Form Cms 437A – Fill Out and Use This PDF

DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICE

OMB NO. 0938-0986

RELATED MEDICARE PROVIDER NUMBER

ROOM NUMBERS IN THE UNIT

FACILITY NAME AND ADDRESS (City, State, Zip Code)

NUMBER OF BEDS IN THE UNIT

SURVEY DATE

REQUEST FOR EXCLUSION FOR COST REPORTING PERIOD

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to

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VERIFIED BY

MM DD

YYYY

MM DD YYYY

• Verification of hospital attestations may bedone

The hospital representative is expected to answer all

byCMSsurveyorsorMACsasapplicable.

questions accurately.

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.

§412.25 Excluded hospital units: Common

requirements.

(a) Basis for exclusion. In order to be excluded

In the case of § 412.25 and § 412.29,as related to

from the prospective payment systems specified in

IRF units,thetermhospital includes CriticalAccess

§412.1(a)(1), a rehabilitation unit must meet the

Hospitals.

following requirements in addition to the all criteria

under Subpart B of Part 412 of the regulations:

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(1) Be part of an institution that has in effect an

•

The surveyor will verify, through the regional

Representative to ensure the hospital has a

agreement under Part 489 to participate as a

office(RO),that thehospital has anagreement

Medicare provider agreement .

hospital,andisnotexcludedinitsentiretyfromthe

to participate in the Medicare program, andthe

prospective payment systems, and has enough beds

hospital is not already excluded in its entirety

that are not excluded to permit the provision of

from IPPS, such as a rehabilitation hospital. In

adequate cost.

other words, the unit seeking exclusions cannot

comprise the entire hospital

• The hospital must be sufficiently staffed,

maintainedandIPPSbedsutilizedthatarenot

part of the rehabilitation unit.

• Verification of this information may be doneby

CMS surveyors or MACs.

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(2) Have written admission criteria that are applied

•

Verify that the hospital has preadmission criteria

Representative to verify the rehab unit has

uniformly to both Medicare and non-Medicare

for the rehabilitationunit.

preadmission criteria.

patients.

• Conduct an open and closed record review to

determine whether the approved preadmission

criteria is applied equally to all patients.

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(3) Have admission & discharge records that are

•

Verify that rehabilitation unit medical records

Representative to verify that the rehab unit houses

separately identified from those of the hospital in

are separate and not commingled with other

only the records of the rehab patients.

whichit islocatedandarereadilyavailable.

hospital records and are readily available for

review.

A3503

(4) Have policies specifying that necessary clinical

•

Verifythat the hospital hasa policy detailing

Representative to verify the hospital has a policy

information is transferred to the unit when a patient

the prompt transfer of information, and that itis

regarding the transfer of information, and the

of the hospital is transferred to the unit.

being followed.

hospital adheres to the policy.

•

Review rehabilitation unit clinical records to

ensure that the clinical information thatshould

be transferred with the record is actually inthe

medical record.

Form CMS-437A (04/30/19)

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(5) Meet applicable State licensure laws.

•

Verify and document that all applicable State

Representative to verify that all applicable State

licensure laws are met.

laws arebeingmet andthat all applicable licenses

are current.

•

Document all unmet Statelicensure

requirements.

• Verify the hospital has current licenses forits

professional staff.

• Arethe licenses issued by theState inwhich the

rehabilitation unit is located?

• Does the unit meet special licensing

requirements issued by the State?

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(6) Have utilization review standards applicable for

•

Verify that the hospital has a utilization

Representative to verify that the hospital has a UR

the type of care offered in the unit.

review plan that includes the review of rehab

plan and that the UR standards are being applied to

services (No utilization review (UR) standards

thecareofferedintherehabunit.

are required if the QIO is conducting review

activities.)

• Verify that the hospital has written UR standards

that areappliedtothecare offeredintheunit.

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(7) Have beds physically separate from (that is, not

•

Is the space containing the rehab beds physically

Representative will verify that the beds on the rehab

commingled with) the hospital’s other beds.

separate from the beds in other units of the

unit do not belong to medical/surgical patients but

NOTE: §412.25(a) (8)-(12) are verified by the FI.

hospital?

are dedicated to rehab patients only.

• There cannot be any beds that are located

within the physical confines of the excluded

rehab unit that are not excluded beds.

• TheIRF unit cannot use its beds for medical

/surgical patients or any other type of patient.

Thosebeds aresolelyfor theuseof IRF patients.

