36C25018R0234-001.docx
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- VISN10 Ohio Home Oxygen Services Federal contract opportunity
- Solicitation number
- 36C25018R0234
About this file
This is a pre-solicitation notice for home oxygen services for veterans in Ohio. The Department of Veterans Affairs Network Contracting Office 10 plans to solicit proposals for a single-award IDIQ contract to provide home oxygen services to an estimated 5,500 beneficiaries per month across five VA medical centers in Ohio. Services will be performed in beneficiaries' places of residence including homes, hospitals, and nursing facilities. The contract will have a one-year base period and four one-year options, with services required from July 2018 through June 2023. The contractor will furnish all labor, equipment, supplies, management, and transportation necessary to deliver the required home oxygen care. The associated NAICS code is 532283 with a $32.5 million size standard. The solicitation is expected to be issued on April 2, 2018. Interested parties must register at SAM.gov and monitor FBO.gov for solicitation details and amendments.
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36C25018R0234
OF
1. REQUISITION NO.
2. CONTRACT NO.
3. AWARD/EFFECTIVE DATE
4. ORDER NO.
5. SOLICITATION NUMBER
6. SOLICITATION ISSUE DATE
a. NAME
b. TELEPHONE NO. (No Collect Calls)
8. OFFER DUE DATE/LOCAL
TIME
9. ISSUED BY
CODE
10. THIS ACQUISITION IS
UNRESTRICTED OR
SET ASIDE:
% FOR:
SMALL BUSINESS
HUBZONE SMALL
BUSINESS
SERVICE-DISABLED
VETERAN-OWNED
SMALL BUSINESS
WOMEN-OWNED SMALL BUSINESS
(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED
SMALL
BUSINESS PROGRAM
EDWOSB
8(A)
NAICS:
SIZE STANDARD:
11. DELIVERY FOR FOB DESTINA-
TION UNLESS BLOCK IS
MARKED
SEE SCHEDULE
12. DISCOUNT TERMS
13a. THIS CONTRACT IS A
RATED ORDER UNDER
DPAS (15 CFR 700)
13b. RATING
14. METHOD OF SOLICITATION
RFQ
IFB
RFP
15. DELIVER TO
CODE
16. ADMINISTERED BY
CODE
17a. CONTRACTOR/OFFEROR
CODE
FACILITY CODE
18a. PAYMENT WILL BE MADE BY
CODE
TELEPHONE NO.
DUNS:
DUNS+4:
PHONE:
FAX:
17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER 18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW IS CHECKED
SEE ADDENDUM
19.
20.
21.
22.
23.
24.
ITEM NO.
SCHEDULE OF SUPPLIES/SERVICES
QUANTITY
UNIT
UNIT PRICE
AMOUNT
(Use Reverse and/or Attach Additional Sheets as Necessary)
25. ACCOUNTING AND APPROPRIATION DATA
26. TOTAL AWARD AMOUNT (For Govt. Use Only) 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA
ARE
ARE NOT ATTACHED.
27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA
ARE
ARE NOT ATTACHED
28. CONTRACTOR IS REQUIRED TO SI
GN THIS DOCUMENT AND RETURN _______________
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. SIGN
ATURE OF OFFEROR/CONTRACTOR
31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER) 30b. NAME AND TITLE OF SIGNER (TYPE OR PRINT) 30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (TYPE OR PRINT) 31c. DATE SIGNED
AUTHORIZED FOR
LOCAL REPRODUCTION
(REV. 2/2012)
PREVIOUS EDITION IS NOT USABLE
Prescribed by GSA - FAR (48 CFR) 53.212
7. FOR SOLICITATION
INFORMATION CALL:
STANDARD FORM 1449
OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30
SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS
36C25018R0234 04-06-2018
DAVINA PERRY; DAVINA.PERRY@VA.GOV
216-447-8300 05-04-2018
5:00 PM EST
36C250 Department of Veterans Affairs Network Contracting Office (NCO) 10 6150 Oak Tree Blvd., Suite 300 Independence OH 44131 X X 532283 $32.5 Million X N/A X 36C250 Department of Veterans Affair Network Contracting Office (NCO) 10 6150 Oaktree Blvd., 3rd Floor Independence OH 44131 36C250 Department of Veterans Affairs Network Contracting Office (NCO) 10 6150 Oak Tree Blvd., Suite 300 Independence OH 44131
Department of Veterans Affairs Financial Services Center P.O. Box 149971 Austin TX 78714-9971 X See CONTINUATION Page The Government is in the need of procuring Home Oxygen Services for VISN 10 Ohio.
Complete the Price Schedule on page:7 View the Performance Work Statement on page:184 View clause 52.212-1, Instructions to Offerors on page:250 View clause 52.212-2, Evaluation on page:
Period of Performance:
Base Year: July 1, 2018 - June 30, 2019 Option Year One: July 1, 2019 - June 30, 2020 Option Year Two: July 1, 2020 - June 30, 2021 Option Year Three: July 1, 2021 - June 30, Option Year Four: July 1, 2022 - June 30, 2023 See CONTINUATION Page X X
ALEX DANIEL
Table of Contents
| SECTION A | 1 |
| A.1 SF 1449 SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS | 1 |
| SECTION B - CONTINUATION OF SF 1449 BLOCKS | 4 |
| B.1 CONTRACT ADMINISTRATION DATA | 4 |
| B.2 LIMITATIONS ON SUBCONTRACTING-- MONITORING AND COMPLIANCE (JUN 2011) | 5 |
| B.3 SUBCONTRACTING COMMITMENTS--MONITORING AND COMPLIANCE (JUN 2011) | 5 |
| B.4 SCHEDULE OF SERVICES/ SUPPLIES | 6 |
| B.5 PERFORMANCE WORK STATEMENT | 185 |
| SECTION C - CONTRACT CLAUSES | 225 |
| C.1 52.212-4 CONTRACT TERMS AND CONDITIONS—COMMERCIAL ITEMS (JAN 2017) | 225 |
| C.2 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998) | 231 |
| C.3 52.216-18 ORDERING (OCT 1995) | 232 |
| C.4 52.216-19 ORDER LIMITATIONS (OCT 1995) | 232 |
| C.5 52.216-22 INDEFINITE QUANTITY (OCT 1995) | 233 |
| C.6 52.217-8 OPTION TO EXTEND SERVICES (NOV 1999) | 233 |
| C.7 52.217-9 OPTION TO EXTEND THE TERM OF THE CONTRACT (MAR 2000) | 234 |
| C.8 VAAR 852.203-70 COMMERCIAL ADVERTISING (JAN 2008) | 234 |
| C.9 VAAR 852.203-71 DISPLAY OF DEPARTMENT OF VETERAN AFFAIRS HOTLINE POSTER (DEC 1992) | 234 |
| C.10 VAAR 852.215-71 EVALUATION FACTOR COMMITMENTS (DEC 2009) | 234 |
| C.11 VAAR 852.232-72 ELECTRONIC SUBMISSION OF PAYMENT REQUESTS (NOV 2012) | 235 |
| C.12 VAAR 852.237-70 CONTRACTOR RESPONSIBILITIES (APR 1984) | 236 |
| C.13 52.212-5 CONTRACT TERMS AND CONDITIONS REQUIRED TO IMPLEMENT STATUTES OR EXECUTIVE ORDERS—COMMERCIAL ITEMS (JAN 2017) | 236 |
