Documentation Guidance

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U.S. Department of Health and Human Services (HHS)
Health Resources and Services Administration (HRSA)
Bureau of Health Professions (BHPr)
Division of Medicine and Dentistry (DMD)
Graduate Medical Education Branch (GMEB)

Parklawn Building, Room 9A-05
5600 Fishers Lane
Rockville, MD 20857-5600

Table of Contents

I. Overview

II. Hospital Eligibility Criteria and Documentation Recommendations

III. Residency Program Eligibility Criteria and Documentation Recommendations

IV. Resident Eligibility Criteria and Documentation Recommendations

V. Intern and Resident Information System and Data Submission Recommendations

Appendix A. Sample Medicare GME Affiliation Agreement for an Aggregate Cap

I. Overview

• Sections II through IV summarize current CHGME PP requirements regarding hospital, residency program, and resident eligibility criteria,  and include recommendations regarding the documentation children’s teaching hospitals need to maintain related to those requirements;
• Section V provides an overview of CHGME PP intern and resident data collection and recommendations for data submission;
• Appendices A and B are provided to assist hospitals in developing agreements for aggregate caps and non-provider/non-hospital settings, respectively;
• Appendices C and D are sample letters of verification for residents sponsored by other (civilian and military) institutions rotating to the children’s hospital;
• Appendix E is an excerpt from the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) standards on primary source verification of credentials information;
• Appendix F is an outline that hospitals can use when submitting documentation to the CHGME PP or CHGME FI; and
• Appendix G includes detailed checklists that hospitals can use when submitting documentation to the CHGME PP or CHGME FI.

Please note that documentation recommendations and checklists provided are not exhaustive in nature.  They represent the minimum documentation recommendations that will allow the CHGME FIs to accurately assess the resident FTEs reported by an eligible children’s teaching hospital on its initial application for CHGME PP payments.

Prior to the submission of a hospital’s initial application for CHGME PP funding, the Department strongly recommends that documentation and supporting data related to resident FTE counts reported in a hospital’s CHGME PP application be collected (by the applicant children’s hospital), certified by an appropriate official of the hospital, including an official responsible for administering the residency programs, and retained by the individual identified in HRSA 99, Section 5 of the hospital’s CHGME PP initial application.  This individual should be able to forward any or all of this information/data to the CHGME PP or CHGME FI upon request.

It should also be noted that the Resident FTE Assessment Program does not take the place of a separate Federal audit to which any participating hospital may be subject.  Participating children’s hospitals may be subject to audit to determine whether the hospital has complied with applicable laws and regulations. 

Hospitals are encouraged to discuss any documentation questions with their CHGME FIs.  CHGME FIs may request additional information or clarification as needed to facilitate the Resident FTE Assessment process.

II. Hospital Eligibility Criteria and Documentation Recommendations

Eligibility Criteria

According to Public Law 106-310, a children’s teaching hospital must meet the following eligibility criteria for CHGME PP funding.  The hospital must:

1. participate in an approved graduate medical education (GME) program;
2. have a Medicare Provider Agreement;
3. be excluded from the Medicare inpatient prospective payment system (PPS) under section 1886(d)(1)(B)(iii) of the Social Security Act, and its accompanying regulations⁽¹⁾; and
4. operate as a “freestanding” children’s teaching hospital, as defined by the CHGME PP.⁽²⁾

⁽¹⁾ A hospital with a 3300 series Medicare provider number would meet this criterion (i.e., 55-3300).

⁽²⁾A children’s teaching hospital is considered “freestanding” if it does not operate under a Medicare hospital provider number assigned to a larger health care entity that receives Medicare GME payments.

Changes in Eligibility

A hospital remains eligible for CHGME PP funding as long as it trains residents as a “freestanding” children’s hospital during the FY for which CHGME PP payments are being made.

If a hospital becomes ineligible for payments:

1. it must notify the HRSA immediately of the change in status and the date of the change; and
2. it will be liable for the reimbursement, with interest, of any funds received during a period of ineligibility.

Documentation Recommendations

Hospitals participating in the CHGME PP should maintain in their documentation file:

• a copy of their Medicare provider agreement;

and/or

• a recent print-out of the list of CHGME PP potentially eligible hospitals published annually on the CHGME PP website at http://bhpr.hrsa.gov/childrenshospitalgme.

