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Phoenix
| PHOENIX VA HEALTH CARE SYSTEM | | | |
| BASE YEAR: XX/XX/XXXX through XX/XX/XXXX | | | |
| ITEM NUMBER | DESCRIPTION OF SUPPLIES/SERVICES | ESTIMATED QUANTITY MONTHLY | UNIT |
| 0001 | Delivery, initial set-up, and education of stationary oxygen concentrator system. Back-up system shall be provided consisting of compressed gas source, regulator, stand, nasal cannula or mask, humidifier, tubing, trachea collar and fire safe valves when specified. Back-up system minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure. Concentrator to be provided by VA with liter flow 0 to 5 and 0 to 10 liters per minute. Health Care Procedural Coding System (HCPCS): A9901. Initial Setups: Initial set-ups are considered to be for those beneficiaries who do not have a VA authorized oxygen therapy delivery system. | 124 | JOB |
| 0002 | Delivery, initial set-up, and education of Government owned portable oxygen concentrator system. Portable system for new set ups includes battery, handcart and/or puch/backpack. Includes delivery, setup, and education. This is a one-time charge for new set-ups. HCPCS: A9901. | 54 | JOB |
| 0003 | Preventive Maintenance (PM) for Government-Owned concentrators. (Includes all labor, tools, equipment, travel and materials necessary to perform PM in accordance with manufactures instructions. HCPCS: VA160 | 125 | JOB |
| 0004 | Monthly Rental of stationary oxygen concentrator system. Back-up system shall be provided for stationary oxygen concentrators consisting of compressed gas source regulator, stand, nasal cannula or mask, tubing, humidifier, trachea collar and fire safe valves when specified. Back-up system minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0-5 liters per minute. HCPCS: E1390 | | |
If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly rate.
| 20 | EACH |
| 0005 | Monthly Rental of stationary oxygen concentrator system. Back-up system shall be provided for stationary oxygen concentrators consisting of compressed gas source regulator, stand, nasal cannula or mask, tubing, humidifier, trachea collar and fire safe valves when specified. Back-up system minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0-10 liters per minute. HCPCS: E1390 |
If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly rate.
| 20 | EACH | | |
| 0006 | Monthly Rental of portable oxygen concentrator system. Portable system includes flow meter, 2 rechargable batteries, handcart, pouch/backpack and disposable supplies. HCPCS: E1392 | 10 | EACH |
| 0007 | Delivery, set-up, and education of self fill oxygen system to include 4 self-fill compatible oxygen tanks as specified on prescription (M6, C, D, or E), carrying bag, cart, conserving device, fill station and self-fill compatible concentrator (as needed) HCPCS: VA160 | 15 | JOB |
| 0008 | Rental of self fill oxygen system to include 4 self-fill compatible oxygen tanks as specified on prescription(B (M6), C, D, or E), carrying bag, cart, conserving device, fill station and self-fill compatible concentrator. Line item shall include all consumable supplies, e.g. tubing, cannulas, connectors. HCPCS: K0738 | 15 | EACH |
| 0009 | Stationary Cylinder set-up, size H or M60. Set-up consisting of regulator, flow meter, safety stand, humidifier and disposable supplies. This is a one time charge for set-up. (This can be used as a back up system or as a primary system). Includes delivery, setup, and education. | 41 | JOB |
| 0010 | Cylinder, size H refill (Backup/Primary) E0441 | 41 | EACH |
| 0011 | Cylinder, size M60 refill (Backup/Primary) E0441 | 12 | EACH |
| 0012 | Cylinder, size “E” refill. Aluminum tanks required. E0443 | 2400 | EACH |
| 0013 | Cylinder, size “C” refill. Aluminum tanks required. E0443 | 12 | EACH |
| 0014 | Cylinder, size “D” refill. Aluminum tanks required. E0443 | 150 | EACH |
| 0015 | Cylinder, size “B” (M6) refill. Aluminum tanks required. E0443 | 550 | EACH |
| 0016 | Portable Oxygen Concentrator Rental for Traveling Patients. Only models that have continuous flow option or those devices that meet the patients liter per minute as indicated on prescription. E1392 | 240 | EACH |
| 0017 | Monthly rental liquid oxygen system with stationary reservoir, (each reservoir) any size suitable for residential use. HCPCS:E0439 | 70 | EACH |
| 0018 | Monthly rental portable liquid oxygen system. HCPCS: E0434 | | |
| 60 | EACH | | |
| 0019 | Liquid oxygen per pound for item #0016. HCPCS: E0444 | 18,300 | LBS |
| 0020 | Home visit by Patient Services Technician for home oxygen patients. Home visit includes assessment of equipment compliance, educational needs and replacement of equipment as needed. HCPCS: VA160 | 350 | JOB |
| 0021 | Delivery, initial set-up, and education/training of ventilator for continuous and/or intermittent ventilation patients with backup ventilator and specified supplies. An LRT must perform initial set-up. Two (2) ventilators per patient are required at all times: 1 primary and 1 backup. Initial Setups: Initial set-ups are considered to be for those beneficiaries who do not have a VA authorized oxygen therapy delivery system. | 9 | JOB |
| 0022 | Monthly Rental of ventilators for continuous or intermittent ventilation patients with backup ventilator. Includes delivery, setup, supplies and education/training. | | |
If a request is received to deliver a Government-owned ventilator and there is no Government inventory available, a vendor-owned ventilator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned ventilator switched out and there is no Government-owned inventory available, a vendor-owned ventilator will be supplied and billed at the vendor-owned monthly rate.
