Cms-437b Rehabilitation Hospital Criteria Work Sheet

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

FORM APPROVED
OMB NO. 0938-0986

REHABILITATION HOSPITAL CRITERIA WORK SHEET
CMS-437B
Name of IRF Hospital:

CCN#:

Date of Last Survey:
Number of Beds in IRF Hospital:

IRF Hospital’s Street Address:
City

State

Telephone Number:

Zip Code

Dates of Cost Reporting Periods for Which Exclusion from the Medicare IPPS Payment System Is Requested:
1.

Day/Month/Year

Tag

to

Day/Month/Year

Regulation

2.

Day/Month/Year

to

Guidance

Day/Month/Year

3.

Day/Month/Year

to

Actions Required to Determine If
Requirements Met

Day/Month/Year

YES

NO

N/A

§412.23- Excluded hospital units:
Classifications.
§412.23(b) - Rehabilitation hospitals.

An inpatient rehabilitation hospital
must meet the requirements specified
in §412.29 of this subpart to be
excluded from the prospective payment
systems specified in §412.1(a)(1) of this
subpart and to be paid under the
prospective payment system specified
in §412.1(a)(3) of this subpart and in
subpart P of this part.
CMS-437B / OMB Approval Expires XX/XX/202X

Page 1 of 14

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

FORM APPROVED
OMB NO. 0938-0986

REHABILITATION HOSPITAL CRITERIA WORK SHEET (CMS-437B)

____________________________________________________________________________________________________________________________________________________________________________________________________

Tag

Regulation

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 system.
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:

A3600 §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.

A3601 §412.29(b)

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 (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 paragraphs (b)(1) and
(b)(2) of this section.

CMS-437B / OMB Approval Expires XX/XX/202X

The facility will verify, through the
regional office (RO), that the
hospital has an agreement to
participate in the Medicare
program.

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

The IRF hospital representative
shall verify that the IRF hospital
has a Medicare provider
agreement.

For existing IRF hospitals that are not
new and have not added new IRF
beds during the past 12 months:

The IRF hospital representative shall
verify that at least 60% of the inpatient
population served by the IRF hospital
during its most recent, consecutive,
and appropriate 12-month time period
(as defined by CMS or the Medicare
contractor) required intensive

Page 2 of 14

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

FORM APPROVED
OMB NO. 0938-0986

REHABILITATION HOSPITAL CRITERIA WORK SHEET (CMS-437B)

____________________________________________________________________________________________________________________________________________________________________________________________________

Tag

Regulation

Guidance

A3601
(Cont.)

A3602

§412.29(c)

The IRF must submit a written
In the case of new IRFs (as defined in
attestation statement as well as form
paragraph (c)(1) of this section) or new IRF CMS 437B (rehabilitation hospital
beds (as defined in paragraph (c)(2) of this worksheet) to the SA as part of their
section), the IRF must provide a written
initial application packet or as
certification that the inpatient population it
determined by CMS to maintain their
intends to serve meets the requirements of
IPPS excluded status.
paragraph (b) of this section.

A3603

This written certification will apply until
the end of the IRF’s 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.
§412.29(c)(1) New IRFs.

Until the SA receives both the
attestation statement and the form
CMS 437B the new rehabilitation
hospital cannot be recommended for
approval.

Actions Required to Determine If
Requirements Met

YES

NO

N/A

rehabilitation services for treatment of
one or more of the conditions specified
in §412.29(b)(1) and §412.29(b)(2).

For new IRF hospitals and IRF
hospitals that have added new
beds during the past 12 months:

The IRF hospital representative
must provide a written attestation
statement which certifies that 60%
of the inpatient population it
intends to serve will require
intensive rehabilitation services for
treatment of one or more of the
conditions specified in
§412.29(b)(2).

NOTE: An IRF hospital or IRF unit is
If an IRF hospital has been closed for 5
considered
new if it has not been paid
years (more than 60 calendar months), it
An IRF hospital or IRF unit is considered
under the IRF PPS in subpart P of this
can open its doors as a new
new if it has not been paid under the IRF
part for at least 5 calendar years. A
rehabilitation hospital.
PPS in subpart P of this part for at least 5
new IRF will be considered new from
calendar years.
the point that it first participates in
Verify either through the SA or RO that
the IRF hospital has been closed for the 5 Medicare as an IRF until the end of its
A new IRF will be considered new from the
first full 12-month cost reporting
years before approving the IRF hospital
point that it first participates in Medicare as
period.
as new.
an IRF until the end of its first full 12-month
cost report period.

