36C26318Q0535-003.pdf

PAGE 1 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 SIGN 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. SIGNATURE 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 84

Included on task orders issued against IDIQ.

36C26318Q0535 06-04-2018

Douglas H. Reed 605-336-3230 x 7844 07-05-2018

10:00am CST

Services Branch

Department of Veterans Affairs

Network Contract Office 23 (NCO 23)

2501 W. 22nd St.

Sioux Falls SD 57105

X

621910

$15 Million

X

N/A

X

Department of Veterans Affairs

VA Nebraska-Western Iowa Health Care

System

4101 Woolworth Avenue

Omaha NE 68105

Services Branch

Department of Veterans Affairs

Network Contract Office 23 (NCO 23)

2501 W. 22nd St.

Sioux Falls SD 57105

Department of Veterans Affairs

Financial Services Center

Via The Tungsten Network

Refer to VAAR Clause 852.232.72

See CONTINUATION Page

Description of Services:

Non-Emergency Ambulance Transportation Services for VA

Nebraska-Western Iowa Health Care System as specified in

Section B.2 (Statement of Work).

Please refer to Section B.3 for Price Schedule

Please refer to Section E, FAR 52.212-1, for Instructions to

Offerors.

Please refer to Section E, FAR 52.212-2, for Evaluation

Factors.

Offeror shall have active registration in System for Award

Management at https://www.sam.gov at time of offer to the

Government.

This is Full and Open Competition Solicitation using authority found in FAR Part 13 (Simplified Acquisition Procedures).

See CONTINUATION Page

To be cited on all task orders issued against awarded

Indefinite Delivery, Indefinite Quantity (IDIQ) Contract.

X X

X 1

Doug Reed

VA-VHA-SAOC-2016-AC23EC83

36C26318Q0535

Table of Contents

SECTION A

A.1 SF 1449 SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

B.2 STATEMENT OF WORK (SOW)……………………………………………………………5

B.3 PRICE SCHEDULE

ITEM INFORMATION

SECTION C - CONTRACT CLAUSES

C.1 52.212-4 CONTRACT TERMS AND CONDITIONS—COMMERCIAL ITEMS (JAN

2017)

C.2 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

C.3 52.216-18 ORDERING (OCT 1995)

C.4 52.216-19 ORDER LIMITATIONS (OCT 1995)

C.5 52.216-22 INDEFINITE QUANTITY (OCT 1995)

C.6 52.237-7 INDEMNIFICATION AND MEDICAL LIABILITY INSURANCE (JAN 1997) 33

C.7 VAAR 852.203-70 COMMERCIAL ADVERTISING (JAN 2008)

C.8 VAAR 852.203-71 DISPLAY OF DEPARTMENT OF VETERAN AFFAIRS HOTLINE

POSTER (DEC 1992)

C.9 VAAR 852.215-71 EVALUATION FACTOR COMMITMENTS (DEC 2009)

C.10 SUBCONTRACTING COMMITMENTS--MONITORING AND COMPLIANCE (JUN

2011)

C.11 VAAR 852.219-9 VA SMALL BUSINESS SUBCONTRACTING PLAN MINIMUM

REQUIREMENTS (DEC 2009)

C.12 SUBCONTRACTING PLAN--MONITORING AND COMPLIANCE (JUN 2011)

C.13 VAAR 852.232-72 ELECTRONIC SUBMISSION OF PAYMENT REQUESTS (NOV

2012)

C.14 VAAR 852.237-7 INDEMNIFICATION AND MEDICAL LIABILITY INSURANCE

(JAN 2008)

C.15 VAAR 852.237-70 CONTRACTOR RESPONSIBILITIES (APR 1984)

C.16 IT CONTRACT SECURITY

C.17 National Archives and Records Administration (NARA) Records Management Language for Contracts

C.18 52.212-5 CONTRACT TERMS AND CONDITIONS REQUIRED TO IMPLEMENT

STATUTES OR EXECUTIVE ORDERS—COMMERCIAL ITEMS (JAN 2018)

SECTION D - CONTRACT DOCUMENTS, EXHIBITS, OR ATTACHMENTS

SECTION E - SOLICITATION PROVISIONS

E.1 52.212-1 INSTRUCTIONS TO OFFERORS—COMMERCIAL ITEMS (JAN 2017)

E.2 52.209-7 INFORMATION REGARDING RESPONSIBILITY MATTERS (JUL 2013)

E.3 52.216-1 TYPE OF CONTRACT (APR 1984)

E.4 52.233-2 SERVICE OF PROTEST (SEP 2006)

E.5 VAAR 852.215-70 SERVICE-DISABLED VETERAN-OWNED AND VETERAN-

OWNED SMALL BUSINESS EVALUATION FACTORS (JUL 2016)(DEVIATION)

E.6 VAAR 852.233-70 PROTEST CONTENT/ALTERNATIVE DISPUTE RESOLUTION

(JAN 2008)

E.7 VAAR 852.270-1 REPRESENTATIVES OF CONTRACTING OFFICERS (JAN 2008) .. 66

E.8 VAAR 852.271-70 NONDISCRIMINATION IN SERVICES PROVIDED TO

BENEFICIARIES (JAN 2008)

E.9 52.212-2 EVALUATION—COMMERCIAL ITEMS (OCT 2014) [TAILORED]

E.10 52.212-3 OFFEROR REPRESENTATIONS AND CERTIFICATIONS—COMMERCIAL

ITEMS (NOV 2017)

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

1. Contract Administration: All contract administration matters will be handled by the following individuals:

a. CONTRACTOR: TBD

b. GOVERNMENT: Contracting Officer 36C263 Doug Reed, douglas.reed3@va.gov

Services Branch

Department of Veterans Affairs

Network Contract Office 23 (NCO 23)

