J.36 CLIN 0003 Cost Proposal Template - Option Year 1 (PM, MIP, RAC).xlsx

XLSX spreadsheet 276 KB Posted Jan 14, 2020

Attached to: Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) Jurisdiction C
Solicitation number: 75FCMC19R0041
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 is a cost proposal template and related documents for a Durable Medical Equipment Medicare Administrative Contractor contract solicitation from the Centers for Medicare and Medicaid Services. The contractor will provide specified health insurance benefit administration services, including Medicare claims processing and payment services, for Jurisdiction C which includes 17 states, Puerto Rico, and the U.S. Virgin Islands. The contractor will perform activities such as Medicare claims processing, payment of claims, appeals, medical review, benefit integrity, provider outreach and education, and other program support functions. The cost proposal template requires the contractor to provide labor hours, rates, and associated costs for each cost element and sub-element to support the work under various contract line item numbers.

View the file

Other files

File	Type	Posted
Q&A Solicitation 75FCMC19R0041 Amend 2.xlsx	XLSX spreadsheet	Feb 19, 2020
Amendment #0002.pdf	PDF	Feb 19, 2020
JC_Solicitation_75FCMC19R0041 CLEAN amend 2.docx	DOCX document	Feb 19, 2020
JC_Solicitation_75FCMC19R0041 redline amend 2.docx	DOCX document	Feb 19, 2020
JC_Solicitation_75FCMC19R0041 redline Amend 1.docx	DOCX document	Feb 13, 2020
J.23 Government Provided Proposal Assumptions (GPPA)-clean.docx	DOCX document	Feb 13, 2020
75FCMC19R0041.pdf	PDF	Feb 13, 2020
J.22 Basis of Estimate-redline.xlsx	XLSX spreadsheet	Feb 13, 2020
J.23 Government Provided Proposal Assumptions (GPPA)-redline.docx	DOCX document	Feb 13, 2020
J.22 Basis of Estimate-clean.xlsx	XLSX spreadsheet	Feb 13, 2020
Q&A Solicitation 75FCMC19R0041.xlsx	XLSX spreadsheet	Feb 13, 2020
JC_Solicitation_75FCMC19R0041 CLEAN Amend 1.docx	DOCX document	Feb 13, 2020
J.45 CLIN 0012 Cost Proposal Template - Option Year 2 (MPIP).xlsx	XLSX spreadsheet	Jan 14, 2020
J.1.B List of Key Acronyms.docx	DOCX document	Jan 14, 2020
J.37 CLIN 0004 Cost Proposal Template - Option Year 2 (PM, MIP, RAC).xlsx	XLSX spreadsheet	Jan 14, 2020
J.47 CLIN 0014 Cost Proposal Template - Option Year 4 (MPIP).xlsx	XLSX spreadsheet	Jan 14, 2020
J.1.C Fee-For-Service Shared System Base Functions.docx	DOCX document	Jan 14, 2020
J.40 CLIN 0007 Cost Proposal Template - Option Year 5 (PM, MIP, RAC).xlsx	XLSX spreadsheet	Jan 14, 2020
J.4 HHS Contracting Guide for Contract of Government Property.docx	DOCX document	Jan 14, 2020
J.24 Attestations.docx	DOCX document	Jan 14, 2020
J.41 CLIN 0008 Cost Proposal Template - Option Year 6 (PM, MIP, RAC).xlsx	XLSX spreadsheet	Jan 14, 2020
J.2 Deliverable Schedule.docx	DOCX document	Jan 14, 2020
J.7 DME MAC Award Fee Plan and Self Assessment Template.docx	DOCX document	Jan 14, 2020
J.35 CLIN 0002 Cost Proposal Template - Base Year (PM, MIP, RAC).xlsx	XLSX spreadsheet	Jan 14, 2020
J.5 Government Systems Provided For Use.docx	DOCX document	Jan 14, 2020
Solicitation 75FCMC19R0041.pdf	PDF	Jan 14, 2020
J.22 Basis of Estimate.xlsx	XLSX spreadsheet	Jan 14, 2020
J.33 Cost Template Summary Sheet.xlsx	XLSX spreadsheet	Jan 14, 2020
J.25 Past Performance Questionnaire.docx	DOCX document	Jan 14, 2020
J.9 Non-Disclosure Statement.docx	DOCX document	Jan 14, 2020
J.49 CLIN 0016 Cost Proposal Template - Option Year 6 (MPIP).xlsx	XLSX spreadsheet	Jan 14, 2020
J.28 Voluntary Product Accessibility Template.docx	DOCX document	Jan 14, 2020
J.23.B Government Provided Proposal Assumptions CSR-Handled Telephone Inquiries Tables.docx	DOCX document	Jan 14, 2020
J.39 CLIN 0006 Cost Proposal Template - Option Year 4 (PM, MIP, RAC).xlsx	XLSX spreadsheet	Jan 14, 2020
J.1.D Cash Collections Worksheet For HIGLAS Users.xlsx	XLSX spreadsheet	Jan 14, 2020
J.34 CLIN 0001 Cost Proposal Template - Implementation.xlsx	XLSX spreadsheet	Jan 14, 2020
J.3 Small Business Subcontracting Plan Template.docx	DOCX document	Jan 14, 2020
J.1 Statement of Work (SOW)_Jurisdiction C sent12-4.docx	DOCX document	Jan 14, 2020
J.11 Personal Conflicts of Interest Financial Disclosure.docx	DOCX document	Jan 14, 2020
J.10 Contractor-Business-Ethics-COI-and-Compliance-Program-Requirements.docx	DOCX document	Jan 14, 2020
J.1.A List of Key Definitions.docx	DOCX document	Jan 14, 2020
J.42 CLIN 0009 Cost Proposal Template - Outgoing Contractor Workload Transition Activities.xlsx	XLSX spreadsheet	Jan 14, 2020
J.6 Contractor Furnished Property.docx	DOCX document	Jan 14, 2020
J.48 CLIN 0015 Cost Proposal Template - Option Year 5 (MPIP).xlsx	XLSX spreadsheet	Jan 14, 2020
J.43 CLIN 0010 Cost Proposal Template - Base Year (MPIP).xlsx	XLSX spreadsheet	Jan 14, 2020
J.32 Systems of Records.docx	DOCX document	Jan 14, 2020
J.8 MAC Security Incident and Reportable Event Reporting and Response.docx	DOCX document	Jan 14, 2020
J.23 Government Provided Proposal Assumptions (GPPA).docx	DOCX document	Jan 14, 2020
J.44 CLIN 0011 Cost Proposal Template - Base Year (MPIP).xlsx	XLSX spreadsheet	Jan 14, 2020
J.38 CLIN 0005 Cost Proposal Template - Option Year 3 (PM, MIP, RAC).xlsx	XLSX spreadsheet	Jan 14, 2020

