ESRD BP Forms J-7 A - ESRD Redesign.xlsx

XLSX spreadsheet 176 KB Posted Jun 15, 2012

Attached to: End Stage Renal Disease Network 18 Federal contract opportunity
Solicitation number: CMS-2012-ESRD-FFPCOMP
Issued by: Department of Health and Human Services Centers for Medicare and Medicaid Services

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Attachment J-7A

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Other files for this federal contract opportunity

Other files attached to End Stage Renal Disease Network 18, newest first.
File	Type	Posted
07-26-12 Signed SF30 Amendment 6.pdf	PDF	Jul 26, 2012
07-20-12 SF30 Amendment 5.pdf	PDF	Jul 20, 2012
07-20-12 Amended ESRD BP Forms J-7 A - ESRD Redesign.xlsx	XLSX spreadsheet	Jul 20, 2012
QAs revised 72012.xlsx	XLSX spreadsheet	Jul 20, 2012
q As716.xls	XLS spreadsheet	Jul 16, 2012
07-16-12_ESRD_FFP_Competitive_RFP_with_TOC1.docx	DOCX document	Jul 16, 2012
ESRD J-20a Information Security Attestation.docx	DOCX document	Jul 16, 2012
J-18 subcontractplan_101911.doc	DOC document	Jul 16, 2012
J-20b Compliance Attestation.docx	DOCX document	Jul 16, 2012
Bidders Conference_Final 062112.pptx	PPTX presentation	Jul 16, 2012
signed SF30 Amendment 4 07-16.pdf	PDF	Jul 16, 2012
J-2 ESRD Manual reference.docx	DOCX document	Jul 16, 2012
ESRD BP Instructions_ REDESIGN.docx	DOCX document	Jun 22, 2012
SF 30 Amendment 3.pdf	PDF	Jun 22, 2012
SF 30.pdf	PDF	Jun 20, 2012
06-19-2012_ESRD_FFP_Competitive_RFP_with_TOC1.docx	DOCX document	Jun 19, 2012
A.4 manual reference matrix.docx	DOCX document	Jun 19, 2012
Attachment J-10.docx	DOCX document	Jun 15, 2012
Attachment J-8 Estimated Level of Effort.docx	DOCX document	Jun 15, 2012
Attachment J-7b.xlsx	XLSX spreadsheet	Jun 15, 2012
06-08-12 NW Geographic Areas Map.pdf	PDF	Jun 15, 2012
Attachment J-7.docx	DOCX document	Jun 15, 2012
Attachment J-13.pdf	PDF	Jun 15, 2012
Attachment J-18 Small Business Subcontracting Plan Form .docx	DOCX document	Jun 15, 2012
5-31-2012 ESRD FFP Competitive RFP with TOC.docx	DOCX document	Jun 15, 2012
06-08-12 SF 33.pdf	PDF	Jun 15, 2012
Attachment J-1 Consent to Subcontract.docx	DOCX document	Jun 15, 2012
Attachment J-14 Government Furnished Property.docx	DOCX document	Jun 15, 2012
Attachment J-11.xlsx	XLSX spreadsheet	Jun 15, 2012
ESRD ffp comp RFP Cover Letter.docx	DOCX document	Jun 15, 2012
Attachment J-5 Instructions for Travel Detail.docx	DOCX document	Jun 15, 2012
Attachment J-9.docx	DOCX document	Jun 15, 2012

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BP J-7 A

J.7	CMS Form 685-A
		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS

Name and Address of ESRD Organization:
	NETWORK #

Appendix A	Network Transition
	No of	Hourly	Number	Total
DIRECT MEDICARE COSTS	FTEs	Rate	of Hours	Salary
a. LABOR
1.0				$ - 0
2.				$ - 0
3.				$ - 0
4.				$ - 0
5.				$ - 0
6.				$ - 0
7.				$ - 0
8.				$ - 0
9.				$ - 0
10.				$ - 0
11.				$ - 0
12.				$ - 0
13.				$ - 0
14.				$ - 0
15.				$ - 0

SUBTOTAL - DIRECT LABOR 0.0 ERROR:#DIV/0! 0 $ - 0

	YEAR 1	1-1-13 to 12-31-13
	No of	Current	Yr. 1	Number	Total
DIRECT MEDICARE COSTS	FTEs	Hourly Rate	Hourly Rate	of Hours	Salary
a. LABOR
1.0					$ - 0
2.					$ - 0
3.					$ - 0
4.					$ - 0
5.					$ - 0
6.					$ - 0
7.					$ - 0
8.					$ - 0
9.					$ - 0
10.					$ - 0
11.					$ - 0
12.					$ - 0
13.					$ - 0
14.					$ - 0
15.					$ - 0

