Cms-437 A Rehabilitation Unit Criteria Work Sheet

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICE

FORM APPROVED
OMB NO. 0938-0986

Rehabilitation Unit Criteria Work Sheet
(CMS-437A)

IRF Unit’s Name:

IRF Unit’s Medicare Provider #:

IRF Unit’s Street Address

Date of Last Survey:
Number of Beds in Unit:

City:

State:

Zip Code:

Telephone Number:

Dates of Cost Reporting Periods for Which Exclusion Is Requested:
1.

to
Day/Month/Year

Tag

Day/Month/Year

Regulations

2.

to
Day/Month/Year

Day/Month/Year

CMS Guidance

§412.25 Excluded hospital
units: Common requirements.
§412.25(a) Basis for exclusion.
In order to be excluded from the
prospective payment systems
specified in §412.1(a)(1), a
rehabilitation unit must meet the
following requirements in
addition to the all criteria under
Subpart B of Part 412 of the
regulations:

to

3.

For the purposes of §412.25 and §412.29,
as related to IRF units, the term hospital
includes Critical Access Hospitals (CAHs).

Day/Month/Year

Actions Required to Determine If
Requirements Met

Day/Month/Year

Yes

No

N/A

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICE

FORM APPROVED
OMB NO. 0938-0986

Rehabilitation Hospital Criteria Work Sheet (CMS-437A)
Tag

Regulation

A3500 §412.25(a)(1)

Be part of an institution that §412.25(a)(1)(i)

Has in effect an agreement under Part
489 of this chapter to participate as a
hospital;

•

•

•

§412.25(a)(1)(ii)

Prior to October 1, 2019, is not excluded
in its entirety from the prospective
payment systems; and
§412.25(a)(1)(iii)

Unless it is a unit in a critical access
hospital, the hospital, in which an IRF
unit is located, must have at least 10
staffed and maintained hospital beds
that are paid under the applicable
payment system under which the
hospital is paid, or at least 1 staffed and
maintained hospital bed for every 10
certified inpatient rehabilitation facility
(IRF) beds, whichever number is
greater. Otherwise, the IRF will be
classified as an IRF hospital, rather than
an IRF unit…..
CMS-437A / OMB Approval Expires XX/XX/20XX

Actions Required to Determine If
Requirements Met

CMS Guidance

•

The SA or CMS surveyor or MAC will
verify the following:

That the hospital, in which the Inpatient
Rehabilitation Facility (“IRF”) unit is
located, has an agreement to participate
in the Medicare program, and
That the hospital in which the IRF
unit is located, is not excluded in its
entirety from the Medicare Inpatient
Prospective Payment System
(“IPPS”); and

That the hospital, in which the IRF
unit is located, meets one of the
following staffing ratios (whichever is
greater):

1. Has at least 10 staffed and maintained
hospital beds that are paid under the
Medicare payment system under
which the hospital is paid; or
2. Has at least 1 staffed and maintained
hospital bed for every 10 certified
inpatient IRF unit beds, whichever
number is greater.

Yes

No N/A

The IRF unit representative shall
verify that:
•

•

•

The hospital, in which the IRF
unit is located, has a Medicare
provider agreement;
The hospital in which the
Inpatient Rehabilitation Unit
(“IRF unit”) is located is not
excluded from the Medicare
IPPS system; and

The hospital (that is not a
CAH), in which the IRF unit is
located, meets one of the
following requirements,
whichever is greater:

1. The hospital has at least 10
staffed and maintained hospital
beds that are paid by Medicare
under the applicable payment
system; or

2. The hospital has at least 1
staffed and maintained hospital
bed for every 10 IRF unit beds,

Page 2

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICE

FORM APPROVED
OMB NO. 0938-0986

Rehabilitation Hospital Criteria Work Sheet (CMS-437A)
Tag

Regulation

A3501 §412.25(a)(2)

Have written admission criteria that are
applied uniformly to both Medicare
and non-Medicare patients.

A3502 §412.25(a)(3)

Have admission & discharge records
that are separately identified from those
of the hospital in which it is located and
are readily available.

