Documentation
Guidance
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Documentation Guidance
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
Appendix
B. Sample Written Agreement for Non-Provider/Non-Hospital Settings
Appendix
C. Sample Letter of Verification for Residents Rotating to a Children’s
Hospital
Appendix
D. Sample Inter-Facility Credentials Transfer Brief (Letter of Verification)
for Department of Defense Residents Rotating to a Children’s Hospital
and Instructions
Appendix
E. Joint Commission on Accreditation of Healthcare Organizations
Standards for Verification of Credentials Information
Appendix
F. Documentation Recommendations Format
Appendix
G. Documentation Recommendation Checklists
I.
Overview
In 1999, Congress
addressed the disparity of explicit Federal graduate medical education
(GME) funding between freestanding children’s teaching hospitals
and other teaching hospitals by passing the Healthcare Research
and Quality Act, which established the Children’s Hospitals Graduate
Medical Education Payment Program (CHGME PP). The Act was signed
on December 6, 1999 and the legislation authorized the program for
fiscal years 2000 and 2001. The Secretary, Department of Health
and Human Services delegated authority of the CHGME PP to the Administrator,
Health Resources and Services Administration (HRSA). On October
17, 2000, the Children’s Health Act of 2000 amended the Healthcare
Research and Quality Act of 1999. One of the amendments extended
the CHGME PP through fiscal year (FY) 2005. Additional amendments
were made to the Program under Public Law 108-490.
Hospitals participating
in the CHGME PP must meet all statutory eligibility requirements
and submit completed CHGME PP applications in accordance with established
deadlines. CHGME PP payments are allocated to children’s teaching
hospitals based on a number of variables including the number of
full time equivalent (FTE) residents participating in approved medical
residency training programs, the number of inpatient discharges,
the severity of illness of the patient population, and the number
of available beds. As required by statute, the CHGME PP makes payments
for both direct medical education (DME) and indirect medical education
(IME) to each of the participating children’s teaching hospitals.
The CHGME PP
statute, P.L. 106-310, mandates that “the Secretary shall determine
any changes to the number of residents reported by a hospital in
the application of the hospital for the current fiscal year for
both direct and indirect expense amounts.” The CHGME PP initially
attempted to assess changes in resident FTE counts in collaboration
with the Centers for Medicare and Medicaid Services (CMS). On June
15, 2001 and January 28, 2002 CMS issued Program Memoranda (PM A-01-75
and PM AB-02-007, respectively) requesting that CMS fiscal intermediaries
(FIs) provide the CHGME PP with resident FTE counts for children’s
teaching hospitals that report residents to Medicare [i.e., file
full Medicare Cost Reports (MCRs)]. This process did not prove
adequate for CHGME PP purposes, as it did not assess resident FTE
counts in children’s teaching hospitals that do not file full MCRs
(i.e., do not report residents to Medicare), and the CMS FIs were
unable to assess the CHGME resident FTE counts within the FY time
constraints mandated by law. A comprehensive process, using program-specific
CHGME FIs to assess resident FTE counts for all participating children’s
hospitals, was developed in response to this need – the Resident
FTE Assessment Program
This Documentation
Guidance document is intended to assist participating hospitals
in collecting and providing the documentation necessary for the
CHGME PP and its CHGME FIs to carry out the Resident FTE Assessment
Program.
This document
is organized as follows:
- 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:
- participate
in an approved graduate medical education (GME) program;
- have a Medicare
Provider Agreement;
- 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
- 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:
- it must
notify the HRSA immediately of the change in status and the date
of the change; and
- 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
Useful
website links:
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:
- Accreditation
Council for Graduate Medical Education (ACGME);
- Committee
on Hospitals of the Bureau of Professional Education of the American
Osteopathic Association;
- Commission
on Dental Accreditation of the American Dental Association; or
- 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:
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:
- initial
residency period (IRP);
- Effective
July 1, 1995, an IRP is defined as the minimum number of years
required for board eligibility.
- 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.
- 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).
