J.35 CLIN 0002 Cost Proposal Template - Base Year

491 KB Posted Sep 4, 2019

Attached to: Part A/B Medicare Administrative Contractor, Jurisdiction E
Solicitation number: 75FCMC19R0023
Issued by: Department of Health and Human Services Centers for Medicare and Medicaid Services

About this file

Written by GovTribe AI · Dec 28, 2023

This document provides details for a forthcoming solicitation from the Centers for Medicare and Medicaid Services seeking a Medicare Administrative Contractor to provide specified health insurance benefit administration services in Jurisdiction E. Key information includes that the contractor will perform claims processing, payment, and provider relationship management functions to support Medicare Fee-For-Service beneficiaries in California, Hawaii, Nevada, American Samoa, Guam, and the Northern Mariana Islands. The base period of performance is one year with six one-year options. Offerors should submit proposals by November 4, 2019, with an anticipated award date of August 4, 2020. The solicitation is expected pending availability of funds.

From the source

RFP Attachment

Text of this file

CLIN-0002 Consolidated SLIN

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

CLIN 0002 Consolidated

SLIN 0002AA (PM)

SLIN 0002AB (MIP)

SLIN 0002AC (RAC)

SLIN 0002AD (VA)

SLIN 0002AK

SLIN 0002AL

A/B SERVICES

Total FTEs

Program Management (PM)

Medicare Integrity Program (MIP)

Support of Recovery Audit Program Operations

VA Remittance Advice Project (JH only)

South Florida Enrollment Project (JN only)

Records Storage and Retrieval Costs (J5 only)

GRAND 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	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$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	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subtotal Direct Labor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00

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

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

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

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

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

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

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

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

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

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

v3-02 20190117

v2-10 20180824

75FCMC19R0023

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

CLIN-0002

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

CLIN 0002

SLIN 0002 PM A

SLIN 0002 MIP A

SLIN 0002 PM B

SLIN 0002 MIP B

SLIN 0002 RAC A

SLIN 0002 RAC B

SLIN 0002 VA A

SLIN 0002 VA B

SLIN 0002AK

SLIN 0002AL

A/B SERVICES

Total FTEs

Part A/Program Management (PM)

Part A/Medicare Integrity Program (MIP)

Part B/Program Management (PM)

Part B/Medicare Integrity Program (MIP)

Part A/Support of Recovery Audit Program Operations

Part B/Support of Recovery Audit Program Operations

VA Remittance Advice Project Part A (JH only)

VA Remittance Advice Project Part B (JH only)

South Florida Enrollment Pilot for High Risk Providers (JN only)

Records Storage and Retrieval Costs for Non-J5 Legacy A Records (J5 only)

GRAND 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	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$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	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$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 (See separate schedule. Total should match)		$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 (See separate schedule. Total should match.) $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	$0	$0	$0	$0	$0	$0	$0	$0	$0.00
Fixed Fee (at ______%)	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0.00

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

Complementary Credits	$0		$0								$0.00
Note: Comp. credit information will be provided by CMS 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	$0.00
v.1.58 05042016

75FCMC19R0023

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

TRAVEL

COST TEMPLATE - Attachment J.35

TRAVEL SUMMARY

CLIN 0002

	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:

75FCMC19R0023

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

ODC

COST TEMPLATE - Attachment J.35
(Provide an ODC Spreadsheet for each CLIN Proposed)
CLIN 0002 A/B SERVICES	SLIN 0002 PM A	SLIN 0002 MIP A	SLIN 0002 PM B	SLIN 0002 MIP B	SLIN 0002 RAC A	SLIN 0002 RAC B	SLIN 0002 VA A	SLIN 0002 VA B	SLIN 0002AK Enrollment Proj.	SLIN 0002AL Rec. Storage	GRAND
Cost Element	Amount	Amount	Amount	Amount	Amount	Amount	Amount	Amount	Amount	Amount	TOTAL
											$0.00
Add costs by category											$0.00
											$0.00
											$0.00
											$0.00
											$0.00
											$0.00
											$0.00
TOTAL ODCs	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00

