23CSMC-213C-Attachment-3-Budget_Form-FINAL-04.19.24.xlsx

XLSX spreadsheet 40 KB Posted Apr 19, 2024

Attached to: RFP # 23CSMC-213C. -Independent Medical Review (IMR)
Solicitation number: 0000031083
Issued by: California

About this file

Written by GovTribe AI · May 16, 2024

This document is a Cost Proposal/Budget Form related to RFP # 23CSMC-213C for Independent Medical Review (IMR) services issued by the California Department of Insurance (CDI). The contract will be for a three (3) year term, with up to two (2) optional 12-month extensions. The RFP requests proposals for providing Experimental/Investigational Reviews, Medical Necessity Reviews, and Withdrawn/Cancelled Reviews at standard and expedited rates. Bidders must complete a Cost Proposal Worksheet for each year of the contract term, including the optional extension years. The RFP has important dates, including a written question submittal deadline of 04/26/2024 and a final proposal submission deadline of 05/17/2024.

The Cost Proposal/Budget Form outlines the required pricing structure, including contract flat fees, multipliers, and weighted fee calculations for the different review types and service levels. Bidders must enter their proposed contract flat fees, and the form will automatically calculate the weighted fees. The Total Average Weighted Fee across all years will be used to determine the competitive bid price. The Form also includes instructions for completing the worksheets and rounding requirements for the calculations.

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File	Type	Posted
23CSMC-213C-RFP-FINAL-04.19.24.pdf	PDF	Apr 19, 2024
23CSMC-213C-Q_As-05.03.24-FINAL.pdf	PDF	Apr 19, 2024

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Instructions *Complete a Cost Proposal Worksheet for each year of the 5 year term of the contract (3 year term, + 2 (12 month) options = 5 worksheets).

The listed multipliers closely reflect the proportion of services billed for in 2020. For example, out of 100 service requests, about two-thirds of the services provided were for Medical Necessity; another one-third of the services provided were for Experimental/ Investigational work. These proportions are not guaranteed, nor are they intended to reflect priority of services; actual billed services will vary. The proportions closely reflect 2017 expenditures so they provide a basis to estimate future workload. The multipliers therefore develop a Total Average Weighted Fee on which the bids will compete. *The Contract Flat Fee for each activity as provided by the Proposer will be the basis of invoicing and will be included in the final contract.

A. Experimental / Invesitgational Review*
Standard Rate SR (Columns B-D)
Contract Flat Fee (Column B)	Enter Rate for each review, as applicable.
Multipler (Column C)	Amount is fixed. Do not change or delete.
Weighted Fee SR (Column D)	Auto populates Total Fee.
Expedited Rate ER (E-G)
Contract Flat Fee (Column E)	Enter Rate for each review, as applicable.
Multipler (Column F)	Amount is fixed. Do not change or delete.
Weighted Fee SR (Column G)	Auto populates Weighted Fee.
B. Medical Necessity Review *
Standard Rate SR (Columns B-D)
Contract Flat Fee (Column B)	Enter Rate for each review, as applicable.
Multipler (Column C)	Amount is fixed. Do not change or delete.
Weighted Fee SR (Column D)	Auto populates Weighted Fee.
Expedited Rate ER (E-G)
Contract Flat Fee (Column E)	Enter Rate for each review, as applicable.
Multipler (Column F)	Amount is fixed. Do not change or delete.
Weighted Fee SR (Column G)	Auto populates Weighted Fee.
C. Withdrawn / Cancelled Review Basic Charge*
Standard Rate SR (Columns B-D)
Contract Flat Fee (Column B)	Enter Rate for each review, as applicable.
Multipler (Column C)	Amount is fixed. Do not change or delete.
Weighted Fee SR (Column D)	Auto populates Weighted Fee.
Expedited Rate ER (E-G)
Contract Flat Fee (Column E)	Enter Rate for each review, as applicable.
Multipler (Column F)	Amount is fixed. Do not change or delete.
Weighted Fee SR (Column G)	Auto populates Total Fee.
D. Total Weighed SR (Columns B-D) & ER (Columns E-G)*
Total Weighted SR (Column D)	Auto populates Total Weighted SR (All of Column D)
Total Weighted ER (Column G)	Auto populates Total Weighted ER (All of Column G)
Average Weighted SR (Columns B-D) & ER (Columns E-G)*
Total Weighted SR (Column D)	Auto populates Average Weighted SR Fee (D. SR Total/9)
Total Weighted ER (Column G)	Auto populates Average Weighted ER Fee (D. ER Total/8)
*All calculations will be rounded to the nearest second (2nd) decimal place.
**Complete a Cost Proposal Worksheet for each subcontractor for each year of the 3 year term of the contract (3 year term, + 2 (12 month) options = 5 worksheets, per Subcontractor). Add tabs as needed.

