60RRBH21R0011 Attachment J.13 CLIN 0004 Cost Proposal Template Opt Year2.xlsx

XLSX spreadsheet 160 KB Posted Jul 22, 2021

Attached to: Solicitation 60RRBH21R0011 - RRB Specialty MAC
Solicitation number: 60RRBH21R0011
Issued by: Railroad Retirement Board

View the file

Other files

File	Type	Posted
60RRBH21R0011 Attachment J.1.C Performance Requirements Summary -Revised.docx	DOCX document	Sep 2, 2021
60RRBH21R0011 Amendment 0002.pdf	PDF	Sep 2, 2021
60RRBH21R0011 Attachment J.13 CLIN 0004 Cost Proposal Template Option Year Two- Revised.xlsx	XLSX spreadsheet	Aug 19, 2021
60RRBH21R0011 Attachment J.16 CLIN 0007 Cost Proposal Template Option Year Five- Revised.xlsx	XLSX spreadsheet	Aug 19, 2021
60RRBH21R0011 RRB SMAC Services- Amendment 0001 Q and A and other changes SF 30.pdf	PDF	Aug 19, 2021
60RRBH21R0011 Attachment J.7 Basis of Estimate- Revised.xlsx	XLSX spreadsheet	Aug 19, 2021
60RRBH21R0011 Attachment J.1.C Performance Requirements Summary.docx	DOCX document	Aug 19, 2021
60RRBH21R0011 Attachment J.14 CLIN 0005 Cost Proposal Template Option Year Three- Revised.xlsx	XLSX spreadsheet	Aug 19, 2021
60RRBH21R0011 Attachment J.18 CLIN 0009 Cost Proposal Template Option Year Seven- Revised.xlsx	XLSX spreadsheet	Aug 19, 2021
60RRBH21R0011 Attachment J.15 CLIN 0006 Cost Proposal Template Option Year Four- Revised.xlsx	XLSX spreadsheet	Aug 19, 2021
60RRBH21R0011 Attachment J.11 CLIN 0002 Cost Proposal Template Base Year- Revised.xlsx	XLSX spreadsheet	Aug 19, 2021
60RRBH21R0011 Attachment J.33 RRB SMAC Providers by State.xlsx	XLSX spreadsheet	Aug 19, 2021
60RRBH21R0011 Attachment J.20 CLIN 0011 Cost Proposal Template Option Year Nine- Revised.xlsx	XLSX spreadsheet	Aug 19, 2021
60RRBH21R0011 Attachment J.12 CLIN 0003 Cost Proposal Template Option Year One- Revised.xlsx	XLSX spreadsheet	Aug 19, 2021
60RRBH21R0011 Attachment J.17 CLIN 0008 Cost Proposal Template Option Year Six- Revised.xlsx	XLSX spreadsheet	Aug 19, 2021
60RRBH21R0011 Attachment J.34 RRB Responses to Offeror Questions.xlsx	XLSX spreadsheet	Aug 19, 2021
60RRBH21R0011 Attachment J.19 CLIN 0010 Cost Proposal Template Option Year Eight- Revised.xlsx	XLSX spreadsheet	Aug 19, 2021
60RRBH21R0011 Attachment J.1 RRB SMAC SOW- Revised.docx	DOCX document	Aug 19, 2021
60RRBH21R0011 Attachment J.14 CLIN 0005 Cost Proposal Template Opt Year 3.xlsx	XLSX spreadsheet	Jul 22, 2021
60RRBH21R0011 Attachment J.17 CLIN 0008 Cost Proposal Template Opt Year 6.xlsx	XLSX spreadsheet	Jul 22, 2021
60RRBH21R0011 Attachment J.18 CLIN 0009 Cost Proposal Template Opt Year 7.xlsx	XLSX spreadsheet	Jul 22, 2021
60RRBH21R0011 Attachment J.10 CLIN 0001 Cost Proposal Template- Implementation Services for RRB SMAC.xlsx	XLSX spreadsheet	Jul 22, 2021
