Rural Emergency Hospitals and radiology.

What is a Rural Emergency Hospital?

• 56hospitals operating as REHs (Sheps Center list, read October 19, 2026)
• 24 hmaximum annual per-patient average length of stay
• +5%Medicare pays REH services at the OPPS rate plus 5%

Congress created the REH designation in the Consolidated Appropriations Act, 2021 (section 125), and CMS finalized the conditions of participation in its CY 2023 rules (42 CFR Part 485, Subpart E). The aim is to keep emergency care open in rural communities where a full inpatient hospital is no longer viable. CMS’s fact sheet (MLN2259384, December 2025) sets out the payment: REH services are paid at the hospital outpatient (OPPS) rate plus 5%, and every REH receives the same additional monthly facility payment, $295,051.54 per month for calendar year 2026 with sequestration deducted.

The UNC Sheps Center keeps the running list of conversions. Its Rural Emergency Hospitals page states that 56 hospitals are currently operating as REHs (read October 19, 2026).

Which hospitals can become an REH?

Critical access hospitals

Any facility that was a CAH on December 27, 2020 (42 CFR 485.506).

Small rural hospitals

A hospital with no more than 50 beds in a rural county, as of December 27, 2020.

Hospitals reclassified as rural

A hospital with no more than 50 beds treated as rural after reclassification from urban to rural, as of the same date.

State licensure

The REH must be in a state that licenses REHs and be licensed under that law (CMS MLN fact sheet).

A converting CAH or small rural hospital files a change of information with Medicare rather than a new enrollment, per the CMS fact sheet. If your hospital is a CAH today, start with our guide to teleradiology for critical access hospitals.

What does CMS require of an REH?

This is a summary, not the full rule set. Your state survey agency and counsel are the final word on any conversion.

Does a Rural Emergency Hospital need a radiologist?

Yes, in practice. The REH radiology condition (42 CFR 485.520) requires the REH to maintain or have available diagnostic radiologic services. It requires a qualified radiologist (an MD or DO) on a full-time, part-time or consulting basis, or other personnel qualified under state law, to interpret the tests your medical staff decides need specialized knowledge. The practitioner who interprets a study must sign the report, and reports and images must be kept for at least 5 years.

Put that next to the emergency department rule (staffed 24 hours a day) and the radiology question becomes a staffing question. An REH’s imaging volume is almost all ED work: head CT after a fall, CT for abdominal pain, chest X-rays, trauma films, ultrasound. Those studies arrive at 3 AM as well as 3 PM, and the ED physician needs a signed read to decide whether to treat, observe or transfer. A transfer to a trauma center that starts with a clear read also starts faster.

Few small hospitals have the overnight volume to keep a radiologist on site, so a consulting radiologist reading remotely, which is teleradiology, is the practical way to meet that rule at every hour.

How is an REH different from a critical access hospital?

CAH figures come from the Rural Health Information Hub (1,386 CAHs as of October 2026) and the CAH emergency services rule (42 CFR 485.618). For an imaging department, the practical difference is simple: a CAH still admits inpatients whose studies need reading; an REH’s imaging is almost all emergency and outpatient work, which makes the ED read the whole job.

How does teleradiology work for an REH?

1. 01

   Order

   The ED orders the study; the order is sent to the teleradiology group by HL7.

2. 02

   Images

   The technologist completes the scan and the images route securely to the reading group’s PACS.

3. 03

   Read

   A radiologist licensed in your state and approved by your medical staff reads the study, emergency and stroke studies first.

4. 04

   Call

   Critical findings are phoned to your ED; the signed report goes back into your system.

5. 05

   Morning

   A handoff note goes to your day coverage, and the month’s turnaround and critical calls go on a scorecard.

Credentialing remote radiologists is the slowest step for a small medical staff office. Hospitals and CAHs may rely on a distant-site hospital or telemedicine entity’s credentialing under a written agreement (42 CFR 482.22, 485.616); ask your surveyor or counsel how your REH bylaws handle it. Our teleradiology credentialing guide explains direct credentialing and credentialing by proxy, and our OP-23 guide covers the 45-minute stroke imaging window.

How TeleRads covers a small ED

Every TeleRads report is a signed final; we read finals only, never preliminaries. Board-certified radiologists, licensed in your state and approved by your medical staff office before they read a single study for you. Stroke studies are read first and critical results are called within 15 minutes. A named backup, already credentialed at your hospital, is on every night, and a handoff note goes to your day coverage at 7 AM.

Orders come to us by HL7 and images by secure routing to our PACS, so there is nothing for your staff to install. Credentialing runs through an NCQA-certified credentials verification organization, built to Joint Commission standards; your medical staff office reviews and approves. Pricing is one monthly price, per study or per wRVU, with no STAT, after-hours or weekend surcharges. Most hospitals are live in 30 days; your medical staff calendar sets the final date.

Questions