Form CMS-10169 Form B _ Bidding Form

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
Bidder Number.

Date Application Received

Competitive Bidding Area (CBA)

Product Category

Bidder’s Identifying Information
Supplier’s Legal Business Name

Primary Supplier’s Legal Business Name (if network)

FORM B: BIDDING FORM - Please read all instructions completely.
One Form B MUST be submitted for each product category and competitive bidding area (CBA) combinations. 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 include 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 Healthcare Common Procedure Coding System (HCPCS) Codes
1a. For the HCPCS codes listed below, 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 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 Bid Preparation Worksheets at
www.dmecompetitivebid.com for the definition of a unit and additional bidding information.

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 your business organization or network would be capable of
providing for all HCPCS codes in the product category for this CBA during a projected 12 month period. The percentage
increase may exceed 100%. ___________________%

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Legal Business Name

Bidder Number

2. Expansion Plans
Can you increase your current capacity for this product category in this CBA?

 Yes  No

If you answer “Yes” to this question, describe your current structure and expansion plan in the space provided. If a
particular item does not apply, please leave the field blank but ensure you provide an explanation in all applicable
fields. If additional space is needed, you may submit documentation along with the required hardcopy documents
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: _________________________________________________________________

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Legal Business Name

Bidder Number

3. Subcontractor Information
Please note that subcontracting arrangements must be in compliance with the 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), the subcontractor 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

4. Manufacturer and Model Information—

For the HCPCS codes listed below, identify the manufacturer, model name and model number of all products that you plan to

make available 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 information.

HCPCS CODE

Manufacturer

Model Name

Model Number

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Legal Business Name

Bidder Number

FORM B: BIDDING SHEET

Bid Sheet Information:
Most columns are pre-populated for you. You must provide your total estimated capacity along with your bid price for
each HCPCS code or product class listed for this product category.

Column A:

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

Column B:

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

Column C:

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

Column D:

Type of Bid (Rental or Purchase) – Indicates whether your bid should be for the purchase or monthly
rental of the item (identified by the HCPCS code or product class). In most cases you must 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.

Column E:

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

Column F:

Total Estimated Capacity – You must indicate the number of units per HCPCS code or product class
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 or product class, 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. This
number does not reflect the minimum or maximum number of units you may be required to provide but
rather how many units you estimate that you can provide. Please refer to the Bid Preparation
Worksheets, including estimated capacity and bid amount calculations, on the CBIC website
(www.dmecompetitivebid.com) for the definition of a unit for each item to assist you in calculating your
capacity.

Column G:

Fee Schedule –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.

Column H:

Bid Price – You must indicate your bid price for this item. Your bid amount must be 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 or product class 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. Please refer to the Bid Preparation Worksheets, including estimated capacity and bid
amount calculations, on the CBIC website (www.dmecompetitivebid.com for the definition of a unit for
each item to assist you in calculating your bid price.

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Legal Business Name

Bidder Number

Note: You are required to complete Columns F & H.
A
HCPCS
Code

B
Product
Class

C
Item
Description

PREPOPULATED

PRE-POPULATED

PRE-POPULATED

D
Rental or
Purchase
(Type of
Bid)

E
Item
Weight

PREPOPULATED

PREPOPULATED

F
Total
Estimated
Capacity
*

G
Fee
Schedule

H
Bid
Price
*

PREPOPULATED

*Required Field

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Legal Business Name

Bidder Number

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 this certification pages
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
PRINT

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 12 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
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-1016

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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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