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DBidS User Manual

1. CBA Product Category List Displayed below is a summary of the CBA s and Product Categories for which you intend to submit a bid Please review for accuracy en ie F era PA Non Test_Oxygen Supplies and Equipment represe PA Non Test_Standard Power Wheelchairs Scooters and EA v This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Save Next Figure 85 DBidS Form A Business Organization Information This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 76 Edaptive intelligently Adapting Technology DBidS User Manual LZ AY DMEPOS BIDDING SYSTEM DBids Bidder 20 2642067 Test Test Welcome HEIMLICH BUGZLIFE Navigation Form A Location Specific Information Print Save Next i Status Page gt Business Organization Types gt Modify Form A Please provide the requested information for each location in your business organization You must provide the unique National Supplier Clearinghouse NSC Provider Transaction Access Number PTAN that applies to each a ae E location The NSC PTAN is hereafter referred to as PTAN If you are bidding as a network the primary network member should provid
2. This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Navigation Form B Manufacturer Print Status Page gt Business Organization Types gt Modify Form A Create Form B Bidder 20 4099116 Modify Form B CBA Test_Orlando Kissimmee FL Non Mail Order Select Bid Product Category Test_Oxygen Supplies and Equipment gt Help PTAN s 1001022210 Logout Welcome Test Test Back Next Print Back Next Figure 70 Form B Manufacturer Page Update the information in the Manufacturer Model Name and Model Number panes Refer to Figure 71 Manufacturer Model Name and Model Number Panes e Manufacturer field Type the manufacturer name e Model Name field Type the model name e Model Number field Type the model number e Click the Add Manufacturer Model Name amp Model Number button to add the information The recently added data displays in the bottom Manufacturer Model Name and Model Numbers pane and the top Manufacturer Model Name and Model Number pane is cleared to allow entry of additional information Repeat the above steps to add additional information e Click the Modify button in the bottom Manufacturer Model Name and Model Numbers pane to modify information The information for the selected manufacturer populates the top Manufacturer Model Name an
3. Modify Delete Contact Person s Modify or delete the contact person s information Figure 10 Contact Person Panes This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 13 Edaptive Intelligently Adapting Technology DBidS User Manual Update the information in the Authorized Official or Key Personnel pane Refer to Figure 11 Authorized Official or Key Personnel Panes e First Name field Type first name of authorized official This is the name on the PTAN file e Last Name field Type last name of authorized official This is the name on the PTAN file e Title field Type title of authorized official e Click the Add Authorized Official or Key Personnel button The recently added data displays in the Modify Delete Authorized Official Key Personnel Information pane and the Authorized Official or Key Personnel pane is cleared to allow entry of additional information Repeat the above steps to add additional personnel A maximum of five personnel per Business Organization is allowed e Click the Modify button in the Modify Delete Authorized Official Key Personnel Information pane to modify personnel The information for the selected contact populates the Authorized Official or Key Personnel pane e Modify the required fields e Cli
4. ccecccceseeeeeeeeeeeeeees 93 Certification with Message Displayed only to AOs and BAOs 93 SUN DOE eseina n eie uiii siin iiini iis irii iii 94 This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document Vill Edaptive intelligently Adapting Technology DBidS User Manual List of Tables Table 1 S6chon 302 ofthe MMA orsersercececrresassse cepmrencnmewnsniacmetunatemedengeeapetetsusesneptedstepatadetepoiatoneeunatengeeneneum l Table lt DBid Enor MoI E E E 68 Table 3 Frequently Asked Questions ccccccseccccseeccceeeeeaeeeeeseeeeeeneeeseeeeeseeeeeeseeeeeseeeeeaeseesseneesaeeeeaes 69 Tibe 4 Terms and et UL ON serer e cass asses eco eee eae eee ee 70 This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 1X Edaptive Intelligently Adapting Technology DBidS User Manual 1 Introduction The Centers for Medicare amp Medicaid Services CMS Durable Medical Equipment Prosthetics Orthotics and Supplies DMEPOS Bidding System DBidS Application User Manual provides an introduction to the DMEPOS program to include a description of the application and its purpose a h
5. Optional Click the Edit button in the Accreditation pane to edit any of the information The Form A Location Specific Information page 2 page displays Scroll if necessary to the Accreditation pane Refer to Section 5 5 2 Update Form A Location Specific Information page 2 for instructions on updating this section Accreditation Organization Product Specific Area s Status Issue Date Expiration Date Accreditation Commission for Healthcare Inc Oxygen Standard PMDs Accredited 12 2009 12 2011 Figure 36 Accreditation Pane Review the information in the Licensure pane Refer to Figure 36 Accreditation Pane Optional Click the Edit button in the Licensure pane to edit any of the information The Form A Location Specific Information page 2 page displays Scroll if necessary to the Licensure pane Refer to Section 5 5 2 Update Form A Location Specific Information page 2 for instructions on updating this section Licensure State Licensure Text Test licensure type text FL Figure 37 Licensure Pane Review the information in the Sanctions pane Refer to Figure 38 Sanctions Pane Optional Click the Edit button in the Sanctions pane to edit any of the information The Form A Location Specific Information page displays Scroll af necessary to the Sanctions pane Refer to Section 5 5 1 Update Form A Location for instructions on updating this section Does this location have any c
6. Test Sole Proprietorship Accreditation Organization Product Specific Area s Expiration Date Accreditation Commission for Healthcare Inc Test_Oxygen Supplies and Equipment 06 2012 Licensure Information fasdasdffds ns Does this location have any current or past legal actions or sanctions such as debarments litional Locations Netwc ers Net m D Select the below to review the information for this location Access to Supplier Checklist and Approval screens are restricted to only Authorized Officials and Backup Authorized Officials This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Print All Locations Back Next Figure 93 DBidS Form A Summary This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 83 Edaptive intelligently Adapting Technology DBidS User Manual CATS DMEPOS BIDDING SYSTEM DBids Form Ar Checkitst Print Datum Page Duseese Crgacicatos Types MeD Form amp Gute 10142941 1057 44 bee PT AMS 1007092210 Legost Bilder Mumrteer 20 4991 16 Suppber Type TeatSegiei ncatorfcxter E you have ary questions piesse contact the Competitie Siding Implementation Contractor CBC custome
7. CENTERS for MEDICARE amp MEDICAID SERVICES Durable Medical Equipment Prosthetics Orthotics amp Supplies DMEPOS Bidding System DBidS DBidS Application User Manual Version 2 10 Last Modified Date January 5 2012 Prepared for The US Department of Health amp Human Services Centers for Medicare amp Medicaid Services CMS Office of Information Services 7500 Security Boulevard Baltimore Maryland 21244 1850 Prepared by Edaptive Systems 400 Red Brook Blvd Suite 220 Owings Mills Maryland 21117 410 327 3366 Document Control Number DBidS0O077_User_Manual Contract HHSM 500 2010 00020C Edaptive intelligently Adapting Technology DBidS User Manual Table of Contents vec aa A ee E er rT Bee Re INO SC a crscicasciers ce etscsernve eine gncis anise seve aejncie geeeisneiseieesoseneae ensues lene ee eat ce ancosaee cance esate ect sae eet ae sence cee DB ASACK COMM s2325ssacessanesanegnsenenessaensosacosasaeadosadacasaeaooadteistsescaeseeeaeseae cece EE EA EE EEE EE EEE E EE EE e AMET ASN a E E E E O ees kede UTERO ea a E A E E A A E A E E k TOW WO se Cis Oe inte 1 E ob bean oe sb ascect du seerus openeeloseeeae Dede DELS TIe Lay OU a E N E AEE EE EE E EE 4 4 Standard Navigation Buttons c cccccccccsescccseecceeecceeeeeeeaeecesensceseeseesseseessecessseesseseeesseeeaenes Aa Menma 3 2 ds ee ee ener eee eT De WS TC 1 APICI ON arts ass rst es es ess sess EEEE E E EE EE E E EEE EE Ie SCLIN TAI cr
8. NOT BY CODE Rental 0 0000000000 175 79 Test_Stationary compressed gas 02 BID FOR ENTIRE CLASS NOT BY CODE Test_Oxygen concentrator dual BID FOR ENTIRE CLASS NOT BY CODE a 3 Test_Portable gaseous 02 BID FOR ENTIRE CLASS USING THIS CODE Test_Portable liquid 02 BID FOR ENTIRE CLASS NOT BY CODE Test_Portable gas oxygen system BID FOR ENTIRE CLASS NOT BY CODE Test_Portable oxygen concentrator BID FOR ENTIRE CLASS USING THIS CODE amp amp x x Test_Oxygen contents gaseous BID FOR ENTIRE CLASS USING THIS CODE Test_Oxygen contents liquid BID FOR ENTIRE CLASS NOT BY CODE 0 396515 0 0000000000 This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Test_Portable 02 contents gas BID FOR ENTIRE CLASS USING THIS CODE 0000000000 36026 0000000000 0000000000 0000000000 0000 0001998807 Test_Portable 02 contents liquid BID FOR ENTIRE CLASS NOT BY CODE Print Save Back Next Figure 102 DBidS Form B Bid Sheet This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 90 Eda Intelligently Adapting Technology CATS tive DBidS User Manual DMEPOS BIDDING SYSTEM DB
9. must provide a bid price that is less than or equal to the fee schedule amount e Bid Price Indicate your bid price for this item You should submit a bona fide bid amount for each HCPCS code The amount submitted should 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 should 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 This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 57 Edaptive Intelligently Adapting Technology DBidS User Manual DMEPOS BIDDING SYSTEM DBidS Bidder 20 4099116 asdfasd Welcome Test Test Navigation Form B Bid Sheet Satano an Print Save Back Next Status Page gt Business Organization Types gt Modify Form A Bidder 20 4099116 Create Form B CBA Test_Orlando Kissimmee FL Non Mail Order gt Modify Form B Product Category Test_Oxygen Supplies and Equipment Select
10. or sanctions such as debarments Option selection Click Yes or No Application defaults to No Click Yes if applicable e If yes please provide additional information regarding any previous or current sanctions Maximum 1000 characters text box If Yes type description of any previous or current sanctions Please note the user is required to manually enter text into the sanctions text box copy paste function from another source is not accepted and may result in an error If using special characters please use the International keyboard or Alt Control buttons to enter the information Indicate whether this location as identified by the PTAN above has been subject to any current or past legal actions or sanctions such as debarments within the past five 5 years Does this location have any current yes No or past legal actions or sanctions E such as debarments Figure 22 Sanctions Pane This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 24 Edaptive intelligently Adapting Technology DBidS User Manual Click Next The Form A Location Specific Information page 2 page displays 5 5 2 Update Form A Location Specific Information page 2 This process provides the procedures involved in updating Form A Location Specific Informat
11. A Approval Print Back Next Status Page Business Organization Types b Modify Form A Required fields are marked with gt Help Logout Approval The Authorized Official AO or Back up Official BAO must approve Form A before proceeding to Form B The User ID assigned during registration must be identified in your response First Name 7 4 Today s 10 13 2011 Date 16 08 35 Open Bid 01 18 2011 Date 09 00 00 Last Name UserID After the AO or BAO approves Form A the AO or BAO must re approve Form A if any changes are made to this form Close Bid 12 31 2011 Date 13 59 59 This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Back Next A aN a Figure 41 Form A Approval Page Print to PDF screen is accessed when you click on Approve on the Form A Approval page Refer to Figure 42 Form A Summary PDF This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 34 Edaptive intelligently Adapting Technology DBidS User Manual peids Application Windows Internet Explorer lt W EUT C TS DMEPOS BIDDING SYSTEM DBids Bidder 20 3509843 Whitemore Shoes Welcome Janet
12. BAO must provide specific information and approve or certify forms Multiple users may enter data in the system at the same time However only one person may enter data on the same form Form A or Form B at the same time Please carefully read the DBidS Technical User Guide before you begin completing the forms If you need help throughout the application please click on the 1 at the top of the screen e www dmecompetitivebid com Before completing the forms and submitting a bid all bidders should carefully review information such as the RFB instructions bidding charts financial documentation requirements and state and local licensure rules on the DMEPOS Competitive Bidding Program Website e Privacy Policy Click to view save or print a copy of the CMS Privacy Policy relating to Web Policies at the CMS Website 5 3 Managing Business Organization Types These sections provide detailed instructions for managing Business Organization Types DBidS will display two distinct pages to capture location specific information DBidS displays a Page Header for page one titled Form A Location Specific Information DBidS displays a Page Header for page two titled Form A Location Specific Information page 2 These instructions assume that the user has already logged in A This section must be completed If this section is not completed no data will be saved This information is vital to moving forward within the application The i
13. Close Bid 01 31 2011 Date 13 59 59 Internet Protected Mode On 100 Figure 84 DBidS Select PTAN to Create Form A Organization with Multiple Locations This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 75 Edaptive intelligently Adapting Technology DBidS User Manual C S DMEPOS BIDDING SYSTEM DBids Welcome Ben Teen Navigation Form A Business Organization Information Print Save gt Business Organization Types gt Help Logout Business Organization Information is required for each supplier type supplier single location supplier multiple locations or network supplier You must complete all required fields Required fields are marked with g Business Organization Information Today s 11 15 2011 Date 14 54 57 Indicate how your business organization will be bidding choose only one Open Bid 01 18 2011 Legal Business Name Date 09 00 00 TEST Close Bid 12 31 2011 i iddi 3 D coe 13 i 9 Supplier Bidding Type TestSingleLocationBidder Specialty Supplier Indicate if you are bidding as a specialty supplier Are you a Skilled Nursing Facility SNF or Nursing O Yes No Facility NF that is bidding as a specialty supplier that plans to provide competitively bid items
14. FOR ENTIRE CLASS USING THIS CODE Rental 0 0000000000 5 745 5 00 E0442 Test Oxygen contents liquid BID FOR ENTIRE CLASS NOT BY CODE Rental 00000396515 5 877 45 5 00 E0443 Test Portable 02 contents gas BID FOR ENTIRE CLASS USING THIS CODE Rental 0 0001998807 5 74 soo 0444 ___Test_Portable 02 contents liquid BID FOR ENTIRE CLASS NOT BY CODE Rental 00000000000 J S 87785 5 00 Figure 76 Bid Sheet Pane This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 61 e Edaptive Intelligently Adapting Technology DBidS User Manual Review the information in the Top HCPCS Manufacturer Model Name and Model Number pane Refer to Figure 77 Top HCPCS Manufacturer Model Name and Model Number Pane Optional Click the Edit button in the Top HCPCS Manufacturer Model Name and Model Number pane to edit any of the information The Form B Manufacturer page displays Scroll if necessary to the information to be edited Refer to Section 5 6 Creating a Form B for instructions on updating this section Top HCPCS Manufacturer Model Name and Model Number HCPCS Code Manufacturer Model Name Model Number E0431 Model Name Model Number E0439 test test test E1390 U aa EE Figure 77 Top HCPCS Manufacturer Mode
15. Licensure Information Pane Update the information in the Sanctions pane Indicate whether this location as identified by the PTAN above has been subject to any current or past legal actions or sanctions such as debarments Refer to Figure 52 Sanctions Pane This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 44 Edaptive intelligently Adapting Technology DBidS User Manual e Does this location have any current or past legal actions or sanctions such as debarments Option selection Click Yes or No Application defaults to No Click Yes if applicable e If yes please provide additional information regarding any previous or current sanctions Maximum 1000 characters text box If yes type description of any previous or current sanctions Please note the user is required to manually enter text into the sanctions text box copy paste function from another source is not accepted and may result in an error If using special characters please use the International keyboard or Alt Control buttons to enter the information indicate whether this location as identified by the PTAN above has been subject to any current or pest legal actions or sanctions such as debanments within the past five 5 years Does this location have any current yes O No or p
16. Logout Business Organization Types Today s 08 03 2011 Date 13 27 46 Open Bid 01 18 2011 Date 09 00 00 Close Bid 09 30 2011 9 59 Date 23 Click Next DBidS User Manual Logout E DMEPOS BIDDING SYSTEM DBidsS Welcome Janet Whitmore Form A Network Member Print Save Back Next Required fields are marked with Add Network Member Please enter the network member name and indicate the contract status You must click the Add Network Member button in order for this information to be saved below After member s information is displayed below click the Add Location button to complete member s location information Only network members identified by their PTANs are eligible to be awarded a contract Network Member Name Jane Doel Add Network Member Clear Network Members Network Member Action s John Doe Modify Delete Add Location No Locations Saved Modify Delete Add Location _ No Locations Saved This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Save Back Next Figure 63 Form A Network Member Panes The Form A Summary page redisplays organized into multiple panes Refer to Section 5 5 4 Review Update Summary for information on the summary Click Next The Form A Checklist page displays organized into multip
17. Once the location s is added the PTAN associated to the location s for the network member displays below the network member name on the Form A Network Member page e Modify the required fields Refer to Section 5 5 15 Add Location for instructions on modifying these fields e Click the Add Location button in the Network Member pane to add a network member location The Form A Add Location page displays This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 45 Edaptive intelligently Adapting Technology DBidS User Manual e Click the Modify button in the Network Member pane to modify network member information The Form A Add Location page displays e Add the required fields e Refer to Section 5 5 15 Add Location for instructions on adding a network member location e Optional Click the Delete button in the Network Member pane to delete a network member C 7S pmeros BIDDING SYSTEM DBids Bidder 20 3509843 axsdd Welcome Janet Whitmore Navigation Form A Network Member Print Save Back Next Status Page Business Organization Types gt Modify Form A Required fields are marked with b ya Add Network Member Please enter the network member name and indicate the contract status You must click the Add Network Member button in
18. Refer to Figure 9 Licensure Pane Do the locations included on your bid comply with the licensure requirements for the CBA Product Category Option selection Click Yes No or N A Application defaults to Yes click No or N A if applicable Some states may not require a license to furnish items in a specific product category Please check the DMEPOS State License Directory on the NSC website and the Licensure for Bidding Suppliers fact sheet on the CBIC website to verify licensure requirements Licensure The bidder is responsible for having a copy of the applicable state license s on file in the Provider Enrollment Change and Ownership System PECOS and with the National Supplier Clearinghouse NSC before they submit a bid Bids will be disqualified if a bidder does not meet all state licensure requirements for the applicable product categories and for every state in a CBA Every supplier location is responsible for having all applicable license s for each state in which it provides services For a multi state CBA the bidder must collectively have all applicable license s for every state in the CBA Each location is not required to have licenses for every state in the CBA as long as each state has a bidding location licensed for the product category For the national mail order competition the CBA includes all parts of the United States including the 50 states the District of Columbia Puerto Rico the U S Virgin Islands Guam and A
19. Subcontractor Information Panes Click Save or Next The Form B Bid Sheet page displays Update the information in the Bid Sheet pane The following list provides a description of the non modifiable fields on the form e HCPCS Healthcare Common Procedure Code System This is a standardized coding system that is used primarily to identify products supplies and services e Product Class A combination of codes for which a single bid is required This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 56 Edaptive Intelligently Adapting Technology DBidS User Manual e Item Description Short narrative description of each HCPCS code For long description go to www dmecompetitivebid com e Type of Bid Rental or Purchase 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 rental o If Purchase is indicated enter a bid amount for total purchase of 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 c
20. Update Form A Location for instructions on updating this section Tax Identification Number TIN Tax Identification Number 473798397 Figure 29 Tax Identification Number TIN Pane Review the information in the Doing Business As DBA pane Refer to Figure 30 Doing Business As DBA Pane Optional Click the Edit button in the Section Doing Business As DBA pane to edit any of the information The Form A Location Specific Information page displays Scroll if necessary to the Business Information pane Refer to Section 5 5 1 Update Form A Location for instructions on updating this section Doing Business As DBA Doing Business As DBA 1 Doing Business As DBA 2 Figure 30 Doing Business As DBA Pane Review the information in the Contact Person pane Refer to Figure 31 Contact Person Pane Optional Click the Edit button in the Contact Person pane to edit any of the information The Form A Business Organization Information page displays Scroll Gif necessary to the Contact Person pane Only an AO or BAO may edit this page as it applies to supplier creation Refer to Section 5 3 1 Create Business Organization for instructions on updating this section Contact Person 2r dio o o First Name Last Name Title Telephone E Mail Jane Doe CEO T455836465 JaneD aol com Figure 31 Contact Person Pane This document contains confidential information Disclosure is restr
21. a message box will be displayed notifying the user that if you continue you will exit the application e Product Specific Area s checkboxes Displays and must be completed if Accredited is selected Check all that apply e Issue Date text boxes Displays and must be completed if Accredited is selected Type the issue date in mm yyyy format in the month and year text boxes e Expiration Date text boxes Displays and must be completed if Accredited is selected Type the expiration date in mm yyyy format in the month and year text boxes e Click the Add Accreditation button to add an organization The recently added data displays in the Modify Delete Accreditation Information pane and the Accreditation pane is cleared to allow entry of additional information Repeat the above steps to add additional criteria e Click the Modify button in the Modify Delete Accreditation Information pane to modify accreditation information The information for the selected organization populates the Accreditation pane e Modify the required fields DBidS displays selected accreditation s under the Section Header titled Modify Delete Accreditation Information e Click Modify Accreditation Information when modifications are complete The updated information displays in the Modify Delete Accreditation Information pane e Optional Click the Delete button in the Modify Delete Accreditation Information pane to delete an organization e Licen
22. a minimum of one CBA and one Product Category The selection you enter will display later in the application If a CBA and Product Category are not selected you will not be able to complete the required information in the application e CBAs drop down list Click the drop down arrow and select the CBA from the list provided e The Product Categories box will update with the Product Categories available for the CBA selected e Check or uncheck Product Categories checkboxes to make changes to the categories to submit a bid for this CBA e Click the Add CBA Product Category button to add a CBA The recently added data displays in the CBA Product Category List pane and the Competitive Bidding Area CBA and Product Category pane is cleared to allow entry of additional information Repeat the above steps to add additional CBAs e Optional Click the Delete button in the CBA Product Category List pane to delete a specific CBA and Product Category Competitive Bidding Area CBA and Product Category For Round 2 select all of the CBA s and product category s for which your business organization or network is submitting a bid s If you are bidding in the national mail order competition for diabetic testing supplies select National Mail Order from the drop down list of CBAs Choose one CBA from the drop down box The product category s for the selected CBA will appear Then select all of the product category s for which you are submitting a
23. actvten fmm ater Peete scivten Cost ot piots sue 7 Begmrng ard entry boomer popis t tepenaen by categery le lt y cash saasom 2 Met Recaro ST ee form 188 pepa t can celeron uoa oaren yew Ne erect a tax rotura haa tne tated Wawel jet eoude sep Tore Hee a Oe Porio 2008 ter ee ore oe wus ecuce Covent meeanes erties tees Total Mebane Degmrrg aed endea fo Fore 960 pages Tote oct assets oF Ca Mees oos t toc temrces Comvector t pau thet o tax mtem Treen f 2 kam rebre hes boor at reper D sere fiac reter ts e sowani farm 1120 pages t te form 11225 pages t Stectoocters egay capi eA Ky c sda cared mganrseces mal oae E Cw mara ot nd hor pect rewan werner rater to Pe rewon nanma hres sene Por ten esiet CONG POE EST RCL UTE Foren 1120 pages Gar Revere form 11295 pagent 4 MUST BE MERMADA aparer Famcag savtes one OF ne rererere c bemir ateen CaL Oweap Cost at goods sais Dogme as enira oeroet by cabegery COW togets Ow toore Met oore tes bew hata Traesamce Sues ory The rogaret tan IERM OF yesi DONATA ped nd BAEP Tem CORE You Ma MORN F ybs Reve Aey sioe Cdi nperi rast reflect s comerta score beiss yos ane sarg Stecdert end Dcera Dendari Poors cect mpor uses st soha score rebred of s romere atore Peretere fhe spori rmat cortet Pr APAD POSE poh OA AAA AA 40 Dapit wE 48 Era DOCA De Hebe Vales S CHEE amp a DEKE MOON PORNO De RelSer i days Depend ETI ae ret oceane
24. at www dmecompetitivebid com bic for the definition of a unit for each item Fee Schedule This indicates the fee schedule amount for the HCPCS code in this CBA For items included in the national mail order competition for diabetic testing supplies the fee schedule amount is the average amount for all parts of the United States including the 50 States the District of Columbia Puerto Rico the U S Virgin Islands Guam and American Samoa You must provide a bid price that is less than or equal to the fee schedule amount Bid Price Indicate your bid price for this item You should submit a bona fide bid amount for each HCPCS code The amount submitted should 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 should 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 i Rental Or Item Total Estimated Fee Bid Class Description Purchase Weight Capacity Schedule Price Test_Oxygen concentrator BID FOR ENTIRE CLASS USING THIS CODE Rental 0 6108082987 175 79 Test_Stationary liquid 02 BID FOR ENTIRE CLASS
25. attempt is made to access a Form A and a message is received indicating that the account is locked the account remains locked until the current user logs out of the application In the event of a system error that generates a locking issue reattempt login in 30 minutes ON Click the Next Back or Save button to save any additions or changes made to the current page once all required information has been entered This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 36 Edaptive Intelligently Adapting Technology DBidS User Manual 5 5 8 Update Form A Users with Multiple PTANs Associated with User ID This process provides the procedures involved in updating Form A when more than one PTAN is associated with the User ID The following page displays upon entry into the application Refer to Figure 43 Select PTAN to Create Form A Page e Optional If the Select PTAN to Create Form A page is not displayed click Business Organization Types gt PTAN Selection from the menu The Select PTAN to Create Form A page is displayed Navigation Select PTAN to Create Form A 4 Business Organization Types PTAN Selection 4 Listed below is the PTAN s that you used for registration purposes Please select the PTAN below for which you would like to com