| 3 | JOB | | |
| 0023 | Monthly Licensed Respiratory Therapist (LRT) visit to inspect equipment and environment, re-educate and/or re-train caregiver, provide supplies as necessary and perform routine preventive maintenance to include support of 2 ventilators per patient: 1 primary and 1 backup. | 12 | JOB |
| 0024 | Delivery of ventilator to local VA Medical Center for hospital discharge purposes only. | 1 | JOB |
| 0025 | Service Call: Trouble shoot or delivery of replacement ventilator to the patient's home. | 1 | HOUR |
| 0026 | Cost to package and ship Government-Owned ventilator to manufacturer for annual preventative maintenance or repairs (outside of warranty) | 1 | |
| 0027 | Delivery for re-supply and/or relocation of equipment due to change in beneficiary’s residence within Region. HCPCS: A9901 | 1 | JOB |
| 0028 | Fee for deliveries/pickups made for over 100 miles from the closest Contractor facility or VAMC/CBOC to the delivery location, whichever is closer. HCPCS: A9901 | 15 | JOB |
| 1st OPTION YEAR: XX/XX/XXXX through XX/XX/XXXX | | | |
| ITEM NUMBER | DESCRIPTION OF SUPPLIES/SERVICES | ESTIMATED QUANTITY MONTHLY | UNIT |
| 1001 | Delivery, initial set-up, and education of stationary oxygen concentrator system. Back-up system shall be provided consisting of compressed gas source, regulator, stand, nasal cannula or mask, humidifier, tubing, trachea collar and fire safe valves when specified. Back-up system minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure. Concentrator to be provided by VA with liter flow 0 to 5 and 0 to 10 liters per minute. Health Care Procedural Coding System (HCPCS): A9901. Initial Setups: Initial set-ups are considered to be for those beneficiaries who do not have a VA authorized oxygen therapy delivery system. | 80 | JOB |
| 1002 | Delivery, initial set-up, and education of Government owned portable oxygen concentrator system. Portable system for new set ups includes battery, handcart and/or puch/backpack. Includes delivery, setup, and education. This is a one-time charge for new set-ups. HCPCS: A9901. | 20 | JOB |
| 1003 | Preventive Maintenance (PM) for Government-Owned concentrators. (Includes all labor, tools, equipment, travel and materials necessary to perform PM in accordance with manufactures instructions. HCPCS: VA160 | 125 | JOB |
| 1004 | Monthly Rental of stationary oxygen concentrator system. Back-up system shall be provided for stationary oxygen concentrators consisting of compressed gas source regulator, stand, nasal cannula or mask, tubing, humidifier, trachea collar and fire safe valves when specified. Back-up system minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0-5 liters per minute. HCPCS: E1390 | | |
If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly rate.
| 20 | EACH |
| 1005 | Monthly Rental of stationary oxygen concentrator system. Back-up system shall be provided for stationary oxygen concentrators consisting of compressed gas source regulator, stand, nasal cannula or mask, tubing, humidifier, trachea collar and fire safe valves when specified. Back-up system minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0-10 liters per minute. HCPCS: E1390 |
If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly rate.
| 20 | EACH | | |
| 1006 | Monthly Rental of portable oxygen concentrator system. Portable system includes flow meter, 2 rechargable batteries, handcart, pouch/backpack and disposable supplies. HCPCS: E1392 | 10 | EACH |
| 1007 | Delivery, set-up, and education of self fill oxygen system to include 4 self-fill compatible oxygen tanks as specified on prescription (M6, C, D, or E), carrying bag, cart, conserving device, fill station and self-fill compatible concentrator (as needed) HCPCS: VA160 | 15 | JOB |
| 1008 | Rental of self fill oxygen system to include 4 self-fill compatible oxygen tanks as specified on prescription(B (M6), C, D, or E), carrying bag, cart, conserving device, fill station and self-fill compatible concentrator. Line item shall include all consumable supplies, e.g. tubing, cannulas, connectors. HCPCS: K0738 | 15 | EACH |
| 1009 | Stationary Cylinder set-up, size H or M60. Set-up consisting of regulator, flow meter, safety stand, humidifier and disposable supplies. This is a one time charge for set-up. (This can be used as a back up system or as a primary system). Includes delivery, setup, and education. | 41 | JOB |
| 1010 | Cylinder, size H refill (Backup/Primary) E0441 | 41 | EACH |
| 1011 | Cylinder, size M60 refill (Backup/Primary) E0441 | 15 | EACH |
| 1012 | Cylinder, size “E” refill. Aluminum tanks required. E0443 | 2400 | EACH |
| 1013 | Cylinder, size “C” refill. Aluminum tanks required. E0443 | 12 | EACH |
| 1014 | Cylinder, size “D” refill. Aluminum tanks required. E0443 | 150 | EACH |
| 1015 | Cylinder, size “B” (M6) refill. Aluminum tanks required. E0443 | 550 | EACH |
| 1016 | Portable Oxygen Concentrator Rental for Traveling Patients. Only models that have continuous flow option or those devices that meet the patients liter per minute as indicated on prescription. E1392 | 240 | EACH |
| 1017 | Monthly rental liquid oxygen system with stationary reservoir, (each reservoir) any size suitable for residential use. HCPCS:E0439 | 70 | EACH |
| 1018 | Monthly rental portable liquid oxygen system. HCPCS: E0434 | | |
| 60 | EACH | | |
| 1019 | Liquid oxygen per pound for item #0016. HCPCS: E0444 | 18,300 | LBS |
| 1020 | Home visit by Patient Services Technician for home oxygen patients. Home visit includes assessment of equipment compliance, educational needs and replacement of equipment as needed. HCPCS: VA160 | 350 | JOB |
| 1021 | Delivery, initial set-up, and education/training of ventilator for continuous and/or intermittent ventilation patients with backup ventilator and specified supplies. An LRT must perform initial set-up. Two (2) ventilators per patient are required at all times: 1 primary and 1 backup. Initial Setups: Initial set-ups are considered to be for those beneficiaries who do not have a VA authorized oxygen therapy delivery system. | 9 | JOB |
| 1022 | Monthly Rental of ventilators for continuous or intermittent ventilation patients with backup ventilator. Includes delivery, setup, supplies and education/training. | | |
If a request is received to deliver a Government-owned ventilator and there is no Government inventory available, a vendor-owned ventilator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned ventilator switched out and there is no Government-owned inventory available, a vendor-owned ventilator will be supplied and billed at the vendor-owned monthly rate.
