24CSMC-041C-Attachment-3-Budget_Form-9.13.24_(CH_9-13-24).xlsx

XLSX spreadsheet 39 KB Posted Sep 13, 2024

Attached to: Independent Medical Review (IMR) RFP # 24CSMC-041C
Solicitation number: 0000032727
Issued by: California

About this file

Written by GovTribe AI · Sep 16, 2024

This document is a Cost Proposal/Budget Form for an Independent Medical Review (IMR) RFP #24CSMC-041C issued by the Consumer Services & Market Conduct Branch. The RFP covers a 5-year contract term, including a 3-year base term and two 1-year option periods. The RFP requests proposals for Experimental/Investigational Reviews, Medical Necessity Reviews, and Withdrawn/Cancelled Reviews, with specific fee structures and multipliers defined for each service. Proposers must complete a Cost Proposal Worksheet for each year of the contract term.

The form provides detailed instructions on how to complete the worksheets, including guidance on calculating weighted fees, average weighted fees, and the total average weighted fee that will be used to determine the competitive bid price. The document also specifies that all calculations must be rounded to the nearest second decimal place. There are no details provided on any set-asides, incumbents, funding sources, or other salient financial information.

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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/1-year) 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/1-year) options = 5 worksheets, per Subcontractor). Add tabs as needed.

&"Arial,Bold"Consumer Services & Market Conduct Branch &"Arial,Bold"Instructions Independent Medical Review (IMR) RFP # 24CSMC-041C &"-,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 Form

&"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 Form

&"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 Form

&"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 Form Independent Medical Review (IMR) RFP # 24SMC-041C

&"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 Form

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

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