75FCMC19R0023

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

SLIN-0002 PM A

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 PM A

C.1.4.4

C.5.3

C.5.4

C.5.5

C.5.7

C.5.8

C.5.9

C.5.10

C.5.11

C.5.23

C.5.27

C.6

C.7

A/B SERVICES

Total FTEs

Home Health and Hospice Requirements

Infrastructure Requirements

Administrative Requirements

Provider Enrollment

Provider Customer Service Program

Claims Processing

Reopenings of Medicare Initial Claims Determinations

Appeals of Medicare Initial Claims Determinations

FM of Trust Fund Dollars

Program Management Office

Support & Coordination with SMRC Operations

Interface Requirements

Jurisdiction Specific 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

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

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

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

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

Travel		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0.00		$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	0	$0	0	$0.00	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	0	$0	0	$0.00	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	0	$0	0	$0.00	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	0	$0	0	$0.00	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	0	$0	0	$0.00	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	0	$0	0	$0.00	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	0	$0	0	$0.00	0	$0.00

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

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

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

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

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

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

Complementary Credits														$0		$0.00
Note: Comp. credit information will be provided by CMS 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	$0	$0	$0.00

75FCMC19R0023

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

C.5.3

COST TEMPLATE - Attachment J.35
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002 PM A - C.5.3		C.5.3.1			C.5.3.2
A/B SERVICES	Total FTEs	VDC			Telecommunications			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 (See separate schedule)		$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 ______%)
Fixed Fee (at ______%)	$0	$0	$0.00

TOTAL OTHER AFTER FEE $0 $0 $0.00

GRAND TOTAL $0 $0 $0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

C.5.4

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 PM A- C.5.4

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

A/B SERVICES

Total FTEs

Security

Quality Assurance Requirements

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

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	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	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	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	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	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	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	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	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	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		$0.00	$0		$0.00	$0	0	$0		$1.00	$0		$1.00	$0		$1.00	$0		$1.00	$0		$1.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0		$0	0	$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00

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

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

Travel		$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	$0.00
Subcontractor Name	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	$0.00
Subcontractor Name	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	$0.00
Subcontractor Name	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	$0.00

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

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

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

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

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

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

GRAND TOTAL $0 $0 $0 $0 $0 $0 $0 $0 $0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

C.5.4.5

COST TEMPLATE - Attachment J.35
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002 PM A - C.5.4.5		C.5.4.5.3
A/B SERVICES	Total FTEs	Responding to Complex Beneficiary Inquiries
Program Management		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 (See separate schedule)		$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 ______%)
Fixed Fee (at ______%)	$0

TOTAL OTHER AFTER FEE $0

GRAND TOTAL $0

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

C.5.5

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 PM A - C.5.5

C.5.5.1

C.5.5.2

C.5.5.3

C.5.5.4

C.5.5.5

C.5.5.6

A/B SERVICES

Total FTEs

Process Initial Enrollment and Revalidation Applications

Process Changes, Updates, Reassignments or Corrections

Revocations/Deactivations

Provider Enrollment Appeals

Maintain State-Specific Licensure/Certification Information

Participating Physician Enrollment

GRAND TOTAL

Program Management

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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0	0	$0.00	$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	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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0	0	$0.00	$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		$0.00	$0		$0.00	$0		$0.00	$0	0	$0.00
Subtotal Direct Labor	0	$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00

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

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

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

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

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

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

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

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

TOTAL COSTS $0 $0 $0 $0 $0 $0 $0.00

GRAND TOTAL $0 $0 $0 $0 $0 $0 $0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

C.5.5.1

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 PM A - C.5.5.1

C.5.5.1.1

C.5.5.1.2

C.5.5.1.3

A/B SERVICES

Total FTEs

Process A/B Initial Enrollments

Process A/B Initial Revalidations

Process Other than A/B Initial Enrollments

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
		$0.00	$0		$0.00	$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 ______%)
Fixed Fee (at ______%)	$0	$0	$0	$0.00

TOTAL COSTS $0 $0 $0 $0.00

GRAND TOTAL $0 $0 $0 $0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

C.5.7

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 PM A - C.5.7

C.5.7.1

C.5.7.2

C.5.7.3

C.5.7.4

A/B SERVICES

Total FTEs

Provider Outreach & Education

Provider Contact Center

Provider Self-Service Technology

PCSP Staff Training

GRAND TOTAL

Program Management

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	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$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	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00
		$0.00	$0	0	$0	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 ______%)
Fixed Fee (at ______%)	$0	$0	$0	$0	$0.00

