Psychiatric Hospitals/Units & PPS-Exempt Units

  • This page is designed to assist providers through the state licensure and federal certification processes, as well as provide additional resources to maintain compliance.

State Licensing

  • State licensing is required for psychiatric hospitals/units under the MI Mental Health Code.

    A state licensure application (BCHS-HFD-100) is required to (Licensure fee required):

    A state licensure application is also required to (No fee required):

    • Change in the hospital name
    • Change in the hospital location
    • Change in bed designations (Appendix E)
    • Decrease in bed capacity - Include Appendix E

     

    LICENSURE

    • Fee: $500, plus $10 per bed
    • Annual renewal invoices sent on June 1st of each year
    • License renewals must be paid online no later than July 31st
  • Other state agencies may require approval prior to licensing actions. Contact the following state agencies to determine whether their approval is required.

    Certificate of Need
    Michigan Department of Health & Human Services (MDHHS)
    Lewis Cass Building, 3rd Floor
    320 S. Walnut Street
    Lansing, MI 48913
    Phone: 517-241-3344

    Health Facilities Engineering Section
    Michigan Department of Licensing and Regulatory Affairs (LARA)
    PO Box 30664
    Lansing, MI 48909
    Phone: 517-241-3408

    Bureau of Fire Services
    Michigan Department of Licensing and Regulatory Affairs (LARA)
    3101 Technology Boulevard, Suite H
    PO Box 30700
    Lansing, MI 48909
    Phone: 517-335-5804

Federal Certification

  • Psychiatric hospitals may apply for certification to participate in the Medicare/Medicaid programs. The Centers for Medicare and Medicaid Services (CMS) contracts with LARA to evaluate compliance with the federal regulations. Hospitals must be licensed with the State of Michigan before Medicare certification is approved.

    For initial certification, relocations or change of ownership:

    • Complete Provider Enrollment Application (CMS-855A) and submit to the and submit to Medicare Administrative Contractor (MAC)/Federal Fiscal Intermediary (FI)
    • Complete and submit to BCHS:
      • One (1) signed original Civil Rights Clearance for Medicare Provider Certification (OMB No. 0990-0243 and HHS-690)
      • Two (2) signed originals Health Insurance Benefit Agreement (CMS-1561)
      • One (1) signed original Hospital/CAH Medicare Database Worksheet (Exhibit 286)

Federal PPS-Exempt Units

  • This section is to assist psychiatric and rehabilitation units seeking to become a Prospective Payment System (PPS) exempt unit.

    • Complete Provider Enrollment Application (CMS-855A)
    • Complete and submit to BCHS:
    • PPS contact BCHS-HFD-826.

    • Information for excluded Psychiatric Units only:
      • Medical record protocols to permit verification that each patient receives a psychiatric evaluation within 60 hours of admission.
      • Documentation that each patient has a comprehensive treatment plan.
      • Documentation that progress notes are routinely recorded.
      • Documentation that each patient has discharge planning and a discharge summary.
      • Description of the type and number of clinical staff, including a qualified medical director of inpatient psychiatric and a qualified director of psychiatric nursing services, registered nurses, licensed practical nurses, and mental health workers to provide care necessary under their patients' active treatment plans.
         
    • Information for excluded Rehabilitation Units only:

      • Documentation such as payroll records, duty rosters, records of appointments, etc., that permits verification that the provider has a qualified medical director who meets the regulatory standards at 42 CFR 412.29(f).

    Note: Psychiatric units require an annual attestation and Rehabilitation units require a triennial attestation in order to stay in compliance with Federal Regulations.

State and Federal Death Reporting Requirements

  • Psychiatric Notification of Death - Michigan Administrative Rule 330.1274 requires licensed psychiatric hospitals/programs to report to the department all deaths - Psychiatric Notification of Death Report (BHCS-HFD-1036). This form must be completed and submitted to the department within five working days (recommended) from when the patient died on the psychiatric unit; after transfer to an acute care hospital, Emergency Department or Medical Unit; or within 48 hours of discharge from your facility.

    Hospital Restraint/Seclusion Deaths – Centers for Medicare and Medicaid Services (CMS) requires (S&C: 14-27) all hospitals, including psychiatric hospitals, to report (by close of next business day)  deaths associated with restraint and/or seclusion on form CMS-10455. Submit reports either via fax at 443-380-8952 or confidential email at 05RESTRAINTRF@CMS.HHS.GOV. Hospitals should attach an additional page to the worksheet to further describe circumstances surrounding the death (e.g., reason for restraint, total length of time in restraints, how patient was monitored, and frequency of monitoring while in restraint). Hospitals should not call to report a death. Questions may be directed to CMS ROV Chicago, Tiffany Lowe-Ross, 312-353-9804 or via email tiffany.lowe@cms.hhs.gov. Please note that reports contain personal health information and should be sent via a secure method.

     

    For a change in administrator, please email BCHS_FedDivision@michigan.gov the following:

    • Facility name, address, and provider # or state facility ID
    • New administrator full name
    • Effective start date of administrator

Contact Information

  • Michigan Department of Licensing & Regulatory Affairs
    Bureau of Community and Health Systems
    611 W. Ottawa Street
    PO Box 30664
    Lansing, MI 48909
    Main Line: 517-335-1980

    Federal Certification
    Phone: 517-284-8953
    FAX: 515-241-2635

    State Licensing
    Phone: 517-241-1970
    FAX: 517-241-3354