Useful website links:

• CHGME PP:  http://bhpr.hrsa.gov/childrenshospitalgme/;
• CMS :  www.cms.gov;        

Additional references:

• Social Security Act, Section 1886
• CHGME PP, Federal Register Notice dated March 1, 2001 (66 FR 12940)

III. Residency Program Eligibility Criteria and Documentation Recommendations

Eligibility Criteria

Residents may be included in a hospital’s resident FTE count for CHGME PP purposes if the residency program (in which the resident is enrolled) meets one of the following criteria:

• The program must be approved by one of the following accrediting bodies:

1. Accreditation Council for Graduate Medical Education (ACGME);
2. Committee on Hospitals of the Bureau of Professional Education of the American Osteopathic Association;
3. Commission on Dental Accreditation of the American Dental Association; or
4. Council of Podiatric Medicine Education of the American Podiatric Medical Association.

• The program may count towards certification of the resident in a specialty or subspecialty listed in the current edition of the Directory of Graduate Medical Education Programs (published by the American Medical Association) or the Annual Report and Reference Handbook (published by the American Board of Medical Specialties).
• The program is approved by the ACGME as a fellowship program in geriatric medicine; or
• The program would be accredited except for the accrediting agency’s reliance upon an accreditation standard that requires an entity to perform an induced abortion or require, provide, or refer for training in the performance of induced abortions, or make arrangements for such training, regardless of whether the standard provides exceptions or exemptions.

Documentation Recommendations

Hospitals participating in the CHGME PP should maintain in their documentation file the following information regarding approved residency training programs:

• A copy of the letter of approval or accreditation from one of the accrediting agency’s listed above for each residency program; or
• A letter from one of the accrediting agency’s indicating that the program would be accredited except for the accrediting agency’s reliance upon an accreditation standard that requires an entity to perform induced abortions or requires, provides, or refers for training in the performance of induced abortions, or made arrangements for such training regardless of whether the standards provides exceptions or exemptions.

In addition, the children’s hospital claiming residents from approved residency training programs for CHGME PP purposes should provide to CHGME FIs during the Resident FTE Assessment:

• A copy of the current edition of the ACGME’s Graduate Medical Education Directory (GMED) or equivalent in which the children’s hospital is listed as a sponsoring or major participating institution for the specified residency program; or
• A copy of the institutional agreement (also known as an affiliation agreement, memorandum of understanding, inter-institutional agreement, letter of commitment, letter of affiliation, letter of agreement, or written agreement) between the children’s hospital and the sponsoring institution/residency program if the children’s hospital is not the sponsoring institution or a major participating institution.  The institutional agreement should identify the name(s) of the sponsoring institution(s), the residency program in which the residents are enrolled, the children’s hospital, the residency program or department at the children’s hospital where the residents will be rotating, the number of resident FTEs allowed (e.g. 1 FTE per month), effective and expiration dates of the agreement, and financial arrangements.  Agreements may vary slightly by specialty due to varying ACGME residency review committee requirements for institutional agreements.

NOTE:  The children’s hospital can substitute printouts from the accrediting body’s website, as long as all pertinent-information related to the residency program’s accreditation and general information is included in the printout.  Pertinent information includes accreditation date, accreditation status, accreditation, program length, etc.

Useful website links:

• Accreditation Council for Graduate Medical Education: www.acgme.org;
• Committee on Hospitals of the Bureau of Professional Education of the American Osteopathic Association:  www.aoa-net.org;
• Commission on Dental Accreditation of the American Dental Association:  www.ada.org/prof/ed/accred/commission.html;
• Council of Podiatric Medicine Education of the American Podiatric Medical Association:  www.apma.org/CPME/index.html;

Additional references:

• Social Security Act, Section 1886
• 42 CFR 413.75 – 413.83 (Centers for Medicaid and Medicare)

IV. Resident Eligibility Criteria and Documentation Recommendations

Eligibility Criteria

In order to be counted in CHGME PP payment calculations, a resident must be:

• in an approved residency training program (see residency program eligibility criteria and documentation requirements);

and either

• a graduate of an accredited medical school in the U.S. or Canada; or
• have passed the United States Medical Licensing Examination (USMLE) Parts I & II (foreign or international medical graduates)

Resident FTE counts are based on the number of residents training at the hospital complex and certain non-hospital/non-provider settings/sites throughout the hospital’s fiscal year.  Residents are counted as FTEs based on the total time necessary to fill a full-time residency slot for the year.

Residents are divided into two categories, those in their:

1. initial residency period (IRP);
   1. Effective July 1, 1995, an IRP is defined as the minimum number of years required for board eligibility.
   2. For osteopathic, dentistry, and podiatric programs, the IRP is the minimum number of years of formal training necessary to satisfy the requirements of the approving body for those programs.
   3. Prior to July 1, 1995, an IRP is defined as the minimum number of years required for board eligibility in a specialty or subspecialty plus 1 year (not to exceed 5 years with some exceptions).
2. and those beyond their IRP.