Actions Required to Determine If
Requirements Met

CMS Guidance
•

Verify that the IRF unit has written
admission criteria.

• Conduct a record review to determine
whether the IRF unit’s admission
criteria are applied equally to both
Medicare and non-Medicare patients.
• The surveyor should verify the
following:

1. That the IRF unit has medical records
that are separate and different from
those used by the hospital in which
the IRF unit is located.

Yes

No N/A

The IRF unit representative shall
verify that:
•

•

The IRF unit has written
admission criteria; and

The IRF’s written admission
criteria are being applied
equally to both Medicare and
non-Medicare patients

The IRF unit representative shall
verify that:
•

The IRF unit admission and
discharge records tare
separate from, (and not comingled with) the records of
the hospital in which the IRF
unit is located.

2. That the IRF unit’s medical records
are not co-mingled with those of the
hospital and not co-mingled with
• The IRF unit admission and
those of the hospital in which the
discharge records are readily
IRF unit is located.
available for review.

• Verify that the IRF unit’s medical
records are readily available for
review.

CMS-437A / OMB Approval Expires XX/XX/20XX

Page 3

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICE

FORM APPROVED
OMB NO. 0938-0986

Rehabilitation Hospital Criteria Work Sheet (CMS-437A)
Tag

Regulation

A3503 §412.25(a)(4)

Have policies specifying that
necessary clinical information is
transferred to the unit when a
patient of the hospital is
transferred to the unit.

CMS Guidance
•

•

Verify that the hospital has a policy
detailing the prompt transfer of
information, and that it is being
followed.

Review rehabilitation unit clinical
records to ensure that the clinical
information that should be
transferred with the record is actually
in the medical record.

Actions Required to Determine If
Requirements Met

Yes No N/A

The IRF unit representative shall
verify that:

• The hospital has a policy
specifying what type of clinical
information should be sent with
a hospital patient that is
transferred to the IRF unit; and
• The hospital adheres to this
policy; and,

• The clinical information and
records that should be sent with
a hospital patient being
transferred to the IRF unit is
actually in the medical record.

CMS-437A / OMB Approval Expires XX/XX/20XX

Page 4

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICE

FORM APPROVED
OMB NO. 0938-0986

Rehabilitation Hospital Criteria Work Sheet (CMS-437A)
Tag

Regulation

A3504 §412.25(a)(5)

Meet applicable state licensure
laws.

The IRF surveyor will:
•

•

•

•

•

A3505 §412.25(a)(6)

Have utilization review standards
applicable for the type of care
offered in the unit.

Verify and document that all
applicable State licensure laws are
met.

Document all unmet State licensure
requirements.

Yes No N/A

The IRF unit representative shall
verify that:
•

•

Verify the IRF unit professional staff
has current licensure.

All applicable state laws are being
met; and
All applicable licensure and
certification requirement for IRF
professional staff are current.

Are there any State licenses required
for the IRF unit?
If so, does the IRF unit meet these
State licensing requirements?

• Verify that the hospital has a
utilization review plan that includes
the review of rehab services (No
utilization review (UR) standards are
required if the QIO is conducting
review activities.)
• Verify that the hospital has written
UR standards that are applied to the
care offered in the unit.

CMS-437A / OMB Approval Expires XX/XX/20XX

Actions Required to Determine If
Requirements Met

CMS Guidance

The IRF unit representative shall
verify that:
•
•

The IRF unit has a Utilization
Review (UR) plan; and

The UR standards are applicable
to the type of care offered in the
IRF unit.
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICE

FORM APPROVED
OMB NO. 0938-0986

Rehabilitation Hospital Criteria Work Sheet (CMS-437A)
Tag

A3506 §412.25(a)(7)

Have beds physically separate
from (that is, not commingled
with) the hospital’s other beds.

•

•

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

•

•

CMS-437A / OMB Approval Expires XX/XX/20XX

Actions Required to Determine If
Requirements Met

CMS Guidance

Regulation

Is the space containing the rehab beds
physically separate from the beds in
other units of the hospital?

There cannot be any beds that are
located within the physical confines of
the excluded rehab unit that are not
excluded beds.

