Attachment B - Facilities Status Report.xlsx
XLSX spreadsheet 185 KB Posted
- Attached to
- National Dialysis Services Contract (NDSC) Federal contract opportunity
- Solicitation number
- 36C10G25R0022
About this file
Attachment B is a Facilities Status Report Excel spreadsheet for the National Dialysis Services Contract (NDSC) with the Department of Veterans Affairs, detailing facility management procedures and tracking changes to dialysis facilities. The document contains multiple tabs with instructions for managing facility listings, including additions, closures, demographic changes, and contractor-initiated transfers, with comprehensive data fields covering facility details such as NPI, provider tax ID, CMS certification number, contact information, treatment modalities, and utilization metrics.
The spreadsheet demonstrates specific facility management actions, including the addition of FKC Smith Dialysis Center effective 10/15/24 with 23 chairs offering both in-center and home dialysis treatments, a facility closure for ABC Dialysis Center, and demographic changes for multiple facilities. The contract number 36C79119D00XX is associated with VISN regions 7, 10, 12, and 23, indicating a multi-regional dialysis service contract that requires detailed tracking of facility status, authorization contacts, and remittance information for VA dialysis service providers.
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Text version
INSTRUCTIONS
| Tabs: |
| Facility List: Contains an all-inclusive listing of facilities by contract number. FOR COR USE ONLY |
| Disqualifying Event: Used for notification of adverse action (e.g. Termination Notices) by the CMS Medicare Program to include exclusion from participation from the Medicare program, Medicaid program, and other federal programs by the contractor, its agents, employees, assigns or successors. |
| Additions: Used to add facilities to the contract. All fields are required to be filled out. If the authorization contact information |
for placing an authorization differs from the facility information, then it is required to fill out columns U – Z, Authorization Contact Information. If the remittance address is different from the facility information, then it is required to fill out columns AA – AE, Remittance Information. The effective date of additions will be the date the Attestation Form is signed.
| Closures: Used to close a facility already listed on your contract. All fields are required to be filled out. |
| Demographics: Used when facilities have administrative changes (Example: facility location changes, phone/fax number |
changes, POC changes, remittance address changes) This is not an all-inclusive list of demographic changes.
Contractor Initiated Transfers: Used when the contractor indicates a Yes in column M on Atch 2B – Closures. All fields are required to be filled out.
Facility List
| Contract # | Authorization Point of Contact/Information | Remittance Information | |||||||||||
| Contract # | VISN | Facility Name | |||||||||||
| (DBA) | Address1 | Address2 | |||||||||||
| (Ste, Bldg) | City | State | Zip Code (+4) | Phone Number | Fax Number | Point of Contact | Email Address | Facility NPI | Provider Tax ID | CMS Certification Number | Effective | ||
| Date | Termination | ||||||||||||
| Date | Modality Treatments Offered (ESRD, AKI, Both) | Number of Chairs | Shifts | Current Utilization | |||||||||
| (Incenter, Home, Both) | 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 |
FACILITY LISTING
FOR COR USE ONLY
FOR COR USE ONLY
Disqualifying Event
| DISQUALIFYING EVENT | ||||||
| Type of Adverse Action | Contract # | VISN | Effective | |||
