RO Requests for Additional Information

2776 - RO Requests for Additional Information (Rev. 1, 05-21-04) The Regional Office Request for Additional Information or Other Action (Form CMS- 1666) (see Exhibit 15) provides the RO a means of requesting further information or additional action from the SA at any stage of processing a certification action or providing technical assistance. The SA uses the reverse side of the form to reply and to summarize additional development. If the RO does not request a specific due date, the SA forwards its response (or an interim response) within 20 calendar days of receipt of the request. The SA keeps a copy of Form CMS-1666 in the provider/supplier file for its records. Form CMS-1666 may be used for a myriad of reasons, such as requesting information or providing technical assistance. It may also be used to request certain actions, such as surveys, or to inform States of processing errors. In preparing Form CMS-1666, the RO completes the self-explanatory portions of the form, (e.g., the addressee, facility name, and provider number) and provides relevant section numbers in the manuals, if appropriate. The RO may include suggestions for the desired action along with a requested response date. The original is sent to the SA, and a copy is filed inside the folder until the completed original is returned. The RO maintains a log or file of requests to the SA for additional information (i.e., Form CMS-1666s, letters, documented telephone contact reports) which reflects the date of each request, the requested information, the requested response date, and the date the RO received the reply.