Attachment 3 CCN Next Generation Medical West Price Schedule.xlsx
XLSX spreadsheet 105 KB Posted
- Attached to
- Q201--CCN-Next Gen Medical
- Solicitation number
- 36C10G26R0003
About this file
This document is a comprehensive pricing template for the Community Care Network (CCN) Next Generation Medical West Region procurement by the Department of Veterans Affairs. The pricing schedule contains multiple Contract Line Item Numbers (CLINs) covering a wide range of healthcare services, including healthcare services, waivers of payment rates, seasonal vaccinations, urgent and emergent medications, administrative services, implementation and transition costs, and optional tasks like appointment scheduling, care coordination, and comprehensive disease management.
The pricing template includes detailed pricing structures for various healthcare service categories, with different pricing tiers based on veteran population volumes and service complexity. Key pricing mechanisms involve percentages of Medicare rates, Average Wholesale Price (AWP) for medications, per member per month (PMPM) administrative fees, and fixed-price implementation costs. The document provides extensive instructions for offerors to quote prices across base and option years, with specific guidance on documenting price sources, inflation considerations, and regional variations, particularly for healthcare services in highly rural areas.
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Pricing Template
| Community Care Network Next Generation - Medical West |
| Pricing Schedule |
| Offeror Name: | ||||||||
| Prices per CLIN per year | Base Period | Option Period | Option Period | |||||
| CLIN | DESCRIPTION | UNIT | Year 1 | Year 2 | Year 3 | Year 4 | Year 5 | Option to Extend Services |
| CLIN X001 | Healthcare Services | |||||||
| CLIN X001AA | Standard Medicare Rate Healthcare Services | Up to 100% Medicare | ||||||
| CLIN X001AB | PPS Exempt Healthcare Services | Up to CMS PPS Exempt Rate | ||||||
| CLIN X002 | Waivers of Payment Rates | Maximum % above Medicare or VA Fee Schedule Rate | ||||||
| CLIN X003 | Seasonal Vaccinations | $ per vaccination | ||||||
| CLIN X004 | VA Fee Schedule | Up to VA Fee Schedule | ||||||
| CLIN X005 | Alaska Fee Schedule | Up to Alaska Fee Schedule | ||||||
| CLIN X006 | Non-Medicare, Non-VA, Non-Alaska Fee Schedule Healthcare Services | 50% billed charges | ||||||
| CLIN X007 | Urgent and Emergent Medication | |||||||
| CLIN X007AA | Brand Name Medication | % of ASP per medication | ||||||
| CLIN X007AB | Generic Medication | % of ASP per medication | ||||||
| CLIN X007AC | Dispensing Fee | $ per medication dispensed | ||||||
| CLIN X008 | Disaster Response: Urgent and Emergent Medication | |||||||
| CLIN X008AA | Brand Name Medication | % of ASP per medication | ||||||
| CLIN X008AB | Generic Medication | % of ASP per medication | ||||||
| CLIN X008AC | Dispensing Fee | $ per medication dispensed | ||||||
| CLIN X009 | Administrative Services | |||||||
| CLIN X009AA | Administrative Services for Healthcare Services | Monthly Enrolled Veteran Population | ||||||
| CLIN X009AB | Administrative Services for Pharmacy Benefits Management (PBM) | Monthly Enrolled Veteran Population | ||||||
| CLIN X009AC | Administrative Services Performance Incentives | % incentive/disincentive | ||||||
| CLIN X010 | Organ Acquisition Cost | Up to 100% Medicare per CMS D-4 Worksheet | ||||||
| CLIN X011 | Implementation | Fixed Price Lump Sum | ||||||
| CLIN X012 | Transition Out | Fixed Price Lump Sum | ||||||
| CLIN X013 | Optional Task Implementation | |||||||
| CLIN X013AA | Implementation for Appointment Scheduling and Comprehensive Care Coordination at the VA Facility | $ total cost of implementation per VA Facility | ||||||
| CLIN X013AB | Implementation for Appointment Scheduling and Comprehensive Care Coordination at the Contractor's Site | $ total cost of implementation at Contractor’s site | ||||||
| CLIN X014 | Optional: Healthcare Appointment Scheduling and Comprehensive Care Coordination | |||||||
| CLIN X014AA | Appointment Scheduling Administration and Comprehensive Care Coordination Tier 1 | $ per Approved Referral for Appointment Scheduling | ||||||
| CLIN X014AB | Appointment Scheduling Administration and Comprehensive Care Coordination Tier 2 | $ per Approved Referral for Appointment Scheduling | ||||||
| CLIN X014AC | Appointment Scheduling Administration and Comprehensive Care Coordination Tier 3 | $ per Approved Referral for Appointment Scheduling | ||||||
| CLIN X014AD | Appointment Scheduling Administration and Comprehensive Care Coordination Tier 4 | $ per Approved Referral for Appointment Scheduling | ||||||
| CLIN X014AE | Appointment Scheduling Administration and Comprehensive Care Coordination Tier 5 | $ per Approved Referral for Appointment Scheduling | ||||||
| CLIN X015 | Optional: Care Coordination Follow-Up | $ per Approved Referral for Care Coordination Follow-up | ||||||
| CLIN X016 | Optional: Software, Process, and Proof of Concept Development | |||||||
| CLIN 0016AA | Extra-Small (XS) Software Development Task Size | $ per software development task | ||||||
| CLIN X016AB | Small Software Development Task Size | $ per software development task | ||||||
| CLIN X016AC | Medium Software Development Task Size | $ per software development task | ||||||
| CLIN X016AD | Large Software Development Task Size | $ per software development task | ||||||
