J.35 CLIN 0002 Cost Proposal Template - Base Year (PM, MIP, RAC) clean Amend 1.xlsx

XLSX spreadsheet 494 KB Posted Sep 4, 2020

Attached to: Part A/Part B Medicare Administrative Contractor (MAC) Jurisdiction L (JL)
Solicitation number: 75FCMC20R0008
Issued by: Department of Health and Human Services Centers for Medicare and Medicaid Services

About this file

Written by GovTribe AI · Dec 27, 2023

This document provides details for a federal contract solicitation to provide Medicare Administrative Contractor services for Jurisdiction L. The solicitation seeks offers to administer Medicare claims processing and payment services in support of the Medicare Fee-For-Service program for Delaware, Maryland, New Jersey, Pennsylvania, Washington D.C., and parts of Virginia. Offerors will provide specified health insurance benefit administration including processing and paying Medicare claims, cost reporting and reimbursement activities, medical review functions, and other program support. The Centers for Medicare and Medicaid Services intends to award a single contract to provide these services for the specified region.

View the file

Other files

File	Type	Posted
J.23 Government Provided Proposal Assumptions (GPPA) redline Amend 2.docx	DOCX document	Sep 16, 2020
J.23 Government Provided Proposal Assumptions (GPPA) clean Amend 2.docx	DOCX document	Sep 16, 2020
75FCMC20R0008 Amend 2.pdf	PDF	Sep 16, 2020
JL Solicitation 75FCMC20R0008 Sections B-M CLEAN Amend 1.pdf	PDF	Sep 4, 2020
Q and A RFP 75FCMC20R00008.xlsx	XLSX spreadsheet	Sep 4, 2020
J.34 CLIN 0001 Cost Proposal Template - Implementation clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.37 CLIN 0004 Cost Proposal Template - Option Year 2 (PM, MIP, RAC) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.23 Government Provided Proposal Assumptions (GPPA) redline Amend 1.docx	DOCX document	Sep 4, 2020
J.48 CLIN 0015 Cost Proposal Template - Option Year 5 (MPIP) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.43 CLIN 0010 Cost Proposal Template - Base Year (MPIP) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.22 Basis of Estimate redline Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.22.A Historic & Proposed FTE, Hours & Gross Cost Instructions & Narrative redline Amend 1.docx	DOCX document	Sep 4, 2020
J.46 CLIN 0013 Cost Proposal Template - Option Year 3 (MPIP) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.1 Statement of Work (SOW) clean Amend 1.docx	DOCX document	Sep 4, 2020
J.33 Cost Template Summary Sheet clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.21 Proposal Self-Check Tool clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.49 CLIN 0016 Cost Proposal Template - Option Year 6 (MPIP) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.22.A Historic & Proposed FTE, Hours & Gross Cost Instructions & Narrative clean Amend 1.docx	DOCX document	Sep 4, 2020
JL Solicitation 75FCMC20R0008 Sections B-M REDLINE Amend 1.pdf	PDF	Sep 4, 2020
J.45 CLIN 0012 Cost Proposal Template - Option Year 2 (MPIP) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.40 CLIN 0007 Cost Proposal Template - Option Year 5 (PM, MIP, RAC) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.41 CLIN 0008 Cost Proposal Template - Option Year 6 (PM, MIP, RAC) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.22 Basis of Estimate clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.38 CLIN 0005 Cost Proposal Template - Option Year 3 (PM, MIP, RAC) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.42 CLIN 0009 Cost Proposal Template - Outgoing Contractor Workload Transition Activities clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.36 CLIN 0003 Cost Proposal Template - Option Year 1 (PM, MIP, RAC) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.1 Statement of Work (SOW) redline Amend 1.docx	DOCX document	Sep 4, 2020
J.47 CLIN 0014 Cost Proposal Template - Option Year 4 (MPIP) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.23 Government Provided Proposal Assumptions (GPPA) clean Amend 1.docx	DOCX document	Sep 4, 2020
J.21 Proposal Self-Check Tool redline Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.39 CLIN 0006 Cost Proposal Template - Option Year 4 (PM, MIP, RAC) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.44 CLIN 0011 Cost Proposal Template - Option Year 1 (MPIP) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
75FCMC20R0008.pdf	PDF	Sep 4, 2020
J.37 CLIN 0004 Cost Proposal Template - Option Year 2 (PM, MIP, RAC).xlsx	XLSX spreadsheet	Aug 3, 2020
J.22.A Historic & Proposed FTE, Hours & Gross Cost Instructions & Narrative.docx	DOCX document	Aug 3, 2020
J.24 Attestations.docx	DOCX document	Aug 3, 2020
J.45 CLIN 0012 Cost Proposal Template - Option Year 2 (MPIP).xlsx	XLSX spreadsheet	Aug 3, 2020
J.10 Contractor Business Ethics COI and Compliance Program Requirements.docx	DOCX document	Aug 3, 2020
J.1.B List of Key Acronyms.docx	DOCX document	Aug 3, 2020
J.33 Cost Template Summary Sheet.xlsx	XLSX spreadsheet	Aug 3, 2020
J.35 CLIN 0002 Cost Proposal Template - Base Year (PM, MIP, RAC).xlsx	XLSX spreadsheet	Aug 3, 2020
J.23.A GPPA Audit & Reimbursement Tables.xlsx	XLSX spreadsheet	Aug 3, 2020
J.42 CLIN 0009 Cost Proposal Template - Outgoing Contractor Workload Transition Activites.xlsx	XLSX spreadsheet	Aug 3, 2020
J.2 Deliverable Schedule.docx	DOCX document	Aug 3, 2020
J.1 Statement of Work (SOW) - Jurisdiction L.docx	DOCX document	Aug 3, 2020
J.7 AB MAC Award Fee Plan and Self Assessment Template.docx	DOCX document	Aug 3, 2020
J.9 Non-Disclosure Statement.docx	DOCX document	Aug 3, 2020
J.40 CLIN 0007 Cost Proposal Template - Option Year 5 (PM, MIP, RAC).xlsx	XLSX spreadsheet	Aug 3, 2020
J.43 CLIN 0010 Cost Proposal Template - Base Year (MPIP).xlsx	XLSX spreadsheet	Aug 3, 2020
J.1.A List of Key Definitions.docx	DOCX document	Aug 3, 2020

