J.38 CLIN 0005 Cost Proposal Template - Option Year 3 (PM, MIP, RAC).xlsx

XLSX spreadsheet 77 KB Posted

Attached to
Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) Jurisdiction C
Solicitation number
75FCMC19R0041
Issued by

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This document package includes a cost proposal template and related federal contract opportunity for Durable Medical Equipment Medicare Administrative Contractor services. The Centers for Medicare and Medicaid Services seeks proposals to administer Medicare claims processing, payment, and related services for Jurisdiction C, which covers 16 states and territories. The contractor will perform activities including claims adjudication, appeals handling, medical reviews, fraud and abuse oversight, and other Medicare administrative functions. The cost proposal template provides a framework for offerors to submit pricing details for the base period and four option years by labor category and task. Proposed costs should cover activities such as program management, provider outreach, audit support, and systems interface management. The opportunity is open to all responsible sources, and proposals are due by the date specified in the solicitation.

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Other files

File Type Posted
Q&A Solicitation 75FCMC19R0041 Amend 2.xlsx XLSX spreadsheet
Amendment #0002.pdf PDF
JC_Solicitation_75FCMC19R0041 CLEAN amend 2.docx DOCX document
JC_Solicitation_75FCMC19R0041 redline amend 2.docx DOCX document
JC_Solicitation_75FCMC19R0041 redline Amend 1.docx DOCX document
J.23 Government Provided Proposal Assumptions (GPPA)-clean.docx DOCX document
75FCMC19R0041.pdf PDF
J.22 Basis of Estimate-redline.xlsx XLSX spreadsheet
J.23 Government Provided Proposal Assumptions (GPPA)-redline.docx DOCX document
J.22 Basis of Estimate-clean.xlsx XLSX spreadsheet
Q&A Solicitation 75FCMC19R0041.xlsx XLSX spreadsheet
JC_Solicitation_75FCMC19R0041 CLEAN Amend 1.docx DOCX document
J.45 CLIN 0012 Cost Proposal Template - Option Year 2 (MPIP).xlsx XLSX spreadsheet
J.1.B List of Key Acronyms.docx DOCX document
J.37 CLIN 0004 Cost Proposal Template - Option Year 2 (PM, MIP, RAC).xlsx XLSX spreadsheet
J.47 CLIN 0014 Cost Proposal Template - Option Year 4 (MPIP).xlsx XLSX spreadsheet
J.36 CLIN 0003 Cost Proposal Template - Option Year 1 (PM, MIP, RAC).xlsx XLSX spreadsheet
J.1.C Fee-For-Service Shared System Base Functions.docx DOCX document
J.40 CLIN 0007 Cost Proposal Template - Option Year 5 (PM, MIP, RAC).xlsx XLSX spreadsheet
J.4 HHS Contracting Guide for Contract of Government Property.docx DOCX document
J.24 Attestations.docx DOCX document
J.41 CLIN 0008 Cost Proposal Template - Option Year 6 (PM, MIP, RAC).xlsx XLSX spreadsheet
J.2 Deliverable Schedule.docx DOCX document
J.7 DME MAC Award Fee Plan and Self Assessment Template.docx DOCX document
J.35 CLIN 0002 Cost Proposal Template - Base Year (PM, MIP, RAC).xlsx XLSX spreadsheet
J.5 Government Systems Provided For Use.docx DOCX document
Solicitation 75FCMC19R0041.pdf PDF
J.22 Basis of Estimate.xlsx XLSX spreadsheet
J.33 Cost Template Summary Sheet.xlsx XLSX spreadsheet
J.25 Past Performance Questionnaire.docx DOCX document
J.9 Non-Disclosure Statement.docx DOCX document
J.49 CLIN 0016 Cost Proposal Template - Option Year 6 (MPIP).xlsx XLSX spreadsheet
J.28 Voluntary Product Accessibility Template.docx DOCX document
J.23.B Government Provided Proposal Assumptions CSR-Handled Telephone Inquiries Tables.docx DOCX document
J.39 CLIN 0006 Cost Proposal Template - Option Year 4 (PM, MIP, RAC).xlsx XLSX spreadsheet
J.1.D Cash Collections Worksheet For HIGLAS Users.xlsx XLSX spreadsheet
J.34 CLIN 0001 Cost Proposal Template - Implementation.xlsx XLSX spreadsheet
J.3 Small Business Subcontracting Plan Template.docx DOCX document
J.1 Statement of Work (SOW)_Jurisdiction C sent12-4.docx DOCX document
J.11 Personal Conflicts of Interest Financial Disclosure.docx DOCX document
J.10 Contractor-Business-Ethics-COI-and-Compliance-Program-Requirements.docx DOCX document
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J.43 CLIN 0010 Cost Proposal Template - Base Year (MPIP).xlsx XLSX spreadsheet
J.32 Systems of Records.docx DOCX document
J.8 MAC Security Incident and Reportable Event Reporting and Response.docx DOCX document
J.23 Government Provided Proposal Assumptions (GPPA).docx DOCX document
J.44 CLIN 0011 Cost Proposal Template - Base Year (MPIP).xlsx XLSX spreadsheet
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CLIN-0005

