36C79118R0022-0003003.xls
XLS spreadsheet 47 KB Posted
- Attached to
- FY19 Dialysis National Contract - Trinity Dialysis Clinic Inc. Federal contract opportunity
- Solicitation number
- 36C79118R0022
About this file
This document contains a federal contract solicitation and facility template for nationwide dialysis services. The Department of Veterans Affairs intends to issue a solicitation on October 18, 2018 for center-based hemodialysis, home-based hemodialysis, peritoneal dialysis, and training for home-based modalities. Interested contractors must possess end stage renal dialysis certification from the Centers for Medicare and Medicaid Services. The facility template requires offerors to indicate whether authorizations and payments will be centralized or sent directly to providing facilities, and to provide facility and contact information for each proposed location. Columns require text entry for CMS certification numbers and lists of modality treatments offered. The number of treatment chairs at each facility may be verified.
36C79118R0022 0003 Attachment 2 - Facility List - FY19.xls
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Text version
INSTRUCTIONS
| Purpose: This spreadsheet will be used by the VA Medical Centers to place authorizations and make payments as well as display the number of facilities under the contract, treatment modalities, and available chairs. |
| Instructions: Offerors must indicate on this spreadsheet whether the process for placing authorizations and making payments will be centralized or sent directly to the facility providing services and fill out the information in this spreadsheet accordingly. If the contact information for placing an authorization differs from the facility information, then offerors must fill out the authorization contact information. If the remittance address is different from the facility address then offerors must fill out the remittance information. The Government reserves the right to verify the number of chairs proposed by any offeror. |
| Column P- CMS Certification Column is formatted to save as "text", please ensure this is entered as text and not another number format. |
Column S- Modality Treatments Offered- Please list any and all Modalities offered (For example- Center HD, Home HD, Center PD, Home PD, Home Training)
FACILITY LISTING
| FACILITY INFORMATION | Authorization Point of Contact/Information | Remittance Information | |||||||||||||||||||||||||||||
| Network | VISN | Facility Name | Address1 | Address2 | City | State | Zip Code (+4) | Phone Number | Fax Number | Point of Contact (Business Hours) | Email Address | Point of Contact (After Hours) | After Hours Phone # | Provider Tax ID | CMS Certification Number | Facility NPI | Modality Treatments Offered | Number of Chairs | Shifts | Current Utilization | Authorization Address | Authorization City | Authorization State | Authorization Zip Code (+4) | Authorization Phone Number | Authorization Fax Number | Remittance Address | Remittance City | Remittance State | Remittance Zip Code (+4) | Remittance Phone Number |
&CFACILITY LISTING
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