| CLIN X016AE | Extra Large (XL) Software Development Task Size | $ per software development task |
CLIN X002 BOE Calculations-East
| CLIN X002 - Waivers of Payment Rates | |
| BOE Calculations | See instructions at bottom |
| Offeror Name: | |||||||||
| Maximum percentage factor above medicare locality based rate needed to solicit service providers in highly rural areas. | |||||||||
| State | BASE | OPTION I | OPTION II | OPTION III | OPTION IV | OPTION V | OPTION VI | OPTION VII | |
| AL | |||||||||
| AR | |||||||||
| CT | |||||||||
| DE | |||||||||
| DC | |||||||||
| FL | |||||||||
| GA | |||||||||
| IL | |||||||||
| IN | |||||||||
| IA | |||||||||
| KS | |||||||||
| KY | |||||||||
| LA | |||||||||
| ME | |||||||||
| MD | |||||||||
| MA | |||||||||
| MI | |||||||||
| MN | |||||||||
| MS | |||||||||
| MO | |||||||||
| NE | |||||||||
| NH | |||||||||
| NJ | |||||||||
| NY | |||||||||
| NC | |||||||||
| ND | |||||||||
| OH | |||||||||
| OK | |||||||||
| PA | |||||||||
| PR | |||||||||
| RI | |||||||||
| SC | |||||||||
| SD | |||||||||
| TN | |||||||||
| VT | |||||||||
| VI | |||||||||
| VA | |||||||||
| WV | |||||||||
| WI |
| BASE | OPTION I | OPTION II | OPTION III | OPTION IV | OPTION V | OPTION VI | OPTION VII | ||
| Total estimated costs | Perhaps get rid of the word "estimated" and replace with "not to exceed"/"maximum"? (may get a clue based on how the pertinent Q, in Greg's list, gets addressed in the Q&A session) |
Section 1. Source /Basis
Section 2. Change Over Space and Time
Section 3. Additional Information
| General Instructions | |
| Reimbursement for Highly Rural Care Areas: For each state, please quote, for each year of the PoP, premiums for Healthcare Services provided to Veterans residing in Highly Rural Areas as a percentage of the Medicare reimbursement rates. For example, if your rate is 20% lower than the Medicare rate, please enter 80%; similar, if your rate is 20% higher than the Medicare rate, please enter 120%. |
This CLIN only applies if the Contractor must execute a specific agreement in a Highly Rural Care Area at a rate that exceeds Medicare as required to maintain Network Adequacy. Adequate documentation must be provided to the Contracting Officer for review and disposition to support a request for higher than Medicare rates. The Contractor may, in Highly Rural Care Areas, exceed Medicare but shall not exceed the rate in this CLIN. This CLIN is priced based on a percentage of locality adjusted Medicare rate.
Include a total estimated cost and associated BOE for budgeting and evalution purposes. Since this cost is a pass-thru, with Gov't approval necessary, (similar to travel), a lower cost does not automatically imply a higher score. The cost estimate provides a budget estimate, and a reasonable cost backed by a good BOE will score highest. Actual cost may vary. Only the premium percentage rate is a contractual ceiling.
CLIN X002 BOE
| CLIN X002 - Waivers of Payment Rates |
| BOE |
Offeror Name:
CLIN X003 BOE
| CLIN X003 - Seasonal Vaccinations |
| BOE |
Offeror Name:
CLIN X007 BOE
| CLIN X007 - Urgent and Emergent Medication |
| BOE |
Offeror Name:
CLIN X008 BOE
| CLIN X008 - Disaster Response ONLY: Urgent and Emergent Medication |
| BOE |
Offeror Name:
CLIN X009 BOE
| CLIN X009 - Administrative Services |
| BOE |
Offeror Name:
CLIN X011 BOE
| CLIN X011 - Implementation |
| BOE |
Offeror Name:
CLIN X012 BOE
| CLIN X012 - Transition Out |
| BOE |
Offeror Name:
CLIN X013 BOE
| CLIN X013 - Optional Task Impelmentation |
| BOE |
Offeror Name:
CLIN X014 BOE
| CLIN X014 - Optional: Healthcare Appointment Scheduling and Comprehensive Care Coordination |
| BOE |
Offeror Name:
CLIN X015 BOE
| CLIN X015 - Optional: Care Coordination Follow-Up |
| BOE |
Offeror Name:
CLIN X016 BOE
| CLIN X016 - Optional: Software Development |
| BOE |
Offeror Name:
CLIN X014 BOE Calculations CLIN X013 BOE Calculations
CLIN X015 BOE Calculations
Main Pricing Sheet
| Community Care Network - West/East Region | |
| Prices Quote for CLINs | See instructions at bottom |
| Offeror Name: | |||||||||||
| Prices per specific CLIN per year | |||||||||||
| CLIN | DESCRIPTION | UNIT/Directions | BASE | OPTION I | OPTION II | OPTION III | OPTION IV | OPTION V | OPTION VI | OPTION VII | |
| CLIN 0001 | Healthcare Services | ||||||||||
| CLIN 0002 | Reimbursement for Highly Rural Care Areas and Scarce Medical Specialist Services | Please use "(Pricing Sheet (CLIN 0002)" | |||||||||
| CLIN 0003 | Home Health Care | ||||||||||
| CLIN 0003AA | Skilled Home Health | ||||||||||
| CLIN 0003AB | Unskilled Home Health | ||||||||||
| CLIN 0004 | Seasonal Vaccination(s) | Each, $_____ | |||||||||
| CLIN 0005 | Non-Medicare Healthcare Services, VA Fee Schedule | ||||||||||
| CLIN 0006 | Non-Medicare, Non-VA Fee Schedule - Medical and Surgical Healthcare Services | ||||||||||
| CLIN 0007 | Home Infusion Therapy | Summary CLIN, not separately priced (NSP) | |||||||||
| CLIN 0007AA | Nursing per hour up to 2 hours | ||||||||||
| CLIN 0007AB | Nursing every 3 hours | ||||||||||
| CLIN 0007AC | Nursing every 4 hours | ||||||||||
| CLIN 0007AD | Nursing every 6 hours | ||||||||||
| CLIN 0007AE | Nursing every 8 hours | ||||||||||
| CLIN 0007AF | Nursing every 12 hours | ||||||||||
| CLIN 0007AG | Nursing every 24 hours | ||||||||||
| CLIN 0007AH | Total Parenteral Nutrition | ||||||||||
| CLIN 0007AI | Hydration | ||||||||||
