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Hospitals

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Overview

Hospitals may apply for certification to participate in the Medicare and Medicaid programs. The Centers for Medicare and Medicaid Services (CMS) contracts with the Department of Licensing and Regulatory Affairs (LARA) to evaluate compliance with federal regulations by conducting certification surveys and complaint investigations. Hospitals must be licensed by the State of Michigan before Medicare certification is approved.

Hospitals must be licensed by the State of Michigan before Medicare certification is approved. Please visit Hospitals (michigan.gov) to obtain information on state licensing.

Resources

State Operations Manual (SOM) Chapter 2

SOM Appendix A-Hospitals

SOM Appendix W-CAH

SOM Appendix Z

Psych Hospitals and Inpatient units: Healthcare Workforce Background Check Information

Administrator/Leadership Changes

Administrator/Leadership Change Request Form

Submitted form is sent to LARA-BSCSupport@michigan.gov.

Initial Certification

To voluntarily become a Medicare-certified provider, you will need to complete the following steps and submit the paperwork electronically to LARA-BSCSupport@michigan.gov, unless otherwise noted in the instructions.

  • Currently, CMS has prioritized initial surveys as a lower-tier work. Following the guidance of the CMS Mission and Priority Document, Michigan is currently not performing initial surveys. A provider can become accredited to obtain certification.
  • Contact Accrediting Organization (AO) to schedule survey.
    • Once the deeming survey is complete, please ensure that the Bureau of Survey and Certification (BSC) receives a copy of the survey report and final approval letter from your deeming authority.

Once all the above documents have been received, your application will be deemed complete, and the Bureau of Survey and Certification will review and forward the packet to the CMS location for final determination and issuance of the Medicare provider number.

Please note: this process can take up to 30-60 days from the date of receipt by the CMS Chicago location.

Conversions

Swing Beds

  • Complete the Provider Enrollment Application (CMS-855A) and submit it to the Medicare Administrative Contractor (MAC). The MAC will provide you with a recommendation letter once the initial review is complete.
  • Once the Bureau of Survey and Certification receives the recommendation letter from the MAC, a survey will be conducted.
    • If deemed, submit a copy of the deeming authority survey report, which includes the new swing bed program.
    • If not deemed, the Bureau of Survey and Certification will conduct an unannounced survey. The survey will be conducted based on the priorities in the CMS Mission and Priority document.
  • Once all the above documents, including the survey reports, have been received, your application will be considered complete. The Bureau of Survey and Certification will review and forward the packet to the CMS location for final determination and issuance of the Medicare provider number.
  • Please note: this process can take up to 30-60 days from the day of receipt by the CMS location.

Change of Ownership (CHOW)

Email the following to the Medicare Administrative Contractor (MAC):

The MAC will provide you a recommendation letter once the initial review is complete.

Once the paperwork is complete, BSC will forward the packet to the CMS Location for final determination and issuance of final approval letter.

Please note: this process can take up to 30-60 days from the date of receipt by the CMS Location.

Prospective Payment System (PPS)

Rehabilitation Unit/Hospital PPS

  • Rehabilitation units and hospitals are required to submit a triennial attestation for compliance with federal regulations.
  • Submit the following paperwork to the LARA-BSCSupport@michigan.gov:
    • CMS 437A for rehabilitation units or CMS 437B for hospitals. 
    • An Attestation Form
    • A Contact Form
    • Documentation that verifies the provider has a qualified medical director who meets the regulatory standards at 42 CFR 412.29(F).
    • A copy of your latest accreditation notice if applicable.
    • A copy of the unit’s floor plan.
  • One mid-cycle change is allowed per cost reporting year. To apply for a change, submit the above paperwork along with a narrative explaining the change.
  • If at any time your PPS contact changes, submit a new contact form to the email address listed above.
  • Once all the above documents have been received, your application will be deemed complete, and the Bureau of Survey and Certification will review and forward the packet to the CMS location for final determination and issuance of the Medicare provider number.

Please note: this process can take up to 30-60 days from the date of receipt by the CMS location.

CMS Location does not send out approval notifications unless changes are made.

Psychiatric Unit PPS

  • Psychiatric units are required to submit an annual attestation for compliance with federal regulations.
  • Submit the following paperwork to the LARA-BSCSupport@michigan.gov:
  • One mid-cycle change is allowed per cost reporting year. To apply for a change, submit the above paperwork along with a narrative explaining the change.
  • If at any time your PPS contact changes, submit a new contact form to the email address listed above.
  • Once all the above documents have been received, your application will be deemed complete, and the Bureau of Survey and Certification will review and forward the packet to the CMS location for final determination and issuance of the Medicare provider number.

Please note: this process can take up to 30-60 days from the date of receipt by the CMS location.

CMS Location does not send out approval notifications unless changes are made.

 

Special Federal Reporting Requirement

Hospital Restraint/Seclusion Deaths - CMS requires all hospitals to report deaths associated with restraint and/or seclusion on the electronic CMS-10455 form. The only exceptions to the reporting requirement are deaths associated with two-point soft wrist restraints. See QSOG-20-04-Hospital-CAH-DPU.

Hospitals must report the following information to CMS no later than the close of business on the next business day following the acknowledgment of the restraint and/or seclusion associated patient death:

  • Death that occurs while a patient is in restraint or seclusion.
  • Death that occurs within 24 hours after the patient has been removed from restraint or seclusion.
  • Death known to the hospital that occurs within one week after restraint or seclusion where it is reasonable to assume that the use of restraint or placement in seclusion contributed directly or indirectly to a patient's death.


Two-Point Soft Wrist Restraint Exception - When the patient was not in seclusion and when the only restraints used on the patient were those applied exclusively to the patient's wrists, the death could be considered a two-point soft wrist restraint situation. To be a soft wrist restraint, the restraint on the patient's wrist must be composed solely of soft, non-rigid, cloth-like materials. In these cases, the hospital staff must record the death in an internal log or other system. The hospital must record and report the following information no later than seven days after the patient’s death:

  • Death that occurs while a patient is in such restraints.
  • Death that occurs within 24 hours after a patient has been removed from such restraints.
  • Death entry must document the patient's name, date of birth, date of death, name of attending physician, or other licensed practitioner who is responsible for the care of the patient, medical record number, and primary diagnoses.

Questions regarding the reporting of hospital restraint or seclusion deaths may be directed to the CMS Chicago Regional Office at ChicagoNLTCPOC@cms.hhs.gov.

Contact Us

Bureau Phone: 517-284-0193

Bureau Fax Number: 517-763-0214

Help for general questions: LARA-BSCHelp@michigan.gov

Certification support email for document submission: LARA-BSCSupport@michigan.gov