| 3 | JOB | | |
| 1023 | Monthly Licensed Respiratory Therapist (LRT) visit to inspect equipment and environment, re-educate and/or re-train caregiver, provide supplies as necessary and perform routine preventive maintenance to include support of 2 ventilators per patient: 1 primary and 1 backup. | 12 | JOB |
| 1024 | Delivery of ventilator to local VA Medical Center for hospital discharge purposes only. | 1 | JOB |
| 1025 | Service Call: Trouble shoot or delivery of replacement ventilator to the patient's home. | 1 | HOUR |
| 1026 | Cost to package and ship Government-Owned ventilator to manufacturer for annual preventative maintenance or repairs (outside of warranty) | 1 | |
| 1027 | Delivery for re-supply and/or relocation of equipment due to change in beneficiary’s residence within Region. HCPCS: A9901 | 1 | JOB |
| 1028 | Fee for deliveries/pickups made for over 100 miles from the closest Contractor facility or VAMC/CBOC to the delivery location, whichever is closer. HCPCS: A9901 | 15 | JOB |
| 2nd OPTION YEAR: XX/XX/XXXX through XX/XX/XXXX | | | |
| ITEM NUMBER | DESCRIPTION OF SUPPLIES/SERVICES | ESTIMATED QUANTITY MONTHLY | UNIT |
| 2001 | Delivery, initial set-up, and education of stationary oxygen concentrator system. Back-up system shall be provided consisting of compressed gas source, regulator, stand, nasal cannula or mask, humidifier, tubing, trachea collar and fire safe valves when specified. Back-up system minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure. Concentrator to be provided by VA with liter flow 0 to 5 and 0 to 10 liters per minute. Health Care Procedural Coding System (HCPCS): A9901. Initial Setups: Initial set-ups are considered to be for those beneficiaries who do not have a VA authorized oxygen therapy delivery system. | 80 | JOB |
| 2002 | Delivery, initial set-up, and education of Government owned portable oxygen concentrator system. Portable system for new set ups includes battery, handcart and/or puch/backpack. Includes delivery, setup, and education. This is a one-time charge for new set-ups. HCPCS: A9901. | 20 | JOB |
| 2003 | Preventive Maintenance (PM) for Government-Owned concentrators. (Includes all labor, tools, equipment, travel and materials necessary to perform PM in accordance with manufactures instructions. HCPCS: VA160 | 125 | JOB |
| 2004 | Monthly Rental of stationary oxygen concentrator system. Back-up system shall be provided for stationary oxygen concentrators consisting of compressed gas source regulator, stand, nasal cannula or mask, tubing, humidifier, trachea collar and fire safe valves when specified. Back-up system minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0-5 liters per minute. HCPCS: E1390 | | |
If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly rate.
| 20 | EACH |
| 2005 | Monthly Rental of stationary oxygen concentrator system. Back-up system shall be provided for stationary oxygen concentrators consisting of compressed gas source regulator, stand, nasal cannula or mask, tubing, humidifier, trachea collar and fire safe valves when specified. Back-up system minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0-10 liters per minute. HCPCS: E1390 |
If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly rate.
