Attachment_J.3-E_TO_0002_Business_Proposal_Forms_Case_Review_.xlsx

XLSX spreadsheet 498 KB Posted

Attached to
BFCC-QIO IDIQ Federal contract opportunity
Solicitation number
75FCMC18R0034
Issued by
Department of Health and Human Services Centers for Medicare and Medicaid Services

About this file

From the source

J.3-E Case Review Business Proposal Forms

View the file

Other files for this federal contract opportunity

Other files attached to BFCC-QIO IDIQ, newest first.
File Type Posted
May_15_BFCC_registered_participants_list.xlsx XLSX spreadsheet
BFCC_Pre-solicitation_Recording_Webex.docx DOCX document
2018-05-15_BFCC_Pre-Solicitation_Conference_Agenda.pdf PDF
2018-05-15_BFCC_Pre-Solicit_Conf_FINAL-508_Final.pptx PPTX presentation
Attachment_J.3-C_TO_0002_Evaluation_Measures_Table.docx DOCX document
Attachment_J.2-F_TO_0001_Business_Proposal_Instructions_BFCC_NCORC.docx DOCX document
Attachment_J.11_Small_Business_Subcontracting_Plan.doc DOC document
Attachment_J.15_VPAT.doc DOC document
Attachment_J.1_BFCC_IDIQ_Statement_of_Work.docx DOCX document
Attachment_J.2-B_TO_0001_Schedule_of_Deliverables_BFCC_NCORC.docx DOCX document
Attachment_J.14_Question_Submission_Format_Sample.xlsx XLSX spreadsheet
Attachment_J.9_Information_Systems_Security_Requirements.docx DOCX document
Attachment_J.2-G_TO_0001_Task_Order_Terms_and_Conditions.docx DOCX document
Attachment_J.2-A_TO_0001_Statement_of_Work_BFCC_NCORC.docx DOCX document
Attachment_J.5_Personal_Conflicts_of_Interest_Financial_Disclosure.docx DOCX document
Attachment_J.3-D_TO_0002_Proposal_Instructions_and_Eval_Criteria_BFCC_Case_Review.docx DOCX document
Attachment_J.10_Consent_to_Subcontract.docx DOCX document
Attachment_J.7_Compliance_Program_Guidance.pdf PDF
Attachment_J.2-E_TO_0001_Business_Proposal_Forms.xlsx XLSX spreadsheet
Attachment_J.3-B_TO_0002_Case_Review_SOD.docx DOCX document
Attachment_J.6_BFCC_Glossary_Terms_and_Acronyms.docx DOCX document
Attachment_J.3-H_LOE_by_Case.xlsx XLSX spreadsheet
Attachment_J.2-D_TO_0001_Proposal_Instructions_and_Eval_Criteria_BFCC_NCORC.docx DOCX document
Attachment_J.3-A_TO_0002_Case_Review_SOW.docx DOCX document
Attachment_J.17_HCQIS_CFE_Guidelines_and_Requirements.docx DOCX document
Attachment_J.16_VDI_Onboarding.pdf PDF
Attachment_J.3-G_TO_0002_Task_Order_Terms_and_Conditions.docx DOCX document
Attachment_J.3-F_TO_0002_Business_Proposal_Instructions_Case_Review.docx DOCX document
SF-33_75FCMC18R0034.pdf PDF
Attachment_J.8_ServiceNow_CMS_Asset_and_Procurement_User_Guide.docx DOCX document
Attachment_J.2-C_TO_0001_Evaluation_Measures_Table_BFCC_NCORC.docx DOCX document
Attachment_J.12_565_Report_of_Accountable_Property.pdf PDF
BFCC_RFP_75FCMC18R0034.docx DOCX document
Attachment_J.4_Contractor_Business_Ethics_COI_and_Compliance_Program_Requirements.docx DOCX document
Show all 34

On GovTribe

Work with this file on GovTribe

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file
Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