• If the unit doesn’t have enough patients to fill

thosebeds,thebedsmustbeleftemptyorthe

unit can decrease the number of beds in the

unit after the hospital has notified CMS of its

intent.

Form CMS-437A (04/30/19)

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(13)As part of the first day of the first cost reporting

•

Prior toschedulingthesurvey,verifywiththe

period for which all other exclusion requirements

FIthattheunitis operational:fullystaffedand

aremet, the unit is fully equipped andstaffed and is

equipped.

capable of providing hospital inpatient rehabilitation

careregardlessofwhetherthereareanyinpatients

• It is not required that the unit has inpatients

in the unit on that date.

on the day of the survey, but must demonstrate

capability of caring for patients.

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(b) Changes in the size of excluded units. Except in

• Verify that the request the IRF is making to add

Representativetoverifythat ifchangesweremade

thespecial cases notedat theend of this paragraph,

beds is the first and onlyrequest duringthecost

totheunit,bothCMS andtheMAC/FI werenotified

changes in the number of beds or square footage

report year.

prior to any change.

consideredto be part of an excluded unit under this

sectionareallowedonetimeduringacostreporting

• A decrease in the number of beds or square

period if the hospital notifies its Medicare contractor

footagemayoccur at anytimeduringthecost

and the CMS RO in writing of the planned change

report period.Inbothcases,thechangemust

at least 30 days before the date of the change.

remain in effect for the remainder of the

The hospital must maintain the information needed

cost report period

to accurately determine costs that are attributable to

•

Nochangescanbemadewithoutnotifyingboth

the excluded unit. A change in bed size or a change

CMSROandthe FI/MACatleast30 daysprior

in square footage may occur at any time during a

to the change.

cost reporting period and must remain in effect for

the rest of that cost reporting period. Changes in

bed size or square footage may be made at any time

if these changes are made necessary by relocation

of a unit to permit construction or renovation

necessaryforcompliancewithchangesinFederal,

State, or local law affecting the physical facility or

because of catastrophic events such as fires,floods,

earthquakes, or tornadoes.

§ 412.29 Classification criteria

for payment under the inpatient

rehabilitation facility prospective

payment systems. 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 rehabilitation hospital or an inpatient

rehabilitation unit of a hospital (otherwise referred

to as an IRF) must meet the following requirements:

A3509

(a) Have (or be part of a hospital that has) a

• TheSA will check these provisions with the RO

Representative to ensure the hospital has a

provider agreement under part 489 of this chapter

prior to the survey.

Medicare provider agreement.

to participate as a hospital.

Form CMS-437A (04/30/19)

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(b) Except in the case of a“new”IRF or“new”IRF

•

TheMAC/FI reviews the inpatient population

beds,as definedinparagraph(c)ofthissection,

oftheIRF.Ifthehospitalhasnotdemonstrated

an IRF must show that, during its most recent,

that it served the appropriate inpatient

consecutive, and appropriate 12-month time period

population as defined in § 412.29 (b)(2), the

(as defined by CMS or the Medicare contractor),

MACnotifiestheRO.

it served an inpatient population that meets the

criteria outlined in § 412.29 (b)(2).

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(c) In the case of new IRFs (as defined in

•

InthecaseofanewIRFunit,thesurveyorwill

The representative completes this form (Form CMS

paragraph (c)(1) of this section) or new IRF beds

verify that the hospital has not previously sought

437A) as well as a signed attestation statement

(asdefinedinparagraph(e)(2)ofthis section),the

exclusion.

attesting that the rehab unit’s patients it intends

IRF must provide a written certification that the

to serve meets the requirements outlined in §

inpatientpopulationitintendstoservemeetsthe

•

The surveyor will verify that the hospital received

412.29(b)(2).

requirements of paragraph (b) of this section. This

approval for the unit under the appropriate

writtencertificationwill apply until theendof the

State licensure laws.

IRF’sfirstfull12-monthcostreportingperiodor,in

•

•The IRF must submit an attestation

the case of new IRF beds, until the end of the cost

statement in addition to the Form CMS 437A

reporting period during which the new beds are

(RehabilitationUnitWork Sheet) totheSAas

addedtothe IRF.

part of their initial application packet.

•

Until the SA receives both the attestation

statement andtheFormCMS 437A,thenew

unit cannot be recommended for approval.

