Official Federal Forms > Centers For Medicare And Medicaid Services
Rehabilitation Hospital Work Sheet CMS-437B - Official Federal Forms
| Rehabilitation Hospital Work Sheet Form. This is a national form and can be used in Centers For Medicare And Medicaid Services . |
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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0986 REHABILITATION HOSPITAL CRITERIA WORK SHEET RELATED MEDICARE PROVIDER NUMBER ROOM NUMBERS IN THE HOSPITAL FACILITY NAME AND ADDRESS (City, State, Zip Code) NUMBER OF BEDS IN THE HOSPITAL SURVEY DATE REQUEST FOR EXCLUSION FOR COST REPORTING PERIOD / / to / / MM DD YYYY MM DD YYYY VERIFIED BY ALL CRITERIA UNDER SUBPART B OF PART 412 OF THE REGULATIONS MUST BE MET FOR EXCLUSION FROM MEDICARE'S ACUTE CARE HOSPITAL PROSPECTIVE PAYMENT SYSTEM TAG REGULATION GUIDANCE Verification of hospital attestations may be done by CMS surveyors or MACs as applicable. THE HOSPITAL REPRESENTATIVE WHO COMPLETES THIS ENTIRE FORM The hospital representative is expected to answer all questions truthfully. The representative should verify the answers with the Director of Rehabilitation physician, medical records office, or any applicable department to ensure correct responses to this form, A "yes" response means the hospital is in compliance with the applicable regulation. YES NO N/A §412.23 Excluded hospital units: Classifications. (b) Rehabilitation hospitals. A rehabilitation hospital must meet the requirements specified in §412.29 of this subpart to be excluded from the prospective payment systems specified in §412.1(a)(1) of this subpart and to be paid under the prospective payment system specified in §412.1(a)(3) of this subpart and in subpart P of this part. §412.29 Classification criteria for payment under the inpatient rehabilitation facility prospective payment system. To be excluded from the prospective payment systems described in §412.1(a)(1) and to be paid under the prospective payment system specified in §412.1(a) (3), an inpatient rehabilitataion hospital or an inpatient rehabilitation unit of a hospital (otherwise referred to as an IRF) must meet the following requirements: Form CMS-437B (06/12) American LegalNet, Inc. www.FormsWorkFlow.com TAG A3600 REGULATION (a) Have (or be part of a hospital that has) a provider agreement under part 489 of this chapter to participate as a hospital. (b) Except in the case of a "new" IRF or "new" IRF beds, as defined in paragraph (c) of this section, an IRF must show that during its most recent, consecutive, and appropriate 12-month time period (as defined by CMS or the Medicare contractor), it served an inpatient population of whom at least 60 percent required intensive rehabilitation services for treatment of one or more of the conditions specified at paragraph (b) (2) of this section. GUIDANCE The surveyor will verify, through the regional office (RO), that the hospital has an agreement to participate in the Medicare program. The MAC/FI reviews the inpatient population of the IRF. If the hospital has not demonstrated that it served the appropriate inpatient population as defined in § 412.29 (b)(2), the MAC notifies the RO. THE HOSPITAL REPRESENTATIVE WHO COMPLETES THIS ENTIRE FORM Representative to ensure the hospital has a Medicare provider agreement. YES NO N/A A3601 A3602 · (c) In the case of new IRFs (as defined in paragraph (c)(1) of this section) or new IRF beds (as defined in paragraph (c)(2) of this section), the IRF must provide a written certification that the inpatient population it intends to serve meets the requirements of paragraph (b) of this section. · This written certification will apply until the end of the IRF's first full 12-month cost report period or in the case of new IRF beds, until the end of the cost report period during which the new beds are added to the IRF. · The IRF must submit a written attestation statement as well as Form CMS 437B (rehabililtation hospital worksheet) to the SA as part of their initial application packet or as determined by CMS to maintain their IPPS excluded status. · Until the SA receives both the attestation statement and the Form CMS 437B the new rehabilitation hospital cannot be recommended for approval. The representative completes this form (Form CMS 437B) as well as a signed attestation statement attesting that the rehab hospital patients it intends to serve meets the requirements outlined in §412.29(b)(2) and submits the documentation to the State Agency. A3603 (1) New IRFs. An IRF hospital or IRF unit is considered new if it has not been paid under the IRF PPS in subpart P of this part for at least 5 calendar years. A new IRF will be considered new from the point that it first participates in Medicare as an IRF until the end of its first full 12-month cost report period. · If an IRF hospital has been closed for 5 years (more than 60 calendar months), it can open its doors as a new rehabilitation hospital. · Verify either through the SA or RO that the IRF hospital has been closed for the 5 years before approving the IRF hospital as new. The representative ensures the IRF hospital has not been paid under the IRFPPS for at least 5 calendar years. Form CMS-437B (06/12) American LegalNet, Inc. www.FormsWorkFlow.com 2 TAG A3604 REGULATION (1) New IRFs beds. Any IRF beds that are added to an existing IRF must meet all applicable State Certificate of Need and State licensure laws. New IRF beds may be added one time at any point during a cost reporting period and will be considered new for the rest of that cost report period. A full 12-month cost report period must elapse between the delicensing or decertification of IRF beds in an IRF hospital or IRF unit and the addition of new IRF hospital or IRF unit. Before an IRF can add new beds, it must receive written approval from the appropriate CMS RO, so that the CMS RO can verify that a full 12-month cost eporting period has elapsed since the IRF has had beds delicensed or decertified, New IRF beds are ncluded in the compliance review calculations under paragraph (b) of this section from the time that they are added to the IRF. GUIDANCE · If the rehabilitation hospital added beds, the surveyor or CMS will verify that the hospital had approval (certificate of need or State license ) before adding beds, if such approval is required. · The surveyor must verify that the hospital received written CMS RO approval before adding any new beds. · The surveyor will verify that the hospital didn't have more than one increase in beds during a single cost reporting period. · Surveyors must verify that if the rehabilitation hospital decreased beds, it didn't thereafter add beds unless a full 12 month cost reporting period had elapsed. THE HOSPITAL REPR
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