doa-3478 Bidder Reference Form.doc

This is a Bidder Reference Form utilized by the State of Wisconsin Department of Administration, Division of Enterprise Operations, in support of a Workers' Compensation Center for Medicare Reporting Compliance Services contract solicitation. The form requires vendors to provide detailed information for four or more installations with requirements similar to those in the solicitation document. For each reference, bidders must submit the company name, complete address with ZIP+4 code, contact person name, telephone number, email address, and a description of the products and/or services provided. If a vendor proposes any arrangement involving a third party, those named references should also be involved in a similar arrangement to ensure relevance and authenticity of the proposed service delivery model.

The form serves as a qualification and evaluation tool designed to assess vendor experience and capability in performing workers' compensation and Medicare reporting compliance services. Bidders must demonstrate substantive prior experience through verifiable references that substantiate their ability to meet the State of Wisconsin's specific requirements for Center for Medicare and Medicaid Services (CMS) reporting compliance, including mandatory reporting under Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007. The document notes that it can be made available in accessible formats for qualified individuals with disabilities, in accordance with accessibility requirements.