Attachment_J-18B_Business_Proposal_Forms_BFCC-QIO_Contract_Revised_Amendment_1_12-24-2013.xlsx

XLSX spreadsheet 231 KB Posted Dec 24, 2013

Attached to: Beneficiary and Family Centered Care (BFCC) Quality Improvement Organization (QIO)
Solicitation number: HHSM-500-2014-RFP-BFCC-QIO
Issued by: Department of Health and Human Services Centers for Medicare and Medicaid Services

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Attachment J-18B Business Proposal Forms BFCC-QIO Contract Revised Amendment 1 12-24-2013

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Other files

File	Type	Posted
HHSM-500-2014-RFP-BFCC-QIO_Amendment_5_Signed_Cover_Letter.pdf	PDF	Jan 21, 2014
HHSM-500-2014-RFP-BFCC-QIO_Amendment_4_SF_33_Solication_Cover_Page.pdf	PDF	Jan 15, 2014
BFCC-QIO_Amendment_4_Additional_Industry_Questions_CMS_Responses.doc	DOC document	Jan 15, 2014
HHSM-500-2014-RFP-BFCC-QIO_Amendment_4_1-15-2014_Revised_RFP.docx	DOCX document	Jan 15, 2014
HHSM-500-2014-RFP-BFCC-QIO_Amendment_4_Signed_Cover_Letter.pdf	PDF	Jan 15, 2014
BFCC-QIO_Amendment_4_Summary_of_Changes.docx	DOCX document	Jan 15, 2014
BFCC-QIO_Amendment_3_Additional_Industry_Questions_CMS_Responses.doc	DOC document	Jan 9, 2014
HHSM-500-2014-RFP-BFCC-QIO_Amendment_3_Signed_Cover_Letter.pdf	PDF	Jan 9, 2014
HHSM-500-2014-RFP-BFCC-QIO_Amendment_3_SF_33_Solication_Cover_Page.pdf	PDF	Jan 9, 2014
BFCC-QIO_Amendment_2_IT_Industry_Questions_CMS_Responses.doc	DOC document	Dec 27, 2013
HHSM-500-2014-RFP-BFCC-QIO_Amendment_Number_2_Signed_Cover_Letter.pdf	PDF	Dec 27, 2013
Amendment_Number_1_Attachment_1_to_Q As.docx	DOCX document	Dec 24, 2013
Attachment_J-24C_Integrated_Innovation_Spread_Strategy_Template.doc	DOC document	Dec 24, 2013
Attachment_J-24A_Integrated_Innovation_Spread_Stretegy_Frequently_Asked_Questions.docx.pdf	PDF	Dec 24, 2013
HHSM-500-2014-RFP-BFCC-QIO_Amendment_1_12-24-2013_Revised_RFP.docx	DOCX document	Dec 24, 2013
Attachment_J-10_Annual_and_54th_Month_Evaluation_Criteris_Measures_Table_Revised_Amendment_1_12-24-2013.docx	DOCX document	Dec 24, 2013
Attachment_J-18A_Business_Proposal_Instructions_Revised_Amendment_1_12-24-2013.docx	DOCX document	Dec 24, 2013
Attachment_J-7_Information_Systems_Library.docx	DOCX document	Dec 24, 2013
HHSM-500-2014-RFP-BFCC-QIO_Amendment_Number_1_Signed_Cover_Letter.pdf	PDF	Dec 24, 2013
Attachment_J-16_Past_Performance_Questionnaire_Revised_Amendment_1_12-24-2013.doc	DOC document	Dec 24, 2013
Attachment_J-24B_Integrated_Innovation_Spread_Strategy_Template_Example.doc	DOC document	Dec 24, 2013
BFCC-QIO_Amendment_1_Summary_of_Changes_.docx	DOCX document	Dec 24, 2013
Attachment_J-19_BFCC-QIO_Pass_Thru_Costs_Revised_Amendment_1_12-24-2013.docx	DOCX document	Dec 24, 2013
Attachment_J-23_BFCC-QIO_Estimated_Level_of_Effort_per_Case_.docx	DOCX document	Dec 24, 2013
BFCC-QIO_Amendment_1_Industry_Questions_CMS_Responses.doc	DOC document	Dec 24, 2013
Attachment_J-9B_Sample_Evaluation_Contractor_Subcontract_Agreement.docx	DOCX document	Dec 5, 2013
HHSM-500-2014-RFP-BFCC-QIO_Signed_Cover_Letter.pdf	PDF	Dec 5, 2013
Attachment_J-18A_Business_Proposal_Instructions.docx	DOCX document	Dec 5, 2013
Attachment_J-16_Past_Performance_Questionnaire.doc	DOC document	Dec 5, 2013
Attachment_J-13_US_DOL_Wage_Determination.doc	DOC document	Dec 5, 2013
Attachment_J-2_BFCC_Acronyms.docx	DOCX document	Dec 5, 2013
Attachment_J-11_HHS_Form_565_Report_of_Accountable_Personal_Property_Template.doc	DOC document	Dec 5, 2013
Attachment_J-21_Conflict_of_Interest_Certificate_and_Compliance_Attestation.docx	DOCX document	Dec 5, 2013
Attachment_J-19_BFCC-QIO_Pass_Thru_Costs.docx	DOCX document	Dec 5, 2013
Attachment_J-3_Requirements_Incorporated_by_Reference.docx	DOCX document	Dec 5, 2013
Attachment_J-20_Organization_Conflict_of_Interest_Sample_Disclosure_Format_Template.docx	DOCX document	Dec 5, 2013
Attachment_J-6_QIOCommunicationsHandbook.pdf	PDF	Dec 5, 2013
HHSM-500-2014-RFP-BFCC-QIO_SF_33_Solication_Cover_Page.pdf	PDF	Dec 5, 2013
Attachment_J-9A_Sample_Survey_Contractor_Subcontract_Agreement.docx	DOCX document	Dec 5, 2013
Attachment_J-4_Data_Supplied_by_CMS.docx	DOCX document	Dec 5, 2013
Attachment_J-1_BFCC_Glossary.docx	DOCX document	Dec 5, 2013
Attachment_J-8_Subcontract_Consent_Form.DOC	DOC document	Dec 5, 2013
Attachment_J-5_Data_Use_Instructions_ _Form.docx	DOCX document	Dec 5, 2013
HHSM-500-2014-RFP-BFCC-QIO_12-5-2013_Final_RFP.docx	DOCX document	Dec 5, 2013
2014_QIO_Program_Contract_Structure.pdf	PDF	Dec 5, 2013
Attachment_J-18B_Business_Proposal_Forms_BFCC-QIO_Contract.xlsx	XLSX spreadsheet	Dec 5, 2013
Attachment_J-22_Information_Security_Attestation.docx	DOCX document	Dec 5, 2013
Attachment_J-17_BFCC-QIO_Volume_Estimates_by_Area.xml.pdf	PDF	Dec 5, 2013
Attachment_J-10_Annual_and_54th_Month_Evaluation_Criteris_Measures_Table.docx	DOCX document	Dec 5, 2013
Attachment_J-12_Engineering_Board_Review_(ERB)_User's_Guide_and_Request_Form.doc	DOC document	Dec 5, 2013

