E.1 Prime Contractor Proposal Checklist .doc

Exhibit E.1

75FCMC18R00046

National Correct Coding Initiative

Prime Proposal Checklist The prime contractor shall complete the following checklist for the National Correct Coding Initiative (NCCI) proposal. This submission will allow CMS to more readily identify various aspects of your proposal. Please check the appropriate items and provide an explanation, if necessary.

1) Company name, address, point of contact and telephone number

2) If a newly formed company, provide name and address of parent companies forming the new entity:

a. __________________ b.__________________

3) List of proposed subcontractors (if applicable):

a. _____________________________________

b. _____________________________________

c. _____________________________________

4) In accordance with the North American Industry Code 541990, indicate the business size of the prime entity/company. If the NAICS above does not fit with the subcontract requirement, provide the appropriate NAICS and why it was chosen.

□ Large Business

□ Small Business – if so, please indicate size standard for the NAICS above:

5) TIN # _______________

6) DUNS# _______________

7) Productive Hours for Exempt and Non-Exempt Employees ________

8) Number of FTEs and Hours Proposed:

TOTAL PROPOSED FTEs:

FTEs

Direct

Indirect

Subs

Total

TOTAL PROPOSED HOURS:

Hours

Direct

Indirect

Subs

Total