Exceptions apply to the IRP for residents enrolled in preventive medicine, geriatric medicine, child neurology, and combined residency programs.  Refer to 42 CFR 413.79 for additional information on the IRP and exceptions.

The CHGME PP, like Medicare, assigns a 0.5 (or ½) weighting factor to residents who are beyond their IRP.  Hence a resident who is beyond his or her IRP is factored by 0.5 regardless of the number of years or length of the training program in which s/he is currently enrolled.

Hospital Complex

The time a resident spends anywhere within the hospital complex may be included in the resident FTE count for CHGME PP purposes. Refer to 42 CFR 413.65 for additional information on the definition of a hospital complex.

The CMS final rule implementing the per resident amount (PRA) methodology for payment of the direct GME costs of approved GME activities defines a hospital complex as “hospitals and hospital-based providers and subproviders” (54 FR 40286, September 29, 1989).  The term “hospital” is defined in section 1861(e) of the Social Security Act (Act) as, in part, an institution which is primarily engaged in providing, by or under the supervision of physicians, diagnostic and therapeutic services to inpatients.  The term “provider of services” is defined in section 1861(u) of the Act as a hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, home health agency, hospice program, or, for purposes of section 1814(g) and section 1835(c), a fund.  The term “subprovider” is defined in the Provider Reimbursement Manual (PRM) Part II, section 2405(b) as “a portion of a general hospital which has been issued a subprovider identification number because it offers a clearly different type of service from the remainder of the hospital, such as long-term psychiatric.”

The CHGME PP, however, does not differentiate between prospective payment system (PPS) and non-PPS locations within a hospital complex. 

Non-Provider/Non-Hospital Settings

The time a resident spends in a non-provider (or non-hospital) setting such as a physician’s office or a freestanding community health center in connection with an approved program may be included in the resident FTE count if the criteria in Federal regulation 42 CFR 413.78 (formerly 42 CFR 413.86) are met.  For CHGME PP purposes, 42 CFR 413.78 applies to both direct medical education and indirect medical education funding received under the CHGME PP.

Written Agreements

Written agreements covering residents’ time spent in non-provider/non-hospital settings shall cover a period of one year and must commence on the start of the cost reporting period and must be between the hospital and the non-hospital setting, not between the related School of Medicine (SOM), School of Podiatric Medicine (SOPM), or School of Dentistry (SOD).  Refer to 42 CFR 413.78 for additional information on written agreements.

Partial Resident Full-Time Equivalents

A partial resident FTE is a resident who does not spend all time that is part of the approved training program in the hospital complex or qualified non-hospital setting.  A resident will count as a partial FTE based on the proportion of time worked at the children’s hospital and qualified non-hospital (provider) settings relative to the total time worked in a full-time residency slot if the resident:

1. is part-time;
2. rotates to other hospitals as part of the approved training program sponsored by the children’s hospital;
3. is in a program sponsored by another hospital and spends one or more rotations at the  children's hospital;
4. is on maternity leave;
5. joins or leaves a program mid-year; or
6. passes the USMLE mid-year.

Hospitals should consult with their fiscal intermediaries regarding additional exceptions.

The sum of partial Resident FTE counts at all institutions where an individual resident works as part of his/her approved residency program may not exceed 1.0 FTE.  Time spent by residents moonlighting may not be counted.

Research Time

Research may be included in a hospital’s resident FTE count if the research is part of the residency program and the resident carries out the research in:

1. the children’s hospital complex (clinical or bench research); or
2. in a non-provider setting where the research involves patient care and the compensation for both the residents and the faculty are paid by the children’s hospital (requirements listed at 42 CFR 413.75 (66 FR 39896, Aug. 1, 2001)).

Department of Defense Residents

Active duty military residents enrolled in Department of Defense residency programs graduate from medical school, complete their first year of residency training at the post graduate year one (PGY1, etc.) and then leave their residency program to serve as a general medical officer (GMO).  GMO operational/utilization assignments are normally 2-4 years in length.  Following an operational/utilization tour many of these residents will return to their residency program at the PGY2 level to complete their training program.  Consequently, these residents are still considered to be in their IRP.  For this reason, these residents should not be weighted by a factor of 0.5 for CHGME PP purposes, as is done for residents that are beyond their IRP.

