Form CMS-10744. Form C CMS-10744. Form C Form C: Semi Annual Report

Form C: SEMI-ANNUAL REPORT
You must complete this report for every competitive bidding area (CBA)/product category combination (competition) in your
Contract and disclose manufacturer and model information for each item specified below by the Centers for Medicare & Medicaid Services
(CMS) that you will offer during the next six months. Please refer to your Contract (Attachment A) for a complete listing of your competitions.
Semi-annual reports are due no later than ten business days after each of the following dates: July 1 and January 1. If the due date for a
particular semi-annual report falls on a federal holiday, the report is due on the next business day. Failure to submit a Form C for all
CBA/product category combination(s) in your contract by the due dates may result in your organization’s removal from the Medicare Supplier
Directory and is a breach of contract.
Prior to submitting the required semi-annual reports, review the Medicare Supplier Directory to determine whether the information is current,
including the lists that indicate which manufacturers’ products you intend to furnish to beneficiaries. You must submit updates so that any
outdated information can be replaced with more current information in the Medicare Supplier Directory.
You must PRINT EACH FORM. ALL forms must be sent (either by mail: Palmetto GBA, Competitive Bidding Implementation Contractor (CBIC),
2743 Perimeter Pkwy, Ste 200-400, Augusta, GA 30909-6499 or fax: 803-264-6228) to the CBIC and RECEIVED by the CBIC by the
deadline.

Business Information
Contract Supplier’s Legal Business Name*

Contract Number* (Check your contract for this number)

If Network, Primary Supplier’s Legal Business Name

Year*

Quarter*

Types of Products
Product Category*
Negative Pressure Wound Therapy (NPWT) Pumps – Example Only
Competitive Bidding Area (CBA)*

Related CBA(s)

Columbia, SC
Lead Item HCPCS Code*

Aiken and Edgefield Counties, SC, Asheville, NC, Charlotte-Concord-Gastonia,

E2402

NC, Raleigh, NC

Make*
Advanced Pumps Therapy System
Manufacturer/Distributor*
Advanced Health
Model Number*

□ No Updates

58EK669964688845564488
Non-Lead Item HCPCS Code
A6550
A7000

Make
A1 Therapy Pump
UB Wound Therapy System

Manufacturer/Distributor
A+ Distributing
UB Company

Model Number
484e5e884e
59596tyyy4667

Product Category*
Competitive Bidding Area (CBA)*

Related CBA(s)

Lead Item HCPCS Code*
Make*
Manufacturer/Distributor*

□ No Updates

Model Number*
Non-Lead Item HCPCS Code

Make

Manufacturer/Distributor

Model Number