2501 W. 22nd St.

Sioux Falls SD 57105

2. CONTRACTOR REMITTANCE ADDRESS: All payments by the Government to the contractor will be made in accordance with:

[X] 52.232-33, Payment by Electronic Funds Transfer—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] Weekly through Tungsten Network

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

Via The Tungsten Network

Refer to VAAR Clause 852.232.72

5. ACKNOWLEDGMENT OF AMENDMENTS: The offeror acknowledges receipt of amendments to the Solicitation numbered and dated as follows:

AMENDMENT NO DATE

B.2 STATEMENT OF WORK (SOW)

Description of Requirement

Non-Emergency Ambulance Transportation Services – VA Nebraska-Western Iowa Health Care System

The Contractor shall furnish Non-Emergency Advanced Life Support (ALS) and Basic Life Support (BLS)

Ambulance Transportation Services for the patients/beneficiaries of the Grand Island and Lincoln

Community Based Outpatient Clinics (CBOCs) within the VA Nebraska-Western Iowa Health Care

System.

Service Contract Act Requirement

Contractor shall provide hourly wages in accordance with U.S. Department of Labor Wage Determinations and FAR Subpart 22.10 (Service Contract Labor Standards); see Solicitation Attachment 1 (USDOL Wage

Determinations).

The following position is applicable:

12010 – Ambulance Driver

Period of Performance

This will be a single award Indefinite Delivery Indefinite Quantity (IDIQ) contract with period of performance of 9-1-2018 to 8-31-2023.

Funds will be obligated via issuance of task orders against IDIQ contract for each ordering period:

Ordering Period Period Begins Period Ends

1 9/1/2018 8/31/2019

2 9/1/2019 8/31/2020

3 9/1/2020 8/31/2021

4 9/1/2021 8/31/2022

5 9/1/2022 8/31/2023

Places of Performance

Grand Island CBOC: 2201 North Broadwell Ave, Grand Island, NE 68803

Lincoln CBOC: 600 South 70th Street, Lincoln, NE 68510

Surrounding areas within 40-mile radius of CBOCs specified above.

HIPAA Compliance/Business Associate Agreement

The Contractor must adhere to the provisions of Public Law 104-191, Health Insurance Portability and

Accountability Act (HIPAA) of 1996 and the National Standards to Protect the Privacy and Security of

Protected Health Information (PHI).

In addition, all VA security policies and applicable confidentiality statues such as 38 U.S.C. §5701 (VA

Claims Confidentiality), 38 U.S.C. §5705 (Confidentiality of Healthcare Quality Assurance Review

Records), 38 U.S.C. §7332 (Confidentiality of certain medical records), as well as 45 C.F.R. Parts 160, 162, and 164 (Health Insurance Portability and Accountability Act) should be followed.

As required by HIPAA, HHS has promulgated rules governing the use and disclosure of protected health information by covered entities. The covered entity component of VA is the Veterans Health

Administration (VHA). In accordance with HIPAA, the Contractor shall be required to enter into a

Business Associate Agreement (BAA) with the VA upon award. Please see Solicitation Attachment 2

(Business Associate Agreement Template) for reference. The BAA shall be signed by the Contractor within five (5) business days after award.

Vehicle Requirements

1. The ambulances under the terms of this IDIQ CONTRACT shall be licensed and meet the minimum requirements as mandated by the rules and regulations governing Ambulance Licensure Certification and Emergency Medical Services law, adopted by the Board of Ambulance Advisors of the State of

Nebraska and approved by the State Department of Health.

2. Each ambulance shall be of a model and make to ensure safe and comfortable transportation of patients and must have sufficient headroom to accommodate the patient in the Fowlers position.

3. Ambulances must be inspected and maintained daily to assure mechanical fitness for public safety.

4. Ambulances shall be equipped with such safety items as required by the rules and regulations governing Ambulance Licensure of the State of Nebraska.

5. Ambulances for the transport of patients must comply with state registration requirements for motor vehicle inspection and must have minimum insurance coverage. Compliance with the state inspection requirements and insurance must be verified annually or prior to exercise of any option year.

6. Each ambulance shall be equipped and stocked in strict accordance with the standards as prescribed by Nebraska state laws and Nebraska Department of Health.

7. Contractor shall have available at all times one (1) ALS and two (2) BLS ambulances for each CBOC facility (Grand Island and Lincoln)

8. Contracted vehicle operators shall enforce the use of seat belts or safety restraint devices by all vehicle occupants.

9. Contracted vehicle operators must not leave a vehicle running and unattended.

10. Contracted vehicle operators are responsible for ensuring all equipment and cargo is secured prior to driving of vehicles. All patient support equipment and supplies shall be fully secured to the vehicle body during transport (lock to body or tie downs).

11. All contracted vehicles used for the transport of patients must contain emergency roadside and communication equipment.

12. Communication equipment must be isolated from the engine battery.

13. Cellular phones and two-way radios are acceptable communication equipment. NOTE: Contract vehicles must be furnished with communication equipment by the contractor.

14. Fire extinguishers must be inspected and maintained in accordance with National Fire Protection

Association (NFPA) Standard 10 and secured to the vehicle body.

15. Personal protective equipment (gloves) and spill kits must be provided to drivers to ensure they are adequately prepared to address biological fluids.

16. If the transfer of clinical specimens with patient passengers is required, it must comply with DOT and OSHA regulations.

17. Clinical staff giving specimens to contracted vehicle operators transporting patients must ensure compliance with the specimen identification, packing and labeling requirements of U.S.