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CLIN-0003

COST TEMPLATE - SAMPLE Attachment J.36

(Provide a cost spreadsheet for each CLIN proposed)

CLIN 0003

SLIN 0003AA

SLIN 0003AB

SLIN 0003AC

SLIN 0003AE

DME SERVICES/OPTION PERIOD

Total FTEs

Program Management (PM)

Medicare Integrity Program (MIP)

Support of Recovery Audit Program Operations

IVG Demo (JA Only)

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

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

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

Travel			$0		$0		$0		$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0	0	$0	0	$0	0	$0	0	$0
Other Direct Costs		0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0
Total Subcontractor		0	$0	0	$0	0	$0	0	$0	0	$0

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0

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

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

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0

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

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0

Complementary Credits	$0				$0
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

v3-02 20190904

&"Arial,Bold"&12 &K00000075FCMC19R0041 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10

Confidential Procurement Sensitive

ODC Schedule

COST TEMPLATE - SAMPLE Attachment J.36
(Provide an ODC Spreadsheet for each CLIN Proposed)
CLIN 0003 DME SERVICES	SLIN 0003 PM	SLIN 0003 MIP	SLIN 0003 RAC	SLIN 0003	SLIN 0003	SLIN 0003	GRAND
Cost Element	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

	ERROR:#REF!	ERROR:#REF!
V1.9 03202012	ERROR:#REF!	ERROR:#REF!
	ERROR:#REF!	ERROR:#REF!
	ERROR:#REF!	ERROR:#REF!
	ERROR:#REF!	ERROR:#REF!
		ERROR:#REF!
		ERROR:#REF!
		ERROR:#REF!
	ERROR:#REF!	ERROR:#REF!
	ERROR:#REF!	ERROR:#REF!
	ERROR:#REF!	ERROR:#REF!
	ERROR:#REF!	ERROR:#REF!
	ERROR:#REF!	ERROR:#REF!
	ERROR:#REF!	ERROR:#REF!
	ERROR:#REF!	ERROR:#REF!
		ERROR:#REF!
		ERROR:#REF!
		ERROR:#REF!
		ERROR:#REF!
		ERROR:#REF!
		ERROR:#REF!
		ERROR:#REF!