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

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

75FCMC19R0023

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

C.5.7.2

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 PM A - C.5.7.2

C.5.7.2.1

C.5.7.2.2

C.5.7.2.3

C.5.7.2.4

A/B SERVICES

Total FTEs

Telephone Inquiries

Written Inquiries

Provider Relations Research Specialist

Inquiry Tracking System

GRAND TOTAL

Program Management

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
	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
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 ______%)
Fixed Fee (at ______%)	$0	$0	$0	$0	$0.00

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

GRAND TOTAL $0 $0 $0 $0 $0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

C.5.7.3

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 PM A - C.5.7.3

C.5.7.3.1

C.5.7.3.2

C.5.7.3.3

C.5.7.3.5

A/B SERVICES

Total FTEs

Interactive Voice Response

Web Technology

Provider Listserv

Provider Internet Portal

GRAND TOTAL

Program Management

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
	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
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 ______%)
Fixed Fee (at ______%)	$0	$0	$0	$0	$0.00

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

GRAND TOTAL $0 $0 $0 $0 $0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

C.5.8

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 PM A- C.5.8

C.5.8.1

C.5.8.2

C.5.8.3

C.5.8.4

A/B SERVICES

Total FTEs

Standard Paper Remittance Advice Transactions

General Claims Processing

Development of Suspended Claims

Back-End Processing

GRAND TOTAL

Program Management

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
		$0.00	$0		$0.00	$0		$0.00	$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 (See separate schedule)		$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 (See separate schedule) $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 ______%)
Fixed Fee (at ______%)	$0	$0	$0	$0	$0.00

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

GRAND TOTAL $0 $0 $0 $0 $0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

C.5.10

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 PM A - C.5.10

C.5.10.1

C.5.10.2

C.5.10.3

A/B SERVICES

Total FTEs

Redermination Requests

Appeal Decision Effectuation

Monthly Statistical Rpt on Reopenings & Appeals Activty

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
		$0.00	$0		$0.00	$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	0
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 ______%)
Fixed Fee (at ______%)	$0	$0	$0	$0.00

TOTAL COSTS $0 $0 $0 $0.00

GRAND TOTAL $0 $0 $0 $0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

C.5.11

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 PM A - C.5.11

C.5.11.1

C.5.11.2

C.5.11.3

C.5.11.4

C.5.11.5

C.5.11.6

C.5.11.7

C.5.11.8

C.5.11.9

C.5.11.10

A/B SERVICES

Total FTEs

Use of Trust Fund

Banking Relations

Cost Reporting and Reimbursement Payment Policy

Non-MSP Overpayment

Non-MSP Debt Collection Activities

Non-MSP Debt Referral

Unsolicited/Voluntary Refunds

Overpayment Related to Bankruptcy

Financial Reporting & Accounting

Medicare Credit Balance Report Activities

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

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$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	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
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	$0.00	$0	0	$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	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	$0.00	$0	0	$0.00	$0	0	$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	$0.00	$0	0	$0.00	$0	0	$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	$0.00	$0	0	$0.00	$0	0	$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	$0.00	$0	0	$0.00	$0	0	$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	$0.00	$0	0	$0.00	$0	0	$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	$0.00	$0	0	$0.00	$0	0	$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
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 ______%)
Fixed Fee (at ______%)	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0.00

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

GRAND TOTAL $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

C.5.11.3

COST TEMPLATE - Attachment J.35
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002 PM A - C.5.11.3		C.5.11.3.3			C.5.11.3.5
A/B SERVICES	Total FTEs	Provider Reimbursement			Provider Based Determinations			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
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
	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 ______%)
Fixed Fee (at ______%)	$0	$0	$0.00

TOTAL OTHER AFTER FEE $0 $0 $0.00

GRAND TOTAL $0 $0 $0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

C.5.11.7

COST TEMPLATE - Attachment J.35
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002 PM A - C.5.11.7		C.5.11.7.1
A/B SERVICES	Total FTEs	UNSOLICITED/VOLUNTARY REFUNDS
Program Management		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 (See separate schedule)		$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 ______%)
Fixed Fee (at ______%)	$0