The IRF unit cannot use its beds for
medical/surgical patients or any other
type of patient. Those beds are solely for
the use of IRF patients.
If the unit doesn’t have enough patients
to fill those beds, the beds must be left
empty or the unit can decrease the
number of beds in the unit after the
hospital has notified CMS of its intent.

Yes No

N/A

The IRF unit representative will
verify that:
•

•

The IRF unit beds are physically
separate from and not comingled with the hospital beds;
and,
No beds in the IRF unit are used
for hospital patients, even if the
IRF unit does not have enough
rehab patients to fill the IRF
unit beds.

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICE

FORM APPROVED
OMB NO. 0938-0986

Rehabilitation Hospital Criteria Work Sheet (CMS-437A)
Tag

Regulation

A3507 §412.25(a)(13)

As part of the first day of the first
cost reporting period for which all
other exclusion requirements are
met, the unit is fully equipped and
staffed and is capable of providing
hospital inpatient rehabilitation
care regardless of whether there
are any inpatients in the unit on
that date.

•

•

Verify with the FI that the unit is
operational: fully staffed and
equipped.

It is not required that the unit has
inpatients on the day of the survey,
but must demonstrate capability of
caring for patients.

• Verify that the request the IRF is
making to add beds is the first and
excluded units.
only request during the cost report
Except in the special cases noted at the
year.
end of this paragraph, changes in the

CMS-437A / OMB Approval Expires XX/XX/20XX

• A decrease in the number of beds or

square footage may occur once during
a cost reporting period, however, this
change can take place at any time
during the cost reporting period.

Yes No N/A

A representative from a new IRF unit
that is requesting an IPPS payment
system exclusion for the first time
must verify with the Fiscal
Intermediary (FI) (i.e. – MAC) that:
As of the 1st day of the first cost
reporting period for which all other
IPPS exclusion requirements are
met, the IRF unit is/was:

•
•
•
•

A3508 §412.25(b) - Changes in the size of

number of beds or square footage
considered to be part of an excluded
unit under this section are allowed
one time during a cost reporting
period if the hospital notifies its
Medicare contractor and the CMS
Regional Office (RO) in writing of the
planned change at least 30 days before
the date of the change.

Actions Required to Determine If
Requirements Met

CMS Guidance

Fully operational:
Fully equipped;
Fully staffed, and
Capable of providing inpatient
rehabilitation care (regardless of
whether there are any inpatients in
the unit on that date.)

If changes were or are to be made to
the size of the IRF unit, the IRF unit
representative will verify that:
•

CMS and the MAC/FI were
notified at least 30 days prior to
making any changes in the size of
the IRF unit.

Page 7

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICE

FORM APPROVED
OMB NO. 0938-0986

Rehabilitation Hospital Criteria Work Sheet (CMS-437A)
Tag

Regulation

CMS Guidance

A3508 The hospital must maintain the
• The change must remain in effect for
(cont.) information needed to accurately
the remainder of the cost report
determine costs that are
period.
attributable to the excluded unit. A
change in bed size or a change in
• Changes in bed size or square footage
square footage may occur at any
may be made at any time, if these
time during a cost reporting period
changes are made necessary by
and must remain in effect for the
relocation of a unit to permit
rest of that cost reporting period.
construction or renovation necessary
Changes in bed size or square
for compliance with changes in
footage may be made at any time if
Federal, State, or local law affecting
these changes are made necessary
the physical facility or because of
by relocation of a unit to permit
catastrophic events such as fires,
construction or renovation
floods, earthquakes, or tornadoes.
necessary for compliance with
changes in Federal, State, or local
• No changes can be made without
law affecting the physical facility or
notifying both CMS RO and the
because of catastrophic events such
FI/MAC at least 30 days prior to the
as fires, floods, earthquakes, or
change.
tornadoes.

