E.2 Subcontractor Proposal Checklist.doc
DOC document 45 KB Posted
- Attached to
- National Corrective Coding Initiative (NCCI)
- Solicitation number
- 75FCMC18R0046
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E.2 Subcontractor Proposal Checklist
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Exhibit E.2
75FCMC18R00046
National Correct Coding Initiative
Subcontractor Proposal Checklist NCCI Each subcontractor to a 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) Prime Offeror’s Name: _________________________________
2) Subcontractor company name, address, point of contact and telephone number
3) If a newly formed company, provide name and address of parent companies forming the new entity:
a. __________________ b.__________________
4) List of proposed subcontractors (if applicable):
a. _____________________________________
b. _____________________________________
c. _____________________________________
5) In accordance with the North American Industry Code 541990, indicate the business size of the prime entity/company.
□ Large Business
□ Small Business – if so, please indicate size standard for the NAICS above:
6) TIN # _______________
7) DUNS# _______________
8) Contract Type _________________________
9) Productive Hours for Exempt and Non-Exempt Employees _______________
10) Number of FTEs and Hours Proposed:
TOTAL PROPOSED FTEs:
FTE’s
| CLIN 0001 |
| CLIN 0002 |
OY1
| CLIN 0003 OY2 |
| CLIN 0004 OY3 |
| CLIN 0005 OY4 |
| TOTAL |
Direct
Indirect
Subs
Total
TOTAL PROPOSED HOURS:
Hours
| CLIN 0001 |
| CLIN 0002 |
OY1
| CLIN 0003 OY2 |
| CLIN 0004 OY3 |
| CLIN 0005 OY4 |
| TOTAL |
Direct
Indirect
Subs
Total
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