J.43 CLIN 0010 Cost Proposal Template - Option Year 4

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Attached to
Part A/B Medicare Administrative Contractor, Jurisdiction E
Solicitation number
75FCMC19R0023
Issued by

About this file

Written by GovTribe AI ·

This document provides details for a federal contract opportunity to serve as the Medicare Administrative Contractor for Jurisdiction E. The Centers for Medicare and Medicaid Services seeks to award a contract to administer Medicare claims processing, payment services, and provider support for California, Hawaii, Nevada, American Samoa, Guam, and Northern Mariana Islands. Key requirements include performing claims-related activities, establishing provider relationships, and ensuring financial integrity of the Medicare Fee-For-Service Program in accordance with applicable laws and regulations. Interested offerors should submit proposals in response to a solicitation expected to be released on September 4, 2019, with a proposal due date of November 4, 2019. The contract would include a one-year base period and six one-year options, to be awarded on August 4, 2020 using a best-value tradeoff process evaluating cost and technical factors.

From the source

RFP Attachment

Text of this file

CLIN-0010 Consolidated SLIN

COST TEMPLATE - Attachment J.43
(Provide a cost spreadsheet for each CLIN proposed)
CLIN 0010 ConsolidatedSLIN 0010AA (PM)SLIN 0010AB (MIP)SLIN 0010AC (RAC)SLIN 0010AD (VA)SLIN 0010AKSLIN 0010AL
A/B SERVICESTotal FTEsProgram Management (PM)Medicare Integrity Program (MIP)Support of Recovery Audit Program OperationsVA Remittance Advice Project (JH only)South Florida Enrollment Project (JN only)Records Storage and Retrieval Costs (J5 only)GRAND TOTAL
HoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursTotal
COST ELEMENTS
Direct Labor
0$00$00$00$00$00$00$0.00
0$00$00$00$00$00$00$0.00
0$00$00$00$00$00$00$0.00
0$00$00$00$00$00$00$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)0$00$00$00$00$00$00$0.00
0$00$00$00$00$00$00$0.00
0$00$00$00$00$00$00$0.00
0$00$00$00$00$00$00$0.00
0$00$00$00$00$00$00$0.00
0$00$00$00$00$00$00$0.00
Subtotal Direct Labor0$00$00$00$00$00$00$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 Name0$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$0.00
Total Subcontractor0$00$00$00$00$00$00$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-0010

COST TEMPLATE - Attachment J.43
(Provide a cost spreadsheet for each CLIN proposed)
CLIN 0010SLIN 0010 PM ASLIN 0010 MIP ASLIN 0010 PM BSLIN 0010 MIP BSLIN 0010 RAC ASLIN 0010 RAC BSLIN 0010 VA ASLIN 0010 VA BSLIN 0010AKSLIN 0010AL
A/B SERVICESTotal FTEsPart 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 OperationsPart B/Support of Recovery Audit Program OperationsVA 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
HoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursTotal
COST ELEMENTS
Direct Labor
0$00$00$00$00$00$00$00$00$00$00$0.00
0$00$00$00$00$00$00$00$00$00$00$0.00
0$00$00$00$00$00$00$00$00$00$00$0.00
0$00$00$00$00$00$00$00$00$00$00$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)0$00$00$00$00$00$00$00$00$00$00$0.00
0$00$00$00$00$00$00$00$00$00$00$0.00
0$00$00$00$00$00$00$00$00$00$00$0.00
0$00$00$00$00$00$00$00$00$00$00$0.00
0$00$00$00$00$00$00$00$00$00$00$0.00
0$00$00$00$00$00$00$00$00$00$00$0.00
Subtotal Direct Labor0$00$00$00$00$00$00$00$00$00$00$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 Name0$00$00$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$0.00
Total Subcontractor0$00$00$00$00$00$00$00$00$00$00$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.43
TRAVEL SUMMARY
CLIN 0010
Purpose of TripSOW WBS
CrosswalkLabor Category Taking TripTrip OriginDestination# People
(A)# Trips
(B)# Days
(C)# Nights
(D)Lodging Rate
(E)Lodging
(F=E*D*A)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.43
(Provide an ODC Spreadsheet for each CLIN Proposed)
CLIN 0010 A/B SERVICESSLIN 0010 PM ASLIN 0010 MIP ASLIN 0010 PM BSLIN 0010 MIP BSLIN 0010 RAC ASLIN 0010 RAC BSLIN 0010 VA ASLIN 0010 VA BSLIN 0010AK Enrollment Proj.SLIN 0010AL Rec. StorageGRAND
Cost ElementAmountAmountAmountAmountAmountAmountAmountAmountAmountAmountTOTAL
$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-0010 PM A