Confidential Procurement Sensitive

Travel

TRAVEL SUMMARY

CLIN 0003

	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 )

	$ -	$ -	$ -	$ -
	$ -	$ -	$ -	$ -
	$ -	$ -	$ -	$ -
	$ -	$ -	$ -	$ -
	$ -	$ -	$ -	$ -
	$ -	$ -	$ -	$ -
	$ -	$ -	$ -	$ -
	$ -	$ -	$ -	$ -
	$ -	$ -	$ -	$ -
V1.9 03202012	$ -	$ -	$ -	$ -
	$ -	$ -	$ -	$ -
	$ -	$ -	$ -	$ -
	$ -	$ -	$ -	$ -
	$ -	$ -	$ -	$ -
	$ -	$ -	$ -	$ -
	$ -	$ -	$ -	$ -
	$ -	$ -	$ -	$ -
	$ -	$ -	$ -	$ -
	$ -	$ -	$ -	$ -

TOTAL TRAVEL $ -

Travel Assumptions:

Confidential Procurement Sensitive

SLIN-0003AA

COST TEMPLATE - SAMPLE Attachment J.36

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA

C.2

C.3

C.4

C.5

C.6

C.7

C.8

C.9

D.1

D.2

D.3

D.4

D.5

D.6

DME SERVICES/OPTION PERIOD

Total FTEs

Infrastructure Requirements

Administrative Requirements

Change Management Process Requirements

FM of Trust Fund Dollars

Contract Award & Monthly Requirements

Task Directives

FOIA Requests

Access to Systems

Bills/Claims Payment

Appeals

Reopenings

Paper Claims Adjustment Editing

Provider Customer Service Program

Public Relations

Interface Requirements

Quality Assurance Requirements

(enter negative number)

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

Rates

COST ELEMENTS
Direct Labor
	0	$0.00	$0	0	$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	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	$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	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	$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	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	$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	0	$0	0	$0	0	$0.00	$0	0	$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	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$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	$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	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	$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	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$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	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	$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	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	$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	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	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	$0

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

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

Travel		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0
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
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
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
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
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
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
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

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

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

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

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

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

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Complementary Credits																		$0		$0
Note: 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	$0	$0	$0	$0

Confidential Procurement Sensitive

C.3

COST TEMPLATE - SAMPLE Attachment J.36

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - C.3

C.3.1

C.3.2

C.3.3

C.3.4

C.3.5

DME SERVICES/OPTION PERIOD

Total FTEs

Security

Compliance Program

Internal Controls

Business Continuity Planning and Disaster Recovery

Participation in Conferences, Meetings and Work Groups

GRAND 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	$0.00	$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	$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
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$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	$0.00	$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	$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
V1.9 03202012	0	$0.00	$0	0	$0.00	$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	$0.00	$0	0	$0
		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0

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

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

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

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0 $0

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

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

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0

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

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0 $0

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

Confidential Procurement Sensitive

C.5

COST TEMPLATE - SAMPLE Attachment J.36

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - C.5

C.5.1

C.5.2

C.5.3

C.5.4

C.5.5

C.5.7

C.5.8

DME SERVICES/OPTION PERIOD

Total FTEs

Trust Fund

Banking Relations

Non MSP Debt Collection

Non MSP Overpayments

Debt Referral

Financial Reporting & Accounting

Support & Coordination with SMRC Operations

GRAND 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	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	0	$0.00	$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	$0.00	$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	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	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	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	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
V1.9 03202012	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
	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
	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
Subtotal Direct Labor	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

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

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

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0 $0 $0 $0

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

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

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0 $0 $0

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

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0 $0 $0 $0

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

Confidential Procurement Sensitive

C.5.4

COST TEMPLATE - SAMPLE Attachment J.36

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - C.5.4

C.5.4.1

C.5.4.2

C.5.4.3

C.5.4.4

C.5.4.5

C.5.4.6

C.5.4.7

DME SERVICES/OPTION PERIOD

Total FTEs

Identify Overpayment Cause

Application for Extended Repayment Schedules

Limitation on Recoupment (Overpymt Subject to 935)

Overpayment Related to Bankruptcy

Administrative Freeze Payments

Closed Bankruptcy Case

DMEPOS Suppliers with Surety Bonds

GRAND 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	$0.00	$0	0	$0.00	$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	$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	$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	$0.00	$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	$0.00	$0	0	$0.00	$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	$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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
V1.9 03202012	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	$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		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0.00	$0	0	$0
Subtotal Direct Labor	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

