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Last Modified: 3/9/2021 Location: FL, PR, USVI Business: Part A

List of key documentation

Some of the key points are documentation for each section of the attestation. This list is not all inclusive. Additional information may be requested as the review of the application progresses.
On and off campus:
Provider enrollment summary report (855A)
Facility is a practice location under the main provider
A map indicating the distance between the main provider and the facility.
A description of the physical setting of the main provider and the provider based facility.
A copy of a current state license of the main provider
A copy of a current state license of the provider based facility or letter from the state indicating a state license is not required for the provider based facility
Clinical services
List of key personnel working at the provider based facility showing job titles and names of employer
Organizational chart
Documentation to support the professional staff at the provider based facility have clinical privileges at the main provider
Documentation or description that explains the level of monitoring and oversight of the facility by the main provider
Documentation or description of responsibilities and relationship between the medical director of the facility, the chief medical officer of the main provider, and the medical staff committees at the main provider
Documentation that inpatient and outpatient services of the facility and the main provider are integrated, and patient treated at facility who require further care have full access to all services of the main provider
Documentation or written policy that explains how the medical records for patients are integrated into a unified retrieval system of the main provider
Financial integration
A trial balance showing the location of the provider based facility’s revenues and expenses in relation to other departments within the hospital.
Documentation worksheet A of cost report documenting the integration of the expenses for the provider based facility
The cost center of the facility on the Medicare cost report.
Public awareness
Documentation that clearly reflects that the provider base facility is part of the main provider. When patients enter the provider based facility they are aware they are entering the main provider and are billed accordingly
Provider letterhead, yellow pages, website, signs, advertisements, patient registration forms, etc.
Obligation of hospital outpatient department and hospital based entities
Copy of the EMTALA policy of CFR 482.12(f)(1)(2) & (3)
Documentation to support compliance with the antidumping rules of 42CFR 489.20(i),(m)(q), and( r ), and 42CFR 489.24
Documentation to support physician services furnished at the hospital based facility and billed with the correct site of service so that the appropriate physician and practitioner payment amounts can be determined. Copy of a 1500 or UB claim.
Documentation that the facility complies with all the terms of the hospital’s provider agreement.
Documentation of compliance with the Non-discrimination provision in accordance with 42CFR489.10 (b).
Documentation that all Medicare patients, for billing purposes, are treated as hospital outpatients and not as physician office patients.
Documentation of a payment window provision policy applicable to PPS hospitals and excluded units
Copy of notice that identifies beneficiary’s potential financial liability for an outpatient visit. Note: The notice can be read and understand by the beneficiary or beneficiary’s representative.
Documentation that outpatient departments meet applicable hospital health and safety rules
Joint venture
Be partially owned by at least on provider
Be located on the main campus of a provider who is a partial owner
Be provider based to the main provider on whose campus the facility or organization is located
For off campus facilities additional data is required:
Operation under the ownership and control of the main provider
Documentation that shows the provider based facility is 100% owned by the main provider, if applicable.
Documentation that the main provider and the facility have the same governing body
Documentation of common article of incorporation and by-laws and operating decisions
Documentation that explains who has final responsibility for administrative decisions, final approval for contracts, final approval for personnel policies, and final approval over medical staff appointments for the provider based facility.
Administration and supervision
List of key administrative staff (positions/titles only) at the main provider and the provider based facility that reflects reporting relationship
Organizational chart that includes main provider and provider base facility and show which department of the main provider the entity is included
Description of the facility directors reporting requirement and accountability procedures for day to day operations.
List of administrative functions at the provider based facility that are integrated with the main provider such as billing services, records, human resources etc…
Copy of any contracts for administrative functions that are completed under arrangements for the main provider
Obligations of hospital outpatient departments and hospital based entitles
Documentation that when a Medicare beneficiary is treated in a hospital outpatient department that is located on the main providers campus and the treatment is not required to be provided by the anti-dumping rules, the hospital must provide written notice to the beneficiary, before the delivery of services, of the amount of the beneficiary’s potential financial liability.
Management contracts
Copy of management contract to operate the provider based facility.
Documentation who is responsible for employing the staff of the provider based facility
Documentation that shows the administrative functions of the provider based facility or organization integrated with those of the main provider.
Documentation or description that explains the relationship between the main provider in terms of control over the operations of the facility or organization.
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.