A23_Attachment_4_-_Price_Cost_Schedule.xlsx

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Independent Medical Examinations for the Public Safety Officer's Benefits Program Office
Solicitation number
15PBJA19R00000001
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Price Cost Schedule

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A23_Attachment_2_-_DOJ_Whistleblower_Information.pdf PDF
A23_Combined_Synopsis_and_Solicitation.pdf PDF
A23_Attachment_3_-_Individual_and_Corporate_NDA.pdf PDF
A23_RFQ_Attachment_1_-_Statement_of_Work.pdf PDF

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Schedule of Prices

PSOB Independent Medical Examination Support

BASE PERIOD
ItemDescriptionUnitUnit Price
0001AMedical Record Review performed by a General Physician – A review of all medical and related records provided by the claimant, physicians, and/or representativeEA$ - 0
0001BMedical Record Review performed by a Neurologist – A review of all medical and related records provided by the claimant, physicians, and/or representativeEA$ - 0
0002AIndependent Medical Review performed by a General Physician – A review of all medical records as well as in-person examination (at an agreed upon location between the medical specialist and the claimant) of a claimantEA$ - 0
0002BIndependent Medical Review performed by a Neurologist – A review of all medical records as well as in-person examination (at an agreed upon location between the medical specialist and the claimant) of a claimantEA$ - 0
0003AVocational Assessment performed by a General Physician – An in-person examination, at an agreed upon location between the medical specialist and the claimant, which assesses whether or not a claimant is able to perform any type of gainful workEA$ - 0
0003BVocational Assessment performed by Neurologist – An in-person examination, at an agreed upon location between the medical specialist and the claimant, which assesses whether or not a claimant is able to perform any type of gainful workEA$ - 0
0004AFunctional Capacity Examination performed by a General Physician – An in-person examination (or review of the records) at an agreed upon location between the medical specialist and the claimant, which determines if claimant is able to function or perform in everyday life needEA$ - 0
0004BFunctional Capacity Examination performed by an ENT or Rheumatologist – An in-person examination (or review of the records) at an agreed upon location between the medical specialist and the claimant, which determines if claimant is able to function or perform in everyday life needEA$ - 0
0005Legal Nurse Review – A review of all medical records by a licensed legal nurseEA$ - 0
0006Additional document and medical record review for cases with over 50 pages (unit is increments of up to 50 pages)EA$ - 0
0007APsychological Testing performed by a PsychologistEA$ - 0
0007BPsychological Testing performed by a PsychiatristEA$ - 0
0008Medical Diagnostic Testing by Current Procedural Terminology (CPT) code. (unit price for the actual test performed is price based on the National Medicare fee schedule on the date of the test)EABy CPT Code
0009ODCs – ODCs including materials, phone charges, postage, copies, etc.EA$ 3,000.00
BASE PERIOD - NOT TO EXCEED$ 50,000.00
OPTION PERIOD 1
ItemDescriptionUnitUnit Price
1001AMedical Record Review performed by a General Physician – A review of all medical and related records provided by the claimant, physicians, and/or representativeEA$ - 0
1001BMedical Record Review performed by a Neurologist – A review of all medical and related records provided by the claimant, physicians, and/or representativeEA$ - 0
1002AIndependent Medical Review performed by a General Physician – A review of all medical records as well as in-person examination (at an agreed upon location between the medical specialist and the claimant) of a claimantEA$ - 0
1002BIndependent Medical Review performed by a Neurologist – A review of all medical records as well as in-person examination (at an agreed upon location between the medical specialist and the claimant) of a claimantEA$ - 0
1003AVocational Assessment performed by a General Physician – An in-person examination, at an agreed upon location between the medical specialist and the claimant, which assesses whether or not a claimant is able to perform any type of gainful workEA$ - 0
1003BVocational Assessment performed by Neurologist – An in-person examination, at an agreed upon location between the medical specialist and the claimant, which assesses whether or not a claimant is able to perform any type of gainful workEA$ - 0