60RRBH21R0011 Attachment J.21 CLIN 0012 Cost Proposal Template Closeout.xlsx	XLSX spreadsheet	Jul 22, 2021
60RRBH21R0011 Attachment J.16 CLIN 0007 Cost Proposal Template Opt Year 5.xlsx	XLSX spreadsheet	Jul 22, 2021
60RRBH21R0011 Attachment J.15 CLIN 0006 Cost Proposal Template Opt Year 4.xlsx	XLSX spreadsheet	Jul 22, 2021
60RRBH21R0011 Attachment J.20 CLIN 0011 Cost Proposal Template Opt Year 9.xlsx	XLSX spreadsheet	Jul 22, 2021
60RRBH21R0011 Attachment J.19 CLIN 0010 Cost Proposal Template Opt Year 8.xlsx	XLSX spreadsheet	Jul 22, 2021
60RRBH21R0011 Attachment J.3 Small Business Subcontracting Plan.docx	DOCX document	Jul 22, 2021
60RRBH21R0011 Attachment J.8 Past Performance Questionnaire.doc	DOC document	Jul 22, 2021
60RRBH21R0011 Attachment J.27 Compliance Attestation.docx	DOCX document	Jul 22, 2021
60RRBH21R0011 Attachment J.23 Non-Disclosure Statement.docx	DOCX document	Jul 22, 2021
60RRBH21R0011 Attachment J.11 CLIN 0002 Cost Proposal Template Base Year.xlsx	XLSX spreadsheet	Jul 22, 2021
60RRBH21R0011 Attachment J.29 Contractor Furnished Property.docx	DOCX document	Jul 22, 2021
60RRBH21R0011 Attachment J.2 RRB SMAC Deliverable Schedule.docx	DOCX document	Jul 22, 2021
60RRBH21R0011 Attachment J.25 Information Security Attestation.docx	DOCX document	Jul 22, 2021
60RRBH21R0011 Attachment J.1.A Fee-For-Service Shared System Base Functions.docx	DOCX document	Jul 22, 2021
60RRBH21R0011 Attachment J.4 Billing Instructions.docx	DOCX document	Jul 22, 2021
60RRBH21R0011 Attachment J.6 Award Fee Plan Template.docx	DOCX document	Jul 22, 2021
60RRBH21R0011 Attachment J.30 CMS Sec and Priv Language for Info Tech Procurements.docx	DOCX document	Jul 22, 2021
60RRBH21R0011 Attachment J.28 HHS Contracting Guide for Contract of Government Property.docx	DOCX document	Jul 22, 2021
60RRBH21R0011 Attachment J.1.B SOW Appendices.docx	DOCX document	Jul 22, 2021
60RRBH21R0011 Attachment J.32 Cash Collections Worksheet.xlsx	XLSX spreadsheet	Jul 22, 2021
60RRBH21R0011 Attachment J.12 CLIN 0003 Cost Proposal Template Opt Year1.xlsx	XLSX spreadsheet	Jul 22, 2021
60RRBH21R0011 Attachment J.24 Proposal Assumptions Template.xlsx	XLSX spreadsheet	Jul 22, 2021
60RRBH21R0011 Attachment J.10A Cost Template Summary Sheet RRB SMAC.xlsx	XLSX spreadsheet	Jul 22, 2021
60RRBH21R0011 Attachment J.31 Systems of Records.docx	DOCX document	Jul 22, 2021
60RRBH21R0011 Attachment J.10B CLIN 0001 Cost Proposal Template- Implementation Services for RRB SMAC.xlsx	XLSX spreadsheet	Jul 22, 2021
60RRBH21R0011-Sections B-M.docx	DOCX document	Jul 22, 2021
60RRBH21R0011 Attachment J.26 Corporate Experience Attestation.docx	DOCX document	Jul 22, 2021
60RRBH21R0011 Attachment J.7 Basis of Estimate.xlsx	XLSX spreadsheet	Jul 22, 2021