- 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:
- is part-time;
- rotates
to other hospitals as part of the approved training program sponsored
by the children’s hospital;
- is in a
program sponsored by another hospital and spends one or more rotations
at the children's hospital;
- is on maternity
leave;
- joins or
leaves a program mid-year; or
- 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:
- the children’s
hospital complex (clinical or bench research); or
- 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:
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:
- 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.
- 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.
- Each hospital’s
1996 FTE count for IME and DGME is as follows:
HOSPITAL |
IME |
DGME |
Hospital
A |
0 |
0 |
Hospital
B |
10 |
10.5 |
- During the
term of this Agreement, the parties project that the FTE caps
will be applied as follows:
|
YEAR
1
7/1/05
– 6/30/06 |
|
IME |
DGME |
Hospital
A |
5 |
5 |
Hospital
B |
5 |
5.5 |
- 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.
- 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.
- The term
of this Agreement shall be 1 year, effective July 1, 20xx through
June 30, 20xx.
- 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:
- 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.
- All time
spent by residents at the Non-Hospital Setting must be in patient
care activities.
- 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).
- Children’s
Hospital Compensation to the Non-Hospital Setting:
- 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
- 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).
- 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.
- 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.
- 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
1. |
LT
JOHN M. DOE, MC, USN, 123-45-6789, CARDIOLOGY FELLOW |
2. |
EDUCATION/TRAINING: |
COMPLETION
DATE |
PSV* |
|
A.
DEGREE: M.D. |
JUNE
1993 |
Y/N |
|
B.
INTERNSHIP: INTERNAL MEDICINE |
JUNE
30, 1995 |
Y/N |
|
C.
RESIDENCY: INTERNAL MEDICINE |
JUNE
30, 1997 |
Y/N |
|
D.
FELLOWSHIP: CARDIOLOGY |
IN
PROGRESS |
Y/N |
|
E.
OTHER QUALIFYING TRAINING |
N/A |
Y/N |
3. |
LICENSE/CERTIFICATION/REGISTRATION
(CURRENT)/EXPIR DATE |
PSV* |
|
A.
ECFMG, APRIL 1994 |
Y/N |
|
B.
WISCONSIN SEPTEMBER 2003 |
Y/N |
4. |
SPECIALTY/BOARD
CERT/RECERT |
EXPIRATION
DATE |
PSV* |
|
A.
INTERNAL MEDICINE, 1998 |
Y/N |
|
*Primary
Source Verification |
5. |
LIFE
SUPPORT/READINESS TRAINING |
EXPIRATION
DATE |
|
A.
BLS |
|
B.
ACLS |
|
C.
ATLS |
|
D.
PALS |
|
E.
NALS |
6. |
CURRENT
STAFF APPOINTMENT WITH CLINICAL PRIVILEGES AT SENDING FACILITY
– N/A |
|
A.
TYPE OF PRIVILEGES AND EXPIRATION DATE |
|
B.
PRIVILEGES GRANTED (PRIVILEGE LIST ATTACHED) |
7. |
DATE
OF NATIONAL PRACTITIONER DATA BANK QUERY: |
|
INFORMATION
PRESENT/ABSENT IN DATA BANK |
8.
LT JOHN M. DOE WILL BE PRACTICING AT YOUR FACILITY
ON AN ONGOING BASIS. PLEASE FORWARD A PERFORMANCE APPRAISAL
TO THIS COMMAND UPON COMPLETION OF THIS ASSIGNMENT OR BEFORE
(date), WHICHEVER COMES FIRST. |
9.
LT JOHN M. DOE IS KNOWN TO BE CLINICALLY COMPETENT
TO PRACTICE THE FULL SCOPE OF PRIVILEGES GRANTED AT (SENDING
FACILITY), TO SATISFACTORILY DISCHARGE HIS/HER PROFESSIONAL
OBLIGATIONS, AND TO CONDUCT HIMSELF/HERSELF ETHICALLY, AS
ATTESTED TO BY (NAME AND TELEPHONE NUMBER OF PERSON PERSONALLY
ACQUAINTED WITH THE PROVIDER'S PROFESSIONAL AND CLINICAL PERFORMANCE).