SUBTOTAL - DIRECT LABOR 0.0 ERROR:#DIV/0! 0 $ - 0

J.7	CMS Form 685-A
		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS

Name and Address of ESRD Organization:
0	NETWORK #
0
0

Appendix A	YEAR 2	1-1-14 to 12-31-14
	No of	Hourly	Number	Total
DIRECT MEDICARE COSTS	FTEs	Rate	of Hours	Salary
a. LABOR
1.0				$ - 0
2.				$ - 0
3.				$ - 0
4.				$ - 0
5.				$ - 0
6.				$ - 0
7.				$ - 0
8.				$ - 0
9.				$ - 0
10.				$ - 0
11.				$ - 0
12.				$ - 0
13.				$ - 0
14.				$ - 0
15.				$ - 0

SUBTOTAL - DIRECT LABOR 0.0 ERROR:#DIV/0! 0 $ - 0

	YEAR 3	1-1-15 to 12-31-15
	No of	Hourly	Number	Total
DIRECT MEDICARE COSTS	FTEs	Rate	of Hours	Salary
a. LABOR
1.0				$ - 0
2.				$ - 0
3.				$ - 0
4.				$ - 0
5.				$ - 0
6.				$ - 0
7.				$ - 0
8.				$ - 0
9.				$ - 0
10.				$ - 0
11.				$ - 0
12.				$ - 0
13.				$ - 0
14.				$ - 0
15.				$ - 0

SUBTOTAL - DIRECT LABOR			0.0	ERROR:#DIV/0!	0	$ - 0
J.7	CMS Form 685-B
Appendix B		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS

Name and Address of ESRD Organization:
0	NETWORK #
0
0

PROGRAM CONSULTANTS	Network Transition
		Rate	Number	Total
Name	Position	Per Hour	Of Hours	Costs
1.0				$ - 0
2.				$ - 0
3.				$ - 0
4.				$ - 0
5.				$ - 0
6.				$ - 0
7.				$ - 0
8.				$ - 0
9.				$ - 0
10.				$ - 0
11.				$ - 0
12.				$ - 0
13.				$ - 0
14.				$ - 0
15.				$ - 0

TOTAL ERROR:#DIV/0! 0 $ - 0

PROGRAM CONSULTANTS	YEAR 1	1-1-13 to 12-31-13
			Rate	Number	Total
Name	Position		Per Hour	Of Hours	Costs
1.0					$ - 0
2.					$ - 0
3.					$ - 0
4.					$ - 0
5.					$ - 0
6.					$ - 0
7.					$ - 0
8.					$ - 0
9.					$ - 0
10.					$ - 0
11.					$ - 0
12.					$ - 0
13.					$ - 0
14.					$ - 0
15.					$ - 0

TOTAL ERROR:#DIV/0! 0 $ - 0

NOTE: SUBMIT SUPPORTING JUSTIFICATION (INCLUDING THE NATURE OF THE ASSIGNMENT(s)).

Appendix B	CMS Form 685-B
		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS

Name and Address of ESRD Organization:
0	NETWORK #
0
0

PROGRAM CONSULTANTS	YEAR 2	1-1-14 to 12-31-14
			Rate	Number	Total
Name	Position		Per Hour	Of Hours	Costs
1.					$ - 0
2.					$ - 0
3.					$ - 0
4.					$ - 0
5.					$ - 0
6.					$ - 0
7.					$ - 0
8.					$ - 0
9.					$ - 0
10.					$ - 0
11.					$ - 0
12.					$ - 0
13.					$ - 0
14.					$ - 0
15.					$ - 0

TOTAL ERROR:#DIV/0! 0 $ - 0

NOTE: SUBMIT SUPPORTING JUSTIFICATION (INCLUDING THE NATURE OF THE ASSIGNMENT(s)).

