5-Attachment C Cost Sheet.xlsx

KK26-10

Vendor's Name:

Attachment C Cost Sheet Instructions:

Part 1: Scenarios (300 points possible)

1. Required Completion: Vendors must provide a total cost for every scenario listed. If any yellow cell is left blank, contains a price range, or shows $0, the proposal will be considered non-responsive and will be disqualified from further evaluation.

2. All-Inclusive Pricing: Each total cost must include all associated expenses, such as labor, administrative overhead, and travel. No additional or separate charges will be accepted outside the scenario totals.

3. Cost Evaluation and Scoring: The total costs submitted for all scenarios will be used to assign cost points.

a. The lowest total proposed price will receive 100% of the available cost points.

b. All other vendors will receive a proportional percentage of the total cost points based on how their total proposed price compares to the lowest proposed price.

c. Formula:

Cost Points × (Lowest Proposed Price ÷ Vendor’s Proposed Price)

Part 2: Contractual Pricing 1.Provide all pricing that supports the total costs submitted in the scenario section. All pricing provided in this section will become contractual pricing for awarded vendors. This list must include a complete breakdown of any line items, rates, or components that were used to calculate the total cost for each scenario.

2. Include any additional costs, fees, or hourly rates that could be associated with completing the scope of work outlined in the RFP. Examples include, but are not limited to: administrative fees, travel costs, consultation time, report preparation, or additional specialties.

3. Clearly label each pricing line with a description that identifies what the cost represents (e.g., “Orthopedic Specialist Hourly Rate,” “Travel Cost per Mile,” “Administrative Fee per Report,” etc.).

4. If different pricing applies by specialty or service type, provide separate lines for each rate category to ensure accurate evaluation and contract setup.

5. Indicate whether pricing is hourly, per case, flat fee, or per occurrence. All pricing should be fully burdened and inclusive of all costs.

6. Ensure pricing aligns with all requirements in the Scope of Work, including timeliness standards, confidentiality, and professional qualifications.

7. Include any assumptions or conditions related to your pricing. For example, if your pricing depends on claim volume, minimum hours, or specific travel parameters, clearly state those assumptions.

8. More lines can be added if needed.

Important Notice:

If an offeror identifies any issue, ambiguity, or concern with the cost sheet, pricing scenarios, or related instructions, the offeror must submit their question or clarification request during the RFP Q&A period as outlined in the RFP Schedule. Failure to raise such concerns during the Q&A period will constitute acknowledgment and acceptance of the cost sheet and all associated pricing requirements.

No in-person examination is required.

Scenario Details:

Medical Record Review: 2 hours Review claimant’s medical records and billing documentation to assess the necessity and appropriateness of treatment and charges.

Report Preparation: 0.5 hour Prepare a brief written report summarizing findings and conclusions.

Total Time: 2.5 hours

Vendor to provide:

Total all-inclusive cost for this scenario.

2- Complex Medical Record Review This scenario involves a claimant with extensive medical history, multiple providers, and prior treatments.

No in-person examination is required.

Scenario Details:

Medical Record Review: 9 hours Conduct a comprehensive review of multiple sets of medical records and supporting documentation.

Report Preparation: 1 hour Prepare a detailed written report summarizing findings, medical reasoning, and recommendations.

Total Time: 10 hours

Vendor to provide:

Total all-inclusive cost for this scenario.

3- Standard Independent Medical Examination This scenario involves a single injury claim requiring an in-person examination of the claimant within Zip Code 84044.

Scenario Details:

Medical Record Review: 2 hours Review all submitted records to determine relevant treatment history and medical conditions.

In-Person Examination: 1 hour Conduct physical examination of the claimant at a facility in Zip Code 84044, following applicable medical and ethical standards.

Report Preparation: 1 hour Prepare a written report summarizing findings and providing a professional opinion on treatment necessity, reasonableness, and causal relationship.

Total Time: 4 hours

Vendor to provide:

Total all-inclusive cost for this scenario (including any travel or administrative fees).

4- Complex Independent Medical Examination This scenario involves a claimant with a complicated medical history, multiple injuries, and extensive documentation. The IME will take place within Zip Code 84044.

Scenario Details:

Medical Record Review: 6 hours Analyze medical documentation from multiple providers and treatment periods.

In-Person Examination: 2 hours Conduct an in-depth examination addressing multiple body systems or chronic conditions at a facility in Zip Code 84044.

Report Preparation: 2 hours Prepare a comprehensive written report detailing findings, opinions, and recommendations.

Total Time: 10 hours

Vendor to provide:

Total all-inclusive cost for this scenario (including any travel or administrative costs).

5- Testimony/Consultation This scenario involves expert participation in a deposition or hearing related to a previously completed IME.

Scenario Details:

Preparation: 0.5 hour Review relevant IME report and supporting documentation to refresh findings and opinions.

Testimony / Consultation: 1.5 hours Provide virtual or in-person testimony (if in-person, assume Zip Code 84044).

Total Time: 2 hours

Vendor to provide:

Total all-inclusive cost for this scenario (including travel time and expenses, if applicable).