Hospital - General

On this page, view the below information.

Information is found in CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 15 Section 4.1.8 and the CMS IOM, Publication 100-07, State Operations Manual, Chapter 2.
A hospital is a health care institution, providing patient treatment with specialized medical and nursing staff and medical equipment

  • Inpatient hospital services are defined in Title XVIII of the Social Security Act (the Act) and in the regulations (42 CFR 409.10)
  • Term "inpatient hospital or inpatient Critical Access Hospital (CAH) services"- means the following services furnished to an inpatient of a participating hospital or of a participating CAH, or to an inpatient of a qualified emergency services or foreign hospital
    • Bed and board
    • Nursing services and other related services
  • Use of hospital or CAH facilities
  • Medical social services
  • Drugs, biologicals, supplies, appliances, and equipment
  • Certain other diagnostic or therapeutic services
  • Medical or surgical services provided by certain interns or residents-in training
  • Transportation services, including transport by ambulance
  • Billing for Acute Care
    • For more information regarding billing, go to the billing portion of the website

Acute Care

  • Acute care is a branch of health care where a patient receives active but short-term treatment for a severe injury or episode of illness, an urgent medical condition, or during recovery from surgery
    • Care for acute health conditions is the opposite from chronic care, or longer-term care
  • Acute care services are generally delivered by teams of health care professionals from a range of medical and surgical specialties
  • Acute care may require a stay in the following:
    • Hospital emergency department
    • Ambulatory surgery center
    • Urgent care center
    • Other short-term stay facility, along with the assistance of diagnostic services, surgery, or follow-up outpatient care in the community
  • Hospital-based acute inpatient care typically has the goal of discharging patients as soon as they are deemed healthy and stable.
  • Acute care settings include but are not limited to:
    • Emergency department
    • Intensive care
    • Coronary care
    • Cardiology
    • Neonatal intensive care
  • Billing for Acute Care
    • For more information regarding billing, go to the billing portion of the website.


  • Long-term care is a variety of services which help meet both the medical and non-medical needs of people with a chronic illness or disability who cannot care for themselves for long periods
  • Long term care is focused on individualized and coordinated services that promote independence, maximize patients' quality of life, and meet patients' needs over a period of time
  • Long-term care is certified as acute care hospitals, but focus on patients who, on average stay more than 25 days
  • Most of the patients are transferred from intensive or critical care units
  • They Specialize in treating patients who may have more than one serious condition but may improve with time.
  • Long-term hospitals do get paid differently, if questioned refer to the Provider Call Center Part A
  • Billing for Long Term
    • For more information regarding billing, go to the billing portion of the website.


  • These services last several weeks or a few months while the patient is recovering from a sudden illness, injury or surgery from which they are expected to recover

Specialty Hospital (Cardiac, Orthopedic, or Surgical)

  • A hospital that provides a limited range of services (e.g., orthopedic surgery, ophthalmology, or obstetrics)
  • Two thirds of Medicare patients receive care for just two Diagnosis-Related Groups (DRGs) and outpatient surgical procedures

Children's Hospital

  • A children's hospital is a hospital which offers its services exclusively to children
  • The hospital will only be enrolled if the child qualifies for Medicare
  • Falls under the Tax Equity and Fiscal Responsibility Act (TEFRA) - meaning they do not require a prospective payment system (PPS) effective date on their enrollment
    • This type of group does not accurately account for the resource costs for the types of patients treated in this facility

Subunits: Swing-bed, Psychiatric, and Rehabilitation Units

  • While these units receive a State survey, a separate provider agreement is not required
    • Hospital's provider agreement incorporates these units
  • Submit 855A change application to add the swing bed unit as a practice location via paper
  • Submit 855A initial application to add the swing bed unit as a practice location via PECOS
  • Approved by CMS to furnish post-hospital skilled nursing facility (SNF) services
    • Hospital or CAH patients' beds can "swing" from furnishing hospital services to providing SNF care without the patient necessarily being moved to another part of the building
    • As stated in 42 CFR §482.66, to obtain swing-bed status the hospital must
      • Have a Medicare provider agreement
      • Be in a rural area
      • Have fewer than 100 non-newborn or intensive care beds
  • Billing for Sub-units
    • For more information regarding billing, go to the billing portion of the website.

Application Requirements

Application Tips
PECOS application
  • "Institutional Provider" (e.g., Hospital, Skilled Nursing Facility, Hospice, Home Health Agency)
  • Complete questionnaire to ensure correct applications (CMS-855A and CMS 588-EFT) populate.
  • Complete all form sections
  • Attach all supporting documentation such as IRS documents
  • List all directors, board members, and contracted or W-2 managing employee
  • Visit the Application Fee webpage to access CMS link to pay application fee
  • Submit completed CMS-588 EFT and voided check/bank letter. EIN required to be on application in Tax Identification Number (TIN) field


Application Time Frame

  • Once Noridian has completed the reviewal of the application, a Recommendation for Approval Letter is sent to the state and CMS. Below are the time frames in which Noridian has to review the application
Application Type Processing Time
PECOS On average, it can take 45 calendar days before application is sent to the state and CMS for approval
Paper On average, it can take 60 calendar days before application is sent to the state and CMS for approval


  • The state agency and the CMS regional office work together on the approval process.  Once the Regional Office has all the required information, they will issue the approval letter.  This is sent to the provider and to Noridian.
  • After receiving the tie-in Noridian will have the following time-frames to complete the application.
    • If a site visit is needed, Noridian will have 45 days to complete the application
    • If a site visit is not needed, Noridian will have 21 days to complete the application


Last Updated Mon, 19 Oct 2020 18:46:37 +0000