COST TEMPLATE - Attachment J.43
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0010 PM AC.1.4.4C.5.3C.5.4C.5.5C.5.7C.5.8C.5.9C.5.10C.5.11C.5.23C.5.27C.6C.7IZ
A/B SERVICESTotal FTEsHome Health and Hospice RequirementsInfrastructure RequirementsAdministrative RequirementsProvider EnrollmentProvider Customer Service ProgramClaims ProcessingReopenings of Medicare Initial Claims DeterminationsAppeals of Medicare Initial Claims DeterminationsFM of Trust Fund DollarsProgram Management OfficeSupport & Coordination with SMRC OperationsInterface RequirementsJurisdiction Specific RequirementsCREDITSAWARD FEEGRAND TOTAL
Program ManagementHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursTotal
COST ELEMENTS
Direct Labor
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
Subtotal Direct Labor0$00$00$00$00$00$00$00$00$00$00$00$00$00$0.00

Fringe Benefits (at ____%) $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 $0.00

Travel$0$0$0$0$0$0$0$0$0$0$0$0$0$0.00
SUBCONTRACTORS
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$00$00$00$0.00
Total Subcontractor0$00$00$00$00$00$00$00$00$00$00$00$00$00$0.00

Other Direct Costs $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 $0.00

Indirect Costs (at ______ %) $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 $0.00

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

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

SLIN-0010 MIP A

COST TEMPLATE - Attachment J.43
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0010 MIP AC.1.4.4C.5.6C.5.7C.5.11C.5.12C.5.13C.5.14C.5.15C.6C.7Z
A/B SERVICESTotal FTEsHome Health and Hospice RequirementsLCDsProvider Customer Service ProgramFM of Trust Fund DollarsMedical ReviewCoordination with PSCs/ZPICsMSPProvider OversightInterface RequirementsJurisdiction Specific RequirementsAWARD FEEGRAND TOTAL
Medicare Integrity ProgramHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursTotal
COST ELEMENTS
Direct Labor
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
Subtotal Direct Labor0$00$00$00$00$00$00$00$00$00$00$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 Name0$00$00$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$0.00
Total Subcontractor0$00$00$00$00$00$00$00$00$00$00$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 ______%)$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 $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

SLIN-0010 PM B

COST TEMPLATE - Attachment J.43
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0010 PM BC.5.3C.5.4C.5.5C.5.7C.5.8C.5.9C.5.10C.5.11C.5.23C.5.27C.6C.7IZ
A/B SERVICESTotal FTEsInfrastructureAdministrative RequirementsProvider EnrollmentProvider Customer Service ProgramClaims ProcessingReopenings of Medicare Initial Claims DeterminationsAppeals of Medicare Initial Claims DeterminationsFM of Trust Fund DollarsProgram Management OfficeSupport & Coordination with SMRC OperationsInterface RequirementsJurisdiction Specific RequirementsCREDITSAWARD FEEGRAND TOTAL
Program ManagementHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursTotal
COST ELEMENTS
Direct Labor
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
Subtotal Direct Labor0$00$00$00$00$00$00$00$00$00$00$00$00$0.00

Fringe Benefits (at ____%) $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 $0.00

Travel$0$0$0$0$0$0$0$0$0$0$0$0$0.00
SUBCONTRACTORS
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$00$00$0.00
Total Subcontractor0$00$00$00$00$00$00$00$00$00$00$00$00$0.00

Other Direct Costs $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 $0.00

Indirect Costs (at ______ %) $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 $0.00

Base Fee (at ____%)$0$0$0$0$0$0$0$0$0$0$0$0$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

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0 $0 $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$0$0$0$0$0$0$0$0.00
V1.3 04092012