| C.14 MANDATORY WRITTEN DISCLOSURES | 243 |
| SECTION D - CONTRACT DOCUMENTS, EXHIBITS, OR ATTACHMENTS | 244 |
| D.1 See attached document: “Evaluation Factors and Submission Instructions VISN 10 Ohio Home O2 Services.” | 244 |
| D.2 See attached document: “Quality Assurance Surveillance Plan (QASP) - VISN 10 Ohio Home O2 Services.” | 244 |
| D.3 See attached document: “Wage Determinations - VISN 10 Ohio Home O2 Services.” | 244 |
| D.4 See attached document: “Past Performance Questionnaire - VISN 10 Ohio Home O2 Services.” | 244 |
| D.5 See attached document: “VISN 10 Ohio Medical Centers Memorandums_ Section 7.4 of PWS.” | 244 |
| D.6 See attached document: “Section 3.5A of PWS – VA-approved Forms.” | 244 |
| D.7 See attached document: “Thermal Fuse Alert.” | 244 |
| D.8 Business Associate Agreement Between the Department of Veterans Affairs Health Administration, , AND _____________________________________. | 245 |
| SECTION E - SOLICITATION PROVISIONS | 250 |
| E.1 52.212-1 INSTRUCTIONS TO OFFERORS—COMMERCIAL ITEMS (JAN 2017) | 250 |
| E.2 52.203-98 PROHIBITION ON CONTRACTING WITH ENTITIES THAT REQUIRE CERTAIN INTERNAL CONFIDENTIALITY AGREEMENTS—REPRESENTATION (DEVIATION) (FEB 2015) | 254 |
| E.3 52.209-5 REPRESENTATION BY CORPORATIONS REGARDING AN UNPAID TAX LIABILITY OR A FELONY CONVICTION UNDER ANY FEDERAL LAW (DEVIATION)(MAR 2012) | 254 |
| E.4 52.209-7 INFORMATION REGARDING RESPONSIBILITY MATTERS (JUL 2013) | 255 |
| E.5 52.216-1 TYPE OF CONTRACT (APR 1984) | 256 |
| E.6 52.216-27 SINGLE OR MULTIPLE AWARDS (OCT 1995) | 256 |
| E.7 52.233-2 SERVICE OF PROTEST (SEP 2006) | 256 |
| E.8 52.252-1 SOLICITATION PROVISIONS INCORPORATED BY REFERENCE (FEB 1998) | 257 |
| E.9 VAAR 852.233-70 PROTEST CONTENT/ALTERNATIVE DISPUTE RESOLUTION (JAN 2008) | 257 |
| E.10 VAAR 852.233-71 ALTERNATE PROTEST PROCEDURE (JAN 1998) | 258 |
| E.11 VAAR 852.215-70 SERVICE-DISABLED VETERAN-OWNED AND VETERAN-OWNED SMALL BUSINESS EVALUATION FACTORS (JUL 2016)(DEVIATION) | 258 |
| E.12 VAAR 852.252-70 SOLICITATION PROVISIONS OR CLAUSES INCORPORATED BY REFERENCE (JAN 2008) | 259 |
| E.13 VAAR 852.270-1 REPRESENTATIVES OF CONTRACTING OFFICERS (JAN 2008) | 259 |
| E.14 VAAR 852.271-70 NONDISCRIMINATION IN SERVICES PROVIDED TO BENEFICIARIES (JAN 2008) | 259 |
| E.15 52.212-2 EVALUATION—COMMERCIAL ITEMS (OCT 2014) | 259 |
| E.16 52.212-3 OFFEROR REPRESENTATIONS AND CERTIFICATIONS—COMMERCIAL ITEMS (JAN 2017) | 260 |
SECTION B - CONTINUATION OF SF 1449 BLOCKS
B.1 CONTRACT ADMINISTRATION DATA
(Continuation from Standard Form 1449, block 18A.)
1. Contract Administration: All contract administration matters will be handled by the following individuals:
| a. CONTRACTOR: | _______________________________________ |
| _______________________________________ | |
| _______________________________________ | |
| _______________________________________ | |
| _______________________________________ | |
| _______________________________________ |
b. GOVERNMENT: Contracting Officer 36C250 ALEX DANIEL Department of Veterans Affairs Network Contracting Office (NCO) 10 260 E. University Avenue Cincinnati, OH 45219 Alexander.Daniel@va.gov
2. CONTRACTOR REMITTANCE ADDRESS: All payments by the Government to the contractor will be made in accordance with:
| [X] |
| 52.232-34, Payment by Electronic Funds Transfer—Other Than System For Award Management, or |
| [] |
| 52.232-36, Payment by Third Party |
3. INVOICES: Invoices shall be submitted in arrears:
| a. Quarterly | [] |
| b. Semi-Annually | [] |
| c. Other | [X] MONTHLY |
4. GOVERNMENT INVOICE ADDRESS: All Invoices from the contractor shall be submitted electronically in accordance with VAAR Clause 852.232-72 Electronic Submission of Payment Requests.
Department of Veterans Affairs Financial Services Center P.O. Box 149971 Austin TX 78714-9971
ACKNOWLEDGMENT OF AMENDMENTS: The offeror acknowledges receipt of amendments to the Solicitation numbered and dated as follows:
| AMENDMENT NO |
| DATE |
B.2 LIMITATIONS ON SUBCONTRACTING-- MONITORING AND COMPLIANCE (JUN 2011)
This solicitation includes FAR 52.219-14 Limitations on Subcontracting. Accordingly, any contract resulting from this solicitation will include this clause. The contractor is advised in performing contract administration functions, the CO may use the services of a support contractor(s) retained by VA to assist in assessing the contractor's compliance with the limitations on subcontracting or percentage of work performance requirements specified in the clause. To that end, the support contractor(s) may require access to contractor's offices where the contractor's business records or other proprietary data are retained and to review such business records regarding the contractor's compliance with this requirement. All support contractors conducting this review on behalf of VA will be required to sign an “Information Protection and Non-Disclosure and Disclosure of Conflicts of Interest Agreement” to ensure the contractor's business records or other proprietary data reviewed or obtained in the course of assisting the CO in assessing the contractor for compliance are protected to ensure information or data is not improperly disclosed or other impropriety occurs. Furthermore, if VA determines any services the support contractor(s) will perform in assessing compliance are advisory and assistance services as defined in FAR 2.101, Definitions, the support contractor(s) must also enter into an agreement with the contractor to protect proprietary information as required by FAR 9.505-4, obtaining access to proprietary information, paragraph (b). The contractor is required to cooperate fully and make available any records as may be required to enable the CO to assess the contractor's compliance with the limitations on subcontracting or percentage of work performance requirement.
B.3 SUBCONTRACTING COMMITMENTS--MONITORING AND COMPLIANCE (JUN 2011)
This solicitation includes VAAR 852.215-70, Service-Disabled Veteran-Owned and Veteran-Owned Small Business Evaluation Factors, and VAAR 852.215-71, Evaluation Factor Commitments. Accordingly, any contract resulting from this solicitation will include these clauses. The contractor is advised in performing contract administration functions, the CO may use the services of a support contractor(s) to assist in assessing contractor compliance with the subcontracting commitments incorporated into the contract. To that end, the support contractor(s) may require access to the contractor's business records or other proprietary data to review such business records regarding contract compliance with this requirement. All support contractors conducting this review on behalf of VA will be required to sign an “Information Protection and Non-Disclosure and Disclosure of Conflicts of Interest Agreement” to ensure the contractor's business records or other proprietary data reviewed or obtained in the course of assisting the CO in assessing the contractor for compliance are protected to ensure information or data is not improperly disclosed or other impropriety occurs. Furthermore, if VA determines any services the support contractor(s) will perform in assessing compliance are advisory and assistance services as defined in FAR 2.101, Definitions, the support contractor(s) must also enter into an agreement with the contractor to protect proprietary information as required by FAR 9.505-4, obtaining access to proprietary information, paragraph (b). The contractor is required to cooperate fully and make available any records as may be required to enable the CO to assess the contractor compliance with the subcontracting commitments.
B.4 SCHEDULE OF SERVICES/ SUPPLIES
ORDERING & INVOICES: Prosthetics and Sensory Aids Service (PSAS) and the Contracting Officer’s Representative (COR) or designee shall provide the Contractor with notification via facsimile to initiate individual patient service requirements. This shall include patient’s oxygen prescription, oxygen prescription expiration date, equipment, supplies and services to be provided including the date and place of delivery. The Contractor shall confirm receipt within two (2) working hours of notification. The Contractor shall confirm by facsimile or secure email to COR or designee/designated staff for Home Oxygen and Respiratory Service initiations, plan of care changes and discharges. The COR or designee shall provide notification of VA initiated discontinuance of service via facsimile. All orders shall be placed, for each facility, by the COR or designee to the Contractor. All changes to patient care shall be confirmed in writing. The written documents shall include the authorizing official’s signature. The prescription is terminated the day the patient expires. For additional ordering instructions refer to 52.216-18.
Invoices shall be submitted upon completion of complete delivery/pickup/setup. Send invoices with proper documentation to the appropriate VA Medical Center listed below:
CLEVELAND Chief Prosthetic & Sensory Aid Svc. (121 W)
Attn: William Jones
Louis Stokes Cleveland VAMC 10701 East Blvd.
Cleveland, Ohio 44106
Phone 216.791.3800 Ext. 4582
William.Joneseee13@va.gov CHILLICOTHE Chief Prosthetic & Sensory Aid Svc. (121 W)
Attn: Corey Smith
Chillicothe VAMC 17273 State Route 104 Chillicothe, Ohio 45601
Phone 740.773.1141
Corey.Smith1@va.gov COLUMBUS Chief Prosthetic & Sensory Aid Svc. (121 W)
Attn: Lewis McCarter
Chalmers P. Wylie 420 North James Road Columbus, Ohio 43219
Phone 614.257.5411
Lewis.McCarter@va.gov
DAYTON Chief Prosthetic & Sensory Aid Svc. (121 W)
Attn: Timothy Gasson
4100 West Third St.
Dayton, Ohio 45428
Phone 937.268.6511.Ext. 2906
Timothy.Gasson@va.gov CINCINNATI Chief Prosthetic & Sensory Aid Svc. (121 W)
Attn: Gary Coates
3200 Vine Street Cincinnati, Ohio 45200
Phone 513.861.3100
Gary.Coates@va.gov
This procurement is under the authority of Title 38 USC 8153 and FAR Part 15.
In accordance with 52.216-22, Indefinite Quantity, the guaranteed minimum that the Government agrees to order during the period of this contract is $152,000.00 of the units prescribed. The total contract maximum to be ordered is $40,200,000.00.
*Contract pricing is all-inclusive per section 2.3 of the PWS.
The contractor shall provide all management, tools, supplies, equipment, and labor necessary for the delivery of Home Oxygen Services within the VA Health Network of Ohio. Period of Performance shall be for one (1) base year with four one (1) year options periods beginning July 1, 2018 through June 30, 2023.
36C25018R0234
Page 1 of Page 1 of
BASE PERIOD
| CLIN |
| DESCRIPTION |
| ESTIMATED MONTHLY QUANTITY |
| UNIT PRICE |
| UNITS |
| TOTAL PRICE |
| A0001 (a) |
| CHILLICOTHE: Rental concentrator with backup system consisting of compressed gas source, regulator, stand, (nasal cannula or mask and humidifier when specified). Concentrator will have flow rate capacity up to 5LPM. E1390. SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment. |
| 300 |
12 MONTHS
| A0001 (b) |
| Rental concentrator with backup system consisting of compressed gas source, regulator, stand (nasal cannula or mask and humidifier when specified). Concentrator must have flow rate capacity up to 10 LPM. E1390. SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment. |
| 10 |
12 MONTHS
| A0001 (c) |
| Rental Concentrator with Portable Gaseous Oxygen System, home compressor used to fill portable oxygen cylinders- (2) self-filling -type oxygen cylinders, oxygen conserving device, regulator, flow meter, humidifier, cannula or mask, tubing, cylinder carrier. Concentrator will have flow rate capacity up to 5 LPM. E1390 |
| 300 |
12 MONTHS
| A0001 (d) |
| Rental Concentrator with Portable Gaseous Oxygen System, home compressor used to fill portable oxygen cylinders- (2) self-filling -type oxygen cylinders, oxygen conserving device, regulator, flow meter, humidifier, cannula or mask, tubing, cylinder carrier. Concentrator will have flow rate capacity up to 10 LPM. E1390 |
| 50 |
12 MONTHS
| A0002 |
| Cylinder, size M or H set-up consisting of regulator, flow meter, safety stand, humidifier and disposable supplies (emergency backup system or as primary) SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment. |
| 300 |
12 MONTHS
| A0003 |
| Cylinder, size M or H refill (Backup/Primary) E0441 SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 100 |
12 MONTHS
| A0004 |
| Portable system ONLY: prescription does not include concentrator: consists of “E”, “D”, “B” (M6), or “C” (M9) size aluminum (or equivalent weight metal) cylinder with regulator, flow meter, handcart, pouch and disposable supplies. |
NOTICE: This shall be invoiced per cylinder provided to the patient. This is NOT a recurring rental PRICE, charges will only incur when an empty cylinder is replaced with a full cylinder.
SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment
12 MONTHS
| A0005 |
| Cylinder, size “E” refill for Item A0004 above; Aluminum (or metal of equivalent weight or less) tanks required E0443 SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 300 |
12 MONTHS
| A0006 |
| Cylinder, size “D” (M15) refill for Item A0004 above. Aluminum (or metal of equivalent weight or less) tanks required E0443 SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 100 |
12 MONTHS
| A0007 |
| Cylinder, size “B” (M6) refill for Item A0004 above; Aluminum (or metal of equivalent weight or less) tanks required E0443 SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 300 |
12 MONTHS
| A0008 |
| Cylinder, size “C” refill for Item A0004 above; Aluminum (or metal of equivalent weight) tanks required E0443 SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 50 |
12 MONTHS
| A0009 |
| Demand Nasal Cannula (e.g. Oximyzer) Reservoir or pendant/equivalent. VA111 |
| 11 |
12 MONTHS
| A0010 |
| ESTIMATED MONTHLY Volume Demand Pulse Conserver Device; no less than a 5:1 ratio or 60 ML/pulse VA111 SPECIAL NOTE: Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 160 |
12 MONTHS
| A0011 |
| Rental liquid oxygen system (90 – 100 lbs) stationary reservoir per patient. E0439; AND Rental portable liquid oxygen system per patient E0434 |
| 2 |
12 MONTHS
| A0012 |
| Liquid oxygen per pound for portable liquid oxygen system under Item A0011 E0444 |
| 3 |
12 MONTHS
| A0013 |
| Volume Delivery for re-supply and/or relocation of equipment due to change in patient’s residence |
| 1 |
12 MONTHS
| A0014 |
| Portable Concentrator- Rental portable oxygen concentrator E1392 |
| 50 |
12 MONTHS
| A0015 |
| Overnight Oximeter- Rental oximeter for overnight oximetry testing E0445 |
| 35 |
12 MONTHS
| A0016 |
| Suction Machine- Rental suction machine E0600 |
| 2 |
12 MONTHS
| A0017 |
| Compressor 50 psi - Rental 50 psi air compressor E0565 |
| 4 |
12 MONTHS
| A0018 |
| Ventilator Negative Pressure ventilator; portable or stationary; Rental negative pressure ventilator E0465 |
| 1 |
12 MONTHS
| A0019 |
| Pressure support ventilator with volume control mode; may include pressure control mode; Rental pressure support ventilator E0465 |
| 4 |
12 MONTHS
| A0020 |
| Oxygen Thermal Fuse (Fire Safe Cannula) - fuse to isolate oxygen supply in case of fire |
| 300 |
12 MONTHS
| A0021 |
| Closed Suction Catheters- Contractor shall provide four (4) closed suction catheters to each ventilator patient each month, so that a clean catheter can be placed into the breathing circuit each week. Catheters shall be replaced as needed during MONTHLY visit by contractor RT. A4605 |
| 4 |
12 MONTHS
| A0022 |
| Heated Humidifier- The contractor shall provide a heated humidifier to Veterans receiving mechanical ventilation only, to provide optimal levels of heat and moisture to the patient’s airway. S8182 |
| 4 |
12 MONTHS
| A0023 |
| Portable Suction Machine- The contractor shall provide a portable suction machine equipped with an internal battery for use during transport to Veterans receiving mechanical ventilation only E0600 |
| 2 |
12 MONTHS
| A0024 |
| Nebulizer with Compressor- The contractor will provide a nebulizer with compressor to ventilator patients only, as ordered by the VA. MONTHLY PRICE shall include spring loaded T-adapter, neb cups, tubing, masks, trach masks E0570 |
| 3 |
12 MONTHS
| A0025 |
| Tracheostomy Care Supplies- The contractor shall provide supplies needed to properly clean and maintain trach and stoma to ventilator patients only. These supplies shall include, tracheostomy drain sponges A6402, basic tracheostomy care kits A4629, 3ml UNIT dose normal saline A4649, cuffed and uncuffed tracheostomy tubes A7521 A7520, tracheostomy inner cannulas A4623 |
| 4 |
12 MONTHS
| A0026 |
| Inline HME- The contractor shall provide an inline heated moisture exchanger (HME) to Veterans receiving non-invasive mechanical ventilation in order to provide optimal levels of heat and moisture to the patient’s airway. A4483 |
| 2 |
12 MONTHS
| A0027 |
| Refillable- type oxygen cylinder- Rental of additional re-fillable cylinders for patients who are assessed to have an extended need for oxygen portability due to high liter flow and /or increased patient activity outside of the home. E0443 |
| 20 |
12 MONTHS
| A0028 |
| Battery for Portable Home Oxygen Concentrator- Temporary rental to be used only during patient travel, when extended time away from a permanent power source is expected |
| 2 |
12 MONTHS
| A0029 |
| PAP Pressure Valve- Contractor shall furnish a Positive Airway Pressure (PAP) Valve to each Veteran on nocturnal oxygen bled into a Positive Airway Pressure (PAP) Device when ordered by the VAMC. E1399 |
| 5 |
12 MONTHS
| A0030 |
| Variable Concentration Trach Mask- The contractor shall provide a variable concentration trach mask to Veterans, as ordered by VA Medical Center Staff. This shall include the mask and all mask components A4620 |
| 1 |
12 MONTHS
| A0031 |
| Cough Stimulating Device – The Contractor Respiratory Therapist shall deliver a Cough Stimulating Device to the Veteran; provide instruction on use of device, with return demonstration by caregiver, along with applicable patient education and equipment maintenance training. This MONTHLY PRICE shall include all components required for operation of the device, both disposable and non-disposable components. E0482 |
| 5 |
12 MONTHS
| A0032 |
| Full Face Mask - The Contractor shall provide a full-face mask to Veterans receiving non-invasive mechanical ventilation. This item is to be provided to ventilator patients only. A7030 |
| 1 |
12 MONTHS
BASE PERIOD TOTAL - CHILLICOTHE:
| CLIN |
| DESCRIPTION |
| ESTIMATED MONTHLY QUANTITY |
| UNIT PRICE |
| UNITS |
| TOTAL PRICE |
| B0001 (a) |
| CINCINNATI: Rental concentrator with backup system consisting of compressed gas source, regulator, stand, (nasal cannula or mask and humidifier when specified). Concentrator will have flow rate capacity up to 5LPM. E1390. SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment. |
