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On August 21st, 2015, CMS published Transmittal 145, which included Exhibit 365 to Chapter 9 of the SOM, titled “Critical Access Hospital Recertification Checklist: Rural and Distance or Necessary Provider Verification.”  Exhibit 365 sets forth the procedures to be followed by the CMS Regional Offices and State Agencies to verify hospital’s compliance with these requirements for program participation prior to conducting a CAH recertification survey.  Specifically, Exhibit 365 lists one key source of evidence in proving your CAH was certified as a Necessary Provider – an NP designation letter issued by the state prior to 1/1/06.

On February 12, 2016, CMS provided further clarifying information in a memo.  This checklist is for use by the CMS Regional Office staff when processing CAH recertification.  These documents represent the most current communication from CMS on the matter.

As a CAH, you are not responsible for completing the checklist.  Rather, it is the responsibility of the Regional Office, as part of the survey/recertification process.

However, it is very important that your hospital be prepared to present proof of your Necessary Provider Designation if requested by a surveyor, or by the CMS Regional Office.  CMS’ revised CAH Recertification Checklist states that “the burden is on the CAH to provide qualifying evidence demonstrating NP designation was made by the state prior to January 1, 2016.”  They go on to say that an example of potentially qualifying evidence includes, “A letter issued before January 1, 2006, from the appropriate State authority designating the CAH by name as a necessary provider.”  At the Wisconsin Office of Rural Health (WORH), we have a letter (either from DHS or WORH) on file for every WI CAH, that designates the CAH as a necessary provider under the Wisconsin Rural Hospital Flexibility Program.”  Based on the recent guidance provided from CMS, it is our interpretation that either of these letters will suffice as the “qualifying evidence” they require.

Types of documentation we have on file vary from hospital to hospital.  You are encouraged to maintain a file of all paperwork pertaining to your original CAH designation- including whatever you have in your files plus the items WI-ORH has emailed to you. Have this information readily available in the event of a survey. This would include some or all of the following:

  • A letter issued before January 1, 2006 from WORH designating your CAH by name as a necessary provider
  • A letter issued before January 1, 2006 from DHS designating your CAH by name as a necessary provider
  • A letter from CMS stating that your CAH meets the requirements of 42CFR Part 485 for participation in the Medicare Program as a CAH
  • If your CAH as re-classed from urban to rural, then you should have a letter from CMS that approves the reclassification
  • A letter from DHS that includes your CAH Certificate of Approval (COA)


This documentation has been e-mailed to every CAH in Wisconsin, specifically to the CEO, CFO and Quality Director.  If you did not receive this important documentation, please contact Kathryn Miller.


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