2_SectionKFinal.doc

PART IV

SECTION K - REPRESENTATIONS, CERTIFICATIONS, AND OTHER STATEMENTS OF OFFERORS OR QUOTERStc \l1 "SECTION K - REPRESENTATIONS, CERTIFICATIONS, AND OTHER STATEMENTS OF OFFERORS OR QUOTERS

The Offeror makes the following Representations and Certifications as part of its proposal:

K.1.

CCR Registration

K.2.

FAR 52.204-8 Annual Representations and Certifications

K.3.

Certification of Eligibility

K.4.

Certification of QIO Performance

K.5.

Certification of Proposal Preparation

K.6.

Valid Offer

K.7.

Representations and Instructions Financial

K.8.

FAR 15.406-2 Certificate of Current Cost or Pricing Data TO BE COMPLETED BY THE OFFEROR: (the Representations and Certifications must be executed by an individual authorized to bind the Offeror):

The Offeror makes the following Representations and Certifications as part of its proposal (complete all appropriate boxes or blanks on the following pages).

CMS-2007-QIO9thSOW-NAHC (Name of Organization)

(Solicitation)

(Signature of Authorized Individual)

(Date)

(Typed Name of Authorized Individual)

Note: The penalty for making false statements in offers is prescribed in 18 U.S.C. 1001.

K.1.

CCR REGISTRATION

The QIO certifies that it has registered at www.ccr.gov, as required by FAR 52.204-7.

K.2.

FAR 52.204-8 ANNUAL REPRESENTATIONS AND CERTIFICATIONS

(JAN 2006)

(a)(1) The North American Industry Classification System (NAICS) code for this acquisition is 541618.

(2) The small business size standard is $6.5 Million.

(3) The small business size standard for a concern which submits an offer in its own name, other than on a construction or service contract, but which proposes to furnish a product which it did not itself manufacture, is 500 employees.

(b)(1) If the clause at 52.204-7, Central Contractor Registration, is included in this solicitation, paragraph (c) of this provision applies.

(2) If the clause at 52.204-7 is not included in this solicitation, and the Offeror is currently registered in CCR, and has completed the ORCA electronically, the Offeror may choose to use paragraph (c) instead of completing the corresponding individual representations and certifications in the solicitation. The Offeror shall indicate which option applies by checking one of the following boxes:

(i) Paragraph (c) applies.

(ii) Paragraph (c) does not apply and the Offeror has completed the individual representations and certifications in the solicitation.

(c) The Offeror has completed the annual representations and certifications electronically via the Online Representations and Certifications Application (ORCA) website at http://orca.bpn.gov. After reviewing the ORCA database information, the Offeror verifies by submission of the offer that the representations and certifications currently posted electronically have been entered or updated within the last 12 months, are current, accurate, complete, and applicable to this solicitation (including the business size standard applicable to the NAICS code referenced for this solicitation), as of the date of this offer and are incorporated in this offer by reference (see FAR 4.1201); except for the changes identified below [Offeror to insert changes, identifying change by clause number, title, date]. These amended representation(s) and/or certification(s) are also incorporated in this offer and are current, accurate, and complete as of the date of this offer.

Any changes provided by the Offeror are applicable to this solicitation only, and do not result in an update to the representations and certifications posted on ORCA.

K.3.

CERTIFICATION OF ELIGIBILITYtc \l2 "17.0 ELIGIBILITY Through submission of this proposal and signature below, the Offeror acknowledges and certifies that:

(1) The QIO contract eligibility requirements are as required by law and that, if it fails to remain in compliance with the eligibility requirements, it will immediately notify the Contracting Officer and describe what actions will be taken to restore eligibility.

(2) It will accept CMS determinations regarding its organizational eligibility as final determinations.

(3) It is not affiliated with (through management, ownership, or common control), an entity (other than a self-insured employer) which directly or indirectly makes payments to any practitioner or provider whose health care services are reviewed by such entity or would be reviewed by such entity if it entered into a contract with the Secretary under Section 1153 of the Social Security Act. For the purposes of this paragraph, an entity shall not be considered to be affiliated with another entity which makes payments (directly or indirectly) to any practitioner or provider, by reason of management, ownership, or common control, if the management, ownership, or common control consists only of members of the governing board being affiliated (through management, ownership, or common control) with a health maintenance organization or competitive medical plan which is an eligible organization as defined in Section 1876(b).