BFCC Sup Sch Total

1. RFP Number:2. Name and Address of QIO Organization:3. QIO Service Area:4. Contract Period:
000From:12/31/99
0To:12/31/99
0
5. Call Center /Beneficiary Helpline6. Case Review Intake: Quality of Care Review Complaints7. Quality of Care Review Complaints8. Quality of Care Reviews Referred9. Quality of Care Review Reconsiderations10. Case Review Intake: Weichardt Appeals11. Weichardt Appeals (FFS & Managed Care)12. Case Review Intake: BIPA Appeals13. Expedited Appeals BIPA14. Case Review Intake: Grijalva Appeals15. Expedited Appeals: Grijalva16. Case Review Intake: Hospital Requested Review17. Hospital Requested Reviews (HHR)18. Case Review Intake: Hospital Issued Notice of Non-Coverage (HINN)19. Hospital Issued Notice of Non-Coverage (HINN) Reviews20. Case Review Intake: Medical Necessity Reviews21. Medical Necessity Reviews22. Case Review Intake: Readmission Reviews FFS23. Readmission Reviews FFS24. Case Review Intake: Readmission Reviews Medicare Advantage25. Readmission Reviews Medicare Advantage26. Case Review Intake: EMTALA Reviews27. Emergency Medical Treatment and Labor Act (EMTALA) 5-Day28. Emergency Medical Treatment and Labor Act (EMTALA) 60-Day29. Focused Reviews30. Immediate Advocacy31. Sanction Activities32. Quality Improvement Initiatives and Technical Assistance33. Discrimination Referrals34. Other Non-Review Activities35. Legal and Regulatory Affairs36. Memorandums of Agreement and Joint Operating Agreements37. Internal Quality Assurance and Surveillance38. Training Medical Staff39. Training Other Personnel40. Information Services41. Collaboration42. Transparency Through Reporting43. BFCC Transition Costs44. Offsite Storage45. Total
HOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURS
a. LABOR:
1.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
2.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
3.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
4.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
5.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
6.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
7.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
8.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
9.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
10.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
11.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
12.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
13.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
14.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
15.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
16.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
17.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
18.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
19.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
20. All Other (Non IT)0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
41.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
42.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
43.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
44.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
45.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
46.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
47.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
48.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
49.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
50.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
SUBTOTAL - Direct Labor0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
b. Leave0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
c. Fringe Benefits0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
SUBTOTAL - Leave / Fringe0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
d. SUBCONTRACTS:
1. Physician Reviewers / Phys. Advisors0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
2. Other Consultants0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
3. Other Subcontractors0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
SUBTOTAL - Subcontracts0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
e. Travel0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
f. Other Direct Costs0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0
SUBTOTAL - DIRECT0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0

g. Indirect Costs $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $ - 0

TOTAL COSTS0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0
h. Fee$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
TOTAL COSTS WITH FEE$0$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!ERROR:#DIV/0!
Projected Volume - # of cases for:
Year 10000000000000000000000000
Year 20000000000000000000000000
Year 30000000000000000000000000
Year 40000000000000000000000000
Year 50000000000000000000000000
i. Pass-thru Costs

GRAND TOTAL: $0 $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 ERROR:#DIV/0!

