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

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