Provider Tie-In Notice (Form CMS-2007)

2783 - Provider Tie-In Notice (Form CMS-2007) (Rev. 1, 05-21-04) 2783A – Purpose (Rev. 201, Issued: 06-19-20, Effective: 06-19-20, Implementation: 07-27-20) Form CMS-2007 (Exhibit 156) is the official notice to the MAC of changes in its list of providers or suppliers (additions, deletions, corrections, recertifications, and terminations). 2783B - CMS Responsibility for Form CMS-2007 Completion (Rev. 201, Issued: 06-19-20, Effective: 06-19-20, Implementation: 07-27-20) The RO completes a Form CMS-2007 each time a provider or supplier is added to or deleted from a MAC’s list of providers and suppliers or when current provider-supplier tie-in records require correction and sends it at the time the provider agreement or supplier approval is countersigned by its office. In involuntary termination actions, the RO sends it at the same time it issues official notification to the provider or supplier. 2783C - CMS Completion of Form CMS-2007 (Rev. 201, Issued: 06-19-20, Effective: 06-19-20, Implementation: 07-27-20) Item I - Identifying Information - This section is self-explanatory. Complete it in all instances. Item II - New Provider or Supplier Certification - CMS completes this section when a new provider or supplier enters the program or when a participating provider or supplier has changed ownership. Items A, C, and D are completed in all cases, and Items E through H for changes in ownership. In item B, CMS shows the month and day of the provider’s or supplier’s fiscal year ending date for Medicare cost report purposes (if it summits cost reports) if the information is available or is readily obtainable. CMS contacts the provider or supplier directly or solicits the aid of the MAC to determine the provider’s or supplier’s Medicare fiscal year ending date. There should be no delay issuing this notice even if the fiscal year information is not obtainable or is not known at the time of certification. This procedure assures that CMS contacts a responsible official or officer of the provider or supplier for this information and allows several days for the provider or supplier to respond when it appears the information is currently available. The information is not considered readily available if the provider does not know or will decide at a later date. Item III - Change of MAC – This section is not applicable to the RO. Item IV – Termination -This section is completed when a provider or supplier involuntarily ends its participation in the program. When the new owner rejects assignment of the existing Medicare agreement following a change in ownership it is treated as a voluntary termination. Item V – Remarks –CMS uses this section for pertinent information. If the provider is part of a chain, insert the name and address of a parent or controlling organization in this section. If Form CMS-2007 corrects previously furnished information, include an explanation of the change. If a SNF’s participation will end, include an explanation relating to services after termination (see §§3008.1 and 3008.2) in the remarks. EXAMPLE: An agreement with a participating SNF is involuntarily terminated for cause (e.g., failure to file cost reports), and the effective date of termination is established as October 15, 2015. As with all providers, this termination takes effect on (0001 hours on a 24 hour clock) October 15, 2015, and not at the close of (2400 hours on a 24 hour clock) October 15, 2015. Therefore, the remarks should indicate “Termination for cause-- payment can continue for up to 30 calendar days of post-hospital skilled nursing care services furnished on or after October 15, 2015, to beneficiaries admitted to the facility before October 15, 2015. Do not make payment for new admissions which occur on or after October 15, 2015.” 2783D – Distribution (Rev. 201, Issued: 06-19-20, Effective: 06-19-20, Implementation: 07-27-20) Whenever there is a change to Form CMS-2007 (new provider or supplier, change in MAC, or involuntary termination) CMS forwards a copy to the provider’s or supplier’s MAC.