Attachment_J.3-F_TO_0002_Business_Proposal_Instructions_Case_Review.docx

BENEFICIARY FAMILY CENTERED CARE BUSINESS PROPOSAL FORMAT

FOR UTILIZATION AND QUALITY CONTROL

QUALITY IMPROVEMENT ORGANIZATIONS

FORMS AND INSTRUCTIONS

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)

BALTIMORE, MARYLAND

Attachment J.3-F Beneficiary Family Centered Care – Case Review Business Proposal Format

TABLE OF CONTENTS

II.GENERAL INSTRUCTIONS 3

III.ADDITIONAL EXPLANATION AND JUSTIFICATION FOR BUSINESS

PROPOSALS 4

IV.BUSINESS PROPOSAL FORMS AND INSTRUCTIONS

A. CMS Form Beneficiary & Family Centered Care Costs – Supplemental Schedules. 4

D. CMS Form Beneficiary & Family Centered Care Costs – Travel Detail. 15

E. CMS Form Beneficiary & Family Centered Care Costs – Other Direct Costs Supplemental Schedules. 17

V.APPENDIX

1: DEFINITIONS AND GUIDELINES: QUALITY IMPROVEMENT ORGANIZATION BFCC BUSINESS PROPOSAL 18

INTRODUCTION

PURPOSE

This guideline package will assist you in preparing the standardized business proposal forms used to award BFCC Medicare Quality Improvement Organization (QIO) contracts.

SCOPE

Offerors must use the electronic file that CMS provides to prepare and submit the business proposal. This guideline package provides instructions for completing the various business proposal forms in the CMS electronic file.

Business proposals are required to include the appropriate supporting information, cross-referenced to the related column, row, and form. The supporting information should be detailed and, as appropriate, fully explain calculations, bases for estimates, etc. Failure to supply the supportive documentation for all proposed costs may be grounds of rejection and the proposal will be returned accordingly. Examples include:

a. Quotes and estimates from vendors;

b. Market surveys;

c. Historical data;

d. Specific calculations used to estimate proposed costs and an explanation;

e. Catalog prices; and

f. Previous billing statements/ expense vouchers.

METHOD OF SUBMISSION

CMS is providing you with the business proposal forms in an Excel spreadsheet file. You should enter your cost data in the Excel files and submit your completed business proposal in electronic format in both Excel and Word/PDF.

The cost information in the electronic version of your completed business proposal must be in Excel2013 format. The narrative supporting information can be in Excel2013 or Word2013 or PDF format.

INSTRUCTIONS FOR BENEFICIARY AND FAMILY CENTERED CARE

SUPPLEMENTAL SCHEDULE

QUALITY IMPROVEMENT ORGANIZATION

BUSINESS PROPOSAL

II. GENERAL INSTRUCTIONS

The following general instructions for the completion and submission of the business proposal forms are in addition to those instructions contained in the RFP issued by CMS to all offerors and in addition to the attached Section III – ADDITIONAL EXPLANATION AND JUSTIFICATION FOR BUSINESS PROPOSAL.

1. The CMS-provided electronic file and the specified Excel and Word/PDF versions are the only acceptable format for your cost proposal submission. Proposals received in any other format will be considered unacceptable.

The business proposal spreadsheets are formatted to accept one decimal place for entries relating to hours and whole dollars for entries relating to costs. However, where appropriate (e.g., hourly rates), the formatting will permit 2 decimal places for costs.

2. As used in this cost proposal process, the term "QIO" refers to both present QIO and potential QIO organizations.

3. A QIO organization proposing a Medicare contract in more than one QIO area must complete a separate business proposal for each QIO area.

4. All blocks on the forms that are shaded are filled out by formulae from within the form or from other forms or are for CMS use only, and they should not be filled out by the submitting QIO. Please fill out, as appropriate, only the unshaded blocks.