(NAME OF PERSON GIVING RECOMMENDATION) HAS/DOES NOT HAVE ADDITIONAL
INFORMATION RELATING TO (PROVIDER'S NAME) COMPETENCE TO PERFORM
GRANTED PRIVILEGES. [When additional information exists, the
gaining facility must be instructed to communicate with the
point of contact for the purpose of exchanging the additional
information.] |
10.
PROVIDER'S CF AND THE DOCUMENTS CONTAINED THEREIN HAVE BEEN
REVIEWED AND VERIFIED AS INDICATED ABOVE. THE INFORMATION
CONVEYED IN THIS LETTER/MESSAGE REFLECTS CREDENTIALS STATUS
AS OF (date). [Choose from the following sentence formats,
or variations thereof, to describe the presence/absence of
additional relevant information in the CF: (a) THE CF CONTAINS
NO ADDITIONAL INFORMATION RELEVANT TO THE PRIVILEGING OF THE
PROVIDER IN YOUR MTF, (b) THE CF CONTAINS ADDITIONAL RELEVANT
INFORMATION REGARDING STATUS OF CURRENT LICENSE, (c) THE CF
CONTAINS ADDITIONAL RELEVANT INFORMATION THAT MAY REFLECT
ON THE CURRENT COMPETENCE OF THE PROVIDER. CONTACT THIS COMMAND
FOR FURTHER INFORMATION BEFORE TAKING APPOINTING AND PRIVILEGING
ACTION.] |
11.
POC: NAME, TITLE, PHONE NUMBER, FAX NUMBER |
12.
(FOR RESERVE OR GUARD HCPS) CURRENTLY HOLDS PRIVILEGES IN
(SPECIALTY) AT (HOSPITAL NAME, ADDRESS). PROVIDER MAY BE REACHED
AT (MAILING ADDRESS, HOME PHONE, OFFICE PHONE). |
13.
CERTIFIED BY: |
COMMANDER |
DATE |
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
- Eligibility
Documentation for Hospital
- Documentation
Checklist (See Applicable Documentation Requirements Checklist
in Appendix G)
- See
Section II Hospital Eligibility and Documentation Requirements)
- Children’s
Hospital’s Initial Application
- Documentation
Checklist (See Applicable Documentation Requirements Checklist
in Appendix G)
- HRSA
99
- HRSA
99-1
- HRSA
99-2
- HRSA
99-3
Tab 2: Most
Recent Cost Reporting Period Ending on or Before December 31, 1996
(as reflected in the HRSA 99-1)
- CHGME FI
Report(s)
- Documentation
Checklist (See Applicable Documentation Requirements Checklist
in Appendix G)
- CHGME
FI report(s) in chronological order with the most recent information/correspondence
on top
- MCR Worksheet
E-3, Part IV
- Documentation
Checklist (See Applicable Documentation Requirements Checklist
in Appendix G)
- MCR Worksheet
E-3, Part IV
- Medicare
GME Affiliation Agreement for an Aggregate Cap
- Documentation
Checklist (See Applicable Documentation Requirements Checklist
in Appendix G)
- Medicare
GME Affiliation Agreement for an Aggregate Cap
- Children’s
Hospital Sponsored Residency Program(s) Documentation
- Documentation
Checklist (See Applicable Documentation Requirements Checklist
in Appendix G)
- (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).
- Resident
Documentation (for residents enrolled in children’s hospital-sponsored
programs)
- Documentation
Checklist (See Applicable Documentation Requirements Checklist
in Appendix G)
- (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).
- Non-Children’s
Hospital Sponsored Residency Program(s) Documentation
- Documentation
Checklist (See Applicable Documentation Requirements Checklist
in Appendix G)
- (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).
