JD-J.13 CLIN 0003 Cost Proposal Templates OY1 12222014.xlsx

XLSX spreadsheet 303 KB Posted Dec 23, 2014

Attached to: DME MAC Jurisdiction D
Solicitation number: HHSM-500-2015-RFP-0101
Issued by: Department of Health and Human Services Centers for Medicare and Medicaid Services

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JD DME RFP Amendment 2 (December 23 2014) Attachment

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File	Type	Posted
JD-J.12 CLIN 0002 Cost Proposal Templates Base Period 12222014.xlsx	XLSX spreadsheet	Dec 23, 2014
JD-J.01.G VA_DME_MRA_SOW_12232014_clean.docx	DOCX document	Dec 23, 2014
JD_DME_Section_B-M_12232014-clean.docx	DOCX document	Dec 23, 2014
JD_DME_RFP_Amendment_2.pdf	PDF	Dec 23, 2014
JD-J.15 CLIN 0005 Cost Proposal Templates OY3 12222014.xlsx	XLSX spreadsheet	Dec 23, 2014
JD-J.18 Basis of Estimate 12232014 clean.xlsx	XLSX spreadsheet	Dec 23, 2014
JD-J.01.G VA_DME_MRA_SOW_12232014_redline.docx	DOCX document	Dec 23, 2014
JD-J.19 Assumptions 12232014 clean.docx	DOCX document	Dec 23, 2014
JD-J.14 CLIN 0004 Cost Proposal Templates OY2 12222014.xlsx	XLSX spreadsheet	Dec 23, 2014
Attachment 1 JD RFP Q A 12.23.14.xls	XLS spreadsheet	Dec 23, 2014
JD-J.19 Assumptions 12232014 redline.docx	DOCX document	Dec 23, 2014
JD-J.18 Basis of Estimate 12232014 redline.xlsx	XLSX spreadsheet	Dec 23, 2014
JD_DME_Section_B-M_12232014-redline.docx	DOCX document	Dec 23, 2014
JD-J.16 CLIN 0006 Cost Proposal Templates OY4 12222014.xlsx	XLSX spreadsheet	Dec 23, 2014
JD_DME_Section_B-M_(12.4.14)_AMENDMENT_1_clean.docx	DOCX document	Dec 4, 2014
JD_DME_SF-30_Amendment_1.pdf	PDF	Dec 4, 2014
JD_DME_Section_B-M_(12.4.14)_AMENDMENT_1_redline.pdf	PDF	Dec 4, 2014
JD_DME_RFP_11.24.14.pdf	PDF	Nov 24, 2014
Attachments_JD-J.01_through_JD-J.21.zip	ZIP file	Nov 24, 2014

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CLIN-0003

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

CLIN 0003

SLIN 0003AA

SLIN 0003AB

SLIN 0003AC

SLIN 0003AD

DME SERVICES/OPTION PERIOD

Total FTEs

Program Management (PM)

Medicare Integrity Program (MIP)

Support of Recovery Audit Program Operations

VA MRA Project (JD Only)

GRAND 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	0	$0
	0	$0	0	$0	0	$0	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	0	$0
	0	$0	0	$0	0	$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
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
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
Award Fee (at ______%)	$0	$0

TOTAL OTHER AFTER FEES $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

v 1-14 09/25/2014

&"Arial,Bold"&12HHSM-500-2015-RFP-0101&K000000 Durable Medical Equipment (DME) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10

Attachment J.13 SLIN = Sub Line Item Number &P

ODC Schedule

COST TEMPLATE - SAMPLE Attachment J-13
(Provide an ODC Spreadsheet for each CLIN Proposed)
CLIN 0003 DME SERVICES
Cost Element	TOTAL

Add costs by category

		0
		0
		0
		0
TOTAL ODCs	$0.00	0
		0
		0
V1.9 03202012		0
		0
		0
		0



		0
		0
		0
		0
		0
		0
		0

Attachment J.13 SLIN = Sub Line Item Number &P

Travel

COST TEMPLATE - SAMPLE Attachment J-13

TRAVEL SUMMARY

CLIN 0003

	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 )