BFCC Sup Sch YR1

1. RFP Number:2. Name and Address of QIO Organization:3. QIO Service Area:4. Contract Period:
From:
To:

5. Call Center /Beneficiary Helpline 6. Case Review Intake: Quality of Care Review Complaints 7. Quality of Care Review Complaints 8. Quality of Care Reviews Referred 9. Quality of Care Review Reconsiderations 10. Case Review Intake: Weichardt Appeals 11. Weichardt Appeals (FFS & Managed Care) 12. Case Review Intake: BIPA Appeals 13. Expedited Appeals BIPA 14. Case Review Intake: Grijalva Appeals 15. Expedited Appeals: Grijalva 16. Case Review Intake: Hospital Requested Review 17. Hospital Requested Reviews (HHR) 18. Case Review Intake: Hospital Issued Notice of Non-Coverage (HINN) 19. Hospital Issued Notice of Non-Coverage (HINN) Reviews 20. Case Review Intake: Medical Necessity Reviews 21. Medical Necessity Reviews 22. Case Review Intake: Readmission Reviews FFS 23. Readmission Reviews FFS 24. Case Review Intake: Readmission Reviews Medicare Advantage 25. Readmission Reviews Medicare Advantage 26. Case Review Intake: EMTALA Reviews 27. Emergency Medical Treatment and Labor Act (EMTALA) 5-Day 28. Emergency Medical Treatment and Labor Act (EMTALA) 60-Day 29. Focused Reviews 30. Immediate Advocacy 31. Sanction Activities 32. Quality Improvement Initiatives and Technical Assistance 33. Discrimination Referrals 34. Other Non-Review Activities 35. Legal and Regulatory Affairs 36. Memorandums of Agreement and Joint Operating Agreements 37. Internal Quality Assurance and Surveillance 38. Training Medical Staff 39. Training Other Personnel 40. Information Services 41. Collaboration 42. Transparency Through Reporting 43. BFCC Transition Costs 44. Offsite Storage 45. Total

HOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURS
a. LABOR:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20. All Other (Non IT)0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
SUBTOTAL - Direct Labor0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0$0$00.0$0$0$00.0$0$0$00.0$0$0$00.0$0$0
b. Leave
c. Fringe Benefits
SUBTOTAL - Leave / Fringe0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0$0$00.0$0$0$00.0$0$0$00.0$0$0$00.0$0$0
d. SUBCONTRACTS:
1. Physician Reviewers / Phys. Advisors
2. Other Consultants$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
3. Other Subcontractors$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
SUBTOTAL - Subcontracts0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0$0$00.0$0$0$00.0$0$0$00.0$0$0$00.0$0$0
e. Travel
f. Other Direct Costs$0$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!ERROR:#DIV/0!
SUBTOTAL - DIRECT0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0ERROR:#DIV/0!$0

g. Indirect Costs $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $ - 0

TOTAL COSTS0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0ERROR:#DIV/0!$0
h. Fee$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
TOTAL COSTS WITH FEE$0$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0$0$0$0$0$0$0$0$0$0$0$0$0
Projected Volume - # of cases for:
Year 1
i. Pass-thru Costs$0

GRAND TOTAL: $0 $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 ERROR:#DIV/0!

BFCC Sup Sch YR2

1. RFP Number:2. Name and Address of QIO Organization:3. QIO Service Area:4. Contract Period:
000From:12/31/99
0To:12/31/99
0
5. Call Center /Beneficiary Helpline6. Case Review Intake: Quality of Care Review Complaints7. Quality of Care Review Complaints8. Quality of Care Reviews Referred9. Quality of Care Review Reconsiderations10. Case Review Intake: Weichardt Appeals11. Weichardt Appeals (FFS & Managed Care)12. Case Review Intake: BIPA Appeals13. Expedited Appeals BIPA14. Case Review Intake: Grijalva Appeals15. Expedited Appeals: Grijalva16. Case Review Intake: Hospital Requested Review17. Hospital Requested Reviews (HHR)18. Case Review Intake: Hospital Issued Notice of Non-Coverage (HINN)19. Hospital Issued Notice of Non-Coverage (HINN) Reviews20. Case Review Intake: Medical Necessity Reviews21. Medical Necessity Reviews22. Case Review Intake: Readmission Reviews FFS23. Readmission Reviews FFS24. Case Review Intake: Readmission Reviews Medicare Advantage25. Readmission Reviews Medicare Advantage26. Case Review Intake: EMTALA Reviews27. Emergency Medical Treatment and Labor Act (EMTALA) 5-Day28. Emergency Medical Treatment and Labor Act (EMTALA) 60-Day29. Focused Reviews30. Immediate Advocacy31. Sanction Activities32. Quality Improvement Initiatives and Technical Assistance33. Discrimination Referrals34. Other Non-Review Activities35. Legal and Regulatory Affairs36. Memorandums of Agreement and Joint Operating Agreements37. Internal Quality Assurance and Surveillance38. Training Medical Staff39. Training Other Personnel40. Information Services41. Collaboration42. Transparency Through Reporting43. BFCC Transition Costs44. Offsite Storage45. Total
HOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURS
a. LABOR:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20. All Other (Non IT)0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
SUBTOTAL - Direct Labor0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0$0$00.0$0$0
b. Leave
c. Fringe Benefits
SUBTOTAL - Leave / Fringe0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0$0$00.0$0$0
d. SUBCONTRACTS:
1. Physician Reviewers / Phys. Advisors
2. Other Consultants$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
3. Other Subcontractors$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
SUBTOTAL - Subcontracts0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0$0$00.0$0$0
e. Travel
f. Other Direct Costs$0$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!ERROR:#DIV/0!
SUBTOTAL - DIRECT0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0ERROR:#DIV/0!$0