5. OMB INSTRUCTIONS REQUIRE THE FOLLOWING BURDEN DISCLOSURE NOTICE TO BE INCORPORATED ON ALL COLLECTIONS OF INFORMATION OR THE ACCOMPANYING INSTRUCTIONS.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0579. The time required to complete this information collection is estimated to average (50 hours) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

III. ADDITIONAL EXPLANATION AND JUSTIFICATION FOR BUSINESS PROPOSAL

General

As a general rule bidders should explain how bidders calculated all items in the business proposal are calculated.

IV. BUSINESS PROPOSAL FORMS AND INSTRUCTIONS

INSTRUCTIONS FOR BENEFICIARY AND FAMILY CENTERED CARE

SUPPLEMENTAL SCHEDULE YR1 – YR5

BFCC QIO

BUSINESS PROPOSAL

ITEM

1. RFP Number. Enter the CMS RFP number for the proposed BFCC QIO contract (make sure the information is entered in the box shown at cell A2.)

2. Name and Address of the QIO Organization. Enter the name and address of the organization submitting the proposal (make sure the information is entered in the boxes shown at cells B2, B3 and B4 on the BFCC Sup Sch YR1 Form).

3. QIO Service Area. Enter the Service Area that the proposed QIO contract will cover (make sure the information is entered in the box shown at cell F2 on the BFCC Sup Sch YR1 Form).

4. Proposed Contract Period. Enter the beginning and ending dates of the proposed QIO contract (make sure the information is entered in the boxes shown at cells I2 and I3 on the BFCC Sup Sch YR1 Form).

COST CENTER COLUMNS – For each cost center column (7, 8, 9, 11, 13, 15, 17, 19, 21, 23, 25, 27, 28, 29, 30, 31), enter the amounts, both hours and costs (a-j), on average for each case type.

7. QUALITY OF CARE REVIEW COMPLAINTS - This column is used for all costs (except intake) directly attributable to quality of care review activities (except quality of care referral activities) as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

8. QUALITY OF CARE REVIEWS REFERRED - This column is used for all costs directly attributable to quality of care referral activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

9. QUALITY OF CARE REVIEWS RECONSIDERATIONS - This column is used for all costs directly attributable to quality of care reconsideration activities as described in the Task Order SOW under Beneficiary and Family Centered Care.

11. WEICHARDT APPEALS - This column is used for all cost directly attributable to hospital based notice appeals activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

13. EXPIDITED APPEALS: BIPA - This column is used for all cost (except intake) directly attributable to fee-for service expedited appeal activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

15. EXPIDITED APPEALS: GRIJALVA - This column is used for all cost (except intake) directly attributable to Medicare Advantage fast track appeal activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

17. HOSPITAL REQUESTED REVIEWS (HHR) - This column is used for all cost (except intake) directly attributable to Hospital Requested Review activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

19. HOSPITAL ISSUED NOTICE OF NON-COVERAGE (HINN) REVIEWS - This column is used for all cost (except intake) directly attributable to Pre-admission/admission HINN activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

21. MEDICAL NECESSITY REVIEWS - This column is used for all cost (except intake) directly attributable to Medical Necessity Review activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

23. READMISSION REVIEWS FFS - This column is used for all cost (except intake) directly attributable to Readmission Review FFS activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

25. READMISSION REVIEWS MEDICARE ADVANTAGE - This column is used for all cost (except intake) directly attributable to Readmission Review Medicare Advantage activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

27. EMERGENCY MEDICAL TREATMENT AND LABOR ACT (EMTALA) 5-DAY – This column is used for all cost (except intake) directly attributable to the Emtala 5-day review activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

28. EMERGENCY MEDICAL TREATMENT AND LABOR ACT (EMTALA) 60-DAY – This column is used for all cost (except intake) directly attributable to the Emtala 60-day review activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

29. FOCUSED REVIEWS – This column is used for all cost (except intake) directly attributable to Focused Review activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

30. IMMEDIATE ADVOCACY - This column is used for all cost (except intake) directly attributable to Immediate Advocacy activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

31. SANCTION ACTIVITIES – This column is used for all cost (except intake) directly attributable to sanction activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

COST CENTER COLUMNS – For cost center columns (5, 6, 10, 12, 14, 16, 18, 20, 22, 24, 26 and 32-44), enter total cost at these activities for the one year period.

