Form Cms-437- Psychiatric Unit Criteria Worksheet
Download a blank fillable Form Cms-437- Psychiatric Unit Criteria Worksheet in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Cms-437- Psychiatric Unit Criteria Worksheet with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8Form Approved
DEPARTMENT OF HEALTH AND HUMAN SERVICES
OMB No. 0938-0358
CENTERS FOR MEDICARE & MEDICAID SERVICES
PSYCHIATRIC UNIT CRITERIA WORK SHEET
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
____ / ____ / ______ to ____ / ____ / ______
MM
DD
YYYY
MM
DD
YYYY
VERIFIED BY
ALL CRITERIA MUST BE MET FOR EXCLUSION FROM MEDICARE’S HOSPITAL PROSPECTIVE PAYMENT SYSTEM (PPS)
TAG
REGULATION
GUIDANCE
YES NO
EXPLANATORY STATEMENT
§412.25 Excluded Hospital Units: Common
Requirements
A1105
(a) Basis for exclusion. In order to be excluded from the
prospective payment system, a psychiatric unit must meet
the requirements under §412.25(a) and (b) which include:
A1106
(1) Be part of an institution that
Has the state agency (SA) verified with the CMS
(i) Has in effect an agreement to participate as a
Regional Office (RO) that the hospital has a
hospital;
current agreement to participate in the Medicare
(ii) Is not excluded in its entirety from the prospective
program and to ensure that the hospital is not
payment systems; and
already excluded in its entirety from PPS, such as a
(iii) Has enough beds that are not excluded from
psychiatric hospital?
the prospective payment systems to permit the
provision of adequate cost information, as required
by §413.24(c)
A1107
(2) Have written admission criteria that are applied
Are the same admission criteria being applied to
uniformly to both Medicare and non-Medicare patients.
all patients?
A1108
(3) Have admission and discharge records that are
Are the psychiatric unit medical records separate
separately identified from those of the hospital in which
from other hospital records?
it is located and are readily available.
Are the records readily available for review?
A1109
(4) Have policies specifying that necessary clinical
Does the hospital have a policy ensuring prompt
information is transferred to the unit when a patient of
transfer of information to the unit?
the hospital is transferred to the unit.
A1110
(5) Meet applicable State licensure laws.
Has the unit verified current active licensure of its
professional staff?
Does the unit meet any special licensing
requirements of the state?
Form CMS-437 (04/06)
1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical