1_SF_33_pages_1-23_5-19-15.pdf

HT9402-15-R-0005

SOLICITATION, OFFER AND AWARD

4. TYPE OF SOLICITATION2. CONTRACT NUMBER 3. SOLICITATION NUMBER

7. ISSUED BY CODE 8. ADDRESS OFFER TO (If other than Item 7)

ORDER UNDER DPAS (15 CFR 700)

6. REQUISITION/PURCHASE NUMBER

NOTE: In sealed bid solicitations "offer" and "offeror" mean "bid" and "bidder".

NEGOTIATED (RFP)

SEALED BID (IFB)

5. DATE ISSUED

1. THIS CONTRACT IS A RATED RATING PAGE OF PAGES

DO-C9 1 127

C. E-MAIL ADDRESS

EXT.NUMBERAREA CODE

B. TELEPHONE (NO COLLECT CALLS)A. NAME

10. FOR

INFORMATION

CALL:

CAUTION: LATE Submissions, Modifications, and Withdrawals: See Section L, Provision No. 52.214-7 or 52.215-1. All offers are subject to all terms and conditions contained in this solicitation.

(Date)(Hour) local timeuntildepository located in copies for furnishing the supplies or services in the Schedule will be received at the place specified in Item 8, or if hand carried, in the

SOLICITATION

9. Sealed offers in original and

PART IV - REPRESENTATIONS AND INSTRUCTIONS

OTHER STATEMENTS OF OFFERORS

EVALUATION FACTORS FOR AWARD

INSTRS., CONDS., AND NOTICES TO OFFERORS

REPRESENTATIONS, CERTIFICATIONS AND

LIST OF ATTACHMENTS

CONTRACT CLAUSES

PART III - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACH.

I

J

K

L

M SPECIAL CONTRACT REQUIREMENTS

CONTRACT ADMINISTRATION DATA

DELIVERIES OR PERFORMANCE

INSPECTION AND ACCEPTANCE

PACKAGING AND MARKING

DESCRIPTION/SPECS./WORK STATEMENT

SUPPLIES OR SERVICES AND PRICES/COSTS

SOLICITATION/CONTRACT FORM

PART II - CONTRACT CLAUSESPART I - THE SCHEDULE

H

G

F

E

D

C

B

A

SEC. DESCRIPTION PAGE(S) (X) DESCRIPTION SEC. (X)

11. TABLE OF CONTENTS

18. OFFER DATE17. SIGNATURE

SUCH ADDRESS IN SCHEDULE.

IS DIFFERENT FROM ABOVE - ENTER

15C. CHECK IF REMITTANCE ADDRESS

EXT.NUMBERAREA CODE

15B. TELEPHONE NUMBER

(Type or print)AND

ADDRESS

OF

OFFEROR

CODE FACILITY

16. NAME AND TITLE OF PERSON AUTHORIZED TO SIGN OFFER15A. NAME

DATEAMENDMENT NO.DATEAMENDMENT NO.

and related documents numbered and dated):

amendments to the SOLICITATION for offerors

(The offeror acknowledges receipt of

14. ACKNOWLEDGEMENT OF AMENDMENTS

CALENDAR DAYS (%)30 CALENDAR DAYS (%)20 CALENDAR DAYS (%)10 CALENDAR DAYS (%)

(See Section I, Clause No. 52.232.8)

13. DISCOUNT FOR PROMPT PAYMENT

designated point(s), within the time specified in the schedule.

by the offeror) from the date for receipt of offers specified above, to furnish any or all items upon which prices are offered at the price set opposite each item, delivered at the

12. In compliance with the above, the undersigned agrees, if this offer is accepted within ____180__________ calendar days (60 calendar days unless a different period is inserted

NOTE: Item 12 does not apply if the solicitation includes the provisions at 52.214-16, Minimum Bid Acceptance Period.

OFFER (Must be fully completed by offeror)

IMPORTANT - Award will be made on this Form, or on Standard Form 26, or by other authorized official written notice.

28. AWARD DATE

(Signature of Contracting Officer)

27. UNITED STATES OF AMERICA

25. PAYMENT WILL BE MADE BY

26. NAME OF CONTRACTING OFFICER (Type or print)

CODE 24. ADMINISTERED BY (If other than Item 7)

ITEM

(4 copies unless otherwise specified)

23. SUBMIT INVOICES TO ADDRESS SHOWN IN

41 U.S.C. 253 (c) ( 10 U.S.C. 2304 (c) (

22. AUTHORITY FOR USING OTHER THAN FULL AND OPEN COMPETITION:

21. ACCOUNTING AND APPROPRIATION20. AMOUNT19. ACCEPTED AS TO ITEMS NUMBERED

AWARD (To be completed by government)

CODE

X

HT9402

DEFENSE HEALTH AGENCY

DEFENSE HEALTH AGENCY-AURORA

16401 E CENTRETECH PARKWAY

AURORA CO 80011

1200 MS 06/19/2015

Cynthia Turk 303 cynthia.d.turk.civ@mail.mil

676-3534

X

X

X

X

X

X

X

X

X

X

X

X

X

PAGE(S)