Special note:  There may be some circumstances where a resident returning to training after an assignment as a GMO has not met all of the PGY1 rotation requirements to begin training at the PGY2 level.  In these circumstances, the resident's training period may be longer than is normal to allow the resident to repeat a portion of his/her PGY1.  When this occurs, the resident is commonly referred to as a resitern while s/he performs the necessary rotations to meet PGY1 requirements and makes the transition from internship to residency.  This situation usually occurs when a resident changes his field of study and the residency experiences at the PGY1 level for the two residencies are dissimilar [i.e., a resident completes an transitional (medical) internship and later decides he wants to do a general surgery residency].

Documentation Recommendations

To meet the documentation requirements delineated in 42 CFR 413.75, the CHGME PP recommends that participating hospitals maintain in their documentation files source documentation containing the following information on residents enrolled in residency programs sponsored by the children’s hospital and claimed by the children’s hospital for CHGME PP purposes:

• name and SSN of the resident;
• resident’s qualifying degree(s) and inclusive dates of training (i.e., medical, osteopathic, dental or podiatric school, internship, residency, etc.);
• type of residency program in which the resident is currently enrolled and the number of years the resident has completed in all types of residency programs;
• employment status (full-time/part-time);
• the resident’s rotation schedule for the academic year that covers the period in which the resident is being claimed for CHGME PP purposes.  The rotation schedule must include for each rotation:  the rotation, rotation location, and the start and end dates of the rotation [e.g., the rotation and inclusive (rotation) dates the resident is assigned to the children’s hospital and any children’s hospital-based providers and the rotation and inclusive (rotation) dates the resident is assigned to other hospitals, or other free-standing providers, and any non-provider/non-hospital setting(s) during the current academic year];
• inclusive dates the resident is assigned to the hospital and any hospital-based providers;
• inclusive dates the resident is assigned to other hospitals, or other free-standing providers, and any non-provider setting(s) during the current academic year;
• if the resident is an international (or foreign) medical graduate, documentation concerning whether the resident has successfully completed Parts I and II of the United States Medical Licensing Examination or a copy of the resident’s verified State medical license;
• name of the employer paying the resident’s salary;
• current certifications, ECFMG, State medical licenses, etc., listing of practice experience to account for all periods of time following graduation from medical school, dental school, etc., not accounted for above.

The following documentation is needed for residents enrolled in residency programs sponsored by institutions other than the children’s hospital applying for CHGME PP funding, but rotating at the children’s hospital as part of the residency program and claimed by the children’s hospital for CHGME PP purposes:

• resident-level documentation listed above for each resident rotating at the children’s hospital following JCAHO primary source verification standards; and
• a letter of verification addressing the same (on official letterhead of the sponsoring institution) to the children’s hospital.  There must be an original signature of the certifying official.  Stamped signatures or signatures on behalf of the certifying official are not acceptable.

Appendices A and B provide additional information to assist hospitals in developing agreements for aggregate caps and non-provider/non-hospital settings.

Appendices C and D include sample letters of verification for residents sponsored by other (civilian and military) institutions rotating to the children’s hospital.

Appendix E is an excerpt from the JCAHO standards on primary source verification of credentials information.

Special Note:  Letters of verification should be on official hospital letterhead and signed by a certifying official of the hospital.  A certifying official is an individual selected and empowered by the hospital to certify the legitimacy of the information contained within the letter of verification (this may be the Chief Executive Officer, Director of Graduate Medical Education, Medical Staff Director, Director of Credentials Review/Privileging, Credentials Coordinator, etc.).

Useful website links:

• ECFMG:  www.ecfmg.org;
• Department of Defense (Inter-facility Credentials Transfer and Privileging):  www.tricare.osd.mil/policy/fy94/cred9404.html;
• JCAHO:  www.jcaho.org;
• USMLE: www.usmle.org;

Additional references:

• Social Security Act, Section 1886
• 42 CFR 413.65, 413.75 – 413.83 (Centers for Medicaid and Medicare)
• CHGME PP, Federal Register Notice dated March 1, 2001 (66 FR 12940)

V. Intern and Resident Information System and Data Submission Recommendations

The Intern and Resident Information System (IRIS) was designed to capture information about interns and residents in approved programs who work at and are claimed by hospitals that participate in the Medicare program in accordance with 42 CFR 413.75 and 42 CFR 412.105.  This information is used to determine Medicare as well as CHGME PP payments.  All teaching hospitals that file full Medicare cost reports are required to complete and submit a Centers for Medicare and Medicaid Services (CMS) IRIS diskette with their completed Medicare cost report which contains all required information for each resident claimed by the hospital for Medicare as well as CHGME PP funding.

