Attachment D - Facilities Status Report.xlsx
XLSX spreadsheet 189 KB Posted
- Solicitation number
- 36C10G25Q0021
About this file
This is a facilities status report template (Attachment D) used to track and report changes to dialysis facilities under VA contracts. The Excel file contains multiple tabs for different reporting scenarios including: a master facility list with detailed location and contact information, a disqualifying events tab for adverse actions, an additions tab for new facilities, a closures tab for facility terminations, a demographics tab for administrative changes, and a contractor transfer tab for tracking patient moves between facilities.
The template requires specific data fields including facility names, addresses, NPI numbers, tax IDs, CMS certification numbers, treatment modalities offered (ESRD/AKI), number of chairs, shifts, utilization types, authorization contact details, and remittance information. The file is designed for COR (Contracting Officer Representative) use and includes example entries showing how to document facility changes like closures, address updates, and patient transfers. This template appears to be part of a larger draft RFP package for the VA's National Dialysis Services Contract (NDSC).
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INSTRUCTIONS
| Tabs: |
| Atch 2 – Facility List: Contains an all-inclusive listing of facilities by contract number. FOR COR USE ONLY |
| Atch 2.1A - 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. |
| Atch 2.1B – 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.
| Atch 2.1C – Closures: Used to close a facility already listed on your contract. All fields are required to be filled out. |
| Atch 2.1D – 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.
Atch 2.1E – 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.
Atch 2 - 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
Atch 2.1A - 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
Atch 2.1B - 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 Atch 2.1C - 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
Atch 2.1D - 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 Atch 2.1E - 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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