OMB control number
Prospective Payments for Hospital Outpatient Services and Supporting Regulations in 42 CFR 413.65 (CMS-R-240)
OMB 0938-0798 · HHS/CMS.
OMB 0938-0798
Section 413.65(b)(3) states that a provider which is seeking a determination of provider-based status for a facility not located on the provider's campus must submit an attestation of compliance with applicable provider-based requirements and must supply documentation supporting its attestation at the time the attestation is made. Section 413.65(a)(1)(ii) establishes a listing of specific facilities for which determinations for provider-based status for payment purposes are not made. As CMS removed certain CAH-based facilities from this list, such facilities are allowed to apply for provider-based determination and are required to meet all provider-based requirements before billing for hospital or CAH based services.
The latest form for Prospective Payments for Hospital Outpatient Services and Supporting Regulations in 42 CFR 413.65 (CMS-R-240) expires 2027-12-31 and is listed under ICR 202408-0938-036.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 CMS-R-240 Supporting Statement A (Final Version).docx | Supporting Statement A |
 (CMS-R-240) Prospective Payments for Hospital Outpatient Services and Supporting Regulations in 42 CFR 413.65 |
Information collection |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202408-0938-036 | Reinstatement without change of a previously approved collection | 2024-09-06 | ||
| 201902-0938-006 | Reinstatement without change of a previously approved collection | 2019-02-12 | Approved without change | |
| 201310-0938-006 | Extension without change of a currently approved collection | 2013-10-25 | Approved without change | |
| 201009-0938-013 | Revision of a currently approved collection | 2010-09-28 | Approved without change | |
| 200701-0938-007 | Extension without change of a currently approved collection | 2007-01-03 | Approved without change | |
| 200305-0938-004 | Extension without change of a currently approved collection | 2003-05-16 | Approved without change | |
| 200006-0938-002 | New collection (Request for a new OMB Control Number) | 2000-06-02 | Approved without change |