g. Indirect Costs $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $ - 0

TOTAL COSTS0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0ERROR:#DIV/0!$0
h. Fee$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
TOTAL COSTS WITH FEE$0$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0$0$0$0$0$0$0$0$0$0$0$0$0
Projected Volume - # of cases for:
Year 2
i. Pass-thru Costs$0

GRAND TOTAL: $0 $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 ERROR:#DIV/0!

BFCC Sup Sch YR3

1. RFP Number:2. Name and Address of QIO Organization:3. QIO Service Area:4. Contract Period:
000From:12/31/99
0To:12/31/99
0
5. Call Center /Beneficiary Helpline6. Case Review Intake: Quality of Care Review Complaints7. Quality of Care Review Complaints8. Quality of Care Reviews Referred9. Quality of Care Review Reconsiderations10. Case Review Intake: Weichardt Appeals11. Weichardt Appeals (FFS & Managed Care)12. Case Review Intake: BIPA Appeals13. Expedited Appeals BIPA14. Case Review Intake: Grijalva Appeals15. Expedited Appeals: Grijalva16. Case Review Intake: Hospital Requested Review17. Hospital Requested Reviews (HHR)18. Case Review Intake: Hospital Issued Notice of Non-Coverage (HINN)19. Hospital Issued Notice of Non-Coverage (HINN) Reviews20. Case Review Intake: Medical Necessity Reviews21. Medical Necessity Reviews22. Case Review Intake: Readmission Reviews FFS23. Readmission Reviews FFS24. Case Review Intake: Readmission Reviews Medicare Advantage25. Readmission Reviews Medicare Advantage26. Case Review Intake: EMTALA Reviews27. Emergency Medical Treatment and Labor Act (EMTALA) 5-Day28. Emergency Medical Treatment and Labor Act (EMTALA) 60-Day29. Focused Reviews30. Immediate Advocacy31. Sanction Activities32. Quality Improvement Initiatives and Technical Assistance33. Discrimination Referrals34. Other Non-Review Activities35. Legal and Regulatory Affairs36. Memorandums of Agreement and Joint Operating Agreements37. Internal Quality Assurance and Surveillance38. Training Medical Staff39. Training Other Personnel40. Information Services41. Collaboration42. Transparency Through Reporting43. BFCC Transition Costs44. Offsite Storage45. Total
HOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURS
a. LABOR:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20. All Other (Non IT)0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
SUBTOTAL - Direct Labor0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0$0$00.0$0$0$00.0$0$0$00.0$0$0$00.0$0$0
b. Leave
c. Fringe Benefits
SUBTOTAL - Leave / Fringe0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0$0$00.0$0$0$00.0$0$0$00.0$0$0$00.0$0$0
d. SUBCONTRACTS:
1. Physician Reviewers / Phys. Advisors
2. Other Consultants$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
3. Other Subcontractors$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
SUBTOTAL - Subcontracts0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0$0$00.0$0$0$00.0$0$0$00.0$0$0$00.0$0$0
e. Travel
f. Other Direct Costs$0$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!ERROR:#DIV/0!
SUBTOTAL - DIRECT0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0ERROR:#DIV/0!$0

g. Indirect Costs $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $ - 0

TOTAL COSTS0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0ERROR:#DIV/0!$0
h. Fee$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
TOTAL COSTS WITH FEE$0$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0$0$0$0$0$0$0$0$0$0$0$0$0
Projected Volume - # of cases for:
Year 3
i. Pass-thru Costs$0

GRAND TOTAL: $0 $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 ERROR:#DIV/0!

