Form CMS-R-138 Statewide Application

MEDICARE GEOGRAPHIC CLASSIFICATION REVIEW BOARD

2520 Lord Baltimore Drive, Suite L

Baltimore, MD 21244-2670

STATEWIDE APPLICATION

Reclassification Period: Federal Fiscal Years 2018 – 2020

Please read the MGCRB rules before completing this application.
This application must be completed and received by the MGCRB by September 1, 2016.

Failure to comply will result in dismissal.

This application must also be sent to CMS via e-mail at [email protected].

Delivery to CMS does not constitute delivery to the MGCRB.

General Information
Statewide Information
State:

_____________________________________________

Representative Information
Identify the representative contact for all communications regarding the application:
Name:

_____________________________________________

Organization:

_____________________________________________

Address:

_____________________________________________
_____________________________________________

City, State, Zip:

_____________________________________________

E-mail Address:

_____________________________________________

Telephone Number: _____________________________________________

Expires 7/31/2020

Page 1

Listing of Providers
Under a tab labeled “Providers,” the statewide representative must provide a listing of
all participating acute care inpatient prospective payment system (“IPPS”) hospitals in the
state. The listing is to be submitted in the following format:
Column A
Provider Number

Column B
Provider Name

Column C
Provider Address

Column D
Did provider also file
an individual or group
application? (Y/N)

All IPPS hospitals in the state must agree to the reclassification to a statewide wage index
through a signed affidavit. Under a tab labeled “Affidavits,” attach an affidavit for each
participating provider in accordance with 43 C.F.R. § 412.235.
Under a tab labeled “Representative” or “Rep,” attach a letter of representation for
each participating provider in accordance with Board Rule 2.4.
Note: The Board will rule on a statewide request first and then a group reclassification
request before it reviews any individual reclassification request. If the Board approves the
statewide application, it will dismiss any group or individual reclassification applications filed
by participating providers.

Background Questionnaire
Note: All required documentation as noted by the questions below must be annotated with
the applicable question number and included under a tab labeled “Background.”
1.

Are all the acute care inpatient prospective payment system (“IPPS”) providers in the
state listed as members of the statewide application?
___ Yes

___ No

Attach support that identifies all the IPPS providers in the state.
If no, attach an explanation that identifies which provider(s) are excluded and the
basis for the exclusion.

2.

Are the providers in the statewide application requesting an oral hearing?
___ Yes

___ No

If yes, attach a letter of rationale for the oral hearing request.

Expires 7/31/2020

Page 2

Certification Statements
*I certify that the application is filed in full compliance with the statutes, regulations,
and Board rules.

*I understand that an omission, misstatement, or error made in the statewide
application and supporting information may be grounds for denial of the statewide
application.

*I certify that I am authorized to file an application on behalf of the listed statewide
group.

Signature:

_____________________________________________

Representative Name:

_____________________________________________

Organization:

_____________________________________________

Date:

__________________

Expires 7/31/2020

Page 3