Form CMS-10169 Form B - Bidding Form

DEPARTMENT OF HEALTH AND HUMAN SERVICES Form Approved

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-1016

MEDICARE DMEPOS COMPETITIVE BIDDING PROGRAM

For CMS Use Only

Supplier Bidder No. Date Application Received

Competitive Bid Area (CBA) Product Category

Supplier’s Identifying Information

Supplier’s Legal Business Name Primary Supplier’s Legal Business Name (if network)

FORM B: BIDDING FORM

One Form B MUST be submitted for each product category and CBA. Information supplied must be aggregate for all locations and for all network member locations that will be providing this product category in this CBA. References to a business organization includes: suppliers with a single location, suppliers with multiple locations, and networks. If the business organization is a network, the primary supplier must complete this form on behalf of the network.

1. TOP HCPCS Codes

1a. The HCPCS codes listed below represent the top codes that account for approximately 80 percent of the allowed charges for this product category. Indicate the number of units that your business organization has furnished to all customers, both Medicare and non-Medicare, in this CBA during the past calendar year. In the next column, indicate the number of units provided only to Medicare beneficiaries in this CBA during the past calendar year. If your business organization has not provided the item, indicate “0” in the appropriate column. Please refer to the Bidding Information Chart titled “Estimated Capacity and Bid Amount Worksheet” at www.dmecompetitivebid.com/bic for the definition of a unit for each item.

HCPCS Code	Total Units Provided To All Customers	Total Units Provided to Medicare Beneficiaries
HCPCS Code	Total Units Provided To All Customers	Total Units Provided to Medicare Beneficiaries
HCPCS Code	Total Units Provided To All Customers	Total Units Provided to Medicare Beneficiaries

1b. Indicate the percentage increase in Medicare business that you would be capable of providing for this product category in this CBA during a projected 12-month period. The percentage increase may exceed 100%. ___________________%

Supplier’s Identifying Information Supplier’s Bidder No.

2. Expansion Plans

Is your estimated capacity, the amount you can provide for this product category in the CBA, greater than the amount you currently provide in the CBA? If yes, you must complete an expansion plan.  Yes  No

If you plan to expand your business under the Competitive Bidding Program, describe your current structure and expansion plan in the space provided.

Staff (manpower)

Current: ________________________________________________________________________

Expansion Plan: _________________________________________________________________

Financing (funding levels):

Current: ________________________________________________________________________

Expansion Plan: _________________________________________________________________

Facilities (square footage, facility):

Current: ________________________________________________________________________

Expansion Plan: _________________________________________________________________

Inventory Control (method of tracking inventory):

Current: ________________________________________________________________________

Expansion Plan: _________________________________________________________________

Distribution Methods (vehicles, mail order):

Current: ________________________________________________________________________

Expansion Plan: _________________________________________________________________

Additional Information:

Current: ________________________________________________________________________

Expansion Plan: _________________________________________________________________

Supplier’s Legal Business Name Supplier’s Bidder No.

3. Subcontractor Information

A copy(s) of the signed letter of intent to enter into an agreement with the subcontractor(s) should be submitted along with the other required hardcopy documents. Please note that “Subcontracting Arrangements” must be in compliance with Supplier Standards and subcontractor(s) can only perform services allowed under these standards. If a subcontractor is providing the service to set-up and/or provide instruction on the use of Medicare-covered item(s) in this product category, it must be accredited by a CMS approved accreditation organization.

Do you plan to use subcontractors to assist you in carrying out the terms of your contract?  Yes  No

Select one or more of the following functions that the subcontractor(s) will perform:

• Delivery of Medicare-covered item only

• Set-up and/or instruction on use of Medicare-covered item

• Repair of rented equipment only

• Purchase of inventory

If the subcontractor sets up and/or instructs, it must be accredited.

You must provide a copy(s) of the signed letter of intent to enter into an agreement with each subcontractor that includes the following:

• Parties involved

• Functions/services to be performed

• Anticipated length of agreement

• Signature of an Authorized Official for each party

Include language obligating subcontractor to abide by state and federal privacy, security, accreditation and licensure requirements

4. Manufacturer and Model Information—

Listed below are the top HCPCS codes, in terms of allowed charges, for this product category. Identify the manufacturer(s), model name(s) and model number(s) of all products that you plan to make available to Medicare beneficiaries in this CBA. You must provide information for each HCPCS code in order for your bid to be complete.