(4) ___It is or ____ is not affiliated (through management, ownership or common control) with a health care facility, or association of such facilities, within the State for which the Offeror is proposing. Any entity that shares more than 20% of the membership of its governing board with another organization through management, ownership or common control, is considered to be affiliated with the other organization.

(5) In-State and Out-of-State a.

It ( ) is an in-State organization. In-State is defined as follows:

An organization that has its primary place of business in the State in which review will be conducted (or, one that is owned by a parent corporation, the headquarters of which is located in the State). Primary place of business is determined as follows:

If you are designated in more than one geographical area, then the location of the corporate headquarters of the parent corporation determines the primary place of business; and

If you are designated in only one geographical area, location of the corporate headquarters, Board of Directors, day-to-day management of its contracts, and place of performance for all contracts determines your primary place of business.

A parent corporation may own multiple subsidiary corporations each of which may be determined to be in-State organizations for the QIO geographical area in which the subsidiary is incorporated and has its primary place of business.

b.

It ( ) is an out-of-State organization.

(6) Physician Sponsored/Physician Access

To be eligible to win or hold a QIO contract an organization must be able to certify, and be prepared to substantiate its certification via appropriate documentation, that it is either a physician-sponsored or physician-access organization in each and every State in which it is (or seeks to compete for) a QIO contract.

(Examples of appropriate documentation to support physician-access status might include articles of incorporation and/or lists of shareholders or members, while examples of documentation to support physician-access status might include contracts with physicians to serve as physician reviewers).

(a) Physician Sponsored

To be eligible as a physician-sponsored organization, the organization must meet the following requirements:

· Be composed (have physicians as owners or members) of at least 20% of the licensed doctors of medicine and osteopathy practicing medicine or surgery in the State, i.e. at least 20% of the practicing physicians in State are owners of the QIO, or the QIO is owned by an entity which includes at least 20% of the practicing physicians in the State as members; or

· Be composed (have physicians as owners or members) of at least 10% of the licensed doctors of medicine and osteopathy practicing medicine or surgery in the State, and demonstrate through means (e.g. letters of support from physicians or physician organizations) acceptable to the Centers for Medicare and Medicaid Services (CMS) that the organization is representative of an additional 10% of the practicing physicians in the State; and

· Not be a health care facility, health care facility association, or health care facility affiliate.

(b) Physician Access

The organization is ( ) is not ( ) a physician-access organization in accordance with Section 1152 of the Social Security Act. The Offeror must have available to it the services of a sufficient number of licensed doctors of medicine or osteopathy engaged in the practice of medicine or surgery in such area to assure that adequate peer review of the services provided by the various medical specialties and subspecialties can be provided. The specialties/subspecialties, shall include, at a minimum, the following fields: Cardiology, Geriatrics, Gynecology, Immunology/Rheumatology/Endocrinology, Internal Medicine, Family Practice Medicine, Neurology, Oncology, Ophthalmology, Orthopedics/Podiatry, Psychiatry, Pulmonary Medicine, Radiology, Surgery (includes sub-specialties) and Urology/Nephrology.

Printed Name of CEO/Executive Director

Signature of CEO/Executive Director

Date

K.4.

CERTIFICATION OF QIO PERFORMANCEtc \l2 "15.0 RENEWAL PRO CERTIFICATION FOR PERFORMANCE I,____________________ (Name of party authorized to bind the QIO) hereby certify that ____________________ (Name of QIO) is capable of performing all of the tasks as currently set forth in solicitation CMS-2007-QIO9thSOW-NAHC ____________________ (Date)

K.5.

CERTIFICATION OF PROPOSAL PREPARATION

The QIO shall obtain and include the following certification for each person involved in the proposal preparation for this requirement:

I ___________________ am currently an employee of the ________________ organization (identify either QIO or consultant/subcontractor name). I participated in the preparation of the ___________ (business and or technical) proposal being submitted in response to RFP CMS-2007-QIO9thSOW-NAHC.

K.6.

VALID OFFER

In accordance with FAR 52.215-1, the QIO certifies that it offer is valid for 180 days from the date of submission.