26. bid for this CBA You must click the Add CBA Product Category button in order for this information to be saved below If you are bidding in more than one Round 2 CBA select Add CBA Product Category Once you have selected the CBA s and product category s scroll down to verify they were entered correctly All of the CBA s and product category s for which your organization will be bidding must be displayed on this screen Later in the application you will be required to identify the CBA s and product category s associated with each of your locations Note Networks are excluded from bidding in the national mail order competition CBAs Select the CBA hi Product Categories No Product Categories Found Add CBA Product Category CBA Product Category List Displayed below is a summary of the CBA s and Product Categories for which you intend to submit a bid Please review for accuracy No CBA Product Categories Saved Figure 12 Competitive Bidding Area CBA and Product Category Panes Click Next Once you have completed the Business Organization page you are assigned a bidder number that identifies your organization A message will display with the bidder number once you click on the Save or Next button Once the bidder number is assigned it will be displayed in the top left hand corner of the screen The bidder number will only be displayed after you have completed all required fields on the Business Organi
27. certify Form B The term User is used throughout this document to refer to all users of the application regardless of role or privileges 4 2 How to Use this Document The main body of this document Section 5 Using the DBidS Application provides all screens and procedures within the application Depending on privileges access to some screens may be limited The remaining sections of this document provide ancillary information that may be useful when performing daily DBidS tasks The following conventions have been adopted for use in this manual An m points out an item that is named in the procedure e Exact page names menu item names and button names if not presented as an image are represented with bold text e References to section table or figure links that navigate to another section of the online User Manual and references to application links within the step by step procedures are represented with italic text e Within a numbered procedure optional steps are preceded by Optional This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 2 e Edaptive Intelligently Adapting Technology DBidS User Manual e Within a numbered procedure selection of a submenu item is depicted as follows Main Menu gt Sub Menu e Emphasis is expressed with un
28. eer i Deak dees Dared OSS eee a Dnk inire pane Fiai iai arpg m Lee rete ee ee ites pre Lease Fes ee Figure 67 Expansion Plan Pane Please note the user is required to manually enter text into the expansion text box copy paste function from another source is not accepted and may result in an error If using special characters please use the International keyboard or Alt Control buttons to enter the information e Staff Current 1000 characters left text box List the current staff If listing of staff will exceed the 1000 character maximum utilize the Additional Information text boxes If the staff listing exceeds this additional entry area additional content may be mailed to the CBIC with the hardcopy package submission e Staff Expansion Plan 1000 characters left text box List any planned modifications or additions to staff e Finance Current 1000 characters left text box Describe the current financial plan e Finance Expansion Plan 1000 characters left text box Describe any planned modifications to the financial plan e Facilities Current 1000 characters left text box Describe the current facilities This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 55 Edaptive intelligently Adapting Technology DBidS User Ma
29. fields are marked with Identifying Information Provide the legal business name and mailing address for the business organization identified by the PTAN below important Note PTAN must be unique to this location Today s 08 15 7011 L i Busine Name Date 12 42 36 ee asdfasdf Open Bid 01 18 2011 Address Line 1 adfsadf Date 09 00 00 s Close Bid 09 30 2011 Address Line 2 Date 23 59 59 7 City asdfasd State Minnesota Zip Code 54564 E Mail sdasfasdfsdaf aol com Telephone Number 654 654 6546 Toll Free Number if available li PTAN for this location 9898880001 Confirm PTAN for this location 9898880001 NPI Identification Number 6546546546 Tax Identification Number TIN 564654645 Physical Address Provide the physical address for the location as identified by the PTAN above in the identifying Information question Physical address is the same as identified above Address Line 1 sadfsadf Address Line 2 City asdfasd State Minnesota Zip Code 64564 Business Information Provide the length of time in business for this location as identified by the PTAN above Years in Business Months in Business Examples 5 years and 7 months or 0 years and 6 months Doing Business As DBA Accreditation Information Select the name s of the Medicare approved organization that has accredited this location The location must be accredited for the product category for which you are bidding You m
30. for the CBA Product Category Some states may not require a license to furnish items in a specific product category Please check the DMEPOS State License Directory on the NSC website and the Licensure for Bidding Suppliers fact sheet on the CBIC website to verify licensure requirements Contact Person Provide the name s of the person s who should be contacted to answer questions regarding the business or network organization You must click the Add Contact Person button in order for this information to be saved below You may enter more than one Contact Person maximum 5 Once you have entered the names of your Contact Person s scroll down to verify the name s was entered correctly First Name Last Name Title E mail Telephone Number y Add Contact Person a ca Modify Delete Contact Person s Modify or delete the contact person s information Action s Test esr est Authorized Official or Key Personnel Provide the name s and title s of authorized officials or key personnel for the business organization or network You must click the Add Authorized Official or Key Personnel button in order for this information to be saved below Once you have entered the names of your authorized official or key personnel scroll down to verify that the names were entered correctly First Name Last Name Title Add Authorized Offic
31. h OBL sii a ah kB E pia Taa idk is ah LALE H F rai pete Bi CG ea pe a E a l amp Pay poe ee pet eee ee Fe eee Begin re eee ee ee eee ee eee ee Be ee eee el ee ee ey ee ee ei ee nR Ep eee acy ees ee AEG Cee ee ee ee or ee Ce eee ed et ae eh ey ia Preece Deco Bac a eee aT ee ee ee ii Erir Eih a i sn lame eke Plt 20 eee ir ose ree Licance Men SS ee Figure 67 Expansion Plan Pane Perform this process if your response is Yes This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 54 Edaptive Intelligently Adapting Technology DBidS User Manual DMEPOS BIDDING SYSTEM DBid Perm Be Espen Print Sue Bak Pei Frese Paes F Bekker m Se H E ka Poe g TEL imi er T e alier Taci Freba Cele Tee eye ee kel Eee 7 FTA a PEE 1 depaingl Beg Spe m mip a Teds a 10s Ra POL Cite 1ao ae pen Bed O01 nero Ciste Tim Cia M DFS Daba 12 59 59 ee phs Lih re Ma Pi Pe ee ee Pen er e ee pis ee en re ere a A Loa Fy nee eed pe ee eee Fe eee Gi ee ee par ee ee pi eee ee ee ee eee eel ee ee ey ee ee ip Epy mR Bp ee ae eee e SO Cee 2 ee ee ee or es Ce ee d TART Cae a ey a Ste p iga Feo oe eee Preece Cae ee a Preece Became Bac a eee aT Pee are ee Pee Lope Par TEU ares i Be ie Loe MS ore i reap abe fee Pl
32. in a Complete and Certified status Only an AO or BAO may update a Form A that has a status of Complete and Approved Refer to Figure 15 Status Page 5 5 Updating Single Location Supplier Information Form A These sections provide instructions for providing single location supplier information Form A The assumption is that login has already occurred The Status page will be displayed upon login for all single location suppliers if one bidder business organization has been created An alternative method of navigation is to use the menu links in the left most Navigation pane The order in which sections are completed is not pertinent One Form A must be completed by each entity supplier single location supplier multiple locations and network supplier However only one Form A needs to be submitted by a business organization bidder number regardless of the number of Form B bidding sheets submitted This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 19 Edaptive intelligently Adapting Technology DBidS User Manual Only one user may access a specific Form A at any one time If an attempt is made to access a Form A and a message is received indicating that the account is locked the account remains locked until the current user logs out of the application
33. 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 American Samoa HCPCS Code Total Units Provided Units Provided to Medicare Beneficiaries TOP HCPCS Codes 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 category for this CBA during a projected 12 month period The percentage increase may exceed 100 percent This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Save Next Ld Figure 100 DBidS Form B Furnished Items This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 88 Edaptive intelligently Adapting Technology DBidS User Manual C VTS pmeros BIDDING SYSTEM DBids Bidder 20 4099116 asdfasd Welcome Test Test Navigation Form B Expansion Print Save Back Next Status Page gt Business Organization Types gt Modify Form A eres Bidder 20 4099116 Modify Form B CBA Test_Orlando Kissimmee FL Non Mail Order Select Bid Product Category Test_Oxygen Supplies and Equipme
34. license Next complete the necessary changes and click Save Licensure to save the modified information below Licensure State Licensure Information Action s No Licensure State s Saved This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Save Back Next Figure 23 Form A Location Specific Information page 2 Click Next The Form A CBAs and Product Categories page displays This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 26 Edaptive Intelligently Adapting Technology DBidS User Manual 5 5 3 Update CBA Product Category This process provides the procedures involved in selecting or updating CBA Product Category To access under the Navigation menu click Modify Form A Then click CBA Product Category If a CBA and or Product Category does not display this is due to the AO or BAO not selecting one and or the other during creation of the business organization e Update the information in the Form A CBAs and Product Categories page panes The location must be accredited for the Product Category to be bid Refer to Figure 24 Form A CBAs and Product Categories e CBA drop down list Click the d
35. locations the primary network member should add these members locations on the next screen To access this screen click Next Today s 10 14 2011 Date 10 43 59 Open Bid 01 18 2011 Legal Business Name PTAN Action s asdfasdf Close Bid 12 31 2011 1001022210 Date 13 59 59 This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Back Next Date 09 00 00 Figure 89 DBidS Form A Add Location This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 79 e e Edaptive Intelligently Adapting Technology DBidS User Manual Logout DMEPOS BIDDING SYSTEM DBids Bidder 20 9489203 a Welcome DOT BUGZLIFE Navigation Form A Additional Locations Print Save Back Next Status Page gt Business Organization Types gt Modify Form A Please provide the requested information for each location in your business organization You must provide the unique National Supplier Clearinghouse NSC Provider Transaction Access Number PTAN that applies to each gt ye t location The NSC PTAN is hereafter referred to as PTAN If you are bidding as a network the primary network member should provide information for all its locations first m ogo Required
36. order for this information to be saved below After member s information is displayed below click the Add Location button to complete member s location information Only network members identified by their PTANs are eligible to be awarded a contract Network Member Name Jane Doel Add Network Member Clear Today s 08 03 2011 Date 13 27 46 Open Bid 01 18 2011 Date 09 00 00 z Network Members Close Bid 09 30 2011 Date 23 59 59 Network Member Action s John Doe Modify Delete Aaa Location No Locations Saved Modify Delete Add Location _ No Locations Saved This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Save Back Next Figure 53 Form A Network Member Panes Click Next The Form A Summary page redisplays organized into multiple panes Refer to Section 5 5 4 Review Update Summary for information on the summary This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 46 Edaptive Intelligently Adapting Technology DBidS User Manual 5 5 18 Add Additional Information to Form A This is an optional process that is accessed when you click the Go button on the Form A Summa
37. process provides the procedures involved in updating Form A when the user has multiple bidder numbers The following page displays upon entry into the application Only an AO or BAO may modify Form A when the status is Complete and Approved Modifying a Complete and Approved Form A will require the AO or BAO to reapprove the form as the status will change to Pending Approval upon update Refer to Figure 45 Location Specific Information e Optional If the Location Specific Information page is not displayed click Business Organization Types gt Modify Business Organization from the menu The Location Specific Information page displays This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 38 Edaptive Intelligently Adapting Technology DBidS User Manual Kozso Ti C TS DMEPOS BIDDING SYSTEM DBids Bidder 20 3509843 Whitemore Shoes Welcome Janet Whitmore Form A Application Status Please select the PTAN to modify Cea ea SS SSS 7309989999 Whitemore Shoes COMPLETE 9893880001 asdfasd COMPLETE 1021102374 asdfasdf COMPLETE Today s 08 03 2011 13 10 04 Figure 45 Location Specific Information Page Click Modify Supplier Type or Access Form A Refer to Section 5 3 1 Create Business Organization starting w
38. required fields are entered This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 62 Edaptive intelligently Adapting Technology DBidS User Manual Review the Public Address Announcement Refer to Figure 79 Form B Public Address Announcement Page Logout C S vmepos BIDDING SYSTEM DBids Bidder 20 3509843 Whitemore Shoes Welcome Janet Whitmore Navigation Form B Public Address Announcement Print Back Next Status Page Business Organization Types gt Modify Form A Create Form B Bidder 20 3509843 Modify Form B CBA Test_Pittsburgh PA Non Mail Order Select Bid Product Category Test_Enteral Nutrients Equipment and Supplies gt Help PTAN s 7309989999 Logout DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE amp MEDICAID SERVICES Today s 08 03 2011 Date 13 43 33 Open Bid 01 18 2011 Date 09 00 00 Form Approved OMB No 0938 1016 Close Bid ebay liebe 1 Date 23 5 PUBLIC ADDRESS ANNOUNCEMENT FORM Penalties for Falsifying Information on this Enrollment Application This section explains the penalties for deliberately furnishing false information to gain enrollment in the Medicare program 1 18 U S C 1001 authorizes criminal penalties against an individual who in any matter within th
39. s No Product Categories Found Today s 10 14 2011 Date 10 42 50 Open Bid 01 18 2011 Date 09 00 00 CBA and Product Category List Close Bid 12 31 2011 Date 13 59 59 Displayed below is a summary of the CBA s and product category s in which this location is bidding Please review for accuracy Test_Orlando Kissimmee FL Non Mail Order Test_Oxygen Supplies and Equipment This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Save Back Next Figure 88 DBidS Form A CBA and Product Categories C VTS pmeros BIDDING SYSTEM DBids Bidder 20 4099116 asdfasd Welcome Test Test Navigation Form A Add Location Print Back Next Status Page Business Organization Types gt Modify Form A gt Help Logout All locations that conduct business within a Round 2 CBA or national mail order CBA and provide the product category for which you are bidding must be listed below It is important that bidders identify all locations by PTAN that will provide competitively bid items in a CBA Only those locations entered on the bid will be identified on the contract and be eligible to receive payment for the competitively bid item s If you are bidding as a network in Round 2 the primary network member should add its location on this screen If there are members of the network with multiple
40. the Application System The Authorized Official AO or the Backup Authorized Official BAO must provide specific information and approve or certify forms Multiple users may enter data in the system at the same time However only one person may enter data on the same form Form A or Form B at the same time Please carefully read the Quick step by step guide to submitting a bid in DBidS and the Technical User Guide below If you need help throughout the application please click on the T at the top of the screen Quick step by step quide to submitting a bid in DBidS DBidS Technical User Guide Privacy Policy Welcome Test Test Figure 83 DBidS Welcome This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 74 Edaptive intelligently Adapting Technology DBidS User Manual r DBidS Application Windows Internet Explore e Logout E DMEPOS BIDDING SYSTEM DBidsS Bidder Welcome De Antonio Miles III Navigation Select PTAN to Create Form A Listed below is the PTAN s that you used for registration purposes Please select the PTAN below for which you would like to complete an application 1027000517 1027000518 1027000519 Today s 01 10 2011 Date 13 24 25 Open Bid 05 01 2010 Date 09 00 00
41. to add additional personnel A maximum of five contact persons per Business Organization is allowed This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 12 Edaptive intelligently Adapting Technology DBidS User Manual The listed individuals may be contacted by CMS CBIC for DBidS announcements or related information o Click the Modify button in the Modify Delete Contact Person s pane to modify contact information The information for the selected contact populates the Contact Person pane o Modify the required fields e Click the Modify Contact Person button when modifications are complete The updated information displays in the Modify Delete Contact Person s pane e Optional Click the Delete button in the Modify Delete Contact Person s pane to delete a contact Contact Person Provide the names of the person s who should be contacted to answer questions regarding the business or nefvork organization You must click the Add Contact Person button in order for this information to be saved below You may enter more than one Contact Person maximum 5 Once you have entered the names of your Contact Person s scroll down to verify the name s was entered correctly First Name Last Name Title E mail Telephone Number
42. vY Close Bid PEN 3 59 59 CBA Product Category List Displayed below is a summary of the CBA s and Product Category s you have selected No CBA s and Product Category s selected This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Next SSS aa ag Figure 64 Competitive Bidding Area CBA Product Category Panes This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 52 Edaptive Intelligently Adapting Technology DBidS User Manual Click Create Bid or Next The bid is created and the Form B Furnished Items page displays organized into two panes Update the information in the TOP HCPCS Codes pane These should be the top HCPCS codes as identified by CMS These codes comprise the top 80 of revenue in terms of volume for this category Refer to Figure 65 TOP HCPCS Codes Pane The total units provided must be greater than or equal to the units provided to Medicare beneficiaries e Total Units Provided field Type the total units provided to all customers in this CBA during the past calendar year e Units Provided to Medicare Beneficiaries field Type the total units provided to Medicare beneficiarie
43. 0 10 2011 Date 16 04 20 ee Open Bid 09 01 2011 Date 09 00 00 Close Bid 12 31 2011 3 59 59 CBA and Product Category List Displayed below is a summary of the CBA s and product category s in which this location is bidding Please review for accuracy CBA Product Categories Action s No CBA Product Categories Saved This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information SSS I I OIE Pd Figure 24 Form A CBAs and Product Categories Page Click Next The Form A Summary page displays This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 27 Edaptive Intelligently Adapting Technology DBidS User Manual 5 5 4 Review Update Summary The Form A Summary page displays when the Next button is clicked on the Form A Additional Locations page when multiple locations are involved or when the Next button is clicked on the Form A CBAs and Product Categories page when a single location is involved or when the item is selected from the Navigation menu The page is organized into multiple panes e Review the information in the Identifying Information pane Refer to Figure 25 Identifying Information Pane Optional Cli
44. 00 00 Close Bid 12 31 2011 Date 13 59 59 Form A Location Specific Information Print Save Next fi Please provide the requested information for each location in your business organization You must provide the unique National Supplier Clearinghouse NSC Provider Transaction Access Number PTAN that applies to each location The NSC PTAN is hereafter referred to as PTAN If you are bidding as a network the primary network member should provide information for all its locations first Required fields are marked with Identifying Information Provide the legal business name and mailing address for the business organization identified by the PTAN below Legal Business Name Test Test Address Line 1 Test Address Line 2 Test City Test State Maryland E Mail test aol com Telephone Number 564 654 Toll Free Number if available PTAN for this location 4101810001 Physical Address Provide the physical address for the location as identified by the PTAN above in the Identifying Information question Physical address is the same as identified above Address Line 1 Test Address Line 2 Test City Test Maryland 65546 Business Information Provide the identifying information for the location as identified by the PTAN above in the identifying Information question Tax Identification Number TIN 465465456 Doing Business As DBA 1 Doing Business
45. 13 59 59 Penalties for Falsifying Information on this Enrollment Application This section explains the penalties for deliberately furnishing false information to gain enrollment in the Medicare program 1 18 U S C 1001 authorizes criminal penalties against an individual who in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies conceals or covers up by any trick scheme or device a material fact or makes any false fictitious or fraudulent statements or representations or makes any false writing or document knowing the same to contain any false fictitious or fraudulent statement or entry Individual offenders are subject to fines of up to 250 000 and imprisonment for up to five years Offenders that are organizations are subject to fines of up to 500 000 18 U S cC 3571 Section 3571 d also authorizes fines of up to twice the gross gain derived by the offender if it is greater than the amount specifically authorized by the sentencing statute 2 Section 1128B a 1 of the Social Security Act authorizes criminal penalties against any individual who knowingly and willfully makes or causes to be made any false statement or representation of a material fact in any application for any benefit or payment under a Federal health care program The offender is subject to fines of up to 25 000 and or imprisonment for up to five years 3 The Civil False Claims Act 31 U S C 3
46. 5 1 Update Form A Location for instructions on updating this section Identifying Information Legal Business Name Test Name Address Line 1 asdfasdf Address Line 2 City asdfsadf State MI Zip Code 56465 Telephone Number oo 00x 2000 546 654 6544 Toll Free Number if available Doo 2001 2000 Email Address sdfasd aol com PTAN for this location 1001042409 NPI Identification Number 5646546454 Figure 57 Supplier Business Information Pane Review the information in the Accreditation pane Refer to Figure 58 Accreditation Pane Optional Click the Edit button in the Accreditation pane to edit any of the information The Form A Additional Locations page displays Scroll if necessary to the Accreditation Information pane Refer to Section 5 5 2 Update Form A Location Specific Information page 2 for instructions on updating this section Accreditation Accreditation Organization Product Specific Area s Status Expiration Date American Board for Certification in Orthotics and E g Prosthetics Inc Test_Oxygen Supplies and Equipment Accredited 04 2006 05 2013 Figure 58 Accreditation Pane Review the information in the Licensure pane Refer to Figure 59 Licensure Pane Optional Click the Edit button in the Licensure pane to edit any of the information The Form A Additional Locations page displays Scroll if necessary to the Licensure Information pane Refer to Section 5 5 2 Update Form A Location Sp
47. 6 Creating a Form B for instructions on updating this section 5 7 3 Update Bid Sheet This section provides instructions for updating the Form B bid sheet e Click Modify Form B gt Bid Sheet in the Navigation menu The Form B Bid Sheet page displays Update the applicable bid sheet information Refer to Section 5 6 Creating a Form B for instructions on updating this section 5 7 4 Update Manufacturer Information This section provides instructions for updating the Form B manufacturer information This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 65 Edaptive Intelligently Adapting Technology DBidS User Manual e Click Modify Form B gt Manufacturer in the Navigation menu The Form B Manufacturer page displays Update the applicable manufacturer information Refer to Section 5 6 Creating a Form B for instructions on updating this section 5 7 5 Update Summary This section provides instructions for updating the Form B summary e Click Modify Form B gt Summary in the Navigation menu The Form B Summary page displays Update the applicable manufacturer information Refer to Section 5 6 Creating a Form B for instructions on updating this section 5 7 6 Review Certification Statement This section provides instructions for reviewing the F
48. 729 imposes civil liability in part on any person who a knowingly presents or causes to be presented to an officer or any employee of the United States Government a false or fraudulent daim for payment or approval b knowingly makes uses or causes to be made or used a false record or statement to get a false or fraudulent daim paid or approved by the Government or c conspires to defraud the Government by getting a false or fraudulent daim allowed or paid The Act imposes a civil penalty of 5 000 to 10 000 per violation plus three times the amount of damages sustained by the Government 4 Section 1128A 1 of the Social Security Act imposes civil liability in part on any person including an organization agency or other entity that knowingly presents or causes to be presented to an officer employee or agent of the United States or of any department or agency thereof or of any State agency a daim that the Secretary determines is for a medical or other item or service that the person knows or know a was not provided as daimed and or b the daim is false or fraudulent This provision authorizes a civil monetary penalty of up to 10 000 for each item or service an assessment of up to three times the amount claimed and exclusion from participation in the Medicare program and State health care programs 5 The government may assert common law claims such as common law fraud money paid by mistake and unjust
49. A Application Status pane for the application to update The Form A Application Status page displays Location and Additional Locations panes Refer to Figure 16 Location and Additional Locations Panes Form A Application Status Please select the PTAN to modify 8120500001 Test COMPLETE Modify 2609920001 Netty Works COMPLETE 2609050001 Test Local COMPLETE Modify Figure 16 Location and Additional Locations Panes Click the Modify button for the location to be modified The Form A Location Specific Information or Additional Locations page for that location displays This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 21 Edaptive intelligently Adapting Technology DBidS User Manual Update the information in the Identifying Information pane This is the official legal business name and mailing address used for tax purposes The remaining information should allow direct contact to you regarding the DBidS program This information may not be a billing agency management service organization or staffing company Refer to Figure 17 Identifying Information Pane e Legal Business Name field Type legal business name e Address Line 1 field Type first line of address e Address Line 2 field Type second line of address e City fie
50. As DBA 2 Years in Business Months in Business 0 Examples 5 years and 7 months or 0 years and 6 months Type of Business Select the business type that describes this location as identified by the PTAN above Bidders must submit certain financial documents based on the type of business identified in this response See the DMEPOS Competitive Bidding Program website at www dmecompetitivebid com financialrequirements for further information Type of Business Test Corporation Service Delivery For the location identified above how will you service beneficiaries in a Round 2 CBA or in the national mail order CBA Check all that apply How will you service beneficiaries Retail in a CBA E Check all that apply Mail Orders Home Delivery Sanctions Indicate whether this location as identified by the PTAN above has been subject to any current or past legal actions or sanctions such as debarments within the past five 5 years Does this location have any current Yes No or past legal actions or sanctions such as debarments This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Save Next Figure 1 Frames Panes and Pages 4 4 Standard Navigation Buttons The following buttons display on the top and bottom right of data entry pages Figure 2 Buttons points to examples of these navigatio
51. Bid PTAN s 1001022210 gt Help Logout You must provide your total estimated capacity along with your bid price for each HCPCS code listed for this product category Important Reminders Today s 10 13 2011 Date 16 17 35 Open Bid 01 18 2011 HCPCS Healthcare Common Procedure Code System This is a standardized coding system that is used primarily to identify products Supplies and services Product Class A combination of codes for which a single bid is required item Description Short narrative description of each HCPCS code For long description go to www dmecompetitivebid com Type of Bid Rental or Purchase 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 rental f Purchase is indicated enter a bid amount for total purchase of the item O f 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 item Weight Indicates the relative market importance of each item to the overall product category 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 For the nationa