| CLIN 0007AJ | All Other Infusion Therapy | ||||||||||
| CLIN 0007AK | Pharmacy | ||||||||||
| CLIN 0008 | Urgent and Emergent Medication | Summary CLIN, not separately priced (NSP) | |||||||||
| CLIN 0008AA | Brand Name Medication | Percent, Up to _% of AWP | |||||||||
| CLIN 0008AB | Generic Medication | Percent, Up to _% of AWP | |||||||||
| CLIN 0008AC | Dispensing Fee | Each in $/prescription | |||||||||
| CLIN 0009 | Administrative Services | Summary CLIN, not separately priced (NSP) | |||||||||
| CLIN 0009Ax | Administrative Services for Healthcare Services | $ Price for Each Active Veteran per month | |||||||||
| CLIN 0009AA | Quantity Tier 1 | Each Active Veteran, 0 – 41,000 | |||||||||
| CLIN 0009AB | Quantity Tier 2 | Each Active Veteran 41,001 – 82,000 | |||||||||
| CLIN 0009AC | Quantity Tier 3 | Each Active Veteran 82,001+ | |||||||||
| CLIN 0009BA | Administrative Fee for Pharmacy Benefits Management (PBM) | $ Price for Each Active Veteran per month | |||||||||
| CLIN 0009CA | Administrative Fee for Assisted Reproductive Technology (ART) | $ Price for Each Collateral (donor/partner) per month | |||||||||
| CLIN 0009DA | Administrative Services Transplant Case (Phases 1, 2, and 4) | $ Price for Each Collateral (donor/partner) per month | |||||||||
| CLIN 0009DB | Administrative Services Transplant Case (Phase 3 only) | $ Price for Each Collateral (donor/partner) per month | |||||||||
| CLIN 0010 | Implementation and Transition Out | N/A | N/A | N/A | N/A | N/A | N/A | ||||
| CLIN 0010AA | Implementation | Lump sum $ price based on # of milestones completed in year | |||||||||
| CLIN 0010AB | Transition Out | Lump sum $ price | |||||||||
| CLIN 0011 | Optional: Appointment Scheduling & Comprehensive Care Coordination | Summary CLIN, not separately priced (NSP) | |||||||||
| CLIN 0011AA | Optional: Implementation for Appointment Scheduling and Comprehensive Care Coordination | Implementation price per VAMC at Government site. | |||||||||
| CLIN 0011Bx | Optional: Implementation for Appointment Scheduling and Comprehensive Care Coordination at the Contractor’s site | Implementation price per VAMC at contractor's site. | |||||||||
| CLIN 0011BA | Tier 1 | 0 – 331,400 | |||||||||
| CLIN 0011BB | Tier 2 | 331,401– 773,300 | |||||||||
| CLIN 0011BC | Tier 3 | 773,301– 1,215,200 | |||||||||
| CLIN 0011BD | Tier 4 | 1,215,201– 1,657,000 | |||||||||
| CLIN 0011BE | Tier 5 | 1,657,001 + | |||||||||
| CLIN 0011CA | Optional: Appointment Scheduling and Comprehensive Care Coordination | $ Price per Unique Approved Referral for each of the tiers of a PoP | |||||||||
| CLIN 0012 | Optional: Care Coordination Follow-Up | Summary CLIN, not separately priced (NSP) | |||||||||
| CLIN 0012AA | Optional: Implementation for Care Coordination Follow-Up | One-time lump sum $ in the year the option is exercised. | |||||||||
| CLIN 0012AB | Optional: Care Coordination Follow-Up Administration | $ Price per lot (of 50 Unique Approved Referrals) for each of the tiers a PoP | |||||||||
| CLIN 0012AB | Tier 1 | 0 – 820 | |||||||||
| CLIN 0012AB | Tier 2 | 821 – 1,640 | |||||||||
| CLIN 0012AB | Tier 3 | 1,641+ | |||||||||
| CLIN 0013 | Assisted Reproductive Technology (ART) Services | Summary CLIN, not separately priced (NSP) | |||||||||
| CLIN 00013AA | Intrauterine insemination (IUI) Female SEOC | Enter data on "Pricing Sheet (CLIN 0013)" | |||||||||
| CLIN 00013AB | Intrauterine insemination (IUI) Male SEOC | Enter data on "Pricing Sheet (CLIN 0013)" | |||||||||
| CLIN 00013AC | IVF Female SEOC | Enter data on "Pricing Sheet (CLIN 0013)" | |||||||||
| CLIN 00013AD | IVF Male SEOC | Enter data on "Pricing Sheet (CLIN 0013)" | |||||||||
| CLIN 00014 | Urgent and Emergent Medication – Disaster Response ONLY | Summary CLIN, not separately priced (NSP) | |||||||||
| CLIN 00014AA | Brand Name Medication | % of AWP, must be identical to XY08AA | |||||||||
| CLIN 00014AB | Generic Medication | % of AWP, must be identical to XY08AB | |||||||||
| CLIN 00014AC | Dispensing Fee | Must be identical to XY08AC | |||||||||
| CLIN 0014 | Organ Acquisition Cost (Certified Transplant Centers) | Medicare Standard Acquisition Charges (SACs) shall be used for reimbursement of the reasonable and necessary costs associated with solid organ acquisition. | |||||||||
| CLIN 0015 ?? | Healthcare Services Approved Under the Veterans Millennium Health Care Act (MILLBILL) | ||||||||||
| CLIN 0016 | Healthcare Provided by Tribal Health/Pacific Islander Service | Summary CLIN, not separately priced (NSP) | |||||||||
| CLIN X016HI | Tribal Inpatient hospital services per diem (IHS rate) (excludes physician/practitioner services) | Per patient per IHS all inclusive inpatient hospital per diem rates | |||||||||
| CLIN X016HO | Tribal Outpatient hospital services all inclusive per visit (IHS rate) | Reimbursement per encounter per the adjusted IHS all inclusive rate | |||||||||
| CLIN X016AS | Tribal Ambulatory Surgical Services | Reimbursed per Medicare rates for free standing surgical centers. | |||||||||
| CLIN X016CO | Tribal Clinic Services, including certified community health aid services | Reimbursement per visit per the IHS all inclusive outpatient rate | Another definition: All-inclusive rate approved each year by IHS under the title "Outpatient Per Visit Rate (excluding Medicare)...paid at 85% of the all-inclusive rate. | ||||||||