COST TEMPLATE - SAMPLE Attachment J.38
(Provide a cost spreadsheet for each CLIN proposed)
CLIN 0005SLIN 0005AASLIN 0005ABSLIN 0005ACSLIN 0005AE
DME SERVICES/OPTION PERIODTotal FTEsProgram Management (PM)Medicare Integrity Program (MIP)Support of Recovery Audit Program OperationsIVG Demo (JA Only)GRAND TOTAL
HoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursTotal
COST ELEMENTS
Direct Labor
0$00$00$00$00$0
0$00$00$00$00$0
0$00$00$00$00$0
0$00$00$00$00$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)0$00$00$00$00$0
0$00$00$00$00$0
0$00$00$00$00$0
0$00$00$00$00$0
0$00$00$00$00$0
0$00$00$00$00$0
Subtotal Direct Labor0$00$00$00$00$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$00$00$00$00$0
Other Direct Costs0$00$00$00$00$0
Subcontractor Name0$00$00$00$00$0
Subcontractor Name0$00$00$00$00$0
Subcontractor Name0$00$00$00$00$0
Subcontractor Name0$00$00$00$00$0
Total Subcontractor0$00$00$00$00$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.38
(Provide an ODC Spreadsheet for each CLIN Proposed)
CLIN 0005 DME SERVICESSLIN 0005 PMSLIN 0005 MIPSLIN 0005 RACSLIN 0005SLIN 0005SLIN 0005GRAND
Cost ElementAmountAmountAmountAmountAmountAmountTOTAL
$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 03202012ERROR:#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 0005
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 )

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

TOTAL TRAVEL $ -

Travel Assumptions:

Confidential Procurement Sensitive

SLIN-0005AA

COST TEMPLATE - SAMPLE Attachment J.38
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0005AAC.2C.3C.4C.5C.6C.7C.8C.9D.1D.2D.3D.4D.5D.6FH
DME SERVICES/OPTION PERIODTotal FTEsInfrastructure RequirementsAdministrative RequirementsChange Management Process RequirementsFM of Trust Fund DollarsContract Award & Monthly RequirementsTask DirectivesFOIA RequestsAccess to SystemsBills/Claims PaymentAppealsReopeningsPaper Claims Adjustment EditingProvider Customer Service ProgramPublic RelationsInterface RequirementsQuality Assurance Requirements
(enter negative number)AWARD FEEGRAND TOTAL
Program ManagementHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRates
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$00$0.00$00$0.00$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$00$0.00$00$0.00$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$00$0.00$00$0.00$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$00$0.00$00$0.00$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$00$0.00$00$0.00$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$00$0.00$00$0.00$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$00$0.00$00$0.00$00
V1.9 032020120$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$00$0.00$00$0.00$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$00$0.00$00$0.00$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$00$0.00$00$0.00$00
Subtotal Direct Labor0$00$00$00$00$00$00$00$00$00$00$00$00$00$00$00$00

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 Name0$00$00$00$00$00$00$00$00$00$00$00$00$00$00$00$00$0
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$00$00$00$00$00$00$0
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$00$00$00$00$00$00$0
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$00$00$00$00$00$00$0
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$00$00$00$00$00$00$0
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$00$00$00$00$00$00$0
Total Subcontractor0$00$00$00$00$00$00$00$00$00$00$00$00$00$00$00$00$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