TOTAL OTHER AFTER FEE $0

GRAND TOTAL $0

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

C.6 (2)

COST TEMPLATE - Attachment J.35
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002 PM A - C.6		C.6.1			C.6.2
A/B SERVICES	Total FTEs	Successful Collaboration with Entities Requiring Joint Operating Agreement			Successful Collaboration and Coordination with Other Internal and External Entities			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 ______%)
Fixed Fee (at ______%)	$0	$0	0

TOTAL OTHER AFTER FEE $0 $0 0

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

75FCMC19R0023

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

C.7

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 PM A - C.7

C.7.1

C.7.2

Reserved

C.7.14

C.7.15

C.7.16

C.7.17

C.7.18

C.7.22

C.7.24

C.7.29

Reserved

C.7.36

C.7.37

A/B SERVICES

Total FTEs

Centralized Billing for Mass Immunizers (JH, J5 only)

Indian Health Services (JH only)

For Future Use

Limited Purpose Insurance Company (JJ only)

Independent Organ Procurement Organizations (JJ only)

Religious Non-Medical Health Care Institutions (JJ only)

Histocompatibility Labs (JJ only)

Spanish Translation of HCPCS Code Descriptors (JN only)

Medicare Coordinated Care Demo (JK only)

Environmental Health Hazards Pilot Project (JF only)

Medicare Essential Hospital Payment Program (JF only)

For Future Use

PA PMD Demo (J6 only)

Mayo Clinic Project (J6 only)

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

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$1.00	$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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0
	0	$0.00	$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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0
	0	$0.00	$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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0
	0	$0.00	$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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0
	0	$0.00	$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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0
	0	$0.00	$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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0
	0	$0.00	$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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0
	0	$0.00	$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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$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	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 $0 $0 $0 $0 $0 $0 $0.00

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

Travel		$0		$0		$0		$0		$0		$0		$0		$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	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	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	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	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	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	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	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 $0 $0 $0 $0 $0 $0 $0.00

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

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0 $0 $0 $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	$0	$0	$0	$0	$0	$0	$0.00
Award Fee (at ______%)
Fixed Fee (at ______%)	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0.00

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

GRAND TOTAL $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

SLIN-0002 MIP A

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 MIP A

C.1.4.4

C.5.6

C.5.7

C.5.11

C.5.12

C.5.13

C.5.14

C.5.15

C.6

C.7

A/B SERVICES

Total FTEs

Home Health and Hospice Requirements

LCDs

Provider Customer Service Program

FM of Trust Fund Dollars

Medical Review

Coordination with PSCs/ZPICs

MSP

Provider Oversight

Interface Requirements

Jurisdiction Specific Requirements

AWARD FEE

GRAND TOTAL

Medicare Integrity Program

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

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

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

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

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

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

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

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

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

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

Complementary Credits
Note: Comp. credit information will be provided by CMS 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	$0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

C.5.7(2)

COST TEMPLATE - Attachment J.35
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002 MIP A - C.5.7		C.5.7.1
A/B SERVICES	Total FTEs	Provider Outreach & Education
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 ______%)
Fixed Fee (at ______%)	$0

TOTAL OTHER AFTER FEE $0

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

75FCMC19R0023

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

C.5.11(2)

COST TEMPLATE - Attachment J.35
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002 MIP A - C.5.11		C.5.11.3
A/B SERVICES	Total FTEs	Cost Reporting and Reimbursement Payment Policy
Medicare Integrity Program		Hours	Rates	Total
COST ELEMENTS

