CMS-R-138 Individual - Special Access (Distance)

Medicare Geographic Classification Review Board Procedures and Criteria and Supporting Regulations in 42 CFR, Section 412.256

2018 Individual - Special Access (Distance)

Medicare Geographic Classification Review Board (MGCRB) Procedures and Criteria and Supporting Regulations in 42 CFR, Section 412.256 & 412.230 (CMS-R-138)

OMB: 0938-0573

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Reclassification Request 

Special Access (Distance) 

Priority of Request
Identify the priority order that the MGCRB should consider this reclassification request,
(e.g., primary, secondary, tertiary, etc.):

________________________

Requested Area
CBSA Code of Requested Area:

__________________ 


CBSA Name of Requested Area:

_____________________________________________ 


Method – Special Access (Distance)
Is the requested area the closest area via distance (miles)?

___ Yes

___ No

If no, attach an explanation as to why the closest area was not selected.
Distance to Requested Area (in miles to the nearest tenth):

__________________

Attach map support showing mileage from the front entrance of the provider to the
requested area.
CBSA Code of Next Closest Area:

__________________ 


CBSA Name of Next Closest Area: _____________________________________________ 

Distance to Next Closest Area (in miles to the nearest tenth):

__________________ 


Attach map support showing mileage from the front entrance of the provider to the next 

closest area. 


Wage Computations
Attach the provider's wage computations using 3-year average hourly wages (i.e., 106 and
82 percent comparison for hospitals located in rural areas and 108 and 84 percent
comparison for hospitals located in urban areas).

Note: Per 42 C.F.R. § 412.230(a)(4), rounding of numbers is not permitted to meet the
mileage or qualifying wage comparison percentage standards.

Expires 7/31/2020


File Typeapplication/pdf
File TitleMicrosoft Word - 2018 Individual - Special Access (Distance).docx
AuthorB4Z9
File Modified2017-01-11
File Created2016-07-20

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