| CLIN X016MD | Physician and practitioner services at Tribal hospitals and non-Medicare services at free standing surgical centers | Per the Alaska Professional VA fee schedule. | |||||||||
| CLIN X016TP | Tribal in-patient transplant related healthcare | 1) Alaska VA fee schedules, 2) Medicare rates (for new codes, not on Alaska VA fee schedules), and 3) agreed upon % of billed charges or all of billed charges | |||||||||
| Section 1. Source /Basis |
Section 2. Change Over Space and Time
Section 3. Additional Information
| General Instructions | |
| 1 | Quote: Quotes are being sought for a partial list of CLINs. Please refer to Section B- Supplies for Services and Price in the RFP document for a description of each of the CLINS. Please input your quote in green colored cells for CLINs 0002, 0008, 0009AA, 0009AB, 0009AC, 0011AA, 0011AB, 0011AC, 0011AD, 0012, 0016AA, 0016AB, 0016AC, 0017AA, 0017AB, 0018AA, 0018AB, 0019AA, 0019AB, and 0020 on this sheet. Please input your quote for CLIN 0010 in "Pricing Sheet (CLIN 0010)" tab. No quote is required for the CLINs/SubCLINs in grayed out cells. |
| 2 | The Offeror must clearly list and describe any additional conditions or exceptions upon which its cost proposal is based. In addition, they may be provided the information in the price volume. In cases where there is an inadvertent inconsistency between the prices in the Pricing Sheet and the Price Volume, VA shall use the Pricing Sheet prices. |
| 3 | Section 1. Source/Basis: Please indicate the source of the prices in the pertinent cell above in green. Please indicate where you have used this schedule of prices with another patient population. If prices are not used elsewhere and/or if the proposed prices have been varied or derived somewhat from the original set, please indicate how. Please provide your quote in terms of the standard price you will charge for the listed procedures. Note one standard price must be provided for the entire region per code regardless of zip code. Provide the ratio (discount or premium) between prior price sheets and the prices proposed for VA. Such adjustments should be uniform across the data set of prices. |
| 4 | Section 2. Change Over Time and Space: Explain the basis for any price changes over time and submarket, if any, in the pertinent cell above in green. For price changes over time indicate source of inflation index. Put the specific price for each CLIN in columns D thru K, and provide the additional prices and weightings of the submarkets on separate tabs or attachments. Note VA will not consider price variations based on location unless the location has been approved via CLIN 2. If a contract extension is approved to facilitate transition out after the last option year, then the price in option year 7 shall govern the transition period. |
| 5 | Section 3. Additional Information: No response is required, but additional information can be provided as part of the proposal. They can be provided in the pertinent cell above in green. If there are additional procedures/codes for which the offeror wishes to be covered and reimbursed, they should be part of the offerors standard offering to other patient communities. The VA may consider including them in post award negotiations. |
| Instructions by CLIN | |
| CLIN 0001 | Healthcare Services: Quote Not Required. This CLIN is priced up to 100% Medicare. Assumptions/considerations related to these services are inclusive of all authorized healthcare services identified in PWS Section 4.1, “CCN Healthcare Services” and Complementary and Integrative Health Services identified in PWS Section 4.2, “CCN Complementary and Integrative Health Services” covered by the applicable Medicare Prospective Payment System (PPS). |
| CLIN 0002 | Reimbursement for Highly Rural Care Areas: For each state, please quote, for each year of the PoP, premiums for Healthcare Services provided to Veterans residing in Highly Rural Areas as a percentage of the Medicare reimbursement rates. For example, if your rate is 20% lower than the Medicare rate, please enter 80%; similar, if your rate is 20% higher than the Medicare rate, please enter 120%. |
This CLIN only applies if the Contractor must execute a specific agreement in a Highly Rural Care Area at a rate that exceeds Medicare as required to maintain Network Adequacy. Adequate documentation must be provided to the Contracting Officer for review and disposition to support a request for higher than Medicare rates. The Contractor may, in Highly Rural Care Areas, exceed Medicare but shall not exceed the rate in this CLIN. This CLIN is priced based on a percentage of locality adjusted Medicare rate.
Include a total estimated cost and associated BOE for budgeting and evalution purposes. Since this cost is a pass-thru, with Gov't approval necessary, (similar to travel), a lower cost does not automatically imply a higher score. The cost estimate provides a budget estimate, and a reasonable cost backed by a good BOE will score highest. Actual cost may vary. Only the premium percentage rate is a contractual ceiling.
Kataria, Rajiv: Kataria, Rajiv For each state, please quote, for each year of the PoP, premiums for Healthcare Services provided to Veterans residing in Highly Rural Areas as a percentage of the Medicare reimbursement rates. For example, if your rate is 20% lower than the Medicare rate, please enter 80%; similar, if your rate is 20% higher than the Medicare rate, please enter 120%.