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CLIN-0002 Consolidated SLIN

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

CLIN 0002 Consolidated

SLIN 0002AA (PM)

SLIN 0002AB (MIP)

SLIN 0002AC (RAC)

Reserved

SLIN 0002AL

A/B SERVICES

Total FTEs

Program Management (PM)

Medicare Integrity Program (MIP)

Support of Recovery Audit Program Operations

Future Use

Records Storage and Retrieval Costs (J5 only)

GRAND TOTAL

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

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

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

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

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

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

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

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

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

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

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

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

20190930

v2-10 20180824

75FCMC20R0008

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

Confidential Procurement Sensitive

CLIN-0002

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

CLIN 0002

SLIN 0002 PM A

SLIN 0002 MIP A

SLIN 0002 PM B

SLIN 0002 MIP B

SLIN 0002 RAC A

SLIN 0002 RAC B

SLIN 0002

SLIN 0002AL

A/B SERVICES

Total FTEs

Part A/Program Management (PM)

Part A/Medicare Integrity Program (MIP)

Part B/Program Management (PM)

Part B/Medicare Integrity Program (MIP)

Part A/Support of Recovery Audit Program Operations

Part B/Support of Recovery Audit Program Operations

Reserved

Records Storage and Retrieval Costs for Non-J5 Legacy A Records (J1, J4, J12) Jurisdiction 5 only

GRAND TOTAL

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

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

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

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

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

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

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

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

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

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

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

Complementary Credits	$0		$0								$0.00
Note: Comp. credit information will be provided by CMS prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0.00
v.1.58 05042016

75FCMC20R0008

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

Confidential Procurement Sensitive

TRAVEL

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

TRAVEL SUMMARY

CLIN 0002

	Purpose of Trip	SOW WBS
Crosswalk	Labor Category Taking Trip	Trip Origin	Destination	# People
(A)	# Trips
(B)	# Days
(C)	# Nights
(D)	Lodging Rate
(E)	Lodging
(F=EDA)	M&IE
(G)	Total Lodging

and M&IE

(H=F+G)	Airfare
(I)	Car Rental
(J)	Misc
(K)	Local

Mileage

(L)	Total Per Trip
(M=H+I+J+K+L)	Total For All Trips

(N=M*B )