Occupational Safety & Health Administration (OSHA) 29 Code of Federal Regulations (CFR)

1910.1030, Bloodborne Pathogens and the Material of Trade (MOT) exception for Class 6, Division 6.2 substances of U.S. Department of Transportation (DOT) 49 CFR 173.134.

18. All specimen packages shall be packed in a container secured to the vehicle body to prevent movement during driving.

19. Contractor shall provide list of vehicles, broken down by make, model, Vehicle Identification

Number (VIN), and License Plate Number/State within five (5) business days after award.

Insurance Requirements

In addition to insurance requirements cited in Section C of solicitation, the Contractor certificate of insurance contain an endorsement to the effect, that cancellation of or any material change in the policies, which adversely affect the interests of the Government, shall not be effective unless a 30-day written notice of cancellation or change is furnished to the Contracting Officer (CO). Certificate of Insurance shall be provided by Contractor within five (5) business days after award. Contractor shall provide copy of updated certificate of insurance based by beginning of each ordering period cited under “Period of

Performance.”

Subcontracting Plan

IAW FAR 19.702 (a)(1), the awarded Contractor shall provide, if large business, a subcontracting plan for

Contracting Officer review no later than five (5) business days after award. See Solicitation Attachment

3_Subcontracting Plan Template.

EMT, Advanced EMT, and Paramedic Qualifications

1. Ambulance “Attendant” is classified either as an Emergency Medical Technician (EMT) or

Paramedic and shall be certified through the State of Nebraska.

2. Emergency Medical Technician (EMT), EMT-A, EMT-I, and Paramedic – shall mean an out-of-hospital emergency care provider trained and certified to the level of basic and advanced life support as prescribed in Nebraska Revised Statute 38 – Health Occupations and Professions (Chapter 38) and for such other skills as determined by the Department of Health Regulations and Standards of the

State of Nebraska.

3. EMTs and Paramedics shall provide a copy of their Nebraska EMT or Paramedic license prior to performing any service under the contract and within one (1) business day after award. The EMT must be certified, licensed, or otherwise officially recognized by the local, state, or regional government or public entity under which the ambulance service is operated or which governs it.

4. An additional Attendant may be required for high acuity patients; an EMT or Paramedic may fill that requirement.

Advanced Life Support (ALS) Ambulance

An ALS Ambulance is staffed with at least one EMT or Paramedic taking direct care of the patient and another EMT, Paramedic or qualified Ambulance driver providing the transportation. The vehicle is to be equipped with all the supplies needed to care for a severely injured or ill patient, such as IV supplies, cardiac monitor, intubation equipment and a ventilator.

Basic Life Support (BLS) Ambulance

A Basic Life Support (BLS) Ambulance is staffed with at least one EMT, EMT-A, EMT-I or Paramedic taking direct care of the patient and an EMT, Paramedic or qualified Ambulance driver providing the transportation. The vehicle is to be equipped with all the supplies needed to provide services including the administration of oxygen and other non-invasive procedures including splinting broken bones, administering glucose for mild hypoglycemia, and basic wound management.

Ambulance Driver

1. All ambulance drivers shall be verified for current and valid State Drivers’ License through the

Department of Transportation (DOT), National Highway Traffic Safety Administration (NHTSA), National Driver Register, or an equivalent State program.

2. The Contracting Officer Representative (COR) must conduct a review prior to the assignment of a new

Ambulance Driver, upon an accident event, and at any other time at the discretion of the COR.

Driving records exhibiting any at-fault accident or moving violation must prompt a review of driver suitability for the transport of patients. Ambulance Drivers may be limited or prohibited from transporting patients based on driving record or license status. Contractor shall provide copy of ambulance driver license and driving records to COR prior to assigning ambulance driver.

3. The COR maintains Ambulance Driver records, license verification, training, and insurance coverage and will conduct an annual review prior to assignment of a new Ambulance Driver.

4. All Ambulance Drivers transporting patients shall receive initial basic safe driver training and annual refresher from Contractor to include defensive driving techniques, use of safety belts, patient safety, and emergency response procedures.

5. A qualified Ambulance driver, other than the EMT or Paramedic, must receive training on basic First

Aid, Cardiopulmonary Resuscitation (CPR), Bloodborne Pathogens, and the use of Personal

Protective Equipment (PPE).

6. Ambulance Drivers shall be trained in methods for securing patients including use of restraint systems and other assistive devices during transportation as well as safe loading and unloading practices.

7. Contractors must provide an annual statement prior to beginning of each ordering period that

Vehicle Operators’ are screened, trained and competent to safely transport patients. This annual statement of driver competency must include any advanced certifications, such as EMT, Paramedic, Advanced Medical Life Support (AMLS), Advanced Cardiac Life Support (ACLS), BLS, CPR, Automated External Defibrillator (AED) First Aid and any other specialized training to assist and secure patients by stretcher.

Number of Patients

It is understood and agreed that only one (1) patient will be transported on a trip unless specifically authorized by COR or authorized VA official. An authorized official of VA may, in the best interest of the beneficiary, allow a relative to accompany him/her at no additional cost. When more than one (1) patient is transported on a trip, reimbursement will be made at the rate not exceeding the cost of transporting a single patient; however, when travel beyond the city limits (40- mile radius from the Grand

Island or Lincoln CBOC) is involved, the longest distance over which a patient is transported may be claimed when more than one (1) patient is transported in a single ambulance concurrently. The contractor must ensure that the pick-ups and drop-offs are scheduled so that the total distance traveled will result in a most economical charge to the Government. The COR will provide a list of authorized officials upon award to the Contractor.