| 20 | EACH | | |
| 2006 | Monthly Rental of portable oxygen concentrator system. Portable system includes flow meter, 2 rechargable batteries, handcart, pouch/backpack and disposable supplies. HCPCS: E1392 | 10 | EACH |
| 2007 | Delivery, set-up, and education of self fill oxygen system to include 4 self-fill compatible oxygen tanks as specified on prescription (M6, C, D, or E), carrying bag, cart, conserving device, fill station and self-fill compatible concentrator (as needed) HCPCS: VA160 | 15 | JOB |
| 2008 | Rental of self fill oxygen system to include 4 self-fill compatible oxygen tanks as specified on prescription(B (M6), C, D, or E), carrying bag, cart, conserving device, fill station and self-fill compatible concentrator. Line item shall include all consumable supplies, e.g. tubing, cannulas, connectors. HCPCS: K0738 | 15 | EACH |
| 2009 | Stationary Cylinder set-up, size H or M60. Set-up consisting of regulator, flow meter, safety stand, humidifier and disposable supplies. This is a one time charge for set-up. (This can be used as a back up system or as a primary system). Includes delivery, setup, and education. | 41 | JOB |
| 2010 | Cylinder, size H refill (Backup/Primary) E0441 | 41 | EACH |
| 2011 | Cylinder, size M60 refill (Backup/Primary) E0441 | 15 | EACH |
| 2012 | Cylinder, size “E” refill. Aluminum tanks required. E0443 | 2400 | EACH |
| 2013 | Cylinder, size “C” refill. Aluminum tanks required. E0443 | 12 | EACH |
| 2014 | Cylinder, size “D” refill. Aluminum tanks required. E0443 | 150 | EACH |
| 2015 | Cylinder, size “B” (M6) refill. Aluminum tanks required. E0443 | 550 | EACH |
| 2016 | Portable Oxygen Concentrator Rental for Traveling Patients. Only models that have continuous flow option or those devices that meet the patients liter per minute as indicated on prescription. E1392 | 240 | EACH |
| 2017 | Monthly rental liquid oxygen system with stationary reservoir, (each reservoir) any size suitable for residential use. HCPCS:E0439 | 70 | EACH |
| 2018 | Monthly rental portable liquid oxygen system. HCPCS: E0434 | | |
| 60 | EACH | | |
| 2019 | Liquid oxygen per pound for item #0016. HCPCS: E0444 | 18,300 | LBS |
| 2020 | Home visit by Patient Services Technician for home oxygen patients. Home visit includes assessment of equipment compliance, educational needs and replacement of equipment as needed. HCPCS: VA160 | 350 | JOB |
| 2021 | Delivery, initial set-up, and education/training of ventilator for continuous and/or intermittent ventilation patients with backup ventilator and specified supplies. An LRT must perform initial set-up. Two (2) ventilators per patient are required at all times: 1 primary and 1 backup. Initial Setups: Initial set-ups are considered to be for those beneficiaries who do not have a VA authorized oxygen therapy delivery system. | 9 | JOB |
| 2022 | Monthly Rental of ventilators for continuous or intermittent ventilation patients with backup ventilator. Includes delivery, setup, supplies and education/training. | | |
If a request is received to deliver a Government-owned ventilator and there is no Government inventory available, a vendor-owned ventilator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned ventilator switched out and there is no Government-owned inventory available, a vendor-owned ventilator will be supplied and billed at the vendor-owned monthly rate.
| 3 | JOB | | |
| 2023 | Monthly Licensed Respiratory Therapist (LRT) visit to inspect equipment and environment, re-educate and/or re-train caregiver, provide supplies as necessary and perform routine preventive maintenance to include support of 2 ventilators per patient: 1 primary and 1 backup. | 12 | JOB |
| 2024 | Delivery of ventilator to local VA Medical Center for hospital discharge purposes only. | 1 | JOB |
| 2025 | Service Call: Trouble shoot or delivery of replacement ventilator to the patient's home. | 1 | HOUR |
| 2026 | Cost to package and ship Government-Owned ventilator to manufacturer for annual preventative maintenance or repairs (outside of warranty) | 1 | |
| 2027 | Delivery for re-supply and/or relocation of equipment due to change in beneficiary’s residence within Region. HCPCS: A9901 | 1 | JOB |
| 2028 | Fee for deliveries/pickups made for over 100 miles from the closest Contractor facility or VAMC/CBOC to the delivery location, whichever is closer. HCPCS: A9901 | 15 | JOB |
| 3rd OPTION YEAR: XX/XX/XXXX through XX/XX/XXXX | | | |
| ITEM NUMBER | DESCRIPTION OF SUPPLIES/SERVICES | ESTIMATED QUANTITY MONTHLY | UNIT |
| 3001 | Delivery, initial set-up, and education of stationary oxygen concentrator system. Back-up system shall be provided consisting of compressed gas source, regulator, stand, nasal cannula or mask, humidifier, tubing, trachea collar and fire safe valves when specified. Back-up system minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure. Concentrator to be provided by VA with liter flow 0 to 5 and 0 to 10 liters per minute. Health Care Procedural Coding System (HCPCS): A9901. Initial Setups: Initial set-ups are considered to be for those beneficiaries who do not have a VA authorized oxygen therapy delivery system. | 80 | JOB |
| 3002 | Delivery, initial set-up, and education of Government owned portable oxygen concentrator system. Portable system for new set ups includes battery, handcart and/or puch/backpack. Includes delivery, setup, and education. This is a one-time charge for new set-ups. HCPCS: A9901. | 20 | JOB |
| 3003 | Preventive Maintenance (PM) for Government-Owned concentrators. (Includes all labor, tools, equipment, travel and materials necessary to perform PM in accordance with manufactures instructions. HCPCS: VA160 | 125 | JOB |
| 3004 | Monthly Rental of stationary oxygen concentrator system. Back-up system shall be provided for stationary oxygen concentrators consisting of compressed gas source regulator, stand, nasal cannula or mask, tubing, humidifier, trachea collar and fire safe valves when specified. Back-up system minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0-5 liters per minute. HCPCS: E1390 | | |
If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly rate.
| 20 | EACH |
| 3005 | Monthly Rental of stationary oxygen concentrator system. Back-up system shall be provided for stationary oxygen concentrators consisting of compressed gas source regulator, stand, nasal cannula or mask, tubing, humidifier, trachea collar and fire safe valves when specified. Back-up system minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0-10 liters per minute. HCPCS: E1390 |
If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly rate.