SLIN-0005AB

COST TEMPLATE - SAMPLE Attachment J.38
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0005ABC.5C.7C.8C.9D.3D.5E.1E.2E.3E.4E.5ReservedFHA
DME SERVICES/OPTION PERIODTotal FTEsFM of Trust Fund DollarsTask DirectivesFOIA RequestsAccess to SystemsReopeningsProvider Customer Service ProgramComprehensive Error Rate Testing (CERT) ProgramBI PSC & ZPIC Support ServicesMedicare Secondary Payer (MSP)Medicare Review Activities Not in Support of BILocal Coverage DeterminationsReservedInterface RequirementsQuality Assurance RequirementsAWARD FEEGRAND TOTAL
Medicare Integrity ProgramHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursTotal
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$00$0
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$00$0
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$00$0
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$00$0
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$00$0
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$00$0
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$00$0
V1.9 032020120$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$00$0
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$00$0
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$00$0
Subtotal Direct Labor0$00$00$00$00$00$00$00$00$00$00$00$00$00$00$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 Name0$00$00$00$00$00$00$00$00$00$00$00$00$00$00$0
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$00$00$00$00$0
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$00$00$00$00$0
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$00$00$00$00$0
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$00$00$00$00$0
Subcontractor Name0$00$00$00$00$00$00$00$00$00$00$00$00$00$00$0
Total Subcontractor0$00$00$00$00$00$00$00$00$00$00$00$00$00$00$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

SLIN-0005AC

COST TEMPLATE - SAMPLE Attachment J.38
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0005ACC.5.6.1C.5.6.2C.5.6.3C.5.6.4C.5.6.5A
DME SERVICES/OPTION PERIODTotal 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 ActivitiesAWARD FEEGRAND TOTAL
HoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursRatesTotalHoursTotal
COST ELEMENTS
Direct Labor
0$0.00$00$00$0.00$00$0.00$00$0.00$00$0.000$0
0$0.00$00$00$0.00$00$0.00$00$0.00$00$0.000$0
0$0.00$00$00$0.00$00$0.00$00$0.00$00$0.000$0
0$0.00$00$00$0.00$00$0.00$00$0.00$00$0.000$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)0$0.00$00$00$0.00$00$0.00$00$0.00$00$0.000$0
0$0.00$00$00$0.00$00$0.00$00$0.00$00$0.000$0
0$0.00$00$00$0.00$00$0.00$00$0.00$00$0.000$0
V1.9 032020120$0.00$00$00$0.00$00$0.00$00$0.00$00$0.000$0
0$0.00$00$00$0.00$00$0.00$00$0.00$00$0.000$0
0$0.00$00$00$0.00$00$0.00$00$0.00$00$0.000$0
Subtotal Direct Labor0$00$00$00$00$00$0.000$0

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

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

Travel$0$0$0$0$0$0.00$0
SUBCONTRACTORS
0$00$00$00$00$00$0.000$0
Subcontractor Name0$00$00$00$00$00$0.000$0
Subcontractor Name0$00$00$00$00$00$0.000$0
Subcontractor Name0$00$00$00$00$00$0.000$0
Subcontractor Name0$00$00$00$00$00$0.000$0
Subcontractor Name0$00$00$00$00$00$0.000$0
Total Subcontractor0$00$00$00$00$00$0.000$0

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0 $0.00 $0

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

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

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0.00 $0

Base Fee (at ____%)$0$0$0$0$0$0.00$0
Award Fee (at ______%)$0$0.00
Fixed Fee (at ______%)$0$0$0$0$0$0.00$0
TOTAL OTHER AFTER FEES$0$0$0$0$0$0$0.00
$0
Complementary Credits
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$0.00

Confidential Procurement Sensitive

SLIN-0005AE

COST TEMPLATE - SAMPLE Attachment J.38
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0005AEC.7.2A
DME SERVICES/OPTION PERIODTotal FTEsIVIG Demo (JA Only)AWARD FEEGRAND TOTAL
HoursRatesTotalHoursRatesTotalHoursTotal
COST ELEMENTS
Direct Labor
0$0.00$00$0.00
0$0.00$00$0.00
0$0.00$00$0.00
0$0.00$00$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)0$0.00$00$0.00
0$0.00$00$0.00
0$0.00$00$0.00
V1.9 032020120$0.00$00$0.00
0$0.00$00$0.00
0$0.00$00$0.00
Subtotal Direct Labor0$00$0.00

Fringe Benefits (at ____%) $0 $0.00

Total Direct Labor $0 $0.00

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

Other Direct Costs (insert & list applicable elements below) $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0.00

Indirect Costs (at ______ %) $0 $0.00

TOTAL OTHER BEFORE FEES $0 $0.00

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

TOTAL OTHER AFTER FEES $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$0.00

Confidential Procurement Sensitive

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