Medicare Conditions of Participation
Specialized Providers

9.) Specialized Providers

        a.) Comprehensive outpatient rehabilitation facilities

Facilities must meet regulatory standards to be certified as comprehensive outpatient rehabilitation facilities (CORFs).187 A CORF must comply with the following conditions of participation:

• A facility and its personnel must meet all applicable state and local laws, including licensure requirements.188
• A CORF must have a governing body that assumes full legal responsibility for establishing policies regarding the management and operation of the facility.189
• A CORF must provide a coordinated rehabilitation program that includes physicians’ services, physical therapy services, and social or psychological services.190
• A facility must maintain clinical records on all patients and safeguard the records against loss or unauthorized use.191
• A facility must provide a physical environment that protects the health and safety of patients, personnel, and the public.192
• A facility must have written policies and procedures that defines the handling of patients, personnel, records, and the public during disasters.193
• A facility must have in effect a written utilization review plan that is implemented every 4 months to assess the necessity of services and promotes the most efficient use of services provided by the facility. A utilization review committee must carry out the utilization review plan.194
• A facility must comply with Medicare’s appeal provisions for providers.195

        b.) Critical access hospitals

A rural health network is an organization that includes at least one critical access hospital (CAH) and at least one hospital that furnishes acute care services.196  Critical access hospitals must hire clinical nurse specialists, nurse practitioners, and physician assistants who are licensed and completed a formal educational program.197

A state that establishes a Medicare rural hospital flexibility program may designate one or more facilities as a critical access hospital if each facility meets the critical access hospital conditions of participation.198 The conditions of participation include:

• A CAH and its staff must comply with applicable federal, state, and local laws.199
• A CAH must be a currently participating hospital and be located in a rural area or treat patients in a rural area.200
• A CAH must have a provider agreement to participate in the Medicare program.201
• A CAH must meet standards relating to agreements with network hospitals, agreements for credentialing and quality assurance, and agreements for credentialing and privileging of telemedicine physicians and practitioners.202
• A CAH must have a governing body that assumes full legal responsibility for determining policies governing the hospital’s operation.203
• A CAH must maintain a clinical records system in a manner that ensures confidentiality.204
• If a CAH provides surgical services, surgical procedures must be performed in a safe manner by qualified practitioners.205
• A CAH must meet standards relating to periodic evaluations of its program and quality assurance.206

        c.) Clinics, rehabilitations agencies, and public health agencies providing outpatient physical therapy and speech-language pathology services

A clinic, rehabilitation agency, and public health agencies providing outpatient physical therapy and speech-language pathology services must comply with the following conditions of participation:

• An organization and its staff must comply with federal, state, and local laws. The organization must comply with state licensure requirements.207
• A clinic or rehabilitation agency must have a governing body that is legally responsible for the conduct of the clinic or rehabilitation agency. 208
• A written plan of care must be established and periodically reviewed by a health care provider for each patient in need of outpatient physical therapy or speech pathology services.209
• An organization must maintain clinical records on all patients and must be safeguarded to protect patient confidentiality.210
• An organization must have procedures that provide for a systematic evaluation of its total program to ensure appropriate utilization of services and to determine whether the organization’s policies are followed in providing services to patients.211