&"Arial,Bold"Consumer Services & Market Conduct Branch &"Arial,Bold"Instructions Independent Medical Review (IMR) RFP # 23CSMC-213C &"-,Regular"

&"Arial,Regular"&5&Z&F {&A} Page &P of &N

Year 1

	COST PROPOSAL/BUDGET FORM**
	Fees and expenses incurred shall be reimbursed at the following rates:
	YEAR - 1
	A. Experimental / Investigational Review	STANDARD RATE (SR)			EXPEDITED RATE (ER)
		Contract Flat Fee*	Multiplier	Weighted Fee (SR)	Contract Flat Fee*	Multiplier	Weighted Fee (ER)
	1. Three (3) Reviewers		26	$0.00		3	$0.00
	2. Re-review		0.25	$0.00		0.25	$0.00
	3. Each Additional Reviewer		0.25	$0.00		--	$0.00
	B. Medical Necessity Review
	4. One (1) Reviewer		64	$0.00		3	$0.00
	5. Re-review		0.25	$0.00		0.25	$0.00
	6. Each Additional Reviewer		0.25	$0.00		--	$0.00
	7. Non-Physician Review		0.25	$0.00		0.25	$0.00
	8. Re-review: Non Physician		0.25	$0.00		0.25	$0.00
	C. Withdrawn / Cancelled Review Basic Charge
	9. After Receipt of Records		1.5	$0.00		--	--
	D.	Total Weighted SR (Add A, B, C):		$0.00	Total Weighted ER (Add A, B):		$0.00
		Average Weighted SR Fee [D. SR Total / 9]		$0.00	Average Weighted ER Fee [D. ER total / 8]		$0.00
	Total Average Weighted Fee = Add SR & ER Average Weighted Fees and divide by 2*
*(this figure will be used to determine the competitive bid price)						$0.00
	**All calculations will be rounded to the nearest second (2nd) decimal place.

&"Arial,Bold"Consumer Services & Market Conduct Branch &"Arial,Bold"Year - 1 &"Arial,Bold"Cost Proposal/Budget Form

&"Arial,Regular"&5&Z&F {&A} Page &P of &N

Year 2

	COST PROPOSAL/BUDGET FORM**
	Fees and expenses incurred shall be reimbursed at the following rates:
	YEAR - 2
	A. Experimental / Investigational Review	STANDARD RATE (SR)			EXPEDITED RATE (ER)
		Contract Flat Fee*	Multiplier	Weighted Fee (SR)	Contract Flat Fee*	Multiplier	Weighted Fee (ER)
	1. Three (3) Reviewers		26	$0.00		3	$0.00
	2. Re-review		0.25	$0.00		0.25	$0.00
	3. Each Additional Reviewer		0.25	$0.00		--	$0.00
	B. Medical Necessity Review
	4. One (1) Reviewer		64	$0.00		3	$0.00
	5. Re-review		0.25	$0.00		0.25	$0.00
	6. Each Additional Reviewer		0.25	$0.00		--	$0.00
	7. Non-Physician Review		0.25	$0.00		0.25	$0.00
	8. Re-review: Non Physician		0.25	$0.00		0.25	$0.00
	C. Withdrawn / Cancelled Review Basic Charge
	9. After Receipt of Records		1.5	$0.00		--	--
	D.	Total Weighted SR (Add A, B, C):		$0.00	Total Weighted ER (Add A, B):		$0.00
		Average Weighted SR Fee [D. SR Total / 9]		$0.00	Average Weighted ER Fee [D. ER total / 8]		$0.00
	Total Average Weighted Fee = Add SR & ER Average Weighted Fees and divide by 2*
*(this figure will be used to determine the competitive bid price)						$0.00
	**All calculations will be rounded to the nearest second (2nd) decimal place.

&"Arial,Bold"Consumer Services & Market Conduct Branch &"Arial,Bold"Year - 2 &"Arial,Bold"Cost Proposal/Budget Fprm

&"Arial,Regular"&5&Z&F {&A} Page &P of &N

Year 3

	COST PROPOSAL/BUDGET FORM**
	Fees and expenses incurred shall be reimbursed at the following rates:
	YEAR - 3
	A. Experimental / Investigational Review	STANDARD RATE (SR)			EXPEDITED RATE (ER)
		Contract Flat Fee*	Multiplier	Weighted Fee (SR)	Contract Flat Fee*	Multiplier	Weighted Fee (ER)
	1. Three (3) Reviewers		26	$0.00		3	$0.00
	2. Re-review		0.25	$0.00		0.25	$0.00
	3. Each Additional Reviewer		0.25	$0.00		--	$0.00
	B. Medical Necessity Review
	4. One (1) Reviewer		64	$0.00		3	$0.00
	5. Re-review		0.25	$0.00		0.25	$0.00
	6. Each Additional Reviewer		0.25	$0.00		--	$0.00
	7. Non-Physician Review		0.25	$0.00		0.25	$0.00
	8. Re-review: Non Physician		0.25	$0.00		0.25	$0.00
	C. Withdrawn / Cancelled Review Basic Charge
	9. After Receipt of Records		1.5	$0.00		--	--
	D.	Total Weighted SR (Add A, B, C):		$0.00	Total Weighted ER (Add A, B):		$0.00
		Average Weighted SR Fee [D. SR Total / 9]		$0.00	Average Weighted ER Fee [D. ER total / 8]		$0.00
	Total Average Weighted Fee = Add SR & ER Average Weighted Fees and divide by 2*
*(this figure will be used to determine the competitive bid price)						$0.00
	**All calculations will be rounded to the nearest second (2nd) decimal place.

&"Arial,Bold"Consumer Services & Market Conduct Branch &"Arial,Bold"Year - 3 &"Arial,Bold"Cost Proposal/Budget Fprm

&"Arial,Regular"&5&Z&F {&A} Page &P of &N

Year 4

	COST PROPOSAL/BUDGET FORM**
	Fees and expenses incurred shall be reimbursed at the following rates:
	YEAR - 4
	A. Experimental / Investigational Review	STANDARD RATE (SR)			EXPEDITED RATE (ER)
		Contract Flat Fee*	Multiplier	Weighted Fee (SR)	Contract Flat Fee*	Multiplier	Weighted Fee (ER)
	1. Three (3) Reviewers		26	$0.00		3	$0.00
	2. Re-review		0.25	$0.00		0.25	$0.00
	3. Each Additional Reviewer		0.25	$0.00		--	$0.00
	B. Medical Necessity Review
	4. One (1) Reviewer		64	$0.00		3	$0.00
	5. Re-review		0.25	$0.00		0.25	$0.00
	6. Each Additional Reviewer		0.25	$0.00		--	$0.00
	7. Non-Physician Review		0.25	$0.00		0.25	$0.00
	8. Re-review: Non Physician		0.25	$0.00		0.25	$0.00
	C. Withdrawn / Cancelled Review Basic Charge
	9. After Receipt of Records		1.5	$0.00		--	--
	D.	Total Weighted SR (Add A, B, C):		$0.00	Total Weighted ER (Add A, B):		$0.00
		Average Weighted SR Fee [D. SR Total / 9]		$0.00	Average Weighted ER Fee [D. ER total / 8]		$0.00
	Total Average Weighted Fee = Add SR & ER Average Weighted Fees and divide by 2*
*(this figure will be used to determine the competitive bid price)						$0.00
	**All calculations will be rounded to the nearest second (2nd) decimal place.

&"Arial,Bold"Consumer Services & Market Conduct Branch &"Arial,Bold"Year - 4 &"Arial,Bold"Cost Proposal/Budget Fprm

&"Arial,Regular"&5&Z&F {&A} Page &P of &N

Year 5

	COST PROPOSAL/BUDGET FORM**
	Fees and expenses incurred shall be reimbursed at the following rates:
	YEAR - 5
	A. Experimental / Investigational Review	STANDARD RATE (SR)			EXPEDITED RATE (ER)
		Contract Flat Fee*	Multiplier	Weighted Fee (SR)	Contract Flat Fee*	Multiplier	Weighted Fee (ER)
	1. Three (3) Reviewers		26	$0.00		3	$0.00
	2. Re-review		0.25	$0.00		0.25	$0.00
	3. Each Additional Reviewer		0.25	$0.00		--	$0.00
	B. Medical Necessity Review
	4. One (1) Reviewer		64	$0.00		3	$0.00
	5. Re-review		0.25	$0.00		0.25	$0.00
	6. Each Additional Reviewer		0.25	$0.00		--	$0.00
	7. Non-Physician Review		0.25	$0.00		0.25	$0.00
	8. Re-review: Non Physician		0.25	$0.00		0.25	$0.00
	C. Withdrawn / Cancelled Review Basic Charge
	9. After Receipt of Records		1.5	$0.00		--	--
	D.	Total Weighted SR (Add A, B, C):		$0.00	Total Weighted ER (Add A, B):		$0.00
		Average Weighted SR Fee [D. SR Total / 9]		$0.00	Average Weighted ER Fee [D. ER total / 8]		$0.00
	Total Average Weighted Fee = Add SR & ER Average Weighted Fees and divide by 2*
*(this figure will be used to determine the competitive bid price)						$0.00
	**All calculations will be rounded to the nearest second (2nd) decimal place.

&"Arial,Bold"Consumer Services & Market Conduct Branch &"Arial,Bold"Year - 5 &"Arial,Bold"Cost Proposal/Budget Fprm

&"Arial,Regular"&5&Z&F {&A} Page &P of &N

TOTAL

	COST PROPOSAL/BUDGET FORM**
	Fees and expenses incurred shall be reimbursed at the following rates:
	TOTAL OF ALL 5 YEARS
	Total Average Weighted Fee = Add SR & ER Average Weighted Fees of all 5 years and divide by 5*
*(this figure will be used to determine the competitive bid price)		$0.00
	**All calculations will be rounded to the nearest second (2nd) decimal place.

&"Arial,Bold"Consumer Services & Market Conduct Branch &"Arial,Bold"Total &"Arial,Bold"Cost Proposal/Budget Fprm

&"Arial,Regular"&5&Z&F {&A} Page &P of &N

File details come from the government source that posted it. Updated May 16, 2024.