If a contract is awarded, the information entered on this screen will be displayed to the public in the online Medicare Supplier Directory located at www.medicare.gov. In order to keep this information current, suppliers who are awarded a contract are required to submit a quarterly report updating the manufacturer and model. This information will be included in the Medicare Supplier Directory at www.medicare.gov.

HCPCS CODE	Manufacturer	Model Name	Model Number

Supplier’s Legal Business Name Supplier’s Bidder No.

FORM B: BIDDING SHEET

Bid Sheet Information:

You must provide your total estimated capacity along with your bid price for each HCPCS code listed for this product category.

Important Reminders:

• HCPCS – Healthcare Common Procedure Code System. This is a standardized coding system that is used primarily to identify products, supplies, and services.

• Product Class – A combination of codes for which a single bid is required.

• Item Description – Short narrative description of each HCPCS code. For long description go to www.dmecompetitivebid.com.

• Type of Bid (Rental or Purchase) – This column indicates whether your bid should be for the purchase or monthly rental of the item (identified by the HCPCS code). In most cases you will be asked to submit a bid amount that represents the purchase price of the item even if that item is routinely paid for on a monthly rental.

  • If “Purchase” is indicated, enter a bid amount for total purchase of the item.

  • If “Rental” is indicated, enter a bid price for one month’s rental of the item.

It is very important that you review your bid amount and ensure it was entered correctly.

• Item Weight – Indicates the relative market importance of each item to the overall product category.

• Total Estimated Capacity – Indicates the number of units per HCPCS code that you estimate you can provide throughout the entire CBA for this product category for one (1) year. To determine the capacity for each HCPCS code, calculate the number of units that you currently furnish on a yearly basis and add any additional number of units or capacity you would be capable of providing annually at the start of the contract period. It is anticipated that suppliers will be capable of sustaining the same level of estimated capacity throughout the entire contract period. Please refer to the Bidding Information Chart titled “Estimated Capacity and Bid Amount Worksheet” at www.dmecompetitivebid.com/bic for the definition of a unit for each item.

• Fee Schedule – This indicates the fee schedule amount for the HCPCs code in this CBA. You must provide a bid price that is less than or equal to the fee schedule amount.

• Bid Price – Indicate your bid price for this item. You must submit a bona fide bid amount for each HCPCS code. The amount submitted must be rational, feasible, supportable, and reflect all costs associated with providing these items and services. If requested, you must be able to provide supporting documentation, such as a manufacturer’s invoice and a rationale that verifies you can provide the item to the beneficiary for the bid amount. The bid amount you submit for each HCPCS code must include the cost of furnishing the item throughout the CBA (except for skilled nursing facilities and nursing facilities that elect to participate as specialty suppliers) for the duration of the contract.

Supplier’s Legal Business Name Supplier’s Bidder No.

Note: Columns F & H are to be completed by your business organization.

A HCPCS Code	B Product Class	C Item Description	D Rental or Purchase (Type of Bid)	E Item Weight	F Total Estimated Capacity	G Fee Schedule	H Bid Price
TO BE COMPLETED BY CBIC	TO BE COMPLETED BY CBIC	TO BE COMPLETED BY CBIC	TO BE COMPLETED BY CBIC	TO BE COMPLETED BY CBIC		TO BE COMPLETED BY CBIC

Supplier’s Legal Business Name Supplier’s Bidder No.

Please sign and attach certification to financial statements.

Certifying Statement Applies to All Information Submitted Electronically or Hardcopy.

I have read the contents of this application. I hereby certify that I have examined the completed application and accompanying financial statements and I certify that they are true, correct, and complete statements that can be substantiated from our books and records. My signature legally and financially binds this supplier to the laws, regulations, and program instructions of the Medicare program. By my signature, I certify that the information contained herein is true, correct, and complete to the best of my knowledge, and I authorize the Competitive Bidding Implementation Contractor (CBIC) to verify this information. I also certify that I will adhere to the terms of the competitive bidding contract if awarded a contract.