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(1) New IRFs. An IRF hospital or IRF unit is

•

If an IRF unit has been closed for 5 years (more

The representative ensures the IRF unit has not been

considerednewifithasnot beenpaidunderthe

than 60 calendar months),it can open its doors

paid under the IRF PPS for at least 5 calendar

new IRF PPS in subpart P of this part for at least 5

as a newunit.

years.

calendar years. A new IRF will be considered new

fromthepoint that it first participates inMedicare

•

Verifyeither throughtheSAor ROthat the

as an IRF until the end of its first full 12-month cost

IRF unit has been closedfor the5 years before

reporting period.

approving the IRF unit as new.

Form CMS-437A (04/30/19)

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(2) New IRF beds. Any IRF beds that are added

•

If the hospital added beds to its IRF unit, the

• The representative verifies that the hospital

toan existingIRF must meet all applicable State

surveyor orCMSwillverifythatthehospitalhad

received State approval (certification of need or

Certificate of Need and State licensure laws. New

approval (certificate of need or State license)

State licensure) if prior approval is requiredby

IRF beds may be added one time at any point during

before adding beds, if such approval is required.

theState,priortoanyIRFunitbedincrease.

a cost reporting period and will be considered new

for the rest of that cost reporting period. A full

•

The surveyor must verify that the hospital

• The representative verifies that the hospital

12-month cost reporting period must elapse

received written CMS RO approvalbefore

received written approval from the CMS RO

between the delicensing or decertification of IRF

adding any new beds to its IRF unit.

before any new beds were added to theIRF

beds in an IRF hospital or IRF unit and the addition

• The surveyor will verify that the hospital’s IRF

unit.

of new IRF beds to that IRF hospital or IRF unit.

unit didn’thavemorethanoneincreaseinbeds

• The representative will verify that if the

BeforeanIRFcanaddnewbeds,itmustreceive

during a single cost reporting period.

hospital’s IRF unit decreased beds, it didn’t

written approval from the appropriate CMS RO, so

thereafter addbeds unless afull 12 monthcost

that the RO can verify that a full 12-month cost

•

Surveyors must verify that if the hospital’s IRF

reporting period had elapsed.

reportingperiodhas elapsedsincetheIRF has had

unit decreasedbeds,it didn’tthereafteradd

beds de-licensed or decertified. New IRF bedsare

beds unless a full 12 month cost reporting

• The representative will verify that the hospital’s

included in the compliance review calculations

period had elapsed.

IRF unit didn’t have more than one increase in

under paragraph (b) of this section from the time

beds during a single cost reporting period.

that theyareadded to the IRF.

A3514

(3) Change of ownership or leasing.

•

IRF status is lost if a hospital is acquired and the

The representative of the IRF unit, that has

An IRF hospital or IRF unit that

new owners reject assignment of the previous

undergone a change of ownership, must ensure

undergoes a change of ownership, or

owner’s Medicare provider assignment.

that the new owner(s) have accepted assignment

leasing as defined in § 489.18 of this

of the previous Medicare provider agreement. If the

chapter, retains its excluded status

•

Onlyentirehospitalsmaybesoldorleased.

new owner(s) have not accepted the assignment,

and will continue to be paid under

• IRFunitsmaynot besoldorleasedseparately

the representative cannot request continued

the prospective payment systems

participation as an IPPS-excluded unit.

from the hospital of which it is a part.

specified in § 412.1(a)(3) before and

after the change of ownership or

leasing if the new owner(s) of the IRF

accept assignment of the previous

owners’ Medicare provider agreement

and the IRF continues to meet all the

requirements for payment under the

IRF prospective payment system. If

the new owner(s) do not accept

assignment of the previous owners’

Medicare provider agreement, the

IRF is considered to be voluntarily

terminated and the new owner(s)

may reapply to participate in the

Medicare program. If the IRF does

not continue to meet all of the

requirements under the new IRF

prospective payment system, then the

IRF loses its excluded status and is paid

according to the prospective payment

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(4) Mergers. If an IRF hospital (or a

•

As with the change of ownership, the

The representative of the IRF unit that has

hospital with an IRF unit) merges with

owner of the merged hospital must accept

undergone a merger must ensure that the new

another hospital and the owner(s) of

assignment of the hospital’s (with the IRF

owner(s) have accepted assignment of the

the merged hospital accept assignment

unit) provider agreement to ensure

previous Medicare provider agreement. If the

of the IRF (or the hospital’s provider

uninterrupted reimbursement.

new owner(s) have not accepted the assignment,

agreement (or the provider agreement

the representative cannot request continued

of the hospital with the IRF unit), then

• If the owner of the hospital to be merged

participation as an IPPS-excluded unit.

