This form is for outpatient PT and SLP facilities seeking Medicare certification

Ensure all therapists meet the qualification requirements in the Medicare CoPs

The facility must maintain a written plan of care for each patient signed by a physician

RehabilitationhardDoctor signature required

Rehabilitation Hospital Criteria Worksheet

CMS-437B · CMS

Submitted to maintain IPPS-excluded status for inpatient rehabilitation facilities.

Form Details

Total fields: 45
Auto-fillable: 18 (40%)
Time without BeneFill: 60 minutes
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Time saved: 45 minutes
Filled by: doctor
Frequency: annual

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Where to Submit This Form

📬

Submit to the Medicare Administrative Contractor (MAC)

Submitted by the Outpatient Physical Therapy or Speech-Language Pathology facility.

🌐

Submit through the CMS PECOS enrollment system

https://pecos.cms.hhs.gov/pecos/login.do

Required Attachments

📎 Completed CMS-437B (Organ-Specific Survey for Outpatient PT/SLP)
📎 Documentation of qualified staffing and professional supervision
📎 Facility policies and procedures for outpatient therapy services
📎 Documentation of compliance with health, fire, and safety codes

Processing Time

30-90 days after the state survey agency conducts the on-site survey.

What Happens Next

The state survey agency conducts the initial or recertification survey. Deficiencies must be corrected within the plan of correction timeline. Certification allows billing Medicare for outpatient therapy services.

Tips for This Form

✓ This form is for outpatient PT and SLP facilities seeking Medicare certification
✓ Ensure all therapists meet the qualification requirements in the Medicare CoPs
✓ The facility must maintain a written plan of care for each patient signed by a physician
✓ Revalidation is required every 5 years — track your due date in PECOS

More Rehabilitation Forms

IRF-PAI (Inpatient Rehabilitation Facility Patient Assessment)

IRF-PAI · CMS

Assessment instrument determining Medicare Part A FFS payment for IRF stays. Must be in the patient's medical record, dated, timed, and authenticated.

Rehabilitation Unit Compliance Form

CMS-437A · CMS

Documents that a rehabilitation unit is fully equipped and staffed for hospital inpatient rehabilitation care.

Inpatient Rehab Pre-Authorization

Insurer-specific · Health insurance plans / UM organizations

Pre-certification for inpatient rehab admission. Must document patient can participate in 3 hours of therapy, 5 days per week (15 hours per week).

Outpatient PT/OT/ST Prior Authorization

Insurer/state-specific · Health insurance plans / State Medicaid

Prior authorization for outpatient physical therapy, occupational therapy, or speech therapy. Must specify frequency, duration, and medical necessity.

Concurrent Therapy Treatment Request / Recertification

Insurer-specific · Health insurance plans

Request for continued therapy beyond initial authorization period. Must document progress toward goals and continued medical necessity.

Vocational Rehabilitation Application

State-specific (e.g., WA DSHS 11-022) · State Divisions of Vocational Rehabilitation

Application for VR services to help people with disabilities prepare for, find, and keep jobs. Eligibility based on disability that creates a barrier to employment.

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