5. CALL CENTER/BENEFICIARY HELPLINE - This column is used for all costs directly attributable to Call Center and Beneficiary Helpline activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

6. CASE REVIEW INTAKE: QUALITY OF CARE REVIEWS COMPLAINTS - This column is used for intake costs directly attributable to quality of care review activities (except quality of care referral activities) as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

10. CASE REVIEW INTAKE: WEICHARDT APPEALS - This column is used for intake cost directly attributable to hospital based notice appeals activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

12. CASE REVIEW INTAKE: BIPA APPEALS - This column is used for intake cost directly attributable to fee-for service expedited appeal activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

14. CASE REVIEW INTAKE: GRIJALVA APPEALS- This column is used for intake cost directly attributable to Medicare Advantage fast track appeal activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

16. CASE REVIEW INTAKE: HOSPITAL REQUESTED REVIEWS (HHR) - This column is used for intake cost directly attributable to Hospital Requested Review activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

18. CASE REVIEW INTAKE: HOSPITAL ISSUED NOTICE OF NON-COVERAGE (HINN) REVIEWS - This column is used for intake cost directly attributable to Pre-admission/admission HINN activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

20. CASE REVIEW INTAKE: MEDICAL NECESSITY REVIEWS - This column is used for intake cost directly attributable to Medical Necessity Review activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

22. CASE REVIEW INTAKE: READMISSION REVIEWS FFS - This column is used for intake cost directly attributable to Readmission Review FFS activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

24. CASE REVIEW INTAKE: READMISSION REVIEWS MEDICARE ADVANTAGE - This column is used for intake cost directly attributable to Readmission Review Medicare Advantage activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

26. CASE REVIEW INTAKE: EMTALA REVIEWS – This column is used for intake cost directly attributable to the Emtala 5-day and Emtala 60-day review activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

32. QUALITY IMPROVEMENT INITIATIVES AND TECHNICAL ASSISTANCE - This column is used for all cost directly attributable to Quality Improvement Initiatives (QIIs) activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

33. DISCRIMINATION REFERRALS - This column is used for all cost directly attributable to Discrimination referral activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

34. OTHER NON-REVIEW ACTIVITIES – This column is used for all cost directly attributable to non-review activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

Examples (include, but not limited to the following):

· General Beneficiary and Family Centered Care oversight

· QIO User Groups

· QIO Advisory Committee.

35. LEGAL AND REGULATORY AFFAIRS - This column is used for all cost directly attributable to legal or legal support activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

36. MEMORANDUMS OF AGREEMENT (MOA) AND JOINT OPERATING AGREEMENTS (JOA) - This column is used for all cost directly attributable to MOA and JOA activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

37. INTERNAL QUALITY ASSURANCE AND SURVEILLANCE - This column is used for all cost directly attributable to Internal Quality Assurance and Surveillance activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

38. TRAINING MEDICAL STAFF: - This column is used for all cost directly attributable to activities involved in training the medical staff as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

39. TRAINING OTHER PERSONNEL: - This column is used for all cost directly attributable to activities involved in training all personnel (except medical staff) as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

40. INFORMATION SERVICES – This column is used for all cost directly attributable to information services. It is the expectation of CMS that bidders and their employees working on this Task Order have corporate issued endpoint devices (phones, laptops, printers, etc.) and networked computing equipment (secure storage, internet connectivity, etc.) and services. This corporate issued equipment shall meet security and privacy standards commensurate with the type of data being collected, processed, and/or reported. The cost for this standard equipment should be reflected within the ODCs or indirect rates of each bidder. It is also the expectation of CMS that awardees will utilize CMS systems where provided and that companion systems or mirrored systems e.g. deliverable management and submission systems developed by the awardees will not be cost reimbursable.