	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
			TOTAL TRAVEL		$ -
Travel Assumptions:

75FCMC20R0008

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

Confidential Procurement Sensitive

ODC

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

(Provide an ODC Spreadsheet for each CLIN Proposed)
CLIN 0002 A/B SERVICES	SLIN 0002 PM A	SLIN 0002 MIP A	SLIN 0002 PM B	SLIN 0002 MIP B	SLIN 0002 RAC A	SLIN 0002 RAC B	SLIN 0002 VA A	SLIN 0002 VA B	SLIN 0002 Reserved	SLIN 0002AL Rec. Storage	GRAND
Cost Element	Amount	Amount	Amount	Amount	Amount	Amount	Amount	Amount	Amount	Amount	TOTAL
											$0.00
Add costs by category											$0.00
											$0.00
											$0.00
											$0.00
											$0.00
											$0.00
											$0.00
TOTAL ODCs	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00

75FCMC20R0008

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

Confidential Procurement Sensitive

SLIN-0002 PM A

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 PM A

C.1.4.4

C.5.3

C.5.4

C.5.5

C.5.7

C.5.8

C.5.9

C.5.10

C.5.11

C.5.23

C.5.27

C.6

C.7

A/B SERVICES

Total FTEs

Total FTE Hours

Home Health and Hospice Requirements

Infrastructure Requirements

Administrative Requirements

Provider Enrollment

Provider Customer Service Program

Claims Processing

Reopenings of Medicare Initial Claims Determinations

Appeals of Medicare Initial Claims Determinations

FM of Trust Fund Dollars

Program Management Office

Support & Coordination with SMRC Operations

Interface Requirements

Jurisdiction Specific Requirements

CREDITS

AWARD FEE

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

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

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

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

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

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

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

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

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

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

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

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

75FCMC20R0008

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

Confidential Procurement Sensitive

C.5.3

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002 PM A - C.5.3		C.5.3.1			C.5.3.2
A/B SERVICES	Total FTEs	VDC			Telecommunications			GRAND TOTAL
Program Management		Hours	Rates	Total	Hours	Rates	Total	Hours	Total
COST ELEMENTS

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

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

Total Direct Labor $0 $0 $0.00

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

Other Direct Costs $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0.00

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

TOTAL OTHER BEFORE FEE $0 $0 $0.00

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

TOTAL OTHER AFTER FEE $0 $0 $0.00

GRAND TOTAL $0 $0 $0.00

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

Confidential Procurement Sensitive

C.5.4

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 PM A- C.5.4

C.5.4.3

C.5.4.4

C.5.4.5

C.5.4.6

C.5.4.7

C.5.4.8

C.5.4.10

C.5.4.11

A/B SERVICES

Total FTEs

Security

Quality Assurance Requirements

Public Relations

Congressional Inquiries

Participation in Conferences, Meetings & Work Groups

Participation in Change Management Process

Internal Controls

Compliance Program

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		$0.00	$0		$0.00	$0	0	$0		$1.00	$0		$1.00	$0		$1.00	$0		$1.00	$0		$1.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0		$0	0	$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00

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

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

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

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

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

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

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

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

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

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

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

Confidential Procurement Sensitive

C.5.4.5

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002 PM A - C.5.4.5		C.5.4.5.3
A/B SERVICES	Total FTEs	Responding to Complex Beneficiary Inquiries
Program Management		Hours	Rates	Total
COST ELEMENTS

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

Fringe Benefits (at ____%) $0

Total Direct Labor $0

Travel (See separate schedule)		$0
SUBCONTRACTORS
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Total Subcontractor	0	$0