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CLIN 0004

COST TEMPLATE - SAMPLE Attachment J.13		OFFERORS SHALL COMPLETE THESE PART B CLINS BY
(Provide a cost spreadsheet for each CLIN proposed)		COMPLETING COSTS IN SUBWORKSHEETS TO THE RIGHT
CLIN 0004		SLIN 0004AA			SLIN 0004AB
Part B SERVICES / OPTION YEAR TWO	Total FTEs	Part B/Program Management (PM)			Part B/Medicare Integrity Program (MIP)			GRAND TOTAL
		Hours	Rates	Total	Hours	Rates	Total	Hours	Total
COST ELEMENTS

Direct Labor
	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0.00
Subtotal Direct Labor	0	$0	0	$0	0	$0.00

Fringe Benefits (at ____%) $0 $0 $0.00

Total Direct Labor $0 $0 $0.00

Travel (See separate schedule. Total should match)		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0.00

Other Direct Costs (See separate schedule. Total should match.) $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0.00

Base Fee (at ____%)	$0	$0	$0.00
Award Fee (at ______%)	$0	$0	$0.00

TOTAL OTHER AFTER FEE $0 $0 $0.00

Complementary Credits	$0		$0.00
Note: comp.credit information will be provided by RRB prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0.00

&"Arial,Bold"&12RFP 60RRBH21R0011

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

ODC

ODC SCHEDULE - SAMPLE
(Provide an ODC Spreadsheet for each CLIN Proposed)
CLIN 0004 PART B SERVICES	SLIN 0004AA	SLIN 0004AB	GRAND
Cost Element	Amount	Amount	TOTAL

Add costs by category	$0.00
	$0.00
	$0.00
	$0.00
	$0.00
	$0.00

TOTAL ODCs $0.00 $0.00 $0.00

&"Arial,Bold"&12 60RRBH21R0011

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

TRAVEL

TRAVEL SUMMARY

CLIN 0004

	Purpose of Trip	SOW WBS
Crosswalk	Labor Category Taking Trip	Trip Origin	Destination	# People
(A)	# Trips
(B)	# Days
(C)	# Nights
(D)	Lodging Rate
(E)	Lodging
(F=EDA)	M&IE
(G)	Total Lodging

and M&IE

(H=F+G)	Airfare
(I)	Car Rental
(J)	Misc
(K)	Local

Mileage

(L)	Total Per Trip
(M=H+I+J+K+L)	Total For All Trips

(N=M*B )

$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -

TOTAL TRAVEL $ -

Travel Assumptions:

&"Arial,Bold"&14RFP 60RRBH21R0011

PART B SPECIALTY MAC

Attachment J-12 &P

SLIN-0004AA

COST TEMPLATE - SAMPLE Attachment J.13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004AA

C.5.3

C.5.4

C.5.11.2

C.5.11.1

C.5.8

C.5.9

C.5.10

C.5.13

C.5.12

C.6

PART B SERVICES / OPTION YEAR TWO

Total FTEs

Infrastructure

Administrative Requirements

Beneficiary Customer Service Program

Provider Customer Service Program

Claims Processing

Reopenings of Initial Claims Determinations

Appeals of Initial Claims Determinations

FM of Trust Fund

Provider Enrollment

Interface Requirements

CREDITS

AWARD FEE

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS
Direct Labor
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00
Subtotal Direct Labor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0		$0	0	$0	0	$0.00

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Total Direct Labor $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Travel		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Base Fee (at ____%)	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0		$0.00
Award Fee (at ______%)											$0	$0.00

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Complementary Credits											0		$0.00
Note: comp.credit information will be provided by CMS/RRB prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0.00

&"Arial,Bold"&12RFP - RRB-11-R-001

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

SLIN = 0003AC

Attachment J-12 &P

C.5.3(2)