41. COLLABORATION - This column is used for all costs directly attributable to collaboration activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

42. TRANSPARENCY THROUGH REPORTING - This column is used for all costs directly attributable to Transparency through Reporting activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

43. BFCC TRANSITION COSTS - This column is used for all costs directly attributable to transition activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ. This is only applicable in the first year of the contract.

44. OFFSITE STORAGE - This column is used for all costs directly attributable to offsite storage activities as described in the Task Order SOW under Beneficiary and Family Centered Care IDIQ.

CATEGORIES

The following information is provided in a format consistent with the categories on BFCC Sup Sch YR 1. This information also applies to similar terms on other forms and worksheets used for the business proposal end for the Financial Information and Vouchering System (FIVS).

Please input the following information by year on the corresponding BFCC Sup Sch YR_ form (i.e. Year 1 information must be input on the BFCC Sup Sch YR1 form; Year 2 information must be input on the BFCC Sup Sch YR2 form; etc.)

a.1- a.50 Labor. Direct labor hours and costs, excluding leave and fringe benefit costs, are to be proposed and reported in the all labor categories.

a.1 – a.19 Enter Labor Category titles (i.e. Nurse Reviewer, Administrative Support, etc.).

a.20 All Other (Non IS) Labor Categories should be added from the Additional Labor Category form, the 7th tab on spreadsheet called Add'l Labor Categ. (a.21-a.40 Enter Additional Labor Category titles that space was not provided for on BFCC Sup Sch YR1 form) a.41-a.50 Enter Information Services Labor Category titles only.

Enter the labor category, labor hours and cost for each case in the particular column cost center for each.

Enter Additional Labor Category labor hours and costs by year on the corresponding year’s table.

Historical Rate Information: Offerors that have Final Indirect Rate Agreements for the past two fiscal years must submit a copy of each Agreement. Offeror’s that do not have Final Indirect Rate Agreements for the past two years must submit a narrative history and breakdown of indirect cost rates. At a minimum, for the past two fiscal years, the Offeror must provide the name of each indirect cost pool or service center pool, a brief description of the cost elements found in the expense pool, the allocation base, cumulative expenses incurred and the indirect rate and/or service center rate (sample below).

Forward Pricing Rate Proposal Information: Offerors that have established provisional and/or Forward Pricing Rate Agreements with federal cognizant agencies must include a copy of each Agreement. Offerors that do not have such Agreements must provide a narrative description and a breakdown of its current year operating and forecasted indirect cost rates and service center rates and all forward-priced years sufficient to cover the anticipated contract period of performance. At a minimum, the Offeror must provide the name of each indirect cost pool or service center pool, a brief description of the cost elements found in the expense pool, the allocation base, cumulative expenses forecasted and the indirect rate or service center rate.

b. Leave. Please provide a copy of your approved leave rate (if applicable). This category includes all indirect leave such as vacation, sick, holiday, and military leave. Accounting treatment of leave as an indirect cost must be consistent for all contracts or lines of business. Please summarize your leave policy. Also, explain any increase in your leave rate as a percentage of direct labor cost.

Enter the leave cost for each case to the particular column cost center.

c. Fringe Benefits. This category includes allowances provided by the contractor to its employees as compensation in addition to regular wages and salaries. The Fringe Benefits line includes all direct costs such as employer’s share of FICA, federal unemployment tax, state unemployment insurance, disability insurance, pension expense, workers compensation, group health insurance, group life insurance, employee relations, and welfare. It also covers leave costs for those organizations that include these costs in the fringe benefit pool. This category does not include benefits provided some, but not all, full-time employees. For Fringe Benefits, if you have an approved provisional rate, it can serve as the justification for the Fringe Benefit expense. If you do not have an approved provisional rate or you do not believe that this rate is correct for your five-year budget, please justify the rate requested, with emphasis on the major items of increase.

Enter the fringe benefit cost for each case to the particular column cost center.

