J-14_CLIN_0005_Cost_Proposal_Templates_Option_Period_3.xlsx

XLSX spreadsheet 225 KB Posted Mar 25, 2010

Attached to: DME MAC Jurisdiction D
Solicitation number: CMS-RFP-2010-0016
Issued by: Department of Health and Human Services Centers for Medicare and Medicaid Services

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Attachment J-14 CLIN 0005 Cost Proposal Templates Implementation ver 2003 and 2007 xlsx

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Other files

File	Type	Posted
SF 30_amendment 3_04.21.10.pdf	PDF	Apr 21, 2010
SF 30_amendment 2_04.19.10.pdf	PDF	Apr 19, 2010
SF 30_amendment 1_04.16.10.pdf	PDF	Apr 19, 2010
Amendment 00002 JD_04.19.10.docx	DOCX document	Apr 19, 2010
SF 33_base_04.16.10.pdf	PDF	Apr 19, 2010
CMS-RFP-2010-0016_DME MAC Juris D RFP_04-19-10 Questions.xls	XLS spreadsheet	Apr 19, 2010
Amendment 00001 JD_03.30.10.docx	DOCX document	Mar 30, 2010
SF 30 Amendment 1_03.30.10.pdf	PDF	Mar 30, 2010
J-13_CLIN_0004_Cost_Proposal_Templates_Option_Period_2.xls	XLS spreadsheet	Mar 25, 2010
CMS-RFP-2010-0016 JD Section B thru M 03.25.10.docx	DOCX document	Mar 25, 2010
J-11_CLIN_0002_Cost_Proposal_Templates_Base_Period.xlsx	XLSX spreadsheet	Mar 25, 2010
J-07_Basis of Estimate.xlsx	XLSX spreadsheet	Mar 25, 2010
J-18_NonDisclosureStatement.doc	DOC document	Mar 25, 2010
J-14_CLIN_0005_Cost_Proposal_Templates_Option_Period_3.xls	XLS spreadsheet	Mar 25, 2010
J-01AA Base-Non Reports PSCs ZPICs Need.xlsx	XLSX spreadsheet	Mar 25, 2010
J-19_Implementation_Handbook_1_28_10.doc	DOC document	Mar 25, 2010
J-23_DirectionsToCentralOffice.pdf	PDF	Mar 25, 2010
J-03_SmallBusinessSubcontractingPlan.doc	DOC document	Mar 25, 2010
J-01B SoW appendices.doc	DOC document	Mar 25, 2010
J-05_GFP-GFI_DME_MAC_JD.xlsx	XLSX spreadsheet	Mar 25, 2010
J-11_CLIN_0002_Cost_Proposal_Templates_Base_Period.xls	XLS spreadsheet	Mar 25, 2010
J-01A MAC Shared System BaseNonbase clean.doc	DOC document	Mar 25, 2010
J-21 Corporate Experience Attestation.docx	DOCX document	Mar 25, 2010
J-10_CLIN_0001_Cost_Proposal_Templates_Implementation.xlsx	XLSX spreadsheet	Mar 25, 2010
CMS-RFP-2010-0016 JD_ Cover Letter.pdf	PDF	Mar 25, 2010
J-08_PastPerformanceQuestionnaire_1_08_10.doc	DOC document	Mar 25, 2010
J-13_CLIN_0004_Cost_Proposal_Templates_Option_Period_2.xlsx	XLSX spreadsheet	Mar 25, 2010
J-12_CLIN_0003_Cost_Proposal_Templates_Option_Period_1.xlsx	XLSX spreadsheet	Mar 25, 2010
J-10_CLIN_0001_Cost_Proposal_Templates_Implementation.xls	XLS spreadsheet	Mar 25, 2010
J-22_Contractors_Guide_for_Gov_Property_12_09_08.pdf	PDF	Mar 25, 2010
CMS-RFP-2010-0016 JD_SF 33.pdf	PDF	Mar 25, 2010
J-20 Information Security Attestation.docx	DOCX document	Mar 25, 2010
J-09_CostProposalInstructions.xls	XLS spreadsheet	Mar 25, 2010
J-17_ProposalChecklist_03.24.10.doc	DOC document	Mar 25, 2010
J-01_Statement_of_Work_1_28_10 - FINAL1.docx	DOCX document	Mar 25, 2010
J-16_CLIN_0007_Cost_Proposal_Templates_Close_Out_Period.xls	XLS spreadsheet	Mar 25, 2010
J-24 Proposal Assumptions Template.xlsx	XLSX spreadsheet	Mar 25, 2010
J-15_CLIN_0006_Cost_Proposal_Templates_Option_Period_4.xls	XLS spreadsheet	Mar 25, 2010
J-15_CLIN_0006_Cost_Proposal_Templates_Option_Period_4.xlsx	XLSX spreadsheet	Mar 25, 2010
J-06_Sample_Award_fee_Plan_(JD)_12_30_09.pdf	PDF	Mar 25, 2010
J-02_Deliverables_DME_MAC_1_28_10.xlsx	XLSX spreadsheet	Mar 25, 2010
J-12_CLIN_0003_Cost_Proposal_Templates_Option_Period_1.xls	XLS spreadsheet	Mar 25, 2010
J-04_Billing_Instructions.doc	DOC document	Mar 25, 2010
J-16_CLIN_0007_Cost_Proposal_Templates_Close_Out_Period.xlsx	XLSX spreadsheet	Mar 25, 2010

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CLIN-0005

COST TEMPLATE - SAMPLE Attachment J-14

(Provide a cost spreadsheet for each CLIN proposed)

CLIN 0005

SLIN 0005AA

SLIN 0005AB

SLIN 0005AC

DME SERVICES/Option Period

Total FTEs

Program Management (PM)

Medicare Integrity Program (MIP)

RAC Operations Support

GRAND TOTAL

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	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	$0	0	$0	0	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	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	$0	0	$0	0	$0	0	$0
	0	$0	0	$0	0	$0	0	$0
	0	$0	0	$0	0	$0	0	$0
Subtotal Direct Labor	0	$0	0	$0	0	$0	0	$0

Fringe Benefits (at ____%) $0 $0 $0 $0

Total Direct Labor $0 $0 $0 $0

Travel			$0		$0		$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0	0	$0	0	$0	0	$0
Other Direct Costs		0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0
Total Subcontractor		0	$0	0	$0	0	$0	0	$0

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0

Indirect Costs (at ______ %) $0 $0 $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $0 $0

Base Fee (at ____%)	$0	$0	$0	$0
Award Fee (at ______%)	$0	$0	$0	$0

TOTOAL OTHER AFTER FEES $0 $0 $0 $0

Complementary Credits	$0			$0
Note: comp.credit information will be provided by CMS prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0	$0

&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0016&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10

SLIN = Sub Line Item Number&KFF0000 Attachment J-14 &P

ODC Schedule

COST TEMPLATE - SAMPLE Attachment J-14
(Provide an ODC Spreadsheet for each CLIN Proposed)
CLIN 000X DME SERVICES
Cost Element	TOTAL

Add costs by category

TOTAL ODCs $0.00

Attachment J-14 &P

Travel

TRAVEL SUMMARY

CLIN 000X

	Purpose of Trip	SOW WBS
Crosswalk	Labor Category Taking Trip	Trip Origin	Destination	# People
(A)	# Trips
(B)	# Days
(C)	# Nights
(D)	Lodging Rate
(E)	Lodging
(F=EDA)	M&IE
(G)	Total Lodging

and M&IE

(H=F+G)	Airfare
(I)	Car Rental
(J)	Misc
(K)	Local

Mileage

(L)	Total Per Trip
(M=H+I+J+K+L)	Total For All Trips

(N=M*B )

$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -

TOTAL TRAVEL $ -

Travel Assumptions:

Attachment J-14 &P

SLIN-0005AA

COST TEMPLATE - SAMPLE Attachment J-14

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0005AA

C.2

C.3

C.4

C.5

C.6

C.7

C.8

C.9

D.1

D.2

D.3

D.4

D.5

D.6

DME SERVICES/Option Period

Total FTEs

Infrastructure Requirements

Administrative Requirements

Change Management Process Requirements

FM of Trust Fund Dollars

Contract Award & Monthly Requirements

Task Directives

FOIA Requests

Access to Systems

Bills/Claims Payment

Appeals

Reopenings

Paper Claims Adjustment Editing

Provider Customer Service Program

Medicare Beneficiary Ombudsman

Interface Requirements

Quality Assurance Requirements

(enter positive number)

AWARD FEE

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

COST ELEMENTS
Direct Labor
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
Subtotal Direct Labor	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	$0	0		$0	0		$0	0		$0	0	$0

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Total Direct Labor $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Travel			$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	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	$0	0	$0	0	$0	0	$0	0	$0
Other Direct Costs		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	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		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	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		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	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		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	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		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	$0	0	$0	0	$0	0	$0	0	$0
Total Subcontractor		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	$0	0	$0	0	$0	0	$0	0	$0

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Base Fee (at ____%)	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0		$0
Award Fee (at ______%)																	$0	$0

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Complementary Credits																	$0		$0
Note: comp.credit information will be provided by CMS prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0

Attachment J-14 &P

C.3

COST TEMPLATE - SAMPLE Attachment J-14

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0005AA - C.3

C.3.1

C.3.2

C.3.3

C.3.4

C.3.5

DME SERVICES/Option Period

Total FTEs

Security

Compliance Program

Internal Controls

Business Continuity Planning and Disaster Recovery

Participation in Conferences, Meetings and Work Groups

GRAND TOTAL

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0

Total Direct Labor $0 $0 $0 $0 $0 $0

Travel			$0		$0		$0		$0		$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Other Direct Costs		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Total Subcontractor		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0

Base Fee (at ____%) $0 $0 $0 $0 $0 $0

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0 $0

GRAND TOTAL $0 $0 $0 $0 $0 $0

Attachment J-14 &P

C.5

COST TEMPLATE - SAMPLE Attachment J-14

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0005AA - C.5

C.5.1

C.5.2

C.5.3

C.5.4

C.5.5

C.5.7

DME SERVICES/Option Period

Total FTEs

Trust Fund

Banking Relations

Debt Collection

Overpayments

Debt Referral

Financial Reporting & Accounting

GRAND TOTAL

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0		$0	0		$0	0	$0	0		$0	0		$0	0	$0

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0 $0

Total Direct Labor $0 $0 $0 $0 $0 $0 $0

Travel			$0		$0		$0		$0		$0		$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Other Direct Costs		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Total Subcontractor		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0 $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0 $0

Base Fee (at ____%) $0 $0 $0 $0 $0 $0 $0

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0 $0 $0

GRAND TOTAL $0 $0 $0 $0 $0 $0 $0

Attachment J-14 &P

C.5.4

COST TEMPLATE - SAMPLE Attachment J-14

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0005AA - C.5.4

C.5.4.1

C.5.4.2

C.5.4.3

C.5.4.4

C.5.4.5

C.5.4.6

DME SERVICES/Option Period

Total FTEs

Identify Overpayment Cause

ERP Applications

Limitation on Recoupment

Overpayment Related to Bankruptcy

Administrative Freeze Payments

Closed Bankruptcy Case

GRAND TOTAL

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0 $0

Total Direct Labor $0 $0 $0 $0 $0 $0 $0

Travel			$0		$0		$0		$0		$0		$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Other Direct Costs		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Total Subcontractor		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0 $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0 $0

Base Fee (at ____%) $0 $0 $0 $0 $0 $0 $0

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0 $0 $0

GRAND TOTAL $0 $0 $0 $0 $0 $0 $0

Attachment J-14 &P

D.1

COST TEMPLATE - SAMPLE Attachment J-14

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0005AA - D.1

D.1.1

D.1.2

D.1.3

D.1.4

D.1.5

D.1.6

DME SERVICES/Option Period

Total FTEs

Medicare Front End Processing

General Claims Processing

Back-end Processing

Common Working File

DMEPOS Fee Schedule

ASCA Reviews

GRAND TOTAL

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
Subtotal Direct Labor	0	$0	0	$0	0	$0	0		$0	0		$0	0		$0	0	0

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0 0

Total Direct Labor $0 $0 $0 $0 $0 $0 0

Travel			$0		$0		$0		$0		$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	0
Other Direct Costs		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	0
Total Subcontractor		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	0