COST TEMPLATE - SAMPLE Attachment J.13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0004AA - C.5.3		C.5.3.1			C.5.3.2
PART B SERVICES / OPTION YEAR TWO	Total FTEs	VDC			Telecommunications			GRAND TOTAL
Program Management		Hours	Rates	Total	Hours	Rates	Total	Hours	Total
COST ELEMENTS

Direct Labor
	0	$0	0	$0.00	$0	0	$0.00
	0	$0	0	$0.00	$0	0	$0.00
	0	$0	0	$0.00	$0	0	$0.00
	0	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0	0	$0.00	$0	0	$0.00
	0	$0	0	$0.00	$0	0	$0.00
	0	$0	0	$0.00	$0	0	$0.00
	0	$0	0	$0.00	$0	0	$0.00
	0	$0	0	$0.00	$0	0	$0.00
	0	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0	$0	0		$0	0	$0.00

Fringe Benefits (at ____%) $0 $0 $0.00

Total Direct Labor $0 $0 $0.00

Travel		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0.00

Base Fee (at ____%)	$0	$0	$0.00
Award Fee (at ______%)

TOTAL OTHER AFTER FEE $0 $0 $0.00

Complementary Credits
Note: comp.credit information will be provided by CMS/RRB prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0.00

&"Arial,Bold"&12RFP 60RRBH21R0011

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

C.5.4(3)

COST TEMPLATE - SAMPLE Attachment J.13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004AA - C.5.4

C.5.4.1

C.5.4.2

C.5.4.3

C.5.4.4

C.5.4.5

C.5.4.6

C.5.4.7

C.5.4.8

C.5.4.10

C.5.4.11

PART B SERVICES / OPTION YEAR TWO

Total FTEs

Key Personnel

Program Management Office Responsibilities

Security

Quality Assurance Req.

Public Relations

Congressional Inquiries

Participation in Conferences, Meetings & Work Groups

Participation in Change Management Process

Internal Controls

Compliance Program

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	0

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 0

Total Direct Labor $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 0

Travel		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		0
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	0
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	0
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	0
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	0
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	0
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	0
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	0

Other Direct Costs $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 0

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 0

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 0

SUBTOTAL COSTS BEFORE FEE $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 0

Base Fee (at ____%)	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	0
Award Fee (at ______%)

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 0

Complementary Credits
Note: comp.credit information will be provided by CMS/RRB prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	0

&"Arial,Bold"&12RFP 60RRBH21R0011

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

Attachment J-12 &P

C.5.8(2)

COST TEMPLATE - SAMPLE Attachment J.13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004AA - C.5.8

C.5.8.1

C.5.8.2

C.5.8.4

C.5.8.5

C.5.8.7

PART B SERVICES / OPTION YEAR TWO

Total FTEs

Standard Paper Remittance Advice Transactions

General Claims Processing

Development of Suspended Claims

Back-End Processing

Incentive Payments

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0.00

Total Direct Labor $0 $0 $0 $0 $0 $0.00

Travel		$0		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0 $0.00

Base Fee (at ____%)	$0	$0	$0	$0	$0	$0.00
Award Fee (at ______%)

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0.00

Complementary Credits
Note: comp.credit information will be provided by CMS/RRB prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0	$0	$0	$0.00

&"Arial,Bold"&12RFP 60RRBH21R0011

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

Attachment J-12 &P

C.5.10(3)

COST TEMPLATE - SAMPLE Attachment J.13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004AA - C.5.10

C.5.10.1

C.5.10.2

C.5.10.3

PART B SERVICES / OPTION YEAR TWO

Total FTEs

Redetermination Requests

Appeal Decision Effectuation

MSR on Reopenging & Appeals

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0		$0	0		$0	0	$0.00

Fringe Benefits (at ____%) $0 $0 $0 $0.00

Total Direct Labor $0 $0 $0 $0.00

Travel		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0.00

Base Fee (at ____%)	$0	$0	$0	$0.00
Award Fee (at ______%)

