To be paid under the IRF-PPS and to be exempted from the IPPS, the distinct part rehabilitation unit is required to meet the requirements found at 42 CFR §412.25, and 42 CFR §412.29

After an initial certification, a distinct part rehabilitation unit requesting continuing payment under the IRF-PPS must complete an annual self-attestation certifying compliance with the requirements found at 42 CFR §412.25, and 42 CFR §412.29.

The annual self attestation should be completed 90 to 120 days before the beginning of a hospital's cost reporting period.

The following forms comprise the Annual PPS Exemption Self Attestation packet and should be completed and submitted no later than 80 calendar days prior to the beginning of the hospital next cost reporting period:

• Form CMS-437A Rehabilitation Unit Criteria Work Sheet. 
• Attestation Statement for Exclusion from PPS for Rehabilitation Unit form.
• Contact Information form.

The above forms may be downloaded at the following links:

 CMS 437A Form

 PPS Self Attestation Form - Rehabilitation Unit

 Contact Information Form 

In completing Form CMS-437A Rehabilitation Unit Criteria Work Sheet:

• The rehabilitation program manager or director should complete and sign the Form CMS-437A Rehabilitation Unit Criteria Work Sheet.
• Respond to every item on the Form CMS-437A Rehabilitation Unit Criteria Work Sheet.
• If a response is marked "no", your explanation should include a description of the degree to which the standard has been met.
• The designated SURVEY DATE on the top of page 1 of the Form CMS-437A Rehabilitation Unit Criteria Work Sheet is the date that you evaluated your rehabilitation unit's compliance with applicable IPPS exemption criteria requirements.
• The designated REQUEST FOR EXCLUSION FOR COST REPORTING PERIOD on the top of page 1 of the Form CMS-437A Rehabilitation Unit Criteria Work Sheet is the beginning date of the next upcoming fiscal year, not the current fiscal year.

Attach a copy of the rehabilitation unit floor plan to the Form CMS-437A Rehabilitation Unit Criteria Work Sheet. On the floor plan, highlight the beds for which PPS exemption is requested.

Your hospital Administrator or Chief Executive Officer should sign and date the Attestation Statement for Exclusion from PPS for Rehabilitation Unit form.

If the rehabilitation unit does not meet the criteria found at 42 CFR §412.25, and 42 CFR §412.29, Medicare payment for rehabilitation inpatient services will be made under the PPS.

Documents submitted by U.S. Mail should be addressed to:

Rehabilitation Program Licensing Office
Division of Licensing and Certification
Bureau of Health Systems
Michigan Department of Licensing and Regulatory Affairs
P.O. Box 30664
Lansing, MI 48909

Documents submitted by a courier or overnight express service should be addressed to:

Rehabilitation Program Licensing Office
Division of Licensing and Certification
Bureau of Health Systems
Michigan Department of Licensing and Regulatory Affairs
Ottawa Building - 1st Floor
611 W. Ottawa Street
Lansing, Michigan 48933

Hospitals/units are under a continuing obligation to notify this office if the hospital or unit fails to meet one of the applicable requirements in the period between the attestation and the start of the fiscal year. If a change in meeting applicable criteria occurs during a cost reporting period, or the hospital requests PPS exclusion after the start of its cost reporting period, the status determined for that period remains for the duration of the period. CMS will continue to verify separately, through the appropriate fiscal intermediary, compliance with certain criteria. Please be advised that without prior notice CMS may also validate the compliance of any requirement.

If you should have any questions regarding the foregoing, please call (517) 241-3844.