| 20 | EACH | | |
| 3006 | Monthly Rental of portable oxygen concentrator system. Portable system includes flow meter, 2 rechargable batteries, handcart, pouch/backpack and disposable supplies. HCPCS: E1392 | 10 | EACH |
| 3007 | Delivery, set-up, and education of self fill oxygen system to include 4 self-fill compatible oxygen tanks as specified on prescription (M6, C, D, or E), carrying bag, cart, conserving device, fill station and self-fill compatible concentrator (as needed) HCPCS: VA160 | 15 | JOB |
| 3008 | Rental of self fill oxygen system to include 4 self-fill compatible oxygen tanks as specified on prescription(B (M6), C, D, or E), carrying bag, cart, conserving device, fill station and self-fill compatible concentrator. Line item shall include all consumable supplies, e.g. tubing, cannulas, connectors. HCPCS: K0738 | 15 | EACH |
| 3009 | Stationary Cylinder set-up, size H or M60. Set-up consisting of regulator, flow meter, safety stand, humidifier and disposable supplies. This is a one time charge for set-up. (This can be used as a back up system or as a primary system). Includes delivery, setup, and education. | 41 | JOB |
| 3010 | Cylinder, size H refill (Backup/Primary) E0441 | 41 | EACH |
| 3011 | Cylinder, size M60 refill (Backup/Primary) E0441 | 15 | EACH |
| 3012 | Cylinder, size “E” refill. Aluminum tanks required. E0443 | 2400 | EACH |
| 3013 | Cylinder, size “C” refill. Aluminum tanks required. E0443 | 12 | EACH |
| 3014 | Cylinder, size “D” refill. Aluminum tanks required. E0443 | 150 | EACH |
| 3015 | Cylinder, size “B” (M6) refill. Aluminum tanks required. E0443 | 550 | EACH |
| 3016 | Portable Oxygen Concentrator Rental for Traveling Patients. Only models that have continuous flow option or those devices that meet the patients liter per minute as indicated on prescription. E1392 | 240 | EACH |
| 3017 | Monthly rental liquid oxygen system with stationary reservoir, (each reservoir) any size suitable for residential use. HCPCS:E0439 | 70 | EACH |
| 3018 | Monthly rental portable liquid oxygen system. HCPCS: E0434 | | |
| 60 | EACH | | |
| 3019 | Liquid oxygen per pound for item #0016. HCPCS: E0444 | 18,300 | LBS |
| 3020 | Home visit by Patient Services Technician for home oxygen patients. Home visit includes assessment of equipment compliance, educational needs and replacement of equipment as needed. HCPCS: VA160 | 350 | JOB |
| 3021 | Delivery, initial set-up, and education/training of ventilator for continuous and/or intermittent ventilation patients with backup ventilator and specified supplies. An LRT must perform initial set-up. Two (2) ventilators per patient are required at all times: 1 primary and 1 backup. Initial Setups: Initial set-ups are considered to be for those beneficiaries who do not have a VA authorized oxygen therapy delivery system. | 9 | JOB |
| 3022 | Monthly Rental of ventilators for continuous or intermittent ventilation patients with backup ventilator. Includes delivery, setup, supplies and education/training. | | |
If a request is received to deliver a Government-owned ventilator and there is no Government inventory available, a vendor-owned ventilator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned ventilator switched out and there is no Government-owned inventory available, a vendor-owned ventilator will be supplied and billed at the vendor-owned monthly rate.
| 3 | JOB | | |
| 3023 | Monthly Licensed Respiratory Therapist (LRT) visit to inspect equipment and environment, re-educate and/or re-train caregiver, provide supplies as necessary and perform routine preventive maintenance to include support of 2 ventilators per patient: 1 primary and 1 backup. | 12 | JOB |
| 3024 | Delivery of ventilator to local VA Medical Center for hospital discharge purposes only. | 1 | JOB |
| 3025 | Service Call: Trouble shoot or delivery of replacement ventilator to the patient's home. | 1 | HOUR |
| 3026 | Cost to package and ship Government-Owned ventilator to manufacturer for annual preventative maintenance or repairs (outside of warranty) | 1 | |
| 3027 | Delivery for re-supply and/or relocation of equipment due to change in beneficiary’s residence within Region. HCPCS: A9901 | 1 | JOB |
| 3028 | Fee for deliveries/pickups made for over 100 miles from the closest Contractor facility or VAMC/CBOC to the delivery location, whichever is closer. HCPCS: A9901 | 15 | JOB |
| 4th OPTION YEAR: XX/XX/XXXX through XX/XX/XXXX | | | |
| ITEM NUMBER | DESCRIPTION OF SUPPLIES/SERVICES | ESTIMATED QUANTITY MONTHLY | UNIT |
| 4001 | Delivery, initial set-up, and education of stationary oxygen concentrator system. Back-up system shall be provided consisting of compressed gas source, regulator, stand, nasal cannula or mask, humidifier, tubing, trachea collar and fire safe valves when specified. Back-up system minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure. Concentrator to be provided by VA with liter flow 0 to 5 and 0 to 10 liters per minute. Health Care Procedural Coding System (HCPCS): A9901. Initial Setups: Initial set-ups are considered to be for those beneficiaries who do not have a VA authorized oxygen therapy delivery system. | 80 | JOB |
| 4002 | Delivery, initial set-up, and education of Government owned portable oxygen concentrator system. Portable system for new set ups includes battery, handcart and/or puch/backpack. Includes delivery, setup, and education. This is a one-time charge for new set-ups. HCPCS: A9901. | 20 | JOB |
| 4003 | Preventive Maintenance (PM) for Government-Owned concentrators. (Includes all labor, tools, equipment, travel and materials necessary to perform PM in accordance with manufactures instructions. HCPCS: VA160 | 125 | JOB |
| 4004 | Monthly Rental of stationary oxygen concentrator system. Back-up system shall be provided for stationary oxygen concentrators consisting of compressed gas source regulator, stand, nasal cannula or mask, tubing, humidifier, trachea collar and fire safe valves when specified. Back-up system minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0-5 liters per minute. HCPCS: E1390 | | |
If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly rate.