K.7.

REPRESENTATIONS AND INSTRUCTIONS FINANCIALtc \l2 "14.0 REPRESENTATIONS AND INSTRUCTIONS FINANCIAL A.

QIO:

Address:*

Telephone No.____________________________________

Individual(s) to contact regarding this proposal:

Dun & Bradstreet, Data Universal Numbering System (DUNS) No.________________________________

(See FAR 52.204-6 -- Data Universal Numbering System (DUNS) Number)

Tax Identification Number (TIN) ______________________

*If financial records are maintained at some other location, show the address of the place where the records are kept.

B.

Cognizant Government Audit Agency:

Address:

Auditor:

Telephone No.____________________________________

C.

Sales:

1.

Work Distribution for the Last Complete Fiscal Accounting Period

Government cost reimbursement type prime contracts and subcontracts:

Government fixed price prime contracts and subcontracts:

Commercial Sales:

Total Sales:

2.

Total Sales for First and Second Fiscal Years Immediately Proceeding Last Completed Fiscal Year

Total sales for first preceding fiscal year:

Total sales for second preceding fiscal year:

D.

Is company a separate entity or division? _______ If a division or subsidiary corporation, name parent company:

E.

Date company organized:___________________________

F.

Manpower:

Total employees:______________

Direct: ______________

Indirect:______________

Standard Work Week (Hours):__________

G.

Commercial Products:

H.

Attach a current organizational chart of the company.

I.

Description of contractor's system of estimating and accumulating costs under Government contracts. (Check appropriate blocks).

Estimated/

Standard

Actual Cost

Cost

Estimating System

Job Order

Process

Accumulating System

Job Order

Process

Has your cost estimating system been approved by any Government agency?

Yes_____No_____

If yes, give name and location of agency:

J.

What is your fiscal year period? (Give month-to-month dates) _____________________

What were the indirect cost rates for your last completed fiscal year?

Basis of Fiscal Year_____ Indirect Cost Rates Allocation

Fringe Benefits

Overhead

G & A Expense

Other

K.

Have the proposed indirect cost rate(s) been evaluated and accepted by any Government agency?

If yes, give name and location of the Government agency:

Date of last pre-award audit review by a Government agency:

L.

Cost estimating is performed by:

( ) accounting department

( ) contract department

( ) other (describe)____________________________

M.

Has system of control of Government property been approved by a Government agency?

If yes, give name and location of agency:

*If the answer is no, data supporting the proposed rates must accompany the cost or price proposal. A breakdown of the items comprising overhead and G & A must be furnished.

N.

Purchasing Procedures:

Are purchasing procedures written? Yes____No____

Has your purchasing system been approved by a Government agency?

Yes_____No_____

If yes, give name and location of agency:

O.

Does your firm have an established written incentive compensation or bonus plan?

Yes_____No_____

K.8.

FAR 15.406-2 CERTIFICATE OF CURRENT COST OR PRICING DATA

tc \l2 "16.0 FAR 15.406-2 CERTIFICATE OF CURRENT COST OR PRICING DATA

CERTIFICATE OF CURRENT COST OR PRICING DATA.

This is to certify that, to the best of my knowledge and belief, the cost or pricing data (as defined in Section 2.101 of the Federal Acquisition Regulation (FAR) and required under FAR subSection 15.403-4) submitted, either actually or by specific identification in writing, to the Contracting Officer or to the Contracting Officer’s representative in support of ____* are accurate, complete, and current as of ____**. This certification includes the cost or pricing data supporting any advance agreements and forward pricing rate agreements between the offeror and the Government that are part of the proposal.

Organization______________________________________.

Signature ________________________________________.

Name ___________________________________________.

Title ____________________________________________.

Date of execution*** _____________________________.

* Identify the proposal, request for price adjustment, or other submission involved, giving the appropriate identifying number (e.g., RFP No.).

** Insert the day, month, and year when price negotiations were concluded and price agreement was reached or, if applicable, an earlier date agreed upon between the parties that is as close as practicable to the date of agreement on price.

*** Insert the day, month, and year of signing, which should be as close as practicable to the date when the price negotiations were concluded and the contract price was agreed to.

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