Appendix B
PROGRAM CONSULTANTS	YEAR 3	1-1-15 to 12-31-15
			Rate	Number	Total
Name	Position		Per Hour	Of Hours	Costs
1.					$ - 0
2.					$ - 0
3.					$ - 0
4.					$ - 0
5.					$ - 0
6.					$ - 0
7.					$ - 0
8.					$ - 0
9.					$ - 0
10.					$ - 0
11.					$ - 0
12.					$ - 0
13.					$ - 0
14.					$ - 0
15.					$ - 0

TOTAL ERROR:#DIV/0! 0 $ - 0

NOTE: SUBMIT SUPPORTING JUSTIFICATION (INCLUDING THE NATURE OF THE ASSIGNMENT(s)).
J.7	CMS Form 685-C
		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS

Name and Address of ESRD Organization:
0	NETWORK #
0
0

Appendix C
SUBCONTRACTOR	Network Transition
	SUBCONTRACTOR	TIME FRAME		Number	Total
Name	ACTIVITIES/PURPOSE	FROM	TO	Of Hours	Costs
					$ - 0
					$ - 0
					$ - 0
					$ - 0
					$ - 0
					$ - 0
					$ - 0
					$ - 0
					$ - 0
					$ - 0
					$ - 0
					$ - 0
					$ - 0
					$ - 0
					$ - 0

TOTAL 0 $ - 0

SUBCONTRACTOR	YEAR 1	1-1-13 to 12-31-13
	SUBCONTRACTOR		TIME FRAME		Number	Total
Name	ACTIVITIES/PURPOSE		FROM	TO	Of Hours	Costs
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0

TOTAL 0 $ - 0

NOTE: SUBMIT SUPPORTING JUSTIFICATION (INCLUDING THE NATURE OF THE ASSIGNMENT(s)).

Appendix C

Name and Address of ESRD Organization:
0	NETWORK #
0
0

SUBCONTRACTOR	YEAR 2	1-1-14 to 12-31-14
	SUBCONTRACTOR		TIME FRAME		Number	Total
Name	ACTIVITIES/PURPOSE		FROM	TO	Of Hours	Costs
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0

TOTAL 0 $ - 0

SUBCONTRACTOR	YEAR 3	1-1-15 to 12-31-15
	SUBCONTRACTOR		TIME FRAME		Number	Total
Name	ACTIVITIES/PURPOSE		FROM	TO	Of Hours	Costs
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0

TOTAL 0 $ - 0

NOTE: SUBMIT SUPPORTING JUSTIFICATION (INCLUDING THE NATURE OF THE ASSIGNMENT(s)).
J.7	CMS Form 685-D
		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS

Name and Address of ESRD Organization:
0	NETWORK #
0
0

Appendix D
OTHER DIRECT COSTS
	TRANSITION	YEAR 1	YEAR 2	YEAR 3	36 MONTH PLUS TRANSITION
	COSTS	COSTS	COSTS	COSTS	TOTAL
Storage	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
Utilities	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
Maintenance & Repairs	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
Depreciation	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
Data Processing	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
Office Supplies	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
Postage & Express Mail	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
Meetings & Conferences	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
Garage & Parking Spaces	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
Dues & Subscriptions	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
Recruiting	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
Temporary Help	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
Continuing Education	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
Legal Fees	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
Accounting/Auditing Fees	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
Printing & Reproduction	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
Training	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
Other - Attach Schedule					$ - 0

TOTAL $ - 0 $ - 0 $ - 0 $ - 0 $ - 0

NOTE: SUBMIT SUPPORTING JUSTIFICATION FOR EACH LINE ITEM.
J.7	CMS Form 685-E
		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS

Name and Address of ESRD Organization:
0	NETWORK #
0
0

Appendix E
FRINGE BENEFITS/LEAVE
	TRANSITION	YEAR 1	YEAR 2	YEAR 3	36 MONTH PLUS TRANSITION
	COSTS	COSTS	COSTS	COSTS	TOTAL
1. Employer's FICA Expense					$ - 0
2. Federal Unemployment Tax					$ - 0
3. State Unemployment Insurance					$ - 0
4. Disability Insurance					$ - 0
5. Pension Expense					$ - 0
6. Workers Compensation					$ - 0
7. Group Health Insurance					$ - 0
8. Group Life Insurance					$ - 0
9. Employee Relations & Welfare					$ - 0
10. Leave					$ - 0
11. Other - Attach Schedule					$ - 0
TOTAL	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0

12. FRINGE BENEFIT RATE/COSTS:

13. LEAVE RATE/COSTS:

J.7 CMS Form 685-F

Appendix F
GENERAL & ADMINISTRATION (G&A) / OVERHEAD
	TRANSITION	YEAR 1	YEAR 2	YEAR 3	36 MONTH PLUS TRANSITION
	COSTS	COSTS	COSTS	COSTS	TOTAL
1. RENT					$ - 0
2. LEASED EQUIPMENT					$ - 0
3. TELEPHONE EXPENSES					$ - 0
4. INSURANCE					$ - 0
5. OTHER					$ - 0

