36C26121Q0745 PALO ALTO UNIT PRICES.xlsx

XLSX spreadsheet 24 KB Posted Jun 28, 2021

Attached to: SOLE SOURCE-VA PALO ALTO HOME OXYGEN BRIDGE
Solicitation number: 36C26121Q0745
Issued by: Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 21

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36C261-21-Q-0745 HOME OXYGEN PALO ALTO STATEMENT OF WORK..pdf	PDF	Jun 28, 2021

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Palo Alto

ITEM#	ITEM NAME	HCPCS	ITEM DESCRIPTION	ESTIMATED	UNIT	TOTAL
		CODE		QUANTITIES	(Where just number,	ESTIMATED COST
					unit is "Month.")
1	Rental of Contractor	E1392	Concentrator, Colored Tubing, Adapter	1	1
	Owned Portable		Humidifier (when required), Cannulas or
	System		Masks and other required supplies and
			equipment, including back up systems.
	Priced Per Month		Perform Equipment Maintenance in
			accordance with manufacturer standards.
			At a minimum of once every 90 calendar
			days, visit and assess patient to assure
			equipment complinace, change filters and
			provide disposable supplies.

1a	Rental of Contractor	E1390	To include all supplies, equipment	535	1
	Owned Low Decibel		maintenance and 90 calendar day visit as
	Concentrator System		described in Item 1

Priced Per Month

1b	Rental of Contractor	E1390	To include all supplies, equipment	1	1
	Owned Home Fill		maintenance and 90 calendar day visit as
	Oxygen System		described in Item 1

Priced Per Month

1c	Rental of Contractor	E1390	To include all supplies, equipment	1	1
	Owned Hi Flow		maintenance and 90 calendar day visit as
	Concentrator System		described in Item 1

Priced Per Month

ITEM#	ITEM NAME	HCPCS	ITEM DESCRIPTION	ESTIMATED	UNIT	TOTAL
		CODE		QUANTITIES	(Where just number,	ESTIMATED COST
					unit is "Month.")
2	Rental of Contractor	E0431	Portable System, Regulator,	570	1
	Owned Portable O2		Flowmeter, Humidifier, Cannulas,
	Gaseous System for		or Masks, Tubing,
	use with or without		Conserving Device and O2 Tank
	Stationary System		Cylinder Stands capable of holding
	Priced Per Month		12 cylinders, sizes E, D, C & M-6

3	Rental of Contractor	E0439	Resevoir, Regulator, Flowmeter,	2	1
	Owned Stationary		Humidifier, Cannulas or Masks, and
	Liquid O2 System		Colored Tubing (priced per month)

4	Rental of Contractor	E0434	Portable Container, Refill Adapter	7	1
	Owned Portable		Flowmeter, Cannulas or Masks, and
	Liquid O2 System		Colored Tubing. Resevoir will be provided
			if another Stationary System (e.g.
	Priced Per Month		Concentrator) is rented.

5	Continuous Positive	E0601	Delivery, Set-up & Training of	4	Each
	Airway Device		Government Owned CPAP in
	(CPAP) Set-up		Patient's Home to include mask and
			all required supplies (priced per each)

6	CPAP Maintenance	E0601	Maintenance of Government Owned	1	Each
	As Requested		CPAP, to include maintenance in
			accordance with Manufacturer
	Priced Per Each		recommendation, replacement of
			Mask, Headgear, Chinstraps, Tubing
			& Filters Disposible/Non-Disposible
			in Patients Home

6a	Pressure Support	E0463	Pressure Support Ventilator with Volume	1	Each
	Ventilator		Control Mode, may include pressure control
			mod, used with invasive interface (e.g.,
			tracheostomy tube)

6b	Pressure Support	E0464	Pressure Support Ventilator with Volume	1	Each
	Ventilator		Control Mode, may include pressure control

14a	Rental of Contractor	E0465	Home Ventilator, Invasive Interface	1	1
	Owned Volume		Delivery, Set-up, Training, and
	Invasive Ventilator		Maintenance of Contractor Owned
			Stationary or Portable Ventilator, to
	Priced Per Month		include back up Ventilator and all supplies

14b	Rental of Contractor	E0466	Home Ventilator, Non-Invasive Interface	1	1
	Owned Volume		Delivery, Set-up, Training, and
	Non-Invasive Ventilator		Maintenance of Contractor Owned
			Stationary or Portable Ventilator, to
	Priced Per Month		include back up Ventilator and all supplies
			mod, used w/non-invasive interface (e.g., mask)

ITEM#	ITEM NAME	HCPCS	ITEM DESCRIPTION	ESTIMATED	UNIT	TOTAL
		CODE		QUANTITIES	(Where just number,	ESTIMATED COST
					unit is "Month.")
7	Continuous Positive	E0601	Delivery, Set-up & Training of	1	Each
	Airway Device		Government Owned CPAP at the
	(CPAP) Set-up		Contractors Facility to include mask
			and all supplies
	Priced Per Each

