Appendix D-1 - Cost Submittal Worksheet LOT 1 Rev.110920.xls

Instructions

Offerors must provide a detailed explanation (i.e. calculations, formulas…A+B=C) to include a cost breakdown to support and verify how the total annual cost for each year is derived. Offerors may use the tab labeled "Lot 1 - Cost Breakdown" as an example to submit their cost breakdown or submit their own cost tables within this Appendix D-1 according to the minimum cost breakdown requirements as specified below. The detailed cost breakdown shall become part of the Contract.

The DOC will not accept a cap on the Offeror's liability for hospitalization and other services. The selected Offeror will be responsible for outpatient care, including emergency room and observation services that do not roll into an inpatient admission at that specific provider. The selected Offeror shall reimburse the providers at Medicare rates. Emergency ambulance services that do not result in an inpatient admission will be paid by the selected Offeror at Medicare rates. Life flights services will be paid by DOC.

• Full-Time Equivalent (FTE) per position title per institution

• Number of weekly/annual hours per position title per institution

• Hourly Rate per position title per institution. The Offeror must provide the number of hours of service the DOC will be provided at each institution for each type of on-site service provided. Furthermore, the Offeror must supply an hourly rate (salary and benefits) that the employee will be paid. The Offeror must also provide an average rate or blended rate for each position. This rate will be utilized for calculating liquidated damages when services are not provided in accordance with the proposed amounts. The hourly rates used would be that of the closest institution geographically. If the Offeror is proposing cost increases for each year, the Offeror must list the rate of increase. Should an increase be tied to the U.S. Department of Labor’s Consumer Price Index, it must be tied to the All Urban Consumers-U.S. City Average for Medical Care Services.

• Blended Rate per position title

• Overall cost summary for all institutions

• Electronic Medical Record Costs

Lot 1 - Cost

APPENDIX D-1

COST SUBMITTAL WORKSHEET - LOT 1

RFP 6100019380

Lot 1 - Cost Breakdown

APPENDIX D-1

COST SUBMITTAL - LOT 1

RFP 6100019380

(SCI-Chester / SCI-Pine Grove) Medical Records Staffing (SCI-Chester / SCI-Pine Grove)