52. Form A Create Form B Displayed below is a summary for the location s for which you are submitting a bid Please print and or save the summary page data to PDF for your records gt Modify Form B Select Bid gt Help Logout Form B Summary Bidder 20 3509843 CBA Test_Pittsburgh PA Non Mail Order Product Category Test_Enteral Nutrients Equipment and Supplies PTAN s 7309989999 Bid Status Complete and Certified Bidder Network ame Today s 08 03 2011 Date 13 46 09 Open Bid 01 18 2011 Date 9 00 00 Close Bid 09 30 2011 Date 23 59 59 Displayed below is a summary of Form B Please carefully review for accuracy Top HCPCS Codes HCPCS Code Total Units Provided Units Provided to Medicare Beneficiaries B4150 9 9 B4152 9 9 Figure 81 Form B Summary Page Print to PDF the Summary Page 5 7 Modifying a Form B These sections provide instructions for modifying a Form B bid The assumption is that login has already occurred Form A is already in a Complete and Approved status Access to a Complete and Certified Form B is restricted to the AO and BAO Modifying a Complete and This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 64 Edaptive intelligently Adapting Technology DBidS User Manual Certified For
53. G ys Screen SOUS ssasssacasssssassnacasasenasonesanasaascanseanansmouanananananouannnnneaneyanoninonsmeuanoneananseaees 73 This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document iV Edaptive intelligently Adapting Technology DBidS User Manual List of Figures Figure 1 Frames Panes and PAGS ivcccccccccawsnessensseassessiaSbiunstadansteadetedudedutadededadedutatedpendsduiatsdyenastansdumsdeen 4 Pone 2 B OS E E E 5 Figure 3 Print All Locations Button eesseeesseeessseeeessessseersssseesseeessersssseeesseeresseeeesseeessseresseeeesseereseeee 6 Figure 4 DBidS Application Menu Hierarchy esessonssssorssseeessseessseressserosseeessseressserossserosseeessseressseeo 7 Figure 5 CMS DMEPOS Bidding System DB1dS nsnnnsennnssensssensseessersssesssersssersssrsssersssessseressessseens 9 Figure 6 Business Organization Information Pane ccssccccsesscccsssccceesssccceesscccceesscccsesecessensecens 11 Figure 7 Business Organization Information Pane Multiple Supplier nssssneesseesessersssserssssersssersese 11 Fig re 8 Specialty Supplier Pane ccccccsarvsnascecanenesmnauewedaneasecassseesadetedudedutadededudedutntedpentsdvintedsennstansaucane 12 aie e E SE a0 A eee E E E 12 Figure 10 Contact Person Panes
54. In the event of a system error that generates a locking issue reattempt login in 30 minutes f A Click the Next Back or Save button to save any additions or changes made to the current page This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 20 Edaptive intelligently Adapting Technology DBidS User Manual 5 5 1 Update Form A Location Specific Information This process provides the procedures involved in updating Form A Location Specific Information To access Location Specific Information under the Navigation menu click Modify Form A The Navigation menu expands to display Location Page 1 and Location Page 2 Click Location Page to modify Refer to Figure 15 Status Page e Optional If the Status page is not displayed click Status Page from the Navigation menu The Status page displays Bidder 20 4478795 Test Multiple Locations Welcome De Antonio Miles Navigation Form A Application Status ra i Status Page gt Business Organization Types 4lModify Form A gt Location Page 1 gt Location Page 2 CBA Product Category Additional Locations gt Summary Supplier Checklist Approve Form A gt Help Logout Figure 15 Status Page Click the Status link in the Form
55. Mote ranns atatenerte shoud be creperet accortesce wih gerrot accented accountng pricptes GAAP TNS PESIS O CEAN CAMEE BRR ROE CO GAT CREO CF METEO MIRC OH CAY OF ETE D PETROS CO MANET V CRE DA wort Figure 40 Form A Checklist Page This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 33 Edaptive Intelligently Adapting Technology DBidS User Manual When review and or print are complete follow this procedure e Review the Supplier Checklist Click Next The Form A Approval page displays 5 5 6 Approve Form A This process is accessed when the Next button is clicked on the Form A Checklist page Only the AO and BAO may perform this action Refer to Error Reference source not found Complete the fields in the Approval pane First Name field Pre populated based upon login Last Name field Pre populated based upon login User ID field Type assigned user ID The user ID is the identifier assigned during registration Click Approve A message displays alerting you that any modifications to Form A will require the AO or BAO to reapprove Form A Click OK The Print to PDF screen displays Logout C7 Ay DMEPOS BIDDING SYSTEM DBids Bidder 20 4099116 asdfasd Welcome Test Test Navigation Form
56. Official or Key Personmel Modify Delete Authorized Official Key Personmel Information Competitie Bidding Arca CBS and Product Category CBA Product Category List ai hbodify Form A wi Location Page 1 dentifving Information Physical Address Business Information Type of Business Service Delhwenry Sanctions a Location Page Accreditation Licensure CBEA Product Category a Summary Additional Locations Supplier Checklist Create Form E Select Bid al Help CMS RFE Instructions DEBS Technical User Guide Quick step by step guide to Submitting a bid in DBids Logout Figure 4 DBidS Application Menu Hierarchy This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 7 e e Edaptive intelligently Adapting Technology DBidS User Manual 5 Using the DBidS Application The following subsections provide step by step instructions for using the DBidS Application 5 1 Getting Help Help is available at the CBIC Help Desk from 9 A M to 9 P M prevailing Eastern time Monday through Friday For assistance with problems encountered while using the application use the following methods e Phone 1 877 577 5331 e Email cbic admin palmettogba com Do not e mail technical questio
57. PETITIVE BOONG IMPLEMENTATION CONTRACTOR 2743 PERIMETER PKWY STE 200 400 AJGUBTA GA 1909 6430 H yoo reed sabat o weed Samant or sadara cecummaton belore the dcas of he ba window you Day Seed to LETE fone Geounems and not the er eter to the Remeret France Decarwert by Damea Type chert for spreol oesreste bused of yes tunmens tre tpe Repent te Eee PR maakas fw epee anew Trancas Hardcopy Documents Ad orpareceien types je p corperaton sate oreptetorete peremehe etc mat mubed De naton Weve Cecuretstm seeing amp the EPS werectore Dedes thal Me tas resres for a caendo year Pe bnt fnanca SocuTerts Dat spioneri comet year D010 or 201 Face pear fiwa eed adr tence Cocarwes Mut present fe stent thet Sa pat of as socaning yew mep POLS nonis mw be TODD The Pree Marcas witewerte are tee tae Gbaa run be fer Pe seme 12 rord pocewiing ered Pai enpe Ml the frances Matecents are ter Pe 2019 calendar prey the lew reire extract mut be tr Pe 2015 coerce pear Tor adatioaa rermatce pases ioves fe transis Cocwmes fect atest oe fe CRC watate Mosi current year fr rich a tax natura naa boes patatet ients not ecoa ary vort aust auoe WOT MCLEE phe te 2200 ter Meet Cereri mora Operetrg actrtes Tota anaes Faaceg otvtes Tarent tobttes pemer acters Totu Mestas Degmung and sieg jo Form 1122 pages Iresen eatr tamh tattoos te Form 11205 pages t it Scoece C pages iw form 1985 pages i rier te 2000 for ocat Piara Operating
58. Technology DBidS User Manual Logout CAET pmeros BIDDING SYSTEM DBids Bidder 20 4099116 asdfasd Welcome Test Test Navigation Form A Summary Print All Locations Back Next Status Page gt Business Organization Types gt Modify Form A Date 10 14 2011 10 46 45 gt Help PTAN s 1001022210 Logout Bidder Number 20 4099116 Supplier Type TestSingleLocationBidder Bidder Status Pending Approval Displayed below is a summary for the location s for which you are submitting a bid Please carefully review the information you provided on Form A application information for accuracy You may modify your information or add a new Today s 10 14 2011 location If you do not wish to make any changes or add another location select NEXT Only locations identified by the PTAN listed on this summary page will be eligible to be awarded a contract and to receive payment under the ries zaid 10 46 53 DMEPOS Competitive Bidding Program You cannot use the same 10 digit PTAN for each location To make any changes click EDIT Open Bid 01 18 2011 ae ae Date 09 00 00 papier dre E EEE Close Bid 12 31 2011 Legal Business Name asdfasdf Date 13 59 59 Address Line 1 sadffasdf City asdffasdsadf Telephone Number oo w000 546 654 5646 Email Address sadfsdaf aol com PTAN for this location 1001022210 Do you have locations that are licensed to furnish competitively bid items for each state within the Yes CBA for which you are bidding
59. Units Provided Units Provided to Medicare Beneficiaries Date 13 59 59 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 category for this CBA during a 9 If you plan to expand your business under the Competitive Bidding Program describe your current structure and expansion plan in the space provided If additional space is needed you may submit documentation along with the required hardcopy documents Is your estimated capacity the amount you can provide for this product category in the CBA greater than the amount you currently provide in No the CBA If yes you must complete an expansion plan Do you plan to use subcontractor s HCPCS Code Item Description Rental Or Purchase Item Weight Total Estimated Capacity Fee Schedule Bid Price E1390 Test_Oxygen concentrator BID FOR ENTIRE CLASS USING THIS CODE Rental 0 6108082987 75 79 5 00 E0439 Test Stationary liquid 02 BID FOR ENTIRE CLASS NOT BY CODE Rental o ooooooo000 s 175 73 5 00 E0424 _Test_Stationary compressed gas 02 BID FOR ENTIRE CLASS NOT BY CODE Rental 0000000000 5 175 73 5 00 E1391 Test_Oxygen concentrator dual BID FOR ENTIRE CLASS NOT BY CODE Rental 0000000000 s 175 73 5 00 Test Portable gaseous 02 BID FOR ENTIRE CLASS USING THIS CODE Rental 0 3602632991 5 7 o Ko738 Test Por
60. Whitmore Navigation Form A Summary Status Page Business Organization Types gt Modify Form A Create Form B gt Help Displayed below is a summary for the location s for which you are submitting a bid Please print and or save the summary page data to PDF for your records Logout Today s 08 03 2011 Date 11 53 45 Form A Summary artes deeded Date 08 03 11 11 53 41 Close Bid 09 30 2011 PTAN s 7309989999 cen aE Bidder Number 20 3509843 Supplier Type TestSingleLocationBidder Bidder Status Complete and Approved Displayed below is a summary for the location s for which you are submitting a bid Please carefully review the information you provided on Form A application information for accuracy Only locations identified by the PTANs listed on this summary page will be eligible to be awarded a contract and to receive payment under the DMEPOS Competitive Bidding Program You cannot use the same 10 digit PTAN for each location Legal Business Name Whitemore Shoes i Address Line1 sadfasdfasasdfasdf Address Line2 Figure 42 Form A Summary PDF This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 35 Edaptive intelligently Adapting Technology DBidS User Manual 5 5 7 Updating Multiple Locations and Network Supplier Informa
61. a signed contract Displays and must be completed if Network Supplier is selected Click Yes or No Click Yes if applicable If no a message displays advising a bid will not be considered for evaluation without a contract e Select one of the following that best describes your business organization structure field Displays and must be completed if Supplier with multiple locations is selected Click the drop down arrow and select the option that best describes your organization Only one option can be selected See Figure 7 Business Organization Information Pane Multiple Supplier If None of the above is selected a text box displays for the user to describe the business organization Structure Business Organization Information Indicate how your business organization will be bidding choose only one Legal Business Name Legal Business Name Here Supplier Bidding Type TestNetworkBidder Network Name Network Name Here Has each network member signed a contract to join this network Yes No Figure 6 Business Organization Information Pane Business Organization Information Indicate how your business organization will be bidding choose only one Legal Business Name Test Name Supplier Bidding Type Select one of the following that best describes your Select Organization Type business organization structure See help for the definitions of business organizations IMPORTANT Refer to t
62. actosetncctoncteastonstonetecstosatosatsastaassontusstasisatiecoinienoininiesaieseinsnmsoneoimbonmionenouwannennnedadd Di A I rosette E oni n eo tise pnb oelealeniestonsesien E E E E E A 5 2 1 Navigating the DBidS Welcome page ccncnnnnncnnnnnnnnnnannnnidiviin 5 3 Managing Business Organization Types cccccccsesccceeeeceeeeeceeeeceseneceseeceseeseessseesseseeeaeneees 10 5 3 1 Create Business Organization ccccccseccccsesccceeccenneeeseeeceeeeeeeseseeeeeeeeseseesaeseesseseeeaanes 10 3 3 2 Modify B sin ss Organization 5559s sessed daca tonatasater onise 17 S AU a o AAE E E E E sect onacosee acs 18 5 5 Updating Single Location Supplier Information Form A cccecccceseeeceeeeeeeeseeeseseseeeeeees 19 5 5 1 Update Form A Location Specific Information ccccccecccccseecccseeeceaeeeeeeseeeaeseeeaeneees 21 5 5 2 Update Form A Location Specific Information page 2 ccccccsescccseeeeeeeeeeeneseeeaeeees 25 Iae UCDO Ml Geko O a nn nna eee p ene Men arene tnt meneeten mist eet er ZF 5 5 4 FRC VC DC AUS 5 AE a ETIE EENE E E uae ean 28 520 FIRE VIC WF Ol A CC kE ecesna neie eren eE EEEE EERE E OE EOE 32 5 5 6 Approve Form A ssssesssossssessssrsssersserssersssrrsserssstrssersssersserosstreserosserseesssersssessseressessserns 34 This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a mann
63. and select state from the list provided e Zip Code field Type zip code Physical Address Provide the physical address for the location as identified by the PTAN above in the Identifying Information question Iv Physical address is the same as identified above Address Line 1 90 Test Drive Address Line 2 Text Input Address Line 2 Optional City Baltimore State Maryland Figure 48 Physical Address Pane Update the information in the Business Information pane Provide information for this location as identified by the PTAN above Refer to Figure 49 Business Information Pane e Tax Identification Number TIN Type taxpayer identification number if sole proprietorship type social security number e Doing Business As DBA field Type doing business as name if different from the legal business name reported in Identifying Information section e Years in Business drop down list Click the drop down arrow and select number of years and months in business the bidder has been supplying Durable Medical Equipment Prosthetics Orthotics and Supplies in the CBA If the number of years is greater than 99 years select 99 years and 11 months Please note that if O years is selected then the user must make a selection in the Months in Business field e Optional Months in Business drop down list Click the drop down arrow and select number of months in business Business Information Pro
64. ane Review the information in the Bid Sheet pane Refer to Figure 76 Bid Sheet Pane Optional Click the Edit button in the Bid Sheet pane to edit any of the information The Form B Bid Sheet page displays Scroll 1f necessary to the information to be edited Refer to Section 5 6 Creating a Form B for instructions on updating this section Bid Sheet gt Edit HCPCS Code Item Description Rental Or Purchase Item Weight Total Estimated Capacity Fee Schedule Bid Price E1390 Test_Oxygen concentrator BID FOR ENTIRE CLASS USING THIS CODE Rental 06108082987 S 175 79 500 E0439 Test Stationary liquid 02 BID FOR ENTIRE CLASS NOT BY CODE Rental o oo00000000 s5 175 73 5 00 E0424 __Test_Stationary compressed gas 02 BID FOR ENTIRE CLASS NOT BY CODE Rental 0 0000000000 5 579 5 00 E1391 Test_Oxygen concentrator dual BID FOR ENTIRE CLASS NOT BY CODE Rental 0 o000000000 s5 8175 79 5 00 E0431 Test Portable gaseous 02 BID FOR ENTIRE CLASS USING THIS CODE Rental 0 3602632991 S 7 500 E0434 Test Portable liquid 02 BID FOR ENTIRE CLASS NOT BY CODE Rental 0000000000 S 7 500 Ko738 Test Portable gas oxygen system BID FOR ENTIRE CLASS NOT BY CODE Rental 0 0286888699 S 163 soo E1392 Test Portable oxygen concentrator BID FOR ENTIRE CLASS USING THIS CODE Rental _0 0000000000 s5 163 5 00 E0441 Test Oxygen contents gaseous BID
65. approve Form A if any changes are made to this form Date 09 00 00 Close Bid 12 31 2011 Date 13 59 59 This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Back Next Figure 95 DBidS Form A Approval Displayed only to AOs and BAOs Bidder 20 1622875 TES Welcome Ben Teen Navigation IES Form A Approval Print Back Next Status Page F Business Organization Types F Modify Form A Create Form B k Help Logout Required fields are marked with Approval The Authorized Official AQ or back up Authorized Official BAO must approve Form A before you can proceed to Form B The User ID is assigned during registration aes Lica Message from webpage Please note that all of the Form 4 required fields have been completed and the 40 or B40 must approve Form 4 before you can proceed to Form B Any modifications to any of the information on Form 4 will require the 40 or BAG to reapprove Form 4 Lox This information is confidential Contents shail not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Back Next Figure 96 DBidS Form A Approval Message Displayed only to AOs and BAOs This document contains confidential information Disclosure is restricted Contents shal
66. ary to the Competitive Bidding Area CBA and Product Category pane Refer to Section 5 5 3 Update CBA Product Category for instructions on updating this section DBidS Application Windows Internet Explorer provided by Edaptive Systems C T7S pmeros BIDDING SYSTEM DBidS Bidder 20 9489203 asd Welcome DOT BUGZLIFE Navigation Form A CBAs and Product Categories Print Save Back Next Status Page Business Organization Types gt Modify Form A Required fields are marked with Create Form B Select Bid CBA and Product Category gt Help Select the CBA s for which this location will be servicing Medicare beneficiaries The product categories were previously identified by your organization You must click the Add CBA button in order for this Logout information to be saved below CBA Select CBA Product Category s Select CBA Test_Charlotte Gastonia Concord NC SC Non Mail Order oath 3 ry eae Test_Orlando Kissimmee FL Non Mail Order Open Bid pe ie Dae o CBA and Product Category List Close Bid pee 11 Date 23 59 59 Displayed below is a summary of the CBA s and Product Category s for which this location is bidding Please review for accuracy Action em iss a Test_Charlotte Gastonia Concord Test_Oxygen Supplies and Equipment Test_Standard Power Wheelchairs Scooters and Related Accessories Test_Complex NC SC Non Mail Order Rehabilitative Power Wheelchairs and Related Acces
67. ase 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 rental If Purchase is indicated enter a bid amount for total purchase of the item 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 item Weight Indicates the relative market importance of each item to the overall product category 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 For the national mail order competition for diabetic testing supplies the CBA includes all parts of the United States including the 50 states the District of Columbia Puerto Rico the U S Virgin Islands Guam and American Samoa 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
68. ast legal actions or sanctions such as debarments lf yes please provide additional 1000 characters left information regarding any previous or current sanctions Maximum 1000 characters Figure 52 Sanctions Pane Click Next The Form A CBAs and Product Categories page displays 5 5 16 Update CBA Product Category Refer to Section 5 5 3 Update CBA Product Category for instructions on completing this process 5 5 17 Add Network Member This action is performed when no additional locations are to be added This page is accessed when Next is selected from the Form A Location Summary page e Update the information in the Form A Network Member page This page allows modification and or deletion of network members A Network Supplier can have a maximum of 20 network members including the primary network member hence they need to provide the network name Each network member name can have multiple locations associated to the specific network member Refer to Figure 53 Form A Network Member Panes e Network Member Name field Type name of network member e Click the Add Network Member button The recently added data displays in the Network Members pane and the Add Network Member pane is cleared to allow entry of additional information Repeat the above steps to add additional network members Once all network members are added click the Add Location button to add the location associated to the network member name
69. ation Print Back Next Figure 79 Form B Public Address Announcement Page Click Next The Form B Certification page displays Only the AO and BAO have access to this page after the specific Form B status is Pending Certification and all required fields are entered Each Form B bid must be certified Any changes to a Form B bid will change the status from Complete and Certified to Pending Certification and will require the bid to be re certified Refer to Figure SO Form B Certification Page Complete the fields in the Certification pane Any modifications to a Complete and Certified bid require certification by an AO or BAO since the status changes to Pending Certification e First Name field Pre populated based upon login e Last Name field Pre populated based upon login e User ID field Type assigned user ID This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 63 Edaptive intelligently Adapting Technology DBidS User Manual DMEPOS BIDDING SYSTEM DBidsS Bidder 20 4099116 asdfasd Welcome Test Test Navigation Form B Certification Print Back Next Status Page gt Business Organization Types gt Modify Form A Create Form B Bidder 20 4099116 Modify Form B CBA Test_Orlando Kissimmee FL No
70. bmitting DMEPOS bids of approved and accredited Medicare DME suppliers that are expected to improve the quality of the suppliers and lower the risk of fraud and abuse It changes the way Medicare currently pays for DMEPOS supplies Charges will no longer be based on fee schedule payment amounts established using historical reasonable charges that are not always available or reliable as in the case of new items or newly covered items but rather be managed by the Center for Medicare CM area of CMS based on information from the competing suppliers The roles and privileges that are assigned to a user are also managed by this application The DBidS application has a regularly scheduled maintenance window from 12 A M EST to 4 A M EST daily During this timeframe DBidS is not available for usage 4 1 User Roles There are three types of users that have capabilities related to the implementation of this user manual e Authorized Official AO This user has administrative privileges not available to the End User to include creation of business organizations access to supplier checklist approval of Form A and certification of Form B e Backup Authorized Official BAO This user has privileges identical to the AO e End User EU This user has access to the application to complete Form A and Form B for suppliers with single and multiple locations as well as network suppliers This user does not have the authority to approve Form A or
71. business the bidder has been supplying Durable Medical Equipment Prosthetics Orthotics and Supplies in the CBA If the number of years is greater than 99 years select 99 years and 11 months Please note that if O years is selected then the user must make a selection in the Months in Business field e Months in Business drop down list Click the drop down arrow and select number of months in business Business Information Provide the identifying information for the location as identified by the PTAN above in the identifying Information question Tax Identification Number TIN 123654987 Doing Business As DBA 1 Doing Business As DBA 2 Years in Business Months in Business 0 gt Examples 5 years and 7 months or 0 years and 6 months Figure 19 Business Information Pane This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 23 Edaptive intelligently Adapting Technology DBidS User Manual Update the information in the Type of Business pane Click the button to review the types of businesses Select the type of business for this location as identified by the PTAN in the Identifying Information pane Refer to Figure 20 Type of Business Pane e Type of Business drop down list Click the drop down arrow and select the type o
72. cal licensure rules on the DMEPOS Competitive Bidding Program website at ww w dmecompetitivebid com Browser Compatibility This online application is best viewed with a screen resolution of 1024 x 763 using Microsoft Internet Explorer 6 0 or greater JavaScript must be enabled Pop up blockers should be disabled For Your Security When you log into the application system you are on a secure server All the information that you provide us is encrypted to provide the highest possible security Using the Application System The Authorized Official AO or the Backup Authorized Official BAO must provide specific information and approve or certify forms Multiple users may enter data in the system at the same time However only one person may enter data on the same form Form A or Form B at the same time Please carefully read the Quick step by step guide to submitting a bid in DBidS and the Technical User Guide below If you need help throughout the application please click on the i at the top of the screen Quick step by step quide to submittinga lt q bid in DBidS DBidS TechnicalUser Guide lt j Privacy Policy lt j Figure 5 CMS DMEPOS Bidding System DBidS 5 2 1 Navigating the DBidS Welcome page Read the contents of this screen in its entirety Specifics regarding application contents browser compatibility security and use of the application are provided In addition five links dis
73. ck Modify Authorized Official or Key Personnel when modifications are complete The updated information displays in the Modify Delete Authorized Official Key Personnel Information pane e Optional Click the Delete button in the Modify Delete Authorized Official Key Personnel Information pane to delete a person Authorized Official or Key Personnel Provide the name s and title s of the authorized officials or key personnel for the business organization or network You must click the Add Authorized Official or Key Personnel button in order for this information to be saved below Once you have entered the names of your authorized official or key personnel scroll down to verify the names were entered correctly First Name Last Name Title Add Authorized Official or Key Personnel Modify Delete Authorized Official Key Personnel Information Modify or delete the authorized official or key personnel information Figure 11 Authorized Official or Key Personnel Panes This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 14 Edaptive Intelligently Adapting Technology DBidS User Manual Update the information in the CBA Product Category List pane Refer to Figure 12 Competitive Bidding Area CBA and Product Category Panes The user should select
74. ck the Edit button in the Identifying Information pane to edit any of the information The Form A Location Specific Information page displays Scroll af necessary to the Identifying Information pane Refer to Section 5 5 1 Update Form A Location for instructions on updating this section Legal Business Name Test Bidder Network Name Debs Network Address Line 1 90 Test Drive Address Line 2 City Baltimore State MD Zip Code 21228 Telephone Number xxx xxx xxxx 899 879 7979 Toll Free Number if available Dox xoxx 00xx Email Address Test tester com PTAN for this location 8120500001 NPI Identification Number 8888888888 Figure 25 Identifying Information Pane Review Information in the Specialty Supplier pane Refer to Figure 26 Specialty Supplier Pane Optional Click the Edit button in the Specialty Supplier pane to edit any of the information The Form A Location Specific Information page displays Scroll Gf necessary to the Specialty Supplier pane Refer to Section 5 5 1 Update Form A Location for instructions on updating this section Speciality Supplier Bidding as a speciality supplier No Figure 26 Specialty Supplier Pane Review the information in the Licensure pane Refer to Figure 27 Licensure Pane Optional Click the Edit button in the Licensure pane to edit any of the information The Form A Location Specific Information page displays Scroll Gif necessary to the Licensure pane R
75. click the Modify button next to the applicable license Next complete the necessary changes and click Save Licensure to save the modified information below i fasdasdffds a This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Save Back Next Figure 87 DBidS Form A Location Specific Information page 2 This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 78 Edaptive intelligently Adapting Technology DBidS User Manual C VT pmeros BIDDING SYSTEM DBids Bidder 20 4099116 asdfasd Welcome Test Test Navigation Form A CBAs and Product Categories Print Save Back Next Status Page gt Business Organization Types gt Modify Form A Required fields are marked with a B CBA and Product Category gt Help You must associate this location with specific CBA Product Category s where it will furnish items and services in order to be eligible to receive Medicare payment for competitively bid items Select the CBA Logout s product category s associated with this location You must click the Add CBA button in order for this information to be saved below CBA Select CBA X Product Category
