Community Health Plan of Washington (CHPW) is required to ensure accurate member cost share allocation in processing claims for Provider Based Clinics under 42CFR §413.65. CHPW is currently updating our records to include a list of Provider Based Clinics that bill a separate facility fee.

Clinic Billing Managers should provide a listing of all outpatient clinic locations, and indicate those that are Provider Based Clinics as defined by CMS memorandum A-03-030, and 42 CFS §413.65. For each unique clinic location site, please indicate the following by using the spreadsheet below: 

  • Contact name/phone/email for Provider Based Clinic Information
  • Clinic Name and Address
  • Clinic Manager name and contact information
  • Effective Date for each clinic as Provider Based
  • Tax ID
  • Group NPI
  • Medicare PTAN Number
  • Medicaid Billing Number
  • Website address for facility/clinics

Please email the requested information in this spreadsheet to your CHPW Contract Administrator.

If you have any questions or concerns, please contact your CHPW Contract Administrator. Your Contract Administrator will place a follow-up call with you by 03/21/14.

Thank you for your assistance and valued service to our members.