2. OTHER CONSULTANTS. This includes all direct costs related to subcontracts with physician and non-physician consultants (other than the physician reviewers and physician advisors performing medical case review, noted above) to perform activities required by the SOW.

3. OTHER SUBCONTRACTORS. This is for all direct subcontracting costs not reportable on lines d.1. or d.2. This includes all direct hours and costs for subcontract arrangements (including those with universities and other organizations) meeting the requirements of the FAR, incurred in performance of the SOW, and not involving consultative services.

Enter the subcontracts cost for each case to the particular column cost center.

e. Travel. This includes all travel directly chargeable to the contract.

Enter the travel cost for each case to the particular column cost center.

f. Other Direct Costs. This includes all direct costs applicable to the Medicare contract that are not reportable on other items. Accounting treatment of other direct costs must be applied consistently to all contracts or lines of business and in accordance with the FAR or OMB Circular A-122.

All direct costs (excluding information services costs) not directly associated with a specific task should be included in the other direct cost pool and allocated to each task based on an allocation methodology developed by the offeror. Offerors must provide supporting documentation describing the proposed allocation method.

Enter the other direct costs for each case to the particular column cost center.

g. Indirect Costs. This includes costs allocated to the Medicare contract but incurred for common or joint objectives. These costs fit in one of the following categories:

1. Costs that benefit all lines of business.

2. Costs that directly benefit the Medicare contract but which cannot be readily allocated to one or more specific cost centers. These costs are also referred to as general overhead costs of the Medicare contract.

Accounting treatment of indirect costs must be applied consistently to all contracts or lines of business and in accordance with the FAR and OMB Circular A-122.

Enter the indirect costs for each case to the particular column cost center.

h. Fee. This is the element of potential total compensation that may be received for contract performance over and above allowable costs and shall not exceed statutory limitations.

Enter the appropriate portion of the total fee in each column cost center.

TOTAL - No entry required. This automatically calculates the total hours and costs for each category from the entries in the costs center columns.

PROJECTED VOLUME - # OF CASES FOR (AS APPLY):

YEAR 1: Enter the projected volume of cases in each column cost center.

OR

YEAR 2: Enter the projected volume of cases in each column cost center.

OR

YEAR 3: Enter the projected volume of cases in each column cost center.

OR

YEAR 4: Enter the projected volume of cases in each column cost center.

OR

YEAR 5: Enter the projected volume of cases in each column cost center.

i. Pass-thru Costs. This includes payments to providers or vendors as specified and negotiated in the contract (See Medical Records Photocopying Clause (B.11) as being pass-thru costs. Examples are reimbursement for medical record reproduction costs and postage costs for mailing medical records from the provider to the QIO. Please refer to contract clause B.11 Medical Records Photocopying. Fee is not to be calculated on pass-thru costs.

Enter the pass-thru costs in total for each year in cell CE65. Additionally, bidders should submit supporting documentation for all pass-thru costs. This includes a spreadsheet that contains a description of what is being copied, number of proposed copies and price per copy, broken out by contract year.

GRAND TOTAL: No entry required. This automatically calculates the total cost based on the projected volumes in each costs center column.

NOTE: PLEASE PROVIDE YOUR ASSUMPTIONS IN DETERMINING YOUR ESTIMATES.

INSTRUCTIONS FOR ADDITIONAL LABOR CATEGORIES

(7th tab on spreadsheet called Add'l Labor Categ.)

BFCC QUALITY IMPROVEMENT ORGANIZATION

BUSINESS PROPOSAL

ITEM

1. RFP Number. No entry required. This information automatically flows from BFCC Sup Sch YR1.

2. Name and Address of the QIO Organization. No entry required. This information automatically flows from BFCC Sup Sch YR1.

