Crosswalk for Form B

Form B 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

Top HCPCS Codes

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 nonMedicare, 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 the
American Samoa.

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 Bid Preparation Worksheet and the
Estimated Capacity and Bid Amount Calculations on
the CBIC website (www.dmecompetitivebid.com) for
the definition of a unit and additional bidding
information.

DBidS Form B
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Top HCPCS Codes

Expansion Plans

Indicate the percentage increase in
Medicare business that you would be
capable of providing for all HCPCS codes in
this CBA during a projected 12-month
period. The percentage increase may
exceed 100%.
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.

No
Yes

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 DBidS Form B
category for this CBA during a projected 12 month
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period. The percentage increase may exceed 100%.
Can you increase your current capacity for this product
category in the CBA? If yes, you must complete an
expansion plan.

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
If you plan to expand your business under leave the field blank but ensure you provide an
explanation in all applicable fields. If additional space
the Competitive Bidding Program,
is needed, you may submit documentation along with DBidS Form B
describe your current structure and
expansion plan in the space provided. If the required hardcopy documents
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additional space is needed, you may
submit documentation along with the
required hardcopy documents. (Maximum
1000 Characters). If an item does not
apply, please enter N/A.

Subcontractor
Information

If you plan to expand using subcontractors
choose "Yes" below. Please note that
"Subcontractor Agreements" 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), they
must be accredited by a CMS approved
accreditation organization. Click on the
"i" above for more specific requirements.
Do you plan to use subcontractor(s)?
 No
Yes

Bid Sheet

HCPCS

If you plan to expand using subcontractors, select Yes
below. 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 Medicarecovered item(s), the subcontractor must be accredited DBidS Form B
by a CMS approved accreditation organization. Click on Screenshot 2
the "i "above for specific requirements.

Do you plan to use a subcontractor(s)?
 No
Yes



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

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

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

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

DBidS Form B
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DBidS Form B
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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
o    If “Purchase” is indicated,
Type of Bid (Rental rental.
enter a bid amount for total purchase of
or Purchase)
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.

Indicates whether your bid should be for the purchase
or monthly rental of the item (identified by the HCPCS
code or payment 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.
DBidS Form B
• If “Rental” is indicated, enter a bid price for one
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month’s rental of the item. It is very important that
you review your bid amount and ensure it was entered
correctly.

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.

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
DBidS Form B
number does not reflect the minimum or maximum
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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.

This indicates the fee schedule amount for Indicates the fee schedule amount for the HCPCS code
the HCPCs code in this CBA. You must
in this CBA. You must provide a bid price that is less
provide a bid price that is less than or
than or equal to the fee schedule amount.
Form B-3.jpg
equal to the fee schedule amount.
Fee Schedule

Indicate your bid price for this item. You
should 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.

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 DBidS Form B
CBA (except for skilled nursing facilities and nursing
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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.

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
Manufacturer and all products that you plan to make
Model Information available to Medicare beneficiaries in this
CBA. You must provide information for
each HCPCS code in order for your bid to
be complete.

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.
DBidS Form B
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Bid Price

If you are bidding in the national mail
THIS LANGUAGE WILL BE DELETED ON THIS PAGE.
order competition for diabetic testing
supplies, national mail-order competition
you must provide manufacturer and
model information for the codes
identified below. In order to meet the
50% rule you must complete the "50
Percent Compliance Form" located on the
CBIC website identifying the products you
Manufacturer and
plan to provide for HCPCs code A4253. In
Model Information
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
Manufacturer and Directory located at
Model Information http://www.medicare.gov.

DBidS Form B
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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 DBidS Form B
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current, suppliers who are awarded a contract are
required to submit a quarterly report updating the
manufacturer and model information.