TOTAL OTHER AFTER FEE $0 $0 $0 $0.00

Complementary Credits
Note: comp.credit information will be provided by CMS/RRB prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0	$0.00

&"Arial,Bold"&12RFP 60RRBH21R0011

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

C.5.11.1(3)

COST TEMPLATE - SAMPLE Attachment J.13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004AA - C.5.11.1

C.5.11.1.2

C.5.11.1.5

C.5.11.1.6

C.5.11.1.7

C.5.11.1.8

C.5.11.1.9

C.5.11.1.10

PART B SERVICES / OPTION YEAR TWO

Total FTEs

Provider Outreach & Education

Provider Contact Center

Provider Relations Research Specialist

Inquiry Tracking System

Provider Self-Service Technology

Provider Electronic Mailing List

PCSP Staff Training

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0	$0	0		$0	0		$0	0	$0	0		$0	0		$0	0	$0.00

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0 $0 $0.00

Total Direct Labor $0 $0 $0 $0 $0 $0 $0 $0.00

Travel		$0		$0		$0		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0 $0 $0 $0.00

Base Fee (at ____%)	$0	$0	$0	$0	$0	$0	$0	$0.00
Award Fee (at ______%)

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0 $0 $0.00

Complementary Credits
Note: comp.credit information will be provided by CMS/RRB prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0	$0	$0	$0	$0	$0.00

&"Arial,Bold"&12RFP 60RRBH21R0011

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

Attachment J-12 &P

C.5.11.1.5(2)

COST TEMPLATE - SAMPLE Attachment J.13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0004AA - C.5.11.1.5		C.5.11.1.5.1			C.5.11.1.5.2
PART B SERVICES / OPTION YEAR TWO	Total FTEs	Telephone Inquiries			Written Inquiries			GRAND TOTAL
Program Management		Hours	Rates	Total	Hours	Rates	Total	Hours	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0		$0	0	$0.00

Fringe Benefits (at ____%) $0 $0 $0.00

Total Direct Labor $0 $0 $0.00

Travel		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0.00

Base Fee (at ____%)	$0	$0	$0.00
Award Fee (at ______%)

TOTAL OTHER AFTER FEE $0 $0 $0.00

Note: comp.credit information will be provided by CMS/RRB prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0.00

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

C.5.11.1.8

COST TEMPLATE - SAMPLE Attachment J.13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0004AA - C.5.11.1.8		C.5.11.1.8.1			C.5.11.1.8.2
PART B SERVICES / OPTION YEAR TWO	Total FTEs	Interactive Voice Response			Web Technology			GRAND TOTAL
Program Management		Hours	Rates	Total	Hours	Rates	Total	Hours	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0		$0	0	$0.00

Fringe Benefits (at ____%) $0 $0 $0.00

Total Direct Labor $0 $0 $0.00

Travel		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0.00

Base Fee (at ____%)	$0	$0	$0.00
Award Fee (at ______%)

TOTAL OTHER AFTER FEE $0 $0 $0.00

Complementary Credits
Note: comp.credit information will be provided by CMS/RRB prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0.00

&"Arial,Bold"&12RFP 60RRBH21R0011

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

C.5.11.2

COST TEMPLATE - SAMPLE Attachment J.13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004AA - C.5.11.2

C.5.11.2.1

C.5.11.2.3

C.5.11.2.5

PART B SERVICES / OPTION YEAR TWO

Total FTEs

Beneficiary Call Center Operations

Written Beneficiary Inquiries

Responding to Complex Beneficiary Inquiries

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0		$0	0		$0	0	$0.00

Fringe Benefits (at ____%) $0 $0 $0 $0.00

Total Direct Labor $0 $0 $0 $0.00

Travel (See separate schedule)		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0.00

Base Fee (at ____%)	$0	$0	$0	$0.00
Award Fee (at ______%)