CMS-437A / OMB Approval Expires XX/XX/20XX

Actions Required to Determine If
Requirements Met

Yes No N/A

• A change in the size of the IRF unit
is only made once per cost
reporting period and that the
change remains in effect for the
remainder of the cost report
period.
• The IRF unit maintains the
information needed to document
changes in bed size or square
footage made necessary by
relocation of a unit to permit
construction or renovation
necessary for compliance with
changes in Federal, State, or local
law affecting the physical facility
or because of catastrophic events
such as fires, floods, earthquakes,
or tornadoes.
• The hospital maintains the
information needed to accurately
determine costs that are
attributable to the excluded unit.

Page 8

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICE

FORM APPROVED
OMB NO. 0938-0986

Rehabilitation Hospital Criteria Work Sheet (CMS-437A)
Tag

Regulation

CMS Guidance

Actions Required to Determine If
Requirements Met

Yes No N/A

§ 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 §412.29(a)

Have (or be part of a hospital that
has) a provider agreement under
part 489 of this chapter to
participate as a hospital.

CMS-437A / OMB Approval Expires XX/XX/20XX

The SA will check these provisions with
the RO prior to the survey.

• The IRF unit representative shall
verify the hospital in which the IRF
unit is located has a Medicare
provider agreement under 42 CFR
part 489.
• The IRF hospital representative
will verify that the IRF hospital has
a provider agreement under 42
CFR part 489 to participate as a
hospital.

Page 9

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICE

FORM APPROVED
OMB NO. 0938-0986

Rehabilitation Hospital Criteria Work Sheet (CMS-437A)
Tag

Regulation

•

CMS Guidance

A3510 §412.29(b)

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

A3511 §412.29(c)
In the case of new IRFs (as defined
in paragraph (c)(1) of this section)
or new IRF beds (as defined in
paragraph (e)(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.

•

•

Except in the case of a “new” IRF
or “new” 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 After July 1, 2005, the IRF patient
(as defined by CMS or the
population must meet the 60% rule.
Medicare contractor), it served an
inpatient population that meets
the criteria outlined in § 412.29
(b)(1) and (b)(2).

CMS-437A / OMB Approval Expires XX/XX/20XX

•

•

In the case of a new IRF unit, the
surveyor will verify that the hospital
has not previously sought exclusion.
The surveyor will verify that the
hospital received approval for the
unit under the appropriate State
licensure laws.

The IRF must submit an attestation
statement in addition to the Form
CMS 437A (Rehabilitation Unit Work
Sheet) to the SA as part of their initial
application packet.

•

•

Actions Required to Determine If
Requirements Met

Yes No N/A

For IRF units or hospitals
established after 07/01/2005,
the IRF representative will verify
that the IRF population meets the
60% rule. (i.e. – at least 60 percent
of the IRF’s population required
intensive rehabilitation services for
treatment of one or more of the
conditions specified at paragraph §
412.29(b)(1) and § 412.29(b)(2).
A patient with a comorbidity, as
defined at § 412.602, may be
included in the inpatient
population that counts toward the
required applicable percentage.)
For new IRFs (defined as an IRF
unit that has not been paid under
the new IRF PPS in subpart P of
this part for at least 5 calendar
years) or for new IRF beds
wadded.

The IRF must provide a written
and signed attestation statement
which states that the inpatient
population it intends to serve
meets the requirements of §
412.29(b).
Page 10

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICE

FORM APPROVED
OMB NO. 0938-0986

Rehabilitation Hospital Criteria Work Sheet (CMS-437A)
Tag

Regulation

A3511 This written certification will
(cont.) apply until the end of the IRF’s
first full 12-month cost reporting
period or, in the case of new IRF
beds, until the end of the cost
reporting period during which the
new beds are added to the IRF.
A3512 §412.29(c) (1) - New IRFs.

An IRF hospital or IRF unit is
considered new if it has not been
paid under the new 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 12month cost reporting period.

CMS-437A / OMB Approval Expires XX/XX/20XX

CMS Guidance
•

Actions Required to Determine If
Requirements Met

Yes No N/A

Until the SA receives both the
attestation statement and the Form
CMS 437A, the new unit cannot be
recommended for approval.

• If an IRF unit has been closed for 5
years (more than 60 calendar
months), it can open its doors as a
new unit.