This CLIN applies only if the the Contracting Officer has approved rates for a certain provider in in a Highly Rural Care Area, at a rate that exceeds the Medicare rate, as required to maintain Network Adequacy. Adequate documentation must be provided to the Contracting Officer for review and disposition to support a request for higher than Medicare rates. The Contractor may, in Highly Rural Care Areas, exceed Medicare but shall not exceed the the quoted rate for this CLIN. The Offeror must price this CLIN based on a percentage of locality adjusted Medicare rate.
Include a total estimated cost and associated BOE for budgeting and evalution purposes. Since this cost is a pass-thru, with Gov't approval necessary, (similar to travel), a lower cost does not automatically imply a higher score. The cost estimate provides a budget estimate, and a reasonable cost backed by a good BOE will score highest. Actual cost may vary. Only the premium percentage rate is a contractual ceiling.
| CLIN 0003 | Durable Medical Equipment: No quote is required from the Offeror for this CLIN. This CLIN is priced up to 100% Medicare. Assumptions/considerations related to these services for purchases against this CLIN that are not bundled under other healthcare services provided pursuant to the contract (e.g. hardware used in orthopedic surgery, prosthetic valves in cardiac surgery, implantable devices), pricing will be equal to the Medicare rates for the products against this CLIN. |
| CLIN 0004AA | Skilled Home Health: No quote is required from the Offeror for this CLIN. This CLIN is priced up to 100% Medicare. Assumptions/considerations related to Skilled Home Health services are that contract pricing for this CLIN is equal to the Medicare rate for the services being performed. |
| CLIN 0004AB | Unskilled Home Health: No quote is required from the Offeror for this CLIN. Contract pricing is up to the VA Fee Schedule. Assumptions/considerations related to these Unskilled Home Health services includes assistance with all daily living activities such as house cleaning, food preparation, grocery shopping, laundry, accompanying Veteran to medical appointments (e.g. Homemaker/Home Health Aide). |
| CLIN 0005 | Seasonal Influenza Vaccination: Please quote your cost of administering one flu vaccine to patient (excluding dosage cost). This CLIN is for the administration and dispensing fees for the influenza vaccine (trivalent, quadrivalent and high dosage). VA will pay the negotiated price for each vaccination. |
| CLIN 0006 | Non-Medical and Surgical Services, VA Fee Schedule: No quote is required from the Offeror. Contract pricing is up to the VA Fee Schedule. Assumptions/considerations related to the non-Medicare Healthcare Services, VA Fee Schedule - When a given medical procedure is not payable under Medicare rules or is payable under Medicare rules but does not have established pricing at the local level, such medical procedures will be paid based on the applicable VA Fee Schedule. Outpatient services performed by Inpatient Prospective Payment System (IPPS) - exempt facilities are also included under this CLIN. |
| CLIN 0007 | Non-Medical, Non-VA Fee Schedule Medical and Surgical Services: No quote is required from the Offeror. Assumptions/considerations - when a given medical procedure is not payable under Medicare rules, or is payable under Medicare rules but does not have established pricing at the local level, and is not included in the VA Fee Schedule, VA will reimburse the healthcare claims pursuant to 38 CFR 17.55 or 38 CFR 17.56, including any subsequent changes to include but not limited to payment based on a percentage of billed charge. |
| CLIN 0008 | Home Infusion Therapy: |
| CLIN 0008AA | Nursing per hour up to 2 hours: Provide hourly rate. |
| CLIN 0008AB | Nursing per hour up to 3 hours: Provide hourly rate. |
| CLIN 0008AC | Nursing per hour up to 4 hours: Provide hourly rate. |
| CLIN 0008AD | Nursing per hour up to 6 hours: Provide hourly rate. |
| CLIN 0008AE | Nursing per hour up to 8 hours: Provide hourly rate. |
| CLIN 0008AF | Nursing per hour up to 12 hours: Provide hourly rate. |
| CLIN 0008AG | Nursing per hour up to 24 hours: Provide hourly rate. |
| CLIN 0008AH | Total Parenteral Nutrition: Provide your standard pricing. |
| CLIN 0008AI | Hydration: Provide your standard pricing. |
| CLIN 0008AJ | All Other Infusion Therapy: Provide your standard pricing. |
| CLIN 0008AK | Pharmacy: Provide your standard pricing. |
| CLIN 0009 | Urgent and Emergent Medication: VA will reimburse the Contractor for brand name medication at Average Wholesale Price (AWP) plus/minus percent, plus a dollar amount for dispensing fee; and generic medication at AWP plus/minus percent, plus a dollar amount for dispensing fee. |
| CLIN 0009AA | Brand Name Medications: Please quote your price of brand name medications as a percentage of Average Wholesale Price (AWP) for each year of the PoP. For example, if your average price of brand name medications is 20% lower than AWP, please enter 80%; similar, if your average price of brand name medications is 20% higher than AWP, please enter 120%. |
| CLIN 0009AB | Generic Medications: Please quote your price of generic medications as a percentage of Average Wholesale Price (AWP) for each year of the PoP. For example, if your average price of generic medications is 20% lower than AWP, please enter 80%; similar, if your average price of generic medications is 20% higher than AWP, please enter 120%. |
| CLIN 0009AC | Dispensing Fee: Please provide your dispensing fee (in $) per prescription for each year of the PoP. |
| CLIN 0010 | Dental Services: Please provide a quote in the sheet named "Pricing Sheet (CLIN 0010)". |
| CLIN 0011 | Administrative Services: Administrative Services based on a per member per month (PMPM) model. The PMPM covers the Contractors charges for all administrative services for managing the services purchased under this contract. The PMPM charge is to be invoiced in accordance with the total number of Active Veterans per month. The PMPM fee is tiered to accommodate for low volumes but to also reduce as volumes increase. |
| CLIN 0011AA | Administrative Services for Healthcare Services: Please provide your Per Member Per Month quote for each of the tiers listed. |
| CLIN 0011AB | Administrative Services for Dental: Please provide your Per Member Per Month quote for each of the tiers listed. |
| CLIN 0011AC | Administrative Services for Pharmacy Benefits Management: Per Member Per Month (PMPM): Please provide your Per Member Per Month quote. Administrative Fee for Pharmacy Benefits Management (PBM) is to be invoiced based on when an urgent /emergent pharmacy claim is paid for an Active Veteran during that billing month. |