TOTAL $ - 0 $ - 0 $ - 0 $ - 0 $ - 0

6. INDIRECT RATE/COSTS: $ - 0

NOTE: SUBMIT SUPPORTING JUSTIFICATION(s) FOR EACH LINE ITEM.
J.7	CMS Form 685-G
		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS

Name and Address of ESRD Organization:
0	NETWORK #
0
0

Appendix G
DIRECT MEDICARE COSTS		Network Transition	Year 1	Year 2	Year 3	36 MONTH PLUS TRANSITION TOTAL
a. LABOR	(See Appendix A)
1.0		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
2.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
3.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
4.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
5.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
6.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
7.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
8.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
9.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
10.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
11.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
12.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
13.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
14.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
15.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0

	SUBTOTAL - DIRECT LABOR		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
b. PROGRAM CONSULTANTS		(See Appendix B)	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
c. TRAVEL		(See Appendix H)	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
d. SUBCONTRACTORS		(See Appendix C)	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
e. OTHER DIRECT COSTS		(See Appendix D)	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
f. FRINGE BENEFITS/LEAVE		(See Appendix E)	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
g. G&A/ INDIRECT COSTS		(See Appendix F)	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0

h. TOTAL COSTS (excluding fee) $ - 0 $ - 0 $ - 0 $ - 0 $ - 0

i. FEE $ - 0 $ - 0 $ - 0 $ - 0 $ - 0

j. TOTAL COSTS WITH FEE $ - 0 $ - 0 $ - 0 $ - 0 $ - 0

Page &P

Travel - Transition

	TRAVEL DETAIL										J-7	CMS Form 685-H
	END STAGE RENAL DISEASE BUSINESS PROPOSAL
	CENTERS FOR MEDICARE & MEDICAID SERVICES
Name and Address of ESRD Organization:				ESRD Network:
0
0
0
Transition Period									Mileage Rate:
Trip Title & Description	# of Days per Trip	# of Nights per Trip	# of Travelers per Trip	Airfare per Person	Departing from:	Arriving to:	FTR Meals & Inc. Daily Rate	FTR Lodging per Night	# of Trips for Year 1	Total # of miles per trip(s)	# of Rental Cars Per Trip	Daily Rental Car Rate	Misc. Cost per Person per Trip (includes parking, gas, taxi, etc.)	TOTAL	Notes
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
TOTAL FOR TRANSITION PERIOD:													$0

Travel Year 1

	TRAVEL DETAIL										J-7	CMS Form 685-H
	END STAGE RENAL DISEASE BUSINESS PROPOSAL
	CENTERS FOR MEDICARE & MEDICAID SERVICES
Name and Address of ESRD Organization:				ESRD Network:
0									YEAR 1:	1-1-13 to 12-31-13
0
0
YEAR 1									Mileage Rate:
Trip Title & Description	# of Days per Trip	# of Nights per Trip	# of Travelers per Trip	Airfare per Person	Departing from:	Arriving to:	FTR Meals & Inc. Daily Rate	FTR Lodging per Night	# of Trips for Year 1	Total # of miles per trip(s)	# of Rental Cars Per Trip	Daily Rental Car Rate	Misc. Cost per Person per Trip (includes parking, gas, taxi, etc.)	TOTAL	Notes
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
TOTAL FOR YEAR ONE:													$0

Travel Year 2

	TRAVEL DETAIL										J-7	CMS Form 685-H
	END STAGE RENAL DISEASE BUSINESS PROPOSAL
	CENTERS FOR MEDICARE & MEDICAID SERVICES
Name and Address of ESRD Organization:				ESRD Network:
0					0				YEAR 2	1-1-14 to 12-31-14
0
0
YEAR 2									Mileage Rate:
Trip Title & Description	# of Days per Trip	# of Nights per Trip	# of Travelers per Trip	Airfare per Person	Departing from:	Arriving to:	FTR Meals & Inc. Daily Rate	FTR Lodging per Night	# of Trips for Year 1	Total # of miles per trip(s)	# of Rental Cars Per Trip	Daily Rental Car Rate	Misc. Cost per Person per Trip (includes parking, gas, taxi, etc.)	TOTAL	Notes
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
TOTAL FOR YEAR TWO:													$0

