Cms-10169

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Overview

Form A Suppliers
Form B

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Sheet 1: Form A Suppliers

	MEDICARE DMEPOS COMPETITIVE BIDDING PROGRAM FORM A: APPLICATIONS FOR DMEPOS COMPETITIVE BIDDING PROGRAM SECTION 1: APPLICATION FOR SUPPLIERS
	Current OMB Approved Form					New Form Approval Request
Row	Topic	Section	Page	Item #		Section	Page	Item #	Comments
1	Business Organization Information / Type of Business		1			1	1	A	Expanded choices for the question regarding Type of Business (Row 9, Item G). Options divided between the organization-level and location-level based on the most appropriate location. These additional choices assist suppliers in better identifying their business structure and clarify subsequent information requests.
2	Specialty Supplier	1	1	1		1	1	B	Renumbered question.
3	Licensure					1	2	C	Included attestation statement regarding compliance with existing licensure requirements for the organization.
4	Identifying Information	1	1-2	A-B		1a	5	G, H	Eliminated detailed identifying information at the organization level. All detailed information regarding the supplier is collected at the location level. This was done to simplify the reporting process by eliminating duplicate collection when the supplier is a single location and clarify the reporting for suppliers with multiple locations
5	Doing Business As Name	1	2	C		1a	5	I	Question will be asked at the location-level in the new form.
6	Establishment / Business Information	1	2	D		1a	5	I	Question will be asked at the location-level in the new form. Removed obsolete question related to State Established / Incorporated.
7	Contact Person(s)	1	2	E		1	2	D	Relocated question.
8	Key Personnel	1	2	F		1	2	E	Added "Authorized Official" to the title to clarify terminology change.
9	Type of Business	1	3	G		1a	5	J	Renumbered and expanded choices for suppliers with multiple locations (see row 1).
10	Service Delivery	1	3	H		1a	6	K	Question will be asked at the location-level in the new form.
11	Sanctions	1	3	I		1a	6	L	Question will be asked at the location-level in the new form.
12	Accreditation	1	3	J		1a	6	M	Question will be asked at the location-level in the new form.
13	CBA / PC	1	3	K		1	3-4	F	Renumbered question
	Location-Specific Questions	1a	4			1a	5		Renumbered question.
14	Indentifying information	1a	4	L		1a	5	G-H	Renumbered question.
15	CBA / PC	1a	4	L		1a	6-7	O	Renumbered question.
16	Accreditation	1a	4	L		1a	6	M	Renumbered question.
17	Licensure					1a	6	N	Included attestation statement regarding compliance with existing licensure requirements for the organization.
18	Establishment / Business Information	1a	4	L		1a	5	I	Renumbered question. Relocated Tax ID and DBA from identifying information to this location. Removed question regarding state incorporated.
19	Type of Business	1	3	G		1a	5	J	Question will be asked at the location level. Incorporated into "Supplier Bidding Type" and included additional options to better describe that type of business structure for suppliers with multiple locations.
20	Additional Comments	1a	4	M					Removed unnecessary item
21	Additional Locations					1b	8	P	Renumbered question. This allows suppliers to enter location information for additional locations.
NOTE: Section 2 for network suppliers contains the same questions as Section 1 so the changes are made in Section 1 will also apply to Section 2.
One difference to note - Networks are not able to bid in the National Mail-Order competition and so there are no references to National Mail-Order
in Section 2.

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Sheet 2: Form B

	MEDICARE DMEPOS COMPETITIVE BIDDING PROGRAM FORM B: BIDDING FORM SECTION 1: APPLICATION FOR SUPPLIERS
	Current OMB Approved Form				New Form Approval Request
Row	Topic	Page	Item #		Page	Item #	Comments
1	Revenue Reporting	1	1				Removed obsolete reporting requirement. Information available through other sources.
2	Customer Volume	1	2				Removed obsolete reporting requirement. Information available through other sources.
3	Counties Served	2	3				Removed obsolete reporting requirement. Information obsolete and/or available through other sources.
4	HCPCS Code	2	4a		1	1a	Renumbered question.
5	Capacity Capabilities	2	4b		1	1b	Renumbered question.
6	Brand Information (Manufacturer, Make & Model)	2	4c		3	4	The reporting of brand is an existing requirement previously approved under the PRA. Bidding suppliers will report brands of diabetic testing supplies using an online form accessed via link in DBidS.
7	Expansion Plans	3	5a		2	2	Renumbered question.
8	Subcontractor Reporting	3	5b		3	3	Renumbered question. Added checkboxes for ease of reporting. Removed listing of subcontractor by name to eliminate duplicate information collection.
9	Other CBA Bidding	4	6				Removed reporting requirement. Information collected on Form A.
10	Additional Information	4	7				Deleted reporting space. Unnecessary optional field.
11	Bidding Sheet	5			4		Replaced "product" with "item" for clarity. Added "product class" to define items represented by a single code.
12	Bidding Spreadsheet	6			5		Same comments as row 11.
13	Certifying Statement	7			6
14	Network Certification Page	8			6		Consolidated into the Certifying Statement to simplify reporting and eliminate confusion.
15	Public Address Announcement	9			7