I agree to notify the CBIC in writing of any changes that may affect the contract and/or my ability to carry out the terms of the contract, prior to such change or within 30 days of the effective date of such change. I understand that I may be in breach of contract if any such change results in my failure to carry out the terms of the contract.

I also certify that I have read, understand, meet, and will continue to meet all supplier standards and quality standards as outlined in 42 CFR §424.57 and 424.58. If I become aware that any information in this application is not true, correct or complete, I agree to notify the CBIC of this fact immediately. I agree that I am a Medicare enrolled supplier and meet the basic eligibility requirements of the DMEPOS Competitive Bidding Program.

I understand that in accordance with 18 U.S.C. §1001, any omission, misrepresentation, or falsification of any information contained in this application and all required attachments and supplemental information or contained in any communication supplying information to CMS or the CBIC may be punishable by criminal, civil, or other administrative actions including revocation of approval, fees, and/or imprisonment under federal law.

I further certify that I am an authorized official of this organization that is submitting a bid in the DMEPOS Competitive Bidding Program.

Network Members:

The primary network supplier and the authorized official for each individual network member must sign a separate hardcopy of this certification page(s) and submit it along with the other required hardcopy documents to the CBIC.

By signing this certification, I further certify that I meet the definition of a small supplier and that I joined the network because I was unable independently to furnish all items in the product category to Medicare beneficiaries throughout the entire geographic bidding area for which the network is submitting a bid.

Authorized Official Name (First, Middle, Last, Jr., Sr., etc.) Title/Position

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Signature Date

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1016. The time required to complete this information collection is estimated to average 14 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Blvd. Baltimore, Maryland 21244.

DEPARTMENT OF HEALTH AND HUMAN SERVICES Form Approved

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-1016

PUBLIC ADDRESS ANNOUNCEMENT FORM

Penalties for Falsifying Information on this Enrollment Application

This section explains the penalties for deliberately furnishing false information to gain enrollment in the Medicare program.

1. 18 U.S.C. §1001 authorizes criminal penalties against an individual who, in any matter within the jurisdiction of any department or agency of the United States, knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact, or makes any false fictitious or fraudulent statements or representations, or makes any false writing or document knowing the same to contain any false, fictitious or fraudulent statement, or entry. Individual offenders are subject to fines of up to $250,000 and imprisonment for up to five years. Offenders that are organizations are subject to fines of up to $500,000 (18 U.S.C. § 3571). Section 3571(d) also authorizes fines of up to twice the gross gain derived by the offender if it is greater than the amount specifically authorized by the sentencing statute.

2. Section 1128B(a)(1) of the Social Security Act authorizes criminal penalties against any individual who, “knowingly and willfully,” makes or causes to be made any false statement or representation of a material fact in any application for any benefit or payment under a Federal health care program. The offender is subject to fines of up to $25,000 and/or imprisonment for up to five years.

3. The Civil False Claims Act, 31 U.S.C. § 3729(a)(1), imposes civil liability, in part, on any person who:

1. knowingly presents, or causes to be presented a false or fraudulent claim for payment or approval:

2. knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim; or

3. conspires to defraud the Government by getting a false or fraudulent claim allowed or paid.

The Act imposes a civil penalty of $5,000 to $10,000 per violation, plus three times the amount of damages sustained by the Government.

4. Section 1128A(a)(1) of the Social Security Act imposes civil liability, in part, on any person (including an organization, agency or other entity) that knowingly presents or causes to be presented to an officer, employee, or agent of the United States, or of any department or agency thereof, or of any State agency…a claim…that the Secretary determines is for a medical or other item or service that the person knows or should know:

1. was not provided as claimed; and/or

2. the claim is false or fraudulent.

This provision authorizes a civil monetary penalty of up to $10,000 for each item or service, an assessment of up to three times the amount claimed, and exclusion from participation in the Medicare program and State health care programs.

5. The government may assert common law claims such as “common law fraud,” “money paid by mistake,” and “unjust enrichment.” Remedies include compensatory and punitive damages, restitution, and recovery of the amount of the unjust profit.

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Form CMS-10169B (07/09) EF(07/2009)