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0 $0 0

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 0

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 0

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0 0

Base Fee (at ____%) $0 $0 $0 $0 $0 $0 0

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0 $0 0

GRAND TOTAL $0 $0 $0 $0 $0 $0 $0

Attachment J-14 &P

D.1.1

COST TEMPLATE - SAMPLE Attachment J-14

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0005AA - D.1.1

D.1.1.1

D.1.1.2

D.1.1.3

D.1.1.4

D.1.1.5

DME SERVICES/Option Period

Total FTEs

Electronic Data Interchange

Front-end for Paper Claims and SPRs

Misidrected Claims

Transition Support

Electronic Funds Transfer Authorization Agreement

GRAND TOTAL

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
		$0.00	$0	0	$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0	$0	0		$0	0		$0	0		$0	0	$0

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0

Total Direct Labor $0 $0 $0 $0 $0 $0

Travel			$0		$0		$0		$0		$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Other Direct Costs		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Total Subcontractor		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0

Base Fee (at ____%) $0 $0 $0 $0 $0 $0

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0 $0

GRAND TOTAL $0 $0 $0 $0 $0 $0

Attachment J-14 &P

D.1.1.2

COST TEMPLATE - SAMPLE Attachment J-14
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0005AA - D.1.1.2		D.1.1.2.1			D.1.1.2.2
DME SERVICES/Option Period	Total FTEs	Manage Paper Bills/Claims			EDI Support Related to Front-End paper Claims and Transactions			GRAND TOTAL
		Hours	Rates	Total	Hours	Rates	Total	Hours	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0
		$0.00	$0		$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0		$0	0	$0

Fringe Benefits (at ____%) $0 $0 $0

Total Direct Labor $0 $0 $0

Travel			$0		$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0	0	$0	0	$0
Other Direct Costs		0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0
Total Subcontractor		0	$0	0	$0	0	$0

Other Direct Costs (insert & list applicable elements below) $0 $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0 $0

Indirect Costs (at ______ %) $0 $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $0

Base Fee (at ____%) $0 $0 $0

TOTAL OTHER AFTER FEES $0 $0 $0

GRAND TOTAL $0 $0 $0

Attachment J-14 &P

D.1.2

COST TEMPLATE - SAMPLE Attachment J-14

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0005AA - D.1.2

D.1.2.1

D.1.2.2

D.1.2.3

D.1.2.4

D.1.2.5

D.1.2.6

D.1.2.7

DME SERVICES/Option Period

Total FTEs

Run Systems

EDI Support Related to General Claims Processing

Report Claims Processing Problems

Handling Incomplete or Invalid Claims

Resolve Claims Transaction Replies and Unsolicited Responses from CWF

Processing Claims

NPI

GRAND TOTAL

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0
		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0		$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0	0		$0	0	$0

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0 $0 $0

Total Direct Labor $0 $0 $0 $0 $0 $0 $0 $0

Travel			$0		$0		$0		$0		$0		$0		$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Other Direct Costs		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Total Subcontractor		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0 $0 $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0 $0

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0 $0 $0

Base Fee (at ____%) $0 $0 $0 $0 $0 $0 $0 $0

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0 $0 $0 $0

GRAND TOTAL $0 $0 $0 $0 $0 $0 $0 $0

Attachment J-14 &P

D.1.2.6

COST TEMPLATE - SAMPLE Attachment J-14

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0005AA - D.1.2.6

D.1.2.6.1

D.1.2.6.2

D.1.2.6.3

DME SERVICES/Option Period

Total FTEs

Bills/Claims Determination

Payment of Claims

Payment of Claims outside of CWF

GRAND TOTAL

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
		$0.00	$0		$0.00	$0		$0.00	$0	0	0
Subtotal Direct Labor	0		$0	0		$0	0		$0	0	0

Fringe Benefits (at ____%) $0 $0 $0 0

Total Direct Labor $0 $0 $0 0

Travel			$0		$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0	0	$0	0	$0	0	0
Other Direct Costs		0	$0	0	$0	0	$0	0	0
Subcontractor Name		0	$0	0	$0	0	$0	0	0
Subcontractor Name		0	$0	0	$0	0	$0	0	0
Subcontractor Name		0	$0	0	$0	0	$0	0	0
Subcontractor Name		0	$0	0	$0	0	$0	0	0
Total Subcontractor		0	$0	0	$0	0	$0	0	0