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BFCC Sup Sch YR1

1. RFP Number:	2. Name and Address of QIO Organization:	3. QIO Service Area:	4. Contract Period:
			From:
			To:

5. Quality of Care Reviews Cost Per Case 6. Weichardt Appeals Cost Per Case 7. BIPA Appeals Cost Per Case 8. Grijalva Appeals Cost Per Case 9. EMTALA: 5-day Reviews Cost Per Review 10. EMTALA: 60-day Reviews Cost Per Review 11. HWDRG Cost Per Case 12. Pre-Admission and Admission HINN 13. Sanction Activities 14. Non-Review Activities 15. Information Services 16. QOC Referrals 17. Transition 18. Total

	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS
a. LABOR:
1.																											0.0	$ - 0
2.																											0.0	$ - 0
3.																											0.0	$ - 0
4.																											0.0	$ - 0
5.																											0.0	$ - 0
6.																											0.0	$ - 0
7.																											0.0	$ - 0
8.																											0.0	$ - 0
9.																											0.0	$ - 0
10.																											0.0	$ - 0
11.																											0.0	$ - 0
12.																											0.0	$ - 0
13.																											0.0	$ - 0
14.																											0.0	$ - 0
15.																											0.0	$ - 0
16.																											0.0	$ - 0
17.																											0.0	$ - 0
18.																											0.0	$ - 0
19.																											0.0	$ - 0
20. All Other (Non IT)	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
41.																											0.0	$ - 0
42.																											0.0	$ - 0
43.																											0.0	$ - 0
44.																											0.0	$ - 0
45.																											0.0	$ - 0
46.																											0.0	$ - 0
47.																											0.0	$ - 0
48.																											0.0	$ - 0
49.																											0.0	$ - 0
50.																											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	0.0	$0	0.0	$0	0.0	$0

b. Leave																											0.0	$ - 0
c. Fringe Benefits																												$ - 0
SUBTOTAL - Leave / Fringe	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

d. SUBCONTRACTS:
1. Physician Reviewers / Phys. Advisors																											0.0	$ - 0
2. Other Consultants		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$ - 0
3. Other Subcontractors		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$ - 0
SUBTOTAL - Subcontracts	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

e. Travel																												$ - 0
f. Other Direct Costs		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		$0		$0		ERROR:#DIV/0!		$0		ERROR:#DIV/0!
SUBTOTAL - DIRECT	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	$0	0.0	$0	0.0	ERROR:#DIV/0!	0.0	$0	0.0	ERROR:#DIV/0!

g. Indirect Costs $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $ - 0

TOTAL COSTS	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	$0	0.0	$0	0.0	ERROR:#DIV/0!	0.0	$0	0.0	ERROR:#DIV/0!
h. Fee				$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$ - 0

TOTAL COSTS WITH FEE

ERROR:#DIV/0!

Projected Volume - # of cases for:

Year 1

i. Pass-thru Costs

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

BFCC Sup Sch YR2

1. RFP Number:

2. Name and Address of QIO Organization:

3. QIO Service Area:

4. Contract Period:

From:

12/31/99

To:

12/31/99

5. Quality of Care Reviews Cost Per Case

6. Weichardt Appeals Cost Per Case

7. BIPA Appeals Cost Per Case

8. Grijalva Appeals Cost Per Case

9. EMTALA: 5-day Reviews Cost Per Review

10. EMTALA: 60-day Reviews Cost Per Review

11. HWDRG Cost Per Case

12. Pre-Admission and Admission HINN

13. Sanction Activities

14. Non-Review Activities

15. Information Services

16. QOC Referrals

17. Transition

18. Total

	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS
a. LABOR:
1.																											0.0	$ - 0
2.																											0.0	$ - 0
3.																											0.0	$ - 0
4.																											0.0	$ - 0
5.																											0.0	$ - 0
6.																											0.0	$ - 0
7.																											0.0	$ - 0
8.																											0.0	$ - 0
9.																											0.0	$ - 0
10.																											0.0	$ - 0
11.																											0.0	$ - 0
12.																											0.0	$ - 0
13.																											0.0	$ - 0
14.																											0.0	$ - 0
15.																											0.0	$ - 0
16.																											0.0	$ - 0
17.																											0.0	$ - 0
18.																											0.0	$ - 0
19.																											0.0	$ - 0
20. All Other (Non IT)	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
41.																											0.0	$ - 0
42.																											0.0	$ - 0
43.																											0.0	$ - 0
44.																											0.0	$ - 0
45.																											0.0	$ - 0
46.																											0.0	$ - 0
47.																											0.0	$ - 0
48.																											0.0	$ - 0
49.																											0.0	$ - 0
50.																											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	0.0	$0	0.0	$0	0.0	$0