1004AFunctional Capacity Examination performed by a General Physician – An in-person examination (or review of the records) at an agreed upon location between the medical specialist and the claimant, which determines if claimant is able to function or perform in everyday life needEA$ - 0
1004BFunctional Capacity Examination performed by an ENT or Rheumatologist – An in-person examination (or review of the records) at an agreed upon location between the medical specialist and the claimant, which determines if claimant is able to function or perform in everyday life needEA$ - 0
1005Legal Nurse Review – A review of all medical records by a licensed legal nurseEA$ - 0
1006Additional document and medical record review for cases with over 50 pages (unit is increments of up to 50 pages)EA$ - 0
1007APsychological Testing performed by a PsychologistEA$ - 0
1007BPsychological Testing performed by a PsychiatristEA$ - 0
1008Medical Diagnostic Testing by Current Procedural Terminology (CPT) code. (unit price for the actual test performed is price based on the National Medicare fee schedule on the date of the test)EABy CPT Code
1009ODCs – ODCs including materials, phone charges, postage, copies, etc.EA$ 3,000.00
OPTION PERIOD 1 - NOT TO EXCEED$ 50,000.00
OPTION PERIOD 2
ItemDescriptionUnitUnit Price
2001AMedical Record Review performed by a General Physician – A review of all medical and related records provided by the claimant, physicians, and/or representativeEA$ - 0
2001BMedical Record Review performed by a Neurologist – A review of all medical and related records provided by the claimant, physicians, and/or representativeEA$ - 0
2002AIndependent Medical Review performed by a General Physician – A review of all medical records as well as in-person examination (at an agreed upon location between the medical specialist and the claimant) of a claimantEA$ - 0
2002BIndependent Medical Review performed by a Neurologist – A review of all medical records as well as in-person examination (at an agreed upon location between the medical specialist and the claimant) of a claimantEA$ - 0
2003AVocational Assessment performed by a General Physician – An in-person examination, at an agreed upon location between the medical specialist and the claimant, which assesses whether or not a claimant is able to perform any type of gainful workEA$ - 0
2003BVocational Assessment performed by Neurologist – An in-person examination, at an agreed upon location between the medical specialist and the claimant, which assesses whether or not a claimant is able to perform any type of gainful workEA$ - 0
2004AFunctional Capacity Examination performed by a General Physician – An in-person examination (or review of the records) at an agreed upon location between the medical specialist and the claimant, which determines if claimant is able to function or perform in everyday life needEA$ - 0
2004BFunctional Capacity Examination performed by an ENT or Rheumatologist – An in-person examination (or review of the records) at an agreed upon location between the medical specialist and the claimant, which determines if claimant is able to function or perform in everyday life needEA$ - 0
2005Legal Nurse Review – A review of all medical records by a licensed legal nurseEA$ - 0
2006Additional document and medical record review for cases with over 50 pages (unit is increments of up to 50 pages)EA$ - 0
2007APsychological Testing performed by a PsychologistEA$ - 0
2007BPsychological Testing performed by a PsychiatristEA$ - 0
2008Medical Diagnostic Testing by Current Procedural Terminology (CPT) code. (unit price for the actual test performed is price based on the National Medicare fee schedule on the date of the test)EABy CPT Code
2009ODCs – ODCs including materials, phone charges, postage, copies, etc.EA$ 3,000.00
OPTION PERIOD 2 - NOT TO EXCEED$ 50,000.00
OPTION PERIOD 3
ItemDescriptionUnitUnit Price
3001AMedical Record Review performed by a General Physician – A review of all medical and related records provided by the claimant, physicians, and/or representativeEA$ - 0
3001BMedical Record Review performed by a Neurologist – A review of all medical and related records provided by the claimant, physicians, and/or representativeEA$ - 0
3002AIndependent Medical Review performed by a General Physician – A review of all medical records as well as in-person examination (at an agreed upon location between the medical specialist and the claimant) of a claimantEA$ - 0
