CMS-10744.Function Fields Updated

CMS-10744.Function Fields Updated.xlsx

Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program – Contracting Forms (CMS-10744)

CMS-10744.Function Fields Updated

OMB: 0938-1408

Document [xlsx]

Download: xlsx | pdf

Overview

Processes
CHOW
Form C
Subcontractor
Certification Examples

Sheet 1: Processes

Process/Function	Information requested	Why we ask it
Change of Ownership (CHOW) Notification	Y or N - Is assignee an approved Medicare Supplier?	Triggers a warning and additional instructions if assignee is not already approved
	Contract Number	To identify which contract will be impacted (appears for non-contract-supplier only)
	Legal Business Name**	Required to verify eligibility
	Doing Business As Name**	Required to verify eligibility
	Tax Identification Number (TIN)**	Required to verify eligibility
	National Provider Number (NPI)**	Required to verify eligibility
	Authorized Official (AO) Name	Required in case we have questions
	AO Contact Phone Number	Required in case we have questions
	AO Contact Email	Required in case we have questions
	Anticipated Effective Date of Change of Ownership	Required to process change
	[dropdown] Resulting Entitity	Required to process change
	[dropdown] Type of Change	Required to expedite change
	Certification (First Name, Last Name, Connexion User ID)	Required - permission to process change
Disclose a subcontractor	Legal Business Name	Required to identify subcontrator and process disclosure
	Doing Business As Name	Required to identify subcontrator and process disclosure
	Address	Required to identify subcontrator and process disclosure
	Phone number	Required to identify subcontrator and process disclosure
	Type of Service(s)	Required to report what services the subcontractor will provide
	Certification (First Name, Last Name, Connexion User ID)	Required - permission to process change
Form C	Manufacturer Name	Allows user to add a product manufacturer if not already on the list
	Model Name	Allows user to add a product model name if not already on the list
	Model #	Allows user to add a product model number if not already on the list
	Certification (First Name, Last Name, Connexion User ID)	Required - permission to process change

	** these items are requested only to validate against the system of record [the Medicare Provider, Enrollment, Chain, and Ownership System (PECOS)]

Depending on the process/function and the type of user, the user may be asked to select from a list their contract number, PTAN, Product Category, or Competitive Bidding Area

Depending on the process/function and the type of user, the Certification will look different, but will always collect the same information (First & Last Name and User ID)

PRA Disclosure Statement - 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-XXXX (Expires XX/XX/XXXX). This is a mandatory information collection. The time
required to complete this information collection is estimated to average 24 minutes for Form C, 1 hour and 24 minutes for Subcontracting disclosures, 1 hour 36 minutes for
Change of Ownership requests, 36 minutes for suppliers that choose not to Grandfather and 12 minutes for suppliers that choose to Grandfather, 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 comments concerning
the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop
C4-26-05, Baltimore, Maryland 21244-1850. **CMS Disclosure** Please do not send applications, claims, payments, medical records or any documents containing sensitive
information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated
OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents,
please contact Julia Howard 410-786-8645.

Sheet 2: CHOW

*Denotes Required Field

PRA Disclosure Statement - 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-XXXX (Expires XX/XX/XXXX). This is a mandatory information collection. The time

required to complete this information collection is estimated to average 24 minutes for Form C, 1 hour and 24 minutes for Subcontracting disclosures, 1 hour 36 minutes for

Change of Ownership requests, 36 minutes for suppliers that choose not to Grandfather and 12 minutes for suppliers that choose to Grandfather, 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 comments concerning

the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop

C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive

information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated

OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents,

please contact Julia Howard 410-786-8645.

Sheet 3: Form C

*Denotes Required Field