76. d I authorize the Competitive Bidding Implementation Contractor CBIC to verify this information I also certify that I will adhere to the terms of the competitive bidding contract if awarded a contract Close Bid EPE Date 13 59 59 I agree to notify the CBIC in writing of any changes that may affect the contract and or my ability to carry out the terms of the contract prior to such change or within 30 days of the effective date of such change I understand that I may be in breach of contract if any such change results in my failure to carry out the terms of the contract I also certify that I have read understand meet and will continue to meet all supplier standards and quality standards as outlined in 42 CFR 424 57 and 424 58 If I become aware that any information in this application is not true correct or complete I agree to notify the CBIC of this fact immediately I agree that I am a Medicare enrolled supplier and meet the basic eligibility requirements of the DMEPOS Competitive Bidding Program I understand that in accordance with 18 U S C 1001 any omission misrepresentation or falsification of any information contained in this application and all required attachments and supplemental information or contained in any communication supplying information to CMS or the CBIC may be punishable by criminal civil or other administrative actions including revocation of approval fees and or imprisonment under federal law I further cert
77. d Letter of ierd be Enter io a tubcontr acting Ayreement Of seperate Setilernenl Agr mewment oF Cov porate lnleyrity Age mere i aogtatie thacetantous Bxdder number on EACH page of EVERY document All documents submitted in loose pege format ro bevters forters sors texteg steptes or pepe cips OWE package per tedder number regertiess of number of bitte for esch prodect category competinve beiding ares For focemerts tee LACH uppie mchuded Me bet and subd OME package for netacna comps af required documenta tam LACK network menter and sabeat OWE package HATIONAL MAM QADIR MDOTRS OSA Y Mahona Mat Order SOM rue toreune Ad hardcopy document packages crest be RECEIVED by He CRIC on or pelore Ine clase ot the bid sidas Packag PALNETTO GOA PETITIVE BIDDING MPLEMENTATION CONTRACTOR 2743 PERIMETER PRW STE 200 400 AUGAIGTA GA 20908 6499 peas neesi Ne seierd a reene Decree oF phita docermmetaien heien he cise RT Me bal wedra ye sety need ts seterd Mose dimms mit ve Te meire package Meter to fhe Recured Pnerosl Documents ty Dsemess Type chert tor spece regaroreres based on your buseess tse Sa es piste aa aaa Mnanciat tardcapy Docements AA GAIMAN NPDES FD CONDE BUR EAA PANAD CC FNI UDN THe MONDE ry THATS A A a Me AEE PAUA HTS Fret tee Cae where Sor a N her must subtest ranen documents fet represert catorter year 201P ar 201 Pecel year Mere shout submi thence focuri that represent the latest Mod Ne pert ef an eccoutine pear mey
78. d Model Number pane o Modify the required fields o Click Modify Manufacturer Model Name amp Model Number when modifications are complete This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 59 Edaptive intelligently Adapting Technology DBidS User Manual The updated information displays in the top Manufacturer Model Name and Model Numbers pane e Optional Click the Delete button in the Manufacturer Model Name and Model Numbers pane to delete a manufacturer Manufacturer Model Name and Model Number EQ431 Please enter the Manufacturer Mode Name and Mode Wumber You must cick the Add Manufacturer Model Name and Vodei Number buttons in order for thls Information to be saved below You must cick the Back button after you fave finished entering Manufacturer data for this ACCS Add Manufacturer Model Mame amp Model Murmber Manufacturers Model Names and Model Numbers Model Name Model Number Action s hanufacturer tlodel Mame Model Humber Delete All Figure 71 Manufacturer Model Name and Model Number Panes Click Save or Back The information is saved and the Form B Manufacturer Page is redisplayed To add more manufacturer information repeat the steps above Click Next The Form B Bid Summary page displays orga
79. d may result in the need to recertify Please visit your DBidS home page to make sure your bid application is complete Date 10 58 24 Open Bid 01 18 2011 First Heme Tost Date 09 00 00 Close Bid 12 31 2011 Last Name Tos Date 13 59 59 User ID This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Back Next Figure 108 DBidS Form B Certification Displayed only to AOs and BAOs C V7S DMEPOS BIDDING SYSTEM DBids Bidder 20 4099116 asdfasd Welcome Test Test Navigation Form B Certification Print Back Next Status Page gt Business Organization Types gt Modify Form A Create Form B Bidder 20 4099116 Modify Form B CBA Test_Orlando Kissimmee FL Non Mail Order Select Bid Product Category Test_Oxygen Supplies and Equipment gt Help PTAN s 1001022210 Logout Required fields are marked with Certification The Authorized Official AO or Back up n _ _ s fy your bid and then click Certify and Submit Bid Changes made to the T oday s 10 14 2011 bid application after you have certified on is complete Date 10 59 10 Open Bid 01 18 2011 Your Form B for this competitive bidding area and product category has been completed and your bid has been submitted Date 09 00 00 Close Bid 12 31 2011 Date 13 59 59 lem T
80. ded to Medicare Beneficiaries B40 Boo Mo B4152 9 9 Figure 110 DBidS Form B Summary pdf This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 95
81. derlined text e Information that should be replaced with user specific text is enclosed in quotation marks e An indicates an action that may result in permanent loss of information Appendix A Glossary of Terms and Definitions provides a listing of terms and definitions used in this document 4 3 DBidS Page Layout The DBidS pages are organized in frames panes and pages The left most frame contains a Navigation menu pane followed by a non selectable date pane that lists today s date the opening bid date and the closing bid date The right most frames provide data entry fields and application navigation through button and link selection Scrolling is available via standard scroll bars when applicable Figure 1 Frames Panes and Pages points to examples of the frames panes and pages discussed above This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 3 Edap tive intelligently Adapting Technology DBidS User Manual CATS Logout DMEPOS BIDDING SYSTEM DBidS Bidder 20 2642067 Test Test Welcome HEIMLICH BUGZLIFE Navigation Status Page gt Business Organization Types gt Modify Form A Create Form B Select Bid gt Help Logout Today s 10 20 2011 Date 14 13 44 Open Bid 09 01 2011 Date 09
82. e Test Test Bidder 20 4099116 asdfasd Navigation Form B Bid Certification Statement Print Back Next fi Status Page gt Business Organization Types gt Modify Form A Create Form B Bidder 20 4099116 gt Modify Form B CBA Test_Orlando Kissimmee FL Non Mail Order Select Bid Product Category Test_Oxygen Supplies and Equipment gt Help PTAN s 1001022210 Logout Certifying Statement Applies to All Information Submitted Electronically or Hardcopy Today s 10 14 2011 Date 10 56 56 Open Bid 01 18 2011 Ihave read the contents of this application I hereby certify that I have examined the completed application and accompanying financial statements and I certify that they are true correct and complete statements that can be substantiated from our books and records My signature legally and financially binds this supplier to the laws regulations and program instructions of the Medicare program By my signature I certify that the information contained herein is true correct and complete to the best of my knowledge and I authorize the Competitive Bidding Implementation Contractor CBIC to verify this information I also certify that I will adhere to the terms of the competitive bidding contract if awarded a contract Date 09 00 00 Close Bid 12 31 2011 Date 13 59 59 I agree to notify the CBIC in writing of any changes that may affect the contract and or my ability to carry out the terms of the contract prio
83. e 60 Sanctions Information Pane sesser a aiai a EEES ni 49 Figure 61 Competitive Bidding Area CBA and Product Category Pane cccceecccccseeeeeeeeeeeeees 49 Figure 62 Network Member Pane ccsccccsssscccssececcsseccceessscccensesecsenseceseessceseasssessensscessensseees 50 Figure 63 Form A Network Member Panes ccccccccccseececeeeeeceeeeeecceaseseeeeaueseceeseeeeeeeeeeeeeaeeseeees 51 Figure 64 Competitive Bidding Area CBA Product Category Panes ccsecccceeseeseeeeteeeeeeeeeeeeees 52 This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document vi Edaptive intelligently Adapting Technology DBidS User Manual Pious 633 TOP HCPC Sy Codes ane i sosiahsonobatsbsnesahebsaseansnonsnceenonsiahobahatsbebsoanereoenseoneaseraseauaeretmaenecnse 53 Figure 66 TOP HCPCS Codes Pane COMUNUCC soo ssanccntaacaenesaadeancssseusaeeeancuneeeanbyoseradiventernieonsenemennen 53 Figure 6 Expansion Plan Pane sssansesssnngsoataceseccsndtyienieeett acu sE e Tee e E 54 Figure 0S Subcontractor In ormanon Panes sessirnar 55 Figure 69 Bid Sheet Pane s cccccssesccssssseccssescccssseccnsncssccacssasceensenccecnssessecssaccceassaccsenssecssoesscens 57 Fe 70 nE M mna a r Fa s E EE E EE E E E E E EES 58 Fi
84. e Competitive Bid Implementation Contractor CBIC The notation above indicates whether the CBIC has received a package of hardcopy documents However it does not acknowledge the accuracy or completeness of the package The CBIC is unable to provide this information Covered Document Review Date CDRD Eligible CDRD Eligible No Figure 14 Status Page Form A Statuses are defined as follows e Incomplete The supplier is missing required fields e Pending Approval Form A has not been approved by the AO or BAO e Complete and Approved Form A is complete and has been approved by the AO or BAO Form B Statuses are defined as follows e Incomplete Form B is missing required information This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 18 Edaptive intelligently Adapting Technology DBidS User Manual e Pending Certification Form B has not been certified by the AO or BAO A bid that is not ina certified status will not be considered for evaluation e Complete and Certified Form B is complete and has been certified by the AO or BAO Note For Incomplete Status to display any error messages click on the Incomplete Status on the Status Page which will guide you to the page with the error Documentation Statuse
85. e current page Form A Location Specific Information page 2 Print Save Back Next Required felis are marked wih lt Select the names of the Medicare aporoved organization that has accredited this location for the product catagory in which you are bidding You musi click the Add Accreditation button in order for this iMformaion fo be saved below Accreditation Organization Solect Accreditation Organization Status Select Accreditation Status Add Accreditation Clear Figure 2 Buttons On Form A Summary page you have the ability to Print All Locations The Print All Locations buttons are located on the top and bottom of the screen The Print All Locations functionality allows the user to print all locations in one report You are able to print all locations once every 10 minutes Should you attempt to print all locations more than once within 10 minutes you will receive an error message Figure 3 Print All Locations Button points to examples of these buttons This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 5 Edaptive Intelligently Adapting Technology Form A Summary DBidS User Manual Print All Locations Back Next Date 06 22 2011 10 09 20 PTAN s 7210019999 Bidder Number 20 62386307 Supplier Type T
86. e information for all its locations first gt Help Required fields are marked with Logout Identifying Information Provide the legal business name and mailing address for the business organization identified by the PTAN below Legal Business Name Test Test Address Line 1 Test Today s 10 20 2011 Date 14 13 44 Open Bid 09 01 2011 Address Line 2 Test Date 09 00 00 Close Bid 12 31 2011 Date 13 59 59 City Test State Maryland E Mail test aol com Telephone Number 564 654 Toll Free Number if available PTAN for this location 4101810001 Physical Address Provide the physical address for the location as identified by the PTAN above in the Identifying Information question Physical address is the same as identified above Address Line 1 Test Address Line 2 Test City Test State Maryland Business Information Provide the identifying information for the location as identified by the PTAN above in the identifying Information question Tax Identification Number TIN 465465456 Doing Business As DBA 1 Doing Business As DBA 2 Years in Business Months in Business 0 Examples 5 years and 7 months or 0 years and 6 months Type of Business Select the business type that describes this location as identified by the PTAN above Bidders must submit certain financial documents based on the type of business identified i
87. e jurisdiction of any department or agency of the United States knowingly and willfully falsifies conceals or covers up by any trick scheme or device a material fact or makes any false fictitious or fraudulent statements or representations or makes any false writing or document knowing the same to contain any false fictitious or fraudulent statement or entry Individual offenders are subject to fines of up to 250 000 and imprisonment for up to five years Offenders that are organizations are subject to fines of up to 500 000 18 U S cC 3571 Section 3571 d also authorizes fines of up to twice the gross gain derived by the offender if it is greater than the amount specifically authorized by the sentencing statute 2 Section 1128B a 1 of the Social Security Act authorizes criminal penalties against any individual who knowingly and willfully makes or causes to be made any false statement or representation of a material fact in any application for any benefit or payment under a Federal health care program The offender is subject to fines of up to 25 000 and or imprisonment for up to five years 3 The Civil False Claims Act 31 U S C 3729 imposes civil liability in part on any person who a knowingly presents or causes to be presented to an officer or any employee of the United States Government a false or fraudulent daim for payment or approval b knowingly makes uses or causes to be made or used a false record or state
88. ecific Information page 2 for instructions on updating this section Licensure Do you have locations that are licensed to furnish competitively bid items for each state withinthe Yes CBA for which you are bidding Figure 59 Licensure Pane This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 48 Edaptive intelligently Adapting Technology DBidS User Manual Review the information in the Sanctions pane Refer to Figure 60 Sanctions Information Pane Optional Click the Edit button in the Sanctions pane to edit any of the information The Form A Additional Locations page displays Scroll if necessary to the Sanctions Information pane Refer to Section 5 5 1 Update Form A Location for instructions on updating this section Sanctions ae Edit Does this location have any current or past legal actions or sanctions such as debarments o Figure 60 Sanctions Information Pane Review the information in the Competitive Bidding Area CBA and Product Category pane Refer to Figure 61 Competitive Bidding Area CBA and Product Category Pane Optional Click the Edit button in the Competitive Bidding Area CBA and Product Category pane to edit any of the information The Form A CBAs and Product Categories page displays Scroll 1f necess
89. eeeeceeseeeeeseeeueseeeaseeeaenes 26 Figure 24 Form A CBAs and Product Categories Page ccccccsssccccsescceeeeceseseecsseceaeseceuseeeseneeeaenes 27 Figure 25 Identifying Information Pane ssssnessseeesssenessseessetessseerssrsressseresseeeesseerssseressseresseressseeress 28 PIOUS 20 Specialy Supplier Paice sanccasecascenaccaseeacacs ansneasesasasasasaaacacasesosasacasanesasadaeasanetasanatasanasasaaanaece 28 Figure 27 Licensure Pane svsscsecesavesesssavaisawsavetateeeesasessaaceosesscaeeseaecaesssaesessesnsaesesasnnessanteccissansenssecsnecssaces 28 Proure 28 Physical Address Pane ic ccczssicecesessescssnauonesesanseqsasqoncasanapeeceaen sooasmeacoogsmeacsognseepsoaaanonseansnonseanets 29 Figure 29 Tax Identification Number TIN Pane cccsscccceseeceneeccenscecescecesceceusceceesesesseseuess 29 Figure 30 Doing Business As DBA Panne ceecccceecccccesesceceeeeceeeeeecceaeeeeceeseeeeeeesaeeeeseeeeeeaaeseeees 29 This document contains confidential information Disclosure 1s restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document V Edaptive intelligently Adapting Technology DBidS User Manual Figure ik Contact Person PANG 2 s355s5shanesasassbonens boboseeaeseanveseetomsuteocasven cmsuenousseonsoenseoueaeereseouaeeetmaeoeceee 29 Figure 32 Authorized Official or Key Perso
90. efer to Section 5 5 1 Update Form A Location for instructions on updating this section Do you have locations that are licensed to furnish competitively bid items for each state within CBA for Yes which you are bidding Figure 27 Licensure Pane This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 28 Edaptive intelligently Adapting Technology DBidS User Manual Review the information in the Physical Address pane Refer to Figure 28 Physical Address Pane Optional Click the Edit button in the Physical Address pane to edit any of the information The Form A Location Specific Information page displays Scroll af necessary to the Physical Address pane Refer to Section 5 5 1 Update Form A Location for instructions on updating this section Physical Address Address Line 1 10 Main St Address Line 2 City Smithville State IL Zip Code 78900 Figure 28 Physical Address Pane Review the information in the Tax Identification Number TIN pane Refer to Figure 29 Tax Identification Number TIN Pane Optional Click the Edit button in the Tax Identification Number TIN pane to edit any of the information The Form A Location Specific Information page displays Scroll af necessary to the Business Information pane Refer to Section 5 5 1
91. egal Business Name PTAN Date 09 00 00 asdfasdf 1001022210 Close Bid 12 31 2011 5 Date 13 59 59 Delete All Locations This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Back Next Figure 46 Form A Add Location Page Click Next The Form A Summary page displays organized into multiple panes Return to Section 5 5 4 Review Update Summary if Next is selected This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 40 Edaptive intelligently Adapting Technology DBidS User Manual 5 5 15 Add Location This process only applies to suppliers with multiple locations or network suppliers who have multiple locations This screen is accessed when the Add Location button is clicked on the Form A Add Location page or when Modify or Add Location is selected from the Form A Network Member page Refer to Figure 46 Form A Add Location The page is organized into multiple panes Access to the supplier checklist and approval screens is restricted to the AO and BAO The PTAN entered for an additional location and or network member cannot be the same PTAN as identified in the Identifying Information pane The PTAN for an additional location o
92. enrichment Remedies indude compensatory and punitive damages restitution and recovery of the amount of the unjust profit This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Back Next Figure 107 DBidS Form B Public Address Announcement Displayed only to AOs and BAOs This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 93 Edaptive Intelligently Adapting Technology DBidS User Manual LZ AY DMEPOS BIDDING SYSTEM DBidS Bidder 20 4099116 asdfasd Welcome Test Test Navigation Form B Certification TY Print Back Next Status Page gt Business Organization Types b Modify Form A Create Form B Bidder 20 4099116 Modify Form B CBA Test_Orlando Kissimmee FL Non Mail Order Select Bid Product Category Test_Oxygen Supplies and Equipment gt Help PTAN s 1001022210 Logout Required fields are marked with Certification The Authorized Official AO or Back up Authorized Official BAO must certify the bid is accurate Please complete all fields below to certify your bid and then click Certify and Submit Bid Changes made to the T den alate Se bid application after you have certifie
93. ential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 8 Edaptive Intelligently Adapting Technology DBidS User Manual DMEPOS BIDDING SYSTEM DBidS Welcome to DMEPOS Bidding System DBidS Welcome to the online application system DBidS for the DMEPOS Competitive Bidding Program The online system is divided into two parts Form A is the application and Form B is the bid Please click Enter DBidS to access the online system Enter DBidS IMPORTANT DMEPOS Bidding System DBidS Reminder The DBidS screens have four tools to help you navigate through the application NEXT BACK SAVE and PRINT To ensure the correct submission of your information YOU MUST use these four navigation tools as well as any available hyperlinks in the application to move from screen to screen DO NOT use the Back and Forward arrow buttons on the Internet browser toolbar to move from one page to another and DO NOT use keyboard navigation hot keys access keys to move within the DBidS application If you have any questions please contact the CBIC helpdesk at 1 877 577 5331 Before completing the application and submitting a bid all bidders should carefully review information such as the RFB instructions bidding charts financial documentation requirements and state and lo
94. ents liquid BID FOR ENTIRE CLASS NOT BY CODE Rental 0 0000396515 Test_Portable 02 contents gas BID FOR ENTIRE CLASS USING THIS CODE Rental 0 0001998807 Test_Portable 02 contents liquid BID FOR ENTIRE CLASS NOT BY CODE 0 0000000000 This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information pr y 8 y el e el Print Save Back Next Figure 69 Bid Sheet Pane Click Save or Next The Form B Manufacturer page displays Refer to Figure 70 Form B Manufacturer Page This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 58 Edaptive intelligently Adapting Technology DBidS User Manual Click Add to add a manufacturer The Form B Manufacturer Model Name and Model Number page displays organized into two panes The manufacturer model name and model number must be submitted for each of the identified HCPCS codes A minimum of one entry is required per HCPCS The displayed HCPCS codes are the top HCPCS codes Refer to Figure 71 Manufacturer Model Name and Model Number Panes Note If a contract is awarded the information entered on this screen will be displayed to the public in the online Supplier Locator tool
95. eport Tami conten Pe sine prade such as AAA AA atc Gauges weh an arrow indicating the relative vate of ect or a credit report m csing De namber of Gays teyord term are oot accectette Mote F Narcan atatererta anaett be prepared N accendance wit genmraly accepted accouring prackes GAAP Tiva uieemetioe us coofgertal Coments stall not be weed modified of cleinQuted elecroecaly or orherwine i persons nor authorized to recedes ihe information Figure 94 DBidS Form A Checklist Displayed only to AOs or BAOs This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document Edaptive Intelligently Adapting Technology DBidS User Manual C VTS pmeros BIDDING SYSTEM DBids Bidder 20 4099116 asdfasd Welcome Test Test Navigation Form A Approval Print Back Next Status Page gt Business Organization Types gt Modify Form A Required fields are marked with gt Help Logout The Authorized Official AO or Back up Official BAO must approve Form A before proceeding to Form B The User ID assigned during registration must be identified in your response First Name Test Today s 10 14 2011 Date 10 49 29 Open Bid 01 18 2011 Last Name Test User ID After the AO or BAO approves Form A the AO or BAO must re
96. equired fields have been completed TheSupplier Checklist pane provides specific reviewing and submittal instructions Printing is strongly recommended as this form contains valuable information Refer to Figure 40 Form A Checklist Page This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 32 Edaptive intelligently Adapting Technology DBidS User Manual DMEPOS BIDDING SYSTEM DBids Dane ONDE CST De PTAA 112161000 Meares meneer t asyo Sapper Type eat le pel scater Osem H pow Rave aay questions pieste contact Ihe Competiave Riding Implementation Contrariar CC csstorer service corner at 1 477 677 6231 Har deomy harren Pax kage aera bat Tha checkint m not a required document tut s pade ts help yos presare year package sf tardcagy docamerts tor subumaten Fact abasta charts ssd other renmurces peters to aubetirg s paciage can be Seed OS The CeCe Baking URN r eA CERT WCOSEE How SEESE Cw Fehr Ie AFG siias Coretedy 1 esere poar Giunterals marel Of FeyRmermerts hemer Mamos semesti edculd be prepared n accordance wrih geseraly scomptes accourrang principles GAAP Emmu Qa neratua oms sinem nai bade te dbweg gt are Experaes Dy Category ah we aniar viidet snt ato Aduanen to sevenaet OF apiet Net mewnetees Contat gooes sst Bousco S
97. er inconsistent with the provisions applicable to this document ii Edaptive intelligently Adapting Technology DBidS User Manual 5 5 7 Updating Multiple Locations and Network Supplier Information Form A 64 36 5 5 8 Update Form A Users with Multiple PTANs Associated with User ID e 37 5 5 9 Update Form A Users with One Bidder Number ccccccccseseccneeeeeeeseeeaeseeeaeeeees 37 5 5 10 Update Form A Users with Multiple Bidder Numbers ccccccsececeseseeeeeseeeeeseees 38 Dosis UWpdatePorm A Locion Page Lecce aa E EEEE R REEE EEE 39 5 5 12 Update Form A Location Page 2 sssnessssesssensssesssnsssersssrsssrrssersssersssesssrrsssesssersssessseres 39 Salo Updaile CBA Prod ci Cae SOV Dre re ane en EEE ET EE EEE 39 AE PP LOCION e E E E E a 39 O AEO O a A E E 41 Zlo Update CBA Prodnot Cae CO i vs sac saccsssaassasonecssscsssvncanansecaasseseenseceassesenusescoeansecnsacomnenenanants 45 5317 Add Network M mber scsssssscssrasesssessossesesstons cece teesuenctaeeececenswenreeaeiescenascespewatenceieetnemsans 45 5 5 18 Add Additional Information to Form A ssssseeesseeesssersssssrssssressseresseresssersssseesseeessseeees 47 3O Ceea T a eee ne en ene ete cree er re ee ee eee eee ee 52 se Modry mo a ak 0 9 10 D eRe A me nme A re ne ee ee Tee nee eee 63 Daleks ADP CATE Punni Dod OS epee e e e EOE EOE SOE EE EEEE 64 5 7 2 Update Expansion Plan ceccccceccccse
98. er you have finished entering Manufacturer data for this HCPCS Manufacturer Model Name Model Number Manufacturers Model Names and Model Numbers Manufacturer Model Name Model Number Action s This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Save Back Figure 104 DBidS Form B Manufacturer Model Name and Number This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 91 Edaptive Intelligently Adapting Technology DBidS User Manual LZ AY MM gets eu DBids Bidder 20 4099116 asdfasd Welcome Test Test Navigation Form B Summary Print Back Next Status Page gt Business Organization Types gt Modify Form A Create Form B Bidder 20 4099116 gt Modify Form B CBA Test_Orlando Kissimmee FL Non Mail Order Select Bid Product Category Test_Oxygen Supplies and Equipment gt Help PTAN s 1001022210 Logout Bid Status Pending Certification Displayed below is a summary of Form B Please carefully review for accuracy You may make changes by selecting Edit Today s 10 14 2011 Date 10 56 26 Open Bid 01 18 2011 Date 09 00 00 Close Bid 12 31 2011 HCPCS Code Total
99. ernments and consumers The competitive bidding program offers beneficiaries in the designated CBAs access to quality DMEPOS products and services with lower out of pocket costs Under the program the single payment amount will become the Medicare allowed payment amount for the competitive bidding items for beneficiaries who reside in the CBAs Contact Person The contact person is the person who may be directly contacted and who is authorized to discuss bids and the business or network organization Corporation This is a commercial establishment or enterprise comprised of one or more employees and legally recognized as a separate entity DBidS DMEPOS Competitive Bidding Process DBidS is a system for online a submissions of bids for the DMEPOS competitive bidding program Refer to the link below for more information This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 71 Competitive Bidding Program Edaptive Intelligently Adapting Technology DBidS User Manual Terms and Definitions http www cms hhs gov DMEPOSCompetitiveBid DME Durable Medical Equipment This is equipment that is primarily and customarily used to serve a medical purpose can withstand repeated use and is appropriate for use in the home DMEPOS Durable Medical Equipment P
100. es Test_CPAP Devices Respiratory Assist Devices and Related Supplies and Accessories Test_Hospital Beds and Related Accessories Test_Walkers and Related Accessories _ Test_Support Surfaces Group 2 mattresses and overlays in Miami _ Test_Hospital Beds and Related Accessories_11 Test_Hospital Beds and Related Accessories_12 Test_Hospital Beds and Related Accessories_13 Test_Hospital Beds and Related Accessories_14 Test_Hospital Beds and Related Accessories_15 Test_Hospital Beds and Related Accessories_16 _ Test_Hospital Beds and Related Accessories_17 Test_Hospital Beds and Related Accessories_18 Close Bid 09 30 2011 Date 23 59 59 CBA and Product Category List Displayed below is a summary of the CBA s and Product Category s for which this location is bidding Please review for accuracy This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Save Back Next SSS SSS Saga SSS Figure 91 DBidS Form A Additional Locations CBAs and Product Categories This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 81 Edaptive Intelligently Adapting Technology DBidS User Ma
101. eseeeeeeeeeeeeeeaaeeeeeseeeeeeeeaeeeeeaaaeeeeeaaneeeees 85 This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document Vil Edaptive intelligently Adapting Technology DBidS User Manual Figure 99 DBidS Form B Create Bid srcssisisionsseachossbehsbohssunwnanseteenstesenenatenene waeuoneaeereoueatereseerinonteaenecstt 86 Figure 100 DBidS Form B Figure 101 DBidS Form B Figure 102 DBidS Form B Figure 103 DBidS Form B Figure 104 DBidS Form B Figure 105 DBidS Form B Figure 106 DBidS Form B Figure 107 DBidS Form B Figure 108 DBidS Form B Figure 109 DBidS Form B Figure 110 DBidS Form B Pori NC ANS sa ss se ose sso E E 87 Expansion Plan and Contractor Yes csecccccsseeeccceeeeecceaeecceeeeeseeenees 88 ISG IC CL E T EE E E E E E 89 Manufacturer with top HCPCS 0 0 0 ccccccecccccseeeceseeeecaeeeeeseseeseeseeeaeseeeaes 90 Manufacturer Model Name and Number c cece cece eee eceececececcecececeees 90 SUMAT csetacudacatencsecatasstasesesuasiaucwnmsmiauaasmnnansaumionusnsupdneanansasmnouaasananondind 91 Certification Statement Displayed only to AOs and BAOsSs 64 92 Public Address Announcement Displayed only to AOs and BAOs 92 Certification Displayed only to AOs and BAOS
