doa-3477 Vendor Information.doc

This is a vendor information form (DOA-3477) issued by the State of Wisconsin Department of Administration, Division of Enterprise Operations, Bureau of Procurement, for use in response to a request for bids or proposals for Workers' Compensation Center for Medicare Reporting Compliance Services. The form collects essential vendor information required for bid submission and contract administration purposes. The State of Wisconsin seeks a contractor to ensure compliance with federal reporting requirements under Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA), which mandates workers' compensation reporting to the U.S. Department of Health and Human Services, Center for Medicare and Medicaid Services (CMS). This requirement became effective April 1, 2010, and applies to all workers' compensation payments, self-insurance, no-fault insurance, and liability insurance claims meeting specific criteria.

The vendor information form requires submission of company contact details, a primary contact person for bid inquiries, personnel responsible for affirmative action compliance (for awards exceeding $50,000), billing and purchase order contact information, and identification of the company's CEO or President. The form is designed to facilitate communication between the State and bidding vendors throughout the procurement process and subsequent contract performance. No specific pricing information, set-asides, or contract terms appear on this vendor information form, as it serves solely as a data collection instrument for vendor identification and administrative purposes.