Form Cms-437b - Rehab Hospital Criteria Worksheet (Page 2 of 6) in pdf

THE HOSPITAL REPRESENTATIVE WHO

TAG

REGULATION

GUIDANCE

YES

N/A

COMPLETES THIS ENTIRE FORM

A3600

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

The surveyor will verify, through the regional office (RO),

Representative to ensure the hospital has a Medicare

agreement under part 489 of this chapter to participate

that the hospital has an agreement to participate in the

provider agreement.

as a hospital.

Medicare program.

A3601

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

The MAC/FI reviews the inpatient population of the IRF.

beds, as defined in paragraph (c) of this section, an IRF

If the hospital has not demonstrated that it served the

must show that during its most recent, consecutive,

appropriate inpatient population as defined in § 412.29

and appropriate 12-month time period (as defined by

(b)(2), the MAC notifies the RO.

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.

A3602

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

• The IRF must submit a written attestation statement

The representative completes this form (Form CMS 437B)

(c)(1) of this section) or new IRF beds (as defined in

as well as Form CMS 437B (rehabililtation hospital

as well as a signed attestation statement attesting that

paragraph (c)(2) of this section), the IRF must provide

worksheet) to the SA as part of their initial

the rehab hospital patients it intends to serve meets the

a written certification that the inpatient population it

application packet or as determined by CMS to

requirements outlined in §412.29(b)(2) and submits the

intends to serve meets the requirements of paragraph

maintain their IPPS excluded status.

documentation to the State Agency.

(b) of this section.

• Until the SA receives both the attestation statement

• This written certification will apply until the end

and the Form CMS 437B the new rehabilitation

of the IRF’s first full 12-month cost report period or

hospital cannot be recommended for approval.

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.

A3603

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

• If an IRF hospital has been closed for 5 years (more

The representative ensures the IRF hospital has not been

new if it has not been paid under the IRF PPS in subpart

than 60 calendar months), it can open its doors as a

paid under the IRFPPS for at least 5 calendar years.

P of this part for at least 5 calendar years. A new IRF will

new rehabilitation hospital.

be considered new from the point that it first participates

• Verify either through the SA or RO that the IRF

in Medicare as an IRF until the end of its first full

hospital has been closed for the 5 years before

12-month cost report period.

approving the IRF hospital as new.

Form CMS-437B (06/12)

Form Cms-437b - Rehab Hospital Criteria Worksheet Page 2

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