102. estSingleLocationBidder Bidder Status Complete and Approved Displayed below is a summary for the location s for which you are submitting a bid Please carefully review the information you provided on Form A application information for accuracy You may modify your information or add a new location If you do not wish to make any changes or add another location select NEXT Only locations identified by the PTAN listed on this summary page will be eligible to be awarded a contract and to receive payment under the DMEPOS Competitive Bidding Program You cannot use the same 10 digit PTAN for each location To make any changes click EDIT Legal Business Name test Address Line 1 test i test City test 12511 Telephone Number Qoo 00x 2000 325 325 2352 Toll Free Number if available 001 201 000 325 235 2352 Email Address test test com PTAN for this location 7210019999 2352352352 Select the PTAN below to review the information for this location Access to Supplier Checklist and Approval screens are restricted to only Authorized Officials and Backup Authorized Officials This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print All Locations Back Next Figure 3 Print All Locations Button This document contains confidential information Disclosure is restricted Contents shall not be
103. expand using subcontractors choose Yes below Please note that Subcontracting Arrangements 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 specific requirements Do you plan to use subcontractor s Select one or more of the following functions that the Delivery of Medicare covered item only subcontractor will perform Pi Set up and or instruction on use of Medicare covered item Repair of rented equipment only Purchase of Inventory Any time the subcontractor sets up and or instructs he she must be accredited If you clicked Yes above you must provide a copy s of the signed letter of intent to enter into an agreement with each subcontractor that includes the following Parties involved Functions services to be performed Anticipated length of agreement Signature of an Authorized Official for each party Include language obligating subcontractor to abide by state and federal privacy security and licensure requirements This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Save Back Next e e Figure 68
104. f business from the list provided Type of Business Select the business type that describes this location as identified by the PTAN above Bidders must submit certain financial documents based on the type of business identified in this response See the OMEPOS Competitive Gidding Program website at www dmecompetitivebid comiTinencisirequirements for further information Type of Business Please Select Business Type Figure 20 Type of Business Pane Update the information in the Service Delivery pane Select how this business provides services to beneficiaries as identified by the PTAN in the Identifying Information pane Refer to Figure 21 Service Delivery Pane e How will you service beneficiaries in a CBA Check all that apply Checkboxes Check all that apply Service Delivery For the location identified above how will you service beneficiaries in a Round 2 CBA or in the national mail order CBA Check all that apply How will you service beneficiaries Retail in a CBA i Check all that apply Mail Orders Home Delivery Figure 21 Service Delivery Pane Update the information in the Sanctions pane Indicate whether this location as identified by the PTAN in the Identifying Information pane has been subject to any current or past legal actions or sanctions such as debarments Refer to Figure 22 Sanctions Pane e Does this location have any current or past legal actions
105. gure 71 Manufacturer Model Name and Model Number Panes ccccsesscceeseeeeeeeeeeeeeaeeeeeees 59 Figure 72 gt Top HCPCS Codes Pane xcssisscbsisictesshadethesebehodonseuesuanancceedsiabobadelsbansasseneeenreoeeatereseeaeenteeneense 59 Figure 73 Top HCPCS Codes Pane continued sessiossa 60 Fase A Epin on Pan Pane a i e e e E E 60 Poe O o PaO e E E T E E 60 Figure 6 Bid Sheet Pane 2 c00essrerevesanesesesaereanttseasseaaceciasaicasassnssaeansscebdsndsacsdonsscoddandionadansecnadwebasedbenss 60 Figure 77 Top HCPCS Manufacturer Model Name and Model Number Pane ccccceeeeeeeeees 61 Figure 78 Form B Bid Certification Statement Page cc eeccccccseececceeeeceeeeeeeeenseneeeeeeeeeeeeaeeeeeees 61 Figure 79 Form B Public Address Announcement Page ccceccccccseeecccceeeceeeeeseceeaeeeeeeseeeeeeaeneeeees 62 FPisure 50 rorm B Gio MINT SIN NTO 0M Pa oe ener rene nee ne net eee a ee ee eee ee ee 63 Fiure sl Fomi bB Summary Papesse ES ane ao Se ao So E 63 Figure 82 Form B Select Bid Pag ocencie rassaa siran sssr EnEn ES S EEEE ES EEEE ESSERE EESE PS ENERE EEAS ka 66 Poue e DOIG N OE E EEEE 73 Figure 84 DBidS Select PTAN to Create Form A Organization with Multiple Locations 74 Figure 85 DBidS Form A Business Organization Information ccceecccccsseeeeeeeeeeeeeeeeeeeeeaeeseeens 75 Figure 86 DBidS Form A Location Specific Informat
106. hat Subcontracting Arrangements 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 specific requirements Do you plan to use subcontractor s Yes No Select one or more of the following functions that the Delivery of Medicare covered item only subcontractor will perform Set up and or instruction on use of Medicare covered item Repair of rented equipment only Purchase of Inventory Any time the subcontractor sets up and or instructs he she must be accredited If you clicked Yes above you must provide a copy s of the signed letter of intent to enter into an agreement with each subcontractor that includes the following Parties involved Functions services to be performed Anticipated length of agreement Signature of an Authorized Official for each party Include language obligating subcontractor to abide by state and federal privacy security and licensure requirements This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Save Back Next aw SSS SSS ee ea Figure 101 DBidS Form B Expansion Plan and Contractor Ye
107. he Financial Instructions for required documents for your business organization type Figure 7 Business Organization Information Pane Multiple Supplier This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 11 Edaptive Intelligently Adapting Technology DBidS User Manual Update the information in the Specialty Supplier pane This is a supplier who agrees to provide DMEPOS items only to its residents if awarded a contract Only skilled nursing facilities and nursing facilities are eligible to be specialty suppliers Identifying oneself as a specialty supplier restricts the list of product categories Refer to Figure 8 Specialty Supplier Pane Are you a Skilled Nursing Facility SNF or Nursing Facility NF that is bidding as a specialty supplier that plans to provide competitive bid items only to its own residents Option selection Click Yes or No Application defaults to No Click Yes if applicable Specialty Supplier a Indicate if you are bidding as a specialty supplier Are you a Skilled Nursing Facility SNF or Nursing P Yes No Facility NF that is bidding as a specialty supplier that plans to provide competitively bid items only to its own residents Figure 8 Specialty Supplier Pane Update the information in the Licensure pane
108. he entire geographic bidding area Se E a a a apie E A A a a a a O a The valid OMB control number for this information collection is 0938 1016 The time required complete this information collection is estimated to average 14 hours per response i the time to review instructions search existing data resources gather the data needed and complete and review the information collection If you have any Annaa en a e r eaea Aira dae eee PRA Reports Clearance Officer 7500 Security Blvd Baltimore Maryland 21244 This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Back Next Figure 106 DBidS Form B Certification Statement Displayed only to AOs and BAOs CATS Bidder 20 4099116 asdfasd DMEPOS BIDDING SYSTEM DBidS Welcome Test Test Navigation Form B Public Address Announcement Print Back Next Status Page gt Business Organization Types gt Modify Form A Create Form B Bidder 20 4099116 gt Modify Form B CBA Test_Orlando Kissimmee FL Non Mail Order Select Bid Product Category Test_Oxygen Supplies and Equipment gt Help PTAN s 1001022210 Logout DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE amp MEDICAID SERVICES Today s 10 14 2011 Date 10 57 41 Open Bid 01 18 2011 Form Approved OMB No 0938 1016 Date 09 00 00 Close Bid 12 31 2011 Date
109. heet mat nichts Be irang Geved esses Trsisssets Toistan Correct mtatee amp Stockholders apiy ar oweerw captai 5 ienen of Com Flows mni ete De Srey Com Mew conalting More operating sctvten Ca Rew renting tee mresep ete Cast few matag fon fasong achia Tas Senra putras DO MOT pand the ardre te rete em De repast pages o CORON Remar E some epret win ST ryt bew O IDE mpteay FT Phe bel meter By Sae 7 ihe Bve apprved CoN HhoOring agmces The 6 Bremitinet Exserinn Eart Marseeer er bineamd i Poora Segeang anc anding asd tatarces Mot Enaissi xara at Legu Agreenert and tenwork Certicatioe Page signed by LACE metwort member f apeicane Magred Letter of imeet to fetes tn a tatecererting Agpeernent F apekcane Setterreret Agreement o Corporate Phegrity Agrees it tpomabe Mncetieremass go Reader sember on EACH page of EVERY Oonemert A documents suterrited n koope page format ss bama Diery sore teeing stares oy paper cips OME package per t namber regardies of sember of bida for each product category compete baking area or commonly PADE sr caan SERA aesir compte sisaret eteen Hew ELOS taper HCAS E Me Oil ahd Sane CPE package For feta WAN ANDE AA eared OS rem LACM Bert MDA Biel faked OM pDA MATION MAL CODER EEE 8S CONT gt Rew Wee Orne SOR ree eee A hardcopy documert packages must be RECENED by fre CEIC on oF prire fhe cope of Ihe Set amdos Packages should be sent is PALMETTO CBA COM
110. his information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Back Next SSS aes Figure 109 DBidS Form B Certification with Message Displayed only to AOs and BAOs This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 94 Edaptive intelligently Adapting Technology DBidS User Manual IL ZAYED aed ers DBids Bidder 20 3509843 Whitemore Shoes Welcome Janet Whitmore Navigation Form B Summary Status Page Business Organization Types b Modify Form A Create Form B Displayed below is a summary for the location s for which you are submitting a bid Please print and or save the summary page data to PDF for your records gt Modify Form B Select Bid gt Help Logout Form B Summary 20 3509843 Test_Pittsburgh PA Non Mail Order Product Category Test_Enteral Nutrients Equipment and Supplies PTAN s 7309989999 Bid Status Complete and Certified Bidder Network Name Today s 08 03 2011 Date 13 46 09 Open Bid 01 18 2011 Date 09 00 00 Close Bid 09 30 2011 Date 23 59 59 Displayed below is a summary of Form B Please carefully review for accuracy Top HCPCS Codes HCPCS Code Total Units Provided Units Provi
111. ial or Key Personnel Modify Delete Authorized Official Key Personnel Information Modify or delete the authorized official or key personnel information First Name jLast Name Action s Competitive Bidding Area CBA and Product Category For Round 2 select all of the CBA s and product category s for which your business organization or network is submitting a bid s If you are bidding in the national mail order competition for diabetic testing supplies select National Mail Order from the drop down list of CBAs Choose one CBA from the drop down box The product category s for the selected CBA will appear Then select all of the product category s for which you are submitting a bid for this CBA You must click the Add CBA Product Category button in order for this information to be saved below If you are bidding in more than one Round 2 CBA select Add CBA Product Category Once you have selected the CBA s and product category s scroll down to verify they were entered correctly All of the CBA s and product category s for which your organization will be bidding must be displayed on this screen Later in the application you will be required to identify the CBA s and product category s associated with each of your locations Note Networks are excluded from bidding in the national mail order competition CBAs Select the CBA Product Categories Wo product Categories Found Add CBA Product Category i
112. icted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 29 Edaptive intelligently Adapting Technology DBidS User Manual Review the information in the Authorized Official or Key Personnel pane Refer to Figure 32 Authorized Official or Key Personnel Pane Optional Click the Edit button in the Authorized Official or Key Personnel pane to edit any of the information The Form A Business Organization Information page displays Scroll af necessary to the Authorized Official or Key Personnel pane Only an AO or BAO may edit this page as it applies to supplier creation Refer to Section 5 3 1 Create Business Organization for instructions on updating this section Authorized Official and Key Personnel First Name Last Name John Doe Figure 32 Authorized Official or Key Personnel Pane Review the information in the Type of Business pane Refer to Figure 33 Type of Business Pane Optional Click the Edit button in the Type of Business pane to edit any of the information The Form A Location Specific Information page displays Scroll af necessary to the Type of Business pane Refer to Section 5 5 1 Update Form A Location for instructions on updating this section Type of Business Type Of Business Test Sole Proprietorship Figure 33 Type of Business Pane Review the information in the Service Delivery pa
113. id for this location t Click the Next Back or Save button to save any additions or changes made to the current page e Click Create Form B in the Navigation menu Form B Create Bid page displays organized into two panes The bottom most pane is a summary of CBAs and product categories selected Refer to Figure 64 Competitive Bidding Area CBA Product Category Panes Update the information in the Competitive Bidding Area CBA Product Category pane Refer to Figure 64 Competitive Bidding Area CBA Product Category Panes e CBA field Click the drop down arrow and select a CBA e Click Select to display the Product Categories associated to the CBA and location s e Product Category field Click the drop down arrow and select the specific Product Category Logout CANT S DMEPOS BIDDING SYSTEM DBidsS Bidder 20 4099116 asdfasd Welcome Test Test Navigation Form B Create Bid Status Page Business og ization Types Required fields are marked with Competitive Bidding Area CBA Product Category Toc bid select the Aip und 2 CBA and product category or t Natio eg l Order if bidding in the national mail order competition This field is populated from the information provided on Form A You ae Select button in order for the product c eee iy drys cae Select the CBA Product Category Today s 10 13 2011 Date I Open Bid 01 19 2011 Date 9 00 0 Select Product Category
114. idS Bidder 20 4099116 asdfasd Welcome Test Test Navigation Status Page gt Business Organization Types gt Modify Form A Create Form B gt Modify Form B Select Bid gt Help Logout Today s 10 14 2011 Date 10 55 13 Open Bid 01 18 2011 Date 09 00 00 Close Bid 12 31 2011 Date 13 59 59 Form B Manufacturer Print Back Next Bidder 20 4099116 CBA Test_Orlando Kissimmee FL Non Mail Order Product Category Test_Oxygen Supplies and Equipment PTAN s 1001022210 Required fields are marked with 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 all products that you plan to make available to Medicare beneficiaries in this CBA You must provide information for each HCPCS code in order for your bid to be complete If you are bidding in the national mail 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 plan to provide for HCPCs code A4253 In 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 di
115. idS Form A Summary pdf DBidS Status Page Windows Internet Explorer provided by Edaptive Systems DMEPOS BIDDING SYSTEM DBidsS Bidder 20 9489203 asd Welcome DOT BUGZLIFE Navigation Form A Application Status a Status Page z z Modify Form A Complete and Approved 08 15 2011 13 05 39 DOT BUGZLIFE Print Save Create Form B gt Help Logout Form B Bid Status Today s 08 15 2011 CBA Product Category Status Last Modified Date Modified By CHCH Date 13 15 50 Open Bid 01 18 2011 No bids found Date 09 00 00 Close Bid 09 30 2011 Date 23 59 59 Documentation Status li Documentation Received No it is the suppliers responsibility to ensure that they have submitted the entire package of all required hardcopy documents to the Competitive Bid Implementation Contractor CBIC The notation above indicates whether the CBIC has received a package of hardcopy documents However it does not acknowledge the accuracy or completeness of the package The CBIC is unable to provide this information Covered Document Review Date CDRD Eligible a CDRD Eligible No Figure 98 DBidS Status This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 86 Edaptive intelligentl
116. ify that I am an authorized official of this organization that is submitting a bid in the DMEPOS Competitive Bidding Program Network Members If I am a member of a network I further certify that I meet the definition of a small supplier who joined the network because I am unable to independently furnish all items in the product category to Medicare beneficiaries throughout the entire geographic bidding area to complete this estimated to average 14 hours per response including the time to review instructions search existing data resources gather the data needed and complete and review the information collection comments concerning the accuracy of the time estimates or suggestions for improving this form please write to CMS Attn PRA Reports Clearance Officer 7500 Security Blvd Baltimore Maryland 21244 ae At D5 Ea eee ta raspen ta a ee OMO mani ainber The valid OMB control number for this information collection is 0938 1016 The time required information collection is If you have any This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Back Next e a a a a Figure 78 Form B Bid Certification Statement Page Click Next The Form B Public Address Announcement page displays Only the AO and BAO have access to this page after the specific Form B status is Pending Certification and all
117. igure 63 Form A Network Member Panes e Network Member Name field Type name of network member e Click the Add Network Member button The recently added data displays in the Network Members pane and the Add Network Member pane is cleared to allow entry of additional information Repeat the above steps to add additional network members Once all network members are added click the Add Location button to add the location associated to the network member name e Modify the required fields Refer to Section 5 5 15 Add Location for instructions on modifying these fields e Click the Add Location button in the Network Member pane to add a network member location The Form A Additional Location page displays e Click the Modify button in the Network Member pane to modify network member information The Form A Additional Locations page displays e Add the required fields Refer to Section 5 5 15 Add Location for instructions on adding a network member location e Optional Click the Delete button in the Network Member pane to delete a network member This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 50 Edaptive Intelligently Adapting Technology CATS Bidder 20 3509843 axsdd Navigation Status Page gt Modify Form A gt Help
118. ine 2 City Anytown State MD rail 12345 Email abc def com PTAN 1234567890 Telephone 123 456 7890 Toll Free Number 800 111 1234 NPI 1111111111 TIN Number 333333333 Figure 55 Additional Location Information Pane Review the information in the Physical Address pane Refer to Figure 56 Physical Address Information Pane Optional Click the Edit button in the Physical Address pane to edit any of the information The Form A Additional Location page displays Scroll if necessary to the Physical Address Information Pane Refer to Section 5 5 1 Update Form A Location for instructions on updating this section Supplier Physical Address Address Line 1 78 Pull Ave Address Line 2 City Baltimore State MD Zip Code 24156 This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 47 e e Edaptive intelligently Adapting Technology DBidS User Manual Figure 56 Physical Address Information Pane Review the information in the Supplier Business Information pane Refer to Figure 57 Supplier Business Information Pane Optional Click the Edit button in the Supplier Business Information pane to edit any of the information The Form A Additional Locations page displays Scroll if necessary to the Business Information pane Refer to Section 5
119. information is confidential Contents shail not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Save Back Next Figure 90 DBidS Form A Additional Locations This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 80 Edaptive intelligently Adapting Technology DBidS User Manual LZ ASM gets dieu DBids Bidder 20 9489203 a Welcome DOT BUGZLIFE Navigation Form A CBAs and Product Categories Print Save Back Next Status Page gt Business Organization Types gt Modify Form A Required fields are marked with gt Help Logout CBA and Product Category Select the CBA s for which this location will be servicing Medicare beneficiaries The product categories were previously identified by your organization You must click the Add CBA button in order for this information to be saved below CBA Test_Charlotte Gastonia Concord NC SC Non Mail Order v Product Category s Today s 08 15 2011 Date 12 44 23 Open Bid 01 18 2011 Date 09 00 00 Test_Oxygen Supplies and Equipment Test_Standard Power Wheelchairs Scooters and Related Accessories Test_Complex Rehabilitative Power Wheelchairs and Related Accessories Group 2 Test_Enteral Nutrients Equipment and Suppli
120. ion cccccceecccccesesceceeeeeeeeeeeeeeeeeeeeeeeaenseeees 76 Figure 87 DBidS Form A Location Specific Information page 2 ccccccccseseccescecseseeceeseeeneseeeaenes 77 Figure 88 DBidS Form A CBA and Product Categories cccceccccccseeeccceeceeceeeeceeeeeseeeeeeeeeeeaeeseeees 78 Figure 89 DBidS Form A Add Location eecccccssescecceesecenseeececeeeeeceeaseeeceeaeeeeceesaeseeesaeeeeeeaanseeees 78 Figure 90 DBidS Form A Additional Locations cccccceecccccceeececeeeececeeescceeaeeseceeseeeceeaeeneeeeaanseeeas 79 Figure 91 DBidS Form A Additional Locations CBAs and Product Categories cccececceeseeeeeees 80 Figure 92 DBidS Form A Add Network Member ccccccccseececcceeeececeeeeeceeaeeeeceeseeseceeeeeeceeaaeseeeas 81 Figure 9 3 DBidS Form iba ware 10 814 01 ab generate part aA SA Acne ene nT rae ET ee RN Cae ER De 82 Figure 94 DBidS Form A Checklist Displayed only to AOs or BAOS ccccccseccccseseeeeeseeeaeseeeaenes 83 Figure 95 DBidS Form A Approval Displayed only to AOs and BAOS ccccccceeeeceeeeeeeeeeneeeeeees 84 Figure 96 DBidS Form A Approval Message Displayed only to AOs and BAOS ccccceeeeeeeeeees 84 Figure 97 DBidS Form A Summary pdf cccccsssecccesccccseccccseecccacecccasecccacesccaseccuacesenacesenasesenaces 85 Figure 98 DBidS Status 00 0 cccccccccccseeececeeeeeeeeeeeeeeeeeeeeeeseeeeee
121. ion page 2 Each location must be accredited DBidS displays the following instructional text below the Section Header titled Accreditation on the Page titled Form A Location Specific Information page 2 Select the name s of the Medicare approved organization that has accredited this location The location must be accredited for the product category for which you are bidding You must click the Add Accreditation button in order for this information to be saved below If a location is not accredited you will not be able to submit a bid for this location A location may select the same accrediting organization only once A maximum of five entries per location is allowed e Update the information in the Form A Location Specific Information page 2 page panes This is the name s of the Medicare approved organization that has accredited this location The location must be accredited for the product category in order to bid Refer to Figure 23 Form A Location Specific Information page 2 e Accreditation Organization drop down list Click the drop down arrow and select the accreditation organization from the list provided e Accreditation Status drop down list Click the drop down arrow and select Accredited or Not Accredited If Accredited is selected additional information is required If Not Accredited is selected a bid may not be submitted and the user will not be able to move forward within the application and
122. istorical record detailing the necessity of the application a description of the intended audience of the user manual and step by step procedures detailing use of the application The DBidS User Manual is a standalone document that is updated for every major release 2 Purpose The purpose of this document is to provide concise instructions to all users of the DBidS application as well as any necessary reinforcement information 3 Background The DMEPOS competitive bidding program is mandated in Section 302 of the Medicare Modernization Act MMA The following text is an abstract from the CMS DMEPOS web page and provides a good overview of the legislation s intent http www cms hhs gov DMEPOSCompetitiveBid Table 1 Section 302 of the MMA Section 302 of the MMA Section 302 of the Medicare Prescription Drug Improvement and Modernization Act of 2003 MMA Pub L 108 173 authorizes the Secretary to utilize our competitive acquisition authority as outlined in the U S Code Section 1847 a Section 302 b 1 of the Medicare Modernization Act requires Medicare to replace the current durable medical equipment DME payment methodology for certain items with a competitive acquisition process to improve the effectiveness of its methodology for setting DME payment amounts This new bidding process will establish payment amounts for certain durable medical equipment enteral nutrition and off the shelf orthotics Competitive bidding pro
123. ith for the steps to complete this process Refer to Section 5 5 Updating Single Location Supplier Information Form A for specific information on completing Form A 5 5 11 Update Form A Location Page 1 Refer to Section 5 5 1 Update Form A Location for instructions on completing this process 5 5 12 Update Form A Location Page 2 Refer to Section 5 5 2 Update Form A Location Specific Information page 2 for instructions on completing this process 5 5 13 Update CBA Product Category Refer to Section 5 5 3 Update CBA Product Category for instructions on completing this process 5 5 14 Update Locations This process provides the procedures involved in updating locations and only applies to suppliers with multiple locations or network suppliers who have multiple locations The primary location entered may not be deleted only modified This screen displays when you click Next on the Form A CBAs and Product Categories page e Update the information in the Form A Add Location page This page allows modification and or deletion of saved additional locations Refer to Figure 46 Form A Add Location This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 39 Edaptive intelligently Adapting Technology DBidS User Manual e Click Modify to modify a l
124. l Name and Model Number Pane Click Next The Form B Bid Certification page displays Only the AO and BAO have access to this page after the specific Form B status is Pending Certification and all required fields are entered Review the Certification Statement Refer to Figure 78 Form B Bid Certification Statement Page CATS DMEPOS BIDDING SYSTEM DBidS Bidder 20 4099116 asdfasd Welcome Test Test Navigation Status Page gt Business Organization Types Logout Form B Bid Certification Statement Print Back Next fi Modify Form A Create Form B Bidder 20 4099116 gt Modify Form B CBA Test_Orlando Kissimmee FL Non Mail Order Select Bid Product Category Test_Oxygen Supplies and Equipment gt Help PTAN s 1001022210 Certifying Statement Applies to All Information Submitted Electronically or Hardcopy Today s pleats Date 16 38 42 Open Bid 01 19 2011 Date 09 0 I have read the contents of this application I hereby certify that I have examined the completed application and accompanying financial statements and I certify that they are true correct and complete statements that can be substantiated from our books and records My signature legally and financially binds this supplier to the laws regulations and program instructions of the Medicare program By my signature I certify that the information contained herein is true correct and complete to the best of my knowledge an
125. l mail order competition for diabetic testing supplies the CBA includes all parts of the United States including the 50 states the District of Columbia Puerto Rico the U S Virgin Islands Guam and American Samoa 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 Fee Schedule This indicates the fee schedule amount for the HCPCS code in this CBA For items included in the national mail order competition for diabetic testing supplies the fee schedule amount is the average amount for all parts of the United States including the 50 States the District of Columbia Puerto Rico the U S Virgin Islands Guam and American Samoa You must provide a bid price that is less than or equal to the fee schedule amount Bid Price Indicate your bid price for this item You should submit a bona fide bid amount for each HCPCS code The amount submitted should be rational feasible supportable and reflect all costs associated with providing these items and
126. l not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 85 Edaptive intelligently Adapting Technology DBidS User Manual DBidS Application Windows Internet Explorer provided by Edaptive Systems EUT C ETS DMEPOS BIDDING SYSTEM DBidS Bidder 20 9489203 Welcome DOT BUGZLIFE Navigation Form A Summary Status Page Business Organization Types gt Modify Form A Create Form B Select Bid Displayed below is a summary for the location s for which you are submitting a bid Please print and or save the summary page data to PDF for your records gt Help Logout Today s 08 15 2011 p Date 13 05 44 Form A Summary Open Bid 01 18 2011 Date 08 15 11 01 05 39 aiat e ehun PTAN s 1101270001 raise teeta fated Ste Bidder Number 20 9489203 Supplier Type TestSingleLocationBidder Bidder Status Complete and Approved Displayed below is a summary for the location s for which you are submitting a bid Please carefully review the information you provided on Form A application information for accuracy Only locations identified by the PTANs listed on this summary page will be eligible to be awarded a contract and to receive payment under the DMEPOS Competitive Bidding Program You cannot use the same 10 digit PTAN for each location Legal Business Name asdf Address Line lasat o O Address Line2 Figure 97 DB