Waiting Time

1. Thirty (30) minutes of wait time is included for all transports. Any wait time in excess of 30 minutes will be reimbursed at the rate prescribed in Section B.2 (Price Schedule).

2. The Contractor will call the Veterans Transportation Services at 402-995-4458 after waiting 15 minutes. This call will enable the Veterans Transportation Services to ensure patient transport has not been additionally delayed.

Requesting Transport

1. Requests for transport will be made by faxing a Trip Ticket from the Grand Island and Lincoln CBOC

Eligibility & Enrollment (Travel) staff designated by the COR.

2. If the Contractor fails to furnish ambulance service within 45 minutes after receiving a request for any order, the VA reserves the right to obtain the service from another source and to charge the Contractor with any excess cost which may result. The COR or authorized official if designated by COR will be the sole judge in determining when to order service from another source.

3. Designed Grand Island and Lincoln CBOC Eligibility & Enrollment (Travel) staff will be designated to schedule patient pickups/drop offs. A letter designating such individuals will be forwarded to the successful Contractor upon award.

Pick-Up and Delivery

1. Pickup and delivery of patients at the Grand Island and Lincoln CBOCs shall be at the following locations:

Grand Island CBOC: Southeast Ambulance Entrance of the Outpatient Clinic

Lincoln CBOC: East side of the Lincoln campus

2. Patients will be taken to or from a pre-arranged destination, for example Outpatient Clinic or the

Inpatient Unit, whenever possible.

3. For clarification of order, Contractor ambulance staff can request direction from an employee of the

Eligibility & Enrollment (Travel) office at that site, the COR, or COR designee.

Safety Requirements

In the performance of this IDIQ CONTRACT, the Contractor shall take such safety precautions as the

Contracting Officer or COR or his/her designee may determine to be reasonably necessary to protect the lives and health of the occupants of the buildings and/or vehicles. The Contracting Officer, COR, or his/her designee will notify the Contractor of any noncompliance with the forgoing provisions and the action to be taken. The Contractor shall, after receipt of such notice, immediately correct the conditions to which attention has been directed. Such notice, when served on the Contractor or his/her designee at the site of the work, shall be deemed sufficient for the purposes aforesaid. If the Contractor fails or refuses to comply promptly, the CO may issue an order stopping all or any part of the work, including legal remedies as stated in Section C.

Incident Reporting

Contractor shall report vehicle accidents and incidents to the COR with a formal accident report within three (3) business days. The COR will forward a copy to the facility Patient Safety Manager.

Every effort shall be made by the contractor to prevent errors, falls, and patient injury caused by acts of commission or omission in the delivery of care.

Any adverse event related to patient injury or other patient safety issues will be reported to the COR verbally immediately following the event and then followed with a written notification (incident report) to

COR within three (3) business days. A Root Cause Analysis will be conducted by VA to determine what happened, why it happened, and what will be done to prevent recurrence.

If the ambulance is involved in an automobile accident, a copy of the police report shall be provided to the COR as soon as it is available.

Preparation of Invoices

In addition to invoice instructions specified in VAAR Clause 852.232-72 of this IDIQ CONTRACT, the

Contractor shall include the following on invoices submitted:

1. All invoices for payment shall be submitted electronically through Tungsten on a weekly basis. These electronic invoices shall avoid placing patient personal information on them but will need include the following in order to cross reference and verify the charges:

a) Trip Ticket Number

b) Run # or Patient’s Acct Number (Contractor’s patient identification number) that is also reflected on each individual claim form described below.

c) Date of Service (Trip Date)

d) Total Charges

2. Additionally, a Health Care Finance Administration (HCFA)/Center for Medicare and Medicaid

Services (CMS)-1500 (professional) or National Uniform Billing Committee (NUBC) UB-04

(institutional) claim form for each patient’s transport will be submitted separately and directly by VA to the claims payer through the mail. HCFA/UB will include the trip ticket number. These will be bundled along with a copy of their corresponding Tungsten invoice from Contractor and a spreadsheet with the following information:

a) Patient’s Name

b) Social Security Number

c) Trip Ticket Number

d) Date of Service (Trip Date)

e) Pick-up point and time

f) Drop-off point and time

g) Number of miles if greater than 40 miles (geographic area)

h) Contract number /PO number

i) Applicable Contract Line Item (CLIN)

3. A ‘trip’ is defined as a one-way transport and is limited to the 40-mile radius of the Grand Island and/or Lincoln CBOC.

4. When round-trip service is provided for the same patient on the same day, both trips may be entered on the same invoice but as separate line items.

5. Mileage beyond the 40-mile radius will be reimbursed ONE WAY ONLY. Contractor will list these charges separately on their invoice.

6. Approved waiting time will be billed as a separate line item on the claim in 15 minute increments at one fourth the hourly rate quoted in his / her bid from the time the driver reports and gains approval for the wait.

7. Prices are to include additional attendant charges separately, when a second attendant is required for high acuity patients.

8. TOLL CHARGES. It is agreed and understood that the prices quoted in the price schedule include any bridge toll charges.