Direct Labor
	0	$0
	0	$0

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Other files

File	Type	Posted
75FCMC19R0023_Amendment_2.pdf	PDF	Oct 17, 2019
Amendment_2,_Attachment_1_-_RFP_Question_Responses.xlsx	XLSX spreadsheet	Oct 17, 2019
JE_Amendment_1_CLEAN_Attachments_UPDATED.zip	ZIP file	Oct 8, 2019
Amendment_1,_Attachment_1_REDLINE_Backpages.pdf	PDF	Oct 8, 2019
JE_Amendment_1_REDLINED_Attachments_UPDATED.zip	ZIP file	Oct 8, 2019
JE_RFP_Questions_and_Responses_Amendment_1.xlsx	XLSX spreadsheet	Oct 8, 2019
75FCMC19R0023_Amendment_1.pdf	PDF	Oct 8, 2019
J.23 Government Provided Proposal Assumptions	—	Sep 4, 2019
J.39 CLIN 0006 Cost Proposal Template - Option Year 2	—	Sep 4, 2019
J.1.G AB MAC Performance Requirements Summary.docx	DOCX document	Sep 4, 2019
J.22 Basis of Estimate.xlsx	XLSX spreadsheet	Sep 4, 2019
J.42 CLIN 0009 Cost Proposal Template - Option Year 3	—	Sep 4, 2019
J.34 CLIN 0001 Cost Proposal Template - Implementation.xlsx	XLSX spreadsheet	Sep 4, 2019
J.1 Statement of Work	—	Sep 4, 2019
J.40 CLIN 0007 Cost Proposal Template - Option Year 2	—	Sep 4, 2019
J.28 Product Accessibility Template.docx	DOCX document	Sep 4, 2019
J.1.C Fee-For-Service Shared System Base Functions.docx	DOCX document	Sep 4, 2019
J.5 Government Systems Provided For Use.docx	DOCX document	Sep 4, 2019
J.46 CLIN 0013 Cost Proposal Template - Option Year 5	—	Sep 4, 2019
J.37 CLIN 0004 Cost Proposal Template - Option Year 1	—	Sep 4, 2019
J.45 CLIN 0012 Cost Proposal Template - Option Year 5	—	Sep 4, 2019
J.49 CLIN 0016 Cost Proposal Template - Outgoing Contractor Workload Transition Activities.xlsx	XLSX spreadsheet	Sep 4, 2019
J.10 Contractor Business Ethics COI and Compliance Program Requirements.docx	DOCX document	Sep 4, 2019
J.1.A List of Key Definitions.docx	DOCX document	Sep 4, 2019
J.23.A Government Provided Proposal Assumptions Audit and Reimbursement Tables.xlsx	XLSX spreadsheet	Sep 4, 2019
J.33 Cost Template Summary Sheet.xlsx	XLSX spreadsheet	Sep 4, 2019
J.23.B Government Provided Proposal Assumptions CSR-Handled Telephone Inquiries Tables.docx	DOCX document	Sep 4, 2019
75FCMC19R0023.pdf	PDF	Sep 4, 2019
J.11 Personal Conflicts of Interest Financial Disclosure.docx	DOCX document	Sep 4, 2019
J.2 Deliverable Schedule.docx	DOCX document	Sep 4, 2019
J.1.D Cash Collections Worksheet For HIGLAS Users.xlsx	XLSX spreadsheet	Sep 4, 2019
J.44 CLIN 0011 Cost Proposal Template - Option Year 4	—	Sep 4, 2019
J.24 Attestations.docx	DOCX document	Sep 4, 2019
J.47 CLIN 0014 Cost Proposal Template - Option Year 6	—	Sep 4, 2019
J.3 Small Business Subcontracting Plan Template.docx	DOCX document	Sep 4, 2019
J.32 Systems of Records.docx	DOCX document	Sep 4, 2019
J.48 CLIN 0015 Cost Proposal Template - Option Year 6	—	Sep 4, 2019
J.7 AB MAC Award Fee Plan and Self Assessment Template.docx	DOCX document	Sep 4, 2019
J.25 Past Performance Questionnaire.docx	DOCX document	Sep 4, 2019
J.4 HHS Contracting Guide for Contract of Government Property.docx	DOCX document	Sep 4, 2019
J.41 CLIN 0008 Cost Proposal Template - Option Year 3	—	Sep 4, 2019
J.43 CLIN 0010 Cost Proposal Template - Option Year 4	—	Sep 4, 2019
J.9 Non-Disclosure Statement.docx	DOCX document	Sep 4, 2019
J.1.B List of Key Acronyms.docx	DOCX document	Sep 4, 2019
J.36 CLIN 0003 Cost Proposal Template - Base Year	—	Sep 4, 2019
J.38 CLIN 0005 Cost Proposal Template - Option Year 1	—	Sep 4, 2019
J.8 MAC Security Incident and Reportable Event Reporting and Response.docx	DOCX document	Sep 4, 2019
J.6 Contractor Furnished Property.docx	DOCX document	Sep 4, 2019

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