CSP008598_REV_Contract.pdf

Index No.: LDC033

Eff. Date: 03/19/25

STATE OF OHIO

DEPARTMENT OF ADMINISTRATIVE SERVICES

GENERAL SERVICES DIVISION

OFFICE OF PROCUREMENT SERVICES

4200 SURFACE ROAD, COLUMBUS, OH 43228-1395

OPTIONAL USE CONTRACT FOR: INDEPENDENT MEDICAL EXAMINATIONS, OTHER MEDICAL EXAMINATIONS AND

INDEPENDENT MEDICAL REVIEWS

CONTRACT NUMBER: CSP008598 EFFECTIVE DATES: 06/01/22 TO 03/31/24

Renewal through 03/31/26

The Department of Administrative Services has accepted Proposals submitted in response to Request for Proposal (RFP) No.

SRC0000001635 that opened on 03/11/22. The evaluation of the Proposal responses has been completed. The Offeror listed herein has been determined to be the highest-ranking Offeror and has been awarded a Contract for the services listed. The respective Proposal response including, Contract Terms & Conditions, any Proposal amendment, special Contract Terms & Conditions, specifications, pricing schedules and any attachments incorporated by reference and accepted by DAS become a part of this Services Contract.

This Requirements Contract is effective beginning and ending on the dates noted above unless, prior to the expiration date, the Contract is renewed, terminated, or cancelled in accordance with the Contract Terms and Conditions.

*This Requirements Contract is available to the Department of Insurance, Department of Administrative Services, Department of Natural Resources, Department of Youth Services, Department of Mental Health, Department of Rehabilitation and Correction, Department of Developmental Disabilities, Department of Public Safety, and Department of Transportation as applicable.

The agency is eligible to make purchases of the contracted services in any amount and at any time as determined by the agency. The State makes no representation or guarantee that department will purchase the volume of services as advertised in the Request for Proposal.

This Requirements Contract and any Amendments thereto are available from the DAS Web site at the following address:

www.ohio.gov/procure

*Indicates addition of the Department of Insurance as a participating organization.

Eff. Date: 07/12/22

MUTUALLY AGREED TO CLARIFICATIONS / MODIFICATIONS TO THE RFP

1. Clarification and Best and Final Offer Letter – response dated 04/13/22

2. Affirmation and Disclosure Form – response dated 04/22/22

3. Mutual Agreement for Cover Letters – response dated 7/5/22 *

* Add the Mutual Agreement for Cover Letters, effective with all orders on or after 07/12/22.

Eff. Date: 04/01/25

COST SUMMARY FORM

Independent Medical Examinations, Other Medical Examinations, and Independent Medical Reviews

CSP008598

UNSPSC CATEGORY CODE: 84131600

No.

DESCRIPTION

COST

*1. Total Reimbursement Charge per Independent Medical Examination $918.75 / each

*2. Total Reimbursement Charge per Functional Capacity Examination $1,034.25 / each

*3. Total Reimbursement Charge per Vocational Evaluation Examination $955.50 / each

*4. Total Reimbursement Charge per Independent Medical Review $918.75 / each

*5. Total Reimbursement Charge per Addendum (Per Agency request for additional information) $472.50 / each

*6. Total Reimbursement Charge per Psychological Assessment $892.50 / each

*7. Total Reimbursement Charge per Polygraphy Assessment $892.50 / each

*8. Review of Record File Fees for 1 -249 Pages $0.00 / each

*9. Review of Record File Fees for 250 – 500 Pages $315.00 / each

*10. Review of Record File Fees for 501 – 1,000 Pages $630.00 / each

*11. Review of Record File Fees for 1,001 – 2,000 Pages $1,050.00 / each

*12. Review of Record File Fees for 2,001 – 5,000 Pages $1,785.00 / each

*13. Review of Record File Fees for 5,001 and Over Pages $2,415.00 / each

14. Interpreter Services (Per 15 minutes, maximum of 30 minutes per date of service) $20.00 / occurrence

15. Interpreter Wait Time (Per 6 minutes) $3.50 / occurrence

16. Interpreter Travel (Per 6 minutes) $3.50 / occurrence

17. Interpreter Mileage (Per Mile) $0.45 / mile

18. No Show / Cancellation Fee (No more than 10% of the Exam) 10% of the Exam Maximum

19. BWC Fee Schedule for any tests requested by the State Agency or TPA BWC Fee Schedule

*20. Cover Letter Fee for Independent Medical Exams, Functional Capacity Examination, and Vocational Evaluation Examination $157.50 / each

Note:

Ohio BWC Fee Schedule will be utilized to reimburse for any tests requested by the State Agency or TPA.

Reimbursement for a cancellation or no-show shall be no more than 10% of the examination cost.

Interpreter Services allowable charges are noted in the Scope of Work.

* Revise the Cost Summary Form for items 1 – 13 and 20, effective with all order on or after 04/01/25.

Eff. Date: 06/01/22

CONTRACTOR INDEX

CONTRACTOR AND TERMS: CONTRACT NO.: CSP008596

0000007826 Medical Evaluators, LLC. DELIVERY: As Specified 28370 Kensington LN, Ste. B Perrysburg, OH 43551 TERMS: Net 30

CONTRACTOR CONTACT:

Michael Rumman PHONE: (419) 874-9101 ext. 6314

FAX: (419) 874-2055

EMAIL: mrumman@medicalevaluators.com mailto:mrumman@medicalevaluators.com

Eff. Date: 03/19/25

SUMMARY OF AMENDMENTS

Amendment

Number Effective

Date Description

6 03/19/25

This amendment is issued to add the Department of Insurance as a participating organization.

All other prices, terms and conditions remain unchanged.

5 04/01/25

This amendment is issued to notify that as a result of mutual agreement between the State of Ohio and the Contractor, this contract is renewed for an additional 12 months, effective 04/01/25 through 03/31/26. Also, this amendment is issued to reflect revision to the Cost Summary Form for items 1-13 and 20, effective with all orders on or after 04/01/25. All other prices, terms and conditions remain unchanged.

4 04/01/24 This amendment is issued to notify that as a result of mutual agreement between the State of Ohio and the Contractor, this contract is renewed for an additional 12 months, effective 04/01/24 through 03/31/25. All other prices, terms and conditions remain unchanged.

3 04/05/23 This amendment is issued to add the Department of Transportation as a participating organization.

2 02/28/23 This amendment is issued to add the Department Public Safety as a participating organization.

1 07/12/22 This amendment is issued to add the mutually agreed upon cover letters, update the Cost Summary form, and add the summary of amendments page, effective with all orders on or after 7/12/22.