July 17th, 2015
The RO uses the provider tie-in notice, Form CMS-2007 (see the CMS forms page at http://www.cms.hhs.gov/forms/), as an official notification to the FI of a change in its list of providers. The RO completes and transmits a Form CMS-2007 to the home office of the FI in each of the following circumstances:
• A provider is certified for participation in the program,
• A provider is issued a notice of termination,
• A change of FI is authorized (including changes between Blue Cross plans or between FI processing facilities, i.e., any changes involving a change in the FI number), or
• To correct information previously furnished the FI.
Part I of the Form CMS-2007, Identifying Information, identifies the provider and is always completed.
Part II, New Provider Certification, is completed where the provider is certified (including certifications required because of a change of ownership).
Part III, Change of FI, is completed where a change of FI has been authorized.
Part IV, Terminations, is completed in all termination actions.
Part V, Remarks, will be used for additional clarifying information.
The FI must promptly notify the RO of any information found to be incorrect. The RO will issue a corrected Form CMS-2007.