• Verify either through the SA or RO
that the IRF unit has been closed for
the 5 years before approving the IRF
unit as new.

• For a new IRF certification, as
required by 412.29(c) above, the
IRF representative must verify that
the IRF unit has not been paid
under the Medicare Inpatient
Rehabilitation Facility Prospective
Payment System (IRF PPS) for at
least 5 calendar years.
NOTE: 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 reporting period.

Page 11

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICE

FORM APPROVED
OMB NO. 0938-0986

Rehabilitation Hospital Criteria Work Sheet (CMS-437A)
Tag

Regulation

A3513 §412.29(c)(2) - New IRF 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
considered new for the rest of
that cost reporting period. A full
12-month cost reporting period
must elapse between the
delicensing or decertification of
IRF beds in an IRF hospital or IRF
unit and the addition of new IRF
beds to that 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 RO can verify that a full
12-month cost reporting period
has elapsed since the IRF has had
beds de-licensed 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.
CMS-437A / OMB Approval Expires XX/XX/20XX

Actions Required to Determine If
Requirements Met

CMS Guidance
•

•

•

•

If the hospital added beds to its IRF
unit, 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.
The surveyor must verify that the
hospital received written CMS RO
approval before adding any new beds
to its IRF unit.
The surveyor will verify that the
hospital’s IRF unit didn’t have more
than one increase in beds during a
single cost reporting period.

Surveyors must verify that if the
hospital’s IRF unit decreased beds, it
didn’t thereafter add beds unless a
full 12-month cost reporting period
had elapsed.

Yes No N/A

If new IRF beds were added during
the previous 12 months, the IRF
hospital representative will verify the
following:
•

•

•

That the IRF unit received State
approval (certification of need or
State licensure) prior to any IRF unit
bed increase, if prior approval is
required by the State,
That the IRF unit received written
approval from the applicable CMS
Location before the new beds were
added to the IRF unit.
That the IRF unit didn’t have more
than one increase in beds during a
single cost reporting period.

If IRF unit removed or decertified
beds, the IRF unit representative will
verify the following:
•

•

The IRF unit didn’t thereafter add any
additional beds until after a full 12month cost reporting period had
elapsed; and
The IRF unit didn’t have more than
one increase in beds during a single
cost reporting period.

Page 12

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICE

FORM APPROVED
OMB NO. 0938-0986

Rehabilitation Hospital Criteria Work Sheet (CMS-437A)
Tag

Regulation

A3514 §412.29(c)(3) - Change of
ownership or leasing.

An IRF hospital or IRF unit that
undergoes a change of ownership, or
leasing as defined in § 489.18 of this
chapter, retains its excluded status
and will continue to be paid under
the prospective payment systems
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.

Actions Required to Determine If
Requirements Met

CMS Guidance
•

•

•

IRF status is lost if a hospital is
acquired and the new owners reject
assignment of the previous owner’s
Medicare provider assignment.

Only entire hospitals may be sold or
leased.

IRF units may not be sold or leased
separately from the hospital of which
it is a part.

•

•

Yes No N/A

The IRF unit representative will
verify whether the IRF unit has or
is currently undergoing a change of
ownership or leasing.
If so, the IRF unit representative
will verify whether the new
owner(s) or leasee of the IRF unit
have accepted assignment of the
IRF unit’s existing Medicare
provider agreement.

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 systems described in §
412.1(a)(1).
CMS-437A / OMB Approval Expires XX/XX/20XX

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICE

FORM APPROVED
OMB NO. 0938-0986

Rehabilitation Hospital Criteria Work Sheet (CMS-437A)
Tag

Regulation

A3515 §412.29(c)(4) - Mergers.

If an IRF hospital (or a hospital
with an IRF unit) merges with
another hospital and the
owner(s) of the merged hospital
accept assignment of the IRF (or
the hospital’s provider agreement
(or the provider agreement of the
hospital with the IRF unit), then
the IRF hospital or IRF unit
retains its excluded status and
will continue to be paid under the
prospective payment system
specified in § 412.1(a)(3) before
and after the merger, as long as
the IRF hospital or IRF unit
continues to meet all the
requirements for payment under
the IRF prospective payment
system. If the owner(s) of the
merged hospital do not accept
assignment of the IRF hospital’s
provider agreement (or the
provider 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.