b. Leave																											0.0	$ - 0
c. Fringe Benefits																												$ - 0
SUBTOTAL - Leave / Fringe	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

d. SUBCONTRACTS:
1. Physician Reviewers / Phys. Advisors																											0.0	$ - 0
2. Other Consultants		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$ - 0
3. Other Subcontractors		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$ - 0
SUBTOTAL - Subcontracts	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

e. Travel																												$ - 0
f. Other Direct Costs		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		$0		$0		ERROR:#DIV/0!		$0		ERROR:#DIV/0!
SUBTOTAL - DIRECT	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	$0	0.0	$0	0.0	ERROR:#DIV/0!	0.0	$0	0.0	ERROR:#DIV/0!

g. Indirect Costs $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $ - 0

TOTAL COSTS	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	$0	0.0	$0	0.0	ERROR:#DIV/0!	0.0	$0	0.0	ERROR:#DIV/0!
h. Fee				$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$ - 0

TOTAL COSTS WITH FEE

ERROR:#DIV/0!

Projected Volume - # of cases for:

Year 2

i. Pass-thru Costs

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

BFCC Sup Sch YR3

1. RFP Number:

2. Name and Address of QIO Organization:

3. QIO Service Area:

4. Contract Period:

From:

12/31/99

To:

12/31/99

5. Quality of Care Reviews Cost Per Case

6. Weichardt Appeals Cost Per Case

7. BIPA Appeals Cost Per Case

8. Grijalva Appeals Cost Per Case

9. EMTALA: 5-day Reviews Cost Per Review

10. EMTALA: 60-day Reviews Cost Per Review

11. HWDRG Cost Per Case

12. Pre-Admission and Admission HINN

13. Sanction Activities

14. Non-Review Activities

15. Information Services

16. QOC Referrals

17. Transition

18. Total

	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS
a. LABOR:
1.																											0.0	$ - 0
2.																											0.0	$ - 0
3.																											0.0	$ - 0
4.																											0.0	$ - 0
5.																											0.0	$ - 0
6.																											0.0	$ - 0
7.																											0.0	$ - 0
8.																											0.0	$ - 0
9.																											0.0	$ - 0
10.																											0.0	$ - 0
11.																											0.0	$ - 0
12.																											0.0	$ - 0
13.																											0.0	$ - 0
14.																											0.0	$ - 0
15.																											0.0	$ - 0
16.																											0.0	$ - 0
17.																											0.0	$ - 0
18.																											0.0	$ - 0
19.																											0.0	$ - 0
20. All Other (Non IT)	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
41.																											0.0	$ - 0
42.																											0.0	$ - 0
43.																											0.0	$ - 0
44.																											0.0	$ - 0
45.																											0.0	$ - 0
46.																											0.0	$ - 0
47.																											0.0	$ - 0
48.																											0.0	$ - 0
49.																											0.0	$ - 0
50.																											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	0.0	$0	0.0	$0	0.0	$ - 0

b. Leave																											0.0	$ - 0
c. Fringe Benefits																												$ - 0
SUBTOTAL - Leave / Fringe	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

d. SUBCONTRACTS:
1. Physician Reviewers / Phys. Advisors																											0.0	$ - 0
2. Other Consultants		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$ - 0
3. Other Subcontractors		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$ - 0
SUBTOTAL - Subcontracts	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

e. Travel																												$ - 0
f. Other Direct Costs		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		$0		$0		ERROR:#DIV/0!		$0		ERROR:#DIV/0!
SUBTOTAL - DIRECT	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	$0	0.0	$0	0.0	ERROR:#DIV/0!	0.0	$0	0.0	ERROR:#DIV/0!

g. Indirect Costs $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $ - 0

TOTAL COSTS	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	$0	0.0	$0	0.0	ERROR:#DIV/0!	0.0	$0	0.0	ERROR:#DIV/0!
h. Fee				$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$ - 0

TOTAL COSTS WITH FEE

ERROR:#DIV/0!

Projected Volume - # of cases for:

Year 3

i. Pass-thru Costs

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

BFCC Sup Sch YR4

1. RFP Number:

2. Name and Address of QIO Organization:

3. QIO Service Area:

4. Contract Period:

From:

12/31/99

To:

12/31/99

5. Quality of Care Reviews Cost Per Case

6. Weichardt Appeals Cost Per Case

7. BIPA Appeals Cost Per Case

8. Grijalva Appeals Cost Per Case

9. EMTALA: 5-day Reviews Cost Per Review

10. EMTALA: 60-day Reviews Cost Per Review

11. HWDRG Cost Per Case

12. Pre-Admission and Admission HINN

13. Sanction Activities

14. Non-Review Activities

15. Information Services

16. QOC Referrals

17. Transition

18. Total

	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS
a. LABOR:
1.																											0.0	$ - 0
2.																											0.0	$ - 0
3.																											0.0	$ - 0
4.																											0.0	$ - 0
5.																											0.0	$ - 0
6.																											0.0	$ - 0
7.																											0.0	$ - 0
8.																											0.0	$ - 0
9.																											0.0	$ - 0
10.																											0.0	$ - 0
11.																											0.0	$ - 0
12.																											0.0	$ - 0
13.																											0.0	$ - 0
14.																											0.0	$ - 0
15.																											0.0	$ - 0
16.																											0.0	$ - 0
17.																											0.0	$ - 0
18.																											0.0	$ - 0
19.																											0.0	$ - 0
20. All Other (Non IT)	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
41.																											0.0	$ - 0
42.																											0.0	$ - 0
43.																											0.0	$ - 0
44.																											0.0	$ - 0
45.																											0.0	$ - 0
46.																											0.0	$ - 0
47.																											0.0	$ - 0
48.																											0.0	$ - 0
49.																											0.0	$ - 0
50.																											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	0.0	$0	0.0	$0	0.0	$0

b. Leave																											0.0	$ - 0
c. Fringe Benefits																												$ - 0
SUBTOTAL - Leave / Fringe	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

d. SUBCONTRACTS:
1. Physician Reviewers / Phys. Advisors																											0.0	$ - 0
2. Other Consultants		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$ - 0
3. Other Subcontractors		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$ - 0
SUBTOTAL - Subcontracts	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

e. Travel																												$ - 0
f. Other Direct Costs		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		$0		$0		ERROR:#DIV/0!		$0		ERROR:#DIV/0!
SUBTOTAL - DIRECT	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	$0	0.0	$0	0.0	ERROR:#DIV/0!	0.0	$0	0.0	ERROR:#DIV/0!

g. Indirect Costs $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $ - 0

TOTAL COSTS	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	$0	0.0	$0	0.0	ERROR:#DIV/0!	0.0	$0	0.0	ERROR:#DIV/0!
h. Fee				$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$ - 0

TOTAL COSTS WITH FEE

ERROR:#DIV/0!

Projected Volume - # of cases for:

Year 4

i. Pass-thru Costs

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

BFCC Sup Sch YR5

1. RFP Number:

2. Name and Address of QIO Organization:

3. QIO Service Area:

4. Contract Period:

From:

12/31/99

To:

12/31/99

5. Quality of Care Reviews Cost Per Case

6. Weichardt Appeals Cost Per Case

7. BIPA Appeals Cost Per Case

8. Grijalva Appeals Cost Per Case

9. EMTALA: 5-day Reviews Cost Per Review

10. EMTALA: 60-day Reviews Cost Per Review

11. HWDRG Cost Per Case

12. Pre-Admission and Admission HINN

13. Sanction Activities

14. Non-Review Activities

15. Information Services

16. QOC Referrals

17. Transition

18. Total

	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS
a. LABOR:
1.																											0.0	$ - 0
2.																											0.0	$ - 0
3.																											0.0	$ - 0
4.																											0.0	$ - 0
5.																											0.0	$ - 0
6.																											0.0	$ - 0
7.																											0.0	$ - 0
8.																											0.0	$ - 0
9.																											0.0	$ - 0
10.																											0.0	$ - 0
11.																											0.0	$ - 0
12.																											0.0	$ - 0
13.																											0.0	$ - 0
14.																											0.0	$ - 0
15.																											0.0	$ - 0
16.																											0.0	$ - 0
17.																											0.0	$ - 0
18.																											0.0	$ - 0
19.																											0.0	$ - 0
20. All Other (Non IT)	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
41.																											0.0	$ - 0
42.																											0.0	$ - 0
43.																											0.0	$ - 0
44.																											0.0	$ - 0
45.																											0.0	$ - 0
46.																											0.0	$ - 0
47.																											0.0	$ - 0
48.																											0.0	$ - 0
49.																											0.0	$ - 0
50.																											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	0.0	$0	0.0	$0	0.0	$0

b. Leave																											0.0	$ - 0
c. Fringe Benefits																												$ - 0
SUBTOTAL - Leave / Fringe	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

d. SUBCONTRACTS:
1. Physician Reviewers / Phys. Advisors																											0.0	$ - 0
2. Other Consultants		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$ - 0
3. Other Subcontractors		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$ - 0
SUBTOTAL - Subcontracts	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

e. Travel																												$ - 0
f. Other Direct Costs		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		ERROR:#DIV/0!		$0		$0		ERROR:#DIV/0!		$0		ERROR:#DIV/0!
SUBTOTAL - DIRECT	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	$0	0.0	$0	0.0	ERROR:#DIV/0!	0.0	$0	0.0	ERROR:#DIV/0!

g. Indirect Costs $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $ - 0

TOTAL COSTS	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	ERROR:#DIV/0!	0.0	$0	0.0	$0	0.0	ERROR:#DIV/0!	0.0	$0	0.0	ERROR:#DIV/0!
h. Fee				$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$ - 0

TOTAL COSTS WITH FEE

ERROR:#DIV/0!

Projected Volume - # of cases for:

Year 5

i. Pass-thru Costs

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

Add'l Labor Categ.

