Crosswalk for Form A

Form A Crosswalk of changes. * Any section not identified on the crosswalk does not have any changes
Section of DBidS
Current Language
Revised Language
Screenshot file
name
Business
Indicate how your business
Indicate how your business organization will be
DBidS Form A
Organization
organization will be bidding (choose
bidding.
Screenshot 1
Information
only one).
Contact person

Provide the name(s) of the person(s)
who should be contacted to answer
questions regarding the business or
network organization. You must click
the Add Contact Person button in
order for this information to be saved
below. You may enter more than one
Contact Person. (maximum 5). Once
you have entered the names of your
Contact Person(s) scroll down to verify
the name(s) was entered correctly.

Provide the name(s) of the person(s) who should
be contacted to answer questions regarding the
business organization. You must click the Add
Contact Person button in order for this
information to be saved below. You may enter
more than one contact person (maximum 5). Once DBidS Form A
you have entered the names of your contact
Screenshot 1
person(s) scroll down to verify the name(s.)

Authorized
Official

Provide the name(s) and title(s) of
authorized officials or key personnel
for the business organization or
network. You must click the Add
Authorized Official or Key Personnel
button in order for this information to
be saved below. Once you have
entered the names of your authorized
official or key personnel scroll down to
verify that the names were entered
correctly.

Provide the name(s) and title(s) of authorized
officials or key personnel for the business
organization . You must click the Add Authorized
Official or Key Personnel button in order for this
information to be saved below. Once you have
entered the names of your authorized official or
key personnel scroll down to verify the names.

DBidS Form A
Screenshot 2

Accreditation
Information

All locations must meet Medicare
enrollment requirements, including
being accredited for all items in the
product category(s) and CBA for which
the bidder is submitting a bid, by the
close of the bid window. As required
by 42 CFR §414.414 (c), each bidder
must be enrolled, meet quality
standards and be accredited in order
to be awarded a contract. Individual
locations of a supplier with multiple
locations must separately meet these
requirements to be included in a
contract offer.

By the close of the bid window, all locations must
meet Medicare enrollment requirements,
including being accredited for all items in the
product category(s) for which you are bidding. As
required by 42 CFR § 414.414 (c), each bidder
must be enrolled, meet quality standards, and be
accredited in order to be awarded a contract.
Individual locations must be accredited to be
included on the contract.

Select the name(s) of the Medicareapproved organization(s) that has
accredited your location(s).

You must click the Add Accreditation button
below for this information to be saved.

Select the name(s) of the Medicare-approved
accreditation organization(s) that has accredited
your business for the product category(s) for
which you are bidding.

DBidS Screenshot
CreateSupplier4

You must click the Add Accreditation
button below for this information to
be saved.
Accreditation
Information(acknowledgement
statement)

I understand that each bidder must
have a location or locations that are
accredited to furnish the specific
product(s) and service(s) included in
the bid.

I acknowledge and understand that I, as a bidder,
must be properly accredited to furnish the specific
item(s) and service(s) included in the bid. This
DBidS Form A
information must be on file in each location’s
Screenshot 2
Medicare enrollment record (i.e., Provider
Enrollment, Chain and Ownership System (PECOS))

Licensure

All bidders must meet Medicare enrollment
requirements, including possessing all
applicable state license(s) for the product
category (s) by the close of the bid window.
Bidders will be disqualified if they do not meet
all state licensure requirements for applicable
product categories and for every state in the
CBA. Every location of the bidder is responsible
for having all license(s) for each state in which
it furnishes items/services. If there is a multistate CBA the bidder must collectively have all
applicable license(s) for every state in the CBA.
For bid evaluation purposes, each location is
not required to have licenses for every state in
the CBA as long as each state has a bidding
location licensed for the product category.
Some states may not require a license to
furnish certain items in a product category.
Please check the licensure directory on the
NSC website, which serves as a guide and the
Licensure for Bidding Suppliers fact sheet on
the CBIC website.

By the close of the bid window, all locations must
meet Medicare enrollment requirements,
including possessing all applicable state license(s)
for the product category(s) and areas for which
you are bidding. Bidders will be disqualified if
they do not meet all state licensure requirements
for the applicable product categories and for
every state in a CBA. For bid evaluation purposes,
each location is not required to have licenses for
every state in the CBA as long as each state has a
bidding location licensed for the product category.
Every location of the bidder is responsible for
DBidS Form A
having all applicable license(s) for each state in
which it furnishes items and services. If there is a Screenshot 3
multi-state CBA, the bidder must collectively have
all applicable license(s) for every state in the CBA.
Some states may not require a license to furnish
certain items in a product category. Please check
the licensure directory on the NSC website, which
serves as a guide and the Licensure for Bidding
Suppliers fact sheet on the CBIC website.