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 0

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 0

Indirect Costs (at ______ %) $0 $0 $0 0

TOTAL OTHER BEFORE FEES $0 $0 $0 0

Base Fee (at ____%) $0 $0 $0 0

TOTAL OTHER AFTER FEES $0 $0 $0 0

GRAND TOTAL $0 $0 $0 0

Attachment J-14 &P

D.1.3

COST TEMPLATE - SAMPLE Attachment J-14
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0005AA - D.1.3		D.1.3.1			D.1.3.2
DME SERVICES/Option Period	Total FTEs	Generate & Deliver SPRs and MSNs			Transfer Claims Info to COBC			GRAND TOTAL
		Hours	Rates	Total	Hours	Rates	Total	Hours	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0
		$0.00	$0		$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0		$0	0	$0

Fringe Benefits (at ____%) $0 $0 $0

Total Direct Labor $0 $0 $0

Travel			$0		$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0	0	$0	0	$0
Other Direct Costs		0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0
Total Subcontractor		0	$0	0	$0	0	$0

Other Direct Costs (insert & list applicable elements below) $0 $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0 $0

Indirect Costs (at ______ %) $0 $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $0

Base Fee (at ____%) $0 $0 $0

TOTAL OTHER AFTER FEES $0 $0 $0

GRAND TOTAL $0 $0 $0

Attachment J-14 &P

D.2

COST TEMPLATE - SAMPLE Attachment J-14

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0005AA - D.2

D.2.1

D.2.2

D.2.3

D.2.4

D.2.5

D.2.6

D.2.7

DME SERVICES/Option Period

Total FTEs

Appeals of Medicare Initial Claims Determinations

Appeal Decision Effectuation

QICs

Incomplete Redetermination Requests

Part B Quality Improvement/ Data Analysis

Document Imaging

ALJ Hearings

GRAND TOTAL

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0 $0 $0

Total Direct Labor $0 $0 $0 $0 $0 $0 $0 $0

Travel			$0		$0		$0		$0		$0		$0		$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Other Direct Costs		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Total Subcontractor		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0 $0 $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0 $0

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0 $0 $0

Base Fee (at ____%) $0 $0 $0 $0 $0 $0 $0 $0

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0 $0 $0 $0

GRAND TOTAL $0 $0 $0 $0 $0 $0 $0 $0

Attachment J-14 &P

D.3

COST TEMPLATE - SAMPLE Attachment J-14
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0005AA - D.3		D.3.1			D.3.3
DME SERVICES/Option Period	Total FTEs	Clerical Error Reopenings			Telephone Reopenings			GRAND TOTAL
		Hours	Rates	Total	Hours	Rates	Total	Hours	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0
		$0.00	$0		$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0		$0	0	$0

Fringe Benefits (at ____%) $0 $0 $0

Total Direct Labor $0 $0 $0

Travel			$0		$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0	0	$0	0	$0
Other Direct Costs		0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0
Total Subcontractor		0	$0	0	$0	0	$0

Other Direct Costs (insert & list applicable elements below) $0 $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0 $0

Indirect Costs (at ______ %) $0 $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $0

Base Fee (at ____%) $0 $0 $0

TOTAL OTHER AFTER FEES $0 $0 $0

GRAND TOTAL $0 $0 $0

Attachment J-14 &P

D.5

COST TEMPLATE - SAMPLE Attachment J-14

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0005AA - D.5

D.5.1

D.5.2

D.5.3

D.5.4

D.5.5

DME SERVICES/Option Period

Total FTEs

Provider Outreach & Education

Provider Contact Center

Provider Self-Service Technology

PCSP Training

MCPSS

GRAND TOTAL

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
		$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0	$0	0	$0	0		$0	0		$0	0	$0

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0

Total Direct Labor $0 $0 $0 $0 $0 $0

Travel			$0		$0		$0		$0		$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Other Direct Costs		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0
Total Subcontractor		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0