1. RFP Number:

2. Name and Address of QIO Organization:

3. QIO Service Area:

4. Contract Period:

From:

12/31/99

To:

12/31/99

5. Quality of Care Reviews Cost Per Case

6. Weichardt Appeals Cost Per Case

7. BIPA Appeals Cost Per Case

8. Grijalva Appeals Cost Per Case

9. EMTALA: 5-day Reviews Cost Per Review

10. EMTALA: 60-day Reviews Cost Per Review

11. HWDRG Cost Per Case

12. Pre-Admission and Admission HINN

13. Sanction Activities

14. Non-Review Activities

15. Information Services

16. QOC Referrals

17. Transition

18. Total

Year 1

	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS
20. All Other (LABOR) :
21.																											0.0	$ - 0
22.																											0.0	$ - 0
23.																											0.0	$ - 0
24.																											0.0	$ - 0
25.																											0.0	$ - 0
26.																											0.0	$ - 0
27.																											0.0	$ - 0
28.																											0.0	$ - 0
29.																											0.0	$ - 0
30.																											0.0	$ - 0
31.																											0.0	$ - 0
32.																											0.0	$ - 0
33.																											0.0	$ - 0
34.																											0.0	$ - 0
35.																											0.0	$ - 0
36.																											0.0	$ - 0
37.																											0.0	$ - 0
38.																											0.0	$ - 0
39.																											0.0	$ - 0
40.																											0.0	$ - 0
SUBTOTAL - 20. All Other (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	0.0	$0	0.0	$0	0.0	$ - 0

Year 2

	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS
20. All Other (LABOR) :
21.																											0.0	$ - 0
22.																											0.0	$ - 0
23.																											0.0	$ - 0
24.																											0.0	$ - 0
25.																											0.0	$ - 0
26.																											0.0	$ - 0
27.																											0.0	$ - 0
28.																											0.0	$ - 0
29.																											0.0	$ - 0
30.																											0.0	$ - 0
31.																											0.0	$ - 0
32.																											0.0	$ - 0
33.																											0.0	$ - 0
34.																											0.0	$ - 0
35.																											0.0	$ - 0
36.																											0.0	$ - 0
37.																											0.0	$ - 0
38.																											0.0	$ - 0
39.																											0.0	$ - 0
40.																											0.0	$ - 0
SUBTOTAL - 20. All Other (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	0.0	$0	0.0	$0	0.0	$ - 0

Year 3

	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS
20. All Other (LABOR) :
21.																											0.0	$ - 0
22.																											0.0	$ - 0
23.																											0.0	$ - 0
24.																											0.0	$ - 0
25.																											0.0	$ - 0
26.																											0.0	$ - 0
27.																											0.0	$ - 0
28.																											0.0	$ - 0
29.																											0.0	$ - 0
30.																											0.0	$ - 0
31.																											0.0	$ - 0
32.																											0.0	$ - 0
33.																											0.0	$ - 0
34.																											0.0	$ - 0
35.																											0.0	$ - 0
36.																											0.0	$ - 0
37.																											0.0	$ - 0
38.																											0.0	$ - 0
39.																											0.0	$ - 0
40.																											0.0	$ - 0
SUBTOTAL - 20. All Other (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	0.0	$0	0.0	$0	0.0	$ - 0

Year 4

	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS
20. All Other (LABOR) :
21.																											0.0	$ - 0
22.																											0.0	$ - 0
23.																											0.0	$ - 0
24.																											0.0	$ - 0
25.																											0.0	$ - 0
26.																											0.0	$ - 0
27.																											0.0	$ - 0
28.																											0.0	$ - 0
29.																											0.0	$ - 0
30.																											0.0	$ - 0
31.																											0.0	$ - 0
32.																											0.0	$ - 0
33.																											0.0	$ - 0
34.																											0.0	$ - 0
35.																											0.0	$ - 0
36.																											0.0	$ - 0
37.																											0.0	$ - 0
38.																											0.0	$ - 0
39.																											0.0	$ - 0
40.																											0.0	$ - 0
SUBTOTAL - 20. All Other (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	0.0	$0	0.0	$0	0.0	$ - 0

Year 5

	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS	HOURS	COSTS
20. All Other (LABOR) :
21.																											0.0	$ - 0
22.																											0.0	$ - 0
23.																											0.0	$ - 0
24.																											0.0	$ - 0
25.																											0.0	$ - 0
26.																											0.0	$ - 0
27.																											0.0	$ - 0
28.																											0.0	$ - 0
29.																											0.0	$ - 0
30.																											0.0	$ - 0
31.																											0.0	$ - 0
32.																											0.0	$ - 0
33.																											0.0	$ - 0
34.																											0.0	$ - 0
35.																											0.0	$ - 0
36.																											0.0	$ - 0
37.																											0.0	$ - 0
38.																											0.0	$ - 0
39.																											0.0	$ - 0
40.																											0.0	$ - 0
SUBTOTAL - 20. All Other (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	0.0	$0	0.0	$0	0.0	$ - 0

QIOSubconts 2

1. RFP Number:

2. Name and Address of QIO Organization:

3. QIO Service Area:

4. Contract Period:

From:

12/31/99

To:

12/31/99

Year 1

18.

19.

20.

5. Quality of Care Reviews Cost Per Case

6. Weichardt Appeals Cost Per Case

7. BIPA Appeals Cost Per Case

8. Grijalva Appeals Cost Per Case

9. EMTALA: 5-day Reviews Cost Per Review

10. EMTALA: 60-day Reviews Cost Per Review

11. HWDRG Cost Per Case

12. Pre-Admission and Admission HINN

13. Sanction Activities

14. Non-Review Activities

15. Information Services

16. QOC Referrals

17. Transition

Total

Name

Year 1 Costs

Current Activity

Proposed Activity

I.	Other Consultants:
a																			$0
b																			$0
c																			$0
d																			$0
e																			$0
f																			$0
g																			$0
h																			$0
i																			$0
j																			$0
k																			$0
	Subtotal - Other Consultants	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0