Licensurecontinued
(acknowledgement
statement)

Business
Information (the
Blue Header on
the Section

I understand that each supplier
location is responsible for having all
applicable state licenses for each state
in which it provides services. Each
location is not required to have
licenses for every state in the CBA as
long as there is a licensed location for
each state.
Business Information

I acknowledge and understand that I, as a bidder,
have all applicable state licenses for every item in
the product category and for each CBA for which I
CreateSupplier5_
am bidding. This information must be on file in
each location’s Medicare enrollment record (i.e., seq_1.png
Provider Enrollment, Chain and Ownership System
(PECOS))
Business Information- Years in Business
CreateSupplier5_
seq_1.png

Type of Business Select the business type that describes
your organization. Bidders must
submit certain financial documents
based on the type of business
identified in this response. Refer to
the Request for Bid (RFB) instructions
a list of required financial documents.
Go to
http://www.dmecompetitivebid.com/f
inancialrequirements for additional
information.

Select the business type that describes your
organization. Bidders must submit certain
financial documents based on the type of business
identified in this response. Refer to the Request
for Bid (RFB) instructions for a checklist of
DBidS Form A
required financial documents.
Screenshot 3
Go to:
http://www.dmecompetitivebid.com/financialreq
uirements for additional information .

Service Delivery Retail Location with Home Delivery
Mail Orders
Home Delivery

Retail Location with Home Delivery
Mail Order
Home Delivery

DBidS Form A
Screenshot 4

Competitive
Competitive Bidding Area (CBA) and
Bidding Area
Product Category
(CBA) and Product
Category (the Blue
Header on the
Section)
Location
Information
Accuracy

Please review the information above
for your primary location, if any data is
inaccurate, select No and provide
details in the text box identifying the
inaccurate data and provide correct
information
Competitive
Select the CBA(s) and product
Bidding Area
category(s) for which your
(CBA) and Product organization is submitting a bid(s).
Category
The CBA and product category
combinations appear below. You must
check the box in the right column for
each combination for which you are
submitting a bid. After you have made
your selection, click the Add CBA/PCs
button to save your selection(s).

Later in the application, you will be
required to identify the locations
within a CBA that will provide
competitively bid items.

Select Competitive Bidding Area (CBA) and
Product Category
(Only changing the name on Blue Header )

Please review the information above for your
primary location. If any of the information is
inaccurate, select No and provide the correct
information in the text box.

DBidS Form A
Screenshot 4

DBidS Form A
Screenshot 5

The CBA and product category combinations
appear below. You must check the box in the
right column for each combination for which you
are submitting a bid. After you have made your
selection, click the Add CBA/PCs button to save
your selection(s).
Select the CBA(s) and product category(s) that
your primary location will be servicing.
The primary location must select at least one
CBA/product category combination

DBidS Form A
Screenshot 5

CBA/ Product
Category List

Displayed below is a summary of the
CBA(s) and Product Categories for
which you intend to submit a bid.
Please review for accuracy.
Form A: Primary Please provide the requested
location Specific information for your primary location.
Information
This is the location (PTAN) that you
(header)
used when you registered for a User ID
and password to access DBidS.
Competitive
Competitive Bidding Area (CBA) and
Bidding Area
Product Category
(CBA) and Product
Category (the Blue
Header on the
Section)
Form A: Assign
Locations

Displayed below is a summary of the CBA(s) and
Product Categories that you have selected. Please DBidS Form A
Screenshot 5
review for accuracy.
Please provide the requested information for
your primary location. This is the location (PTAN)
that you used when you registered for a User ID
DBidS Form A
and password to access DBidS. The information
Screenshot 6
provided is from your enrollment record in the
Provider Enrollment, Chain and Ownership System
(PECOS.)
Competitive Bidding Area (CBA) and Product
Category- Primary Location
(Only changing the name on Blue Header )

DBidS Form A
Screenshot 7

Your primary location is listed below. Your primary location is listed below.
click View/Modify to go to the location
To view, modify or complete information for a
to view, modify or complete
location, click on View/Modify.
information for the location.
If the location status is Update
Available your PECOS record contains
new information. Click Refresh
Location to view updated information
for the location.

If the location status is Update Available, this
means there has been an update to your PECOS
record. Click Refresh Location to view updated
information for the location.

DBidS Form A
Screenshot 8

Form A: Summary Displayed below is a summary for the
location(s) for which you are
submitting a bid. Please carefully
review the information you provided
on Form A application information for
accuracy. You may modify your
information or add a new location. If
you do not wish to make any changes
or add another location, select NEXT.
Only locations identified by the PTAN
listed on this summary page will be
eligible to be awarded a contract and
to receive payment under the
DMEPOS Competitive Bidding
Program. You cannot use the same 10digit PTAN for each location. To make
any changes, click EDIT.

Displayed below is a summary of all the
information for the location(s) included on your
bid. Please carefully review it for accuracy. You
may modify your information or add a new
location. If you do not wish to make any changes
or add another location, select Next. Only
locations identified by the PTAN listed on this
summary page will be eligible to be awarded a
contract and to receive payment under the
DMEPOS Competitive Bidding Program. You
cannot use the same 10-digit PTAN for each
location. To make any changes, click Edit.

DBidS Form A
Screenshot 9

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