Travel Year 3

	TRAVEL DETAIL										J-7	CMS Form 685-H
	END STAGE RENAL DISEASE BUSINESS PROPOSAL
	CENTERS FOR MEDICARE & MEDICAID SERVICES
Name and Address of ESRD Organization:				ESRD Network:
0					0				YEAR 3	1-1-15 to 12-31-15
0
0
YEAR 3									Mileage Rate:
Trip Title & Description	# of Days per Trip	# of Nights per Trip	# of Travelers per Trip	Airfare per Person	Departing from:	Arriving to:	FTR Meals & Inc. Daily Rate	FTR Lodging per Night	# of Trips for Year 1	Total # of miles per trip(s)	# of Rental Cars Per Trip	Daily Rental Car Rate	Misc. Cost per Person per Trip (includes parking, gas, taxi, etc.)	TOTAL	Notes
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
TOTAL FOR YEAR THREE:													$0

Management Plan J.7 CMS Form 685-I

ESRD NETWORK

		ANNUAL MANAGEMENT PLAN 1/1/2013 - 12/31/2013								YEAR 1
DIRECT MEDICARE		TOTAL		Supporting	Promoting App. Access:	Promoting App. Access:	Vascalur	Reduction of	Immun. /
		CONTRACT	Grievances	ICH CAHPs	IVD/IVT & Failure	Dialysis Access Rep.	Access	HAIs	Transplant Coord.	TOTAL
	FTE	HOURS	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	PERCENT*
a. LABOR
1.										0%
2.										0%
3.										0%
4.										0%
5.										0%
6.										0%
7.										0%
8.										0%
9.										0%
10.										0%
11.										0%
12.										0%
13.										0%
14.										0%
15.										0%
										0%
SUBTOTAL - DIRECT LABOR	0	0								0%

b. PROGRAM CONSULTANTS
1.			0%
2.			0%
3.			0%
4.			0%
5.			0%
6.			0%
7.			0%
8.			0%
9.			0%
10.			0%
SUBTOTAL-PROGRAM CONSULTANTS	0	0	0%

NOTE: Enter the Percent of "TOTAL HOURS" in each labor category

* 100% of TOTAL CONTRACT HOURS

J.7 CMS Form 685

ESRD NETWORK

		ANNUAL MANAGEMENT PLAN 1/1/2014 - 12/31/2014								YEAR 2
DIRECT MEDICARE		TOTAL		Supporting	Promoting App. Access:	Promoting App. Access:	Vascalur	Reduction of	Immun. /
		CONTRACT	Grievances	ICH CAHPs	IVD/IVT & Failure	Dialysis Access Rep.	Access	HAIs	Transplant Coord.	TOTAL
	FTE	HOURS	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	PERCENT*
a. LABOR
1.										0%
2.										0%
3.										0%
4.										0%
5.										0%
6.										0%
7.										0%
8.										0%
9.										0%
10.										0%
11.										0%
12.										0%
13.										0%
14.										0%
15.										0%
										0%
SUBTOTAL - DIRECT LABOR	0	0								0%

b. PROGRAM CONSULTANTS
1.			0%
2.			0%
3.			0%
4.			0%
5.			0%
6.			0%
7.			0%
8.			0%
9.			0%
10.			0%
SUBTOTAL-PROGRAM CONSULTANTS	0	0	0%

NOTE: Enter the Percent of "TOTAL HOURS" in each labor category

* 100% of TOTAL CONTRACT HOURS

J.7 CMS Form 685

ESRD NETWORK

		ANNUAL MANAGEMENT PLAN 1/1/2015 - 12/31/2015								YEAR 3
DIRECT MEDICARE		TOTAL		Supporting	Promoting App. Access:	Promoting App. Access:	Vascalur	Reduction of	Immun. /
		CONTRACT	Grievances	ICH CAHPs	IVD/IVT & Failure	Dialysis Access Rep.	Access	HAIs	Transplant Coord.	TOTAL
	FTE	HOURS	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	PERCENT*
a. LABOR
1.										0%
2.										0%
3.										0%
4.										0%
5.										0%
6.										0%
7.										0%
8.										0%
9.										0%
10.										0%
11.										0%
12.										0%
13.										0%
14.										0%
15.										0%
										0%
SUBTOTAL - DIRECT LABOR	0	0								0%

b. PROGRAM CONSULTANTS
1.			0%
2.			0%
3.			0%
4.			0%
5.			0%
6.			0%
7.			0%
8.			0%
9.			0%
10.			0%
SUBTOTAL-PROGRAM CONSULTANTS	0	0	0%

NOTE: Enter the Percent of "TOTAL HOURS" in each labor category

* 100% of TOTAL CONTRACT HOURS

File details come from the government source that posted it. Updated Nov 14, 2017.