Base Fee (at ____%) $0 $0 $0 $0 $0 $0

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0 $0

GRAND TOTAL $0 $0 $0 $0 $0 $0

Attachment J-14 &P

D.5.2

COST TEMPLATE - SAMPLE Attachment J-14

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0005AA - D.5.2

D.5.2.1

D.5.2.2

D.5.2.3

D.5.2.4

DME SERVICES/Option Period

Total FTEs

Telephone Inquiries

Written Inquiries

Provider Relations Research Specialists

Inquiry Tracking System

GRAND TOTAL

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0
		$0.00	$0		$0.00	$0	0	$0		$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0		$0	0	$0	0		$0	0	$0

Fringe Benefits (at ____%) $0 $0 $0 $0 $0

Total Direct Labor $0 $0 $0 $0 $0

Travel			$0		$0		$0		$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0	0	$0	0	$0	0	$0	0	$0
Other Direct Costs		0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0
Total Subcontractor		0	$0	0	$0	0	$0	0	$0	0	$0

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0

Indirect Costs (at ______ %) $0 $0 $0 $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0

Base Fee (at ____%) $0 $0 $0 $0 $0

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0

GRAND TOTAL $0 $0 $0 $0 $0

Attachment J-14 &P

D.5.2.3

COST TEMPLATE - SAMPLE Attachment J-14
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0005AA - D.5.2.3		D.5.2.3.1
DME SERVICES/Option Period	Total FTEs	Responding to Complex Beneficiary Inquiries
		Hours	Rates	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
		$0.00	$0
Subtotal Direct Labor	0		$0

Fringe Benefits (at ____%) $0

Total Direct Labor $0

Travel			$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0
Other Direct Costs		0	$0
Subcontractor Name		0	$0
Subcontractor Name		0	$0
Subcontractor Name		0	$0
Subcontractor Name		0	$0
Total Subcontractor		0	$0

Other Direct Costs (insert & list applicable elements below) $0

SUBTOTAL ALL DIRECT COSTS $0

Indirect Costs (at ______ %) $0

TOTAL OTHER BEFORE FEES $0

Base Fee (at ____%) $0

TOTAL OTHER AFTER FEES $0

GRAND TOTAL $0

Attachment J-14 &P

D.5.3

COST TEMPLATE - SAMPLE Attachment J-14

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0005AA - D.5.3

D.5.3.1

D.5.3.2

D.5.3.3

DME SERVICES/Option Period

Total FTEs

Interactive Voice Response

Web Technology

Provider Listserv

GRAND TOTAL

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
		$0.00	$0		$0.00	$0		$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0		$0	0		$0	0	$0

Fringe Benefits (at ____%) $0 $0 $0 $0

Total Direct Labor $0 $0 $0 $0

Travel			$0		$0		$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0	0	$0	0	$0	0	$0
Other Direct Costs		0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0
Total Subcontractor		0	$0	0	$0	0	$0	0	$0

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0

Indirect Costs (at ______ %) $0 $0 $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $0 $0

Base Fee (at ____%) $0 $0 $0 $0

TOTAL OTHER AFTER FEES $0 $0 $0 $0

GRAND TOTAL $0 $0 $0 $0

Attachment J-14 &P

SLIN-0005AB

COST TEMPLATE - SAMPLE Attachment J-14

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0005AB

C.5

C.7

C.8

C.9

D.3

D.5

E.1

E.2

E.3

E.4

E.5

DME SERVICES/Option Period

Total FTEs

FM of Trust Fund Dollars

Task Directives

FOIA Requests

Access to Systems

Reopenings

Provider Customer Service Program

CERT Program

BI PSC & ZPIC Support Services

MSP

Medicare Review Activities Not in Support of BI

Local Coverage Determinations

Interface Requirements

Quality Assurance Requirements

AWARD FEE

GRAND TOTAL

Medicare Integrity Program

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS
Direct Labor
	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
Subtotal Direct Labor	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		$0	0	$0

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Total Direct Labor $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Travel			$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	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	$0	0	$0
Other Direct Costs		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	$0	0	$0
Subcontractor Name		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	$0	0	$0
Subcontractor Name		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	$0	0	$0
Subcontractor Name		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	$0	0	$0
Subcontractor Name		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	$0	0	$0
Total Subcontractor		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	$0	0	$0