As a part of the CHGME PP resident FTE assessment, CHGME FIs need to review information for each resident claimed by a children’s hospital for CHGME PP funding.  The Department recommends two electronic methods for submitting this information to the CHGME FIs: the CMS Intern and Resident Information System (IRIS) diskette, or the CHGME Intern and Resident Low/No Listing Template (I&R Template) developed for the CHGME PP and available to eligible children’s hospitals at no charge. 

Data Submission Options

The CHGME PP recommends that children’s hospitals submit intern and resident information electronically to streamline the CHGME PP resident FTE assessment process and to ensure that resident FTEs claimed by hospitals in all MCR categories undergo the same assessment process.

• Children’s teaching hospitals filing full MCRs and IRIS diskettes with CMS are requested to send a copy of the IRIS diskette to their CHGME FI to be reviewed in the CHGME resident FTE assessment. 
• Similarly, children’s teaching hospitals that file low or no-utilization MCRs are requested to submit intern and resident information to their CHGME FI through the CHGME I&R Template available from the Department.

Edit Checks

Medicare regulations require that intern and resident information pass a series of acceptability checks.  For Medicare cost reporting years ending on or before July 31, 2000, CMS FIs use version IRISFIV3 edit software to check the information.  For Medicare cost reporting years ending after July 31, 2000, version IRISEDV3 is used.  CHGME FIs will use the same software to check electronically-submitted CHGME PP resident and intern information.  If a hospital’s IRIS disk or CHGME I&R Template is found to be incomplete (e.g., it does not pass 100% of the edit checks because it was completed incorrectly or is missing information), it will be returned to the provider for correction.  Children’s hospitals filing full MCRs should be aware that the CHGME FI review is independent of the CMS Medicare FI review.  Children’s hospitals filing low/no-utilization MCRs should also comply with this requirement.

Reporting

Once all edit checks are satisfied, CHGME FIs will generate a report for the children’s hospital detailing claimed FTEs by cost reporting year and identify overlaps with other facilities (i.e., two facilities claim a resident for the same or an overlapping period of time).  These reports will be used by CHGME FIs as a basis for determining allowable FTEs in their review of CHGME PP initial applications.  The overlap reports will be coordinated with the Medicare FI by the CHGME FI, when applicable.

Error Resolution

The resolution of errors is the responsibility of each hospital.  Where overlaps exist (i.e., two or more hospitals claim a resident for the same or an overlapping period of time), the hospitals must resolve the mutual claim and communicate their final decisions to their CHGME FI and/or their Medicare FI.  Because of the CHGME PP application cycle, all errors must be resolved and reported to CHGME FIs on or before March 1 of the current FY payment cycle (i.e., for the FY2006 application cycle, the deadline is March 1, 2006), or the resident FTE counts in question will be excluded from CHGME PP reimbursement for the FY.  The government will not pay twice for the same resident.  It is the responsibility of the hospital to resolve any overlaps before a disputed resident FTE count will be included in the calculation of CHGME PP funding.

Appendix A:  Sample Medicare GME Affiliation Agreement for an Aggregate Cap

Hospital A and Hospital B hereby enter into this Affiliation Agreement (“Agreement”), and hereby agree as follows:

1. Hospital A, provider number 00-0000, and Hospital B, provider number 00-0001, desire to form an affiliated group for purposes of applying both the Direct Graduate Medical Education (“DGME”) and Indirect Medical Education (“IME”) FTE Caps.
2. The Providers meet the regulatory requirements of 42 CFR §413.75(b) to form an affiliated group due to the fact that they meet the shared rotational requirement and they are located in the same MSA.
3. Each hospital’s 1996 FTE count for IME and DGME is as follows:

4. During the term of this Agreement, the parties project that the FTE caps will be applied as follows:

5. The adjustment to each hospital’s FTE counts results from the shared rotational arrangement between Hospital A and Hospital B, consisting of 5 FTEs for IME and 5 FTEs for DGME. Thus, during the year of this Agreement, the FTE caps for Hospital A for purposes of IME and DGME will be increased by 5 FTEs, and the FTE caps for Hospital B for purposes of IME and DGME will be decreased by 5 FTEs. 
6. The parties agree that since residency programs change throughout the academic year, the parties may make amendments to this Agreement and notify their respective fiscal intermediaries up through June 30 of each academic year for changes that occurred throughout that academic year.
7. The term of this Agreement shall be 1 year, effective July 1, 20xx through June 30, 20xx.
8. Upon the expiration of the 1-year term of this Agreement, the hospitals will revert to their own individual FTE caps in effect prior to this agreement.

