This form is no longer available for the Round 1 Rebid.
The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) requires contract suppliers to disclose to CMS information regarding their subcontracting relationships. This information must be provided within 10 business days after final contract execution. For subcontracting arrangements entered into after contract award, contract suppliers must provide the required information no later than 10 business days after the date the contract supplier enters into a subcontracting arrangement.
The Supplier Standards limit Medicare-enrolled suppliers’ subcontracting arrangements to:
1) purchase of inventory;
2) delivery and instruction on the use of Medicare-covered items; and
3) maintenance and repair of rented equipment.
Services such as intake and assessment, coordination of care with the physician, submitting claims on behalf of the beneficiary, ownership and responsibility of equipment furnished to the beneficiary, and ensuring product safety must be provided by the contract supplier.
Contract suppliers must identify the name of the subcontractor, the address of the particular location that will perform the subcontracting service (corporate headquarters' addresses are not acceptable), the services to be provided by the subcontractor, and whether the subcontractor is accredited, as applicable. For your convenience, we have provided a sample subcontractor disclosure form. Please submit the required information to the Competitive Bidding Implementation Contractor (CBIC) as directed on the sample form.