the IRF hospital or IRF unit retains its

doesn’t accept assignment of the previous

excluded status and will continue to be

owner(s) Medicare provider agreement, the new

paid under the prospective payment

owner(s)will notbeeligibleforreimbursement

system specified in § 412.1(a)(3) before

until the new owner(s) reapplies to theMedicare

and after the merger, as long as the IRF

program to operate a new hospital and have

hospital or IRF unit continues to meet all

additionally been granted IRF status.

the requirements for payment under the

• IRF status is lost if a hospital is acquired and the

IRF prospective payment system. If the

new owner(s) reject assignment of the previous

owner(s) of the merged hospital do not

owner’s Medicare provider agreement. This also

accept assignment of the IRF hospital’s

applies to an acquisition that is followed by a

provider agreement (or the provider

merger.

agreement of the hospital with the IRF

unit), then the IRF hospital or IRF unit is

considered voluntarily terminated and

the owner(s) of the merged hospital

may reapply to the Medicare program to

operate a new IRF.

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(d) Have in effect a preadmission screening

•

Review the hospital’s procedures, or other

The representative will ensure the hospital’s

procedure under which each prospective patient’s

alternativedocuments orrecords,toverifythe

rehabilitation unit is using the preadmission

condition and medical history are reviewed to

hospital’s rehabilitation unit has a preadmission

screening procedure on all patients admitted to the

determine whether the patient is likely to benefit

screening procedure inplace.

rehab unit.

significantly from an intensive inpatient hospital

program. This procedure must ensure that the

• A review of the clinical records should indicate

preadmission screening is reviewed and approved

whether the IRF has such a screening procedure

by a rehabilitation physician prior to the patient’s

and whether it is using the screening procedure.

admission to the IRF.

• The purpose of the preadmission screen is to

reduce the rate of hospital readmission by

ensuringthatthepatientsthatareacceptedto

the IRF will benefit from intensive rehabilitation

services.

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(e) Have in effect a procedure to ensure that

•

Review the hospital’s procedures or other

The representative will ensure the rehab unit has a

patients receive close medical supervision, as

alternativedocuments or records toverifythe

procedure or other alternative documents or records

evidenced by at least 3face-to-face visits per week

hospital has a procedure detailing close medical

verifying the hospital has a procedure detailing close

by a licensed physician with specialized training and

supervision forpatients,including atleast 3

medical supervision that includes the rehabilitation

experienceininpatientrehabilitationtoaccessthe

face-to-face visits per week.

physician making at least 3 face-to-face visits per

patient both medically and functionally, as well as

week.

to modify the courses of treatment as needed to

• As part of the clinical record review, look

maximize the patient’s capacity to benefit from the

for documentation supporting the physician

rehabilitation process.

visits.

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(f) Furnish, through the use of qualified personnel,

• Review the licenses of all qualified personnel

The representative verifies that all qualified

rehabilitation nursing, physical therapy, and

that arerequiredbytheStatetobelicensed,to

personnel, which are required by the State to be

occupational therapy, plus as needed, speech-

verify the licenses are up-to-date.

licensed, have licenses that are up-to-date.

language pathology, social services, psychological

services (including neuropsychological service) and

• Qualified personnel would include either

orthotic and prosthetic services.

personnel that arelicensedintheStateinwhich

the services are provided or those personnel that

arerecognizedunder reciprocity by theStatein

which the services areprovided.

• Determineif thehospital has andfollows a

proceduretoevaluateanddocument that

personnel are qualified and that those

personnel maintain their qualifications.

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(g) Have a director of rehabilitation who —

•

Verify the rehab unit has a director of

The representative will verify that the rehab unit has

rehabilitation by reviewing personnel logsor

a physician Director of Rehabilitation.

rosters and organization charts.

A3520

(1) Provides services to the rehabilitation unit and to

• The20hoursmaybeanycombinationof patient

The representative will verify that the physician

unit’s inpatients for at least 20 hours per week;

services and administration. Hours cannot be

is spending 20 hours per week providing a

substituted by a Physician Assistant or by any

combination of patient services and

other qualified professional. Verify the 20 hours

administration the rehab unit.

through review of personnel time cards/logs, etc.

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(2) Is a doctor of medicine or osteopathy;

• Review the physician’s license to verify the

The representative will review the physician’s license

physician is an MD or DO.

to ensure the physician is an MD or DO.

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(3)IslicensedunderStatelawtopracticemedicine

•

Ensure license is current and issued by the State.

The representative will review the physician’s license

or surgery; and

is current.

Form CMS-437A (04/30/19)

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