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

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

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0 $0 $0 $0

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

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

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0 $0 $0

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

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0 $0 $0 $0

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

Confidential Procurement Sensitive

D.1

COST TEMPLATE - SAMPLE Attachment J.36

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - D.1

D.1.1

D.1.2

D.1.3

D.1.4

D.1.5

D.1.6

D.1.8

DME SERVICES/OPTION PERIOD

Total FTEs

Medicare Front End Processing

General Claims Processing

Back-end Processing

Common Working File

DMEPOS Fee Schedule

ASCA Reviews

Environmental Health Hazards Pilot Program (Jurisdiction D 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

Total

COST ELEMENTS

Direct Labor
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
V1.9 03202012	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
Subtotal Direct Labor	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

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

Travel		$0		$0		$0		$0		$0		$0		$0
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	0
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	0
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	0
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	0
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	0
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	0
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	0
																0
Other Direct Costs (insert & list applicable elements below)		$0		$0		$0		$0		$0		$0		$0		0

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

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

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0 $0 0

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

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0 $0 $0 $0

GRAND TOTAL - 0 $0 $0 $0 $0 $0 $0 $0 $0

Confidential Procurement Sensitive

D.1.1

COST TEMPLATE - SAMPLE Attachment J.36

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - D.1.1

D.1.1.1

D.1.1.2

D.1.1.3

D.1.1.4

D.1.1.5

D.1.1.6

DME SERVICES/OPTION PERIOD

Total FTEs

Electronic Data Interchange

Front-end for Paper Claims and Standard Paper Remittance Advice (SPR) transactions

Misdirected Claims

Transition Support

Electronic Funds Transfer Authorization Agreement

Claim Adjustment Reason Code (CARC) Remittance Advice Remark Code (RARC)

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	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$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
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$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
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$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
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$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
		$0.00	$0	0	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0	$0	0		$0	0		$0	0		$0	0		$0	0	$0

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

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

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

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0 $0 $0

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

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

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0 $0

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

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0 $0 $0

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

Confidential Procurement Sensitive

D.1.1.2

COST TEMPLATE - SAMPLE Attachment J.36
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AA - D.1.1.2		D.1.1.2.1			D.1.1.2.2
DME SERVICES/OPTION PERIOD	Total FTEs	Manage Paper Bills/Claims			EDI Support Related to Front-End paper Claims and Transactions			GRAND 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	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$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
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
		$0.00	$0		$0.00	$0	0	$0	0	$0
Subtotal Direct Labor	0		$0	0		$0	0	$0	0	$0

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

Total Direct Labor $0 $0 $0 $0

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

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0

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

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

TOTAL OTHER BEFORE FEES $0 $0 $0 $0

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

TOTAL OTHER AFTER FEES $0 $0 $0 $0

GRAND TOTAL $0 $0 $0 $0

Confidential Procurement Sensitive

D.1.2

COST TEMPLATE - SAMPLE Attachment J.36

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - D.1.2

D.1.2.1

D.1.2.2

D.1.2.3

D.1.2.4

D.1.2.5

D.1.2.6

D.1.2.7

DME SERVICES/OPTION PERIOD

Total FTEs

Run Systems

EDI Support Related to General Claims Processing

Report Claims Processing Problems

Handling Incomplete or Invalid Paper Claims

Resolve Claims Transaction Replies and Unsolicited Responses from CWF

Processing Claims

National Provider Identifier

GRAND 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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$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	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	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	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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$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	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	0	$0.00	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$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	0	$0.00	$0	0	$0
		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0		$0.00	$0	0	$0
Subtotal Direct Labor	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

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

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

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0 $0 $0 $0

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

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

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0 $0 $0

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

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0 $0 $0 $0

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

Confidential Procurement Sensitive

D.1.2.6

COST TEMPLATE - SAMPLE Attachment J.36

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - D.1.2.6

D.1.2.6.1

D.1.2.6.2

D.1.2.6.3

DME SERVICES/OPTION PERIOD

Total FTEs

Bills/Claims Determination

Payment of Claims

Payment of Claims outside of CWF

GRAND 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	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	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	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
		$0.00	$0		$0.00	$0		$0.00	$0	0	$0	0	$0
Subtotal Direct Labor	0		$0	0		$0	0		$0	0	$0	0	$0

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

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

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

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0

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

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

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0

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

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0

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

Confidential Procurement Sensitive

D.1.3

COST TEMPLATE - SAMPLE Attachment J.36
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AA - D.1.3		D.1.3.1			D.1.3.2
DME SERVICES/OPTION PERIOD	Total FTEs	Generate & Deliver Standard Paper Ras (SPRs) and Medicare Summary Notices (MSNs)			Transferring Coordination of Benefits Flat Files to the BCRC			GRAND 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	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$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
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
		$0.00	$0		$0.00	$0	0	$0	0	$0
Subtotal Direct Labor	0		$0	0		$0	0	$0	0	$0

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

Total Direct Labor $0 $0 $0 $0

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

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0

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

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

TOTAL OTHER BEFORE FEES $0 $0 $0 $0

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

TOTAL OTHER AFTER FEES $0 $0 $0 $0

GRAND TOTAL $0 $0 $0 $0

Confidential Procurement Sensitive

D.2

COST TEMPLATE - SAMPLE Attachment J.36

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - D.2

D.2.1

D.2.2

D.2.3

D.2.4

D.2.5

D.2.6

DME SERVICES/OPTION PERIOD

Total FTEs

Appeals of Medicare Initial Claims Determinations

Appeal Decision Effectuation

QICs

Incomplete Redetermination Requests

Part B Quality Improvement/ Data Analysis

Document Imaging

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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$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
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
	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	$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	$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	$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
V1.9 03202012	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	$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		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0

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

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

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

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0 $0 $0

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

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

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0 $0

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

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0 $0 $0

GRAND TOTAL - 0 $0 $0 $0 $0 $0 $0 $0

Confidential Procurement Sensitive

D.3

COST TEMPLATE - SAMPLE Attachment J.36
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AA - D.3		D.3.1			D.3.3
DME SERVICES/OPTION PERIOD	Total FTEs	Clerical Error Reopenings			Telephone Reopenings			GRAND 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	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$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
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
		$0.00	$0		$0.00	$0	0	$0	0	$0
Subtotal Direct Labor	0		$0	0		$0	0	$0	0	$0

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

Total Direct Labor $0 $0 $0 $0

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

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0

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

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

TOTAL OTHER BEFORE FEES $0 $0 $0 $0

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

TOTAL OTHER AFTER FEES $0 $0 $0 $0

GRAND TOTAL $0 $0 $0 $0

Confidential Procurement Sensitive

D.5

COST TEMPLATE - SAMPLE Attachment J.36

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - D.5

D.5.1

D.5.2

D.5.3

D.5.4

D.5.5

DME SERVICES/OPTION PERIOD

Total FTEs

Provider Outreach & Education

Provider Contact Center

Provider Self-Service Technology

PCSP Training

MAC Satisfaction Indicator

GRAND 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	$0.00	$0	0	$0.00	$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
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$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
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	$0	0	$0
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
		$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0	$0	0	$0	0		$0	0		$0	0	$0

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

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

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

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0 $0

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

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

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0

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

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0 $0

GRAND TOTAL - 0 $0 $0 $0 $0 $0 $0

Confidential Procurement Sensitive

D.5.2

COST TEMPLATE - SAMPLE Attachment J.36

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - D.5.2

D.5.2.1

D.5.2.2

D.5.2.3

D.5.2.4

DME SERVICES/OPTION PERIOD

Total FTEs

Telephone Inquiries

Written Inquiries

Provider Relations Research Specialists

Inquiry Tracking System

GRAND 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	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	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	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0	0	$0
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0	$0	0	$0

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

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

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

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0

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

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

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0

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

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0

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

Confidential Procurement Sensitive

D.5.3

COST TEMPLATE - SAMPLE Attachment J.36

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - D.5.3

D.5.3.1

D.5.3.2

D.5.3.3

D.5.3.4

DME SERVICES/OPTION PERIOD

Total FTEs

Interactive Voice Response

Web Technology

Provider Listserv

Provider Internet Portal

GRAND 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	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	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	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0	0	$0
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0	$0	0	$0

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

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

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

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0

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

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

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0

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

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0

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

Confidential Procurement Sensitive

D.6

COST TEMPLATE - SAMPLE Attachment J.36

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - D.6

D.6.1

D.6.2

D.6.3

D.6.4

DME SERVICES/OPTION PERIOD

Total FTEs

Medicare Beneficiary Ombudsman

Regional Office Liaison

Responding to Complex Beneficiary Inquiries

Responses to Congressional Inquiries

GRAND 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	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0
		$0.00	$0	0	$0		$0.00	$0	0	$0	0	$0
Subtotal Direct Labor	0		$0	0	$0	0		$0	0	$0	0	$0