	$ -	$ -	$ -	$ -
	$ -	$ -	$ -	$ -
	$ -	$ -	$ -	$ -	0	0.0
	$ -	$ -	$ -	$ -	0	0.0
	$ -	$ -	$ -	$ -	0	0.0
	$ -	$ -	$ -	$ -	0	0.0
	$ -	$ -	$ -	$ -	0	0.0
	$ -	$ -	$ -	$ -	0	0.0
	$ -	$ -	$ -	$ -	0	0.0
V1.9 03202012	$ -	$ -	$ -	$ -	0	0.0
	$ -	$ -	$ -	$ -	0	0.0
	$ -	$ -	$ -	$ -	0	0.0
	$ -	$ -	$ -	$ -	0	0.0
	$ -	$ -	$ -	$ -
	$ -	$ -	$ -	$ -		0.0
	$ -	$ -	$ -	$ -
	$ -	$ -	$ -	$ -		0.0
	$ -	$ -	$ -	$ -
	$ -	$ -	$ -	$ -		0.0

	TOTAL TRAVEL	$ -	0
			0
			0
			0
			0
Travel Assumptions:			0
			0

Attachment J.13 SLIN = Sub Line Item Number &P

SLIN-0003AA

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA

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

Jurisdiction Specific Requirements and Task Directives

FOIA Requests

Access to Systems

Bills/Claims Payment

Appeals

Reopenings

Paper Claims Adjustment Editing

Provider Customer Service Program

Public Relations

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	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	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	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	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	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	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	0	$0.00	$0	0	$0.00	$0	0	$0
V1.9 03202012	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	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	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	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
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
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 $0

SUBTOTAL ALL DIRECT COSTS $0 $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 $0

TOTAL OTHER BEFORE FEES $0 $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		$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 $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	$0

Attachment J.13 SLIN = Sub Line Item Number &P

C.3

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - 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
	0	$0.00	$0	0	$0.00	$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	$0.00	$0	0	$0.00	$0	0	$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
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
	0	$0.00	$0	0	$0.00	$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	$0.00	$0	0	$0.00	$0	0	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$0.00	$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	$0.00	$0	0	$0.00	$0	0	$0	0	$0
		$0.00	$0		$0.00	$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	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
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
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.13 SLIN = Sub Line Item Number &P

C.5

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - 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

Non-MSP Debt Collection

Non-MSP 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
	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
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
	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
	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
	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
	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
V1.9 03202012	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
	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
	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
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
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
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.13 SLIN = Sub Line Item Number &P

C.5.4

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - 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

C.5.4.7

DME SERVICES/OPTION PERIOD

Total FTEs

Identify Overpayment Cause

Applications for Extended Repayment Schedules

Limitation on Recoupment

Overpayment Related to Bankruptcy

Administrative Freeze Payments

Closed Bankruptcy Case

DMEPOS Suppliers with Surety Bonds

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
	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
	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
	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
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
	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
	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
V1.9 03202012	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
	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
		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0.00	$0	0	$0	0	$0
Subtotal Direct Labor	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

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

Travel			$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
Subcontractor Name		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
Subcontractor Name		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
Subcontractor Name		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

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

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

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

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

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

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

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

Attachment J.13 SLIN = Sub Line Item Number &P

D.1

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - D.1

D.1.1

D.1.2

D.1.3

D.1.4

D.1.5

D.1.6

D.1.8

DME SERVICES/OPTION PERIOD

Total FTEs

Medicare Front End Processing

General Claims Processing

Back-end Processing

Common Working File

DMEPOS Fee Schedule

ASCA Reviews

Environmental Health Hazards Pilot Program (Jurisdiction D only)

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	0	$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	0	$0	0	$0.00	$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	0	$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	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	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	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	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0	0	$0
V1.9 03202012	0	$0	0	$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	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	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0	0	$0
Subtotal Direct Labor	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

Total Direct Labor $0 $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	0	$0
Subcontractor Name		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
Subcontractor Name		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
Subcontractor Name		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
Other Direct Costs (insert & list applicable elements below)			$0		$0		$0		$0		$0		$0		$0		0		$0

