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OMB No. 0938-1016

Form C: QUARTERLY REPORT

This report is used to update the Supplier Directory on the Medicare website at www.Medicare.gov/supplier with the products you plan to provide during the NEXT quarter.1

Please review your product information in the Supplier Directory before completing this report. You must complete this report for every competitive bidding area (CBA)/product category combination in your contract. Please refer to your contract for a complete listing of your CBA/product category combinations.

  • If you need to update product information for a CBA/product category combination(s), you must complete section II.
  • If you do not need to update product information for specific CBA/product category combination(s), you must complete section III. Select "I have no updates for any of my CBA/product category combinations" if you do not need to update product information for any of your CBA/product category combinations.

Failure to submit a Form C for all CBA/product category combinations in your contract may be considered a breach of contract and result in termination of your contract.

IMPORTANT: Data entered into Form C does NOT save. After 60 minutes of inactivity, Form C will time out and all data entered will be lost.

You may enter all required information at one time and then select “View Completed Form and Print,” OR you may choose to enter product information for each single CBA/product category combination and then select “View Completed Form and Print.” You must PRINT EACH FORM since this information is not saved and cannot be retrieved after your browser closes. ALL forms must be signed by a company official and sent (either by mail or fax) to the Competitive Bidding Implementation Contractor (CBIC) and RECEIVED by the CBIC by the deadline.

For more information, please view the round-specific Form C FAQs, which can be found on the DMEPOS Competitive Bidding Implementation Contractor(CBIC) website or by selecting one of the links below.


I. Contract Information If you DO NOT need to update product information, skip sections I and II and only complete section III.
* - denotes required fields
Does this apply to multiple contracts?
*
(Check your contract(s) for the contract number.)
-

*

*
*

*
*
Hold CTRL key and click to select multiples
Add PC/CBAs

Review contract and competition information

Delete Contract Number Product Category Competitive Bidding Areas Edit

II. Update(s) to the Supplier Directory
  1. Select an Update Type. You may choose to replace all the information on the Supplier Directory for the CBA/product category combination(s) selected above, or update the information on the Supplier Directory with additional products.
  2. Select a HCPCS code from the drop down. If you choose to replace all the information on the Supplier Directory, you must enter at least one product for every HCPCS code listed in the drop down below.
  3. Select how you would like to search for products. You may search by manufacturer, model, or model/product number.
  4. Select the product-specific information. This dropdown will be the list of manufacturers, models, or model/product numbers available for the HCPCS code. You can also search the items in this dropdown using at least three characters in the Search field.
  5. In the Search Results table, select the products you want listed on the Supplier Directory. You may select all of the products in the table by checking Select All.
  6. Click "Add Product Information." The information you entered will appear under the List of Updates to the Supplier Directory. If you wish to remove a product from this section, click the Remove Row next to the applicable product.
  7. Repeat the process to add all the products you plan to make available in the next quarter for the listed HCPCS codes and for ALL CBA/product category combinations for which you were awarded a contract.

Select an Update Type:*

Select the HCPCS Code:
*Help Search

OR Search:

Search Results:
Select HCPCS Code Manufacturer Model Model/Product Number

Add Product Information

List of Updates to the Supplier Directory

Delete Contract # HCPCS Code Manufacturer Model/Product Number

III. No Updates to the Supplier Directory
If the product information in the Supplier Directory is current for some but not all of your CBA/product category combinations, select the CBA/product category combination(s) that do NOT need to be updated.
*
(Check your contract(s) for the contract number.)
-
*

*
*
Hold CTRL key and click to select multiples
If the product information in the Supplier Directory is current for ALL CBA/product category combinations, check below.
Add CBA/Product Category combination

List of CBA/Product Category combination(s) that do NOT need to be updated in the Supplier Directory

Delete Contract # CBA Product Category

Disclaimer:
You are responsible for ensuring that you enter only products that meet the requirements for each HCPCS code. Products listed in the drop down box for a HCPCS code have been verified by the Pricing, Data Analysis, and Coding (PDAC) contractor. If you would like to enter a product that is not listed in a drop down box but are not sure if the product meets the requirements for the HCPCS code, we urge you to contact the PDAC contractor for coding guidance via the contact form located at www.dmepdac.com/contact. As a reminder, failure to bill Medicare using the appropriate code may result in substantial penalties under the False Claims Act and exclusion from the Medicare Program.

View Completed Form and Print


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