CMS-437A / OMB Approval Expires XX/XX/20XX

Actions Required to Determine If
Requirements Met

CMS Guidance
•

•

•

As with the change of ownership, the
owner of the merged hospital must
accept assignment of the hospital’s
(with the IRF unit) provider
agreement to ensure uninterrupted
reimbursement.

If the owner of the hospital to be
merged doesn’t accept assignment of
the previous owner(s) Medicare
provider agreement, the new
owner(s) will not be eligible for
reimbursement until the new
owner(s) reapplies to the Medicare
program to operate a new hospital
and have additionally been granted
IRF status.

•

•

Yes

No

N/A

The IRF unit representative will
verify whether the hospital in which
the IRF unit is located has merged
with another hospital.

If so, the IRF unit representative will
verify whether the new hospital
owner(s) accepted assignment of
the IRF unit’s existing Medicare
provider agreement.

IRF status is lost if a hospital is
acquired and the new owner(s)
reject assignment of the previous
owner’s Medicare provider
agreement. This also applies to an
acquisition that is followed by a
merger.

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICE

FORM APPROVED
OMB NO. 0938-0986

Rehabilitation Hospital Criteria Work Sheet (CMS-437A)
Tag

Regulation

A3516 §412.29(d)

Have in effect a preadmission
screening procedure under which
each prospective patient’s
condition and medical history are
reviewed to determine whether
the patient is likely to benefit
significantly from an intensive
inpatient hospital program. This
procedure must ensure that the
preadmission screening is
reviewed and approved by a
rehabilitation physician prior to
the patient’s admission to the IRF.

CMS-437A / OMB Approval Expires XX/XX/20XX

CMS Guidance
•

•

•

Actions Required to Determine if
Requirements Met

Yes No N/A

Review the hospital’s procedures, or The IRF unit representative will verify
other alternative documents or
that:
records, to verify the hospital’s
rehabilitation unit has a
• The IRF unit has a preadmission
preadmission screening procedure in
screening procedure under which
place.
each prospective patient’s
condition and medical history are
A review of the clinical records
reviewed to determine whether
should indicate whether the IRF has
the patient is likely to benefit
such a screening procedure and
significantly from an intensive
whether it is using the screening
inpatient hospital program; and,
procedure.
• The IRF unit is using the
The purpose of the preadmission
preadmission screening procedure
screen is to reduce the rate of
on all patients admitted to the
hospital readmission by ensuring
rehab unit.
that the patients that are accepted to
the IRF will benefit from intensive
rehabilitation services.

Page 15

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICE

FORM APPROVED
OMB NO. 0938-0986

Rehabilitation Hospital Criteria Work Sheet (CMS-437A)
Tag

Regulation

A3517 §412.29(e)

Have in effect a procedure to
ensure that patients receive close
medical supervision, as evidenced
by at least 3 face-to-face visits per
week by a licensed physician with
specialized training and
experience in inpatient
rehabilitation to assess the
patient both medically and
functionally, as well as to modify
the courses of treatment as
needed to maximize the patient’s
capacity to benefit from the
rehabilitation process.

A3518 §412.29(f)

Furnish, through the use of
qualified personnel,
rehabilitation nursing, physical
therapy, and occupational
therapy, plus as needed, speechlanguage pathology, social
services, psychological services
(including neuropsychological
service) and orthotic and
prosthetic services.

CMS-437A / OMB Approval Expires XX/XX/20XX

Actions Required to Determine If
Requirements Met

CMS Guidance
•

•

•

Review the hospital’s procedures or
other alternative documents or
records to verify the hospital has a
procedure detailing close medical
supervision for patients, including at
least 3 face-to-face visits per week.

The IRF unit representative will verify
that:

Review the licenses of all qualified
personnel that are required by the State
to be licensed, to verify the licenses are
up-to-date.

The IRF unit representative will verify
the following:

As part of the clinical record review,
look for documentation supporting
the physician visits.

