Form Cms-437a - Rehab Unit Criteria Worksheet (Page 5 of 9) in pdf

THE HOSPITAL REPRESENTATIVE WHO

TAG

REGULATION

GUIDANCE

YES

N/A

COMPLETES THIS ENTIRE FORM

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

• The MAC/FI reviews the inpatient population

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

of the IRF. If the hospital has not demonstrated

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),

MAC notifies the RO.

it served an inpatient population that meets the

criteria outlined in § 412.29 (b)(2).

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• In the case of a new IRF unit, the surveyor will

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

(as defined in paragraph (e)(2) of this 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 §

• The surveyor will verify that the hospital received

inpatient population it intends to serve meets the

412.29(b)(2).

approval for the unit under the appropriate

requirements of paragraph (b) of this section. This

State licensure laws.

written certification will apply until the end of the

IRF’s first full 12-month cost reporting period or, 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

(rehabilitation unit worksheet) to the SA as part

added to the IRF.

of their initial application packet.

• Until the SA receives both the attestation

statement and the Form CMS 437A, the new

unit cannot be recommended for approval.

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

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

The representative ensures the IRF unit has not been

considered new if it has not been paid under the

than 60 calendar months), it can open its doors

paid under the IRFPPS for at least 5 calendar years.

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

as a new unit.

calendar years. A new IRF will be considered new

• Verify either through the SA or RO that the

from the point that it first participates in Medicare

IRF unit has been closed for the 5 years before

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

approving the IRF unit as new.

reporting period.

Form CMS-437A (06/12)

Form Cms-437a - Rehab Unit Criteria Worksheet Page 5

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