| 20 | EACH |
| 4005 | Monthly Rental of stationary oxygen concentrator system. Back-up system shall be provided for stationary oxygen concentrators consisting of compressed gas source regulator, stand, nasal cannula or mask, tubing, humidifier, trachea collar and fire safe valves when specified. Back-up system minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0-10 liters per minute. HCPCS: E1390 |
If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly rate.
| 20 | EACH | | |
| 4006 | Monthly Rental of portable oxygen concentrator system. Portable system includes flow meter, 2 rechargable batteries, handcart, pouch/backpack and disposable supplies. HCPCS: E1392 | 10 | EACH |
| 4007 | Delivery, set-up, and education of self fill oxygen system to include 4 self-fill compatible oxygen tanks as specified on prescription (M6, C, D, or E), carrying bag, cart, conserving device, fill station and self-fill compatible concentrator (as needed) HCPCS: VA160 | 15 | JOB |
| 4008 | Rental of self fill oxygen system to include 4 self-fill compatible oxygen tanks as specified on prescription(B (M6), C, D, or E), carrying bag, cart, conserving device, fill station and self-fill compatible concentrator. Line item shall include all consumable supplies, e.g. tubing, cannulas, connectors. HCPCS: K0738 | 15 | EACH |
| 4009 | Stationary Cylinder set-up, size H or M60. Set-up consisting of regulator, flow meter, safety stand, humidifier and disposable supplies. This is a one time charge for set-up. (This can be used as a back up system or as a primary system). Includes delivery, setup, and education. | 41 | JOB |
| 4010 | Cylinder, size H refill (Backup/Primary) E0441 | 41 | EACH |
| 4011 | Cylinder, size M60 refill (Backup/Primary) E0441 | 15 | EACH |
| 4012 | Cylinder, size “E” refill. Aluminum tanks required. E0443 | 2400 | EACH |
| 4013 | Cylinder, size “C” refill. Aluminum tanks required. E0443 | 12 | EACH |
| 4014 | Cylinder, size “D” refill. Aluminum tanks required. E0443 | 150 | EACH |
| 4015 | Cylinder, size “B” (M6) refill. Aluminum tanks required. E0443 | 550 | EACH |
| 4016 | Portable Oxygen Concentrator Rental for Traveling Patients. Only models that have continuous flow option or those devices that meet the patients liter per minute as indicated on prescription. E1392 | 240 | EACH |
| 4017 | Monthly rental liquid oxygen system with stationary reservoir, (each reservoir) any size suitable for residential use. HCPCS:E0439 | 70 | EACH |
| 4018 | Monthly rental portable liquid oxygen system. HCPCS: E0434 | | |
| 60 | EACH | | |
| 4019 | Liquid oxygen per pound for item #0016. HCPCS: E0444 | 18,300 | LBS |
| 4020 | Home visit by Patient Services Technician for home oxygen patients. Home visit includes assessment of equipment compliance, educational needs and replacement of equipment as needed. HCPCS: VA160 | 350 | JOB |
| 4021 | Delivery, initial set-up, and education/training of ventilator for continuous and/or intermittent ventilation patients with backup ventilator and specified supplies. An LRT must perform initial set-up. Two (2) ventilators per patient are required at all times: 1 primary and 1 backup. Initial Setups: Initial set-ups are considered to be for those beneficiaries who do not have a VA authorized oxygen therapy delivery system. | 9 | JOB |
| 4022 | Monthly Rental of ventilators for continuous or intermittent ventilation patients with backup ventilator. Includes delivery, setup, supplies and education/training. | | |
If a request is received to deliver a Government-owned ventilator and there is no Government inventory available, a vendor-owned ventilator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned ventilator switched out and there is no Government-owned inventory available, a vendor-owned ventilator will be supplied and billed at the vendor-owned monthly rate.
| 3 | JOB | | |
| 4023 | Monthly Licensed Respiratory Therapist (LRT) visit to inspect equipment and environment, re-educate and/or re-train caregiver, provide supplies as necessary and perform routine preventive maintenance to include support of 2 ventilators per patient: 1 primary and 1 backup. | 12 | JOB |
| 4024 | Delivery of ventilator to local VA Medical Center for hospital discharge purposes only. | 1 | JOB |
| 4025 | Service Call: Trouble shoot or delivery of replacement ventilator to the patient's home. | 1 | HOUR |
| 4026 | Cost to package and ship Government-Owned ventilator to manufacturer for annual preventative maintenance or repairs (outside of warranty) | 1 | |
| 4027 | Delivery for re-supply and/or relocation of equipment due to change in beneficiary’s residence within Region. HCPCS: A9901 | 1 | JOB |
| 4028 | Fee for deliveries/pickups made for over 100 miles from the closest Contractor facility or VAMC/CBOC to the delivery location, whichever is closer. HCPCS: A9901 | 15 | JOB |
| 5th OPTION YEAR: XX/XX/XXXX through XX/XX/XXXX | | | |
| ITEM NUMBER | DESCRIPTION OF SUPPLIES/SERVICES | ESTIMATED QUANTITY MONTHLY | UNIT |
| 5001 | Delivery, initial set-up, and education of stationary oxygen concentrator system. Back-up system shall be provided consisting of compressed gas source, regulator, stand, nasal cannula or mask, humidifier, tubing, trachea collar and fire safe valves when specified. Back-up system minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure. Concentrator to be provided by VA with liter flow 0 to 5 and 0 to 10 liters per minute. Health Care Procedural Coding System (HCPCS): A9901. Initial Setups: Initial set-ups are considered to be for those beneficiaries who do not have a VA authorized oxygen therapy delivery system. | 80 | JOB |
| 5002 | Delivery, initial set-up, and education of Government owned portable oxygen concentrator system. Portable system for new set ups includes battery, handcart and/or puch/backpack. Includes delivery, setup, and education. This is a one-time charge for new set-ups. HCPCS: A9901. | 20 | JOB |
| 5003 | Preventive Maintenance (PM) for Government-Owned concentrators. (Includes all labor, tools, equipment, travel and materials necessary to perform PM in accordance with manufactures instructions. HCPCS: VA160 | 125 | JOB |
| 5004 | Monthly Rental of stationary oxygen concentrator system. Back-up system shall be provided for stationary oxygen concentrators consisting of compressed gas source regulator, stand, nasal cannula or mask, tubing, humidifier, trachea collar and fire safe valves when specified. Back-up system minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0-5 liters per minute. HCPCS: E1390 | | |
If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly rate.
