(d)(1)

1. Licensing/Credentialling

1. Is the site listed on the hospital’s Department of Health application?

2. Is this site listed on the Medicare enrollment form CMS-855A?

(d)(2)(i)

2. Clinical Services Integration

1. Is medical staff privileged at the main hospital?

(d)(2)(ii)

2. Are monitoring and oversight of the department the same as for other hospital departments (e.g., executive leadership, information control, quality, etc.)?

(d)(2)(iii)

3. Does the department’s medical director have a reporting relationship to the chief medical officer of the main hospital?

(d)(2)(iv)

4. Does the medical staff committee of the main hospital oversee the medical activities of the department?

(d)(2)(v)

5. Do the medical records identify the patient as being a patient in the main hospital?

(d)(2)(vi)

6. Do the clinic patients have access to the full range of services at the main hospital?

(d)(3)

3. Financial Integration

1. Are departmental costs included on the hospital cost report?

(d)(3)

2. Are the income and expenses of the department shared with the main hospital?

(d)(3)

3. Is the department on the trial balance of the main hospital?

State Operations Manual § 2026A and Centers for Medicare & Medicaid Services (CMS) rulings not in manual form

4. Building/Space Integration (Provide detailed information for each “Yes” answer in the Notes section)

1. Is the entrance to the department shared with any other department/clinic/service?

2. Does the department share waiting room space with any other department/clinic/service?

3. Does the department share office or front desk space with any other department/clinic/service at any time, day or night? If yes, provide detailed information in the Notes section.

4. Does the department share staff with any other department, including registration staff?

(d)(4)

5. Public Awareness/How the Department Is Held Out to the Public as a Department of the Main Hospital

1. Does the department signage indicate the name of the hospital?

(d)(4)

2. Take a photo of the clinic sign(s), including sign on outside of building, sign on door, etc.

(d)(4)

3. Do the department registration documents reference the name of the hospital?

(d)(4)

4. Locate the department/location on the internet (external organizational website). Document the naming and description information provided.

(d)(4)

5. If you were a patient, would it be obvious to you that this location is part of the main hospital?

(e)(1)(i)

1. Ownership & Control

1. Is the department under 100% control of the main hospital?

(e)(1)(ii)

2. Does the department have the same governing body (directors) and organizational documents as the main hospital?

(e)(1)(iii)

3. Is the department subject to common bylaws of the main provider where it is based?

(e)(1)(iv)

4. Does the main hospital have final responsibility for administrative decisions; final approval of contracts, personnel actions, and personnel policies of clinic staff; and medical staff appointments?

(e)(2)(i)

2. Administration & Supervision

1. Does the main hospital provide direct supervision of the department, with the same frequency, intensity, and accountability as between the hospital and on-campus departments?

(e)(2)(ii)

2. Does the main hospital provide monitoring and oversight of the department?

(e)(2)(iii)

3. Does the department obtain the following services, including employed and contracted services, in the same manner as the main hospital?

• Billing

• Medical records

• Human resources

• Payroll

• Employee benefit structure

• Salary structure

• Purchasing

(e)(3)(i)

3. Geographic Location

1. Is the department located within 35 miles of the main hospital (straight line, not road miles)?

Geo-pin:

(f)

4. Joint Ventures

1. Is the department part of a joint venture?

(g)(1)(i)

1. Emergency Medical Treatment and Labor Act (EMTALA)

1. Does department comply with the anti-dumping rules?

(g)(1)(ii)

2. Is the department an off-campus “dedicated emergency department” (DED)? (An off-campus site must comply if a DED)

(g)(2)

2. Site-of-Service

1. Is the department set up in Epic to bill the appropriate place-of-service code?

(g)(3)

3. Provider Agreement

1. Does the department comply with all the terms of the hospital’s provider agreement?

(g)(4)

4. Nondiscrimination Provisions

1. Does the department comply with the nondiscrimination provision of Social Security Act Title XVIII?

(g)(5)

5. Billing of Medicare Patients

1. Are all Medicare patients treated as hospital outpatients for the purpose of billing?

(b)

2. Has an attestation/notification of provider-based status been submitted to CMS?

(b)

3. Has CMS provided acknowledgement or approval of the provider-based status for this department?

(g)(5)

4. Are any Medicare patients treated as nonhospital patients for any services provided in the department?

(g)(6)

6. Payment Window

1. Are department charges rolled up into the related hospital bill when the patient is admitted to the hospital within three days of receiving services in the provider-based department?

(g)(7)(i)

7. Informing Beneficiaries

1. Does the off-campus department provide notice to Medicare patients before services are rendered that they are receiving hospital outpatient services and will receive two co-pays?

2. Does the off-campus department display signage indicating the same as above?

(g)(8)

8. Health & Safety

1. Does the department meet the applicable hospital health and safety rules for Medicare participating hospitals?

(h)(1)

1. Management Contract

1. Are all direct patient care staff employed by the hospital or the management company?

(h)(4)

2. Who holds the management contract—the main hospital or the parent organization?

(h)(3)

3. Does the main hospital have significant operational control over the operations of the facility?

(h)(2)

4. Is the department integrated administratively with the main hospital?