Attachment X - CLIN 0002 Utilization Justification Template.pdf
PDF 68 KB Posted
- Solicitation number
- 36C10G25Q0021
About this file
This is a CLIN002 Utilization Justification Template form used for the VA's National Dialysis Services Contract (NDSC) when contractors need to request billing above Medicare rates. The template requires contractors to provide basic information including facility name, address, NPI number, and contact details.
The form requires contractors to justify their need to utilize CLIN002 (higher than Medicare rates) instead of CLIN0001 (Medicare rates) by providing evidence addressing three key areas: 1) whether they have providers/facilities in the core-based statistical area (CBSA) that bill at Medicare rates, 2) whether the provider/facility landscape has changed making certain providers unavailable, and 3) the rates being offered by providers in the CBSA. The template includes an optional narrative section for additional justification text. This is a blank template form that would be filled out by contractors as needed to request higher reimbursement rates.
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Other files
| File | Type | Posted |
|---|---|---|
| Attachment Z - CLIN 0002 RFI.pdf | ||
| Attachment Y - NDSC Labor Harmony Agreement RFI.pdf | ||
| Attachment H - Progress Report.pdf | ||
| 36C10G25Q0021.docx | DOCX document | |
| Attachment G - Project Risk Register.xlsx | XLSX spreadsheet | |
| Attachment J - Contractor Training Report.pdf | ||
| 36C10G25Q0021 NDSC Draft RFP.pdf | ||
| Attachment B - Quality Assurance Surveillance Plan.xlsx | XLSX spreadsheet | |
| Attachment E - QASP Summary Report Template.pdf | ||
| Attachment D - Facilities Status Report.xlsx | XLSX spreadsheet |
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Text version
CLIN002 Utilization Justification Template
(File naming convention: NDSC_Date_Contractor_Contract ID)
Part I: Contractor Information
Provider/ Facility Name
Provider Street Address
Provider City
Provider State
Provider ZIP Code
NPI #
Provider Phone Number
Additional Notes
Part II: Rationale for CLIN002 Utilization Justification
If the Contractor is unable to deliver services requested in an Approved Referral at locality-adjusted
Medicare rates, through CLIN 0001, the Contractor shall submit a request to utilize CLIN 0002. The request shall contain conclusive evidence and documentation, specific to the care authorized in the
Approved Referral, addressing the following:
• Whether the Contractor has providers or facilities in the core-based statistical area (CBSA) that bill at the Medicare rate
• Whether the landscape of providers or facilities has changed, and certain providers or facilities are not available,
• The rates offered by providers in the core-based statistical area (CBSA)
Part IV: Narrative Text (Optional)
Please use the below box to enter any additional text to justify your CLIN002 Utilization request.
File details come from the government source that posted it. Updated .