1_AttachmentJ-8aBP9SOW.xls

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9th SOW Quality Improvement Contracts Federal contract opportunity
Solicitation number
CMS-2007-QIO9thSOW-NAHC
Issued by
Department of Health and Human Services Centers for Medicare and Medicaid Services

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F718 BP SUM

1. Name and Address of QIO Organization3. RFP #
4: Proposed Contract Period
2. QIO Area (State):From:
To:
Medicare5. Total Proposed6. CMS Recommended7. $8. %
ContractCostsCostsDifferenceDIfference
Direct Cost
a. LABOR:
1. Professional$0$0$00.0%
2. Information Systems$0$0$00.0%
3. Corporate Management$0$0$00.0%
4. Support Staff$0$0$00.0%
SUBTOTAL - Direct Labor$0$0$00.0%
b. Leave$0$0$00.0%
c. Fringe Benefits$0$0$00.0%
SUBTOTAL - Leave/Fringe$0$0$00.0%
d. Subcontractors
1. Physician Reviewers/ Phys.Advisors$0$0$00.0%
2. Other Consultants$0$0$00.0%
3. Other Subcontracts$0$0$00.0%
SUBTOTAL - Subcontractors$0$0$00.0%
e. Travel$0$0$00.0%
f. Other Direct Costs$0$0$00.0%
SUBTOTAL - DIRECT$0$0$00.0%
g. Indirect Costs$0$0$00.0%
h. Pass-thru Costs$0$0$00.0%
TOTAL COSTS$0$0$00.0%
i. Fee$0$0$00.0%
TOTAL COST WITH FEE$0$0$00.0%
9.
10. Signature of Authorized Official:CMS USE ONLY
Fringe Rate
14. Proposal Receipt Date:
Indirect Rate11. Type or Print Name and Title:
Other Rate15. Review By:
12. DATE:13. Telephone #
16. Signature/Title:

&C&"Arial,Bold"QUALITY IMPROVEMENT ORGANIZATION 9th SOW BUSINESS PROPOSAL SUMMARY &"Arial,Regular"CENTERS FOR MEDICARE and MEDICAID SERVICES &LForm 718 BP&R&9Prepared on:

QIO F719

1. RFP Number:2. Name and Address of QIO Organization:3. QIO Area (State):4. Contract Period
00From:12/31/99
00To:12/31/99
0
5. Quality Data Reporting6. Other Beneficiary Protection CostsRESERVED 7. Patient Pathways8. MRSA9. NH Pressure Ulcers10. Hospital Pressure Ulcers11. NH Restraints12. SCIP13. Drug Safety14. Poor Performing NH15. Core PreventionRESERVED 16. DisparitiesRESERVED 17. CKD18. IS19. Total
9. PHYSICIAN PRACTICEUNDERSERVEDPHARMACY:12.13. BENEFICIARY14. HOSPITAL PAYMENT15. SPECIAL STUDIES16.INFORMATION SERVICES17.CONTRACTUAL19.
MEDICARE COSTSPOPULATIONSPART-D BENEFITPROTECTIONMONITORING PROGRAMREQUIREMENTS20. TOTAL
Theme: Beneficiary ProtectionTheme: Beneficiary ProtectionTheme: Patient PathwaysTheme: Patient SafetyTheme: Patient SafetyTheme: Patient SafetyTheme: Patient SafetyTheme: Patient SafetyTheme: Patient SafetyTheme: Patient SafetyTheme: PreventionTheme: PreventionTheme: Prevention
HOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTS
a. LABOR:
1. Professional0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$ - 0
2. Information Systems0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$ - 0
3. Corporate Management0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$ - 0
4. Support Staff0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$ - 0
SUBTOTAL - Direct Labor0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$ - 0
b. Leave0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$ - 0
c. Fringe Benefits$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
SUBTOTAL - Leave / Fringe0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$ - 0
d. Subcontracts:
1. Physician Reviewers / Phys. Advisors0.0$00.0$ - 0
2. Other Consultants$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
3. Other Subcontractors$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
SUBTOTAL - Subcontracts0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$ - 0
e. Travel$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
f. Other Direct Costs$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
SUBTOTAL - DIRECT0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0
g. Indirect Costs$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
h. Pass-thru Costs$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
TOTAL COSTS0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0
i. Fee$0$0$0$0$0$0$0$0$0$0$0$ - 0
TOTAL COSTS WITH FEE$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
TOTAL PROPOSED PROVIDERS
AVERAGE 3 YR COSTS/PROVIDER00000000

&C&11Quality Improvement Organization 9th SOW Business Proposal&10 Centers for Medicare and Medicaid Services &L&11Form 719 BP&CPage &P&RPrepared on:

QIO F720

FRINGE BENEFIT PROPOSAL
QUALITY IMPROVEMENT ORGANIZATION 9th SOW BUSINESS PROPOSAL
CENTERS FOR MEDICARE & MEDICAID SERVICES
1. Name and Address of QIO Organization3. RFP #
00
0
04: Proposed Contract Period
2. QIO Area (State):0From:12/31/99
To:12/31/99
6. Prior Year7. Projected8. Prior Year9. Projected
DETAIL COSTSTotalTotal 3-YRTotalTotal 3-YR
Organization CostsOrganization CostsMedicare CostsMedicare Costs
Fringe Benefits
a. Employer's FICA Expense$0$0
b. Federal Unemployment Insurance$0$0
c. State Unemployment Insurance$0$0
d. Disability Insurance$0$0
e. Pension Expense$0$0
f. Workers Compensation$0$0
g. Group Health Insurance$0$0
h. Group Life Insurance$0$0
i. Empl. Relations & Welfare$0$0
j. Leave$0$0
k. Other - see attached$0$0
l. Total Fringe Benefits$0$0
m. Fringe Benefit Rate0.00%0.00%0.00%0.00%

