Form CMS-10169 Quarterly Report

OMB No. 0938-1016

Form C: QUARTERLY REPORT
This report is used to update the Supplier Directory on the Medicare website at www.Medicare.gov/supplier
with the products you plan to provide during the NEXT quarter.1
Please review your product information in the Supplier Directory before completing this report. You must
complete this report for every competitive bidding area (CBA)/product category combination in your
contract. Please refer to your contract for a complete listing of your CBA/product category combinations.
z

z

If you need to update product information for a CBA/product category combination(s), you must
complete section II.
If you do not need to update product information for specific CBA/product category combination(s),
you must complete section III. Select "I have no updates for any of my CBA/product category
combinations" if you do not need to update product information for any of your CBA/product
category combinations.

Failure to submit a Form C for 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 NOT save. After 60 minutes of inactivity, Form C will
time out and all data entered will be lost.
You may enter all required information at one time and then select “View Completed Form and Print,” OR
you may choose to enter product information for each single CBA/product category combination and then
select “View Completed Form 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 fax) to the Competitive Bidding Implementation Contractor (CBIC) and
RECEIVED by the CBIC by the deadline.
For more information, please view the round-specific Form C FAQs, which can be found on the DMEPOS
Competitive Bidding Implementation Contractor(CBIC) website or by selecting one of the links below.
Round 1 Recompete Form C FAQ
Round 2 Form C FAQ
I. Contract Information If you DO NOT need to update product information, skip sections I and II and only

complete section III.

* - denotes required fields

Does this apply to multiple contracts?
Yes No
Contract Number*
(Check your contract(s) for the contract number.)
Year*
Quarter*
 2014 
2nd 
Legal Business Name*
CBA (Select all that apply)*
Hold CTRL key and click to select multiples
Product Category*



Add PC/CBAs

Review contract and competition information

Delete Contract Number

Product Category

Competitive Bidding Areas

Edit

II. Update(s) to the Supplier Directory
1. Select an Update Type. You may choose to replace all the information on the Supplier Directory for
the CBA/product category combination(s) selected above, or update the information on the Supplier
Directory with additional products.
2. Select a HCPCS code from the drop down. If you choose to replace all the information on the
Supplier Directory, you must enter at least one product for every HCPCS code listed in the drop down
below.
3. Select how you would like to search for products. You may search by manufacturer, model, or

model/product number.

4. Select the product-specific 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 want listed on the Supplier Directory. You may
select all of the 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. If you wish to remove a product from this section, click the next to the
applicable product.
7. Repeat the process to add all the products you plan to make available in the next quarter for the listed
HCPCS codes and for ALL CBA/product category combinations for which you were awarded a
contract.
Select an Update Type:*
Replace all of my information on the Supplier Directory.
Update my information currently on the Supplier Directory with additional products.

Select the HCPCS Code:

HCPCS Code*



Select how you would like to search for products:*
Manufacturer Model Model/Product Number
You can search using at least 3 characters.
Select the following information:*
OR


Search: Go
Search Results:
HCPCS
Select
Manufacturer
Code

Model

Model/Product Number

Select All:
Add Product Information

List of Updates to the Supplier Directory
Delete

Contract HCPCS
Manufacturer
#
Code

Model/Product Number

III. No Updates to the Supplier Directory
If 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*
(Check your contract(s) for the contract number.)

 -

Legal Business Name*

CBA (Select all that apply)*
Hold CTRL key and click to select multiples

Product Category*



If the product information in the Supplier Directory is current for ALL CBA/product category
combinations, check below.
I have no updates for any of my CBA/product category combinations.
Add CBA/Product Category combination

List of CBA/Product Category combination(s) that do NOT need to
be updated in the Supplier Directory
Delete Contract #

CBA

Product Category

Disclaimer:
You are responsible for ensuring that you enter only products that meet the requirements for each HCPCS
code. Products listed in the drop down box for a HCPCS code have been verified by the Pricing, Data
Analysis, and Coding (PDAC) contractor. If you would like to enter a product that is not listed in a drop
down box but are not sure if the product meets the requirements for the HCPCS code, we urge you to contact
the PDAC contractor for coding guidance via the contact form located at www.dmepdac.com/contact. As a
reminder, failure to bill Medicare using the appropriate code may result in substantial penalties under the
False Claims Act and exclusion from the Medicare Program.
View Completed Form and Print