127. ld Type city name e State drop down list Click the drop down arrow and select state from the list provided e Zip Code field Type zip code e E Mail field Type email address e Telephone Number field Type telephone number e Toll free Number if available field Type toll free number e PTAN for this Location field Pre populated based on PTAN authenticated in IACS e NPI Identification Number field Type National Provider Identifier NPI number Identifying Information Provide the legal business name and mailing address for the business organization identified by the PTAN below City State Zip Code Telephone Number a Toll Free Number if available ae PTAN for this location 3120500001 NPI Identification Number fd Figure 17 Identifying Information Pane Update the information in the Physical Address pane Complete this information if the information differs from the Section above Otherwise the box must be checked to populate the address A Post Office box is not accepted as a physical address Refer to Figure 18 Physical Address Pane e Physical Address is the same as identified in the section above Check if addresses are the same e Address Line 1 field Type first line of address e Address Line 2 field Type second line of address e City field Type city name e State drop down list Click the drop down arr
128. le panes Refer to Section 5 5 5 Review Form A Checklist for information on the checklist Click Next The Form A Approval page displays Refer to Section 5 5 6 Approve Form A for information on approval This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 51 Edaptive Intelligently Adapting Technology DBidS User Manual 5 6 Creating a Form B These sections provide instructions for creating a Form B bid The assumptions are that login has already occurred and that Form A status is listed as Completed and Approved on the Status page The option for Form B in the Navigation menu is only available when Form A is in the Completed and Approved status An alternative method of navigation through the various pages in the application is to use the menu links in the left most Navigation pane The order in which sections are completed is not pertinent If during business organization creation a CBA and product category was not selected and during Form A location creation a location was not associated to a CBA no bids can be created Only an AO BAO can go back to modify the business organization to include a missing CBA and product category This action must be repeated for each location If a location is not accredited you will not be able to submit a b
129. located on http www medicare gov PLZ AY MM et Aue Bidder 20 4099116 asdfasd Required fields are marked with Today s 10 13 2011 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 all products that you plan to make available to Date 16 35 44 Medicare beneficiaries in this CBA You must provide information for each HCPCS code in order for your bid to be complete Open Bid 01 18 2011 Date 09 00 00 If you are bidding in the national mail 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 Close Bid 12 31 2011 meet the 50 rule you must complete the 50 Percent Compliance Form located on the CBIC website identifying the products you plan to provide for HCPCs code A4253 In order for your bid to be considered this Date 13 59 59 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 ifa contract is awarded the information entered on this screen will be displayed to the public in the online Medicare Supplier Directory located at htto Awww medicare gov HCPCS Manufacturers Model Names Action s Code and Model Numbers Entered E1390 0 E0439 E0424 E1391 E0431 E0434
130. m B will require the AO or BAO to recertify the form as the status will change to Pending Approval upon update An alternative method of navigation through the various pages in the application is to use the menu links in the left most Navigation pane The order in which sections are completed is not pertinent If an attempt is made to access a Form B and a message is received indicating that the account is locked the account remains locked until you log out of the application In the event of a system error that generates a locking issue reattempt login in 30 minutes faa L Click the Next Back or Save button to save any additions or changes made to the current page 5 7 1 Update Furnished Items This section provides instructions for updating the Form B furnished items section e Click Modify Form B gt Furnished Items in the Navigation menu The Form B Furnished Items page displays Update the applicable items Refer to Section 5 6 Creating a Form B for instructions on updating this section 5 7 2 Update Expansion Plan This section provides instructions for updating the Form B expansion plan e Click Modify Form B gt Expansion in the Navigation menu The Form B Expansion page displays organized into multiple panes Update the Expansion Plan pane information Refer to Section 5 6 Creating a Form B for instructions on updating this section Update the Subcontractor Information pane information Refer to Section 5
131. ment to get a false or fraudulent daim paid or approved by the Government or c conspires to defraud the Government by getting a false or fraudulent claim allowed or paid The Act imposes a civil penalty of 5 000 to 10 000 per violation plus three times the amount of damages sustained by the Government 4 Section 1128A a 1 of the Social Security Act imposes civil liability in part on any person induding an organization agency or other entity that knowingly presents or causes to be presented to an officer employee or agent of the United States or of any department or agency thereof or of any State agency a claim that the Secretary determines is for a medical or other item or service that the person knows or should know a was not provided as daimed and or b the daim is false or fraudulent This provision authorizes a civil monetary penalty of up to 10 000 for each item or service an assessment of up to three times the amount daimed and exclusion from participation in the Medicare program and State health care programs 5 The government may assert common law claims such as common law fraud money paid by mistake and unjust enrichment Remedies include compensatory and punitive damages restitution and recovery of the amount of the unjust profit This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the inform
132. merican Samoa The supplier must have all applicable licenses needed to provide mail order diabetic testing supplies throughout the entire CBA Please use the drop down box to identify each state in which you have 2 license to provide diabetic testing supplies and then indicate the type of license that you have for each of those states See the CBIC website for a listing of CBAs Do the locations included on your bid comply withthe Yes No WIA licensure requirements for the CBA Product i i i Category Some states may not require 2 license to furnish items in a specific product category Please check the DMEPOS State License Directory on the NSC website and the Licensure for Bidding Suppliers fact sheet on the CBIC website to verify licensure requirements Figure 9 Licensure Pane Update the information in the Contact Person pane The person listed should be the authorized person to answer questions regarding bids Refer to Figure 10 Contact Person Panes First Name field Type first name of contact person Last Name field Type last name of contact person Title field Type title of contact person E Mail field Type email address Telephone Number field Type telephone number Click the Add Contact Person button The recently added data displays in the Modify Delete Contact Person s pane and the Contact Person pane is cleared to allow entry of additional information Repeat the above steps
133. n page 2 Print Save Back Next Status Page gt Business Organization Types gt Modify Form A Required fields are marked with oo Accreditation gt Help Select the name s of the Medicare approved organization that has accredited this location for the product category in which you are bidding You must click the Add Accreditation button in order for this Logout information to be saved below Accreditation Organization Select Accreditation Organization h Status Select Accreditation Status v Today s 10 14 2011 Date 10 42 07 Open Bid 01 18 2011 Date 09 00 00 Modify Delete Accreditation Information Close Bid 12 31 2011 Date 13 59 59 To modify your accreditation information status products issue or expiration dates click the Modify button next to the applicable accreditation organization Once the changes are complete click the Save Accreditation button to save the modified information The selected accreditation organization cannot be modified To make a change to this information you must delete the entry and re enter a new accreditation organization for this location Accreditation Organization Action s Accreditation Commission for Healthcare Inc Licensure Select the state s in the CBA in which you have a license to furnish the competitively bid item s State Select State v Modify Delete Licensure Information To modify your licensure information for the selected state s you must
134. n Mail Order Select Bid Product Category Test_Oxygen Supplies and Equipment gt Help PTAN s 1001022210 Logout Required fields are marked with Certification Today s 10 13 2011 The Authorized Official AO or Back up Authorized Official BAO must certify the bid is accurate Please complete all fields below to certify your bid and then click Certify and Submit Bid Changes made to the Date 16 54 10 bid application after you have certified may result in the need to recertify Please visit your DBidS home page to make sure your bid application is complete Open Bid 01 18 2011 First Name 7 Date 09 00 00 Close Bid 12 31 2011 Last Name gt Date 13 59 59 User ID Certify and Submit Bid This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Back Next Figure 80 Form B Certification Page Click Certify and Submit Bid The completed Form B is certified A message displays alerting the user that the Form B has been submitted Click OK The Form B Summary page displays alerting you to print in PDF the Summary page for your records Refer to Figure 81 Form B Summary Page C 75 DMEPOS BIDDING SYSTEM DBids Bidder 20 3509843 Whitemore Shoes Welcome Janet Whitmore Navigation Form B Summary Status Page Business Organization Types gt Modify
135. n buttons This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document Edaptive Intelligently Adapting Technology DBidS User Manual e Click the Log out button to properly logout of the system The Log Out button only displays on the top right not the bottom right as the other buttons e Click the Print button to print the current page ba A Click the application Back button to navigate to the previous page and save any additions or changes made to the current page The browser buttons have been disabled for your convenience e Click the Save button to save any updated information on the page ha Y Click the Next button to navigate to the next page and save any additions or changes made to the current page e Click to access application help e An indicates a field that must be completed e You must use the approved DBidS navigation buttons to move forwards and backwards in the application If a user attempts to use any keys other than the approved DBidS navigation buttons a message will display alerting you that you have used non DBidS navigation and to click OK or Cancel If you select OK you will be directed to the Welcome page and any data entered on the previous pages will not be saved If you select Cancel you will remain on th
136. n this response See the DMEPOS Competitive Bidding Program website at www dmecompetitivebid com financialrequirements for further information Type of Business Test Corporation Service Delivery For the location identified above how will you service beneficiaries in a Round 2 CBA or in the national mail order CBA Check all that apply How will you service beneficiaries Retail in a CBA p Check all that apply Mail Orders Home Delivery Sanctions Indicate whether this location as identified by the PTAN above has been subject to any current or past legal actions or sanctions such as debarments within the past five 5 years Does this location have any current Yes No or past legal actions or sanctions such as debarments This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Save Next eS SSS Figure 86 DBidS Form A Location Specific Information This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 71 Edaptive Intelligently Adapting Technology DBidS User Manual Logout ILL AY MM aged eeu DBids Bidder 20 4099116 asdfasd Welcome Test Test Navigation Form A Location Specific Informatio
137. nakde monite prior to 2009 The three france statements ssd fe tax extract must be tor the seme 2 morf accourteg pered for example if ihe francis ateterent are for fie 2010 calendar year the tax return axtrect asst Oe tor he 2910 comedar year For esate BAMEN pease raea Ihe Thence Eaa tact aneet on he OC wenete Moat current year tor WST Of PREPARED Oy Fev rare Corres asseta Qperatno actrees Lerret o Torsi onsets Pronceg octe tes reverses Correct bartas meeng actntes Cost of gasas mat Tote iasaiten Foon 112 pages t Eapenses Oy category fe Sicbmeaters contr tw Cm Bisosreet Net rcormicne form 11295 pages Esperan 4er Cquttax Rehetee pages t Treen Stardard amp Poor s Moat current year tor rest raport wt acors mre e iga retorn has ma Comuetes teor saten ed vroue 99 clays prior to net acasa erry martta s opening of he be panor to 2006 fer Sepai wWwagdp a Revere Operating actives MIST OF PREPARED Sy Ltproieert w Frere octvees reverses reewsng acthtws Cost of gasca mae bezenn and enaing chatiis C pagas t Espenses Oy salegory cesh bswnces Net rcomminae MUST aaus Coustax Tense tet acate prey morita prso to 2099 for tecst Peers MUST CLUE ost of goed oe Bogermp prs oneng Pon 1088 pages t cash beences s carme vee ST CLUDE Operating actrees Feancing acy tas veers screws Segenns and mang Torn 200 pages caah baeoces ange ts Oun amp Brecker t prren Eaurtan Transunion Siargao 6 Pe
138. ne Refer to Figure 34 Service Delivery Pane Optional Click the Edit button in the Service Delivery pane to edit any of the information The Form A Location Specific Information page displays Scroll af necessary to the Service Delivery pane Refer to Section 5 5 1 Update Form A Location for instructions on updating this section Service Delivery Retail Service Delivery Type s Mail Orders Figure 34 Service Delivery Pane Review the information in the Years in Business Months in Business pane Refer to Figure 35 Years in Business Months in Business Pane Optional Click the Edit button in the Years in Business Months in Business pane to edit any of the information The Form A Location Specific Information page displays Scroll af necessary to the Business Information pane Refer to Section 5 5 1 Update Form A Location for instructions on updating this section Years in Business Months in Business Years supplying DMEPOS items T Months supplying DMEPOS items 0 Figure 35 Years in Business Months in Business Pane This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 30 Edaptive Intelligently Adapting Technology DBidS User Manual Review the information in the Accreditation pane Refer to Figure 36 Accreditation Pane
139. ness Organization Types gt Modify Form A Required fields are marked with gt Help EPS Logout Accreditation Select the name s of the Medicare approved organization that has accredited this location for the product category in which you are bidding You must click the Add Accreditation button in order for this information to be saved below Accreditation Organization Select Accreditation Organization X Today s 10 10 2011 2 Dates 15 53 49 Status Select Accreditation Status v Open Bid 09 01 2011 0 Add Accreditation Clear Date 09 00 00 Close Bid 12 31 2011 Soo ee Modify Delete Accreditation Information To modify your accreditation information status products issue or expiration dates click the Modify button next to the applicable accreditation organization Once the changes are complete click the Save Accreditation button to save the modified information The selected accreditation organization cannot be modified To make a change to this information you must delete the entry and re enter a new accreditation organization for this location Accreditation Organization Action s No Accreditation s Saved Licensure Select the state s in the CBA in which you have a license to furnish the competitively bid item s State Select State v Modify Delete Licensure Information To modify your licensure information for the selected state s you must click the Modify button next to the applicable
140. ness that your business would be capable of providing for all HCPCS codes in the product category for this CBA during a projected 12 month period The percentage increase may exceed 100 but may not exceed 100000 TOP HCPCS Codes fndicat e the percentage Increase In Medicare business that your business organization or pebwors would be cana ble of providing for al ACPCS codes In the produci category for is CBA during a projected 12 month period The percentage increase may exceed 100 percent ke Figure 66 TOP HCPCS Codes Pane continued Click Save or Next The Form B Expansion page displays organized into two panes Is your estimated capacity greater than your historic capacity If yes you must complete an expansion plan option selection Click Yes or No Application defaults to No click Yes if applicable If Yes the user is required to complete the expansion fields This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 53 Edaptive Intelligently Adapting Technology DBidS User Manual Complete the information in the Expansion Plan pane Refer to E hih Fees RA Teal rater Fo ai Made Tami B Prekni letegerp Ten egen bok and Poop a PTA mk EHEH Begs Sele prg marie oo as 1S PPO r n T mm E pi AH dg E BiM pho CEA pE E a Bee pbp e
141. nformation Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 43 Edaptive Intelligently Adapting Technology DBidS User Manual e Click the Modify button in the Modify Delete Licensure Information pane to modify licensure information The information for the selected state s populates the Licensure pane e Modify the required fields e Click Modify Licensure Information when modifications are complete The updated information displays in the Modify Delete Licensure Information pane e Optional Click the Delete button in the Modify Delete Licensure Information pane to delete state s e You must have a license for each state in which you are providing durable medical equipment prosthetics orthotics and supplies If you do not have a license you may not be able to submit a bid Refer to Figure 51 Licensure Information Pane Licensure Select the state s in the CBA in which you have a license to furnish the competitively bid item s State ASEA Aad censure Clear Modify Delete Licensure Information To modify your licensure information for the selected state s you must click the Modify button next to the applicable license Next complete the necessary changes and click Save Licensure to save the modified information below Licensure State Licensure Information fo E H Figure 51
142. nformation may be modified later but any changes made at a later time may impact locations in Form A and Form B bids particularly the selection of a Competitive Bidding Area CBA and Product Category This task may only be performed by an AO or BAO Click the Next Back or Save button to save any additions or changes made to the current page 5 3 1 Create Business Organization This section provides step by step instructions for creating the Business Organization e Click Business Organization Types gt Create Business Organization The Form A Business Organization Information page displays organized into multiple panes This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 10 Edaptive Intelligently Adapting Technology DBidS User Manual Update the information in the Business Organization Information pane Refer to Figure 6 Business Organization Information Pane e Legal Business Name field This is the name used for tax purposes e Supplier Bidding Type field Click the drop down arrow and select Supplier with single location Supplier with multiple locations or Network supplier e Network Name field Displays and must be completed if Network Supplier is selected Type the network name assigned to the business organization e Do you have
143. nformation to be saved below Accreditation Organization Select Accreditation Organization Status Select Accreditation Status Add Accreditation Modify Delete Accreditation Information Modify the status product specific area s issue or expiration dates The location must be accredited for the product category for which you are bidding You must click the Modify Accreditation button in order for this information to be saved below The Accreditation Organization cannot be modified You must delete entry and re enter a new accreditation for this location Figure 50 Accreditation Information Panes Update the information in the Licensure Information pane You must have a license for each state in which you are providing Durable Medical Equipment Prosthetics Orthotics and Supplies If you do not have a license you may not be able to submit a bid Refer to Figure 51 Licensure Information Pane e Licensure drop down list Click the drop down arrow and select the state s for which you have a license to furnish Durable Medical Equipment Prosthetics Orthotics and Supplies e The Identify the type s of license s you have in this state text box will display Input the type of license you have for the state identified in the Licensure drop down list e Click the Add Licensure button to add the state s The recently added data displays in the Modify Delete Licensure Information pane This document contains confidential i
144. nized into multiple panes Review the information in the Top HCPCS Codes pane Refer to Figure 72 Top HCPCS Codes Pane Optional Click the Edit button in the Top HCPCS Codes pane to edit any of the information The Form B Business Organization page displays Scroll if necessary to the TOP HCPCS Codes pane Refer to Section 5 6 Creating a Form B for instructions on updating this section Top HCPCS Codes HEPES Code Total Units Provided Units Provided to Medicare Beneficiaries E 31 E0439 E 2 a eS E1390 p E Figure 72 Top HCPCS Codes Pane This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 60 Edaptive intelligently Adapting Technology DBidS User Manual Review the information in the Top HCPCS Codes pane Refer to Figure 73 Top HCPCS Codes Pane continued Optional Click the Edit button in the Top HCPCS Codes pane to edit any of the information The Form B Business Organization page displays Scroll if necessary to the TOP HCPCS Codes pane Refer to Section 5 6 Creating a Form B for instructions on updating this section TOP HCPCS Codes 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 category for this CBA d
145. nnel Pane cscsscccssssscccssececeesseccceesscecseusecessensecees 30 Figure 33 Type of Business PANG sa ccsssannsesstasesanssaseoasipecedacedeesd acesueees senetdecsdacudecteecusseseasddeeceedsdecbbaewaces 30 Poe 33 e 1Ce 106 ICP AN rasa senes seecece E T E 30 Figure 35 Years in Business Months in Business Pane ccceeccccceseeceeceeeceeeeeeceeeeeesceeeeeeeeeesaeseeees 30 BE FC IN NU IN cases ss seep eros E E A A A 31 Fig re 3 Licens re Panes s ccsucstonstecetansdesetecstwaiesnataasncteansdecedeaadesetuadetontsmncdwiaseindeiaieiacoionasereiaeensesseded 31 Fi SUS DO SANCTIONS Pane eearri oror nn ena n S EE ETEEN E EEEE 31 Figure 39 Competitive Bidding Area CBA and Product Category Pane ccccceeecceenseeeeeeeeeeeees 32 Figure 20 Form A Checklist Page coscsaceccsatcansanseatnesiieseeasunecsadesseostasttecseeetbesss tbeauuiesbasduetbosstesGasteact 33 ree Fel Onin Ot PeO eenn a aaa a a 34 Figure 42 Form A Summary PDF esssssessessseeessseresserssseresseeressseresseressseressseresseressseeessseresseeresseeee 35 Fooie do elect VAN to Croate Formi A Pat acnmsenenccasecsescesececs sernnenneuacmenmasenceenaconmeomecaseusaseccponuante 37 POO AA Status PaE eeose isai na EOE EENEI EENES E REE EEEE TENSES ESE EnS 38 Figure 45 Location Specific Intormation Page sasssisossiossoscii e a a a a 39 Pawe do rom A Add Location Page sssr E E ee ee a ee ee ee ee eee ete 40 Figure 4 Identifying Into
146. ns or problems Please call the Customer Service Center for assistance Additional help in the form of links from the Navigation menu is discussed in Section 5 9 Accessing DBidS Online Help 5 2 Logging In To log into the DBidS Application follow the instructions in this section Obtain a username and password by submitting a request through the Individuals Authorized Access to CMS Computer Systems ACS application ACS user ID and passwords are case sensitive After 10 minutes of inactivity a message will display instructing the user they will be logged out in five minutes After a total of 15 minutes of inactivity the user will be logged out For more information about the privileges your role allows you refer to Section 4 1 User Roles e Type http www dmecompetitivebid com e Click on the Enter Bid Submission System link e User is directed to the ACS Terms and Conditions page e Click on I Accept button e User is directed to the ACS Application Login page e Type IACS User ID in the User ID field e Type IACS password in the Password field e Click Log In button The page shown in Figure 5 CMS DMEPOS Bidding System DBidS displays Refer to Section 5 2 1 Navigating the DBidS Welcome page for information on using this page JavaScript must be enabled to view and use the DBidS Application If assistance in enabling JavaScript is required contact your IT Help Desk This document contains confid
147. nt gt Help PTAN s 1001022210 Logout Required fields are marked with Expansion Plan T kes y J TA a I ls 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 Yes Open Bid 01 18 2011 Date 09 00 00 Close Bid 12 31 2011 Date 13 59 59 If you plan to expand your business under the Competitive Bidding Program describe your current structure and expansion plan in the space provided If 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 Staff Current 1000 characters left Staff Expansion Plan 1000 characters left Finance Current 1000 characters left Finance Expansion Plan 1000 characters left Facilities Current 1000 characters left Facilities Expansion Plan 1000 characters left Inventory Control Current 1000 characters left Inventory Control Expansion Plan 1000 characters left Distribution Current 1000 characters left Distribution Expansion Plan 1000 characters left Additional Information Current 1000 characters left Additional Information Expansion Plan 1000 characters left Subcontractor Information If you plan to expand using subcontractors choose Yes below Please note t
148. nual DBidS Network Member Windows Internet Explorer provi i arm Logout amp C TS pmepos BIDDING SYSTEM DBids Form A Network Member Print Save Back Next Status Page Business Organization Types gt Modify Form A Required fields are marked with gt Help Logout Add Network Member Please enter the network member name and indicate the contract status You must click the Add Network Member button in order for this information to be saved below After member s information is displayed below click the Add Location button to complete member s location information Only network members identified by their PTANs are eligible to be awarded a contract Network Member Name Today s 08 15 2011 Date 12 47 07 Open Bid 01 18 2011 Date 09 00 00 Close Bid 09 30 2011 Date 23 59 59 Network Members Network Member Action s werwadsf Aceh Lonation No Locations Saved This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Save Back Next Figure 92 DBidS Form A Add Network Member This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 82 Edaptive intelligently Adapting
149. nual 5 9 Accessing DBidS Online Help Help is available from the Navigation menu The following sections detail the steps to access this help 5 9 1 Access CMS RFB Instructions This action provides a link to a viewable printable version of CMS Request for Bid RFB instructions These instructions should be referenced for any questions regarding the bidding rules and regulations e Click Help gt CMS RFB Instructions The CBIC Website displays a link to CMS RFB instructions 5 9 2 Access DBidS Technical User Guide This action provides a viewable printable version of the DBidS Technical User Guide These instructions should be referenced for any questions regarding the actual procedures involved in the DBidS process e Click Help gt DBidS Technical User Guide The DBidS Technical User guide displays 5 9 3 Access Quick step by step guide to submitting a bid in DBidS This action provides a viewable printable version of the DBidS Reference Guide These instructions should be referenced for any questions regarding entering or modifying a bid in the DBidS system e Click Help gt Quick step by step guide to submitting a bid in DBidS The DBidS User Guide displays 5 10 Logging Out Perform this task to log out of DBidS e Click Logout button in the top right hand corner of the screen or click Logout on the Navigation menu Logout occurs and Login must be performed before any further actions may be taken in the DBidS proce
150. nual e Facilities Expansion Plan 1000 characters left text box Describe any planned modifications or additions to the facilities e Inventory Control Current 1000 characters left text box Describe the current inventory process e Inventory Control Expansion Plan 1000 characters left text box Describe any planned modifications to the inventory control process e Distribution Current 1000 characters left text box Describe the current distribution process e Distribution Expansion Plan 1000 characters left text box Describe any planned modifications to the distribution process e Additional Information Current 1000 characters left text box Provide any additional information that may be applicable but is not covered elsewhere on this form e Additional Information Expansion Plan 1000 characters left text box Provide any additional information that may be applicable to the expansion plan but is not covered elsewhere on this form Update the information in the Subcontractor Information pane Refer to Figure 68 Subcontractor Information Panes Perform this process if there is a plan to modify subcontractors under the DMEPOS Competitive Bidding Program e Do you plan to use subcontractor s field Click Yes or No No is the default Click Yes if applicable If yes you will be required to select one or more of the functions the subcontractor will perform Subcontractor Information If you plan to