Deliverables Table

Item Section Referenced Due By Format Provided To

Copies of EMT and Paramedic

Licenses

B.2 (SOW), EMT,

Advanced EMT, and

Paramedic

Qualifications

One (1) business day after award

E-mail or alternate format if approved by

COR

COR

BAA Signed B.2 (SOW), HIPAA

Compliance/Business

Associate Agreement

Five (5) business days after award

E-mail CO with cc to

COR

Subcontracting

Plan

B.2 (SOW),

Subcontracting Plan

Five (5) business days after award

E-mail CO

Certificate of

Insurance

B.2 (SOW),

Insurance

Requirements

Five (5) business days after award;

updated certificate prior to beginning of each ordering period

E-mail CO with cc to

COR

Provide list of vehicles, broken down by make, model, Vehicle

Identification

Number (VIN), and License Plate

Number/State

B.2 (SOW), Vehicle

Requirements

Five (5) business days after award

E-mail or alternate format if approved by

COR

COR

Copy of

Ambulance Driver

License and

Driving Records

B.2 (SOW),

Ambulance Driver

Prior to assigning ambulance driver

E-mail or alternate format if approved by

Vehicle Accident

Report

B.2 (SOW), Incident

Reporting

Three (3) business days after incident

E-mail or alternate format if approved by

COR

COR

Incident Report B.2 (SOW), Incident

Reporting

Verbal notification immediately upon incident, with written report no later than three (3) business days of incident

E-mail or alternate format if approved by

Annual statement that vehicle operators are screened, trained and competent to safely transport patients

B.2 (SOW),

Ambulance Driver

Prior to beginning of each ordering period listed in

B.3 (SOW),

Period of

Performance

E-mail or alternate format if approved by

B.3 PRICE SCHEDULE

Contract Guaranteed Minimum to be fulfilled during Ordering Period 1: $40,000. Contract Maximum:

$4,000,000. Only a warranted Contracting Officer from Veterans Health Administration (VHA), Network

Contracting Office (NCO) 23, is authorized to issue task orders from resulting IDIQ contract.

ITEM INFORMATION

ITEM

NUMBER

DESCRIPTION OF

SUPPLIES/SERVICES

ESTIMATED

QUANTITY UNIT UNIT PRICE

ESTIMATED

AMOUNT

0001 Ordering Period 1: 9-1-

2018 to 8-31-2019

ALS Ambulance Service

One-way from the

Lincoln VA CBOC or the

Grand Island VAMC to any location within their respective Metropolitan

Area (within 40 miles of the Lincoln VA CBOC or

Grand Island CBOC facility) to include delivery of the patient to the designated location and 30 minutes of waiting time.

210.00 EA __________________ __________________

0002 Ordering Period 1: 9-1-

2018 to 8-31-2019

BLS Ambulance Service

One-way from the

Lincoln VA CBOC or the

Grand Island VAMC to any location within their respective Metropolitan

Area (within 40 miles of the Lincoln VA CBOC or

Grand Island CBOC facility) to include delivery of the patient to the designated location

415.00 EA __________________ __________________

0003 Ordering Period 1: 9-1-

2018 to 8-31-2019

Ambulance Service

Mileage

Mileage Beyond the 40-

Mile Radius of Lincoln

CBOC or Grand Island

CBOC

(Cost In Addition to Base

Rate for ALS Ambulance

Service and BLS

Ambulance Service)

37,390.00 EA __________________ __________________

0004 Ordering Period 1: 9-1-

2018 to 8-31-2019

Waiting Time, when required and verified

(more than 30 minutes) at

15-minute intervals

(quarter hour)

5.00 EA __________________ __________________

0005 Ordering Period 1: 9-1-

2018 to 8-31-2019

Trip Cancellation Fee, occurs when the VA beneficiary is not present at the destination and the contractor has waited the minimum 30-minute waiting time, the beneficiary refuses transportation (through no fault of the contractor), or the VA cancels the pickup after the contractor has departed from the contractor’s place of business enroute to the destination.

5.00 EA __________________ __________________

0006 Ordering Period 1: 9-1-

2018 to 8-31-2019

Additional Attendant required for high acuity patient.

0007 Ordering Period 1: 9-1-

2018 to 8-31-2019

Lift Assist – Second Unit for added safety of patient/contractor staff to maneuver stairs/heavy patient

1001 Ordering Period 2: 9-1-

2019 to 8-31-2020

ALS Ambulance Service

One-way from the

Lincoln VA CBOC or the

Grand Island VAMC to any location within their respective Metropolitan

Area (within 40 miles of the Lincoln VA CBOC or

Grand Island CBOC facility) to include delivery of the patient to the designated location

1002 Ordering Period 2: 9-1-

2019 to 8-31-2020

BLS Ambulance Service

One-way from the

Lincoln VA CBOC or the

Grand Island VAMC to any location within their respective Metropolitan

Area (within 40 miles of the Lincoln VA CBOC or

Grand Island CBOC facility) to include delivery of the patient to the designated location

1003 Ordering Period 2: 9-1-

2019 to 8-31-2020

Ambulance Service

Mileage

Mileage Beyond the 40-

Mile Radius of Lincoln

CBOC or Grand Island

CBOC

(Cost In Addition to Base

Rate for ALS Ambulance

Service and BLS

Ambulance Service)

37,390.00 EA __________________ __________________

1004 Ordering Period 2: 9-1-

2019 to 8-31-2020

Waiting Time, when required and verified

(more than 30 minutes) at

15-minute intervals

(quarter hour)

1005 Ordering Period 2: 9-1-

2019 to 8-31-2020

Trip Cancellation Fee, occurs when the VA beneficiary is not present at the destination and the contractor has waited the minimum 30-minute waiting time, the beneficiary refuses transportation (through no fault of the contractor), or the VA cancels the pickup after the contractor has departed from the contractor’s place of

1006 Ordering Period 2: 9-1-

2019 to 8-31-2020

Additional Attendant

1007 Ordering Period 2: 9-1-

2019 to 8-31-2020

Lift Assist – Second Unit for added safety of patient/contractor staff to

2001 Ordering Period 3: 9-1-

2020 to 8-31-2021

ALS Ambulance Service

One-way from the

Lincoln VA CBOC or the

Grand Island VAMC to any location within their respective Metropolitan

Area (within 40 miles of the Lincoln VA CBOC or

Grand Island CBOC facility) to include delivery of the patient to the designated location

