters Number: SE18002: Change Requests (CR) Number:  9613, 9907

Medicare will validate service facility location submitted on Medicare claim form 1500, Box 32 to ensure services are provided in a Medicare enrolled location. The validation must match exactly to the information submitted on the Form CMS-855A submitted by the provider and entered into the Provider Enrollment, Chain and Ownership System (PECOS).

Benefits of Submitting a Provider-Based Attestation

As mentioned above, although meeting the criteria in 42 CFR 413.65 is required, the self-attestation and review process is voluntary. If you elect to bill as provider-based, yet forgo the self-attestation and review process and are later found to not be in compliance with the regulatory requirements, CMS may recover the difference between the amounts reimbursed as provider-based and that amount that would have been reimbursed for freestanding facilities. This recovery may be made for all periods subject to reopening.

If you decide to submit a self-attestation for formal review, this increases your assurance that you are properly adhering to the provider-based criteria of 42 CFR 413.65. In addition, if CMS subsequently discovers that the facility has been billing as provider-based and an attestation has been made and approved in fact does not meet the provider-based rules, then CMS would not recover all past payments for periods subject to reopening, but instead would limit such recoupment back to the date the complete request for a provider-based determination was submitted. At the time that CMS determines that a facility that submitted a complete attestation is actually not provider-based, payment would continue for up to 6 months but only at a reduced rate as described at §413.65(j)(5).

It could benefit the provider to self-attest and obtain a determination because, under §413.65(l)(1), treatment of a facility as provider-based would cease only with the date that CMS determines that the facility no longer qualifies for provider-based status, if the reason the provider-based criteria are not met is a material change in the provider-facility relationship that was properly reported to CMS. By contrast, a provider that did not seek such a determination or obtained a determination but failed to report a material change in its relationship with the facility, could face a partial recovery of past payments. Also, a provider that does not seek a provider-based determination and incorrectly bill as such could be subject to the partial recovery of payments for all cost reporting periods subject to reopening in accordance with 42 CFR §405.1885 and §405.1889. 

Allowance of Provider-Based Attestations

Provider-based determinations only serve a purpose if there is a reimbursement (payment) impact or a difference in coinsurance liability between billing as provider-based or freestanding. Neither the Medicare Administrative Contractor (MAC) or CMS Regional Office (RO) will make determinations of provider-based status (and provider-based attestations should not be submitted) 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 rehabilitation units, facilities that furnish only clinical diagnostic laboratory tests, or facilities that furnish only physical, occupational, or speech therapy throughout any period during which the annual financial therapy cap is suspended by legislation.  

In essence, submissions and reviews will only be allowed when there is a difference in payment or beneficiary liability. When submitting an attestation, one of the questions that will be asked is, "what is the difference in payment between freestanding and provider-based status for this service?" If there is no difference, the attestation will immediately be closed with no recommendation made.

In addition, regardless of payment differences between freestanding and provider-based. Provider-based attestations will not be accepted or reviewed for the following two situations: 

1. When the entity is located on the floor of the main building/department of the hospital, or within the four walls of the provider's main building, or
2. When the provider plans to bill Part B - because provider-based attestation only impacts Part A services

Note that these exemptions listed above do not mean such entities cannot bill as a provider-based, it simply means that no self-review or attestation will be required or allowed. 

Submission of Attestation Prior to Receipt of All Documentation

Per CR 10095 , do not submit your provider-based attestation if the Provider Enrollment Approval Form 855A has not been submitted or the Provider Enrollment letter has not been received.  If the provider-based location is not being approved or is not on PECOS, the attestation will be rejected and returned.  Do not submit your provider-based attestation unless all necessary information is included and/or available. For example, if you have not included a copy of the license showing that the main and provider-based facility are operated under the same license, or support showing that your state does not allow this, a missing information letter will be issued requesting such information.
 
If no additional information is requested the provider-based attestation MAC recommendation of approval/denial, attestation and supporting documentation will be submitted to CMS RO within 60 days of receipt of the initial package.  If additional documentation is requested, providers will be given 30 days to submit the additional documentation.  If the MAC has not received the requested additional information by the given 30-day due date, the provider-based attestation and supporting documentation will be rejected and returned to the provider.  The provider will be required to resubmit the entire provider-based attestation package along with the missing documentation.  Once all of the documentation has been received the MAC has 120-days from initial receipt of the provider-based documentation to submit to the appropriate CMS RO.

Submission of CMS Form 855A to Report New Service Location Prior to, at Same Time, or After Submission of the Provider-Based Attestation

Preferably the form 855A will be submitted and approved prior to your submission of the provider-based attestation; however, if it is submitted at the same time as the 855A, the provider-based attestation will be rejected and returned.  It is the provider’s responsibility to resubmit the entire package once the location is on PECOS.
 
Requirements to Reattest or Report Changes

Again, the entire attestation process is voluntary. However, if you have previously chosen to go through the attestation process, and have now experienced material changes in the relationship between the hospital and any provider-based facility or organization, such as a change in ownership of the facility or organization or entry into a new or different management contract that could affect the provider-based status of the facility or organization, you may want to consider reporting those changes in the form of an updated attestation statement. 

Form and/or Documentation Requirements for Attestation Process

There is no officially required form that must be used when providers elect to go through the attestation review process. A provider is allowed to create their own form if they prefer, but it must address the issues discussed in 42 CFR 413.65. Per CR 10095 , CMS has allowed the MACs to include the CMS Provider-Based Designation Checklist on our website to assist providers with submitting the required documentation.

In addition to completing this attestation, documentation that demonstrates that the provider-based requirements have been met, i.e., organizational chart, etc., must be submitted with this request. CMS RO and the MAC have the discretion to request additional information not listed on the provider-based application in order to further substantiate compliance with 42 CFR §413.65 or §413.174. Any special circumstances should be fully explained in a cover letter with this request.

Although there is no required form, we have created a suggested form that can be used. See the main page of this section for this suggested attestation form. This template includes all of the regulatory verbiage, as well as explanations as to what type of documentation that we would need to see regarding that issue. Use of this form, although not required, will assist in ensuring that all necessary documentation was sent in to ensure a quick and accurate review. Note that although the MAC is the first point of contact for reviewing the attestation, we only recommend approval or denial to CMS RO, who makes the final determination.

Facility Charge versus Professional Charge for Provider-Based Facilities

Medicare Claims Processing Manual, IOM 100-04, Chapter 6 , Section 20.1.1.2 discusses the provider-based facility charge.