151. numeric digits Verify that the TIN is nine numeric digits Example 123456789 You may only enter up to 20 characters for Verify that 20 characters or fewer are entered for your first You may only enter up to 30 characters for Verify that 30 characters or fewer are entered for your last your last name name Your request has timed out Please try If problem persists please contact the administrator at 1 again If problem persists please contact 877 577 5331 the administrator at 1 877 577 5331 Please fix the errors and re submit the form Note For Incomplete Status to display any error messages click on the Incomplete Status on the Status Page which will guide you to the page with the error This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 69 Edaptive Intelligently Adapting Technology DBidS User Manual 7 Frequently Asked Questions This section provides a list of frequently asked questions as well as the answers to those questions Who can I contact for help How do I ensure that information I ve entered is saved before I move to the next page Why can t I access the Approval pages for Form A Why can t I access the Certification pages for Form B Table 3 Frequently Asked Questions Frequently Asked Questi
152. ocation 3 ri _ Legal Business Name Local Test Address Line 1 78 Pull Ave Address Line 2 City Baltimore State Maryland Zip Code 24156 E Mail test aal com Telephone Number d 456 b 456 4564 J PTAH for this location 1027000605 Toll Free Number if available Confirm PTAN for this location 1027000605 NPI Identification Humber 5555555555 Tax Identification Number TIM 444444444 Figure 47 Identifying Information Pane This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 4 Edaptive intelligently Adapting Technology DBidS User Manual Update the information in the Physical Address pane Complete this information if the information differs from the Section above Otherwise the box must be checked to populate the address A Post Office box is not accepted as a physical address Refer to Figure 48 Physical Address Pane e Physical Address is the same as identified in the section above Check if addresses are the same e Address Line 1 field Type first line of address e Address Line 2 field Type second line of address e City field Type city name e State drop down list Click the drop down arrow
153. ocation The Form A Location Specific Information page displays Refer to Section 5 5 1 Update Form A Location to update the location information e Optional Click Delete to delete a location e Optional Click Add Location to add a location e Optional Click Delete All to delete all locations If OK is selected all additional locations will be permanently deleted from the application for this bidder The Form A Add Location page displays C S DMEPOS BIDDING SYSTEM DBids Bidder 20 4099116 asdfasd Welcome Test Test Navigation Form A Add Location Print Back Next Status Page Business Organization Types Modify Form A gt Help Logout All locations that conduct business within a Round 2 CBA or national mail order CBA and provide the product category for which you are bidding must be listed below It is important that bidders identify all locations by PTAN that will provide competitively bid items in a CBA Only those locations entered on the bid will be identified on the contract and be eligible to receive payment for the competitively bid item s If you are bidding as a network in Round 2 the primary network member should add its location on this screen If there are members of the network with multiple locations the primary network member should add these members locations on the next screen To access this screen click Next Today s 10 13 2011 Date 14 11 34 Open Bid 01 18 2011 L
154. occurred Form A is in a Complete and Approved status Access to the certification statement public address and certification is restricted to the AO and BAO An alternative method of navigation through the various pages in the application is to use the menu links in the left most Navigation pane The order in which sections are completed is not pertinent Click the Next Back or Save button to save any additions or changes made to the current page e Click Select Bid in the Navigation menu The Form B Select Bid page displays Refer to Figure 82 Form B Select Bid Form B Select Bid Update and Modify Bid Select the bid for which you would like to update modify or delete Competitive Bidding Area CBA Product Category Action sy TEST_Cleveland Elyria Mentor OH TEST_Oxygen Supplies Equip TEST _Cleveland Elyria Mentor OH TEST_PMD Complex TEST_Cleveland Elyria Mentor OH TEST_PMD Standard Figure 82 Form B Select Bid Page Click Select to select a CBA and product category bid The Form B Business Organization page displays Refer to Section 5 6 Creating a Form B to perform any actions associated with this selection This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 67 Edaptive intelligently Adapting Technology DBidS User Ma
155. on and Form B is the bid Please click Enter DBidS to access the online system Enter DBidS IMPORTANT DMEPOS Bidding System DBidS Reminder The DBidS screens have four tools to help you navigate through the application NEXT BACK SAVE and PRINT To ensure the correct submission of your information YOU MUST use these four navigation tools as well as any available hyperlinks in the application to move from screen to screen DO NOT use the Back and Forward arrow buttons on the Internet browser toolbar to move from one page to another and DO NOT use keyboard navigation hot keys access keys to move within the DBidS application If you have any questions please contact the CBIC helpdesk at 1 877 577 5331 Before completing the application and submitting a bid all bidders should carefully review information such as the RFB instructions bidding charts financial documentation requirements and state and local licensure rules on the DMEPOS Competitive Bidding Program website at www dmecompetitivebid com Browser Compatibility This online application is best viewed with a screen resolution of 1024 x 768 using Microsoft Internet Explorer 6 0 or greater JavaScript must be enabled Pop up blockers should be disabled For Your Security When you log into the application system you are on a secure server All the information that you provide us is encrypted to provide the highest possible security Using
156. only to its own residents Licensure The bidder is responsible for having a copy of the applicable state license s on file in the Provider Enrollment Change and Ownership System PECOS and with the National Supplier Clearinghouse NSC before they submit a bid Bids will be disqualified if a bidder does not meet all state licensure requirements for the applicable product categories and for every state in a CBA Every supplier location is responsible for having all applicable license s for each state in which it provides services For a multi state CBA the bidder must collectively have all applicable license s for every state in the CBA Each location is not required to have licenses for every state in the CBA as long as each state has a bidding location licensed for the product category For the national mail order competition the CBA includes all parts of the United States including the 50 states the District of Columbia Puerto Rico the U S Virgin Islands Guam and American Samoa The supplier must have all applicable licenses needed to provide mail order diabetic testing supplies throughout the entire CBA Please use the drop down box to identify each state in which you have a license to provide diabetic testing supplies and then indicate the type of license that you have for each of those states See the CBIC website for a listing of CBAs Do the locations included on your bid comply with the Yes O No WA licensure requirements
157. ons Contact the CBIC Help Desk Monday through Friday between 9 A M and 9 P M prevailing Eastern time e Phone 1 877 577 5331 e Email cbic admin palmettogba com Do not e mail technical questions or problems Please call the Customer Service Center for assistance Click to access application help Click the Next Back or Save button to save any additions or changes made to the current page Only the AO and BAO have the privileges necessary to access these pages Only the AO and BAO have the privileges necessary to access these pages This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 70 Edaptive Intelligently Adapting Technology DBidS User Manual Appendix A Glossary of Terms and Definitions Table 4 Terms and Definitions Terms and Definitions Accreditation Each location in the CBA that shares common ownership and each member in a network must be accredited AO Authorized Official An authorized official is an appointed official to whom the supplier has granted the legal authority to enroll it in the Medicare program to make changes and or updates to the supplier s status in the Medicare program e g new practice locations change of address etc to verify correctness of the information on the form and to commit the
158. ons and national identifiers for providers health insurance plans and employers Individuals Authorized to Access CMS Computer Services The IACS system is an on line application used to register and provision authorized users for access to CMS Part C and D business applications and systems HIPAA Act IACS Item Description Short narrative description of each HCPCS code For long description go to www dmecompetitivebid com Item Weight Indicates the relative market importance of each item to the overall product category MMA Medicare Prescription Drug Improvement and Modernization Act sometimes shortened to Medicare Modernization Act This act provides seniors and individuals with disabilities with a prescription drug benefit more choices and better benefits under Medicare Municipality Owned This is an enterprise owned by an urban district Non Profit This is a not for profit organization This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document T2 Edaptive Terms and Definitions Intelligently Adapting Technology DBidS User Manual National Provider Identifier The Administrative Simplification provisions of the HIPAA Act of 1996 mandated the adoption of a standard unique identifier for health care providers The NPPES collects identif
159. orm B certification statement e Click Modify Form B gt Certification Statement in the Navigation menu The Form B Certification Statement page displays e Review the Certification Statement 5 7 7 Review Public Address Announcement This section provides instructions for reviewing the Form B public address announcement e Click Modify Form B gt Public Address Announcement in the Navigation menu The Form B Public Address Announcement page displays e Review the Public Address Announcement 5 7 8 Complete Certification This section provides instructions for updating the Form B certification If modifications are made to a Complete and Certified Form B bid the certification process must be completed again If viewing Certification the User ID will not be displayed for security reasons e Click Modify Form B gt Certification in the Navigation menu The Form B Certification page displays e Complete the certification fields Refer to Section 5 6 Creating a Form B for instructions on completing this section This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 66 Edaptive Intelligently Adapting Technology DBidS User Manual 5 8 Selecting a Bid These sections provide instructions for selecting a bid The assumption is that login has already
160. orrectly e Item Weight Indicates the relative market importance of each item to the overall product category e 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 For the national mail order competition for diabetic testing supplies the CBA includes all parts of the United States including the 50 states the District of Columbia Puerto Rico the U S Virgin Islands Guam and American Samoa 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 for the definition of a unit for each item e Fee Schedule This indicates the fee schedule amount for the HCPCS code in this CBA For items included in the national mail order competition for diabetic testing supplies the fee schedule amount is the average amount for all parts of the United States including the 50 states the District of Columbia Puerto Rico the U S Virgin Islands Guam and American Samoa You
161. ors UST ecLUCe ost repent mth core at mee competes 98 lays prior o ne openan oF he Det weon IST HE PMEPANED retern meesme end Coat of goods aoe Rogers ard etn caah balances Tronson Mardard amp oora if a tae return hae beer reat report wth acors foni rater m tha ramvast Pat man cargamos OF days prior be he operas of the be wade UST OC PREPARED Sy OMe OF THE OUO Fom 1129 pages t Ser form 11205 pages 1 Tones assets Fmancen actrees Com amp Beeceweet Corrent botaten rerewing scitis trporen Toned istatus Cegenng and neng Courter Seanckmeadere expe caan nsancea Senatus C pages t Transen ewsers cepts ze Siansa 5 Poor s Ner orpte form 700 pezes cuespaly er state wads weed ogere eters ramt metde tetai ret anneta ar fund beaeoes aseos of stockhotter s exuty or swaers captai ta oret repon a wot One year tor esca ust sauvo vustecuoe usT WCLUDE Pon 112 pages 1 6 or Revenue Corrent avacts Operating sortes form 11295 pages 1 4 Atquarrert w Total anssta l eancrg acr tes cr resmen nesine actheee Fom 1096 pages 1 or tepremp ard eng Schedule pepes 2 caah balnces or ewnerw captai Forn 60 pages t and Tha Ree Ere JAPANSE DN YOST BOORUNTING PINDI AAA Dus EASS Tyee CONAC your tax preparer It you tave any eraions Cred reports vant retect a merto sogre uresa yos are vemp Blatderd and Moors Mandard amp Moors credt ropert vers an ebhe scurt asiead of a nemere score Ihoreture Ihe r
162. ow and select state from the list provided e Zip Code field Type zip code This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 22 Edaptive Intelligently Adapting Technology DBidS User Manual Physical Address Provide the physical address for the location as identified by the PTAN above in the Identifying Information question d Physical address is the same as identified above City State Select State Zip Code Figure 18 Physical Address Pane Update the information in the Business Information pane Provide information for this location as identified by the PTAN in the Identifying Information pane Refer to Figure 19 Business Information Pane e Tax Identification Number TIN Type taxpayer identification number if sole proprietorship type social security number e Doing Business As DBA 1 field Type doing business as name if different from the legal business name reported in Identifying Information section e Doing Business As DBA 2 field Type doing business as name if doing business under an additional name differing from the legal business name reported in the Identifying Information section e Years in Business drop down list Click the drop down arrow and select number of years and months in
163. play on the Welcome page e Enter DBidS Click to enter the DBidS application Once Enter DBidS is selected from the Welcome page the initial page displays The initial page that displays depends upon the Provider Transactional Access Number PTAN and User ID o The PTAN Selection page displays if more than one PTAN is associated with the User ID o The Bidder Selection page displays if more than one business organization is associated with a PTAN o If this is your first time logging into DBidS with a single PTAN then the Form A Create Business Organization Information page displays o The Status page displays if only one PTAN and one business organization is associated with the User ID has already been created e Quick Step by Step Guide to Submitting a Bid in DBidS Click to view save or print a copy of the Quick Step by Step Guide e DBidS Technical User Guide Click to view save or print a copy of the DBidS User Guide Note that this guide may be accessed via the User Guide link in the Using the Application section of the Welcome page This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 9 Edaptive intelligently Adapting Technology DBidS User Manual e Using the Application The Authorized Official AO or the Backup Authorized Official
164. plete an application gt Create Business Organization gt Help 8120500001 Logout Today s 05 18 2010 Date 15 53 16 Open Bid 10 20 2009 Date 15 15 00 Close Bid 08 31 2010 Date 20 59 00 Figure 43 Select PTAN to Create Form A Page Click Select for the PTAN to create a Form A Refer to Section 5 3 1 Create Business Organization for the steps to complete this process Refer to Section 5 5 Updating Single Location Supplier Information Form A for specific information on completing Form A 5 5 9 Update Form A Users with One Bidder Number This process provides the procedures involved in updating Form A when the user has only one bidder number The following page displays upon entry into the application Only an AO or BAO may update Form A when the status is Complete and Approved Refer to Figure 44 Status Page e Optional If the Status page is not displayed click Status Page from the menu The Status page displays This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 37 Edaptive Intelligently Adapting Technology DBidS User Manual C7 Ay DMEPOS BIDDING SYSTEM DBidsS Bidder 20 3509843 Whitemore Shoes Welcome Janet Whitmore Navigation Form A Application Status a Status Page Modif
165. r network member must be different e Update the information in the Identifying Information pane This is the name and address used for tax purposes The remaining information should allow direct contact to you regarding the DBidS program This information may not be a billing agency management service organization or staffing company Refer to Figure 47 Identifying Information Pane e Legal Business Name field Type legal business name e Address Line 1 field Type first line of address e Address Line 2 field Type second line of address e City field Type city name e State drop down list Click the drop down arrow and select state from the list provided e Zip Code field Type zip code e Email Address field Type email address e Telephone Number field Type telephone number e Toll Free Telephone Number field Optional Type toll free telephone number e PTAN for this Location field Type PTAN e Confirm PTAN for this location field Re type PTAN from the above PTAN field Please note that a user will not be able to copy paste the PTAN into the Confirm PTAN field e NPI Identification Number field Type NPI number e Tax Identification Number TIN Type taxpayer identification number Identifying Information Provide the legal business name and mailing address for the business organization identified by the PTAN below Important Note PTAN must be unique to this l
166. r service center at 77 517 5331 upper Checttet Maracay Document Package Checker CRIS A A A FEED DOENE Deel A GEE WW RED yos ODAO pO BOOED PE OT Ey P ED Saira PaO SBE COUT O80 ETRE es eLCes PENDENG DD UAIG PASE a OF found on the Competteve Doang ireterertiation Coriractsr wenete mure greecempetinvetes com Poffo the AFB instructons carefully to ensere your documents meet af requirements Remember financial statements ahould be prepared in accordance with generally accepted accounting ponciptes GAAP Loansiai osuma manan come Statement vest eoude Pe fotow rng Revenues Excenees by categery mich aa aalery otfitien rent ote Adpentrents to reverses f arptcatie Net mcormefoas Cast of goes soi Balance Sheet reat acute he fotowng Crrere sencte Tete seente Tow istasa Gares naees Gmcencatery Haney or punere capta SEERA ION Of Cosh Fhows musi nonae he tiswa p CAP Nowe resuming Wem operanng oct tes Caan tow reseting von mening potres Cosh Never remy hor Meronp ecthtes Beymer and enteg cast betes co Tax Return Extract DO MOT send the orire tar retar orty the rogaret peges Creda Report wth sone prepered within D9 days pir te the opening of he bet windew ty are of the Ave arproved credi reporting agencies Dun amp Bradvireet boernes boefa Trensunen of Sanderd amp Poor s font mences Dos urmersaticn Legs Agreement and MEtwOre COFlTOanOn Page HONI By LACH netwerk meerder oT appaiate Bane
167. r to such change or within 30 days of the effective date of such change I understand that I may be in breach of contract if any such change results in my failure to carry out the terms of the contract I also certify that I have read understand meet and will continue to meet all supplier standards and quality standards as outlined in 42 CFR 424 57 and 424 58 If I become aware that any information in this application is not true correct or complete I agree to notify the CBIC of this fact immediately I agree that I am a Medicare enrolled supplier and meet the basic eligibility requirements of the DMEPOS Competitive Bidding Program I understand that in accordance with 18 U S C 1001 any omission misrepresentation or falsification of any information contained in this application and all required attachments and supplemental information or contained in any communication supplying information to CMS or the CBIC may be punishable by criminal civil or other administrative actions including revocation of approval fees and or imprisonment under federal law I further certify that I am an authorized official of this organization that is submitting a bid in the DMEPOS Competitive Bidding Program Network Members If I am a member of a network I further certify that I meet the definition of a small supplier who joined the network because I am unable to independently furnish all items in the product category to Medicare beneficiaries throughout t
168. rmation Pane sessssissisessssnssnenoiin seusia a a a aaa 4 Figure 48 Physical Address Pane cccsssscccsessccessscccnesseccesssccceesecccseusecessesseseneussceesesesensensesens 42 Figure 49 Business Information Pane sisccczsaczcsce ssc cecnssaccccsanaccedeassecessaesecsaeasseosaeacsecsaacsdeewanassoossaescooseaces 42 Figure 50 Accreditation Information Panes ccccccsescccceeeeeceeeeecceeeeeeceeaseeeceeseeseceesenseeeeeaeeeeesanseeeas 43 Figure 51 Licensure Information Pane ccccceccccccseeeeceeeeeceeaeeeeeeeeeeceeseeeeeeeseeeeeeesaeeeeeeaeeceeaenseeees 44 Peura eas 8103 8 0 Om ce 0 gt RR a nr rn A ER SE ES ESR eR Ee eT 45 Figu re 53 Form A Network Member Panes nn eee ce el ee ee eee ee eee ee 46 Figure 54 Additional Locations Network Members Network Members Additional Locations Pane 47 Figure 55 Additional Location Information Pane ccccceccccccseeeccceeeeceeeeecceeaeeeeeeesaneeeeeeeeeceeaenseeeas 47 Figure 56 Physical Address Information Pane cccccccccsseecccceeeecceeeeeeeeaseeceeaaeeeceeseeeeeesseeeceeaaeeeeees 47 Figure 57 Supplier Business Information Pane cccccccsssscccceecceeeeeecceaeeeececseeseceeseeeeeaeeeeeeaenseeeas 48 Figure 58 Accreditation Pane ccccsssscccsssseccesssccccessscecsesssccceenssccsessssessenseceseessccseassseesenseceseanseseas 48 S Norby eee y t 01st PA Renna an ne Ree ro ee 48 Figur
169. rop down arrow and select the CBA from the list provided The Product Categories box will update with the Product Categories available for the CBA selected e Click the Add CBA button to add a CBA The recently added data displays in the CBA Product Category List pane and the Competitive Bidding Area CBA and Product Category pane is cleared to allow entry of additional information Repeat the above steps to add additional CBAs e Optional Click the Delete button in the CBA Product Category List pane to delete a CBA Deletion of a CBA per a location after Form B bid s have been created and or certified may impact the bid Clicking the delete button removes this CBA and all its pre selected Product Categories from the available bid selection on Form B Logout DMEPOS BIDDING SYSTEM DBids Bidder 20 6120419 asdfasfd Welcome HEIMLICH BUGZLIFE Navigation Form A CBAs and Product Categories Print Save Back Next Status Page gt Business Organization Types gt Modify Form A Required fields are marked with gt Help Logout CBA and Product Category You must associate this location with specific CBA Product Category s where it will furnish items and services in order to be eligible to receive Medicare payment for competitively bid items Select the CBA s product category s associated with this location You must click the Add CBA button in order for this information to be saved below CBA Select CBA Today s 1
170. rosthetics Orthotics and Supplies The DMEPOS competitive bidding program is mandated in Section 302 of the MMA An end user requires access to the application to create forms for suppliers with single and multiple locations as well as network suppliers This user may also create and select bids Entity See Business Organization Form A One Form A must be completed by each entity supplier single location supplier multiple locations and network supplier However only one Form A needs to be submitted by a particular supplier for each entity regardless of the number of Form B bidding sheets submitted End User Form B This is the bidding sheet that must be submitted for each CBA and product category Each Form B bid will be considered for evaluation individually The supplier completes this form for the business organization and associated locations If bidding as a network the information supplied must be aggregate information for the network HCPCS Healthcare Common Procedure Code System This is a standardized coding system that is used primarily to identify products supplies and services Health Insurance Portability and Accountability Act Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs Title II of HIPAA the Administrative Simplification AS provisions requires the establishment of national standards for electronic health care transacti
171. ry page in the Additional Locations Network Members Network Members Additional Locations pane Refer to Figure 54 Additional Locations Network Members Network Members Additional Locations Pane This process allows you to review the summary of all additional locations and network members for business organizations Additional Locations Network Members Network Members Additional Locations Select the PTAN below to review the information for this location 2609090001 2609050001 2609920001 Access to Supplier Checklist and Approval screens are restricted to only Authorized Officials and Backup Authorized Officials Figure 54 Additional Locations Network Members Network Members Additional Locations Pane e Click the PTAN to review the information for this location The selected PTAN is highlighted Click Go The Form A Summary page displays organized into multiple panes Review the information in the Additional Location Information pane Refer to Figure 55 Additional Location Information Pane Optional Click the Edit button in the Additional Location Information pane to edit any of the information The Form A Additional Locations page displays Scroll if necessary to the Identifying Information pane Refer to Section 5 5 1 Update Form A Location for instructions on updating this section Additional Location Information Legal Business Name Test 2 Address Line 1 2 Test Ave Address P O Box 123 L
172. s This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 89 Edaptive Intelligently Adapting Technology DMEPOS BIDDING SYSTEM DBidS DBidS User Manual Bidder 20 4099116 asdfasd Welcome Test Test Print Save Back Navigation Form B Bid Sheet Status Page gt Business Organization Types gt Modify Form A Bidder 20 4099116 Create Form B CBA Test_Orlando Kissimmee FL Non Mail Order gt Modify Form B Product Category Test_Oxygen Supplies and Equipment Select Bid PTAN s 1001022210 gt Help Logout Today s 10 14 2011 Date 10 54 38 Open Bid 01 18 2011 Date 09 00 00 Close Bid 12 31 2011 Date 13 59 59 You must provide your total estimated capacity along with your bid price for each HCPCS code listed for this product category Important Reminders HCPCS Product Item Code HCPCS Healthcare Common Procedure Code System This is a standardized coding system that is used primarily to identify products Supplies and services Product Class A combination of codes for which a single bid is required item Description Short narrative description of each HCPCS code For long description go to www dmecompetitivebid com Type of Bid Rental or Purchase This column indicates whether your bid should be for the purch
173. s Form A to navigate to the Form A Location Specific Information page Refer to Section 5 5 Updating Single Location Supplier Information Form A or Section 5 5 7 This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 16 Edaptive intelligently Adapting Technology DBidS User Manual Updating Multiple Locations and Network Supplier Information Form A for information on completing Form A 5 3 2 Modify Business Organization This section provides instructions for modifying the Form A Business Organization This task may only be performed by an AO or BAO e Under the Navigation Menu click Business Organization Types gt Modify Business Organization The Location Specific Information page displays Refer to the above illustration Figure 13 Location Specific Information Refer to the above procedure to complete the steps to modify a Business Organization This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 17 Edaptive Intelligently Adapting Technology DBidS User Manual 5 4 Status Page This section provides specific information regarding the statuses that display on
174. s are defined as follows e Documentation Received Yes displays if CBIC has received the package No displays if CBIC has not received the package It is the supplier s responsibility to ensure that they have submitted the entire package of all required hardcopy documents to the Competitive Bidding Implementation Contractor CBIC The Yes or No indicator indicates whether the CBIC has received a package of hardcopy documents However it does not acknowledge the accuracy or completeness of the package The CBIC is unable to provide this information CDRD Statuses are defined as follows e Yes Documentation was received within the timeframe for Covered Document Review Date eligibility e No Documentation was not received within the timeframe for Covered Document Review Date eligibility This indicates whether or not the supplier submitted the required hardcopy financial documents by the Covered Document Review Date CDRD Suppliers who meet this deadline will be notified of any missing financial documents and permitted to submit them within a specified timeframe This notification does NOT indicate whether the received financial documents are acceptable accurate or meet applicable requirements You have the ability to print in PDF or save in PDF a Form A from the Status page only if the Form A status is Complete and Approved You have the ability to print in PDF or save in PDF a Form B from the Status page only if the Form B is
175. s in this CBA during the past calendar year If zero units were provided type 0 The number of units provided to Medicare beneficiaries must be less than or equal to total units provided Required Tields are marked with w 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 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 Bidding Information Chart titled Estimated Capacity and Bid Amount Worksheet at mww 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 American Samoa HCPCS Code Total Units Provided Units Provided to Medicare Beneficiaries sn inl Di ee Figure 65 TOP HCPCS Codes Pane Update the information in the TOP HCPCS Codes pane Refer to Figure 66 TOP HCPCS Codes Pane continued e Percentage Increase field Type the percentage increase in Medicare busi