3. QIO Service Area. No entry required. This information automatically flows from BFCC Sup Sch YR1.

4. Proposed Contract Period. No entry required. This information automatically flows from BFCC Sup Sch YR1.

COST CENTER COLUMNS - Same instructions as stated above (see pages 4-8)

CATEGORIES

The following information is provided in a format consistent with the categories on Additional Labor Categories. This information also applies to similar terms on other forms and worksheets used for the business proposal end for the Financial Information and Vouchering System (FIVS).

Please input the following information by year on the corresponding table (i.e. Year 1 information must be input on the Year 1 table; Year 2 information must be input on the Year 2 table; etc.)

21. - 40. Labor. Direct labor hours and costs, excluding leave and fringe benefit costs, are to be proposed and reported in the all labor categories.

Enter Labor Category titles (i.e. Nurse Reviewer, Administrative Support, etc.).

Enter the labor category, labor hours and cost for each case in the particular column cost center for each.

Enter Additional Labor Category labor hours and costs by year on the corresponding year’s table.

TOTAL - No entry required. This automatically calculates the total hours and costs for each category from the entries in the costs center columns.

INSTRUCTIONS FOR CMS FORM SC 2

SUBCONTRACTS PROPOSAL - OTHER

ITEM

1. RFP Number. No entry required. This information automatically flows from BFCC Sup Sch YR1.

2. Name and Address of the QIO Organization. No entry required. This information automatically flows from BFCC Sup Sch YR1.

3. QIO Service Area. No entry required. This information automatically flows from BFCC Sup Sch YR1.

4. Proposed Contract Period. No entry required. This information automatically flows from BFCC Sup Sch YR1.

COST CENTER COLUMNS – Same instructions as stated above (see pages 4-8

CATEGORIES)

The following information is provided in a format consistent with the categories on Additional Labor Categories. This information also applies to similar terms on other forms and worksheets used for the business proposal end for the Financial Information and Vouchering System (FIVS).

Please input the following information by year on the corresponding table (i.e. Year 1 information must be input on the Year 1 table; Year 2 information must be input on the Year 2 table; etc.)

NOTE: Please enter the requested cost information separately for each other consultant in Section 1 and each other subcontractor in Section 2. If you have more than 10 entries for Section 1 or 2, provide the additional consultant/subcontractor information on an attachment and carry the attachments subtotals to line k.

I.a-j & II.a-j Name. Enter the first initial and last name of the subcontractor, when appropriate. If it is more appropriate to identify the subcontractor by a company or organizational name, enter this name instead of an individual’s name. Enter TBD if you are proposing a particular subcontracting activity for the 5-year BFCC QIO contract but have not yet identified a particular subcontractor.

INSTRUCTIONS FOR TRAVEL DETAIL

BUSINESS PROPOSAL

ITEM

1. RFP Number. No entry required. This information automatically flows from BFCC Sup Sch YR1.

2. Name and Address of QIO Organization. No entry required. This information automatically flows from BFCC Sup Sch YR1.

3. QIO Services Area. No entry required. This information automatically flows from BFCC Sup Sch YR1.

4. Proposed Contract Period. No entry required. This information automatically flows from BFCC Sup Sch YR1.

5. Mileage Rate. Enter the current Federal Travel Regulation mileage rate.

6. Area. Enter the quality improvement element the proposed trip relates to.

7. Trip Title and Description/Purpose. Enter the trip title and provide a brief description/purpose of the trip.

8. # of Days per Trip. Enter the number of days the trip will occur.

9. # of Night per Trip. Enter the number of nights the trip will occur.

10. # of Travelers per Trip. Enter the number of travelers, per trip, in whole figures.

11. Airfare per Person. Enter airfare amount per person.

12. Departing From. Enter the city and state the travelers are departing from.

13. Arriving To. Enter the city and state the travelers will arrive to.

14. FTR Meals and Incidentals Daily Rate. Enter the current Federal Travel Regulations (FTR) Meals and Incidental Rate for the location. Note: The formula in the Total column will calculate the max Per Diem rate for the first and last day of travel based on the number of days reported.