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

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

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

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

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

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

Attachment J.13 SLIN = Sub Line Item Number &P

D.1.1

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - 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
	0	$0.00	$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	0	$0.00	$0	0	$0.00	$0	0	$0.00	$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
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
	0	$0.00	$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	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
V1.9 03202012	0	$0.00	$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	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
		$0.00	$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	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
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
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.13 SLIN = Sub Line Item Number &P

D.1.1.2

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AA - 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
	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	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
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
		$0.00	$0		$0.00	$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
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
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.13 SLIN = Sub Line Item Number &P

D.1.2.6

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - 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
	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
V1.9 03202012	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
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	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
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.13 SLIN = Sub Line Item Number &P

D.1.2

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - 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
	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
	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
	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
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
	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
	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
V1.9 03202012	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
	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
		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0		$0.00	$0	0	$0	0	$0
Subtotal Direct Labor	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

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

Travel			$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
Subcontractor Name		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
Subcontractor Name		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
Subcontractor Name		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

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

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

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

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

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

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

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

Attachment J.13 SLIN = Sub Line Item Number &P

D.1.3

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AA - D.1.3		D.1.3.1			D.1.3.2
DME SERVICES/OPTION PERIOD	Total FTEs	Generate & Deliver SPRs and MSNs			Transferring Coordination of Benefits Flat Files to the BCRC			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
	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	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
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
		$0.00	$0		$0.00	$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
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
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.13 SLIN = Sub Line Item Number &P

D.2

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - D.2

D.2.1

D.2.2

D.2.3

D.2.4

D.2.5

D.2.6

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

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	ERROR:#REF!	ERROR:#REF!
	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	ERROR:#REF!	ERROR:#REF!
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	ERROR:#REF!	ERROR:#REF!
	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	ERROR:#REF!	ERROR:#REF!
	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	ERROR:#REF!	ERROR:#REF!
	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	ERROR:#REF!	ERROR:#REF!
	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	ERROR:#REF!	ERROR:#REF!
V1.9 03202012	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	ERROR:#REF!	ERROR:#REF!
	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	ERROR:#REF!	ERROR:#REF!
		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0	ERROR:#REF!	ERROR:#REF!
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0	ERROR:#REF!	ERROR:#REF!

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0 $0 ERROR:#REF!

Total Direct Labor $0 $0 $0 $0 $0 $0 $0 ERROR:#REF!

Travel			$0		$0		$0		$0		$0		$0		$0		ERROR:#REF!
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	ERROR:#REF!	ERROR:#REF!
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	ERROR:#REF!	ERROR:#REF!
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	ERROR:#REF!	ERROR:#REF!
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	ERROR:#REF!	ERROR:#REF!
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	ERROR:#REF!	ERROR:#REF!
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	ERROR:#REF!	ERROR:#REF!
Total Subcontractor		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	ERROR:#REF!	ERROR:#REF!

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0 $0 $0 ERROR:#REF!

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0 ERROR:#REF!

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0 ERROR:#REF!

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0 $0 ERROR:#REF!

Base Fee (at ____%) $0 $0 $0 $0 $0 $0 $0 ERROR:#REF!

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0 $0 $0 ERROR:#REF!

GRAND TOTAL $0 $0 $0 $0 $0 $0 $0 ERROR:#REF!

Attachment J.13 SLIN = Sub Line Item Number &P

D.3

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AA - 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
	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	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
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
		$0.00	$0		$0.00	$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
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
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.13 SLIN = Sub Line Item Number &P

D.5

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - 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

MAC Satisfaction Indicator

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
	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	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0	0	$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	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$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	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
V1.9 03202012	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	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
		$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$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
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
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.13 SLIN = Sub Line Item Number &P

D.5.2

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - 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	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$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	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$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	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
V1.9 03202012	0	$0.00	$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	$0.00	$0	0	$0	0	$0
		$0.00	$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	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
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
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.13 SLIN = Sub Line Item Number &P

D.5.3

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - D.5.3

D.5.3.1

D.5.3.2

D.5.3.3

D.5.3.4

DME SERVICES/OPTION PERIOD

Total FTEs

Interactive Voice Response

Web Technology

Provider Listserv

Provider Internet Portal

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
	0	$0.00	$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	$0.00	$0	0	$0	0	$0
	0	$0.00	$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	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0
V1.9 03202012	0	$0.00	$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	$0.00	$0	0	$0	0	$0
		$0.00	$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	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
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
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.13 SLIN = Sub Line Item Number &P