| 135 |
12 MONTHS
| B0001 (b) |
| Rental concentrator with backup system consisting of compressed gas source, regulator, stand (nasal cannula or mask and humidifier when specified). Concentrator must have flow rate capacity up to 10 LPM. E1390. SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment. |
| 30 |
12 MONTHS
| B0001 (c) |
| Rental Concentrator with Portable Gaseous Oxygen System, home compressor used to fill portable oxygen cylinders- (2) self-filling -type oxygen cylinders, oxygen conserving device, regulator, flow meter, humidifier, cannula or mask, tubing, cylinder carrier. Concentrator will have flow rate capacity up to 5 LPM. E1390 |
| 600 |
12 MONTHS
| B0001 (d) |
| Rental Concentrator with Portable Gaseous Oxygen System, home compressor used to fill portable oxygen cylinders- (2) self-filling -type oxygen cylinders, oxygen conserving device, regulator, flow meter, humidifier, cannula or mask, tubing, cylinder carrier. Concentrator will have flow rate capacity up to 10 LPM. E1390 |
| 30 |
12 MONTHS
| B0002 |
| Cylinder, size M or H set-up consisting of regulator, flow meter, safety stand, humidifier and disposable supplies (emergency backup system or as primary) SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment. |
| 1 |
12 MONTHS
| B0003 |
| Cylinder, size M or H refill (Backup/Primary) E0441 SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 1 |
12 MONTHS
| B0004 |
| Portable system ONLY: prescription does not include concentrator: consists of “E”, “D”, “B” (M6), or “C” (M9) size aluminum (or equivalent weight metal) cylinder with regulator, flow meter, handcart, pouch and disposable supplies. |
NOTICE: This shall be invoiced per cylinder provided to the patient. This is NOT a recurring rental PRICE, charges will only incur when an empty cylinder is replaced with a full cylinder.
SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment
12 MONTHS
| B0005 |
| Cylinder, size “E” refill for Item B0004 above; Aluminum (or metal of equivalent weight or less) tanks required E0443 SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 50 |
12 MONTHS
| B0006 |
| Cylinder, size “D” (M15) refill for Item B0004 above. Aluminum (or metal of equivalent weight or less) tanks required E0443 SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 50 |
12 MONTHS
| B0007 |
| Cylinder, size “B” (M6) refill for Item B0004 above; Aluminum (or metal of equivalent weight or less) tanks required E0443 SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 5 |
12 MONTHS
| B0008 |
| Cylinder, size “C” refill for Item B0004 above; Aluminum (or metal of equivalent weight) tanks required E0443 SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 5 |
12 MONTHS
| B0009 |
| Demand Nasal Cannula (e.g. Oximyzer) Reservoir or pendant/equivalent. VA111 |
| 1 |
12 MONTHS
| B0010 |
| ESTIMATED MONTHLY Volume Demand Pulse Conserver Device; no less than a 5:1 ratio or 60 ML/pulse VA111 SPECIAL NOTE: Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 200 |
12 MONTHS
| B0011 |
| Rental liquid oxygen system (90 – 100 lbs) stationary reservoir per patient. E0439; AND Rental portable liquid oxygen system per patient E0434 |
| 1 |
12 MONTHS
| B0012 |
| Liquid oxygen per pound for portable liquid oxygen system under Item B0011 E0444 |
| 1 |
12 MONTHS
| B0013 |
| Volume Delivery for re-supply and/or relocation of equipment due to change in patient’s residence |
| 1 |
12 MONTHS
| B0014 |
| Portable Concentrator- Rental portable oxygen concentrator E1392 |
| 50 |
12 MONTHS
| B0015 |
| Overnight Oximeter- Rental oximeter for overnight oximetry testing E0445 |
| 2 |
12 MONTHS
| B0016 |
| Suction Machine- Rental suction machine E0600 |
| 2 |
12 MONTHS
| B0017 |
| Compressor 50 psi - Rental 50 psi air compressor E0565 |
| 2 |
12 MONTHS
| B0018 |
| Ventilator Negative Pressure ventilator; portable or stationary; Rental negative pressure ventilator E0465 |
| 1 |
12 MONTHS
| B0019 |
| Pressure support ventilator with volume control mode; may include pressure control mode; Rental pressure support ventilator E0465 |
| 20 |
12 MONTHS
| B0020 |
| Oxygen Thermal Fuse (Fire Safe Cannula) - fuse to isolate oxygen supply in case of fire |
| 300 |
12 MONTHS
| B0021 |
| Closed Suction Catheters- Contractor shall provide four (4) closed suction catheters to each ventilator patient each month, so that a clean catheter can be placed into the breathing circuit each week. Catheters shall be replaced as needed during MONTHLY visit by contractor RT. A4605 |
| 20 |
12 MONTHS
| B0022 |
| Heated Humidifier- The contractor shall provide a heated humidifier to Veterans receiving mechanical ventilation only, to provide optimal levels of heat and moisture to the patient’s airway. S8182 |
| 20 |
12 MONTHS
| B0023 |
| Portable Suction Machine- The contractor shall provide a portable suction machine equipped with an internal battery for use during transport to Veterans receiving mechanical ventilation only E0600 |
| 20 |
12 MONTHS
| B0024 |
| Nebulizer with Compressor- The contractor will provide a nebulizer with compressor to ventilator patients only, as ordered by the VA. MONTHLY PRICE shall include spring loaded T-adapter, neb cups, tubing, masks, trach masks E0570 |
| 5 |
12 MONTHS
| B0025 |
| Tracheostomy Care Supplies- The contractor shall provide supplies needed to properly clean and maintain trach and stoma to ventilator patients only. These supplies shall include, tracheostomy drain sponges A6402, basic tracheostomy care kits A4629, 3ml UNIT dose normal saline A4649, cuffed and uncuffed tracheostomy tubes A7521 A7520, tracheostomy inner cannulas A4623 |
| 15 |
12 MONTHS
| B0026 |
| Inline HME- The contractor shall provide an inline heated moisture exchanger (HME) to Veterans receiving non-invasive mechanical ventilation in order to provide optimal levels of heat and moisture to the patient’s airway. A4483 |