Hospital A Representative

By:

Date:

Hospital B Representative

By:

Date:

Appendix B:  Sample Written Agreement for Non-Provider/Non-Hospital Settings

Name of children’s hospital (hereinafter “Children’s Hospital”) and name of non-provider/non-hospital setting (hereinafter “Non-Hospital Setting”) hereby enter into this written agreement (hereinafter “Agreement”) pursuant to 42 CFR 413.78 and 42 CFR 415.152 for purposes of documenting time spent by residents enrolled in the Children’s Hospital’s name of residency program (hereinafter “Residency Program”) rotating at the Non-Hospital Setting as part of their approved medical education program.  The obligations and terms of this Agreement are as follows:

1. Time spent by residents enrolled in the Children’s Hospital’s Residency Program rotating at the Non-Hospital Setting, as defined by 42 CFR 415.152, must be part of the residents approved medical education program.
2. All time spent by residents at the Non-Hospital Setting must be in patient care activities.
3. The Children’s Hospital will incur all or substantially all of the costs for the training program in the Non-Hospital Setting in accordance with the definition in 42 CFR 413.78(d) and 42 CFR 413.78(e).
4. Children’s Hospital Compensation to the Non-Hospital Setting:
   1. The Children’s Hospital will provide reasonable compensation to the Non-Hospital Setting for supervisory teaching activities.  This compensation consists of (insert agreed upon compensation between the Children’s Hospital and the Non-Hospital Setting); OR
   2. Name of supervisory physician at Non-Hospital Setting hereby agrees to supervise and train residents on a voluntary basis as no supervisory teaching costs are incurred by the Non-Hospital Setting.  Name of supervisory physician at Non-Hospital Setting receives his/her compensation on a fee-for-services basis and not as a salary or any other type of arrangement that can be considered a salary.  Insert terms of compensation arrangement here (and must be outlined in detail and supported by acceptable documentation).
5. The term of this Agreement shall be one (1) year, commencing insert date (MM/DD/YYYY), and terminating insert date (MM/DD/YYYY).  This agreement may be terminated by either party, for any reason, by the party electing to terminate giving the other party a ninety (90) day written notice of such election to terminate.  This agreement shall terminate ninety (90) days from the date of such notice.
6. Notices required under this Agreement shall be sufficient if in writing and mailed to the respective parties by registered mail, return receipt required, at the address as shown below.
7. This Agreement may be amended from time to time by mutual consent of the parties hereto.  Any amendment shall be in writing.

Children’s Hospital Representative                                           

By:

Date:

Non-Hospital Setting Representative

By:

Date:

NOTE:  The signatures must be original signatures by the certifying officer of each organization.  A separate signature is required by the supervisory physician that is considered a “volunteer” (if applicable.)

Appendix C: Sample Letter of Verification for Residents Rotating to a Children’s Hospital

(Today’s Date)

(Name of Children’s Hospital where Resident Will be Rotating)

(Address)

(City, State Zip Code)

Re:  Name (First, MI, Last) and SSN of Trainee

To Whom It May Concern:

(Name of trainee) is currently a (PL or PGY level) enrolled in our (type/name of residency program) under the leadership of (name of program director).  (name of resident) is scheduled to rotate on the (department or service where trainee will be rotating) with (name of person responsible for resident while rotating at the children’s hospital) at (name of children’s hospital) from (start date of rotation) to (end date of rotation) as part of his/her residency program requirements under the provisions of the written agreement established between the (name of children’s hospital) and the (name of institution sponsoring the residency program in which the resident is enrolled).

This letter certifies that (name of trainee) is in good academic standing in the aforementioned training program and our (name of office performing verifications below) has verified his/her qualifying credentials in accordance with Joint Commission on the Accreditation of Hospital Organizations (JCAHO) standards as follows:

Qualifying degrees and inclusive dates of training:

M.D.
University of the Royal Academy of Health Sciences
London, England
July 1987 – June 1993
Graduation Date:  June 13, 1993
Internship: Internal Medicine
University of Maryland
July 1994 – June 1995
Residency: Internal Medicine
George Washington University
July 1995 – June 1997
Fellowship: Cardiology
National Naval Medical Center
July 2000 - present

Current certifications, board certifications, state licenses, etc.:

ECFMG: Education Commission on Foreign medical Graduate
(if applicable) Certification # 123-45-6789-00
Issued:  April 1994
Board Certification: American Board of Internal Medicine
Issued:  January 1998
Licensure: State of Wisconsin
License # 123-45-6789
Expiration:  September 30, 1999

Practice experience for periods of time following graduation from medical school, dental school, etc., not accounted for above:

Staff Physician: Internal Medicine
George Washington University
July 1997 – June 2000

The subject resident is employed by (name of employer paying the resident’s salary). 