| CLIN 0011AD | Administrative Services for ART: Please provide your Per Member Per Month quote for each collateral spouse. |
Kataria, Rajiv: Kataria, Rajiv:
or per standard episode of care or
Per collateral spouce per standard episode of care
| CLIN 0012 | Implementation: Please provide your quote. Separately, please provide a description of the milestones associated with the implementation plan, a breakout of the priced components, and a justification of the proposed prices for identified milestones. Do not include implementation services associated with CLIN 0016 through CLIN 0019. |
| CLIN 0013 | Data: No quote is required from the Offeror for this CLIN. Assumptions/considerations for this CLIN includes all services associated with delivery of data throughout performance and at the end of the contract. |
| CLIN 0014 | Agreed Upon Procedures: No quote is required from the Offeror for this CLIN. Assumptions/consideration for this CLIN is that the contractor will be paid the negotiated price upon completion of the Agreed Upon Procedures audit as stated in PWS section 12.14. |
| CLIN 0015 | Healthcare Services Approved Under the Veterans Millennium Health Care Act (MILLBILL): No quote is required from the Offeror for this CLIN. Assumptions/consideration for this CLIN refers to PWS Section 7.1 which directs the Contractor to pend claims for emergent or urgent care and submit a Referral Request in order to obtain an Approved Referral from VA. VA will review and determine if authority exists to return an Approved Referral. Care authorized by VA under the authority of 38 U.S.C. 1725, will be annotated by VA as such and paid by the Contractor at the 70th percentile of CMS rates. |
Kataria, Rajiv: Kataria, Rajiv:
We need to decide whether to provide specific volume info for all optional CLINs and if so what the volumen info is.
CLIN 0016-0019 General Provisions on optional tasks. Implementation and administrative costs for optional tasks are not co-mingled with the costs listed under CLINs 0011 and 0012. The Government shall be able to choose when to implement optional tasks. Lump sum payments shall be made for implementation within the year(s) that the contract is exercised in a manner similar to that of CLIN 0012. The contractor should propose a list of interim implementation milestones in terms of days after option exercised, with associated payments for CLINs 0017 through 0019. For the purposes of estimating realistic quotes assume that the optional CLINs shall not be immediately exercised upon contract award, but only after the non-optional medical services have been fully transitioned. CLINs 0017 through 0019 may require CLIN 0016 to be implemented and volumes on these CLINs may depend on the number of facilities that order scheduling services.
Kataria, Rajiv: Kataria, Rajiv:
I think we should delete: "CLINs 0017 through 0019 may require CLIN 0016 to be implemented and volumes on these CLINs may depend on the number of facilities that order scheduling services."
| CLIN 0016 | Optional: Appointment Scheduling and Comprehensive Care Coordination: |
| CLIN 0016AA | Optional: Implementation for Appointment Scheduling and Comprehensive Care Coordination: Please provide your quote for each year of the PoP. VA will pay the negotiated fixed price for each VA Facility that orders Appointment Scheduling and Comprehensive Care Coordination. The contractor can earn only one implementation payment per VA Facility during the entire contract. |
| CLIN 0016AB | Optional: Implementation for Appointment Scheduling and Comprehensive Care Coordination at the Contractor’s site: Please provide your quote for the total dollar price for each year of the PoP. VA will pay the negotiated fixed price. The contractor can earn only one implementation payment during the entire contract. |
Kataria, Rajiv: Kataria, Rajiv:
In conflict with the green cells throughout the PoP
| CLIN 0016AC | Optional: Appointment Scheduling and Comprehensive Care Coordination: Please provide your $ Price per Unique Approved Referral, for each of the tiers listed, for a PoP. |
| CLIN 0017 | Optional: Care Coordination Follow-Up: |
| CLIN 0017AA | Optional: Implementation for Care Coordination Follow-Up: Please provide your quote for the total lump sum for CLIN 0017 implementation services for the entire contract duration. |
| CLIN 0017AB | Optional: Care Coordination Follow-Up Administration: Please provide your $ Price per Unique Approved Referral, for each of the tiers listed, for a PoP. Care Coordination Follow Up Administration for all Healthcare Services is based on a lot model. VA will pay the negotiated price per Lot of 50 unique Approved Referrals for each of the tiers. |
| CLIN 0018 | Optional: Comprehensive Case Management Program Administration: |
| CLIN 0018AA | Optional: Implementation for Comprehensive Case Management Program: Please provide your quote for the total lump sum for CLIN 0018 implementation services for the entire contract duration. |
| CLIN 0018AB | Optional: Comprehensive Case Management Program Administration: Please provide your $ Price per Unique Approved Referral, for each of the tiers listed, for each PoP. |
| CLIN 0019 | Optional: Comprehensive Disease Management Administration: |
| CLIN 0019AA | Optional: Implementation for Comprehensive Disease Management: Please provide your quote for the cost of implementation. Pricing for this CLIN reflects the total lump sum of implementation services. |
| CLIN 0019AB | Optional: Comprehensive Disease Management Program Administration: Please provide your $ Price per Unique Approved Referral, for each of the tiers listed, for a PoP. |
| CLIN 0020 | Assisted Reproductive Technology (ART) Services: The CLIN is to be used pay for ART services. Provide a firm fixed price for each ART episode of care. An offeror can make a profit or loss on any specific episode. An episode of care shall be designated by a primary ART authorization associated with a Veteran and his/her spouse. Note: the number of VA authorizations for Region 4 under a similar contract as shown in attachment AJ. Statistical costs of a VA ARTS authorization nationwide were: mean =$1,412 max =$16,710, min = $21. Offerors. Note: related administrative services are included under CLIN 11AA for the Veteran and CLIN 11AD for the Veteran's spouse. Implementation costs should be detailed in the BOE for CLIN 12. See standard episode of care tab for a definition of the maximum set of services that can fall under a single authorization. |
Kataria, Rajiv: Kataria, Rajiv:
This will change based on info from VA. We will need to provide them ESOC info. Don’t think authorization info will be required.
