Form CMS-10169 Form C: QUARTERLY REPORT

Form C: QUARTERLY REPORT
This report is used to update the Supplier Directory on the Medicare website at www.Medicare.gov with the products you plan to provide during the NEXT quarter.
Please review your product Information in the Supplier Directory before completing this report. You must complete this report for every competitive bidding area
(CBA)Iproduct category combination in your contract. Please refer to your contract for a complete listing of your CBA/product category combinations.
•

If you need to update product infonnation for a CBA/product category combination(s), you must complete sedlon 11.

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If you do not need to update product infonnation for specific CBA/product category combination(s), you must complete sedlon Ill. Select "I have no updates

tor any or my CBA/product category combinations• it you do not need to update product inlonnation lor iQr of your CBA/product category combinations.
Failure to submit a Form C lor all CBA/product category combinations in your contract may be considered a breaCh of contract and result in termination of your
contract.
IMPORTANT: Data entered into Form C does IIOT save. Alter 60 minutes of inactivity, Form C will time out and all data entered will be losl
You may enter all required information at one time and then select "View Completed Fonn and Prinl" OR you may Choose to enter product inlonnation tor eaCh single
CBA/product category combination and then select "View Completed Fonn and Print• You must PRINT EACH FORM since this information is not saved and cannot
be retrieved after your browser Closes. All forms must be signed by a company official and sent (either by mail or tax) to the Competitive Bidding Implementation
Contractor (CBIC) and RECEIVED by the CBIC by the deadline.

I. Contract Information

* ~ denotes reQuired fields
Doe s thi s opp ly to multipl e contr acts?

r

Yes

r

No

Co ntract N umber*
(Check your contr,.cl(s) for the contract number.)

13 - 1

Year*

Quarter*

120133

fiSt3

Legal Busi ness Na m e *

CBA (Select all that apply )•

I

-•

Akron, OH
Albuquerque. NM
Albany-Schnectady-Troy, NY
Asheville. NC
Atlanta. GA
Augusta-Richmond County, GA-SC

Pro duct Cat egory•

I<- SELECT PRODUCT CATEGORY->

(

Add PC/CBAs

..:J

)

II. Update(s) to the Supplier Directory
1. Select an Update Type. You may choose to replace all the information on the Supplier DirectOJy lor the CBA/product category combination(s) selected above, or
update the lnfomatlon on the Supplier Directory with addrtional products.

2. Select a HCPCS code from the drop down. It you choose to replace all the info rmation on the Supplier Directory, you must enter at least one product tor every
HCPCS code listed In the dropdown below.
3. Select how you would like to search for products. You may search by man uta cturer. model. or model/product number.
4. Select the product.speclfic Information. This dropdown will be the list of manufacturers. models. or model/product numbers available for the HCPCS code.
You can also search the Items in this dropdown using at least three characters in the Search field.
5. In the Search Results table, select the products you wanllisled on the Supplier Directory. You may select all ofthe products in the table by checking Select All.

6. Click "Add Product Information." The information you entered will appear under the list of Updates to the Supplier Directory. II you wish to remove a product

from this secllon. click the X next to the applicable product.

7. Repeatthe process to add all the products you plan to make available in the next quarter for the listed HCPCS codes and for ALL CBAiproducl category
combinallons for which you were awarded a contract.

Select an Updllte Type:

r Replace all of myInformation on the Supplier Directory for the CBA/Product category combinations selected above.

r

Update my Information currently on the Supplier Directory with additional products.

Select the HCPCS Code:
(You mu$1•ntor lllo•$1ono ptOducl for -ry HCPCS li$1ed in the dropdown be-.)

HCPCS Code "

®

Select how you would like t o search for products:*
Manufacturer
r MOdel
r ModeUProduct Number

r

Select the following information: •

®

You can search using at /ea$1 3 c~ractert;.

•

ORSearch:

( Add Product Information )

List of Updates to the Supplier Directory
Delete

+

Contract II

CBA

Product Categ01y

HCPCS Code

Manufacturer

+Modei!Produ
Number

ModeVProduct Numbers are not listed on the Supplier Directow This field is for searching purposes only.

III. No Updates to the Supplier Directory
I f the product information in the Supplier Directory is current for some but not all of your CBA/product category

combinations, select the CBA/product category combination(s) that do NOT need to be updated.
Contract Number•

13 -1
Le gal Business Name•

I
Produ ct Cat egory"

CBA (Select all tha t app ly)•

I<- SELECT PRODUCT CATEGORY->

Akron, OH
Albuquerque, NM
Atbany-Schnectady-Troy, NY
Asheville, NC
Atlanta, GA
Augusta-Richmond County, GA-SC

..:J

If the product informetion in the Supplier Directory is current for ALL CBA/product category combinations, cheek below.

r

I have no update.s for~ of my CBA/ product catego r-y combina t io ns .

[

Add CBA/Product Category combination )

List of CBA/ Ptoduct Categoty combination(s) that do NOT need to be updated in the Supplier Directory
Contract II

CBA

Product Catego ry

( Vie w Completed Form and Print

J