2002 Ordering Period 3: 9-1-

2020 to 8-31-2021

BLS Ambulance Service

One-way from the

Lincoln VA CBOC or the

Grand Island VAMC to any location within their respective Metropolitan

Area (within 40 miles of the Lincoln VA CBOC or

Grand Island CBOC facility) to include delivery of the patient to the designated location

2003 Ordering Period 3: 9-1-

2020 to 8-31-2021

Ambulance Service

Mileage

Mileage Beyond the 40-

Mile Radius of Lincoln

CBOC or Grand Island

CBOC

(Cost In Addition to Base

Rate for ALS Ambulance

2004 Ordering Period 3: 9-1-

2020 to 8-31-2021

Waiting Time, when required and verified

(more than 30 minutes) at

2005 Ordering Period 3: 9-1-

2020 to 8-31-2021

Trip Cancellation Fee, occurs when the VA beneficiary is not present at the destination and the contractor has waited the minimum 30-minute waiting time, the beneficiary refuses transportation (through no fault of the contractor), or the VA cancels the pickup after the contractor has departed from the contractor’s place of

2006 Ordering Period 3: 9-1-

2020 to 8-31-2021

Additional Attendant

2007 Ordering Period 3: 9-1-

2020 to 8-31-2021

Lift Assist – Second Unit for added safety of patient/contractor staff to

3001 Ordering Period 4: 9-1-

2021 to 8-31-2022

ALS Ambulance Service

One-way from the

Lincoln VA CBOC or the

Grand Island VAMC to any location within their respective Metropolitan

Area (within 40 miles of the Lincoln VA CBOC or

Grand Island CBOC facility) to include delivery of the patient to the designated location

3002 Ordering Period 4: 9-1-

2021 to 8-31-2022

BLS Ambulance Service

One-way from the

Lincoln VA CBOC or the

Grand Island VAMC to any location within their respective Metropolitan

Area (within 40 miles of the Lincoln VA CBOC or

Grand Island CBOC facility) to include delivery of the patient to the designated location and 30 minutes of waiting time.

3003 Ordering Period 4: 9-1-

2021 to 8-31-2022

Ambulance Service

Mileage

Mileage Beyond the 40-

Mile Radius of Lincoln

CBOC or Grand Island

CBOC

(Cost In Addition to Base

Rate for ALS Ambulance

3004 Ordering Period 4: 9-1-

2021 to 8-31-2022

Waiting Time, when required and verified

(more than 30 minutes) at

3005 Ordering Period 4: 9-1-

2021 to 8-31-2022

Trip Cancellation Fee, occurs when the VA beneficiary is not present at the destination and the contractor has waited the minimum 30-minute waiting time, the beneficiary refuses transportation (through no fault of the contractor), or the VA cancels the pickup after the contractor has departed from the contractor’s place of

3006 Ordering Period 4: 9-1-

2021 to 8-31-2022

Additional Attendant

3007 Ordering Period 4: 9-1-

2021 to 8-31-2022

Lift Assist – Second Unit for added safety of patient/contractor staff to

4001 Ordering Period 5: 9-1-

2022 to 8-31-2023

ALS Ambulance Service

One-way from the

Lincoln VA CBOC or the

Grand Island VAMC to any location within their respective Metropolitan

Area (within 40 miles of the Lincoln VA CBOC or

Grand Island CBOC facility) to include delivery of the patient to the designated location

4002 Ordering Period 5: 9-1-

2022 to 8-31-2023

BLS Ambulance Service

One-way from the

Lincoln VA CBOC or the

Grand Island VAMC to any location within their respective Metropolitan

Area (within 40 miles of the Lincoln VA CBOC or

Grand Island CBOC facility) to include delivery of the patient to the designated location

4003 Ordering Period 5: 9-1-

2022 to 8-31-2023

Ambulance Service

Mileage

Mileage Beyond the 40-

Mile Radius of Lincoln

CBOC or Grand Island

CBOC

(Cost In Addition to Base

Rate for ALS Ambulance

4004 Ordering Period 5: 9-1-

2022 to 8-31-2023

Waiting Time, when required and verified

(more than 30 minutes) at

4005 Ordering Period 5: 9-1-

2022 to 8-31-2023

Trip Cancellation Fee, occurs when the VA beneficiary is not present at the destination and the contractor has waited the minimum 30-minute waiting time, the beneficiary refuses transportation (through no fault of the contractor), or the VA cancels the pickup after the contractor has departed from the contractor’s place of

4006 Ordering Period 5: 9-1-

2022 to 8-31-2023

Additional Attendant

4007 Ordering Period 5: 9-1-

2022 to 8-31-2023

Lift Assist – Second Unit for added safety of patient/contractor staff to

ESTIMATED

GRAND TOTAL

SECTION C - CONTRACT CLAUSES

C.1 52.212-4 CONTRACT TERMS AND CONDITIONS—COMMERCIAL

ITEMS (JAN 2017)

(a) Inspection/Acceptance. The Contractor shall only tender for acceptance those items that conform to the requirements of this contract. The Government reserves the right to inspect or test any supplies or services that have been tendered for acceptance. The Government may require repair or replacement of nonconforming supplies or reperformance of nonconforming services at no increase in contract price. If repair/replacement or reperformance will not correct the defects or is not possible, the Government may seek an equitable price reduction or adequate consideration for acceptance of nonconforming supplies or services. The Government must exercise its post-acceptance rights—

(1) Within a reasonable time after the defect was discovered or should have been discovered; and

(2) Before any substantial change occurs in the condition of the item, unless the change is due to the defect in the item.