Qualified personnel would include
either personnel that are licensed in the
State in which the services are provided
or those personnel that are recognized
under reciprocity by the State in which
the services are provided.

•

•

Yes No N/A

The IRF unit has a procedure for close
medical supervision of the patients,
and

That this procedure includes at least 3
face-to-face visits per week by a
licensed physician with specialized
training and experience in inpatient
rehabilitation, for the purpose of
assessing the patient both medically
and functionally, as well as to modify
the courses of treatment as needed to
maximize the patient’s capacity to
benefit from the rehabilitation process.

That the IRF’s patients receive
rehabilitation nursing care, physical
therapy, and occupational therapy,
and, if needed, that they received
speech-language pathology services,
social services, psychological services
(including neuropsychological
services) and orthotic and prosthetic
services.

Page 16

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICE

FORM APPROVED
OMB NO. 0938-0986

Rehabilitation Hospital Criteria Work Sheet (CMS-437A)
Tag

Regulation

Actions Required to Determine If
Requirements Met

CMS Guidance

A3518
(cont.)

•

A3519 §412.29(g)

• Verify the rehab unit has a director
of rehabilitation by reviewing
personnel logs or rosters and
organization charts.

• The IRF unit representative will
verify that the rehab unit has a
Director of Rehabilitation.

• The 20 hours may be any
combination of patient services and
administration. Hours cannot be
substituted by a Physician Assistant
or by any other qualified
professional. Verify the 20 hours
through review of personnel time
cards/logs, etc.

• The IRF unit representative will
verify that the IRF unit director
spends at least 20 hours per week
providing a combination of patient
services and administration at the
rehab unit.

Have a director of rehabilitation
who —

A3520 §412.29(g)(1)

Provides services to
the…rehabilitation unit, at least
20 hours per week;

A3521 §412.29(g)(2)

Is a doctor of medicine or
osteopathy;

CMS-437A / OMB Approval Expires XX/XX/20XX

Determine if the hospital has and
follows a procedure to evaluate and
document that personnel are
qualified and that those personnel
maintain their qualifications.

•

Yes No N/A

That all of the IRF unit professional
staff that provide the above-stated
services have current licenses and
certifications, as applicable.

• Review the IRF unit director’s license • The IRF unit representative will

to verify the he or she is a physician
MD or DO.

review the IRF unit director’s
qualifications to verify that he or
she is a physician with current
licensure as an MD or DO.

Page 17

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICE

FORM APPROVED
OMB NO. 0938-0986

Rehabilitation Hospital Criteria Work Sheet (CMS-437A)
Tag

Regulation

CMS Guidance

Actions Required to Determine If
Requirements Met

A3522 §412.29(g)(3)

• Ensure that the IRF unit director’s
physician license is current and
issued by the State in which the IRF
unit is located.

• The IRF unit representative will

A3523 §412.29(g)(4)

• Review personnel and/or

A3524 §412.29(h)

• Conduct a clinical record review to
verify that each IRF patient has a
plan of treatment and that the plans
are updated whenever there is a
change in the patient’s condition.

• The IRF unit representative will
verify that the director of the IRF
unit has at least 2 years of training
or experience in the medical
management of inpatients
requiring rehabilitation services
(after completing 1 year of
residency).

Is licensed under State law to
practice medicine or surgery; and

Has had, after completing a 1year hospital internship, at least 2
years of training or experience in
the medical management of
inpatients requiring
rehabilitation services.

credentialing files to verify the IRF
unit director’s training and
experience complies with the
regulation.

Have a plan of treatment for each
inpatient that is established,
reviewed, and revised as needed
by a physician in consultation
with other professional personnel
• The plan of treatment should include
who provide services to the
the patient’s medical prognosis and
patient.
the anticipated interventions,
functional outcomes, and discharge
destination from the IRF stay.

CMS-437A / OMB Approval Expires XX/XX/20XX

Yes No N/A

verify that the Director of
Rehabilitation holds current,
unexpired licensure as a physician
in the State in which the IRF unit is
located.