3002BIndependent Medical Review performed by a Neurologist – A review of all medical records as well as in-person examination (at an agreed upon location between the medical specialist and the claimant) of a claimantEA$ - 0
3003AVocational Assessment performed by a General Physician – An in-person examination, at an agreed upon location between the medical specialist and the claimant, which assesses whether or not a claimant is able to perform any type of gainful workEA$ - 0
3003BVocational Assessment performed by Neurologist – An in-person examination, at an agreed upon location between the medical specialist and the claimant, which assesses whether or not a claimant is able to perform any type of gainful workEA$ - 0
3004AFunctional Capacity Examination performed by a General Physician – An in-person examination (or review of the records) at an agreed upon location between the medical specialist and the claimant, which determines if claimant is able to function or perform in everyday life needEA$ - 0
3004BFunctional Capacity Examination performed by an ENT or Rheumatologist – An in-person examination (or review of the records) at an agreed upon location between the medical specialist and the claimant, which determines if claimant is able to function or perform in everyday life needEA$ - 0
3005Legal Nurse Review – A review of all medical records by a licensed legal nurseEA$ - 0
3006Additional document and medical record review for cases with over 50 pages (unit is increments of up to 50 pages)EA$ - 0
3007APsychological Testing performed by a PsychologistEA$ - 0
3007BPsychological Testing performed by a PsychiatristEA$ - 0
3008Medical Diagnostic Testing by Current Procedural Terminology (CPT) code. (unit price for the actual test performed is price based on the National Medicare fee schedule on the date of the test)EABy CPT Code
3009ODCs – ODCs including materials, phone charges, postage, copies, etc.EA$ 3,000.00
OPTION PERIOD 3 - NOT TO EXCEED$ 50,000.00
OPTION PERIOD 4
ItemDescriptionUnitUnit Price
4001AMedical Record Review performed by a General Physician – A review of all medical and related records provided by the claimant, physicians, and/or representativeEA$ - 0
4001BMedical Record Review performed by a Neurologist – A review of all medical and related records provided by the claimant, physicians, and/or representativeEA$ - 0
4002AIndependent Medical Review performed by a General Physician – A review of all medical records as well as in-person examination (at an agreed upon location between the medical specialist and the claimant) of a claimantEA$ - 0
4002BIndependent Medical Review performed by a Neurologist – A review of all medical records as well as in-person examination (at an agreed upon location between the medical specialist and the claimant) of a claimantEA$ - 0
4003AVocational Assessment performed by a General Physician – An in-person examination, at an agreed upon location between the medical specialist and the claimant, which assesses whether or not a claimant is able to perform any type of gainful workEA$ - 0
4003BVocational Assessment performed by Neurologist – An in-person examination, at an agreed upon location between the medical specialist and the claimant, which assesses whether or not a claimant is able to perform any type of gainful workEA$ - 0
4004AFunctional Capacity Examination performed by a General Physician – An in-person examination (or review of the records) at an agreed upon location between the medical specialist and the claimant, which determines if claimant is able to function or perform in everyday life needEA$ - 0
4004BFunctional Capacity Examination performed by an ENT or Rheumatologist – An in-person examination (or review of the records) at an agreed upon location between the medical specialist and the claimant, which determines if claimant is able to function or perform in everyday life needEA$ - 0
4005Legal Nurse Review – A review of all medical records by a licensed legal nurseEA$ - 0
4006Additional document and medical record review for cases with over 50 pages (unit is increments of up to 50 pages)EA$ - 0
4007APsychological Testing performed by a PsychologistEA$ - 0
4007BPsychological Testing performed by a PsychiatristEA$ - 0
4008Medical Diagnostic Testing by Current Procedural Terminology (CPT) code. (unit price for the actual test performed is price based on the National Medicare fee schedule on the date of the test)EABy CPT Code
4009ODCs – ODCs including materials, phone charges, postage, copies, etc.EA$ 3,000.00
OPTION PERIOD 4 - NOT TO EXCEED$ 50,000.00

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