II.	Other Subcontractors:
a																		$0
b																		$0
c																		$0
d																		$0
e																		$0
f																		$0
g																		$0
h																		$0
i																		$0
j																		$0
k																		$0
	Subtotal - Other Subcontractors	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
Year 2
																		18.	19.	20.
		5. Quality of Care Reviews Cost Per Case	6. Weichardt Appeals Cost Per Case	7. BIPA Appeals Cost Per Case	8. Grijalva Appeals Cost Per Case	9. EMTALA: 5-day Reviews Cost Per Review	10. EMTALA: 60-day Reviews Cost Per Review	11. HWDRG Cost Per Case	12. Pre-Admission and Admission HINN	13. Sanction Activities	14. Non-Review Activities	15. Information Services	16. QOC Referrals	17. Transition				Total
	Name																	Year 2 Costs	Current Activity	Proposed Activity

1	Other Consultants:
a																			$0
b																			$0
c																			$0
d																			$0
e																			$0
f																			$0
g																			$0
h																			$0
i																			$0
j																			$0
k																			$0
	Subtotal - Other Consultants	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0

2	Other Subcontractors:
a																		$0
b																		$0
c																		$0
d																		$0
e																		$0
f																		$0
g																		$0
h																		$0
i																		$0
j																		$0
k																		$0
	Subtotal - Other Subcontractors	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
Year 3
																		18.	19.	20.
		5. Quality of Care Reviews Cost Per Case	6. Weichardt Appeals Cost Per Case	7. BIPA Appeals Cost Per Case	8. Grijalva Appeals Cost Per Case	9. EMTALA: 5-day Reviews Cost Per Review	10. EMTALA: 60-day Reviews Cost Per Review	11. HWDRG Cost Per Case	12. Pre-Admission and Admission HINN	13. Sanction Activities	14. Non-Review Activities	15. Information Services	16. QOC Referrals	17. Transition				Total
	Name																	Year 3 Costs	Current Activity	Proposed Activity

1	Other Consultants:
a																			$0
b																			$0
c																			$0
d																			$0
e																			$0
f																			$0
g																			$0
h																			$0
i																			$0
j																			$0
k																			$0
	Subtotal - Other Consultants	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0

2	Other Subcontractors:
a																		$0
b																		$0
c																		$0
d																		$0
e																		$0
f																		$0
g																		$0
h																		$0
i																		$0
j																		$0
k																		$0
	Subtotal - Other Subcontractors	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
Year 4
																		18.	19.	20.
		5. Quality of Care Reviews Cost Per Case	6. Weichardt Appeals Cost Per Case	7. BIPA Appeals Cost Per Case	8. Grijalva Appeals Cost Per Case	9. EMTALA: 5-day Reviews Cost Per Review	10. EMTALA: 60-day Reviews Cost Per Review	11. HWDRG Cost Per Case	12. Pre-Admission and Admission HINN	13. Sanction Activities	14. Non-Review Activities	15. Information Services	16. QOC Referrals	17. Transition				Total
	Name																	Year 4 Costs	Current Activity	Proposed Activity

1	Other Consultants:
a																			$0
b																			$0
c																			$0
d																			$0
e																			$0
f																			$0
g																			$0
h																			$0
i																			$0
j																			$0
k																			$0
	Subtotal - Other Consultants	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0

2	Other Subcontractors:
a																		$0
b																		$0
c																		$0
d																		$0
e																		$0
f																		$0
g																		$0
h																		$0
i																		$0
j																		$0
k																		$0
	Subtotal - Other Subcontractors	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
Year 5
																		18.	19.	20.
		5. Quality of Care Reviews Cost Per Case	6. Weichardt Appeals Cost Per Case	7. BIPA Appeals Cost Per Case	8. Grijalva Appeals Cost Per Case	9. EMTALA: 5-day Reviews Cost Per Review	10. EMTALA: 60-day Reviews Cost Per Review	11. HWDRG Cost Per Case	12. Pre-Admission and Admission HINN	13. Sanction Activities	14. Non-Review Activities	15. Information Services	16. QOC Referrals	17. Transition				Total
	Name																	Year 5 Costs	Current Activity	Proposed Activity

1	Other Consultants:
a																			$0
b																			$0
c																			$0
d																			$0
e																			$0
f																			$0
g																			$0
h																			$0
i																			$0
j																			$0
k																			$0
	Subtotal - Other Consultants	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0

2	Other Subcontractors:
a																		$0
b																		$0
c																		$0
d																		$0
e																		$0
f																		$0
g																		$0
h																		$0
i																		$0
j																		$0
k																		$0
	Subtotal - Other Subcontractors	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0

&11Subcontracts Proposal Quality Improvement Organization 10th SOW Business Proposal &"Arial,Bold"Other Consultants and Other Subcontractors

Form SC 2 Page &P Prepared on:

Travel Detail Form

TRAVEL DETAIL

BFCC QUALITY IMPROVEMENT ORGANIZATION BUSINESS PROPOSAL

CENTERS FOR MEDICARE & MEDICAID SERVICES

1. RFP Number:	2. Name and Address of QIO Organization:				3. QIO Service Area:				4. Contract Period
0	0					0			From:	12/31/99
	0								To:	12/31/99
	0
Year 1									5. Mileage Rate:	$0.565
6. Area	7. Trip Title & Description/Purpose	8. # of Days per Trip	9. # of Nights per Trip	10. # of Travelers per Trip	11. Airfare per Person	12. Departing from:	13. Arriving to:	14. FTR Meals & Inc. Daily Rate	15. FTR Lodging per Night	16. # of Trips	17. Total # of miles per trip	18. # of Rental Cars Per Trip	19. Daily Rental Car Rate	20. Misc. Cost per Person per Trip (includes parking, gas, taxi, etc.)	21. TOTAL	22. Notes
5. Quality of Care Reviews															$0
															$0
															$0
															$0
6. Weichardt Appeals															$0
															$0
															$0
															$0
7. BIPA Appeals															$0
															$0
															$0
															$0
8. Grijalva Appeals															$0
															$0
															$0
															$0
9. EMTALA: 5-day Reviews															$0
															$0
															$0
															$0
10. EMTALA: 60-day Reviews															$0
															$0
															$0
															$0
11. HWDRG															$0
															$0
															$0
															$0
12. Pre-Admission and Admission HINN															$0
															$0
															$0
															$0
13. Sanction Activities															$0
															$0
															$0
															$0
14. Non-Review Activities															$0
															$0
															$0
															$0
15. Information Services															$0
															$0
															$0
															$0
16. QOC Referrals															$0
															$0
															$0
															$0
17. Transition															$0
															$0
															$0
															$0
23. YEAR 1 GRAND TOTAL:													$0

Year 2									5. Mileage Rate:
6. Area	7. Trip Title & Description/Purpose	8. # of Days per Trip	9. # of Nights per Trip	10. # of Travelers per Trip	11. Airfare per Person	12. Departing from:	13. Arriving to:	14. FTR Meals & Inc. Daily Rate	15. FTR Lodging per Night	16. # of Trips	17. Total # of miles per trip	18. # of Rental Cars Per Trip	19. Daily Rental Car Rate	20. Misc. Cost per Person per Trip (includes parking, gas, taxi, etc.)	21. TOTAL	22. Notes
5. Quality of Care Reviews															$0
															$0
															$0
															$0
6. Weichardt Appeals															$0
															$0
															$0
															$0
7. BIPA Appeals															$0
															$0
															$0
															$0
8. Grijalva Appeals															$0
															$0
															$0
															$0
9. EMTALA: 5-day Reviews															$0
															$0
															$0
															$0
10. EMTALA: 60-day Reviews															$0
															$0
															$0
															$0
11. HWDRG															$0
															$0
															$0
															$0
12. Pre-Admission and Admission HINN															$0
															$0
															$0
															$0
13. Sanction Activities															$0
															$0
															$0
															$0
14. Non-Review Activities															$0
															$0
															$0
															$0
15. Information Services															$0
															$0
															$0
															$0
16. QOC Referrals															$0
															$0
															$0
															$0
17. Transition															$0
															$0
															$0
															$0
23. YEAR 2 GRAND TOTAL:													$0
Year 3									5. Mileage Rate:
6. Area	7. Trip Title & Description/Purpose	8. # of Days per Trip	9. # of Nights per Trip	10. # of Travelers per Trip	11. Airfare per Person	12. Departing from:	13. Arriving to:	14. FTR Meals & Inc. Daily Rate	15. FTR Lodging per Night	16. # of Trips	17. Total # of miles per trip	18. # of Rental Cars Per Trip	19. Daily Rental Car Rate	20. Misc. Cost per Person per Trip (includes parking, gas, taxi, etc.)	21. TOTAL	22. Notes
5. Quality of Care Reviews															$0
															$0
															$0
															$0
6. Weichardt Appeals															$0
															$0
															$0
															$0
7. BIPA Appeals															$0
															$0
															$0
															$0
8. Grijalva Appeals															$0
															$0
															$0
															$0
9. EMTALA: 5-day Reviews															$0
															$0
															$0
															$0
10. EMTALA: 60-day Reviews															$0
															$0
															$0
															$0
11. HWDRG															$0
															$0
															$0
															$0
12. Pre-Admission and Admission HINN															$0
															$0
															$0
															$0
13. Sanction Activities															$0
															$0
															$0
															$0
14. Non-Review Activities															$0
															$0
															$0
															$0
15. Information Services															$0
															$0
															$0
															$0
16. QOC Referrals															$0
															$0
															$0
															$0
17. Transition															$0
															$0
															$0
															$0
23. YEAR 3 GRAND TOTAL:													$0
Year 4									5. Mileage Rate:
6. Area	7. Trip Title & Description/Purpose	8. # of Days per Trip	9. # of Nights per Trip	10. # of Travelers per Trip	11. Airfare per Person	12. Departing from:	13. Arriving to:	14. FTR Meals & Inc. Daily Rate	15. FTR Lodging per Night	16. # of Trips	17. Total # of miles per trip	18. # of Rental Cars Per Trip	19. Daily Rental Car Rate	20. Misc. Cost per Person per Trip (includes parking, gas, taxi, etc.)	21. TOTAL	22. Notes
5. Quality of Care Reviews															$0
															$0
															$0
															$0
6. Weichardt Appeals															$0
															$0
															$0
															$0
7. BIPA Appeals															$0
															$0
															$0
															$0
8. Grijalva Appeals															$0
															$0
															$0
															$0
9. EMTALA: 5-day Reviews															$0
															$0
															$0
															$0
10. EMTALA: 60-day Reviews															$0
															$0
															$0
															$0
11. HWDRG															$0
															$0
															$0
															$0
12. Pre-Admission and Admission HINN															$0
															$0
															$0
															$0
13. Sanction Activities															$0
															$0
															$0
															$0
14. Non-Review Activities															$0
															$0
															$0
															$0
15. Information Services															$0
															$0
															$0
															$0
16. QOC Referrals															$0
															$0
															$0
															$0
17. Transition															$0
															$0
															$0
															$0
23. YEAR 4 GRAND TOTAL:													$0
Year 5									5. Mileage Rate:
6. Area	7. Trip Title & Description/Purpose	8. # of Days per Trip	9. # of Nights per Trip	10. # of Travelers per Trip	11. Airfare per Person	12. Departing from:	13. Arriving to:	14. FTR Meals & Inc. Daily Rate	15. FTR Lodging per Night	16. # of Trips	17. Total # of miles per trip	18. # of Rental Cars Per Trip	19. Daily Rental Car Rate	20. Misc. Cost per Person per Trip (includes parking, gas, taxi, etc.)	21. TOTAL	22. Notes
5. Quality of Care Reviews															$0
															$0
															$0
															$0
6. Weichardt Appeals															$0
															$0
															$0
															$0
7. BIPA Appeals															$0
															$0
															$0
															$0
8. Grijalva Appeals															$0
															$0
															$0
															$0
9. EMTALA: 5-day Reviews															$0
															$0
															$0
															$0
10. EMTALA: 60-day Reviews															$0
															$0
															$0
															$0
11. HWDRG															$0
															$0
															$0
															$0
12. Pre-Admission and Admission HINN															$0
															$0
															$0
															$0
13. Sanction Activities															$0
															$0
															$0
															$0
14. Non-Review Activities															$0
															$0
															$0
															$0
15. Information Services															$0
															$0
															$0
															$0
16. QOC Referrals															$0
															$0
															$0
															$0
17. Transition															$0
															$0
															$0
															$0
23. YEAR 5 GRAND TOTAL:													$0