Other Direct Costs $0

SUBTOTAL ALL DIRECT COSTS $0

Indirect Costs (at ______ %) $0

TOTAL OTHER BEFORE FEE $0

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

TOTAL OTHER AFTER FEE $0

GRAND TOTAL $0

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

Confidential Procurement Sensitive

C.5.5

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 PM A - C.5.5

C.5.5.1

C.5.5.2

C.5.5.3

C.5.5.4

C.5.5.5

C.5.5.6

A/B SERVICES

Total FTEs

Total FTE Hours

Process Initial Enrollment and Revalidation Applications

Process Changes, Updates, Reassignments or Corrections

Revocations/Deactivations

Provider Enrollment Appeals

Maintain State-Specific Licensure/Certification Information

Participating Physician Enrollment

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

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

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

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

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

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

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

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

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

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

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

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

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

Confidential Procurement Sensitive

C.5.5.1

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 PM A - C.5.5.1

C.5.5.1.1

C.5.5.1.2

C.5.5.1.3

A/B SERVICES

Total FTEs

Process A/B Initial Enrollments

Process A/B Initial Revalidations

Process Other than A/B Initial Enrollments

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

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

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

Total Direct Labor $0 $0 $0 $0.00

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

Other Direct Costs $0 $0 $0 $0.00

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

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

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

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

TOTAL COSTS $0 $0 $0 $0.00

GRAND TOTAL $0 $0 $0 $0.00

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

Confidential Procurement Sensitive

C.5.7

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 PM A - C.5.7

C.5.7.1

C.5.7.2

C.5.7.3

C.5.7.4

A/B SERVICES

Total FTEs

Total FTE Hours

Provider Outreach & Education

Provider Contact Center

Provider Self-Service Technology

PCSP Staff Training

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

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

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

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

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

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

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

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

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

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

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

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

75FCMC20R0008

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

Confidential Procurement Sensitive

C.5.7.2

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 PM A - C.5.7.2

C.5.7.2.1

C.5.7.2.2

C.5.7.2.3

C.5.7.2.4

A/B SERVICES

Total FTEs

Telephone Inquiries

Written Inquiries

Provider Relations Research Specialist

Inquiry Tracking System

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

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

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

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

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

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

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

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

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

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

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

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

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

Confidential Procurement Sensitive

C.5.7.3

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 PM A - C.5.7.3

C.5.7.3.1

C.5.7.3.2

C.5.7.3.3

C.5.7.3.5

A/B SERVICES

Total FTEs

Interactive Voice Response

Web Technology

Provider Listserv

Provider Internet Portal

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

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

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

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

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

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

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

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

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

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

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

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

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

Confidential Procurement Sensitive

C.5.8

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 PM A- C.5.8

C.5.8.1

C.5.8.2

C.5.8.3

C.5.8.4

A/B SERVICES

Total FTEs

Total FTE Hours

Standard Paper Remittance Advice Transactions

General Claims Processing

Development of Suspended Claims

Back-End Processing

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

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

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

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

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

Other Direct Costs (See separate schedule) $0 $0 $0 $0 $0.00

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

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

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

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

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

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

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

Confidential Procurement Sensitive

C.5.10

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 PM A - C.5.10

C.5.10.1

C.5.10.2

C.5.10.3

A/B SERVICES

Total FTEs

Total FTE Hours

Redermination Requests

Appeal Decision Effectuation

Monthly Statistical Rpt on Reopenings & Appeals Activty

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

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

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

Total Direct Labor $0 $0 $0 $0.00

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

Other Direct Costs $0 $0 $0 $0.00

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

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

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

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

TOTAL COSTS $0 $0 $0 $0.00

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

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

Confidential Procurement Sensitive

C.5.11

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 PM A - C.5.11

C.5.11.1

C.5.11.2

C.5.11.3

C.5.11.4

C.5.11.5

C.5.11.6

C.5.11.7

C.5.11.8

C.5.11.9

C.5.11.10

A/B SERVICES

Total FTEs

Use of Trust Fund

Banking Relations

Cost Reporting and Reimbursement Payment Policy

Non-MSP Overpayment

Non-MSP Debt Collection Activities

Non-MSP Debt Referral

Unsolicited/Voluntary Refunds

Overpayment Related to Bankruptcy

Financial Reporting & Accounting

Medicare Credit Balance Report Activities

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

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

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

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

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

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

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

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

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

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

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

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

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

Confidential Procurement Sensitive

C.5.11.3

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002 PM A - C.5.11.3		C.5.11.3.3			C.5.11.3.5
A/B SERVICES	Total FTEs	Provider Reimbursement			Provider Based Determinations			GRAND TOTAL
Program Management		Hours	Rates	Total	Hours	Rates	Total	Hours	Total
COST ELEMENTS