Also attached for your review are copies of the his/her curriculum vitae, ECFMG certificate, if applicable, board certification, current state license(s), and a copy of his/her complete rotation schedule for the academic year in which the resident will be rotating at your facility.

I understand that while the resident is rotating at your facility during the time period specified above, s/he may not be claimed by our facility for reimbursement purposes (i.e., Medicare or Children’s Hospitals Graduate Medical Education Payment Program reimbursement).  Also, in the event of an audit, internal or external, we understand that our facility may be required to provide additional evidence attesting to the above documentation within 5 working days.  If our staff may be of further assistance, my point of contact is (name) at (area code and phone number).

(signature of certifying official* for the hospital)

(name of certifying official)

(title of certifying official)

NOTE:  The signature of the certifying official must be an original signature.  Stamped signatures or signatures “on behalf of” are unacceptable.

Where the rotation schedules use abbreviations or short names for the rotations, the provider must maintain an expanded definition for each rotation.  The expanded definition must explain briefly the services being performed, and the location of the service.

*A certifying official is an individual selected and empowered by the hospital to certify the legitimacy of the information contained within this letter of verification (this person may be the Chief Executive Officer, Director of Graduate Medical Education, the Medical Staff Director/Director Credentials Review and Privileging, the Credentials Coordinator, etc.).

Appendix D: Sample Inter-Facility Credentials Transfer Brief (ICTB) for Department of Defense Residents Rotating to a Children’s Hospital

FROM: MILITARY HOSPITAL

SUBJECT: Credentials and Privileging Transfer Brief

TO: CHARLIE’S ANGELS CHILDREN’S CENTER

Appendix E:  Joint Commission on Accreditation of Healthcare Organizations Standards for Verification of Credentials Information

The below excerpt was taken from the Joint Commission on Accreditation of Healthcare Organizations Website at

http://www.jointcommission.org/

September 14, 2001

Verification of Credentials Information

Q. Can a documented phone conversation be utilized as primary source verification for licensure, education, training and experience, competence and peer references?

A. A documented telephone conversation can be utilized as primary source verification for all information including licensure, education, training and experience, competence and peer references. When verifying information via telephone the following information should be documented:

• the date of the conversation
• the name and title of the person providing the information
• the name of the organization when appropriate, e.g., the school, certifying board, employing organization, etc.
• the specific information provided
• the date and signature of the person receiving the information

Origination Date:  September 14, 2001

Appendix F:  Documentation Format

To facilitate the resident FTE assessment process, children’s hospitals can organize documentation in support of data reflected in their CHGME PP application as follows:

Tab 1: Hospital Eligibility Documentation

1. Eligibility Documentation for Hospital
   1. Documentation Checklist (See Applicable Documentation Requirements Checklist in Appendix G)
   2. See Section II Hospital Eligibility and Documentation Requirements)
2. Children’s Hospital’s Initial Application
   1. Documentation Checklist (See Applicable Documentation Requirements Checklist in Appendix G)
   2. HRSA 99
   3. HRSA 99-1
   4. HRSA 99-2
   5. HRSA 99-3

Tab 2: Most Recent Cost Reporting Period Ending on or Before December 31, 1996 (as reflected in the HRSA 99-1)