CMS-437B / OMB Approval Expires XX/XX/202X

Page 3 of 14

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

FORM APPROVED
OMB NO. 0938-0986

REHABILITATION HOSPITAL CRITERIA WORK SHEET (CMS-437B)

____________________________________________________________________________________________________________________________________________________________________________________________________

Tag
A3604

Regulation

Guidance

§412.29(c)(2) New IRFs beds.

If the rehabilitation hospital added
beds, the surveyor or CMS will verify
Any IRF beds that are added to an existing
that the hospital had approval
IRF must meet all applicable State
Certificate of Need and State licensure laws. (certificate of need or State license
before adding beds, if such approval
New IRF beds may be added one time at
is required.
any point during a cost reporting period
and will be considered new for the rest of
that cost report period.

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-437B / OMB Approval Expires XX/XX/202X

YES

NO

N/A

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

The IRF hospital received State
approval (certification of need or
The surveyor must verify that the
State licensure) prior to any bed
hospital received written CMS RO
increase, if prior approval is
approval before adding any new beds. required by the State;

A full 12-month cost report period must
elapse between the delicensing or
decertification of IRF beds in an IRF hospital
The surveyor will verify that the
or IRF unit and the addition of new IRF
hospital didn’t have more than one
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.

Actions Required to Determine If
Requirements Met

increase in beds during a single cost
reporting period.

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

The IRF hospital received written
approval from the applicable CMS
Location before the new beds were
added; and,
The IRF hospital didn’t have more
than one increase in beds during a
single cost reporting period.
If the IRF hospital removed or
decertified beds, the IRF hospital
representative will verify that:

The IRF hospital didn’t thereafter
add any additional beds until after
a full 12-month cost reporting
period had elapsed.

Page 4 of 14

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

FORM APPROVED
OMB NO. 0938-0986

REHABILITATION HOSPITAL CRITERIA WORK SHEET (CMS-437B)

____________________________________________________________________________________________________________________________________________________________________________________________________

Tag
A3605

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

Actions Required to Determine
If Requirements Met

Guidance

Regulation

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

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 system 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 owner’s Medicare provider
agreement, and the IRF continues to
meet all of the requirements for payment
under the IRF prospective payment
system.

Only entire hospitals may be sold
or leased, IRF units may not be
sold or leased.

•

•

YES

NO

N/A

The IRF hospital representative
will verify whether the IRF
hospital is currently undergoing
a change of ownership.

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

If the new owner(s) do not accept
assignment of the previous owner’s
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
§412(a)(1).

CMS-437B / OMB Approval Expires XX/XX/202X

Page 5 of 14

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

FORM APPROVED
OMB NO. 0938-0986

REHABILITATION HOSPITAL CRITERIA WORK SHEET (CMS-437B)

____________________________________________________________________________________________________________________________________________________________________________________________________

Tag
A3606

Regulation
§412.29(c)(4) Mergers.

As with the change of ownership, the
owner of the merged hospital must
If an IRF hospital (or a hospital with an accept assignment of the hospital with
IRF unit) merges with another hospital the existing provider agreement to
and the owner(s)of the merged hospital ensure uninterrupted reimbursement.
accept assignment of the IRF hospital’s
provider agreement (or the provider
If the owner of the hospital to be
agreement of the hospital with the IRF merged doesn’t accept assignment of
unit), then the IRF hospital or IRF unit the previous owner’s Medicare
retains its excluded status and will
provider agreement, the new owner(s)
continue to be paid under the
would not be eligible for
prospective payment system specified reimbursement until the new
in § 412,1(a)(3) before and after the
owner(s) reapplied to the Medicare
merger, as long as the IRF hospital or
program to operate a new hospital and
IRF unit continues to meet all of the
have additionally been granted IRF
requirements for payment under the
status,
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-437B / OMB Approval Expires XX/XX/202X

Actions Required to Determine If
Requirements Met

Guidance
•

•

YES

NO

N/A

The IRF hospital representative
will verify whether the IRF
hospital has merged with another
hospital.

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

Page 6 of 14

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

FORM APPROVED
OMB NO. 0938-0986

REHABILITATION HOSPITAL CRITERIA WORK SHEET (CMS-437B)

____________________________________________________________________________________________________________________________________________________________________________________________________

Regulation

Tag
A3607 §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.

A3608

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.
§412.29(e)

Except for care furnished to patients
in a freestanding IRF hospital solely
to relieve acute care hospital
capacity in a state (or region, as
applicable) that is experiencing a
surge, as defined in § 412.622,
during the Public Health Emergency,
as defined in § 400.200 of this
chapter, have in effect a procedure to
ensure that patients receive close
medical supervision, as evidenced by

CMS-437B / OMB Approval Expires XX/XX/202X

Guidance
•

•

Actions Required to Determine If
YES
Requirements Met

•

N/A

Review the hospital’s procedures, or The IRF unit representative will verify
that:
other alternative documents or
records, to verify the hospital has a
preadmission screening procedure in • The IRF hospital has a
preadmission screening
place.

