Last Modified: 3/9/2021
Location: FL, PR, USVI
Business: Part A
The provider-based designation checklist is a standardized tool developed by CMS
. It is used by MACs to address key areas required to be met by an entity seeking approval for a provider-based status in accordance with 42 CFR 413.65. The checklist gives MACs the ability to identify and/or develop a list of the type of documentation necessary to address the various sections in order to make a determination within the expect CMS requirements.
In the process of requesting a provider-based status, providers are expected to file an attestation that addresses the various requirements to receive a determination. Generally, the attestation is accompanied by supporting documents and is subsequently reviewed by a MAC. It is critical to the review that proper supporting documents are supplied in a timely manner in order to ensure compliance with provider-based criteria within the expected time requirements from the receipt of the provider’s application. We are including the provider-based designation checklist and list of key documentation on our website as a source for providers to use as a guide to know the exact documentation necessary to make the review process more efficient and to achieve their expected determination.
Below are links to the CMS provider-based designation checklist and list of key documentation.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.