| Date | Facility NPI | |||||
| (Mandatory) | Facility Name | |||||
| (DBA) | Address1 | Address2 | ||||
| (Ste, Bldg) | City | State | Zip Code (+4) | Provider Tax ID | CMS Certification Number | Reason for Adverse Action |
Facility CMS Termination 36C79119D00XX 7 10/15/24 123456789 FKC Dialysis Center 123 Dialysis Road Ste 101 Anywhere CO 30277-3588 8433331 84-101
Additions
| FACILITY ADDITIONS | Authorization Contact Information | ||||||||||||||||||||||||||
| (if different from facility contact information) | Remittance Information | ||||||||||||||||||||||||||
| Contract # | VISN | Effective | |||||||||||||||||||||||||
| Date | Facility Name | ||||||||||||||||||||||||||
| (DBA) | Address1 | Address2 | |||||||||||||||||||||||||
| (Ste, Bldg) | City | State | Zip Code (+4) | Phone Number | Fax Number | Point of Contact | Email Address | Facility NPI | Provider Tax ID | CMS Certification Number | Modality Treatments Offered (ESRD, AKI, Both) | Number of Chairs | Shifts | Current Utilization | |||||||||||||
| (Incenter, Home, Both) | 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 | ||||||||||||||||
| 36C79119D00XX | 7 | 10/15/24 | FKC Smith Dialysis | ||||||||||||||||||||||||
| Center | 123 Dialysis Road | Ste 101 | Anywhere | CO | 30277-3588 | 123-123-4567 | 123-123-5678 | John Doe | dialysis@dialysis.com | 123456789 | 10-000002 | 01-0101 | Both | 23 | 1st, 2nd | Both | 123 America St | Anywhere | GA | 30144 | 123-123-0987 | 123-123-8765 | PO BOX 111111 | Anywhere | GA | 30392-1518 | 123-000-0000 |
mailto:dialysis@dialysis.com Closures
| FACILITY CLOSURES | ||||||
| Contract # | VISN | FACILITY NAME | ||||
| (DBA) | FACILITY ADDRESS | CITY | STATE | Zip Code (+4) | Facility NPI | Provider Tax |
| ID | CMS Certification Number | ACTION TAKEN | ||||
| (PERM OR TEMP) | CLOSURE EFF DATE | Veteran(s) Affected |
(Y or N) *if Y, fill in Atch 2B-1 36C79119D00XX 10 ABC Dialysis Center 234 Elm Street AnyTown CO 12345-0000 123456789 01-010101 01-0101 PERM 10/15/24 N
Demographics
| FACILITY DEMOGRAPHICS | Authorization Information | Remittance Information | ||||||||||||||||||||||||||
| Type of Change | Contract # | VISN | Effective | |||||||||||||||||||||||||
| Date | Facility NPI | |||||||||||||||||||||||||||
| (Mandatory) | Facility Name | |||||||||||||||||||||||||||
| (DBA) | Address1 | Address2 | ||||||||||||||||||||||||||
| (Ste, Bldg) | City | State | Zip Code (+4) | Phone Number | Fax Number | Point of Contact | Email Address | Provider Tax ID | CMS Certification Number | 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 | ||||||||
| Address Change | 36C79119D00XX | 7 | 10/15/24 | 123456789 | FKC Dialysis Center | 123 Dialysis Road | Ste 101 | Anywhere | CO | 30277-3588 | NC | NC | NC | NC | NC | NC | NC | NC | NC | NC | NC | NC | NC | NC | NC | NC | NC |
Phone # Change 36C79119D00XX 12 10/1/24 368459621 FMC Gilligan Island 4567 Broad St Gilligan MS 12345-9874 123-123-4567 NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC
Remittance Address Change 36C79119D00XX 23 10/9/24 785439510 FKC Washington 879 Market St Washington DC 36985-2574 NC NC NC NC NC NC NC NC NC NC NC NC PO Box 1122 Aurora CO 8-0011 (303) 000-0000 mailto:dialysis@dialysis.commailto:dialysis@dialysis.commailto:dialysis@dialysis.com Contractor Transfer
| FACILITY CLOSURE - CONTRACTOR INITIATED TRANSFERS | |||||||
| Veteran Last Name | |||||||
| (first 4 letters only) | SSN (last 4 only) | Current Auth # | New Auth # | New Facility Name | New Facility Address | New Facility NPI# | |
| Smit | 1234 | VA000123403 | VA00023455 | ABC Dialysis Center | 123 Elm St, Aurora, CO 80016 | 123456789 |
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