Spell of Illness Supplement, Form CMS-1539A (Exhibit 10)

2766 - Spell of Illness Supplement, Form CMS-1539A (Exhibit 10) (Rev. 1, 05-21-04) 2766A - Form(s) to Use (Rev. 1, 05-21-04) The SA completes both a Form CMS-1539 and a Spell of Illness Supplement, Form CMS- 1539A, in making §§1861(e)(1) and 1819(a)(1) (formerly 1861(j)(1)) certifications. The SA forwards the forms to the RO for determination, maintenance of listings, and notification to intermediaries and other interested parties. For convenience, a single Form CMS-1539A may include certifications for all areas of an institution when there is more than one part. Situation - Hospital being approved for participation, contains part rendering non-hospital services. Action - The SA checks Item 14(c) (1 or 2) on Form CMS-1539 and prepares §1819(a)(1) certification(s) on Form CMS-1539A. If “Does not meet §1819(a)(1)” is checked on Form CMS-1539A, add: “or (e)(1).” Situation - Hospital being denied or terminated and fails to meet §1861(e)(1) definition; entire facility meets (or does not meet) §1819(a)(1) definition. Action - The SA checks Item 14(b)(2) and Item 14(c)(1) or (3) on Form CMS-1539 and explains in Item 17. Situation - Hospital fails to meet §1861(e)(1) definition; part of facility meets and part does not meet §1819(a)(1) definition. Action - The SA checks Items 14(b)(1) or (2) and 14(c)(1) and (2) on Form CMS-1539, and provides explanation in Item 17. The SA prepares §1819(a)(1) certification(s) on Form CMS-1539A. If “Does not meet §1819(a)(1)” is checked, add “or (e)(1).” Situation - Hospital not participating and no termination involvement; contains part rendering non-hospital services. Action - The SA prepares §1819(a)(1) certification(s) on Form CMS-1539A. If “Does not meet §1819(a)(1)” is checked, add or (e)(1). Situation - Distinct part SNF being approved for participation. Action - The SA checks Item 14(c)(1) of Form CMS-1539 and prepares Form CMS-1539A. Situation - SNF does not meet one or more Conditions; entire facility meets (or does not meet) §1819(a)(1) definition. Action - The SA checks Item 14(c)(1) and (2) on Form CMS-1539; prepares Form CMS- 1539A. Situation - SNF does not meet one or more Conditions; part of facility meets and part does not meet §1819(a)(1) definition. Action - The SA checks Item 14(c)(1) and (2) on Form CMS-1539; provides explanation in Item 17; prepares Form CMS-1539A. Situation - Nursing facility with no SNF and no termination involvement. Action - Prepare Form CMS-1539 and Form CMS-1539A. 2766B - Items on Form CMS-1539A (Rev. 1, 05-21-04) Item 2 - In addition to the name and address of the facility, the SA identifies the part of the facility the spell of illness certification refers to; e.g., first and second floors of the West Building, or rooms numbered 23-31 of the East Wing of the Tower Building. Items 3-7 - Self-explanatory. Item 8 - Number of beds, and number of beds occupied. These items pertain to the number of beds within the part of the institution identified in Item 1.