75FCMC19R0023

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

Confidential Procurement Sensitive

SLIN-0010 MIP B

COST TEMPLATE - Attachment J.43
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0010 MIP BC.5.6C.5.7C.5.12C.5.13C.5.14C.5.15C.6C.7Z
A/B SERVICESTotal FTEsLCDsProvider Customer Service ProgramMedical ReviewCoordination with PSCs/ZPICsMSPProvider OversightInterface RequirementsJurisdiction Specific RequirementsAWARD FEEGRAND TOTAL
Medicare Integrity ProgramHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursTotal
COST ELEMENTS
Direct Labor
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
Subtotal Direct Labor0$00$00$00$00$00$00$00$00$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 Name0$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$00$00$00$0.00
Total Subcontractor0$00$00$00$00$00$00$00$00$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 ______%)$0$0.00
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 $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$0.00

75FCMC19R0023

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

Confidential Procurement Sensitive

SLIN-0010 RAC A

COST TEMPLATE - Attachment J.43
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0010 RAC AC.5.26.1C.5.26.2C.5.26.3C.5.26.4C.5.26.5ReservedReservedZ
A/B SERVICESTotal FTEsAdjustment of Recovery Auditor Selected ClaimsHandling Underpayments and Overpayments Identified by the Recovery AuditorAppeals of Recovery Auditor Adjusted ClaimsReporting for Recovery Audit Program Support OperationsOther Recovery Audit Program Support ActivitiesFuture UseFuture UseAWARD FEEGRAND TOTAL
HoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursTotal
COST ELEMENTS
Direct Labor
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
Subtotal Direct Labor0$00$00$00$00$00$0.00

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

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

Travel$0$0$0$0$0$0.00
SUBCONTRACTORS
Subcontractor Name0$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$0.00
Total Subcontractor0$00$00$00$00$00$0.00

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

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

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

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

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

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

75FCMC19R0023

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

Confidential Procurement Sensitive

SLIN-0010 RAC B

COST TEMPLATE - Attachment J.43
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0010 RAC BC.5.26.1C.5.26.2C.5.26.3C.5.26.4C.5.26.5ReservedZ
A/B SERVICESTotal FTEsAdjustment of Recovery Auditor Selected ClaimsHandling Underpayments and Overpayments Identified by the Recovery AuditorAppeals of Recovery Auditor Adjusted ClaimsReporting for Recovery Audit Program Support OperationsOther Recovery Audit Program Support ActivitiesFuture UseAWARD FEEGRAND TOTAL
HoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursTotal
COST ELEMENTS
Direct Labor
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
0$0.00$00$0.00$00$0.00$00$0.00$00$0.00$00$0.00
Subtotal Direct Labor0$00$00$00$00$00$0.00

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

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

Travel$0$0$0$0$0$0.00
SUBCONTRACTORS
Subcontractor Name0$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$0.00
Subcontractor Name0$00$00$00$00$00$0.00
Total Subcontractor0$00$00$00$00$00$0.00

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

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

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

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

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

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

75FCMC19R0023

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

Confidential Procurement Sensitive

SLIN-0010AK

COST TEMPLATE - Attachment J.43
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0010AK - C.7.23C.7.23
A/B SERVICESTotal FTEsSouth Florida Enrollment Pilot for High Risk Providers (JN only)
HoursRatesTotal
COST ELEMENTS
Direct Labor
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
0$0.00$0
0$0.00$0
Subtotal Direct Labor0$0

Fringe Benefits (at ____%) $0

Total Direct Labor $0

Travel$0
SUBCONTRACTORS
Subcontractor Name0$0
Subcontractor Name0$0
Subcontractor Name0$0
Subcontractor Name0$0
Subcontractor Name0$0
Subcontractor Name0$0
Total Subcontractor0$0

Other Direct Costs $0

TOTAL ALL DIRECT COSTS $0

Indirect Costs (at ______ %) $0

TOTAL OTHER BEFORE FEE $0

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

SLIN-0010AL

COST TEMPLATE - Attachment J.43
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0010AL - C.7.34C.7.34
A/B SERVICESTotal FTEsRecords Storage and Retrieval Costs for non-J5 Legacy A Records (J1, J4, J12) (Jurisdiction 5 only)
HoursRatesTotal
COST ELEMENTS
Direct Labor
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
0$0.00$0
0$0.00$0
Subtotal Direct Labor0$0