| 5 |
12 MONTHS
| B0027 |
| Refillable- type oxygen cylinder- Rental of additional re-fillable cylinders for patients who are assessed to have an extended need for oxygen portability due to high liter flow and /or increased patient activity outside of the home. E0443 |
| 100 |
12 MONTHS
| B0028 |
| Battery for Portable Home Oxygen Concentrator- Temporary rental to be used only during patient travel, when extended time away from a permanent power source is expected |
| 6 |
12 MONTHS
| B0029 |
| PAP Pressure Valve- Contractor shall furnish a Positive Airway Pressure (PAP) Valve to each Veteran on nocturnal oxygen bled into a Positive Airway Pressure (PAP) Device when ordered by the VAMC. E1399 |
| 20 |
12 MONTHS
| B0030 |
| Variable Concentration Trach Mask- The contractor shall provide a variable concentration trach mask to Veterans, as ordered by VA Medical Center Staff. This shall include the mask and all mask components A4620 |
| 1 |
12 MONTHS
| B0031 |
| Cough Stimulating Device – The Contractor Respiratory Therapist shall deliver a Cough Stimulating Device to the Veteran; provide instruction on use of device, with return demonstration by caregiver, along with applicable patient education and equipment maintenance training. This MONTHLY PRICE shall include all components required for operation of the device, both disposable and non-disposable components. E0482 |
| 1 |
12 MONTHS
| B0032 |
| Full Face Mask - The Contractor shall provide a full-face mask to Veterans receiving non-invasive mechanical ventilation. This item is to be provided to ventilator patients only. A7030 |
| 1 |
12 MONTHS
BASE PERIOD TOTAL - CINCINNATI:
| CLIN |
| DESCRIPTION |
| ESTIMATED MONTHLY QUANTITY |
| UNIT PRICE |
| UNITS |
| TOTAL PRICE |
| C0001 (a) |
| CLEVELAND: Rental concentrator with backup system consisting of compressed gas source, regulator, stand, (nasal cannula or mask and humidifier when specified). Concentrator will have flow rate capacity up to 5LPM. E1390. SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment. |
| 500 |
12 MONTHS
| C0001 (b) |
| Rental concentrator with backup system consisting of compressed gas source, regulator, stand (nasal cannula or mask and humidifier when specified). Concentrator must have flow rate capacity up to 10 LPM. E1390. SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment. |
| 200 |
12 MONTHS
| C0001 (c) |
| Rental Concentrator with Portable Gaseous Oxygen System, home compressor used to fill portable oxygen cylinders- (2) self-filling -type oxygen cylinders, oxygen conserving device, regulator, flow meter, humidifier, cannula or mask, tubing, cylinder carrier. Concentrator will have flow rate capacity up to 5 LPM. E1390 |
| 400 |
12 MONTHS
| C0001 (d) |
| Rental Concentrator with Portable Gaseous Oxygen System, home compressor used to fill portable oxygen cylinders- (2) self-filling -type oxygen cylinders, oxygen conserving device, regulator, flow meter, humidifier, cannula or mask, tubing, cylinder carrier. Concentrator will have flow rate capacity up to 10 LPM. E1390 |
| 100 |
12 MONTHS
| C0002 |
| Cylinder, size M or H set-up consisting of regulator, flow meter, safety stand, humidifier and disposable supplies (emergency backup system or as primary) SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment. |
| 45 |
12 MONTHS
| C0003 |
| Cylinder, size M or H refill (Backup/Primary) E0441 SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 18 |
12 MONTHS
| C0004 |
| Portable system ONLY: prescription does not include concentrator: consists of “E”, “D”, “B” (M6), or “C” (M9) size aluminum (or equivalent weight metal) cylinder with regulator, flow meter, handcart, pouch and disposable supplies. |
NOTICE: This shall be invoiced per cylinder provided to the patient. This is NOT a recurring rental PRICE, charges will only incur when an empty cylinder is replaced with a full cylinder.
SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment
12 MONTHS
| C0005 |
| Cylinder, size “E” refill for Item C0004 above; Aluminum (or metal of equivalent weight or less) tanks required E0443 SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 30 |
12 MONTHS
| C0006 |
| Cylinder, size “D” (M15) refill for Item C0004 above. Aluminum (or metal of equivalent weight or less) tanks required E0443 SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 30 |
12 MONTHS
| C0007 |
| Cylinder, size “B” (M6) refill for Item C0004 above; Aluminum (or metal of equivalent weight or less) tanks required E0443 SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 10 |
12 MONTHS
| C0008 |
| Cylinder, size “C” refill for Item C0004 above; Aluminum (or metal of equivalent weight) tanks required E0443 SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 10 |
12 MONTHS
| C0009 |
| Demand Nasal Cannula (e.g. Oximyzer) Reservoir or pendant/equivalent. VA111 |
| 1 |
12 MONTHS
| C0010 |
| ESTIMATED MONTHLY Volume Demand Pulse Conserver Device; no less than a 5:1 ratio or 60 ML/pulse VA111 SPECIAL NOTE: Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 30 |
12 MONTHS
| C0011 |
| Rental liquid oxygen system (90 – 100 lbs) stationary reservoir per patient. E0439; AND Rental portable liquid oxygen system per patient E0434 |
| 1 |
12 MONTHS
| C0012 |
| Liquid oxygen per pound for portable liquid oxygen system under Item C0011 E0444 |
| 1 |
12 MONTHS
| C0013 |
| Volume Delivery for re-supply and/or relocation of equipment due to change in patient’s residence |
| 1 |
12 MONTHS
| C0014 |
| Portable Concentrator- Rental portable oxygen concentrator E1392 |
| 50 |
12 MONTHS
| C0015 |
| Overnight Oximeter- Rental oximeter for overnight oximetry testing E0445 |
| 1 |
12 MONTHS
| C0016 |
| Suction Machine- Rental suction machine E0600 |
| 8 |
12 MONTHS
| C0017 |
| Compressor 50 psi - Rental 50 psi air compressor E0565 |
| 3 |
12 MONTHS
| C0018 |