176. scecseeeeesnecceeeceeeeeeeseeeeesaeeeeeeeeeeeeeeeeseeeeeseseeeaeneees 64 AY Fis Upe Bi i cx Omran een ne rn reine ot ret Ce en Oe een CR eR Ce eR aren ren ena tne a 64 5 7 4 Update Manufacturer Information ccccccccsescccseeecceeeccceeececaeeeceseseeeeeseeeseseeeseseeeaeeeees 64 zo Uae 10100121 a een eee ee eee ee ee ae ae ee ee ee ee eee eee 65 5 7 6 Review GC Ci IC AO ie Statement sissien Ea asa aaa 65 ILN Review Public Address Announcement ccccceccccccseecceceeeceeseeeeeeeeeeeeeseeeeeeeaenseeeaees 65 5 7 8 Comple O c gil hls 1 0 1 een enna ee Meee eat ere none eee ere eee ere ree or eT 65 So e 6 a A E A E EEA 66 29 PCC CSS a OM LD es cscs cscs aces e r a aN ieoi 67 This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document iii Edaptive Intelligently Adapting Technology DBidS User Manual Delis PROCESS CMS REB Ins MUCUONS sssi a EE EEEE E EE 67 392 ACCesSS DBidS Technical User Guide sericsson ie sd i 67 5 9 3 Access Quick step by step guide to submitting a bid in DBidS ee eeecceeeeeeeeeeeees 67 5 10 LO OO shana A E 67 O Ero N a E EE E E EEE E 68 l Preguen y Asked UCC OMS serecek aea eaan 69 Appendix A Glossary of Terms and Definitions cccceccccsseeccceeccceeeeccaseeeseseeeaeseeeseseceseneeesneeeaanes 70 Appendix By DIBI
177. 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 should 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 Date 09 00 00 Close Bid 12 31 2011 Date 13 59 59 i HCPCS Product Item Rental Or Item Total Estimated Fee Code Class Description Purchase Weight Capacity Schedule oe Test_Oxygen concentrator BID FOR ENTIRE CLASS USING THIS CODE Rental 0 6108082987 175 79 Test_Stationary liquid 02 BID FOR ENTIRE CLASS NOT BY CODE Rental 0 0000000000 175 79 Test_Stationary compressed gas 02 BID FOR ENTIRE CLASS NOT BY CODE Rental 0 0000000000 Test_Oxygen concentrator dual BID FOR ENTIRE CLASS NOT BY CODE Rental 0 0000000000 Test_Portable gaseous 02 BID FOR ENTIRE CLASS USING THIS CODE Rental 0 3602632991 Test_Portable liquid 02 BID FOR ENTIRE CLASS NOT BY CODE Rental 0 0000000000 Test_Portable gas oxygen system BID FOR ENTIRE CLASS NOT BY CODE Rental 0 0286888699 Test_Portable oxygen concentrator BID FOR ENTIRE CLASS USING THIS CODE Rental 0 0000000000 Test_Oxygen contents gaseous BID FOR ENTIRE CLASS USING THIS CODE Rental 0 0000000000 Test_Oxygen cont
178. sories Group 2 Test_Enteral Nutrients Equipment and Supplies Test_Orlando Kissimmee FL Non Test_Oxygen Supplies and Equipment Delete Mail Order This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Save Back Next Figure 61 Competitive Bidding Area CBA and Product Category Pane Review the information in the Network Member pane if applicable Refer to Figure 62 Network Member Pane Optional Click the Edit button in the Network Member pane to edit any of the information The Form A Network Member page displays This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 49 Edaptive Intelligently Adapting Technology DBidS User Manual Network Member Do network members have a signed legal contract Yes Network Member Name John Doe Figure 62 Network Member Pane Update the information in the Form A Network Member page This page allows modification and or deletion of network members A Network Supplier can have a maximum of 19 network members hence they need to provide the network name Each network member name can have multiple locations associated to the specific network member Refer to F
179. squalification of your bid Ifa contract is awarded the information entered on this screen will be displayed to the public in the online Medicare Supplier Directory located at htto Avww medicare gov HCPCS Manufacturers Model Names Acti Code and Model Numbers Entered eee 2 1 0439 1 Aaa Aaa Aaa Aaa Aaa This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Back Next CATS Figure 103 DBidS Form B Manufacturer with top HCPCS DMEPOS BIDDING SYSTEM DBidS Bidder 20 4099116 asdfasd Welcome Test Test Navigation Status Page gt Business Organization Types gt Modify Form A Create Form B b Modify Form B Select Bid gt Help Logout Today s 10 14 2011 Date 10 55 52 Open Bid 01 18 2011 Date 09 00 00 Close Bid 12 31 2011 Date 13 59 59 Form B Manufacturer Model Name and Number Print Save Back Bidder 20 4099116 CBA Test_Orlando Kissimmee FL Non Mail Order Product Category Test_Oxygen Supplies and Equipment PTAN s 1001022210 Required fields are marked with Manufacturer Model Name and Model Number E1390 Please enter the Manufacturer Model Name and Model Number You must click the Add Manufacturer Model Name and Model Number button in order for this information to be saved below You must click the Back button aft
180. ss When logging out with a bid pending certification a message will display upon clicking Logout alerting the user that the bid is pending certification and the bid will need to be certified before it can be submitted This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 68 Edaptive Intelligently Adapting Technology DBidS User Manual 6 Error Messages This section provides an example of the types of Error Messages that may be seen as well as examples of actions required to resolve the errors In addition to the Error Messages provided here various other error messages and alerts will instruct the user as needed Table 2 DBidS Error Messages Error Message Resolution The zip code must be five digits only Verify that five numeric digits are typed Example 12345 You must enter a valid email address Verify that a valid email address is typed Example jdoe test com The PTAN must be ten 10 numeric digits Verify that the PTAN is ten numeric digits and that the and must be the PTAN that corresponds to number corresponds to the address provided Example the address information being provided 1234567891 The NPI number must be ten 10 numeric Verify that the NPI number is ten numeric digits Example digits 1234567891 The TIN must be nine 9
181. ssenssseesssserssssessseeossseeossscesssecessseeosssseossrcesssecessseeossrerosseeessseeesss 13 Figure 11 Authorized Official or Key Personnel Panes nneessensssseessssessseerssseerssseressseresseeresseeresee 14 Figure 12 Competitive Bidding Area CBA and Product Category Panes cccceeccccesseeeeeeeeeeeeees 15 Figure 13 Location Specific Information Page ccccccccsseececceeeecceeeeeccesseeceeeaueeeceeseeeeeeaeeeeeeeaaeseeees 16 FEU We PAS PAS saz ccs ase sepectscs sents incataestietetauanenctae E E E 18 Figure 15 LA BG Sa ceases srscisecnrd steels E alates aeea aaa 21 Figure 16 Location and Additional Locations Panes ccccccccseeecccneeceeaeeeececeeeseeeesenseceseeeeceeaaeseeees 21 Figure 17 Identifying Information Pane xccsessecesssscenwsscscuasiee scissvtiaaiehievtaivalee yates vale alee aa dative 22 Fizure 15 Phbysical Address atl ee i an E rt nee rrr ee nee 23 Figure 19 Business Tit Ormia i OME anes saccccasscsccaeaaaseosssesacsensiocssesecocoussacccousnecuceosacmasossackosesaeceosconeaossaeese 23 Figure 20 Type of Business Pane cccccceecccccseeseceeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeseeeeeeeseeeeeeeseeeeeeeeeeeeeaaeeeeees 24 roti 2 L Service Delivery Pane aacccrcnstincatacsusccenamasesceacsease E E iE EAE ap EE E E Eie Ei net 24 a E E O a 0 E E E E EEEE E E ee ene eae ee 24 Figure 23 Form A Location Specific Information page 2 cccccccseecceseeeee
182. supplier to fully abide by the laws regulations and program instructions of Medicare The authorized official must be the supplier s general partner chairman of the board chief financial officer chief executive officer president direct owner of the supplier organization or must hold a position of similar status and authority within the supplier s organization The authorized official also has the legal authority to submit a bid on behalf of the company and to enter into contract with Medicare to provide competitive bid items to Medicare beneficiaries An authorized official is identified on the 855 S form Backup Authorized Official This user has authority and privileges identical to the AO Business Organization a k a An Entity For competitive bidding there are three types Supplier single location supplier with multiple locations and network supplier Competitive Bid Area These areas are organized and identified by counties CM Center for Medicare This is one of the three divisions of CMS and is involved in deciding what types of health policies the government would support setting the reimbursement rate for doctors and managing the volumes of Medicare paperwork Centers for Medicare amp Medicaid Services This is the US federal agency that administers Medicare Medicaid and the State Children s Health Insurance Program The agency provides associated information for health professionals regional gov
183. sure drop down list Click the drop down arrow and select the state s for which you have a license to furnish Durable Medical Equipment Prosthetics Orthotics and Supplies This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 25 Edaptive intelligently Adapting Technology DBidS User Manual e The Identify the type s of license s you have in this state text box will display Input the type of license you have for the state identified in the Licensure drop down list e Click the Add Licensure button to add the state s The recently added data displays in the Modify Delete Licensure Information pane e Click the Modify button in the Modify Delete Licensure Information pane to modify licensure information The information for the selected state s populates the Licensure pane e Modify the required fields e Click Modify Licensure Information when modifications are complete The updated information displays in the Modify Delete Licensure Information pane e Optional Click the Delete button in the Modify Delete Licensure Information pane to delete state s LZ ASM gets eeu DBids Bidder 20 6120419 asdfasfd Welcome HEIMLICH BUGZLIFE Navigation Form A Location Specific Information page 2 Print Save Back Next Status Page Busi
184. t the accreditation organization from the list provided e Accreditation Status drop down list Click the drop down arrow and select Accredited or Not Accredited If Accredited is selected additional information is required If Not Accredited is selected a bid may not be submitted and you will not be able to move forward within the application and a message box will be displayed notifying you that if you continue you will exit the application e Click the Add Accreditation button to add an organization The recently added data displays in the Modify Delete Accreditation Information pane and the Accreditation pane is cleared to allow entry of additional information Repeat the above steps to add additional criteria e Click the Modify button in the Modify Delete Accreditation Information pane to modify accreditation information The information for the selected organization populates the Accreditation pane e Modify the required fields e Click Modify Accreditation Information when modifications are complete The updated information displays in the Modify Delete Accreditation Information pane e Optional Click the Delete button in the Modify Delete Accreditation Information pane to delete an organization Select the name s of the Medicare approved organization thet hes accredited this location The location must be accredited for the product category for which you are Bidding You must click the Add Accreditation button in order for this i
185. table gas oxygen system BID FOR ENTIRE CLASS NOT BY CODE Rental 0 0286888699 5 s1e3 5 00 Test Portable oxygen concentrator BID FOR ENTIRE CLASS USING THIS CODE Rental 0 0000000000 5 5163 5 00 Test Oxygen contents gaseous BID FOR ENTIRE CLASS USING THIS CODE Rental 0 0000000000 s5 745 soo Test Oxygen contents liquid BID FOR ENTIRE CLASS NOT BY CODE Rental 0 0000396515 5 745 soo Test Portable 02 contents gas BID FOR ENTIRE CLASS USING THIS CODE Rental o 0001998807 5 mas o E0444 ___Test_Portable 02 contents liquid BID FOR ENTIRE CLASS NOT BY CODE Rental 00000000000 S 877 45 5 00 HCPCS Code Manufacturer Model Name Model Number Access to Certification Statement Public Address Announcement and Certify screens are restricted to only Authorized Officials and Backup Authorized Officials This information is confidential Contents shail not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Back Next Figure 105 DBidS Form B Summary This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 92 Edaptive intelligently Adapting Technology DBidS User Manual CATS DMEPOS BIDDING SYSTEM DBidS Welcom
186. the Status page Refer to Figure 14 Status Page Once you have completed the Business Organization page you are assigned a bidder number that identifies that organization A message will display with the bidder number once you clicks on Next Once the bidder number is assigned it will be displayed in the top left hand corner of the screen The bidder number will only be displayed after you have completed all required fields on the Business Organization screen and the data is saved The bidder number displays as XX XXXXXXX The first two numbers represent the bidding round ID and the remaining seven numbers are the bidder number Should you find a lock on your account you will need to provide the bidder number i a DBidS Status Page Windows Internet Explorer provided by Edaptive Systems _ y Logout C V7S DMEPOS BIDDING SYSTEM DBids _Bidaer 20 9489203 asan gt Welcome DOT BUGZLIFE Navigation Form A Application Status Status Page Business Organization Types gt Modify Form A Create Form B gt Help Logout Form B Bid Status coerce O ae eee ae CHCH Date 13 15 50 Open Bid 01 18 2011 No bids found Date 09 00 00 Close Bid 09 30 2011 Date 23 59 59 Documentation Status oa Documentation Received No it is the suppliers responsibility to ensure that they have submitted the entire package of all required hardcopy documents to th
187. therwise in a manner inconsistent with the provisions applicable to this document 87 Edaptive intelligently Adapting Technology DBidS User Manual Logout LZ AY MM gets eeu DBids Bidder 20 4099116 asdfasd Welcome Test Test Navigation Form B Furnished Items Print Save Next Status Page gt Business Organization Types gt Modify Form A Create Form B Bidder 20 4099116 Modify Form B CBA Test_Orlando Kissimmee FL Non Mail Order Select Bid Product Category Test_Oxygen Supplies and Equipment Help PTAN s 1001022210 Logout Required fields are marked with TOP HCPCS Codes Today s 10 14 2011 Date 10 53 20 Open Bid 01 18 2011 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 Date 09 00 00 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 Close Bid 12 31 2011 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 Date 13 59 59 Worksheet at www dmecompetitivebid com bic for the definition of a unit for each item If bidding
188. tion Form A These sections provide instructions for updating multiple location supplier information Form A The assumption is that login has already occurred e Users with more than one PTAN associated with their User ID The Select PTAN to Create Form A page is displayed upon login for all users with more than one PTAN associated with their user ID Refer to Section 5 5 8 Update Form A Users with Multiple PTANs Associated with User ID to complete this process e Users with only one bidder number The Form A Status page is displayed upon login for all users with only one bidder number Refer to Section 5 5 9 Update Form A Users with One Bidder Number to complete this process e Users with more than one bidder number The bidder selection or Location Specific Information page is displayed upon login for all users with more than one bidder number Refer to Section 5 5 10 Update Form A Users with Multiple Bidder Numbers to complete this process An alternative method of navigation is to use the menu links in the left most Navigation pane The order in which sections are completed is not pertinent One Form A must be completed by each entity supplier single location supplier multiple location and network supplier However only one Form A needs to be submitted by the business organization regardless of the number of Form B bidding sheets submitted Only one user may access a specific Form A at any one time If an
189. uring a projected 12 month period The percentage increase may exceed 100 percent G9 o Figure 73 Top HCPCS Codes Pane continued Review the information in the Expansion Plan pane Refer to Figure 74 Expansion Plan Pane Click the Edit button in the Expansion Plan pane to edit any of the information The Form B Expansion page displays Scroll if necessary to the Expansion Plan pane Refer to Section 5 6 Creating a Form B for instructions on updating this section Expansion Plan gt Edit If you plan to expand your business under the Competitive Bidding Program describe your current structure and expansion plan in the space provided If additional space is needed you may submit documentation along with the required hardcopy documents Is your estimated capacity the amount you can provide for this product category in the CBA greater than the amount you currently provide in No the CBA If yes you must complete an expansion plan Figure 74 Expansion Plan Pane Review the information in the Subcontractors pane Refer to Figure 75 Subcontractors Pane Click the Edit button in the Subcontractors pane to edit any of the information The Form B Expansion page displays Scroll if necessary to the Subcontractors pane Refer to Section 5 6 Creating a Form B for instructions on updating this section Subcontractor Information gt Edit Do you plan to use use subcontractor s No Figure 75 Subcontractors P
190. urrent or past legal actions or sanctions No such as debarments Figure 38 Sanctions Pane This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 31 Edaptive Intelligently Adapting Technology DBidS User Manual Review the information in the Competitive Bidding Area CBA and Product Category pane Refer to Figure 39 Competitive Bidding Area CBA and Product Category Pane Optional Click the Edit button in the Competitive Bidding Area CBA and Product Category pane to edit any of the information The Form A Location Specific Information page displays Scroll af necessary to the Competitive Bidding Area CBA and Product Category pane Refer to Section 5 5 3 Update CBA Product Category for instructions on updating this section Competitive Bidding Area CBA and Product Category CBA Product Category TEST_Cleveland Elyria Mentar OH TEST_Oxygen Supplies Equip TEST_PMD Standard TEST_PMD Complex Figure 39 Competitive Bidding Area CBA and Product Category Pane Click Next The Form A Checklist page displays organized into multiple panes 5 5 5 Review Form A Checklist This is an optional process that 1s accessed when the Next button is clicked on the Form A Summary page Only an AO or BAO may access this page and only when all r
191. used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 6 Edaptive Intelligently Adapting Technology DBidS User Manual 4 5 Menu Hierarchy Navigation through the DBidS application is accomplished via a Navigation pane in the left most frame of all pages Once Enter DBidS is selected from the Welcome page the initial DBidS page displays Figure 4 DBidS Application Menu Hierarchy shows the menu hierarchy The menu initially displays as collapsed with the sub menu items hidden The menu is user role and context specific the options available depend upon your user role and the page of the application that you are on e Click the a beside each main menu item to expand the menu and to see all available menu options e Click the again to hide the sub menu items Statue Page a Business Organization Types PTAN Selection a Create Business Organization Business Organization Information Specialty Supplier Licensure Contact Person Modify Delete Contact Persons Authorized Official or Key Perfonnel Modify Delete Authorized Official Key Personnel Information Competitrve Bidding Area CB4 and Product Category CBASProduct Category List ahiodity Business Organization Business Organization Infermation Specialty Supplier Licensure Contact Person Modify Delete Contact Persons Authorized
192. ust click the Add Accreditation button in order for this information to be saved below Accreditation Organization Select Accreditation Organization i Status Select Accreditation Status Modify Delete Accreditation Information Modify the status product specific area s issue or expiration dates The location must be accredited for the product category for which you are bidding You must click the Modify Accreditation button in order for this information to be saved below The Accreditation Organization cannot be modified You must delete entry and re enter a new accreditation for this location Licensure Select the state or states in the CBA for which you have a license to furnish the durable medical equipment prosthetics orthotics and supplies ODMEPOS for which you are bidding Select all that apply State Select State Licensure Modify Delete Licensure Information Modify the licensure information for selected states You must click the Modify Licensure button in order for this information to be saved below Licensure State Licensure Text Action s dafggdsdftg a asdfsadf NC sadfasdf Sanctions indicate whether this location as identified by the PTAN above has been subject to any current or past legal actions or sanctions such as deberments within the past five 5 years Does this location have any current Yes No or past legal actions or sanctions 7 F such as debarments This
193. vide the length of time in business for this location as identified by the PTAN above Years in Business Months in Business Examples 5 years and 7 months or 0 years and 6 months Doing Business As DBA Figure 49 Business Information Pane Update the information in the Accreditation Information panes The location must be accredited for the product category to be bid DBidS displays the following instructional text below the Section Header titled Accreditation on the Page titled Form A Add Location Select the name s of the Medicare approved organization that has accredited this This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 42 Edaptive Intelligently Adapting Technology DBidS User Manual location The location must be accredited for the product category for which you are bidding You must click the Add Accreditation button in order for this information to be saved below If a location is not accredited you will not be able to submit a bid for this location A location may Select the same accrediting organization only once A maximum of five entries per location is allowed Refer to Figure 50 Accreditation Information Panes e Accreditation Organization drop down list Click the drop down arrow and selec
194. vides a way to harness marketplace dynamics to create incentives for suppliers to provide quality items and services in an efficient manner and at reasonable cost The Medicare DME Competitive Bidding Program has five objectives 1 To operationalize competitive bidding for DME and to use this to determine appropriate prices for categories of DME covered by Medicare Part B 2 To protect beneficiary access to quality DME throughout the program 3 To reduce the amount Medicare pays for DMEPOS and brings the reimbursement amount more in line with that of a competitive market 4 To limit the burden on beneficiaries by reducing their out of pocket expenses and 5 To mitigate proliferation of use of certain items of DMEPOS by contracting with suppliers who engage in a business model that is beneficial for the program and for Medicare beneficiaries This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document Edaptive intelligently Adapting Technology DBidS User Manual 4 Application Basics The DBidS application provides navigational capabilities to create business organizations and submit bids for items and associated services such as equipment delivery and accompanying instruction on the appropriate use of the equipment It also provides a vehicle for capturing and su
195. y Adapting Technology DBidS User Manual C VTS pmeros BIDDING SYSTEM DBids Bidder 20 4099116 asdfasd Welcome Test Test Navigation Form B Create Bid Print Next Status Page Business Organization Types gt Modify Form A Required fields are marked with ona oe B Competitive Bidding Area CBA Product Category gt Help To create a bid select the Round 2 CBA and product category or select National Mail Order if bidding in the national mail order competition This field is populated from the information provided on Form A You Logout must click the Select button in order for the product category to be displayed below Coax Select the CBA M Product Category Select Product Category Today s 10 14 2011 Date 10 50 53 Open Bid 01 18 2011 Create Bid Date 09 00 00 Close Bid 12 31 2011 Date 13 59 59 CBA Product Category List Displayed below is a summary of the CBA s and Product Category s you have selected CBA Product Category Test_Orlando Kissimmee FL Non Mail Order Test_Oxygen Supplies and Equipment This information is confidential Contents shall not be used modified or distributed electronically or otherwise to persons not authorized to receive the information Print Next Figure 99 DBidS Form B Create Bid This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or o
196. y Form A Create Form B Select Bid gt Help Logout Complete and Approved 08 03 2011 13 04 09 Janet Whitmore Print Save Form B Bid Status a Today s oe a Date 13 Open Bid 03 19 2011 Date Test_Pittsburgh PA Non Mail Order Test_Enteral Nutrients Equipment and Supplies Ce tion 08 03 2011 13 06 01 Janet Whitmore Close Bid 09 30 20 11 Date 7 E aer Documentation Status a Documentation Received No it is the suppliers responsibility to ensure that they have submitted the entire package of all required hardcopy documents to the Competitive Bid Implementation Contractor CBIC The notation above indicates whether the CBIC has received a package of hardcopy documents However it does not acknowledge the accuracy or completeness of the package The CBIC is unable to provide this information Covered Document Review Date CDRD Eligible a CDRD Eligible No Figure 44 Status Page Click the Status link in the Form A Application Status pane for the application to update The Form A Application Status page displays Location and Additional Locations panes Refer to Section 5 5 1 Update Form A Location for the steps to complete this process Refer to the subsections within Section 5 5 Updating Single Location Supplier Information Form A for specific information on completing Form A 5 5 10 Update Form A Users with Multiple Bidder Numbers This
197. y the Department of Health and Human Services Office of the Inspector General or sanctions issued at the state or local level This includes any actions taken against any member of the board of directors chief corporate officers high level employees affiliated companies network members or subcontractors Sole Proprietorship This is an unincorporated business that is owned by one individual Specialty Supplier This is a supplier that only provides DMEPOS items to its residents Only skilled nursing facilities and nursing facilities are eligible to be specialty suppliers TIN Taxpayer Identification Number This is a unique tax processing number issued by the IRS User This term is used throughout this document to refer to all users of the application regardless of role or privileges This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 73 Edaptive intelligently Adapting Technology DBidS User Manual Appendix B DBidS Screen Shots The following screenshots represent the DBidS application screen flow DMEPOS BIDDING SYSTEM DBidS Welcome to DMEPOS Bidding System DBidS Welcome to the online application system DBidS for the DMEPOS Competitive Bidding Program The online system is divided into two parts Form A is the applicati
198. ying NPI information on health care providers and assigns each a unique NPI NPPES National Plan and Provider Enumeration System The NPPES collects identifying information on health care providers and assigns each a unique NPI Partnership This is a contract entered into by two or more persons in which each agrees to furnish either a part of the capital or labor of a business enterprise and by which each shares in a portion of the profits and losses PECOS Provider Enrollment Chain and Ownership System This is the organizational entity contracted by CMS to issue Medicare billing privileges to suppliers of DMEPOS and to maintain a supplier file that contains information collected via the CMS 855S enrollment form This system transfers the PTAN file to DBidS Product Class A combination of codes for which a single bid is required PTAN Provider Transaction Access Number This is the ten digit number required to bill CMS for DMEPOS transactions The number must be specific to the location submitting the bid and should not be the corporate number Suppliers with multiple locations that share common ownership must list their PTAN numbers for all locations within the CBA Sanctions Any information about current or past within last five years legal actions Sanctions or debarments should be disclosed Sanctions include but are not limited to debarment from any Federal program revocation from the Medicare program sanctions issued b
199. zation screen and the data is saved The bidder number displays as XX XXXXXXX The first two numbers represent the bidding round ID and the remaining seven numbers are the bidder number Should you find a lock on your account you will need to provide the bidder number This document contains confidential information Disclosure is restricted Contents shall not be used modified distributed electronically or otherwise in a manner inconsistent with the provisions applicable to this document 15 Edaptive Intelligently Adapting Technology DBidS User Manual The Location Specific Information page displays A bidder with a single location will see a single row with their Bidder Number Supplier Name and the Action s available to modify their Supplier Type or access their Form A Location Specific Information Select the bidder number below in which you would like to complete an application Listed below are the bidder numbers associated to a supplier type in which you are submilting a bid Select Access Form A to enter location specific information if you wish to modify supplier type click Modify Bidder Number Supplier Name Actionis 1245790 Test Corp Modify Supplier Type 9876421 Another Bidder Figure 13 Location Specific Information Page Click Modify Supplier Type to return to the Form A Business Organization Information page Refer to the steps in this section to modify the business organization information Click Acces

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