Appendix 4 Pricing Proposal Revised 071422.xlsm
XLSM spreadsheet 32 KB Posted
- Solicitation number
- 22-510CPOGS-CPOGS-B-30194
- Issued by
- St. Clair County, Illinois
About this file
This document is a Pricing Proposal for a Request for Proposal (RFP) issued by the Chief Procurement Office for General Services, in consultation with the Department of Central Management Services, for Third Party Administrator services to administer the State Employee Workers Compensation Program for the State of Illinois. The RFP requests comprehensive workers' compensation services including medical only claims, indemnity claims, permanent disability, survivor claims, independent medical exams, utilization review, clinical review, peer review, early intervention, and bill review services. The contract term is for 5 years, with estimated quantities of services provided for evaluation purposes.
The pricing proposal includes one-time implementation fees as well as unit pricing for the various claims management and related services over the 5-year contract term. Offerors are required to provide proposed pricing, discount percentages, and dispensing fees. The State reserves the right to reject any proposed price increases for renewal years and cancel the contract if determined to be in the best interest of the State.
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| Appendix 2 Workers Compensation Open Claim Data.xlsx | XLSX spreadsheet | |
| Appendix 3 Network Providers by County.xlsx | XLSX spreadsheet | |
| BEP ADDENDUM for B-30194 BEP Facilitation document.xlsx | XLSX spreadsheet | |
| Forms A Section V.18.1.docx | DOCX document | |
| Notice of Electronic Submission Only v.22.1_18.pdf | ||
| Appendix 5 SOI REPORTED CLAIMS CY 2017_2021 revised.xls | XLS spreadsheet | |
| B30194 RFP Questions and Answers 1~1.docx | DOCX document | |
| Forms B Section V.20.1~2.docx | DOCX document | |
| WC RFP Final_4.docx | DOCX document | |
| B-30194 CPOGS BEP Goal Facilitation email.pdf | ||
| B-30194 NOA WC TP Claims Admin.pdf | ||
| Utilization Plan Version 21.0 -4.12.2021.pdf | ||
| Question and Response Addendum 2 071422.docx | DOCX document | |
| Vendor Instruction for RFPs v22.2.docx | DOCX document |
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Input
| B-2 | |
| Select One | |
| Yes | |
| No | |
| B-3 | |
| Select One | |
| Explanation | |
| Deviation |
Financial
| Comprehensive Workers' Compensation TPA Services for the State of Illinois | |
| Appendix 4: Pricing Proposal |
| Estimated # of Services | Contract Year 1 | Contract Year 2 | Contract Year 3 | Contract Year 4 | Contract Year 5 | Total | |||||||||||||
| Fee | Unit | Total | Fee | Unit | Total | Fee | Unit | Total | Fee | Unit | Total | Fee | Unit | Total | |||||
| WORKERS' COMPENSATION PROGRAM IMPLEMENTATION | |||||||||||||||||||
| One- Time Implementation Fee (to include costs associated with contract start-up) | 1 | One-time | $ - 0 | ||||||||||||||||
| WORKERS' COMPENSATION CLAIMS MANAGEMENT | |||||||||||||||||||
| Medical Only Claims | 600 | Per Claim | $ - 0 | $ - 0 | Per Claim | $ - 0 | Per Claim | $ - 0 | Per Claim | $ - 0 | Per Claim | $ - 0 | $ - 0 | ||||||
| Indemnity Claims | 4,200 | Per Claim | $ - 0 | $ - 0 | Per Claim | $ - 0 | Per Claim | $ - 0 | Per Claim | $ - 0 | Per Claim | $ - 0 | $ - 0 | ||||||
| Permanent Disablity | 325 | Per Claim | $ - 0 | $ - 0 | Per Claim | $ - 0 | Per Claim | $ - 0 | Per Claim | $ - 0 | Per Claim | $ - 0 | $ - 0 | ||||||
| Survivor Claims | 35 | Per Claim | $ - 0 | $ - 0 | Per Claim | $ - 0 | Per Claim | $ - 0 | Per Claim | $ - 0 | Per Claim | $ - 0 | $ - 0 | ||||||
| WORKERS' COMPENSATION CLAIMS MANAGEMENT INDIVIDUAL ELEMENTS | |||||||||||||||||||
| Independent Medical Exams | 1,000 | Per Exam | $ - 0 | $ - 0 | Per Exam | $ - 0 | Per Exam | $ - 0 | Per Exam | $ - 0 | Per Exam | $ - 0 | $ - 0 | ||||||