BFCC Sup Sch YR4

1. RFP Number:2. Name and Address of QIO Organization:3. QIO Service Area:4. Contract Period:
000From:12/31/99
0To:12/31/99
0
5. Call Center /Beneficiary Helpline6. Case Review Intake: Quality of Care Review Complaints7. Quality of Care Review Complaints8. Quality of Care Reviews Referred9. Quality of Care Review Reconsiderations10. Case Review Intake: Weichardt Appeals11. Weichardt Appeals (FFS & Managed Care)12. Case Review Intake: BIPA Appeals13. Expedited Appeals BIPA14. Case Review Intake: Grijalva Appeals15. Expedited Appeals: Grijalva16. Case Review Intake: Hospital Requested Review17. Hospital Requested Reviews (HHR)18. Case Review Intake: Hospital Issued Notice of Non-Coverage (HINN)19. Hospital Issued Notice of Non-Coverage (HINN) Reviews20. Case Review Intake: Medical Necessity Reviews21. Medical Necessity Reviews22. Case Review Intake: Readmission Reviews FFS23. Readmission Reviews FFS24. Case Review Intake: Readmission Reviews Medicare Advantage25. Readmission Reviews Medicare Advantage26. Case Review Intake: EMTALA Reviews27. Emergency Medical Treatment and Labor Act (EMTALA) 5-Day28. Emergency Medical Treatment and Labor Act (EMTALA) 60-Day29. Focused Reviews30. Immediate Advocacy31. Sanction Activities32. Quality Improvement Initiatives and Technical Assistance33. Discrimination Referrals34. Other Non-Review Activities35. Legal and Regulatory Affairs36. Memorandums of Agreement and Joint Operating Agreements37. Internal Quality Assurance and Surveillance38. Training Medical Staff39. Training Other Personnel40. Information Services41. Collaboration42. Transparency Through Reporting43. BFCC Transition Costs44. Offsite Storage45. Total
HOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURS
a. LABOR:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20. All Other (Non IT)0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
SUBTOTAL - Direct Labor0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
b. Leave
c. Fringe Benefits
SUBTOTAL - Leave / Fringe0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
d. SUBCONTRACTS:
1. Physician Reviewers / Phys. Advisors
2. Other Consultants$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
3. Other Subcontractors$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
SUBTOTAL - Subcontracts0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
e. Travel
f. Other Direct Costs$0$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!ERROR:#DIV/0!
SUBTOTAL - DIRECT0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0

g. Indirect Costs $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $ - 0

TOTAL COSTS0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0
h. Fee$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
TOTAL COSTS WITH FEE$0$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0$0$0$0$0$0$0$0$0$0$0$0$0
Projected Volume - # of cases for:
Year 4
i. Pass-thru Costs$0

GRAND TOTAL: $0 $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 ERROR:#DIV/0!

