CMS-R-138 Individual Application

MEDICARE GEOGRAPHIC CLASSIFICATION REVIEW BOARD

2520 Lord Baltimore Drive, Suite L

Baltimore, MD 21244-2670

INDIVIDUAL 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
Provider Organization Information
Provider Number:

__________________

Provider Name:

_____________________________________________

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

_____________________________________________

Organization:

_____________________________________________

Address:

_____________________________________________
_____________________________________________

City, State, Zip:

_____________________________________________

E-mail Address:

_____________________________________________

Telephone Number: _____________________________________________
Under a tab labeled “Representative” or “Rep,” attach a letter of representation in
accordance with Board Rule 2.4.

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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.

Is the provider also a member of a group reclassification request?
___ Yes

2.

___ No

Is the provider also a member of a statewide wage index area request?
___ Yes

___ No

Note: The Board will rule on a statewide request first and then a group
reclassification request before it reviews any individual reclassification request.

3.

Is the provider an urban hospital currently classified as rural by the CMS Regional
Office under 42 C.F.R. § 412.103?
___ Yes

4.

___ Status Pending

Is the provider currently classified as a sole community hospital (“SCH”)?
___ Yes

5.

___ No

___ No

Has the provider lost its designation as an SCH due to previous MGCRB
reclassification?
___ Yes

___ No

If yes, attach the letter from the Medicare Administrative Contractor (“MAC”) or
CMS Regional Office indicating the date and reason the provider's SCH status was
lost.

6.

Is the provider currently a rural referral center (“RRC”)?
___ Yes

Expires 7/31/2020

___ No

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Background Questionnaire
(continued)
7.

Has the provider ever been an RRC?
___ Yes

___ No

If yes, attach the letter from the MAC or CMS Regional Office indicating the RRC
status.

8.

Has the provider lost its designation as an RRC due to previous MGCRB
reclassification?
___ Yes

___ No

If yes, attach the letter from the MAC or CMS Regional Office indicating the date
and reason that the provider's RRC status was lost.

9.

Is the provider the single acute care inpatient prospective payment system (“IPPS”)
hospital in the provider's urban area?
___ Yes

___ No

If yes, attach documentation to support the provider’s status as the single acute
care IPPS hospital.

10. Is the provider classified as a Lugar hospital and deemed to an urban area under 42
C.F.R. § 412.64(b)(3)(i)?

___ Yes

___ No

11. Is the provider requesting an oral hearing?
___ Yes

___ No

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

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Reclassification Request
Provider’s Current Area
Identify the geographic address for the front entrance of the provider:

Street Address:

_____________________________________________

City:

_____________________________________________

County:

_____________________________________________

State:

_____________________________________________

Zip Code:

_____________________________________________

Identify the CBSA applicable to the provider’s physical location:

CBSA Code:

__________________

CBSA Name:

_____________________________________________

Reclassification Requests
How many MGCRB reclassification requests are included in this application?

____

For each request, under tabs marked by priority order, attach a separate reclassification
request form to identify the:


priority of request, (e.g., primary, secondary, tertiary, etc.);



CBSA of requested area;



reclassification method, e.g.,
o Proximity (Distance),
o Proximity (Employee Commuting Pattern),
o Special Access (Distance), or
o Special Access (Driving Time);



required supporting documentation including, but not limited to, maps and wage
comparisons.

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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 provider’s
application and supporting information may be grounds for denial of the provider’s
application.

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

Signature:

_____________________________________________

Representative Name:

_____________________________________________

Organization:

_____________________________________________

Date:

__________________

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