D.6

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - D.6

D.6.1

D.6.2

D.6.3

D.6.4

DME SERVICES/OPTION PERIOD

Total FTEs

Medicare Beneficiary Ombudsman

Regional Office Liason

Responding to Complex Beneficiary Inquiries

Responses to Congressional Inquiries

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	0	$0.00	$0	0	$0	0	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$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	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0
		$0.00	$0	0	$0		$0.00	$0	0	$0	0	$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
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
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.13 SLIN = Sub Line Item Number &P

D.6.2

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AA - D.6.2		D.6.2.1.
DME SERVICES/OPTION PERIOD	Total FTEs	Urgent Need Regional Office Casework
		Hours	Rates	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$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
	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
		$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0	$0

Fringe Benefits (at ____%) $0 $0

Total Direct Labor $0 $0

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

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

SUBTOTAL ALL DIRECT COSTS $0 $0

Indirect Costs (at ______ %) $0 $0

TOTAL OTHER BEFORE FEES $0 $0

Base Fee (at ____%) $0 $0

TOTAL OTHER AFTER FEES $0 $0

GRAND TOTAL $0 $0

Attachment J.13 SLIN = Sub Line Item Number &P

D.6.4

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AA - D.6.4		D.6.4.1
DME SERVICES/OPTION PERIOD	Total FTEs	Congressional Outreach and Education
		Hours	Rates	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$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
	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
		$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0	$0

Fringe Benefits (at ____%) $0 $0

Total Direct Labor $0 $0

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

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

SUBTOTAL ALL DIRECT COSTS $0 $0

Indirect Costs (at ______ %) $0 $0

TOTAL OTHER BEFORE FEES $0 $0

Base Fee (at ____%) $0 $0

TOTAL OTHER AFTER FEES $0 $0

GRAND TOTAL $0 $0

Attachment J.13 SLIN = Sub Line Item Number &P

SLIN-0003AB

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AB

C.5

C.7

C.8

C.9

D.3

D.5

E.1

E.2

E.3

E.4

E.5

E.6

DME SERVICES/OPTION PERIOD

Total FTEs

FM of Trust Fund Dollars

Jurisdiction Specific Requirements and 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

HEAT Initiative

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
V1.9 03202012	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	$0.00	$0	0	$0

Fringe Benefits (at ____%) $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

Travel			$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
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
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
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
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
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
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

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

Indirect Costs (at ______ %) $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

Base Fee (at ____%)	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0		$0
Award Fee (at ______%)															$0	$0
													$0
TOTAL OTHER AFTER FEES	$0	$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

V1-14 09122014.xls

Attachment J.13 SLIN = Sub Line Item Number &P

C.5 (2)

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AB - 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
	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
V1.9 03202012	0	$0	0	$0
	0	$0	0	$0
	0	$0	0	$0
Subtotal Direct Labor	0	$0	0	$0

Fringe Benefits (at ____%) $0 $0

Total Direct Labor $0 $0

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

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

SUBTOTAL ALL DIRECT COSTS $0 $0

Indirect Costs (at ______ %) $0 $0

TOTAL OTHER BEFORE FEES $0 $0

Base Fee (at ____%) $0 $0

TOTAL OTHER AFTER FEES $0 $0

GRAND TOTAL $0 $0

Attachment J.13 SLIN = Sub Line Item Number &P

C.5.4 (2)

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AB - 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
	0	$0.00	$0	0	$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
	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
V1.9 03202012	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0
		$0.00	$0	0	$0
Subtotal Direct Labor	0		$0	0	$0

Fringe Benefits (at ____%) $0 $0

Total Direct Labor $0 $0

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

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

SUBTOTAL ALL DIRECT COSTS $0 $0

Indirect Costs (at ______ %) $0 $0

TOTAL OTHER BEFORE FEES $0 $0

Base Fee (at ____%) $0 $0

TOTAL OTHER AFTER FEES $0 $0

GRAND TOTAL $0 $0

Attachment J.13 SLIN = Sub Line Item Number &P

D.3(2)

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AB - D.3		D.3.2

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.