CMS-R-138 Group Application

MEDICARE GEOGRAPHIC CLASSIFICATION REVIEW BOARD

2520 Lord Baltimore Drive, Suite L

Baltimore, MD 21244-2670

GROUP 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
Group Information
County: _____________________________________________

State:

__________________

CBSA Code of Current Area:

__________________

CBSA Name of Current Area:

_____________________________________________

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

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Listing of Providers
Under a tab labeled “Providers,” the group representative must provide a listing of all
participating acute care inpatient prospective payment system (“IPPS”) hospitals in the
county. 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 file
an Individual
Application? (Y/N)

Column E
Is provider an
urban hospital
currently
classified as rural
by CMS under 42
C.F.R. § 412.103?
(Y/N or Status
Pending)

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 the group reclassification
request before it reviews any individual reclassification request. If the Board approves the
reclassification for the group, it will dismiss any individual reclassification application filed by
providers participating in this group.

Reclassification Request
Requested Area
CBSA Code of Requested Area:

__________________

CBSA Name of Requested Area:

_____________________________________________

Wage Computations
Under a tab labeled “Primary,” attach the group's aggregate hourly wage computations
using the 3-year averages of wages and hours (i.e., 85 percent comparison). Per 42 C.F.R.
§§ 412.232(c) and 412.234(b) the rounding of numbers is not permitted to meet the
qualifying wage comparison percentage standards.

Note: If the group has a secondary reclassification request, attach a supplemental form
indicating the CBSA code and name of the requested area and include the group's aggregate
hourly wage computations under a tab labeled “Secondary.”

Expires 7/31/2020

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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.

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

___ No

Attach support that identifies all the IPPS providers in the county.
If no, attach an explanation that identifies which provider(s) are excluded and the
basis for the exclusion.
2.

Is the county in which the providers are located adjacent to the area to which the
group is requesting reclassification?
___ Yes

___ No

Attach map support showing the location of the group’s county and the location of
the requested area.
3.

If the county in which the providers are located is a rural area, does it meet the
standards for redesignation to an urban area as an “outlying county” under 42 C.F.R.
§ 412.232(b)?
___ Yes

___ No

___ N/A

If yes, attach Census Bureau support showing that the county has been designated
as an outlying county.
4.

If the county in which the providers are located is an urban area, is it part of the CSA
or CBSA that includes the urban area to which the group is requesting reclassification?
___ Yes

___ No

___ N/A

If yes, attach the Census Bureau CSA or CBSA listing.
5.

Are the providers in the group also members of a statewide wage index area request?
___ Yes

6.

___ No

Is the group requesting an oral hearing?
___ Yes

___ No

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

Expires 7/31/2020

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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 group application
and supporting information may be grounds for denial of the group application.

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

Signature:

_____________________________________________

Representative Name:

_____________________________________________

Organization:

_____________________________________________

Date:

__________________

Expires 7/31/2020

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