CMS-10169 CMS-10169.RFB Form B

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
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.
If bidding in the national mail-order CBA, the competitive bidding area includes all 50 states, the District of Columbia, Puerto
Rico, the U.S. Virgin Islands, Guam, and American Samoa.
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%. ___________________%

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

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: _________________________________________________________________

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

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.
 Yes  No

Do you plan to use subcontractors to assist you in carrying out the terms of your contract?
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 you are bidding in the national mail-order competition for diabetic testing supplies, you must provide manufacturer and model
information for the codes identified below. Please note that the HCPCS code A4253 is not listed in this question and information
on this code must be provided separately. In order to meet the 50% rule you must complete the ―50 Percent Compliance Form‖
located on the CBIC website at www.dmecompetitivebid.com/50PercentComplianceForm identifying the products you plan to
provide for HCPCs code A4253. In order for your bid to be considered, this form must be submitted to the CBIC as part of your
package of hardcopy documents. This form is a requirement and failure to submit will result in disqualification of your bid.
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. For national mail order the information provided on the ―50% Compliance Form‖ will also
be used to update the supplier directory. 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

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

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.
o If ―Purchase‖ is indicated, enter a bid amount for total purchase of the item.
o 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. For the national mail-order competition for
diabetic testing supplies, the CBA includes all parts of the United States, including the 50 states, the District of
Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, and American Samoa. 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. For items included in the
national mail-order competition for diabetic testing supplies, the fee schedule amount is the average amount for all
parts of the United States, including the 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands,
Guam, and American Samoa. 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.

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

Supplier’s Bidder No.

Supplier’s Legal Business Name

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

B
Product Class

TO BE
TO BE
COMPL COMPLETED BY
ETED
CBIC
BY CBIC

C
Item
Description

D
Rental or
Purchase
(Type of
Bid)
TO BE
TO BE
COMPLETED COMPLET
BY CBIC
ED BY
CBIC

E
Item
Weight

TO BE
COMPLE
TED BY
CBIC

F
Total
Estimated
Capacity

G
Fee
Schedule

H
Bid
Price

TO BE
COMPLET
ED BY
CBIC

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

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.)
PRINT

Signature

Title/Position

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.

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
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:
a) knowingly presents, or causes to be presented a false or fraudulent claim for payment or approval:
b) knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent
claim; or
c) 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:
a) was not provided as claimed; and/or
b) 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)