Form A: Crosswalk

Form A Section

Current Field/Language

Revised Placement

Reason for Change

Form A: Business
Organization
Information

N/A - this is a newly added section.

Business Organization Information

Form A: Business
Organization
Information

Contact Person section:
Provide the name(s) of the person(s) who
should be contacted to answer questions
regarding the business organization. You must
click the Add Contact Person button for this
information to be saved below. You may enter
more than one contact person (maximum five).
Once you have entered the name(s) of your
contact person(s), scroll down to verify the
name(s).

N/A - the Contact Person section and the
corresponding fields on the Form A Business
Organization Information screen have been
removed.

The Contact Person section is no longer required
and has been removed, as this information can
be received from the Provider Enrollment,
Chain, and Ownership System (PECOS).

N/A - the Authorized Official or Key Personnel
section and the corresponding fields on the
Form A Business Organization Information
screen has been removed.

The Authorized Official or Key Personnel section
is no longer required and has been removed, as
this information can be received from the
Provider Enrollment, Chain, and Ownership
System (PECOS).

N/A - the Accrediting Organization field in the
Accreditation Information section has been
removed.

The Accrediting Organization field in the
Accreditation Information section has been
removed to streamline Form A and eliminate
non-essential data collection as it can be obtain
from the Provider Enrollment, Chain, and
Ownership System (PECOS), improving user
experience.

Form A: Business
Organization
Information

Form A: Business
Organization
Information

First Name
Last Name
Title
Telephone
E-Mail
Authorized Official or Key Personnel section:
Provide the name(s) and title(s) of the
authorized official(s) or key personnel for the
business organization. You must click the Add
Authorized Official or Key Personnel button for
this information to be saved below. You may
enter more than one authorized official or key
personnel (maximum five). Once you have
entered the name(s) of your authorized official
or key personnel, scroll down to verify the
name(s).
First Name
Last Name
Title
Accreditation Information section
By the close of the bid window, all locations
must meet Medicare enrollment requirements,
including being accredited for all items in the
product category(s) for which you are bidding.
As required by 42 CFR § 414.414(c), each
supplier location must be enrolled, meet quality
standards, and be accredited to be awarded a
contract. Only eligible locations will be included
on the contract.

As a result of the decreased covered document
submission requirement CMS would no longer
I attest that the bidding organization qualifies as be able to utilize revenue data from the bidding
a small supplier under the definition provided
entity’s tax return to determine if it meets the
by the Centers for Medicare & Medicaid
definition of a “small supplier” in the DMEPOS
Services (CMS) for the DMEPOS Competitive
CBP (that is, a bidding entity that generates
Bidding Program.
gross revenue of $3.5 million or less in annual
receipts including Medicare and non-Medicare
revenue). To address this, CMS is proposing to
add a question to Form A (Application for
DMEPOS Competitive Bidding Program) that
would allow a bidding entity to attest whether it
meets the definition of a small supplier.

Select the name(s) of the Medicare-approved
organization(s) that has accredited the
location(s) in your business organization.
You must click the Add Accreditation button for
this information to be saved below.
You must also review and acknowlege that you
have read and agree with the statement below.
Click the box to accept.
Accrediting Organization (Select Accrediting
Organization)
Form A: Business
Organization
Information

Accreditation List section

N/A - the Accreditation List section and
corresponding field on the Form A Business
To delete your accreditation information, click Organization Information screen has been
the Delete button next to the applicable
removed.
accrediting organization. To change this
information, you must delete the entry and add
a new accrediting organization.

The Accreditation List section and corresponding
field has been removed to streamline Form A
and eliminate non-essential data collection as it
can be obtain from the Provider Enrollment,
Chain, and Ownership System (PECOS),
improving user experience.

Form A: Business
Organization
Information

Business Information - Years in Business
section

The Business Information - Years in Business
section and corresponding fields have been
removed to streamline the Form A and
eliminate non-essential data collection as it will
be included on financial documentation
provided by the bidder, improving user
experience.

Provide the number of years and month your
organization has been in business.
Organization Years in Business
Organization Months in Business
Example: 5 years and 7 months or 0 years and 6
months.

N/A - the Business Information - Years in
Business section and corresponding field on the
Form A Business Organization Information
screen has been removed.

Form A Section
Form A: Business
Organization
Information

Current Field/Language
Service Delivery section
How will your organization furnish items and
services to Medicare beneficiaries?

Revised Placement
N/A - the Service Delivery section and
corresponding field on the Form A Business
Organization Information screen has been
removed.

Reason for Change
The Service Delivery section and corresponding
field on the Form A Business Organization has
been removed to streamline the Form A and
eliminate non-essential data collection,
improving user experience.