QIO ODC

OTHER DIRECT COST

BFCC QUALITY IMPROVEMENT ORGANIZATION 11th SOW BUSINESS PROPOSAL

CENTERS FOR MEDICARE & MEDICAID SERVICES

1. RFP Number	3. QIO Service Area:
0	0

2. Name and Address of QIO Organization	4: Proposed Contract Period
0	From:	12/31/99
0
0	To:	12/31/99

DETAIL COSTS YEAR 1	5	6	7	8	9	10	11	12	13	14	15	16	17	Total Projected Medicare - Year 1 Other Direct Costs
	Quality of Care Reviews	Weichardt Appeals	BIPA Appeals Cost	Grijalva Appeals Cost	EMTALA: 5-day Reviews Cost	EMTALA: 60-day Reviews Cost	HWDRG Cost	Pre-Admission and Admission HINN	Sanction Activities	Non-Review Activities	Information Services	QOC Referrals	Transition

d. Rent	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
e. Storage	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
f. Utilities	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
g. Maintenance & Repairs	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
h. Depreciation	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
i. Data Processing	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
j. Equipment Leasing & Rental	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
k. Office Supplies	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
l. Reproduction & Printing	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
m. Telephone	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
n. Postage & Express Mail	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
o. Consultants
p. Meeting & Conferences	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
q. Travel
r. Training	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
s. Garage & Parking Spaces	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
t. Dues & Subscriptions	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
u. Recruiting	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
v. Temporary Help	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
w. Continuing Education	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
x. Legal Fees	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
y. Accounting/Audit Fees	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
z. Board of Directors Fees	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
aa. Insurance	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
bb. Bank Charges	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
cc. Other - see attached	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0

TOTAL YEAR 1 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

DETAIL COSTS YEAR 2	5	6	7	8	9	10	11	12	13	14	15	16	17	Total Projected Medicare - Year 2 Other Direct Costs
	Quality of Care Reviews	Weichardt Appeals	BIPA Appeals Cost	Grijalva Appeals Cost	EMTALA: 5-day Reviews Cost	EMTALA: 60-day Reviews Cost	HWDRG Cost	Pre-Admission and Admission HINN	Sanction Activities	Non-Review Activities	Information Services	QOC Referrals	Transition

d. Rent	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
e. Storage	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
f. Utilities	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
g. Maintenance & Repairs	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
h. Depreciation	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
i. Data Processing	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
j. Equipment Leasing & Rental	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
k. Office Supplies	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
l. Reproduction & Printing	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
m. Telephone	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
n. Postage & Express Mail	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
o. Consultants
p. Meeting & Conferences	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
q. Travel
r. Training	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
s. Garage & Parking Spaces	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
t. Dues & Subscriptions	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
u. Recruiting	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
v. Temporary Help	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
w. Continuing Education	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
x. Legal Fees	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
y. Accounting/Audit Fees	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
z. Board of Directors Fees	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
aa. Insurance	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
bb. Bank Charges	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
cc. Other - see attached	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0

TOTAL YEAR 2	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
DETAIL COSTS YEAR 3	5	6	7	8	9	10	11	12	13	14	15	16	17		Total Projected Medicare - Year 3 Other Direct Costs
	Quality of Care Reviews	Weichardt Appeals	BIPA Appeals Cost	Grijalva Appeals Cost	EMTALA: 5-day Reviews Cost	EMTALA: 60-day Reviews Cost	HWDRG Cost	Pre-Admission and Admission HINN	Sanction Activities	Non-Review Activities	Information Services	QOC Referrals	Transition

d. Rent	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
e. Storage	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
f. Utilities	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
g. Maintenance & Repairs	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
h. Depreciation	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
i. Data Processing	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
j. Equipment Leasing & Rental	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
k. Office Supplies	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
l. Reproduction & Printing	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
m. Telephone	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
n. Postage & Express Mail	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
o. Consultants
p. Meeting & Conferences	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
q. Travel
r. Training	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
s. Garage & Parking Spaces	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
t. Dues & Subscriptions	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
u. Recruiting	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
v. Temporary Help	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
w. Continuing Education	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
x. Legal Fees	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
y. Accounting/Audit Fees	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
z. Board of Directors Fees	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
aa. Insurance	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
bb. Bank Charges	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0

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.