JD-J.16 CLIN 0006 Cost Proposal Templates OY4 12222014.xlsx

XLSX spreadsheet 83 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-J.13 CLIN 0003 Cost Proposal Templates OY1 12222014.xlsx	XLSX spreadsheet	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_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-0006

COST TEMPLATE - SAMPLE Attachment J-16

(Provide a cost spreadsheet for each CLIN proposed)

CLIN 0006

SLIN 0006AA

SLIN 0006AB

SLIN 0006AC

SLIN 0006AD

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&KFF0000 &K000000Durable Medical Equipment (D&K000000ME) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10

Attachment J.16 SLIN = Sub Line Item Number &P

ODC Schedule

COST TEMPLATE - SAMPLE Attachment J-16
(Provide an ODC Spreadsheet for each CLIN Proposed)
CLIN 0006 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

&K000000Durable Medical Equipment (D&K000000ME) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10

Attachment J.16 SLIN = Sub Line Item Number &P

Travel

COST TEMPLATE - SAMPLE Attachment J-16

TRAVEL SUMMARY

CLIN 0006

	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

&K000000Durable Medical Equipment (D&K000000ME) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10

Attachment J.16 SLIN = Sub Line Item Number &P

SLIN-0006AA

COST TEMPLATE - SAMPLE Attachment J-16

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0006AA

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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00	$0	0	$0.00	$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	$0.00	$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	$0.00	$0	0	$0.00	$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	$0.00	$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	$0.00	$0	0	$0.00	$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	$0.00	$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	$0.00	$0	0	$0.00	$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	$0.00	$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	$0.00	$0	0	$0.00	$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	$0.00	$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	$0.00	$0	0	$0.00	$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	$0.00	$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	$0.00	$0	0	$0.00	$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	$0.00	$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	$0.00	$0	0	$0.00	$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	$0.00	$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	$0.00	$0	0	$0.00	$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

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

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

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

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

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

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

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

&K000000Durable Medical Equipment (D&K000000ME) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10

Attachment J.16 SLIN = Sub Line Item Number &P

SLIN-0006AB

COST TEMPLATE - SAMPLE Attachment J-16

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0006AB

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

Provider Customer Service 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	$0.00	$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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$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

&K000000Durable Medical Equipment (D&K000000ME) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10

Attachment J.16 SLIN = Sub Line Item Number &P

SLIN-0006AC

COST TEMPLATE - SAMPLE Attachment J-16

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0006AC

C.5.6.1

C.5.6.2

C.5.6.3

C.5.6.4

C.5.6.5

DME SERVICES/OPTION PERIOD

Total FTEs

Adjustment of Recovery Auditor Selected Claims

Handling Underpayments and Overpayments Identified by the Recovery Auditor

Appeals of Recovery Auditor Adjusted Claims

Reporting for Recovery Audit Program Support Operations

Other Recovery Audit Program Support Activities

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

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0.00 ERROR:#REF!

Total Direct Labor $0 $0 $0 $0 $0 $0.00 ERROR:#REF!

Travel			$0		$0		$0		$0		$0		$0.00		ERROR:#REF!
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	ERROR:#REF!	ERROR:#REF!
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	ERROR:#REF!	ERROR:#REF!
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	ERROR:#REF!	ERROR:#REF!
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	ERROR:#REF!	ERROR:#REF!
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	ERROR:#REF!	ERROR:#REF!
Subcontractor Name		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	ERROR:#REF!	ERROR:#REF!
Total Subcontractor		0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	ERROR:#REF!	ERROR:#REF!

Other Direct Costs (insert & list applicable elements below) $0 $0 $0 $0 $0 $0.00 ERROR:#REF!

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0.00 ERROR:#REF!

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0.00 ERROR:#REF!

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0 $0.00 ERROR:#REF!

Base Fee (at ____%)	$0	$0	$0	$0	$0	$0.00	ERROR:#REF!
Award Fee (at ______%)
							ERROR:#REF!
TOTAL OTHER AFTER FEES	$0	$0	$0	$0	$0	$0.00
							ERROR:#REF!
Complementary Credits
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	$0.00

&K000000Durable Medical Equipment (D&K000000ME) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10

Attachment J.16 SLIN = Sub Line Item Number &P

SLIN-0006AD

COST TEMPLATE - SAMPLE Attachment J-16
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0006AD		C.7.1
DME Services	Total FTEs	VA MRA Project (JD Only)
		Hours	Rates	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
V1.9 03202012	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
Subtotal Direct Labor	0		$0

Fringe Benefits (at ____%) $0

Total Direct Labor $0

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

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

SUBTOTAL ALL DIRECT COSTS $0

Indirect Costs (at ______ %) $0

TOTAL OTHER BEFORE FEES $0

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

TOTAL OTHER AFTER FEES $0

Complementary Credits
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

&K000000Durable Medical Equipment (D&K000000ME) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10

Attachment J.16 SLIN = Sub Line Item Number &P

Sheet1

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.