- Resident
Documentation (for residents enrolled in non-children’s hospital-sponsored
programs)
- Documentation
Checklist (See Applicable Documentation Requirements Checklist
in Appendix G)
- (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
Applicant
(Children’s Hospital): |
|
Medicare
Provider Number: |
|
Residency
Program, where applicable: |
|
Sponsoring
Institution, where applicable: |
|
Resident
Name, where applicable: |
|
Tab |
Documentation |
If not applicable
check here |
Children’s
Hospital Medicare Provider Agreement |
___
A copy of the children’s hospital’s Medicare provider agreement;
or |
___
|
___
A copy of the CHGME PP’s list of hospitals potentially eligible
to participate with the children’s hospital highlighted. |
___
|
Applicant
(Children’s Hospital): |
|
Medicare
Provider Number: |
|
Residency
Program, where applicable: |
|
Sponsoring
Institution, where applicable: |
|
Resident
Name, where applicable: |
|
Tab |
Documentation |
If not applicable
check here |
Children’s
Hospital’s Initial Application |
___
A copy of the children’s hospital’s completed initial application
for CHGME PP funding in chronological order by form (i.e.,
HRSA 99, HRSA 99-1, HRSA 99-2, HRSA 99-3) |
___
|
Applicant
(Children’s Hospital): |
|
Medicare
Provider Number: |
|
Residency
Program, where applicable: |
|
Sponsoring
Institution, where applicable: |
|
Resident
Name, where applicable: |
|
Tab |
Documentation |
If not applicable
check here |
CHGME
FI Report(s) |
___
A copy of all CHGME FI correspondence/reports regarding the
subject Medicare cost reporting period in chronological order
with the most recent information on top. |
___
|
Applicant
(Children’s Hospital): |
|
Medicare
Provider Number: |
|
Residency
Program, where applicable: |
|
Sponsoring
Institution, where applicable: |
|
Resident
Name, where applicable: |
|
Tab |
Documentation |
If not applicable
check here |
Medicare
Cost Report (MCR) Worksheet E-3, Part IV |
___
A copy of the MCR, Worksheet E-3, Part IV for the subject
Medicare cost reporting period. |
___
|
Applicant
(Children’s Hospital): |
|
Medicare
Provider Number: |
|
Residency
Program, where applicable: |
|
Sponsoring
Institution, where applicable: |
|
Resident
Name, where applicable: |
|
Tab |
Documentation |
If not applicable
check here |
Medicare
GME Affiliation Agreement for an Aggregate Cap |
___
A copy of the affiliation agreement for the aggregate cap
(increasing or decreasing resident FTE counts) for the subject
Medicare cost reporting period. |
___
|
Applicant
(Children’s Hospital): |
|
Medicare
Provider Number: |
|
Residency
Program, where applicable: |
|
Sponsoring
Institution, where applicable: |
|
Resident
Name, where applicable: |
|
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.
Tab |
Documentation |
If not applicable
check here |
Children’s
Hospital-Sponsored Residency Program(s) Documentation |
___
A copy of the letter of approval or accreditation for the
specified residency program from one of the following national
organizations: the Accreditation Council for Graduate Medical
Education (ACGME); Committee on Hospitals of the Bureau of
Professional Education of the American Osteopathic Association;
Commission on Dental Accreditation of the ADA; or the Council
of Podiatric Medicine Education of the American Podiatric
Medical Association; or |
___
|
___ 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 (see Appendix D of the GMED). A
printout from the accrediting body’s website will suffice
as long as all information related to the program’s accreditation
and general information is included in the printout (i.e.,
accreditation date, accreditation status, accreditation, program
length, etc.). |
___
|
Applicant
(Children’s Hospital): |
|
Medicare
Provider Number: |
|
Residency
Program, where applicable: |
|
Sponsoring
Institution, where applicable: |
|
Resident
Name, where applicable: |
|
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.
Tab |
Documentation |
If not applicable
check here |
Resident
Documentation (for residents enrolled in Children’s Hospital-Sponsored
Residency Programs) |
___
The name and SSN of the resident; |
___
|
___
The resident’s qualifying degree(s) and graduation date (i.e.,
medical, osteopathic, dental or podiatric school); |
___
|
___
The type of residency program in which the resident is currently
enrolled in, the residency year (i.e., PGY1, or R2, etc.)