(b) Assignment. The Contractor or its assignee may assign its rights to receive payment due as a result of performance of this contract to a bank, trust company, or other financing institution, including any

Federal lending agency in accordance with the Assignment of Claims Act (31 U.S.C. 3727). However, when a third party makes payment (e.g., use of the Governmentwide commercial purchase card), the

Contractor may not assign its rights to receive payment under this contract.

(c) Changes. Changes in the terms and conditions of this contract may be made only by written agreement of the parties.

(d) Disputes. This contract is subject to 41 U.S.C. chapter 71, Contract Disputes. Failure of the parties to this contract to reach agreement on any request for equitable adjustment, claim, appeal or action arising under or relating to this contract shall be a dispute to be resolved in accordance with the clause at FAR

52.233-1, Disputes, which is incorporated herein by reference. The Contractor shall proceed diligently with performance of this contract, pending final resolution of any dispute arising under the contract.

(e) Definitions. The clause at FAR 52.202-1, Definitions, is incorporated herein by reference.

(f) Excusable delays. The Contractor shall be liable for default unless nonperformance is caused by an occurrence beyond the reasonable control of the Contractor and without its fault or negligence such as, acts of God or the public enemy, acts of the Government in either its sovereign or contractual capacity, fires, floods, epidemics, quarantine restrictions, strikes, unusually severe weather, and delays of common carriers. The Contractor shall notify the Contracting Officer in writing as soon as it is reasonably possible after the commencement of any excusable delay, setting forth the full particulars in connection therewith, shall remedy such occurrence with all reasonable dispatch, and shall promptly give written notice to the

Contracting Officer of the cessation of such occurrence.

(g) Invoice.

(1) The Contractor shall submit an original invoice and three copies (or electronic invoice, if authorized) to the address designated in the contract to receive invoices. An invoice must include—

(i) Name and address of the Contractor;

(ii) Invoice date and number;

(iii) Contract number, line item number and, if applicable, the order number;

(iv) Description, quantity, unit of measure, unit price and extended price of the items delivered;

(v) Shipping number and date of shipment, including the bill of lading number and weight of shipment if shipped on Government bill of lading;

(vi) Terms of any discount for prompt payment offered;

(vii) Name and address of official to whom payment is to be sent;

(viii) Name, title, and phone number of person to notify in event of defective invoice; and

(ix) Taxpayer Identification Number (TIN). The Contractor shall include its TIN on the invoice only if required elsewhere in this contract.

(x) Electronic funds transfer (EFT) banking information.

(A) The Contractor shall include EFT banking information on the invoice only if required elsewhere in this contract.

(B) If EFT banking information is not required to be on the invoice, in order for the invoice to be a proper invoice, the Contractor shall have submitted correct EFT banking information in accordance with the applicable solicitation provision, contract clause (e.g., 52.232-33, Payment by Electronic Funds

Transfer—System for Award Management, or 52.232-34, Payment by Electronic Funds Transfer—Other

Than System for Award Management), or applicable agency procedures.

(C) EFT banking information is not required if the Government waived the requirement to pay by

EFT.

(2) Invoices will be handled in accordance with the Prompt Payment Act (31 U.S.C. 3903) and Office of Management and Budget (OMB) prompt payment regulations at 5 CFR part 1315.

(h) Patent indemnity. The Contractor shall indemnify the Government and its officers, employees and agents against liability, including costs, for actual or alleged direct or contributory infringement of, or inducement to infringe, any United States or foreign patent, trademark or copyright, arising out of the performance of this contract, provided the Contractor is reasonably notified of such claims and proceedings.

(i) Payment.—

(1) Items accepted. Payment shall be made for items accepted by the Government that have been delivered to the delivery destinations set forth in this contract.

(2) Prompt payment. The Government will make payment in accordance with the Prompt Payment Act

(31 U.S.C. 3903) and prompt payment regulations at 5 CFR part 1315.

(3) Electronic Funds Transfer (EFT). If the Government makes payment by EFT, see 52.212-5(b) for the appropriate EFT clause.

(4) Discount. In connection with any discount offered for early payment, time shall be computed from the date of the invoice. For the purpose of computing the discount earned, payment shall be considered to have been made on the date which appears on the payment check or the specified payment date if an electronic funds transfer payment is made.

(5) Overpayments. If the Contractor becomes aware of a duplicate contract financing or invoice payment or that the Government has otherwise overpaid on a contract financing or invoice payment, the

Contractor shall—

(i) Remit the overpayment amount to the payment office cited in the contract along with a description of the overpayment including the—

(A) Circumstances of the overpayment (e.g., duplicate payment, erroneous payment, liquidation errors, date(s) of overpayment);

(B) Affected contract number and delivery order number, if applicable;

(C) Affected line item or subline item, if applicable; and

(D) Contractor point of contact.

(ii) Provide a copy of the remittance and supporting documentation to the Contracting Officer.

(6) Interest.

(i) All amounts that become payable by the Contractor to the Government under this contract shall bear simple interest from the date due until paid unless paid within 30 days of becoming due. The interest rate shall be the interest rate established by the Secretary of the Treasury as provided in 41 U.S.C. 7109, which is applicable to the period in which the amount becomes due, as provided in (i)(6)(v) of this clause, and then at the rate applicable for each six-month period as fixed by the Secretary until the amount is paid.

(ii) The Government may issue a demand for payment to the Contractor upon finding a debt is due under the contract.