&LForm 720 BP&R&D

QIO F721

INDIRECT AND OTHER DIRECT COST
QUALITY IMPROVEMENT ORGANIZATION 9th SOW BUSINESS PROPOSAL
CENTERS FOR MEDICARE & MEDICAID SERVICES
1. Name and Address of QIO Organization3. RFP #
00
0
04: Proposed Contract Period
2. QIO Area (State):0From:12/31/99
To:12/31/99
5. Prior Year6. Projected7. Prior Year8. Projected9. Prior Year10. Projected
DETAIL COSTSTotalTotal 3yr.MedicareMedicare 3yrMedicareMedicare 3yr
Indirect CostsIndirect CostsIndirect CostsIndirect CostsOther Direct.Other Direct.
a. Indirect Labor$0$0
b. Indirect Leave$0$0
c. Indirect Fringe$0$0
d. Rent$0$0$0$0
e. Storage$0$0$0$0
f. Utilities$0$0$0$0
g. Maintenance & Repairs$0$0$0$0
h. Depreciation$0$0$0$0
i. Data Processing$0$0$0$0
j. Equipment Leasing & Rental$0$0$0$0
k. Office Supplies$0$0$0$0
l. Reproduction & Printing$0$0$0$0
m. Telephone$0$0$0$0
n. Postage & Express Mail$0$0$0$0
o. Consultants$0$0
p. Meeting & Conferences$0$0$0$0
q. Travel$0$0
r. Training$0$0$0$0
s. Garage & Parking Spaces$0$0$0$0
t. Dues & Subscriptions$0$0$0$0
u. Recruiting$0$0$0$0
v. Temporary Help$0$0$0$0
w. Continuing Education$0$0$0$0
x. Legal Fees$0$0$0$0
y. Accounting/Audit Fees$0$0$0$0
z. Board of Directors Fees$0$0$0$0
aa. Insurance$0$0$0$0
bb. Bank Charges$0$0$0$0
cc. Other - see attached$0$0$0$0
dd. ** TOTAL$0$0$0$0
ee. Indirect Cost Rate0.00%0.00%

&LForm 721 BP &R&D

QIO STAFFING

11. AverageQuality Data ReportingQuality Data ReportingQuality Data ReportingQuality Data Reporting12. Total 3yrQuality Data ReportingQuality Data ReportingQuality Data ReportingQuality Data Reporting13. AverageOther Ben. Protec.Other Ben. Protec.Other Ben. Protec.Other Ben. Protec.14. Total 3yrOther Ben. Protec.Other Ben. Protec.Other Ben. Protec.Other Ben. Protec.Patient PathwaysPatient Pathways
4a current4b current4c current4d current5. Proposed5aProposedYr 15bPropYr15c Prop Yr 15d Prop Yr 17. Proposed7aProposedYr7bPropYr27c Prop Yr 27d Prop Yr 29. Proposed9aProposedYr 39bPropYr39c Prop Yr 39d Prop Yr 3Quality DataProf. HoursIS hrsCorp AdminSupportQuality DataProf. LaborIS laborCorp AdminSupportOtherProf. HoursIS hrsCorp AdminSupportOtherProf. LaborIS laborCorp AdminSupport15. AverageProf. HoursIS hrs
1. Staff2. Position3. Labor4. CurrenthourlyhourlyhourlyhourlyYear 1hourlyhourlyhourlyhourly6. PercentYear 2hourlyhourlyhourlyhourly8. PercentYear 3hourlyhourlyhourlyhourly10. PercentReportingper yearper yearhours per yrStaff Hrs perReportingcosts/yr$$ per yearLabor $ per yrStaff Hrs perBenef Protecper yearper yearhours per yrStaff Hrs perBenef Proteccosts/yr$$ per yearLabor $ per yrStaff Hrs perPatient Pathwaysper yearper year
NameTitleCategory CodeHourly RateprofessionalISCorp Adminsupport staffHourly RateprofessionalISCorp Adminsupport staffChangeHourly RateprofessionalISCorp Adminsupport staffChangeHourly RateprofessionalISCorp Adminsupport staffChangeHours Per Yearavgavgavgyr, avgLabor CostsavgavgavgLabor $$yr, avgHours Per Yearavgavgavgyr, avgLabor CostsavgavgavgLabor $$yr, avgHours Per Yearavgavg
1$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
2$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
3$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
4$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
5$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
6$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
7$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
8$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
9$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
10$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
11$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
12$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
13$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
14$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
15$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
16$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
17$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
18$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
19$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
20$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
21$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
22$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
23$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
24$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
25$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
26$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
27$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
28$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
29$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
30$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
31$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
32$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
33$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%$0.00$0.00$0.00$0.000.0%0000$0$ - 0$ - 0$ - 0$ - 00000$0$ - 0$ - 0$ - 0$ - 000
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