8	Bilevel Positive Airway	E0470	Delivery, Set-up & Training of	1	Each
	Pressure Device		Government Owned BiLevel in
	Set-up		Patient's Home to include mask
			and all supplies
	Priced Per Each

9	BiLevel Maintenance	E0470	Maintenance of Government Owned	1	Each
	As Requested		BiLevel, to include maintenance in
			accordance with Manufacturer
			recommendation, replacement of
	Priced Per Each		Mask, Headgear, Chinstraps, Tubing
			& Filters Disposible/Non-Disposible
			in Patients Home

10	BiLevel Set-up	E0470	Delivery, Set-up & Training of	1	Each
			Government Owned BiLevel at the
			Contractors Facility to include mask
	Priced Per Each		and all supplies

11	Nebulizers	E0570	Delivery, Set-up and Training of	1	Each
			Government Owned Nebulizer,
			Compressor or Battery Powered as
	Priced Per Each		ordered

ITEM#	ITEM NAME	HCPCS	ITEM DESCRIPTION	ESTIMATED	UNIT	TOTAL
		CODE		QUANTITIES	(Where just number,	ESTIMATED COST
					unit is "Month.")
12	Suction Pump	E0600	Purchase, Delivery, Set-up and	1	Each
			Training of Contractor Home Model
			Respiratory Suction Pump, portable
	Priced Per Each		or stationary electric to include all
			supplies

13	Suction Pump Rental	E0600	Delivery, Set-up, and Training of	5	Each
			Contractor Owned Suction Pump to
			Include all supplies
	Priced Per Each

14	Rental of Contractor	E0450	Delivery, Set-up, Training, and	1	1
	Owned Volume		Maintenance of Contractor Owned
	Ventilator		Stationary or Portable Ventilator, to
			include back up Ventilator and all supplies
	Priced Per Month

15	Government Owned	E0450	Delivery, Set-up, and Training of a	1	Each
	Ventilator Set-up		Government Owned Ventilator
			to include all necessary supplies
	Priced Per Each

16	Ventilator	E0450	Maintenance of Government Owned	2	1
	Maintenance		Ventilator Systems, to include all
			supplies
	Priced Per Month

ITEM#	ITEM NAME	HCPCS	ITEM DESCRIPTION	ESTIMATED	UNIT	TOTAL
		CODE		QUANTITIES	(Where just number,	ESTIMATED COST
					unit is "Month.")
17	Air Compressor	E0565	Rental of Contractor Owned and	1	1
			Maintained continuous or intermittent
			air compressor for use with
			equipment not self contained or
	Priced Per Month		cylinder driven, to include all
			associated supplies

18	Full Face Masks	A7030	CPAP/Bilevel Full Face Masks	1	Each
			Including Headgear

Priced Per Each

19	Nasal Interface Mask	A7034	CPAP/Bilevel Masks, Nasal	1	Each
	or Cannula Type		Interface, Nasal Pillows & Nasal
			Cushions (Mask or Cannula Type)
	Priced Per Each		Including Headgear

20	Delivery Charge	A9901	Deliveries not made under all other	2	Each
			line items

Priced Per Each

21	Respiratory Therapist	VA120	Government requested Respiratory	1	Each
	Visit		Therapist visit not covered by other
			Line Items
	Priced Per Each

Palo Alto specific pricing instructions

Line Items 1-1c Require Quarterly Maintenance Visits

				REFILLS - ALL QUANTITIES ARE MONTHLY	ESTIMATED
ITEM#	ITEM NAME	HCPCS	ITEM DESCRIPTION		MONTHLY	UNIT	TOTAL ESTIMATED
		CODE			QUANTITIES		MONTHLY COST
R1	E Cylinder	E0443	E Cylinder Refill		1110	Cylinder

R2 D Cylinder E0443 D Cylinder Refill 60 Cylinder

R3 C Cylinder E0443 C Cylinder Refill 1 Cylinder

R4 M-6 Cylinder E0443 M-6 Cylinder Refill 2085 Cylinder

R5 H Tank E0443 H Tank Refill 8 Cylinder

R6	Liquide Oxygen	E0444	Liquide Oxygen	833	LBS
			Refill

PRICING TOTAL PAGE

LINE ITEMS 1 THROUGH 21

TOTAL ESTIMATED PRICE

LINE ITEMS R1 - R6

TOTAL ESTIMATED PRICE

Grand Total

&"Arial,Bold Italic"Palo Alto Pricing Sheet

&"Arial,Bold Italic"Palo Alto Page &P O2 Line Items Amendment #1

File details come from the government source that posted it. Updated Jun 28, 2021.