AMENDMENT_0003_FCI_ASHLAND_15B10218R00000001.pdf

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT 11. CONTRACT ID CODE IPA~E OF PAGES

I 1

2. AMENDMENT/MODIFICATION NUMBER 3. EFFECTIVE DATE 4. REQUISITION/PURCHASE REQUISITION NUMBER 15. PROJECT NUMBER (If applicable)

0003 02/02/2018

6. ISSUED BY CODE FAO 7. ADMINISTERED BY (If other than Item 6) CODE !BASH US Department of Justice-Federal Bureau of Prisons FBOP-FCI ASHLAND Field Acquisitions Office(FAO) Federal Bureau of Prisons US Armed Forces Dr. FCI Ashland State Route 716 Grand Prairie, TX 75051 Ashland, Kentucky 41105

8. NAME AND ADDRESS OF CONTRACTOR (Number, street, county, State and ZIP Code) ~ 9A. AMENDMENT OF SOLICITATION NUMBER

D 15B10218R00000001

9B. DATED (SEE ITEM 11)

02/02/2018

10A. MODIFICATION OF CONTRACT/ORDER NUMBE

D

10B. DATED (SEE ITEM 13)

CODE I FACILITY CODE

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

[8:J The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers D is extended. [8:J is not extended.

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:

(a) By completing items 8 and 15, and returning 1 copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted;

or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE

RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

12. ACCOUNTING AND APPROPRIATION DATA (If required)

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS.

IT MODIFIES THE CONTRACT/ORDER NUMBER AS DESCRIBED IN ITEM 14.

CHECK ONE A THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER

D

NUMBER IN ITEM 10A.

D B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, appropriation data, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

D C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D D. OTHER (Specify type of modification and authority)

E. IMPORTANT: Contractor D is not Dis required to sign this document and return ____ _ copies to the issuing office.

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

The RFP15B10218R00000001 amendment 0003 issued to correct the following:

1. SF1449 box 17a the address for the contractor should be blank, (See Corrected SF1449) attached.

2. Line Item 2c-2c4 Outpatient Institution Services: The last sentence of the paragraph was not complete it should read:

The BOP will not use the services of a third party medical claims adjudicator for verification of these services.

(See Attached)

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 1 OA, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME AND TITLE OF SIGNER (Type or print) 16A. NAME AND TITLE OF CONTRACTING OFFICER (Type or print)

15B. CONTRACTOR/OFFEROR 15C. DATE SIGNED 16B. UNITED STATES OF AMERICA 16C. DATE SIGNED

(Signature of person authorized to sign) (Signature of Contracting Officer)

R

Previous edition unusable STANDARD FORM 30 (REV. 11/2016) Prescribed by GSA FAR (48 CFR) 53.243

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS 1. REQUISITION NUMBER PAGE 1 OF

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

2 CONTRACT NO. 3. AWARD/EFFECTIVE 4. ORDER NUMBER 5. SOLICITATION NUMBER 6. SOLICITATION ISSUE

DATE DATE

15810218R00000001 12/22/2017

a. NAME b. TELEPHONE NUMBER (No collect 8. OFFER DUE DATE/

7. FOR SOLICITATION calls) LOCAL TIME

INFORMATION CALL: 02/15/2018 ~ TARYN JONES TSJONES@BOP.GOV 972-352-4506 2:00 pm C.T.

9. ISSUED BY CODE BFAO 10. THIS ACQUISITION IS ~NRESTRICTED OR LJSET ASIDE: % FOR:

Federal Bureau of Prisons Field Acquisition Office 0SMALL BUSINESS

WOMEN-OWNED SMALL BUSINESS ---

D(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

U.S. Armed Forces Reserve Complex 346 Marine Forces DHUBZONE SMALL SMALL BUSINESS PROGRAM NAICS:

Drive BUSINESS

0EDWOSB 622110

Grand Prairie, TX 75051 ctERVICE-DISABLED

ETERAN-OWNED SIZE STANDARD:

SMALL BUSINESS D8(A) 38.5 Million

11. DELIVERY FOR FOB DESTINA- 12. DISCOUNT TERMS 13b. RATING TION UNLESS BLOCK IS 013a. THIS CONTRACT IS A

MARKED RATED ORDER UNDER

DPAS (15 CFR 700) 14. METHOD OF SOLICITATION

D SEE SCHEDULE ~FQ n1FB fXRFP

15. DELIVER TO CODE BASH 16. ADMINISTERED BY CODE I

Federal Bureau of Prisons Federal Bureau of Prisons FCI Ashland State Route 716 FCI Ashland State Route 716 Ashland, Kentucky 41105 Ashland, Kentucky 41105 17a. CONTRACTOR/ CODEI I

FACILITY 18a. PAYMENT WILL BE MADE BY CODE I Ut-t-l::KUK vuuc

Federal Bureau of Prisons FCI Ashland State Route 716 Ashland, Kentucky 41105

TELEPHONE NO.

17b. CHECK IF REMITIANCE IS DIFFERENT AND PUT SUCH ADDRESS IN 18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK

D OFFER BELOW IS CHECKED D SEE ADDENDUM

19. 20. 21. 22. 23. 24.