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

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

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

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0

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

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

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0

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

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0

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

Confidential Procurement Sensitive

D.6.2

COST TEMPLATE - SAMPLE Attachment J.36
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AA - D.6.2		D.6.2.1.
DME SERVICES/OPTION PERIOD	Total FTEs	Urgent Need Regional Office Casework
		Hours	Rates	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
		$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0	$0

Fringe Benefits (at ____%) $0 $0

Total Direct Labor $0 $0

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

Other Direct Costs (insert & list applicable elements below) $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0

Indirect Costs (at ______ %) $0 $0

TOTAL OTHER BEFORE FEES $0 $0

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

TOTAL OTHER AFTER FEES $0 $0

GRAND TOTAL $0 $0

Confidential Procurement Sensitive

D.6.4

COST TEMPLATE - SAMPLE Attachment J.36
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AA - D.6.4		D.6.4.1
DME SERVICES/OPTION PERIOD	Total FTEs	Congressional Outreach and Education
		Hours	Rates	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
		$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0	$0

Fringe Benefits (at ____%) $0 $0

Total Direct Labor $0 $0

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

Other Direct Costs (insert & list applicable elements below) $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0

Indirect Costs (at ______ %) $0 $0

TOTAL OTHER BEFORE FEES $0 $0

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

TOTAL OTHER AFTER FEES $0 $0

GRAND TOTAL $0 $0

Confidential Procurement Sensitive

SLIN-0003AB

COST TEMPLATE - SAMPLE Attachment J.36

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AB

C.5

C.7

C.8

C.9

D.3

D.5

E.1

E.2

E.3

E.4

E.5

Reserved

DME SERVICES/OPTION PERIOD

Total FTEs

FM of Trust Fund Dollars

Task Directives

FOIA Requests

Access to Systems

Reopenings

Provider Customer Service Program

Comprehensive Error Rate Testing (CERT) Program

BI PSC & ZPIC Support Services

Medicare Secondary Payer (MSP)

Medicare Review Activities Not in Support of BI

Local Coverage Determinations

Reserved

Interface Requirements

Quality Assurance 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

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	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
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	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
V1.9 03202012	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	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

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

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

Travel		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0
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
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
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
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
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
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
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

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

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

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

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

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

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

GRAND TOTAL - 0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Confidential Procurement Sensitive

C.5 (2)

COST TEMPLATE - SAMPLE Attachment J.36
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AB - C.5		C.5.4
DME SERVICES/OPTION PERIOD	Total FTEs	Overpayments
Medicare Integrity Program		Hours	Rates	Total

COST ELEMENTS
Direct Labor
	0	$0	0	$0
	0	$0	0	$0
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
V1.9 03202012	0	$0	0	$0
	0	$0	0	$0
	0	$0	0	$0
Subtotal Direct Labor	0	$0	0	$0

Fringe Benefits (at ____%) $0 $0

Total Direct Labor $0 $0

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

Other Direct Costs (insert & list applicable elements below) $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0

Indirect Costs (at ______ %) $0 $0

TOTAL OTHER BEFORE FEES $0 $0

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

TOTAL OTHER AFTER FEES $0 $0

GRAND TOTAL $0 $0

Confidential Procurement Sensitive

C.5.4 (2)

COST TEMPLATE - SAMPLE Attachment J.36
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AB - C.5.4		C.5.4.1
DME SERVICES/OPTION PERIOD	Total FTEs	Identify Overpayment Cause
		Hours	Rates	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
		$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0	$0

Fringe Benefits (at ____%) $0 $0

Total Direct Labor $0 $0

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

Other Direct Costs (insert & list applicable elements below) $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0

Indirect Costs (at ______ %) $0 $0

TOTAL OTHER BEFORE FEES $0 $0

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

TOTAL OTHER AFTER FEES $0 $0

GRAND TOTAL $0 $0

Confidential Procurement Sensitive

D.3(2)

COST TEMPLATE - SAMPLE Attachment J.36
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AB - D.3		D.3.2
DME SERVICES/OPTION PERIOD	Total FTEs	Unanswered Additional Documentation Reopenings (ADR)
		Hours	Rates	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
		$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0	$0

Fringe Benefits (at ____%) $0 $0

Total Direct Labor $0 $0

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

This is the start of the file's text. The full file is on GovTribe.

File details come from the government source that posted it. Updated Jan 14, 2020.