TOTAL OTHER AFTER FEE $0 $0 $0 $0.00

Note: comp.credit information will be provided by CMS/RRB prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0	$0.00

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

C.5.13(3)

COST TEMPLATE - SAMPLE Attachment J.13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004AA - C.5.13

C.5.13.1

C.5.13.2

C.5.13.4

C.5.13.5

C.5.13.6

C.5.13.8

C.5.13.9

PART B SERVICES / OPTION YEAR TWO

Total FTEs

Use of Trust Fund

Banking Relations

Non-MSP Overpay

Non-MSP Debt Collection Activities

Non-MSP Debt Referral

Overpay Related to Bankruptcy

Financial Reporting & Accounting

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0 $0 $0.00

Total Direct Labor $0 $0 $0 $0 $0 $0 $0 $0.00

Travel		$0		$0		$0		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0 $0 $0 $0.00

Base Fee (at ____%)	$0	$0	$0	$0	$0	$0	$0	$0.00
Award Fee (at ______%)

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0 $0 $0.00

Complementary Credits
Note: comp.credit information will be provided by CMS/RRB prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0	$0	$0	$0	$0	$0.00

&"Arial,Bold"&12RFP 60RRBH21R0011

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

Attachment J-12 &P

C.6

COST TEMPLATE - SAMPLE Attachment J.13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0004AA - C.6		C.6.1			C.6.2
PART B SERVICES / OPTION YEAR TWO	Total FTEs	Successful Collaboration with Entities Requiring Joint Operating Agreement			Successful Collaboration and Coordination with Other Internal and External Agencies			GRAND TOTAL
Program Management		Hours	Rates	Total	Hours	Rates	Total	Hours	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	0
Subtotal Direct Labor	0		$0	0		$0	0	0

Fringe Benefits (at ____%) $0 $0 0

Total Direct Labor $0 $0 0

Travel		$0		$0		0
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	0
Subcontractor Name	0	$0	0	$0	0	0
Subcontractor Name	0	$0	0	$0	0	0
Subcontractor Name	0	$0	0	$0	0	0
Subcontractor Name	0	$0	0	$0	0	0
Subcontractor Name	0	$0	0	$0	0	0
Total Subcontractor	0	$0	0	$0	0	0

Other Direct Costs $0 $0 0

SUBTOTAL ALL DIRECT COSTS $0 $0 0

Indirect Costs (at ______ %) $0 $0 0

TOTAL OTHER BEFORE FEE $0 $0 0

Base Fee (at ____%)	$0	$0	0
Award Fee (at ______%)

TOTAL OTHER AFTER FEE $0 $0 0

Complementary Credits
Note: comp.credit information will be provided by CMS/RRB prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	0

&"Arial,Bold"&12RFP 60RRBH21R0011

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

SLIN-0004AB

COST TEMPLATE - SAMPLE Attachment J.13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004AB

C.5.4

C.5.14

C.5.15

C.5.16

PART B SERVICES / OPTION YEAR TWO

Total FTEs

Administrative Requirements (for MIP)

Medical Review

Benefit Integrity

MSP

AWARD FEE

GRAND TOTAL

Medicare Integrity Program

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS
Direct Labor
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00
Subtotal Direct Labor	0		$0	0	$0	0		$0	0	$0	0	$0.00

Fringe Benefits (at ____%) $0 $0 $0 $0 $0.00

Total Direct Labor $0 $0 $0 $0 $0.00

Travel		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0.00

Base Fee (at ____%)	$0	$0	$0	$0		$0.00
Award Fee (at ______%)					$0	$0.00

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0.00

Complementary Credits
Note: comp.credit information will be provided by CMS/RRB prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0	$0	$0	$0.00

&"Arial,Bold"&12RFP - RRB-11-R-001

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = 0003

Attachment J-12 &P

C.5.14(2)

COST TEMPLATE - SAMPLE Attachment J.13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004AB - C.5.14