BFCC Sup Sch YR5

1. RFP Number:2. Name and Address of QIO Organization:3. QIO Service Area:4. Contract Period:
000From:12/31/99
0To:12/31/99
0
5. Call Center /Beneficiary Helpline6. Case Review Intake: Quality of Care Review Complaints7. Quality of Care Review Complaints8. Quality of Care Reviews Referred9. Quality of Care Review Reconsiderations10. Case Review Intake: Weichardt Appeals11. Weichardt Appeals (FFS & Managed Care)12. Case Review Intake: BIPA Appeals13. Expedited Appeals BIPA14. Case Review Intake: Grijalva Appeals15. Expedited Appeals: Grijalva16. Case Review Intake: Hospital Requested Review17. Hospital Requested Reviews (HHR)18. Case Review Intake: Hospital Issued Notice of Non-Coverage (HINN)19. Hospital Issued Notice of Non-Coverage (HINN) Reviews20. Case Review Intake: Medical Necessity Reviews21. Medical Necessity Reviews22. Case Review Intake: Readmission Reviews FFS23. Readmission Reviews FFS24. Case Review Intake: Readmission Reviews Medicare Advantage25. Readmission Reviews Medicare Advantage26. Case Review Intake: EMTALA Reviews27. Emergency Medical Treatment and Labor Act (EMTALA) 5-Day28. Emergency Medical Treatment and Labor Act (EMTALA) 60-Day29. Focused Reviews30. Immediate Advocacy31. Sanction Activities32. Quality Improvement Initiatives and Technical Assistance33. Discrimination Referrals34. Other Non-Review Activities35. Legal and Regulatory Affairs36. Memorandums of Agreement and Joint Operating Agreements37. Internal Quality Assurance and Surveillance38. Training Medical Staff39. Training Other Personnel40. Information Services41. Collaboration42. Transparency Through Reporting43. BFCC Transition Costs44. Offsite Storage45. Total
HOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURS
a. LABOR:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20. All Other (Non IT)0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
SUBTOTAL - Direct Labor0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
b. Leave
c. Fringe Benefits
SUBTOTAL - Leave / Fringe0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
d. SUBCONTRACTS:
1. Physician Reviewers / Phys. Advisors
2. Other Consultants$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
3. Other Subcontractors$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
SUBTOTAL - Subcontracts0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
e. Travel
f. Other Direct Costs$0$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!ERROR:#DIV/0!
SUBTOTAL - DIRECT0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0

g. Indirect Costs $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $ - 0

TOTAL COSTS0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0
h. Fee$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
TOTAL COSTS WITH FEE$0$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0$0$0$0$0$0$0$0$0$0$0$0$0
Projected Volume - # of cases for:
Year 5
i. Pass-thru Costs$0

GRAND TOTAL: $0 $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 ERROR:#DIV/0!

Add'l Labor Categ.

1. RFP Number:2. Name and Address of QIO Organization:3. QIO Service Area:4. Contract Period:
000From:12/31/99
0To:12/31/99
0
5. Call Center /Beneficiary Helpline6. Case Review Intake: Quality of Care Review Complaints7. Quality of Care Review Complaints8. Quality of Care Reviews Referred9. Quality of Care Review Reconsiderations10. Case Review Intake: Weichardt Appeals11. Weichardt Appeals (FFS & Managed Care)12. Case Review Intake: BIPA Appeals13. Expedited Appeals BIPA14. Case Review Intake: Grijalva Appeals15. Expedited Appeals: Grijalva16. Case Review Intake: Hospital Requested Review17. Hospital Requested Reviews (HHR)18. Case Review Intake: Hospital Issued Notice of Non-Coverage (HINN)19. Hospital Issued Notice of Non-Coverage (HINN) Reviews20. Case Review Intake: Medical Necessity Reviews21. Medical Necessity Reviews22. Case Review Intake: Readmission Reviews FFS23. Readmission Reviews FFS24. Case Review Intake: Readmission Reviews Medicare Advantage25. Readmission Reviews Medicare Advantage26. Case Review Intake: EMTALA Reviews27. Emergency Medical Treatment and Labor Act (EMTALA) 5-Day28. Emergency Medical Treatment and Labor Act (EMTALA) 60-Day29. Focused Reviews30. Immediate Advocacy31. Sanction Activities32. Quality Improvement Initiatives and Technical Assistance33. Discrimination Referrals34. Other Non-Review Activities35. Legal and Regulatory Affairs36. Memorandums of Agreement and Joint Operating Agreements37. Internal Quality Assurance and Surveillance38. Training Medical Staff39. Training Other Personnel40. Information Services41. Collaboration42. Transparency Through Reporting43. BFCC Transition Costs44. Offsite Storage45. Total

Year 1

HOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURS
20. All Other (LABOR) :
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.

This is the start of the file's text. The full file is on GovTribe.

File details come from the government source that posted it.