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 should include for
each rotation: the rotation, rotation location, and the start
and end dates of the rotation);
For example,
the rotation schedule should identify:
___ the
rotation and inclusive (rotation) dates the resident is assigned
to the children’s hospital and any children’s hospital-based
providers;
___ 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; |
___
|
___
|
___
|
___
Documentation which meet the criteria set forth in 42 CFR
413.75 for each rotation spent by the resident in a non-provider
or non-hospital settings such as freestanding clinics, nursing
homes, and physicians’ offices in connection with the approved
program; |
___
|
___
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; |
___
|
___
Name of the employer paying the resident’s salary; |
___
|
___
Current certifications, ECFMG, board certifications, state
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; |
___
|
Applicant
(Children’s Hospital): |
|
Medicare
Provider Number: |
|
Residency
Program, where applicable: |
|
Sponsoring
Institution, where applicable: |
|
Resident
Name, where applicable: |
|
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.
Tab |
Documentation |
If not applicable
check here |
Non-Children’s
Hospital-Sponsored Residency Program(s) Documentation |
___
A copy of the letter of approval or accreditation from one
of the following national organizations: the Accreditation
Council for Graduate Medical Education (ACGME); Committee
on Hospitals of the Bureau of Professional Education of the
American Osteopathic Association; Commission on Dental Accreditation
of the ADA; or the Council of Podiatric Medicine Education
of the American Podiatric Medical Association; and |
___
|
___ A copy of the current edition of the ACGME’s Graduate
Medical Education Directory (GMED) or equivalent in which
the children’s hospital claiming the resident for CHGME PP
funding is listed as a major participating institution (see
Appendix D of the GMED). A printout from the accrediting
body’s website will suffice as long as all information related
to the program’s accreditation and general information is
included in the printout (i.e., accreditation date, accreditation
status, accreditation, program length, etc.). |
___
|
|
___ A copy of the institutional agreement (also known as a(n)
affiliation agreement, memorandum of understanding, inter-institutional
agreement, letter of commitment, letter of affiliation, letter
of agreement, 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, and the residency program or department at the children’s
hospital where the resident will be rotating, effective and
expiration dates of the agreement. |
___
|
Applicant
(Children’s Hospital): |
|
Medicare
Provider Number: |
|
Residency
Program, where applicable: |
|
Sponsoring
Institution, where applicable: |
|
Resident
Name, where applicable: |
|
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.
Tab |
Documentation |
If not applicable
check here |
Resident
Documentation (for residents enrolled in Non-Children’s Hospital-Sponsored
Residency Programs)
|
___
The name and SSN of the resident; |
___
|
___
The resident’s qualifying degree(s) and inclusive dates of
training (i.e., medical, osteopathic, dental or podiatric
school, internship, residency, etc.); |
___
|
___
The type of residency program in which the resident is currently
enrolled in, the residency year (i.e., PGY1, or R2, etc.)
and the number of years the resident has completed in all
types of residency programs; |
___
|
___
The rotation and inclusive rotation dates the resident is
assigned to the children’s hospital and any children’s hospital-based
providers; |
___
|
___
The rotation and 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; |
___
|
___
Name of the employer paying the resident’s salary; |
___
|
___
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 the start
and end dates of each rotation); |
___
|
___
Current certifications, ECFMG, board certifications, state
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; |
___
|
Applicant
(Children’s Hospital): |
|
Medicare
Provider Number: |
|
Residency
Program, where applicable: |
|
Sponsoring
Institution, where applicable: |
|
Resident
Name, where applicable: |
|
Tab |
Documentation |
If not applicable
check here |
Intern
and Resident Information System (IRIS)
|
___
Children’s hospitals filing full Medicare cost reports should
complete and submit a Centers for Medicare and Medicaid Services
(CMS) IRIS diskette which contains all required information
for each resident claimed by the children’s hospital for CHGME
PP funding. |
___
|
___
Children’s hospitals filing low or no-utilization Medicare
cost reports should complete and submit an IRIS diskette or
CHGME Intern and Resident Low-No Listing which contains all
required information for each resident claimed by the children’s
hospital for CHGME PP funding. |
___
|
|