15. FTR Lodging per Night. Enter the current the current Federal Travel Regulations (FTR) maximum Lodging Rate (excluding taxes) for the Primary Destination for each trip. Note: The formula in the Total column will calculate the lodging costs based on the nights reported previously.

16. # of Trips. Enter the number of trips for the respective year.

17. Mileage per Traveler per Trip. Enter the roundtrip mileage per trip, if applicable.

18. # of Rental Car(s) per Trip. Enter the number of rental cars needed for each trip.

19. Daily Rental Car Rate. Enter the proposed daily rental car rate.

20. Miscellaneous Costs per Person per Trip. Enter the miscellaneous cost per person per trip. You may include parking fees, gas, taxi, metro fees, and the like.

21. Total. No entry required. This automatically calculates the total travel costs for the listed trip.

22. Notes. Provide a detailed explanation of the miscellaneous cost calculations (what and how your organization reached the proposed figures – i.e.: $20 taxi & $3 airport parking).

23. Grand Total. No entry required. This automatically calculates the total travel costs for the respective year.

** Shaded cells represent no entry required and the totals for these activities DO roll into the TRAVEL listed on the forms "BFCC Sup Sch YRX".

INSTRUCTIONS FOR OTHER DIRECT COSTS

SUPPLEMENTAL SCHEDULE

BFCC QIO BUSINESS PROPOSAL

Projected 5-yr BFCC QIO Other Direct Costs

ITEM

Please input the following information by year on the corresponding table (i.e. Year 1 information must be input on the Year 1 table; Year 2 information must be input on the Year 2 table; etc.)

d. - cc. Individual categories. For each item, enter the other direct cost projected for the designated year of the 5-yr BFCC QIO contract.

Your supporting documentation should explain, in great detail, any amount you entered for items d - cc. The supporting documentation should also fully explain the assumptions and bases you used for your projection, including appropriate supporting schedules.

Item o. Consultants does not apply to this column. Enter direct costs related to consultants on Form SC-2 (Excel tab: QIO Subconts2).

Item q. Travel does not apply to this column. Enter direct costs related to travel on Travel Detail Form.

Total Year X. No entry required. This automatically calculates the total of d. thru cc.

APPENDIX

APPENDIX 1: DEFINITIONS AND GUIDELINES

BFCC QIO BUSINESS PROPOSAL

I. GENERAL.

The forms that you need to complete your business proposal are forwarded electronically in an Excel spreadsheet file. Upon opening the Excel file, the forms are accessible by clicking the various tabs at the bottom of your screen. Each tab represents one of the business proposal forms. The forms and their related tab titles are as follows:

Form Tab Title Description

BFCC Sup Sch Total BFCC Sup Sch Total Beneficiary and Family Centered Care – Supplemental Schedule Total

BFCC Sup Sch YR1 BFCC Sup Sch YR1 Beneficiary and Family Centered Care – Supplemental Schedule YR1

BFCC Sup Sch YR2 BFCC Sup Sch YR2 Beneficiary and Family Centered Care – Supplemental Schedule YR2

BFCC Sup Sch YR3 BFCC Sup Sch YR3 Beneficiary and Family Centered Care – Supplemental Schedule YR3

BFCC Sup Sch YR4 BFCC Sup Sch YR4 Beneficiary and Family Centered Care – Supplemental Schedule YR4

BFCC Sup Sch YR5 BFCC Sup Sch YR5 Beneficiary and Family Centered Care – Supplemental Schedule YR5

Add’l Labor Categ. Add’l Labor Categ. Additional Labor Category Form

SC 2 QIO Subconts2 Personnel loading chart for other consultants and other subcontractors

Travel Detail Form Travel Detail Form Travel Detail Form

QIO ODC QIO ODC Other Direct Costs

All of the cost information is entered on the BFCC Sup Sch YR 1-5 forms, the Additional Labor Category form, the Travel Detail Form and the QIO ODC form. The information you enter on these forms flows to the BFCC Sup Sch Total form. Cells that do not require your entry are blocked. For specific data entry instructions, please see Section IV of the Table of Contents.