1. CHGME FI Report(s)
   1. Documentation Checklist (See Applicable Documentation Requirements Checklist in Appendix G)
   2. CHGME FI report(s) in chronological order with the most recent information/correspondence on top
2. MCR Worksheet E-3, Part IV
   1. Documentation Checklist (See Applicable Documentation Requirements Checklist in Appendix G)
   2. MCR Worksheet E-3, Part IV
3. Medicare GME Affiliation Agreement for an Aggregate Cap
   1. Documentation Checklist (See Applicable Documentation Requirements Checklist in Appendix G)
   2. Medicare GME Affiliation Agreement for an Aggregate Cap
4. Children’s Hospital Sponsored Residency Program(s) Documentation
   1. Documentation Checklist (See Applicable Documentation Requirements Checklist in Appendix G)
   2. (See Section III Residency Program Eligibility and Documentation Requirements)  Documentation should be in alphabetical order by residency program (i.e., Anesthesiology, Dermatology, Pediatrics, Psychiatry, Surgery, Urology).
5. Resident Documentation (for residents enrolled in children’s hospital-sponsored programs)
   1. Documentation Checklist (See Applicable Documentation Requirements Checklist in Appendix G)
   2. (See Section IV Resident Eligibility and Documentation Requirements)  Documentation should be in alphabetical order by residency program and resident name (i.e., Anesthesiology:  Evans, Julie; Dermatology:  Doe, John; Surgery:  Allen, Alicia).
6. Non-Children’s Hospital Sponsored Residency Program(s) Documentation
   1. Documentation Checklist (See Applicable Documentation Requirements Checklist in Appendix G)
   2. (See Section III Residency Program Eligibility and Documentation Requirements)  Documentation should be in alphabetical order by sponsoring institution and residency program (i.e., Charlie’s Angels Children’s Center:  Dermatology; Pediatrics; Good Times Medical Center:  Anesthesiology; Psychiatry; Surgery).
7. Resident Documentation (for residents enrolled in non-children’s hospital-sponsored programs)
   1. Documentation Checklist (See Applicable Documentation Requirements Checklist in Appendix G)
   2. (See Sections IV Resident Eligibility and Documentation Requirements and Section V Sample Letter of Verification for Residents Rotating to the Children’s Hospital)  Documentation should be in alphabetical order by sponsoring institution, residency program and resident name (i.e., Charlie’s Angels Children’s Center:  Dermatology Evans, Julie; Dermatology:  Doe, John; Surgery:  Allen, Alicia).

Tab 3: Most Recently Completed Cost Reporting Period (as reflected in the HRSA 99-1) - Same as Tab 2 above.

Tab 4: Prior Cost Reporting Period (as reflected in the HRSA 99-1) - Same as Tab 2 above.

Tab 5: Penultimate Cost Reporting Period (as reflected in the HRSA 99-1) - Same as Tab 2 above.

Tab 6: Intern and Resident Information System (IRIS) or IRIS Proxy Diskette

The documentation must be certified by an official of the hospital and, if different, an official responsible for administering the residency programs.  A cover letter stating the aforementioned is acceptable.  A certifying official is an individual selected and empowered by the hospital to certify the legitimacy of the information contained in the documentation binder(s) (this person may be the Chief Executive Officer, Director of Graduate Medical Education, etc.).

Appendix G:  CHGME PP Documentation Checklists

This checklist can be photocopied and attached to the documentation provided in support of residency program(s) sponsored by the children’s hospital when residents, enrolled in such residency program(s), are being claimed by the children’s hospital for CHGME PP funding.

This checklist can be photocopied and attached to the documentation provided in support of residents enrolled in children’s hospital-sponsored residency program(s) and being claimed by the children’s hospital for CHGME PP funding.

If the information requested below is reported by the children’s hospital in its IRIS diskette or CHGME Intern and Resident Low-No Listing, the children’s hospital is not required to provide a hardcopy of subject information if all requested information is present in the electronic version.  For example, a children’s hospital does not need to provide the CHGME FI s with a piece of paper containing a resident’s complete name and SSN because this information is reported by the children’s hospital in IRIS.

This checklist can be photocopied and attached to the documentation provided in support of residency program(s) sponsored by institutions other than the children’s hospital that is applying for CHGME PP funding, but the residents, enrolled in the residency program, are rotating at the children’s hospital as part of their residency program and are being claimed by the children’s hospital for CHGME PP funding.

This checklist can be photocopied and attached to the documentation provided in support of residents enrolled in residency programs sponsored by institutions other than the children’s hospital that is applying for CHGME PP funding, but the residents are rotating at the children’s hospital as part of their residency program and are being claimed by the children’s hospital for CHGME PP funding.

If the information requested below is reported by the children’s hospital in its IRIS diskette or CHGME Intern and Resident Low-No Listing, the children’s hospital is not required to provide a hardcopy of subject information if all requested information is present in the electronic version.  For example, a children’s hospital does not need to provide the CHGME FI s with a piece of paper containing a resident’s complete name and SSN because this information is reported by the children’s hospital in IRIS.

The sponsoring institution should provide and verify the documentation requirements listed below for each of its residents rotating at the children’s hospital following Joint Commission on the Accreditation of Hospital Organization (JCAHO) primary source verification standards and provide a letter of verification addressing the same to the children’s hospital.  A sample letter of verification is attached.