| 20 | EACH |
| 5005 | Monthly Rental of stationary oxygen concentrator system. Back-up system shall be provided for stationary oxygen concentrators consisting of compressed gas source regulator, stand, nasal cannula or mask, tubing, humidifier, trachea collar and fire safe valves when specified. Back-up system minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0-10 liters per minute. HCPCS: E1390 |
If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly rate.
| 20 | EACH | | |
| 5006 | Monthly Rental of portable oxygen concentrator system. Portable system includes flow meter, 2 rechargable batteries, handcart, pouch/backpack and disposable supplies. HCPCS: E1392 | 10 | EACH |
| 5007 | Delivery, set-up, and education of self fill oxygen system to include 4 self-fill compatible oxygen tanks as specified on prescription (M6, C, D, or E), carrying bag, cart, conserving device, fill station and self-fill compatible concentrator (as needed) HCPCS: VA160 | 15 | JOB |
| 5008 | Rental of self fill oxygen system to include 4 self-fill compatible oxygen tanks as specified on prescription(B (M6), C, D, or E), carrying bag, cart, conserving device, fill station and self-fill compatible concentrator. Line item shall include all consumable supplies, e.g. tubing, cannulas, connectors. HCPCS: K0738 | 15 | EACH |
| 5009 | Stationary Cylinder set-up, size H or M60. Set-up consisting of regulator, flow meter, safety stand, humidifier and disposable supplies. This is a one time charge for set-up. (This can be used as a back up system or as a primary system). Includes delivery, setup, and education. | 41 | JOB |
| 5010 | Cylinder, size H refill (Backup/Primary) E0441 | 41 | EACH |
| 5011 | Cylinder, size M60 refill (Backup/Primary) E0441 | 15 | EACH |
| 5012 | Cylinder, size “E” refill. Aluminum tanks required. E0443 | 2400 | EACH |
| 5013 | Cylinder, size “C” refill. Aluminum tanks required. E0443 | 12 | EACH |
| 5014 | Cylinder, size “D” refill. Aluminum tanks required. E0443 | 150 | EACH |
| 5015 | Cylinder, size “B” (M6) refill. Aluminum tanks required. E0443 | 550 | EACH |
| 5016 | Portable Oxygen Concentrator Rental for Traveling Patients. Only models that have continuous flow option or those devices that meet the patients liter per minute as indicated on prescription. E1392 | 240 | EACH |
| 5017 | Monthly rental liquid oxygen system with stationary reservoir, (each reservoir) any size suitable for residential use. HCPCS:E0439 | 70 | EACH |
| 5018 | Monthly rental portable liquid oxygen system. HCPCS: E0434 | | |
| 60 | EACH | | |
| 5019 | Liquid oxygen per pound for item #0016. HCPCS: E0444 | 18,300 | LBS |
| 5020 | Home visit by Patient Services Technician for home oxygen patients. Home visit includes assessment of equipment compliance, educational needs and replacement of equipment as needed. HCPCS: VA160 | 350 | JOB |
| 5021 | Delivery, initial set-up, and education/training of ventilator for continuous and/or intermittent ventilation patients with backup ventilator and specified supplies. An LRT must perform initial set-up. Two (2) ventilators per patient are required at all times: 1 primary and 1 backup. Initial Setups: Initial set-ups are considered to be for those beneficiaries who do not have a VA authorized oxygen therapy delivery system. | 9 | JOB |
| 5022 | Monthly Rental of ventilators for continuous or intermittent ventilation patients with backup ventilator. Includes delivery, setup, supplies and education/training. | | |
If a request is received to deliver a Government-owned ventilator and there is no Government inventory available, a vendor-owned ventilator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned ventilator switched out and there is no Government-owned inventory available, a vendor-owned ventilator will be supplied and billed at the vendor-owned monthly rate.