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Base Fee (at ____%)	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0		$0
Award Fee (at ______%)														$0	$0

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

GRAND TOTAL $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Attachment J-14 &P

C.5 (2)

COST TEMPLATE - SAMPLE Attachment J-14
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0005AB - C.5		C.5.4
DME SERVICES/Option Period	Total FTEs	Overpayments
Medicare Integrity Program		Hours	Rates	Total

COST ELEMENTS
Direct Labor
	0	$0
	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0
	0	$0
	0	$0
	0	$0
	0	$0
	0	$0
	0	$0
	0	$0
Subtotal Direct Labor	0	$0

Fringe Benefits (at ____%) $0

Total Direct Labor $0

Travel			$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0
Other Direct Costs		0	$0
Subcontractor Name		0	$0
Subcontractor Name		0	$0
Subcontractor Name		0	$0
Subcontractor Name		0	$0
Total Subcontractor		0	$0

Other Direct Costs (insert & list applicable elements below) $0

SUBTOTAL ALL DIRECT COSTS $0

Indirect Costs (at ______ %) $0

TOTAL OTHER BEFORE FEES $0

Base Fee (at ____%) $0

TOTAL OTHER AFTER FEES $0

GRAND TOTAL $0

SLIN = Sub Line Item Number &KFF0000Attachment J-14 &P

C.5.4 (2)

COST TEMPLATE - SAMPLE Attachment J-14
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0005AB - C.5.4		C.5.4.1
DME SERVICES/Option Period	Total FTEs	Identify Overpayment Cause
		Hours	Rates	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
		$0.00	$0
Subtotal Direct Labor	0		$0

Fringe Benefits (at ____%) $0

Total Direct Labor $0

Travel			$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0
Other Direct Costs		0	$0
Subcontractor Name		0	$0
Subcontractor Name		0	$0
Subcontractor Name		0	$0
Subcontractor Name		0	$0
Total Subcontractor		0	$0

Other Direct Costs (insert & list applicable elements below) $0

SUBTOTAL ALL DIRECT COSTS $0

Indirect Costs (at ______ %) $0

TOTAL OTHER BEFORE FEES $0

Base Fee (at ____%) $0

TOTAL OTHER AFTER FEES $0

GRAND TOTAL $0

Attachment J-14 &P

D.3(2)

COST TEMPLATE - SAMPLE Attachment J-14
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0005AB - D.3		D.3.2
DME SERVICES/Option Period	Total FTEs	Unanswered ADR
		Hours	Rates	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
		$0.00	$0
Subtotal Direct Labor	0		$0

Fringe Benefits (at ____%) $0

Total Direct Labor $0

Travel			$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0
Other Direct Costs		0	$0
Subcontractor Name		0	$0
Subcontractor Name		0	$0
Subcontractor Name		0	$0
Subcontractor Name		0	$0
Total Subcontractor		0	$0

Other Direct Costs (insert & list applicable elements below) $0

SUBTOTAL ALL DIRECT COSTS $0

Indirect Costs (at ______ %) $0

TOTAL OTHER BEFORE FEES $0

Base Fee (at ____%) $0

TOTAL OTHER AFTER FEES $0

GRAND TOTAL $0

Attachment J-14 &P

D.5 (2)

COST TEMPLATE - SAMPLE Attachment J-14
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0005AB - D.5		D.5.1
DME SERVICES/Option Period	Total FTEs	Provider Outreach & Education
		Hours	Rates	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
		$0.00	$0
Subtotal Direct Labor	0		$0

Fringe Benefits (at ____%) $0

Total Direct Labor $0

Travel			$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0
Other Direct Costs		0	$0
Subcontractor Name		0	$0
Subcontractor Name		0	$0
Subcontractor Name		0	$0
Subcontractor Name		0	$0
Total Subcontractor		0	$0

