Form CMS - 437B ( 04 / 30 /19 ) 2 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICE OMB NO. 0938-0986 REHABILITATION HOSPITAL CRITERIA WORK SHEET CMS-437B 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 MEDICARE222S ACUTE CARE HOSPITAL PROSPECTIVE PAYMENT SYSTEM TAG REGULATION GUIDANCE THE HOSPITAL REPRESENTATIVE WHO COMPLETES THIS ENTIRE FORM YES NO N/A Verification of hospital attestations may be done by CMS surveyors or MACs as applicable. 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 223yes224 response means the hospital is in compliance with the applicable regulation. 247412.23 Excluded hospital units: Classifications. (b) Rehabilitation hospitals. A rehabilitation hospital must meet the requirements specified in 247412.29 of this subpart to be excluded from the prospective payment systems specified in 247412.1(a)(1) of this subpart and to be paid under the prospective payment system specified in 247412.1(a)(3) of this subpart and in subpart P of this part. American LegalNet, Inc. www.FormsWorkFlow.com Form CMS - 437B ( 04 / 30 /19 ) 3 AG REGULATION GUIDANCE THE HOSPITAL REPRESENTATIVE WHO COMPLETES THIS ENTIRE FORM YES NO N/A 247412.29 Classification criteria for payment under the inpatient rehabilitation facility prospective payment system. To be excluded from the prospective payment systems described in 247412.1(a)(1) and to be paid under the prospective payment system specified in 247412.1(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: A3600 (a) Have (or be part of a hospital that has) a provider agreement under part 489 of this chapter to participate as a hospital. The surveyor will verify, through the regional office (RO), that the hospital has an agreement to participate in the Medicare program. Representative to ensure the hospital has a Medicare provider agreement. A3601 (b) Except in the case of a 223new224 IRF or 223new224 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. 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 247 412.29 (b)(2), the MAC notifies the RO. A3602 225 (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. 225 This written certification will apply until the end of the IRF222s 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. 225 The IRF must submit a written attestation statement as well as Form CMS 437B (rehabilitation hospital worksheet) to the SA as part of their initial application packet or as determined by CMS to maintain their IPPS excluded status. 225 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 247412.29(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. 225 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. 225 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 IRF PPS for at least 5 calendar years. American LegalNet, Inc. www.FormsWorkFlow.com Form CMS - 437B ( 04 / 30 /19 ) 4 TAG REGULATION GUIDANCE THE HOSPITAL REPRESENTATIVE WHO COMPLETES THIS ENTIRE FORM YES NO N/A A3604 (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 reporting period has elapsed since the IRF has had beds delicensed or decertified, New IRF beds are included in the compliance review calculations under paragraph (b) of this section from the time that they are added to the IRF. 225 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. 225 The surveyor must verify that the hospital received written CMS RO approval before adding any new beds. 225 The surveyor will verify that the hospital didn222t have more than one increase in beds during a single cost reporting period. 225 Surveyors must verify that if the rehabilitation hospital decreased beds, it didn222t thereafter add beds unless a full 12 month cost reporting period had elapsed. The representative completes this form (Form CMS 437B) as well as a signed attestation statement attesting that the rehab patients it intends to serve meets the requirements outlined in 247 412.29(b)(2). A3605 (3) Change of ownership or leasing. An IRF hospital or IRF unit that undergoes a change of ownership or leasing, as defined in 247 489, 18 of this chapter, retains its excluded status and will continue to be paid under the prospective payment system specified in 247 412.1(a)(3) before and after the change of ownership or leasing, if the new owner(s) of the IRF accept assignment of the previous owner222s Medicare provider agreement, and the IRF continues to meet all of the requirements for payment under the IRF prospective payment system. If the new owner(s) do not accept assignment of the previous owner222s Medicare provider agreement, the IRF is considered to be voluntarily terminated, and the new owner(s) may re-apply to participate in the Medicare program. If the IRF does not continue to meet all of the requirements for payment under the IRF prospective payment system, then the IRF loses its excluded status and is paid according to the prospective payment systems described in 247412,(a)(1), 225 IRF status is lost if a hospital is acquired and the new owners reject assignment of the previous owner222s Medicare provider assignment 225 Only entire hospitals may be sold or leased, IRF units may not be sold or leased, The representative of the IRF hospital that has undergone a change of owner