ITEM NO. SCHEDULE OF SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

COMPREHENSIVE MEDICAL SERVICES AT

FCI ASHLAND

(Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA 26. TOTAL AWARD AMOUNT (For Govt. Use Only)

[8) 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATIACHED. ADDENDA

D 27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATIACHED. ADDENDA

[8] ARE DARE NOT ATIACHED

DARE DARE NOT A TI ACHED

D 28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN D 29. AWARD OF CONTRACT: REF. OFFER

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND ---

DATED. . YOUR OFFER ON SOLICITATION

DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY (BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE

ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED SET FORTH HEREIN, IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFERORICONTRACTOR 31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)

30b. NAME AND TITLE OF SIGNER (Type or print)

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

30c. DATE SIGNED 31 b. NAME OF CONTRACTING OFFICER (Type or print) 31c. DATE SIGNED

STANDARD FORM 1449 (REV 212012)

Prescribed by GSA - FAR (48 CFR) 53.212

19 20. 21. 22. 23. 24.

ITEM NO. SCHEDULE OF SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

001 Comprehensive Medical Services Located at FCI 12 MO Ashland, Kentucky Base Year: Date of Award D.O.A through 12 months from D.O.A

Ashland, Kentucky Option Year 1: 13 Months

002 Comprehensive Medical Services Located at FCI 12 MO Ashland, Kentucky Option Year 1: 13 Months through 24 months from D.O.A

003 Comprehensive Medical Services Located at FCI 12 MO Ashland, Kentucky Option Year 2:25 Months through 36 months from D.O.A

004 Comprehensive Medical Services Located at FCI 12 MO Ashland, Kentucky Option Year 3:37 Months through 48 months on D.O.A

005 Comprehensive Medical Services Located at FCI 12 MO Ashland, Kentucky Option Year 4:49 Months through 60 months from D.O.A

006 Comprehensive Medical Services Located at FCI 6 MO Ashland, Kentucky (6) months extension as authorized by the Federal Acquisition Regulation (FAR)

52.217-8 Option to Extend Services

32a. QUANTITY IN COLUMN 21 HAS BEEN

0RECEIVED 01NSPECTED D ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED:

32b. SIGNATURE OF AUTHORIZED GOVERNMENT 32c. DATE 32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE REPRESENTATIVE

32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE 32f. TELPHONE NUMBER OF AUTHORZED GOVERNMENT REPRESENTATIVE

32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE

33. SHIP NUMBER 34. VOUCHER NUMBER 35. AMOUNT VERIFIED 36. PAYMENT 37. CHECK NUMBER

CORRECT FOR

0PARTIAL DFINAL 0COMPLETE 0PARTIAL DFINAL

38. S/R ACCOUNT NO. 39. S/R VOUCHER NUMBER 40. PAID BY

41a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT 42a. RECEIVED BY (Print)

41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER 41c. DATE

42b. RECEIVED AT (Location)

42c. DATE REC'D (YYIMM/00) 142d. TOTAL CONTAINERS

STANDARD FORM 1449 (REV 212012) BACK

Line Item 2c2 - 2c4 - Outpatient Institution Services: An invoice for services rendered under line item 2c2, 2c3, and 2c4 shall be a paper invoice detailing the date(s) sessions were provided, the number of sessions provided/per diem days provided, the unit pricing applied, and the extended total amount due The BOP will not use the services of a third party medical claims adjudicator for verification of these services.

Submission of Provider Data to the BOP's Medical Claims Adjudicator. Within ten calendar days after notification that a third party medical claims adjudication service will be utilized by the FCI, the Contractor shall provide the

BOP's medical claims adjudicator with a complete list of provider information, which will enable the medical claims adjudicator to accurately identify the correct payable amount for any provider performing services under the contract. Specific informational requirements are provided in Attachment 4. Provider information supplied to the

BOP's medical claims adjudicator should be appropriately marked to identify the data as proprietary information so that it may be adequately protected by the BOP and its contracted medical claims adjudicator. Provider information shall be submitted directly to the BO P's medical claims adjudicator. As individual providers are added to the Contractor's network, the Contractor shall provide the information listed in Attachment 4 to the medical claims adjudicator no less than three business days prior to filing medical claims electronically for services rendered by such new providers.

National Provider Identifier (NPI) Numbers. The Contractor shall utilize only providers who have a current

National Provider Identifier (NPI) number.

Electronic Trading Partner Agreement. The BOP will execute the Electronic Trading Partner Agreement with the medical claims adjudicator (Attachment 5). The Contractor shall participate in the medical claims adjudication process described herein as a "Business Associate" of the BOP. As a Business Associate, the Contractor agrees to abide by all terms of the Trading Partner Agreement as it pertains to Business Associates.

Technical Data for Submission of Medical Claims. Prior to the submission of an invoice to the FCI, the Contractor shall electronically transmit the information found on each individual invoiced medical claim via ANSI 837 format only, to the BOP's medical claims adjudicator. After the Contractor's electronic transmission to the BOP's medical claims adjudicator, the Contractor shall promptly submit a paper copy of the invoice to the FCI. The Contractor will also post the ANSI 837 file in an FTP site set up and maintained by the BOP's medical claims adjudicator. The only exceptions to the electronic filing requirement shall be corrected medical claims for professional services. Address information for the submission of a paper medical claim to the BOP's medical claims adjudicator is provided in

Attachment 6, along with other pertinent details.

Facility Services. If it becomes necessary to file a corrected medical claim for facility services, the Contractor shall electronically transmit the information found on each individual corrected medical claim via ANSI 837 format only, to the BOP's medical claims adjudicator. After the Contractor's electronic transmission to the BOP's medical claims adjudicator, the Contractor shall promptly submit a paper copy of the invoice or credit memo, as applicable, to the

FCI. Invoices for corrected medical claims shall be clearly marked as such and shall be separate from routine invoices. Invoices or credit memos for corrected medical claims shall detail information pertaining to the original medical claim submission (including any amount(s) previously paid and the associated invoice numbers) and shall bill only for the corrected medical claim submission or reflect the credit amount due for the corrected medical claim submission.