| Utilization Review | 1,400 | Flat Rate | $ - 0 | $ - 0 | Flat Rate | $ - 0 | Flat Rate | $ - 0 | Flat Rate | $ - 0 | Flat Rate | $ - 0 | $ - 0 | ||||||
| Clinical Review | 4,368 | Flat Rate | $ - 0 | $ - 0 | Flat Rate | $ - 0 | Flat Rate | $ - 0 | Flat Rate | $ - 0 | Flat Rate | $ - 0 | $ - 0 | ||||||
| Peer Review | 761 | Per Review | $ - 0 | $ - 0 | Per Review | $ - 0 | Per Review | $ - 0 | Per Review | $ - 0 | Per Review | $ - 0 | $ - 0 | ||||||
| Early Intervention | |||||||||||||||||||
| Flat rate for all cases (Including preparation of IC-45) | 6,000 | Flat Rate | |||||||||||||||||
| for All Cases | $ - 0 | $ - 0 | Flat Rate | ||||||||||||||||
| for All Cases | $ - 0 | Flat Rate | |||||||||||||||||
| for All Cases | $ - 0 | Flat Rate | |||||||||||||||||
| for All Cases | $ - 0 | Flat Rate | |||||||||||||||||
| for All Cases | $ - 0 | $ - 0 | |||||||||||||||||
| 30 day extension beyond 60 days | 400 | Per Case | $ - 0 | $ - 0 | Per Case | $ - 0 | Per Case | $ - 0 | Per Case | $ - 0 | Per Case | $ - 0 | $ - 0 | ||||||
| 60 day extension | 129 | Per Case | $ - 0 | $ - 0 | Per Case | $ - 0 | Per Case | $ - 0 | Per Case | $ - 0 | Per Case | $ - 0 | $ - 0 | ||||||
| 90 day extension | 28 | Per Case | $ - 0 | $ - 0 | Per Case | $ - 0 | Per Case | $ - 0 | Per Case | $ - 0 | Per Case | $ - 0 | $ - 0 | ||||||
| BILL REVIEW SERVICES | |||||||||||||||||||
| Cost per Bill | 58,766 | Per Bill | $ - 0 | $ - 0 | Per Bill | $ - 0 | Per Bill | $ - 0 | Per Bill | $ - 0 | Per Bill | $ - 0 | $ - 0 | ||||||
| Medical Management Services | |||||||||||||||||||
| Professional Services | 150 | Per Hour | $ - 0 | $ - 0 | Per Hour | $ - 0 | Per Hour | $ - 0 | Per Hour | $ - 0 | Per Hour | $ - 0 | $ - 0 | ||||||
| Loss Prevention Services | |||||||||||||||||||
| Professional Services | 150 | Per Hour | $ - 0 | $ - 0 | Per Hour | $ - 0 | Per Hour | $ - 0 | Per Hour | $ - 0 | Per Hour | $ - 0 | $ - 0 | ||||||
| Investigation Services | |||||||||||||||||||
| Professional Services | 10,000 | Per Hour | $ - 0 | $ - 0 | Per Hour | $ - 0 | Per Hour | $ - 0 | Per Hour | $ - 0 | Per Hour | $ - 0 | $ - 0 | ||||||
| Grand Total | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| The following information will be used for contracting and not proposal evaluation purposes. Network savings amount can be submitted directly in this spreadsheet. | |||||
| Network Savings | Contract Year | ||||
| 1 | 2 | 3 | 4 | 5 | |
| Pharmacy PPO Network | Discount (%) off of AWP | ||||
| Retail - Discount off of Average Wholesale Price for Brand Name Drugs | 0% | ||||
| Retail - Discount off of Average Wholesale Price for Generic Drugs | 0% | ||||
| Home Delivery - Discount off of Average Wholesale Price for Brand Name Drugs | 0% | ||||
| Home Delivery - Discount off of Average Wholesale Price for Generic Drugs | 0% | ||||
| Treating PPO Network | Discount (%) | ||||
| PPO Network Discount | 0% |
| Dispensing Fee Per Prescription | Fee | Fee | Fee | Fee | Fee |
| Dispensing Fee Per Prescription | $ - 0 | ||||
| * Implementation to include costs associated with Contract Start-Up, including but not limited to, historical date transfer, system(s) and data transer set-up and security. One-time implementation cost to be paid upon completion of successful go-live. The fee can be $0. | |||||
| Notes: | |||||
| a. Offeror should provide proposed fees and discount % in the cells shaded green above. |
b. The Estimated # of Services in Column C above represents uniform assumptions for purposes of proposal evaluation. Offeror must guarantee the fees quoted regardless of actual number of services.
c. The State further reserves the right to reject any proposed price increase submitted for renewal years, cancel the contract and re-bid if determined it is in the best interest of the State.
d. Fees will be evaluated based on toal cost for Contract Year 1 through Contract Year 5 in cell S35.
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