A review of the clinical records should
indicate whether the IRF is using the
screening procedure.

•

•

NO

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; and,
The IRF hospital is using the
preadmission screening
procedure on all patients
admitted to the rehab unit.

As part of the clinical record review,
The IRF hospital representative
look for documentation supporting the will verify that:
physician and non-physician
practitioner visits.
• The IRF hospital has a
procedure which requires close
Review the hospital’s procedures or
medical supervision of the
other alternative documents or
patients; and
records to verify the hospital has a
• This procedure includes the
procedure detailing close medical
rehabilitation physician making
supervision for patients.
at least 3 face-to-face visits per
week by a licensed physician
with specialized training and
Page 7 of 14

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

FORM APPROVED
OMB NO. 0938-0986

REHABILITATION HOSPITAL CRITERIA WORK SHEET (CMS-437B)

____________________________________________________________________________________________________________________________________________________________________________________________________

Tag

Regulation

A3608
(cont.)

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
course of treatment as needed to
maximize the patient's capacity to
benefit from the rehabilitation
process except that during the Public
Health Emergency, as defined in §
400.200 of this chapter, for the
COVID-19 pandemic such visits may
be conducted using telehealth
services (as defined in section
1834(m)(4)(F) of the Act).
Beginning with the second week, as
defined in § 412.622, of admission
to the IRF, a non-physician
practitioner who is determined by
the IRF to have specialized training
and experience in inpatient
rehabilitation may conduct 1 of the
3 required face-to-face visits with
the patient per week, provided that
such duties are within the nonphysician practitioner's scope of
practice under applicable state law.

CMS-437B / OMB Approval Expires XX/XX/202X

Guidance

Actions Required to Determine If
Requirements Met

YES

NO

N/A

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;
and
Beginning with the second week
of admission to the IRF, a nonphysician practitioner who is
determined by the IRF to have
specialized training and
experience in inpatient
rehabilitation may conduct 1 of
the 3 required face-to-face visits
with the patient per week,
provided that such duties are
within the non-physician
practitioner's scope of practice
under applicable state law.

Page 8 of 14

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

FORM APPROVED
OMB NO. 0938-0986

REHABILITATION HOSPITAL CRITERIA WORK SHEET (CMS-437B)

____________________________________________________________________________________________________________________________________________________________________________________________________

Tag

Regulation

A3609 §412.29(f)

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

A3610 §412.29 (g)

Have a director of rehabilitation
who-

CMS-437B / OMB Approval Expires XX/XX/202X

Guidance
•

•

•

Actions Required to Determine If
Requirements Met

YES

NO

N/A

Review the licenses of all qualified
The IRF hospital representative
personnel that are required by the State will verify that:
to be licensed, to verify the licenses are
•
The IRF hospital’s patients
up-to-date.
receive rehabilitation nursing
care, physical therapy,
Qualified personnel would include
either personnel that are licensed in the
occupational therapy, and, if
State in which the services are provided
needed, speech-language
or those personnel that are recognized
pathology services, social
under reciprocity by the State in which
services, psychological services
the services are provided.
(including neuropsychological
services) and orthotic and
Determine if the hospital has and
prosthetic services; and
follows a procedure to evaluate and
document that personnel are qualified
•
All IRF unit professional staff
and that those personnel maintain their
that provide the above-stated
services have current licenses
qualifications.
and certifications, as applicable.

Verifies the rehab hospital has a director
of rehabilitation by reviewing personnel
logs or rosters and organization charts.

The IRF hospital representative
will verify that the IRF hospital has
a Director of Rehabilitation.

Page 9 of 14

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

FORM APPROVED
OMB NO. 0938-0986

REHABILITATION HOSPITAL CRITERIA WORK SHEET (CMS-437B)

____________________________________________________________________________________________________________________________________________________________________________________________________

Tag

Regulation

A3611 §412.29 (g)(1)

Provides services to the IRF hospital
and its inpatients on a full-time basis.

Guidance
The hospital will:

• Verify the full-time hours through
review of personnel time cards/logs,
etc.
•

•

•

Define the term “full-time” as it
applies to all of its employees.

A director of rehabilitation hours
cannot be substituted by a Physician
Assistant.

Review the physician’s license to verify
the physician is an MD or DO.

A3613 §412.29(g)(3)
Is licensed under State law to practice
medicine or surgery;

Surveyor will verify the physician has a
current license issued by the State, as
appropriate.