Kataria, Rajiv: Kataria, Rajiv For each state, please quote, for each year of the PoP, premiums for Healthcare Services provided to Veterans residing in Highly Rural Areas as a percentage of the Medicare reimbursement rates. For example, if your rate is 20% lower than the Medicare rate, please enter 80%; similar, if your rate is 20% higher than the Medicare rate, please enter 120%.
This CLIN applies only if the the Contracting Officer has approved rates for a certain provider in in a Highly Rural Care Area, at a rate that exceeds the Medicare rate, as required to maintain Network Adequacy. Adequate documentation must be provided to the Contracting Officer for review and disposition to support a request for higher than Medicare rates. The Contractor may, in Highly Rural Care Areas, exceed Medicare but shall not exceed the the quoted rate for this CLIN. The Offeror must price this CLIN based on a percentage of locality adjusted Medicare rate.
Include a total estimated cost and associated BOE for budgeting and evalution purposes. Since this cost is a pass-thru, with Gov't approval necessary, (similar to travel), a lower cost does not automatically imply a higher score. The cost estimate provides a budget estimate, and a reasonable cost backed by a good BOE will score highest. Actual cost may vary. Only the premium percentage rate is a contractual ceiling.
Kataria, Rajiv: Kataria, Rajiv:
We need to decide whether to provide specific volume info for all optional CLINs and if so what the volumen info is.
Kataria, Rajiv: Kataria, Rajiv:
I think we should delete: "CLINs 0017 through 0019 may require CLIN 0016 to be implemented and volumes on these CLINs may depend on the number of facilities that order scheduling services."
Kataria, Rajiv: Kataria, Rajiv:
In conflict with the green cells throughout the PoP Kataria, Rajiv: Kataria, Rajiv:
or per standard episode of care or
Per collateral spouce per standard episode of care name
NEED TO WORK ON THESE ITEMS AND BELOW
Pricing Sheet (CLIN 0013)
| Community Care Network - Region 5 | |
| Price Proposal for CLIN XY20 -ART Codes | |
| Insert Offeror Name below: |
| See bottom of page for footnotes and other instructions. | ||||||||||||||
| SEOC | Prices per specific code per year, no more than 2 decimal places. | |||||||||||||
| 1.0.2 Female IVF | 1.1.2 Male IVF | 1.2.2 Female IUI | 1.3.2 Male IUI | IUI | CPT | |||||||||
| Code | Description | UNIT/Directions | Average Volume* | Base | OY1 | OY2 | OY3 | OY4 | OY5 | OY6 | OY7 | Exten. (upto 6 mo.)** | ||
| TRUE | TRUE | TRUE | TRUE | TRUE | 00840 | Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 01965 | Anesthesia for incomplete or missed abortion procedures | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 10021 | Fine needle aspiration; without imaging guidance | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 10022 | Fine needle aspiration; with imaging guidance | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 36415 | Collection of venous blood by venipuncture | Unit $ Price | 18.39 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 36416 | Collection of capillary blood specimen (e.g., finger, heel, ear stick) | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | TRUE | FALSE | TRUE | TRUE | 52402 | Cystourethroscopy with transurethral resection or incision of ejaculatory ducts | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | TRUE | FALSE | TRUE | TRUE | 54110 | Excision of penile plaque (Peyronie disease) | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | TRUE | FALSE | TRUE | TRUE | 54111 | Excision of penile plaque (Peyronie disease); with graft to 5 cm in length | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | TRUE | FALSE | TRUE | TRUE | 54112 | Excision of penile plaque (Peyronie disease); with graft greater than 5 cm in length | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | TRUE | FALSE | TRUE | TRUE | 54500 | Biopsy of testis, needle (separate procedure) | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | TRUE | FALSE | TRUE | TRUE | 54505 | Biopsy of testis, incisional (separate procedure) | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | TRUE | FALSE | TRUE | TRUE | 54800 | Biopsy of epididymis, needle | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | TRUE | FALSE | TRUE | TRUE | 54900 | Epididymovasostomy, anastomosis of epididymis to vas deferens; unilateral | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | TRUE | FALSE | TRUE | TRUE | 54901 | Epididymovasostomy, anastomosis of epididymis to vas deferens; bilatera | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | FALSE | FALSE | TRUE | TRUE | 55200 | Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate procedure) | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | FALSE | FALSE | TRUE | TRUE | 55300 | Vasotomy for vasograms, seminal vesiculograms, or epididymograms, unilateral or bilateral | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | TRUE | FALSE | TRUE | TRUE | 55400 | Vasovasostomy, vasovasorrhaphy | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | TRUE | FALSE | TRUE | TRUE | 55530 | Excision of varicocele or ligation of spermatic veins for varicocele; (separate procedure) | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | TRUE | FALSE | TRUE | TRUE | 55535 | Excision of varicocele or ligation of spermatic veins for varicocele; abdominal approach | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | TRUE | FALSE | TRUE | TRUE | 55540 | The provider excises a varicocele, a dilation of the veins in the spermatic cord, often reaching into the scrotum, or ligates one or more spermatic veins and repairs a hernia. | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | TRUE | FALSE | TRUE | TRUE | 55550 | Laparoscopy, surgical, with ligation of spermatic veins for varicocele | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | TRUE | FALSE | TRUE | TRUE | 55870 | Electroejaculation | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58140 | Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; abdominal approach | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58145 | Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; vaginal approach | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58146 | Myomectomy, excision of fibroid tumor(s) of uterus, 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g, abdominal approach | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58321 | Artificial insemination; intra-cervical | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58322 | Artificial insemination; intra-uterine | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 58323 | Sperm washing for artificial insemination | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58340 | Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58345 | Transcervical introduction of fallopian tube catheter for diagnosis and/or re- establishing patency (any method), with or without hysterosalpingography | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58350 | Chromotubation of oviduct, including materials | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | FALSE | TRUE | FALSE | TRUE | 58353 | Endometrial ablation, thermal, without hysteroscopic guidance | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | FALSE | TRUE | FALSE | TRUE | 58356 | Endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58540 | Hysteroplasty, repair of uterine anomaly (Strassman type) | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58545 | Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 grams or less and/or removal of surface myomas | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58546 | Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 grams | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58555 | Hysteroscopy, diagnostic (separate procedure) | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58558 | Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58559 | Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method) | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58560 | Hysteroscopy, surgical; with division or resection of intrauterine septum (any method) | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58561 | Hysteroscopy, surgical; with removal of leiomyomata | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58660 | Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure) | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58662 | Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58670 | Laparoscopy, surgical; with fulguration of oviducts (with or without transection) | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58672 | Laparoscopy, surgical; with fimbrioplasty | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58673 | Laparoscopy, surgical; with salpingostomy (salpingoneostomy) | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58679 | Unlisted laparoscopy procedure, oviduct, ovary | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58700 | Salpingectomy, complete or partial, unilateral or bilateral (separate procedure) | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58740 | Lysis of adhesions (salpingolysis, ovariolysis) | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58752 | Tubouterine implantation | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 58770 | Salpingostomy (salpingoneostomy) | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 59160 | Curettage, postpartum | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 59812 | Treatment of incomplete abortion, any trimester, completed surgically | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 59820 | Treatment of missed abortion, completed surgically; first trimester | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 59821 | Treatment of missed abortion, completed surgically; second trimester | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 59830 | Treatment of septic abortion, completed surgically | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 71045 | Radiologic examination, chest; single view | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 71046 | Radiologic examination, chest; 2 views | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 71047 | Radiologic examination, chest; 3 views | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 71048 | Radiologic examination, chest; 4 or more views | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 74740 | Hysterosalpingography, radiological supervision and interpretation | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 74742 | Transcervical catheterization of fallopian tube, radiological supervision and interpretation | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 76376 | 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 76700 | Ultrasound, abdominal, real time with image documentation; complete | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 76812 | Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; each additional gestation (List separately in addition to code for primary procedure) | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 76815 | Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 76816 | Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a prev | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 76830 | Ultrasound, transvaginal | Unit $ Price | 32.91 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 76831 | Saline infusion sonohysterography (SIS), including color flow Doppler, when performed | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 76856 | Ultrasound, pelvic (nonobstetric), real time with image documentation; complete | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 76857 | Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (e.g., for follicles) | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | TRUE | FALSE | TRUE | TRUE | 76870 | Ultrasound, scrotum and contents | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | TRUE | FALSE | TRUE | TRUE | 76872 | Ultrasound, transrectal | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 76941 | Ultrasonic guidance for intrauterine fetal transfusion or cordocentesis, imaging supervision and interpretation | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 76942 | Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation | Unit $ Price | 6.78 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 80047 | Basic metabolic panel (Calcium, ionized) This panel must include the following: Calcium, ionized (82330) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea Nitrogen (BUN) (84520) | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 80048 | Basic metabolic panel (Calcium, total) This panel must include the following: Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520) | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 80050 | General health panel This panel must include the following: Comprehensive metabolic panel (80053) Blood count, complete (CBC), automated and automated differential WBC count (85025 or 85027 and 85004) OR Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009) Thyroid stimulating hormone (TSH) (84443) | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 80053 | Comprehensive metabolic panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphatase, alkaline (84075) Potassium (84132) Protein, total (84155) Sodium (84295) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) Urea nitrogen (BUN) (84520) | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 80076 | Hepatic function panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Bilirubin, direct (82248) Phosphatase, alkaline (84075) Protein, total (84155) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 80414 | Chorionic gonadotropin stimulation panel; testosterone response This panel must include the following: Testosterone (84403 x 2 on 3 pooled blood samples) | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 80415 | Chorionic gonadotropin stimulation panel; estradiol response This panel must include the following: Estradiol (82670 x 2 on 3 pooled blood samples) | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 80426 | Gonadotropin releasing hormone stimulation panel This panel must include the following: Follicle stimulating hormone (FSH) (83001 x 4) Luteinizing hormone (LH) (83002 x 4) | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 81000 | Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 81001 | Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 81002 | Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 81003 | Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 81005 | Urinalysis; qualitative or semiquantitative, except immunoassays | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 81007 | Urinalysis; bacteriuria screen, except by culture or dipstick | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | TRUE | TRUE | TRUE | TRUE | 81015 | Urinalysis; microscopic only | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | TRUE | TRUE | TRUE | TRUE | 81020 | Urinalysis; 2 or 3 glass test | Unit $ Price | 0.10 | - 0 | |||||
| TRUE | FALSE | TRUE | FALSE | TRUE | 81025 | Urine pregnancy test, by visual color comparison methods | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | TRUE | FALSE | TRUE | TRUE | 81220 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; common variants (eg, ACMG/ACOG guidelines) | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | TRUE | FALSE | TRUE | TRUE | 81221 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; known familial variants | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | TRUE | FALSE | TRUE | TRUE | 81222 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; duplication/deletion variants | Unit $ Price | 0.10 | - 0 | |||||
| FALSE | TRUE | FALSE | TRUE | TRUE | 81223 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; full gene sequence | Unit $ Price | 0.10 | - 0 |
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