Fringe Benefits (at ____%) $0

Total Direct Labor $0

Travel$0
SUBCONTRACTORS
Subcontractor Name0$0
Subcontractor Name0$0
Subcontractor Name0$0
Subcontractor Name0$0
Subcontractor Name0$0
Subcontractor Name0$0
Total Subcontractor0$0

Other Direct Costs $0

TOTAL ALL DIRECT COSTS $0

Indirect Costs (at ______ %) $0

TOTAL OTHER BEFORE FEE $0

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

Reserved

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

Confidential Procurement Sensitive

Other files

File Type Posted
75FCMC19R0023_Amendment_2.pdf PDF
Amendment_2,_Attachment_1_-_RFP_Question_Responses.xlsx XLSX spreadsheet
JE_Amendment_1_CLEAN_Attachments_UPDATED.zip ZIP file
Amendment_1,_Attachment_1_REDLINE_Backpages.pdf PDF
JE_Amendment_1_REDLINED_Attachments_UPDATED.zip ZIP file
JE_RFP_Questions_and_Responses_Amendment_1.xlsx XLSX spreadsheet
75FCMC19R0023_Amendment_1.pdf PDF
J.23 Government Provided Proposal Assumptions —
J.39 CLIN 0006 Cost Proposal Template - Option Year 2 —
J.1.G AB MAC Performance Requirements Summary.docx DOCX document
J.22 Basis of Estimate.xlsx XLSX spreadsheet
J.42 CLIN 0009 Cost Proposal Template - Option Year 3 —
J.34 CLIN 0001 Cost Proposal Template - Implementation.xlsx XLSX spreadsheet
J.1 Statement of Work —
J.40 CLIN 0007 Cost Proposal Template - Option Year 2 —
J.28 Product Accessibility Template.docx DOCX document
J.1.C Fee-For-Service Shared System Base Functions.docx DOCX document
J.5 Government Systems Provided For Use.docx DOCX document
J.46 CLIN 0013 Cost Proposal Template - Option Year 5 —
J.37 CLIN 0004 Cost Proposal Template - Option Year 1 —
J.45 CLIN 0012 Cost Proposal Template - Option Year 5 —
J.49 CLIN 0016 Cost Proposal Template - Outgoing Contractor Workload Transition Activities.xlsx XLSX spreadsheet
J.10 Contractor Business Ethics COI and Compliance Program Requirements.docx DOCX document
J.1.A List of Key Definitions.docx DOCX document
J.23.A Government Provided Proposal Assumptions Audit and Reimbursement Tables.xlsx XLSX spreadsheet
J.33 Cost Template Summary Sheet.xlsx XLSX spreadsheet
J.23.B Government Provided Proposal Assumptions CSR-Handled Telephone Inquiries Tables.docx DOCX document
75FCMC19R0023.pdf PDF
J.11 Personal Conflicts of Interest Financial Disclosure.docx DOCX document
J.2 Deliverable Schedule.docx DOCX document
J.1.D Cash Collections Worksheet For HIGLAS Users.xlsx XLSX spreadsheet
J.44 CLIN 0011 Cost Proposal Template - Option Year 4 —
J.24 Attestations.docx DOCX document
J.47 CLIN 0014 Cost Proposal Template - Option Year 6 —
J.3 Small Business Subcontracting Plan Template.docx DOCX document
J.35 CLIN 0002 Cost Proposal Template - Base Year —
J.32 Systems of Records.docx DOCX document
J.48 CLIN 0015 Cost Proposal Template - Option Year 6 —
J.7 AB MAC Award Fee Plan and Self Assessment Template.docx DOCX document
J.25 Past Performance Questionnaire.docx DOCX document
J.4 HHS Contracting Guide for Contract of Government Property.docx DOCX document
J.41 CLIN 0008 Cost Proposal Template - Option Year 3 —
J.9 Non-Disclosure Statement.docx DOCX document
J.1.B List of Key Acronyms.docx DOCX document
J.36 CLIN 0003 Cost Proposal Template - Base Year —
J.38 CLIN 0005 Cost Proposal Template - Option Year 1 —
J.8 MAC Security Incident and Reportable Event Reporting and Response.docx DOCX document
J.6 Contractor Furnished Property.docx DOCX document
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