CMS-437B / OMB Approval Expires XX/XX/202X

YES

NO

N/A

The IRF hospital representative
will verify that the IRF hospital
director provides service to the
IRF hospital and its patients on a
full-time basis.

The full-time hours may be any
combination of patient services and
administration.

A3612 §412.29(g)(2)

Is a doctor of medicine or osteopathy;

Actions Required to Determine If
Requirements Met

The IRF hospital representative
will verify that the Director of
Rehabilitation is a physician with
current, valid licensure as an MD
or DO.

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

Page 10 of 14

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

FORM APPROVED
OMB NO. 0938-0986

REHABILITATION HOSPITAL CRITERIA WORK SHEET (CMS-437B)

____________________________________________________________________________________________________________________________________________________________________________________________________

Tag

Regulation

Guidance

A3614 §412.29(g)(4)

Review personnel and/or credentialing
files to verify the physician’s training
and experience complies with the
regulation.

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

A3615

§412.29(h)
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 who provide
services to the patient.

•

•

•

CMS-437B / OMB Approval Expires XX/XX/202X

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 plan of treatment should include the
patient’s medical prognosis and the
anticipated interventions, functional
outcomes, and discharge destination from
the IRF stay.

Actions Required to Determine If
Requirements Met

YES

NO

N/A

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

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.

Page 11 of 14

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

FORM APPROVED
OMB NO. 0938-0986

REHABILITATION HOSPITAL CRITERIA WORK SHEET (CMS-437B)

____________________________________________________________________________________________________________________________________________________________________________________________________

Tag
A3616

A3617

Regulation
§412.29(h)(i)
Use a coordinated interdisciplinary
team approach in the rehabilitation
of each inpatient, as documented by
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.

§412.29(h)(j)

Retroactive adjustments. If a new
IRF (or new beds that are added to
an existing IRF) are excluded from
the prospective payment systems
specified in§ 412.1(a)(1) and paid
under the prospective payment
system specified in § 412.1(a)(3) for
a cost reporting period under
paragraph (c) of this section, but the
inpatient population actually treated
during that period does not meet the
requirements of paragraph (b) of
this section, we adjust payments to
the IRF retroactively in accordance
with the provisions in § 412.130.

CMS-437B / OMB Approval Expires XX/XX/202X

Guidance
•

•

Review clinical records to determine
whether the interdisciplinary team is
meeting once a week to review
patient progress toward goal
attainment and discharge planning.
Determine if the documentation
complies with the regulatory
requirement.

Actions Required to Determine If
Requirements Met

YES

NO

N/A

The IRF hospital representative
will verify whether the IRF
hospital has an interdisciplinary
team that meets once weekly to
review patient progress and that
documentation of this is put in
each patient’s medical record.

If the new IRF’s inpatient population
doesn’t meet the 60% rule, the IRF will
lose its IPPS exclusionary status. The RO
will send notification to the facility prior
to the beginning of the next cost report
period that the facility has lost its IPPS
excluded status and will revert to acute
care hospital status.

Page 12 of 14

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

FORM APPROVED
OMB NO. 0938-0986

REHABILITATION HOSPITAL CRITERIA WORK SHEET (CMS-437B)

____________________________________________________________________________________________________________________________________________________________________________________________________

ATTESTATION STATEMENT
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.
I hereby certify that the responses in this form are true and correct to the best of my knowledge, information and belief.
Printed Name of IRF Hospital Representative:

Title of IRF Hospital Representative:

Signature of IRF Hospital 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 (required to obtain payment from Medicare) information collection. The time required to complete this information collection is
estimated to average 4 hours 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 caroline.gallaher@cms.hhs.gov.
CMS-437B / OMB Approval Expires XX/XX/202X

Page 13 of 14

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

FORM APPROVED
OMB NO. 0938-0986

REHABILITATION HOSPITAL CRITERIA WORK SHEET (CMS-437B)

____________________________________________________________________________________________________________________________________________________________________________________________________

INSTRUCTIONS
1. The CMS-437B form is to be used by Inpatient Rehabilitation Facility (IRF) hospitals 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 412.23 and 412.29 must be met by the IRF hospital 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 hospital has complied with the applicable regulations. A “No” response indicates that the IRF hospital has not
complied with the regulation. An “N/A” response indicates that the regulation section does not apply to that IRF hospital.

5. The IRF hospital representative 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 ensure the accuracy of all responses.
6. The IRF hospital must submit the completed and verified CMS-437B form to the CMS Location via the State Survey Agency for their State.

7. The information and attestations contained in a CMS-437B form submitted by an IRF hospital may be verified by the State Survey Agency, CMS Location,
or MAC, as applicable.

CMS-437B / OMB Approval Expires XX/XX/202X

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