• The IRF unit representative will

verify that the IRF unit has an
established plan of treatment for
each inpatient, that is prepared,
reviewed, and revised as needed by
a physician in consultation with
other professional personnel who
provide services to the patient.

Page 18

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICE

FORM APPROVED
OMB NO. 0938-0986

Rehabilitation Hospital Criteria Work Sheet (CMS-437A)
Tag

Regulation

A3524
(cont.)

§412.29(h)

A3525

§412.29(h)(i)

continued

Use a coordinated
interdisciplinary team approach
in the rehabilitation of each
inpatient, as documented by the
periodic clinical entries made in
the patient’s medical record to
note the patient’s status in
relationship to goal attainment
and discharge plans and that
team conferences are held at
least once per week to
determine the appropriateness
of treatment.

CMS-437A / OMB Approval Expires XX/XX/20XX

Actions Required to Determine If
Requirements Met

CMS Guidance
The anticipated interventions detailed
in the overall plan of care should
include the expected intensity
(meaning number of hours per day),
frequency (meaning number of days
per week), and duration (meaning
total number of days during the IRF
stay) of physical, occupational, speechlanguage pathology, and prosthetic/
orthotic therapies required by the
patient during the IRF stay.

• Determine whether the IRF unit uses
an interdisciplinary team approach.

• Review clinical records to determine
whether the interdisciplinary team is
meeting once a week to review
patient progress toward goal
attainment and discharge planning.

•

Yes

No

N/A

The IRF unit representative will
verify whether the IRF unit has
an interdisciplinary team, that
meets once weekly to review
patient progress and that
documentation is in the medical
records.

• Determine if the documentation

complies with the regulatory
requirements.

Page 19

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICE

FORM APPROVED
OMB NO. 0938-0986

Rehabilitation Hospital Criteria Work Sheet (CMS-437A)
ATTESTATION STATEMENT
I hereby certify that the responses in this form are true and correct to the best of my knowledge, information and belief. Whoever
knowingly and willfully makes or causes to be made a false statement or representation on this statement, may be prosecuted under
applicable federal and state laws.

Printed Name of IRF Unit Representative:

Title of IRF Unit Representative:

Signature of IRF Unit Representative:

Date Signed:

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-0986 (Expires XX/XX/20XX). This is a mandatory information collection. The
time required to complete this information collection is estimated to average 1 hour per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.

***CMS Disclosure****

Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please
note that any correspondence not pertaining to the information collection burden, approved under the OMB control number listed on this form, will not be
reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Caroline Gallaher at
[email protected].
CMS-437A / OMB Approval Expires XX/XX/20XX

Page 20

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICE

FORM APPROVED
OMB NO. 0938-0986

Rehabilitation Hospital Criteria Work Sheet (CMS-437A)
INSTRUCTIONS
1. The CMS-437A form is to be used by Inpatient Rehabilitation Facility (IRF) units to attest to meeting the criteria set forth at 42 CFR, Subchapter B,
Part 412, sections 412.25 and 412.29 to be excluded from the Medicare Hospital Inpatient Prospective Payment System (IPPS).
2. All criteria of sections 412.25 and 412.29 must be met by the IRF unit in order to qualify for exclusion from Medicare’s Hospital Inpatient Prospective
Payment System (Hospital IPPS) or from the payment system used to pay Critical Access Hospitals (CAHs).
3. The hospital representative is expected to answer all questions accurately.
4. A “Yes” response indicates that the IRF unit has complied with the applicable regulations. A “No” response indicates that the IRF unit has not
complied with the regulation. An “N/A” response indicates that the regulation section does not apply to that IRF unit.
5. The facility staff person completing this form should have all answers verified by the director of rehabilitation, medical director, medical records
office, or any applicable facility management staff to verify the accuracy of all responses.
6. The IRF Unit must submit the completed and verified CMS-437A form to the State Survey Agency for their State.
7. The information and attestations contained in a CMS-437A form submitted by an IRF unit may be verified by the State Survey Agency, CMS
Location, or MAC, as applicable.

CMS-437A / OMB Approval Expires XX/XX/20XX

Page 21