C.5.14.1

C.5.14.3

C.5.14.2

PART B SERVICES / OPTION YEAR TWO

Total FTEs

Medical Review of Claims

Medical Review Data and Activity Definitions

Development of Annual Improper Payment Reduction Strategy

GRAND TOTAL

Medicare Integrity Program

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0	$0	0		$0	0	$0.00

Fringe Benefits (at ____%) $0 $0 $0 $0.00

Total Direct Labor $0 $0 $0 $0.00

Travel (See separate schedule)		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs (See separate schedule) $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0.00

Base Fee (at ____%)	$0	$0	$0	$0.00
Award Fee (at ______%)

TOTAL OTHER AFTER FEE $0 $0 $0 $0.00

Complementary Credits
Note: comp.credit information will be provided by CMS/RRB prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0	$0.00

&"Arial,Bold"&12RFP 60RRBH21R0011

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

C.5.14.3(2)

COST TEMPLATE - SAMPLE Attachment J.13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AB - C.5.14.3

C.5.14.3.1

C.5.14.3.2

C.5.14.3.3

C.5.14.3.4

PART B SERVICES / OPTION YEAR TWO

Total FTEs

Medical Review Data:

Data Analysis

Medical Review Data:

Edit Effectiveness

Medical Review Data:

Probe Reviews

Provider Tracking

GRAND TOTAL

Medicare Integrity Program

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0	$0.00

Fringe Benefits (at ____%) $0 $0 $0 $0 $0.00

Total Direct Labor $0 $0 $0 $0 $0.00

Travel		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0.00

Base Fee (at ____%)	$0	$0	$0	$0	$0.00
Award Fee (at ______%)

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0.00

Complementary Credits
Note: comp.credit information will be provided by CMS/RRB prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0	$0	$0.00

&"Arial,Bold"&12RFP - RRB-11-R-001

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

SLIN = 0003

Attachment J-12 &P

C.5.16(2)

COST TEMPLATE - SAMPLE Attachment J.13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004AB - C.5.16

C.5.16.1

C.5.16.2

C.5.16.4

C.5.16.8

C.5.16.9

PART B SERVICES / OPTION YEAR TWO

Total FTEs

Implementation of MSP Operations

Electronic Correspondence Referral System

MSP Claims Adjudication and Validation

Transfer to BCRC

MSP Post-Pay Recovery

GRAND TOTAL

Medicare Integrity Program

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0.00

Total Direct Labor $0 $0 $0 $0 $0 $0.00

Travel		$0		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0 $0.00

Base Fee (at ____%)	$0	$0	$0	$0	$0	$0.00
Award Fee (at ______%)

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0.00

Complementary Credits
Note: comp.credit information will be provided by CMS/RRB prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0	$0	$0	$0.00

&"Arial,Bold"&12RFP 60RRBH21R0011

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

SLIN = 0003AD

Attachment J-12 &P

C.5.17(4)

COST TEMPLATE - SAMPLE Attachment J.13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0004AB - C.5.17		C.5.17
PART B SERVICES / OPTION YEAR TWO	Total FTEs	Provider Outreach & Education (MIP)
Medicare Integrity Program		Hours	Rates	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
Subtotal Direct Labor	0		$0

Fringe Benefits (at ____%) $0

Total Direct Labor $0

Travel		$0
SUBCONTRACTORS
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Total Subcontractor	0	$0

Other Direct Costs $0

SUBTOTAL ALL DIRECT COSTS $0

Indirect Costs (at ______ %) $0

TOTAL OTHER BEFORE FEE $0

Base Fee (at ____%)	$0
Award Fee (at ______%)

TOTAL OTHER AFTER FEE $0

Complementary Credits
Note: comp.credit information will be provided by CMS/RRB prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0

&"Arial,Bold"&12RFP 60RRB21R0011

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

File details come from the government source that posted it. Updated Jul 22, 2021.

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