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

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

Total Direct Labor $0 $0 $0.00

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

Other Direct Costs $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0.00

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

TOTAL OTHER BEFORE FEE $0 $0 $0.00

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

TOTAL OTHER AFTER FEE $0 $0 $0.00

GRAND TOTAL $0 $0 $0.00

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

Confidential Procurement Sensitive

C.5.11.7

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002 PM A - C.5.11.7		C.5.11.7.1
A/B SERVICES	Total FTEs	UNSOLICITED/VOLUNTARY REFUNDS
Program Management		Hours	Rates	Total
COST ELEMENTS

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

Fringe Benefits (at ____%) $0

Total Direct Labor $0

Travel (See separate schedule)		$0
SUBCONTRACTORS
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Total Subcontractor	0	$0

Other Direct Costs $0

SUBTOTAL ALL DIRECT COSTS $0

Indirect Costs (at ______ %) $0

TOTAL OTHER BEFORE FEE $0

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

TOTAL OTHER AFTER FEE $0

GRAND TOTAL $0

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

Confidential Procurement Sensitive

C.6 (2)

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002 PM A - C.6		C.6.1			C.6.2
A/B SERVICES	Total FTEs	Successful Collaboration with Entities Requiring Joint Operating Agreement			Successful Collaboration and Coordination with Other Internal and External Entities			GRAND TOTAL
Program Management		Hours	Rates	Total	Hours	Rates	Total	Hours	Total
COST ELEMENTS

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

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

Total Direct Labor $0 $0 0

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

Other Direct Costs $0 $0 0

SUBTOTAL ALL DIRECT COSTS $0 $0 0

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

TOTAL OTHER BEFORE FEE $0 $0 0

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

TOTAL OTHER AFTER FEE $0 $0 0

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

75FCMC20R0008

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

Confidential Procurement Sensitive

C.7

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 PM A - C.7

C.7.1

C.7.2

Reserved

C.7.14

C.7.15

C.7.16

C.7.17

C.7.18

C.7.22

C.7.24

C.7.29

Reserved

C.7.36

C.7.37

A/B SERVICES

Total FTEs

Centralized Billing for Mass Immunizers (JH, J5 only)

Indian Health Services (JH only)

For Future Use

Limited Purpose Insurance Company (JJ only)

Independent Organ Procurement Organizations (JJ only)

Religious Non-Medical Health Care Institutions (JJ only)

Histocompatibility Labs (JJ only)

Spanish Translation of HCPCS Code Descriptors (JN only)

Medicare Coordinated Care Demo (JK only)

Environmental Health Hazards Pilot Project (JF only)

Medicare Essential Hospital Payment Program (JF only)

For Future Use

PA PMD Demo (J6 only)

Mayo Clinic Project (J6 only)

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$1.00	$0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0

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

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

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

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

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

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

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

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

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

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

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

Confidential Procurement Sensitive

SLIN-0002 MIP A

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002 MIP A

C.1.4.4

C.5.6

C.5.7

C.5.11

C.5.12

C.5.13

C.5.14

C.5.15

C.6

C.7

A/B SERVICES

Total FTEs

Total FTE Hours

Home Health and Hospice Requirements

LCDs

Provider Customer Service Program

FM of Trust Fund Dollars

Medical Review

Coordination with PSCs/ZPICs

MSP

Provider Oversight

Interface Requirements

Jurisdiction Specific Requirements

AWARD FEE

GRAND TOTAL

Medicare Integrity Program

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

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

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

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

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

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

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

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

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

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

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

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

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

Confidential Procurement Sensitive

C.5.7(2)

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002 MIP A - C.5.7			C.5.7.1
A/B SERVICES	Total FTEs	Total FTE Hours	Provider Outreach & Education
Medicare Integrity Program			Hours	Rates	Total
COST ELEMENTS

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

Fringe Benefits (at ____%) $0

Total Direct Labor $0

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

Other Direct Costs $0

SUBTOTAL ALL DIRECT COSTS $0

Indirect Costs (at ______ %) $0

TOTAL OTHER BEFORE FEE $0

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

TOTAL OTHER AFTER FEE $0

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

75FCMC20R0008

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

Confidential Procurement Sensitive

C.5.11(2)

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.35

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

Direct Labor
	0	$0
	0	$0

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File details come from the government source that posted it. Updated Sep 4, 2020.