| Ventilator Negative Pressure ventilator; portable or stationary; Rental negative pressure ventilator E0465 |
| 29 |
12 MONTHS
| C0019 |
| Pressure support ventilator with volume control mode; may include pressure control mode; Rental pressure support ventilator E0465 |
| 1 |
12 MONTHS
| C0020 |
| Oxygen Thermal Fuse (Fire Safe Cannula) - fuse to isolate oxygen supply in case of fire |
| 615 |
12 MONTHS
| C0021 |
| Closed Suction Catheters- Contractor shall provide four (4) closed suction catheters to each ventilator patient each month, so that a clean catheter can be placed into the breathing circuit each week. Catheters shall be replaced as needed during MONTHLY visit by contractor RT. A4605 |
| 4 |
12 MONTHS
| C0022 |
| Heated Humidifier- The contractor shall provide a heated humidifier to Veterans receiving mechanical ventilation only, to provide optimal levels of heat and moisture to the patient’s airway. S8182 |
| 11 |
12 MONTHS
| C0023 |
| Portable Suction Machine- The contractor shall provide a portable suction machine equipped with an internal battery for use during transport to Veterans receiving mechanical ventilation only E0600 |
| 8 |
12 MONTHS
| C0024 |
| Nebulizer with Compressor- The contractor will provide a nebulizer with compressor to ventilator patients only, as ordered by the VA. MONTHLY PRICE shall include spring loaded T-adapter, neb cups, tubing, masks, trach masks E0570 |
| 3 |
12 MONTHS
| C0025 |
| Tracheostomy Care Supplies- The contractor shall provide supplies needed to properly clean and maintain trach and stoma to ventilator patients only. These supplies shall include, tracheostomy drain sponges A6402, basic tracheostomy care kits A4629, 3ml UNIT dose normal saline A4649, cuffed and uncuffed tracheostomy tubes A7521 A7520, tracheostomy inner cannulas A4623 |
| 5 |
12 MONTHS
| C0026 |
| Inline HME- The contractor shall provide an inline heated moisture exchanger (HME) to Veterans receiving non-invasive mechanical ventilation in order to provide optimal levels of heat and moisture to the patient’s airway. A4483 |
| 29 |
12 MONTHS
| C0027 |
| Refillable- type oxygen cylinder- Rental of additional re-fillable cylinders for patients who are assessed to have an extended need for oxygen portability due to high liter flow and /or increased patient activity outside of the home. E0443 |
| 50 |
12 MONTHS
| C0028 |
| Battery for Portable Home Oxygen Concentrator- Temporary rental to be used only during patient travel, when extended time away from a permanent power source is expected |
| 11 |
12 MONTHS
| C0029 |
| PAP Pressure Valve- Contractor shall furnish a Positive Airway Pressure (PAP) Valve to each Veteran on nocturnal oxygen bled into a Positive Airway Pressure (PAP) Device when ordered by the VAMC. E1399 |
| 2 |
12 MONTHS
| C0030 |
| Variable Concentration Trach Mask- The contractor shall provide a variable concentration trach mask to Veterans, as ordered by VA Medical Center Staff. This shall include the mask and all mask components A4620 |
| 5 |
12 MONTHS
| C0031 |
| Cough Stimulating Device – The Contractor Respiratory Therapist shall deliver a Cough Stimulating Device to the Veteran; provide instruction on use of device, with return demonstration by caregiver, along with applicable patient education and equipment maintenance training. This MONTHLY PRICE shall include all components required for operation of the device, both disposable and non-disposable components. E0482 |
| 20 |
12 MONTHS
| C0032 |
| Full Face Mask - The Contractor shall provide a full-face mask to Veterans receiving non-invasive mechanical ventilation. This item is to be provided to ventilator patients only. A7030 |
| 1 |
12 MONTHS
BASE PERIOD TOTAL - CLEVELAND:
| CLIN |
| DESCRIPTION |
| ESTIMATED MONTHLY QUANTITY |
| UNIT PRICE |
| UNITS |
| TOTAL PRICE |
| D0001 (a) |
| DAYTON: Rental concentrator with backup system consisting of compressed gas source, regulator, stand, (nasal cannula or mask and humidifier when specified). Concentrator will have flow rate capacity up to 5LPM. E1390. SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment. |
| 691 |
12 MOTNHS
| D0001 (b) |
| Rental concentrator with backup system consisting of compressed gas source, regulator, stand (nasal cannula or mask and humidifier when specified). Concentrator must have flow rate capacity up to 10 LPM. E1390. SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment. |
| 36 |
12 MONTHS
| D0001 (c) |
| Rental Concentrator with Portable Gaseous Oxygen System, home compressor used to fill portable oxygen cylinders- (2) self-filling -type oxygen cylinders, oxygen conserving device, regulator, flow meter, humidifier, cannula or mask, tubing, cylinder carrier. Concentrator will have flow rate capacity up to 5 LPM. E1390 |
| 403 |
12 MONTHS
| D0001 (d) |
| Rental Concentrator with Portable Gaseous Oxygen System, home compressor used to fill portable oxygen cylinders- (2) self-filling -type oxygen cylinders, oxygen conserving device, regulator, flow meter, humidifier, cannula or mask, tubing, cylinder carrier. Concentrator will have flow rate capacity up to 10 LPM. E1390 |
| 22 |
12 MONTHS
| D0002 |
| Cylinder, size M or H set-up consisting of regulator, flow meter, safety stand, humidifier and disposable supplies (emergency backup system or as primary) SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment. |
| 71 |
12 MONTHS
| D0003 |
| Cylinder, size M or H refill (Backup/Primary) E0441 SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 71 |
12 MONTHS
| D0004 |
| Portable system ONLY: prescription does not include concentrator: consists of “E”, “D”, “B” (M6), or “C” (M9) size aluminum (or equivalent weight metal) cylinder with regulator, flow meter, handcart, pouch and disposable supplies. |
NOTICE: This shall be invoiced per cylinder provided to the patient. This is NOT a recurring rental PRICE, charges will only incur when an empty cylinder is replaced with a full cylinder.
SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment
12 MONTHS
| D0005 |
| Cylinder, size “E” refill for Item D0004 above; Aluminum (or metal of equivalent weight or less) tanks required E0443 SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 63 |
12 MONTHS
| D0006 |
| Cylinder, size “D” (M15) refill for Item D0004 above. Aluminum (or metal of equivalent weight or less) tanks required E0443 SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 36 |
12 MONTHS
| D0007 |
| Cylinder, size “B” (M6) refill for Item D0004 above; Aluminum (or metal of equivalent weight or less) tanks required E0443 SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 71 |
12 MONTHS
| D0008 |
| Cylinder, size “C” refill for Item D0004 above; Aluminum (or metal of equivalent weight) tanks required E0443 SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 58 |
12 MONTHS
| D0009 |
| Demand Nasal Cannula (e.g. Oximyzer) Reservoir or pendant/equivalent. VA111 |
| 6 |
12 MONTHS
| D0010 |
| ESTIMATED MONTHLY Volume Demand Pulse Conserver Device; no less than a 5:1 ratio or 60 ML/pulse VA111 SPECIAL NOTE: Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment |
| 430 |
12 MONTHS
| D0011 |
| Rental liquid oxygen system (90 – 100 lbs) stationary reservoir per patient. E0439; AND Rental portable liquid oxygen system per patient E0434 |
| 6 |
12 MONTHS
| D0012 |
| Liquid oxygen per pound for portable liquid oxygen system under Item D0011 E0444 |
| 6 |
12 MONTHS
| D0013 |
| Volume Delivery for re-supply and/or relocation of equipment due to change in patient’s residence |
| 5 |
12 MONTHS
| D0014 |
| Portable Concentrator- Rental portable oxygen concentrator E1392 |
| 88 |
12 MONTHS
| D0015 |
| Overnight Oximeter- Rental oximeter for overnight oximetry testing E0445 |
| 1 |
12 MONTHS
| D0016 |
| Suction Machine- Rental suction machine E0600 |
| 1 |
12 MONTHS
| D0017 |
| Compressor 50 psi - Rental 50 psi air compressor E0565 |
| 5 |
12 MONTHS
| D0018 |
| Ventilator Negative Pressure ventilator; portable or stationary; Rental negative pressure ventilator E0465 |
| 1 |
12 MONTHS
| D0019 |
| Pressure support ventilator with volume control mode; may include pressure control mode; Rental pressure support ventilator E0465 |
| 1 |
12 MONTHS
| D0020 |
| Oxygen Thermal Fuse (Fire Safe Cannula) - fuse to isolate oxygen supply in case of fire |
| 409 |
12 MONTHS
| D0021 |
| Closed Suction Catheters- Contractor shall provide four (4) closed suction catheters to each ventilator patient each month, so that a clean catheter can be placed into the breathing circuit each week. Catheters shall be replaced as needed during MONTHLY visit by contractor RT. A4605 |
| 1 |
12 MONTHS
| D0022 |
| Heated Humidifier- The contractor shall provide a heated humidifier to Veterans receiving mechanical ventilation only, to provide optimal levels of heat and moisture to the patient’s airway. S8182 |
| 1 |
12 MONTHS
| D0023 |
| Portable Suction Machine- The contractor shall provide a portable suction machine equipped with an internal battery for use during transport to Veterans receiving mechanical ventilation only E0600 |
| 1 |
12 MONTHS
| D0024 |
| Nebulizer with Compressor- The contractor will provide a nebulizer with compressor to ventilator patients only, as ordered by the VA. MONTHLY PRICE shall include spring loaded T-adapter, neb cups, tubing, masks, trach masks E0570 |
| 1 |
12 MONTHS
| D0025 |
| Tracheostomy Care Supplies- The contractor shall provide supplies needed to properly clean and maintain trach and stoma to ventilator patients only. These supplies shall include, tracheostomy drain sponges A6402, basic tracheostomy care kits A4629, 3ml UNIT dose normal saline A4649, cuffed and uncuffed tracheostomy tubes A7521 A7520, tracheostomy inner cannulas A4623 |
| 1 |
12 MONTHS
| D0026 |
| Inline HME- The contractor shall provide an inline heated moisture exchanger (HME) to Veterans receiving non-invasive mechanical ventilation in order to provide optimal levels of heat and moisture to the patient’s airway. A4483 |
| 1 |
12 MONTHS
| D0027 |
| Refillable- type oxygen cylinder- Rental of additional re-fillable cylinders for patients who are assessed to have an extended need for oxygen portability due to high liter flow and /or increased patient activity outside of the home. E0443 |
| 10 |
12 MONTHS
| D0028 |
| Battery for Portable Home Oxygen Concentrator- Temporary rental to be used only during patient travel, when extended time away from a permanent power source is expected |
| 23 |
12 MONTHS
| D0029 |
| PAP Pressure Valve- Contractor shall furnish a Positive Airway Pressure (PAP) Valve to each Veteran on nocturnal oxygen bled into a Positive Airway Pressure (PAP) Device when ordered by the VAMC. E1399 |
| 1 |
12 MONTHS
| D0030 |
| Variable Concentration Trach Mask- The contractor shall provide a variable concentration trach mask to Veterans, as ordered by VA Medical Center Staff. This shall include the mask and all mask components A4620 |
| 1 |
12 MONTHS
| D0031 |
| Cough Stimulating Device – The Contractor Respiratory Therapist shall deliver a Cough Stimulating Device to the Veteran; provide instruction on use of device, with return demonstration by caregiver, along with applicable patient education and equipment maintenance training. This MONTHLY PRICE shall include all components required for operation of the device, both disposable and non-disposable components. E0482 |
| 1 |
12 MONTHS
| D0032 |
| Full Face Mask - The Contractor shall provide a full-face mask to Veterans receiving non-invasive mechanical ventilation. This item is to be provided to ventilator patients only. A7030 |
| 1 |
12 MONTHS
BASE PERIOD TOTAL - DAYTON:
| CLIN |
| DESCRIPTION |
| ESTIMATED MONTHLY QUANTITY |
| UNIT PRICE |
| UNITS |
| TOTAL PRICE |
| E0001 (a) |
| COLUMBUS: Rental concentrator with backup system consisting of compressed gas source, regulator, stand, (nasal cannula or mask and humidifier when specified). Concentrator will have flow rate capacity up to 5LPM. E1390. SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment. |
| 172 |
12 MOTNHS
| E0001 (b) |
| Rental concentrator with backup system consisting of compressed gas source, regulator, stand (nasal cannula or mask and humidifier when specified). Concentrator must have flow rate capacity up to 10 LPM. E1390. SPECIAL NOTE: Regulators, Flowmeters, Adapter Pieces, Swivels and Conserving devices shall be included in the MONTHLY rental PRICE for all applicable equipment. |
| 5 |
12 MONTHS
| E0001 (c) |
| Rental Concentrator with Portable Gaseous Oxygen System, home compressor used to fill portable oxygen cylinders- (2) self-filling -type oxygen cylinders, oxygen conserving device, regulator, flow meter, humidifier, cannula or mask, tubing, cylinder carrier. Concentrator will have flow rate capacity up to 5 LPM. E1390 |
| 659 |
12 MONTHS
| E0001 (d) |
| Rental Concentrator with Portable Gaseous Oxygen System, home compressor used to fill portable oxygen cylinders- (2) self-filling -type oxygen cylinders, oxygen conserving device, regulator, flow meter, humidifier, cannula or mask, tubing, cylinder carrier. Concentrator will have flow rate capacity up to 10 LPM. E1390 |
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