(iii) Final decisions. The Contracting Officer will issue a final decision as required by 33.211 if—

(A) The Contracting Officer and the Contractor are unable to reach agreement on the existence or amount of a debt within 30 days;

(B) The Contractor fails to liquidate a debt previously demanded by the Contracting Officer within the timeline specified in the demand for payment unless the amounts were not repaid because the

Contractor has requested an installment payment agreement; or

(C) The Contractor requests a deferment of collection on a debt previously demanded by the

Contracting Officer (see 32.607-2).

(iv) If a demand for payment was previously issued for the debt, the demand for payment included in the final decision shall identify the same due date as the original demand for payment.

(v) Amounts shall be due at the earliest of the following dates:

(A) The date fixed under this contract.

(B) The date of the first written demand for payment, including any demand for payment resulting from a default termination.

(vi) The interest charge shall be computed for the actual number of calendar days involved beginning on the due date and ending on—

(A) The date on which the designated office receives payment from the Contractor;

(B) The date of issuance of a Government check to the Contractor from which an amount otherwise payable has been withheld as a credit against the contract debt; or

(C) The date on which an amount withheld and applied to the contract debt would otherwise have become payable to the Contractor.

(vii) The interest charge made under this clause may be reduced under the procedures prescribed in

32.608-2 of the Federal Acquisition Regulation in effect on the date of this contract.

(j) Risk of loss. Unless the contract specifically provides otherwise, risk of loss or damage to the supplies provided under this contract shall remain with the Contractor until, and shall pass to the Government upon:

(1) Delivery of the supplies to a carrier, if transportation is f.o.b. origin; or

(2) Delivery of the supplies to the Government at the destination specified in the contract, if transportation is f.o.b. destination.

(k) Taxes. The contract price includes all applicable Federal, State, and local taxes and duties.

(l) Termination for the Government's convenience. The Government reserves the right to terminate this contract, or any part hereof, for its sole convenience. In the event of such termination, the Contractor shall immediately stop all work hereunder and shall immediately cause any and all of its suppliers and subcontractors to cease work. Subject to the terms of this contract, the Contractor shall be paid a percentage of the contract price reflecting the percentage of the work performed prior to the notice of termination, plus reasonable charges the Contractor can demonstrate to the satisfaction of the Government using its standard record keeping system, have resulted from the termination. The Contractor shall not be required to comply with the cost accounting standards or contract cost principles for this purpose. This paragraph does not give the Government any right to audit the Contractor's records. The Contractor shall not be paid for any work performed or costs incurred which reasonably could have been avoided.

(m) Termination for cause. The Government may terminate this contract, or any part hereof, for cause in the event of any default by the Contractor, or if the Contractor fails to comply with any contract terms and conditions, or fails to provide the Government, upon request, with adequate assurances of future performance. In the event of termination for cause, the Government shall not be liable to the Contractor for any amount for supplies or services not accepted, and the Contractor shall be liable to the Government for any and all rights and remedies provided by law. If it is determined that the Government improperly terminated this contract for default, such termination shall be deemed a termination for convenience.

(n) Title. Unless specified elsewhere in this contract, title to items furnished under this contract shall pass to the Government upon acceptance, regardless of when or where the Government takes physical possession.

(o) Warranty. The Contractor warrants and implies that the items delivered hereunder are merchantable and fit for use for the particular purpose described in this contract.

(p) Limitation of liability. Except as otherwise provided by an express warranty, the Contractor will not be liable to the Government for consequential damages resulting from any defect or deficiencies in accepted items.

(q) Other compliances. The Contractor shall comply with all applicable Federal, State and local laws, executive orders, rules and regulations applicable to its performance under this contract.

(r) Compliance with laws unique to Government contracts. The Contractor agrees to comply with 31

U.S.C. 1352 relating to limitations on the use of appropriated funds to influence certain Federal contracts;

18 U.S.C. 431 relating to officials not to benefit; 40 U.S.C. chapter 37, Contract Work Hours and Safety

Standards; 41 U.S.C. chapter 87, Kickbacks; 41 U.S.C. 4712 and 10 U.S.C. 2409 relating to whistleblower protections; 49 U.S.C. 40118, Fly American; and 41 U.S.C. chapter 21 relating to procurement integrity.

(s) Order of precedence. Any inconsistencies in this solicitation or contract shall be resolved by giving precedence in the following order:

(1) The schedule of supplies/services.

(2) The Assignments, Disputes, Payments, Invoice, Other Compliances, Compliance with Laws Unique to Government Contracts, and Unauthorized Obligations paragraphs of this clause;

(3) The clause at 52.212-5.

(4) Addenda to this solicitation or contract, including any license agreements for computer software.

(5) Solicitation provisions if this is a solicitation.

(6) Other paragraphs of this clause.

(7) The Standard Form 1449.

(8) Other documents, exhibits, and attachments

(9) The specification.

(t) System for Award Management (SAM).

(1) Unless exempted by an addendum to this contract, the Contractor is responsible during performance and through final payment of any contract for the accuracy and completeness of the data within the SAM database, and for any liability resulting from the Government's reliance on inaccurate or incomplete data.

To remain registered in the SAM database after the initial registration, the Contractor is required to review and update on an annual basis from the date of initial registration or subsequent updates its information in the SAM database to ensure it is current, accurate and complete. Updating information in the SAM does not alter the terms and conditions of this contract and is not a substitute for a properly executed contractual document.

(2)(i) If a Contractor has legally changed its business name, "doing business as" name, or division name (whichever is shown on the contract), or has transferred the assets used in performing the contract, but has not completed the necessary requirements regarding novation and change-of-name agreements in

FAR subpart 42.12, the Contractor shall provide the responsible Contracting Officer a minimum of one business day's written notification of its intention to (A) change the name in the SAM database; (B) comply with the requirements of subpart 42.12; and (C) agree in writing to the…