| 3 | JOB | | |
| 5023 | Monthly Licensed Respiratory Therapist (LRT) visit to inspect equipment and environment, re-educate and/or re-train caregiver, provide supplies as necessary and perform routine preventive maintenance to include support of 2 ventilators per patient: 1 primary and 1 backup. | 12 | JOB |
| 5024 | Delivery of ventilator to local VA Medical Center for hospital discharge purposes only. | 1 | JOB |
| 5025 | Service Call: Trouble shoot or delivery of replacement ventilator to the patient's home. | 1 | HOUR |
| 5026 | Cost to package and ship Government-Owned ventilator to manufacturer for annual preventative maintenance or repairs (outside of warranty) | 1 | |
| 5027 | Delivery for re-supply and/or relocation of equipment due to change in beneficiary’s residence within Region. HCPCS: A9901 | 1 | JOB |
| 5028 | Fee for deliveries/pickups made for over 100 miles from the closest Contractor facility or VAMC/CBOC to the delivery location, whichever is closer. HCPCS: A9901 | 15 | JOB |
| 6th OPTION YEAR: XX/XX/XXXX through XX/XX/XXXX | | | |
| ITEM NUMBER | DESCRIPTION OF SUPPLIES/SERVICES | ESTIMATED QUANTITY MONTHLY | UNIT |
| 6001 | Delivery, initial set-up, and education of stationary oxygen concentrator system. Back-up system shall be provided consisting of compressed gas source, regulator, stand, nasal cannula or mask, humidifier, tubing, trachea collar and fire safe valves when specified. Back-up system minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure. Concentrator to be provided by VA with liter flow 0 to 5 and 0 to 10 liters per minute. Health Care Procedural Coding System (HCPCS): A9901. Initial Setups: Initial set-ups are considered to be for those beneficiaries who do not have a VA authorized oxygen therapy delivery system. | 80 | JOB |
| 6002 | Delivery, initial set-up, and education of Government owned portable oxygen concentrator system. Portable system for new set ups includes battery, handcart and/or puch/backpack. Includes delivery, setup, and education. This is a one-time charge for new set-ups. HCPCS: A9901. | 20 | JOB |
| 6003 | Preventive Maintenance (PM) for Government-Owned concentrators. (Includes all labor, tools, equipment, travel and materials necessary to perform PM in accordance with manufactures instructions. HCPCS: VA160 | 125 | JOB |
| 6004 | Monthly Rental of stationary oxygen concentrator system. Back-up system shall be provided for stationary oxygen concentrators consisting of compressed gas source regulator, stand, nasal cannula or mask, tubing, humidifier, trachea collar and fire safe valves when specified. Back-up system minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0-5 liters per minute. HCPCS: E1390 | | |
If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly rate.
| 20 | EACH |
| 6005 | Monthly Rental of stationary oxygen concentrator system. Back-up system shall be provided for stationary oxygen concentrators consisting of compressed gas source regulator, stand, nasal cannula or mask, tubing, humidifier, trachea collar and fire safe valves when specified. Back-up system minimum supply of oxygen shall be equal to three times the maximum response time for use in case of system malfunction and/or power failure; With flow rate of 0-10 liters per minute. HCPCS: E1390 |
If a request is received to deliver a Government-owned concentrator and there is no Government inventory available, a vendor-owned concentrator will be supplied at the vendor monthly rate. In the event a patient needs to have the Government-owned concentrator switched out and there is no Government-owned inventory available, a vendor-owned concentrator will be supplied and billed at the vendor-owned monthly rate.
| 20 | EACH | | |
| 6006 | Monthly Rental of portable oxygen concentrator system. Portable system includes flow meter, 2 rechargable batteries, handcart, pouch/backpack and disposable supplies. HCPCS: E1392 | 10 | EACH |
| 6007 | Delivery, set-up, and education of self fill oxygen system to include 4 self-fill compatible oxygen tanks as specified on prescription (M6, C, D, or E), carrying bag, cart, conserving device, fill station and self-fill compatible concentrator (as needed) HCPCS: VA160 | 15 | JOB |
| 6008 | Rental of self fill oxygen system to include 4 self-fill compatible oxygen tanks as specified on prescription(B (M6), C, D, or E), carrying bag, cart, conserving device, fill station and self-fill compatible concentrator. Line item shall include all consumable supplies, e.g. tubing, cannulas, connectors. HCPCS: K0738 | 15 | EACH |
| 6009 | Stationary Cylinder set-up, size H or M60. Set-up consisting of regulator, flow meter, safety stand, humidifier and disposable supplies. This is a one time charge for set-up. (This can be used as a back up system or as a primary system). Includes delivery, setup, and education. | 41 | JOB |
| 6010 | Cylinder, size H refill (Backup/Primary) E0441 | 41 | EACH |
| 6011 | Cylinder, size M60 refill (Backup/Primary) E0441 | 15 | EACH |
| 6012 | Cylinder, size “E” refill. Aluminum tanks required. E0443 | 2400 | EACH |
| 6013 | Cylinder, size “C” refill. Aluminum tanks required. E0443 | 12 | EACH |
| 6014 | Cylinder, size “D” refill. Aluminum tanks required. E0443 | 150 | EACH |
| 6015 | Cylinder, size “B” (M6) refill. Aluminum tanks required. E0443 | 550 | EACH |
| 6016 | Portable Oxygen Concentrator Rental for Traveling Patients. Only models that have continuous flow option or those devices that meet the patients liter per minute as indicated on prescription. E1392 | 240 | EACH |
| 6017 | Monthly rental liquid oxygen system with stationary reservoir, (each reservoir) any size suitable for residential use. HCPCS:E0439 | 70 | EACH |
| 6018 | Monthly rental portable liquid oxygen system. HCPCS: E0434 | | |
| 60 | EACH | | |
| 6019 | Liquid oxygen per pound for item #0016. HCPCS: E0444 | 18,300 | LBS |
| 6020 | Home visit by Patient Services Technician for home oxygen patients. Home visit includes assessment of equipment compliance, educational needs and replacement of equipment as needed. HCPCS: VA160 | 350 | JOB |
| 6021 | Delivery, initial set-up, and education/training of ventilator for continuous and/or intermittent ventilation patients with backup ventilator and specified supplies. An LRT must perform initial set-up. Two (2) ventilators per patient are required at all times: 1 primary and 1 backup. Initial Setups: Initial set-ups are considered to be for those beneficiaries who do not have a VA authorized oxygen therapy delivery system. | 9 | JOB |
This is the start of the file's text. The full file is on GovTribe.
