Medicare/Medicaid Certification and Transmittal, Form CMS-

2762 - Medicare/Medicaid Certification and Transmittal, Form CMS- 1539 (Rev. 1, 05-21-04) 2762A - Purpose of Form CMS-1539 (Rev. 201, Issued: 06-19-20, Effective: 06-19-20, Implementation: 07-27-20) The SA uses Form CMS-1539 to certify findings to the RO, MACs or State Medicaid Agency (SMA) with respect to a facility’s compliance with Conditions of Participation, Conditions for Coverage, Conditions for Certification, or Nursing Home Requirements. Form CMS-1539 is also a transmittal cover sheet for the certification packet. (See Exhibit 9.) Together with the SA certification file, Form CMS-1539 constitutes the primary record of the determination to approve a provider or supplier. It may be used with supporting documentation in any appellate action. It is essential, therefore, that the SA completes each item fully and accurately. Each new certification action requires a separate Form CMS-1539. The Form CMS-1539 also exists as an electronic form and is more frequently used than the paper version of the form. The Form CMS-1539 is used to process updates to a provider/supplier’s information in the national data system. 2762B - Definitions of Terms Used on Form CMS-1539 (Rev. 1, 05-21-04)