Other Direct Costs (insert & list applicable elements below) $0

SUBTOTAL ALL DIRECT COSTS $0

Indirect Costs (at ______ %) $0

TOTAL OTHER BEFORE FEES $0

Base Fee (at ____%) $0

TOTAL OTHER AFTER FEES $0

GRAND TOTAL $0

Attachment J-14 &P

E.3

COST TEMPLATE - SAMPLE Attachment J-14
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0005AB - E.3		E.3.1			E.3.2
DME SERVICES/Option Period	Total FTEs	MSP Pre-Payment			MSP Post Payment Recovery			GRAND TOTAL
		Hours	Rates	Total	Hours	Rates	Total	Hours	Total
COST ELEMENTS

Direct Labor
	0	$0	0	$0	0	$0
	0	$0	0	$0	0	$0
	0	$0	0	$0	0	$0
	0	$0	0	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	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	$0	0	$0	0	$0
	0	$0	0	$0	0	$0
Subtotal Direct Labor	0	$0	0	$0	0	$0

Fringe Benefits (at ____%) $0 $0 $0

Total Direct Labor $0 $0 $0

Travel			$0		$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0	0	$0	0	$0
Other Direct Costs		0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0
Total Subcontractor		0	$0	0	$0	0	$0

Other Direct Costs (insert & list applicable elements below) $0 $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0 $0

Indirect Costs (at ______ %) $0 $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $0

Base Fee (at ____%) $0 $0 $0

TOTAL OTHER AFTER FEES $0 $0 $0

GRAND TOTAL $0 $0 $0

SLIN = Sub Line Item Number &KFF0000Attachment J-14

E.3.1

COST TEMPLATE - SAMPLE Attachment J-14

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0005AB - E.3.1

E.3.1.1

E.3.1.2

E.3.1.3

E.3.1.4

DME SERVICES/Option Period

Total FTEs

MSP Claim w/Complete EOB: Update CWF

Incomplete EOB: Possible MSP Claim, possible MSP Situation, or CWF Exclusion: Forward to COBC

ECRS Status Inquiry

Identification & Adjudication of MSP Claims, Applying Benefits & Application of MSP Processing Formula

GRAND TOTAL

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
		$0.00	$0		$0.00	$0		$0.00	$0	0	$0	0	$0
Subtotal Direct Labor	0		$0	0		$0	0		$0	0	$0	0	$0

Fringe Benefits (at ____%) $0 $0 $0 $0 $0

Total Direct Labor $0 $0 $0 $0 $0

Travel			$0		$0		$0		$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0	0	$0	0	$0	0	$0	0	$0
Other Direct Costs		0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0
Total Subcontractor		0	$0	0	$0	0	$0	0	$0	0	$0

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0

Indirect Costs (at ______ %) $0 $0 $0 $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0

Base Fee (at ____%) $0 $0 $0 $0 $0

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0

GRAND TOTAL $0 $0 $0 $0 $0

Attachment J-14 &P

E.3.1.4

COST TEMPLATE - SAMPLE Attachment J-14

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0005AB - E.3.1.4

E.3.1.4.1

E.3.1.4.2

E.3.1.4.3

E.3.1.4.4

DME SERVICES/Option Period

Total FTEs

MSP Claims Determindations

MSP Claims Adjudication & Validation

MSP Claims Inquiries

Tranference of Documentation & Phone Calls to COBC

GRAND TOTAL

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0	$0

Fringe Benefits (at ____%) $0 $0 $0 $0 $0

Total Direct Labor $0 $0 $0 $0 $0

Travel			$0		$0		$0		$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0	0	$0	0	$0	0	$0	0	$0
Other Direct Costs		0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0
Total Subcontractor		0	$0	0	$0	0	$0	0	$0	0	$0

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0

Indirect Costs (at ______ %) $0 $0 $0 $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0

Base Fee (at ____%) $0 $0 $0 $0 $0

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0

Attachment J-14 &P

E.3.2

COST TEMPLATE - SAMPLE Attachment J-14

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0005AB - E.3.2

E.3.2.1

E.3.2.2

E.3.2.3

DME SERVICES/Option Period

Total FTEs

Supplier Duplicate Primary Payments

Mis-Routed MSP Recovery Checks

Mis-Routed MSP Recovery Correspondence

GRAND TOTAL

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
		$0.00	$0		$0.00	$0		$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0		$0	0		$0	0	$0

Fringe…

This is the start of the file's text. The full file is on GovTribe.

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

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