MARGARET A. ZANCANELLA

AUTHORIZED FOR LOCAL REPRODUCTION

Previous edition is unusable

STANDARD FORM 33 (Rev. 9-97)

Prescribed by GSA - FAR (48 CFR) 53.214(c)

2-27 1-22 1-3 1-6 1-12

1-11

1-12

1-21

1-10

303-676-3451

MARGARET.A.ZANCANELLA.civ@mail.mil

MZancanella Typewritten Text

MZancanella Typewritten Text

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

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(A) (B) (C) (D) (E) (F)

TRICARE Quality Monitoring Contract (TQMC) This is an Indefinite Delivery/Indefinite Quantity (IDIQ) Advisory & Assistance Services (A&AS)Contract in accordance with FAR 52.216-1, Contract Type, for the scheduled period and for Option Years 1-5 if exercised. All services shall be ordered in accordance with Sections G and I, FAR Clauses 52.216-18, Ordering;

52.216-19, Order Limitations; and 52.216-22, Indefinite Quantity; and DFARS Clause 252.216-7006, Ordering.

Guaranteed Minimum: $50,000.00 Contract Ceiling: $65 million.

Period of Performance: 08/01/2015 to 09/30/2020

Section B, Supplies or Services and Prices/costs.

TQMC Base Period Period of Performance: Date of Award to 09/30/2015.

0001 Transition-in. Section C paragraph 6.2.1. 1 LO ________ ________ Firm-fixed-price (FFP).

0002 Deliverables (DD Forms 1423-1, Contract Data 1 LO NSP Requirements List (CDRLS)) (Not Separately Priced)

TQMC Option Year 1.

THE SCHEDULE QUANTITIES ARE ESTIMATED EXCEPT FOR

CLINs 1001, 1002, 1003, 1023, 1024, 1025, 1026 and 1027.

Option Year 1 Period of Performance: 10/01/2015 to 09/30/2016.

1001 Option Year 1 Health Plan Clinical Quality 12 MO ________ ________ Measures (Section C paragraph 6.3.1) FFP per month.

1002 Option Year 1 Annual NCQA HEDIS® Validation Audit 1 LO ________ ________ (Section C paragraph 6.3.1.4) FFP.

Continued ...

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1003 Option Year 1 National Hospital Quality Measures 4 EA ________ ________ (NHQM) (Section C paragraph 6.3.2) FFP per quarter.

1004 Option Year 1 Joint Commission ORYX® Hospital Quality Measures

Informational CLIN

1004AA Option Year 1 Joint Commission ORYX® Chart 95,000 EA ________ ________ Abstraction (Section C paragraph 6.3.3.1) Fixed price per chart. Not to exceed:

1004AB Option Year 1 Joint Commission ORYX® Data 4 EA ________ ________ Submission (Section C paragraphs 6.3.3.2-6.3.3.7) FFP per quarterly submission.

1005 Option Year 1 Institute for Healthcare 14,040 EA ________ ________ Improvement (IHI) Global Trigger Tool (GTT) (Section C paragraph 6.3.4 ) Fixed price per chart. Not to exceed:

1006 Option Year 1 Reviews of Behavioral Health 80 EA ________ ________ Facility Applications for Certification (Section C paragraph 6.4 ) Fixed price per application.

Not to exceed:

1007 Option Year 1 Onsite Reviews of Behavioral Health 20 EA Facility Certifications (Section C paragraph 6.4 ) Fixed price per review. Not to exceed:

1008 Option Year 1 Quality and Utilization Reviews 6,500 EA ________ ________ (Purchased care) (Section C paragraph 6.5.1) Fixed price per chart. Not to exceed.

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1009 Option Year 1 Medical Necessity Reconsideration 400 EA ________ ________ Reviews (Second Level Appeals) (Section C paragraph 6.5.2) Fixed price per review. Not to exceed:

1010 Option Year 1 Appeals & Hearings Internal Reviews 6 EA ________ ________ (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:

1011 Option Year 1 Appeals & Hearings Urgent External 16 EA ________ ________ Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:

1012 Option Year 1 Appeals & Hearings Routine External 300 EA ________ ________ Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:

1013 Option Year 1 Appeals & Hearings Support (Section C, paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per hour.

Informational CLIN

1013AA Option Year 1 Pre-Hearing Preparations. Fixed 10 HR ________ ________ price per hour. Not to exceed:

1013AB Option Year 1 Hearing Appearance. Fixed price 50 HR ________ ________ per hour. Not to exceed:

1013AC Option Year 1 Post Hearing. Fixed price per hour. 10 HR ________ ________ Not to exceed:

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1013AD Option Year 1 Transcription. Fixed price per 5 HR ________ ________ hour. Not to exceed:

1014 Option Year 1 Transition Assistance Management 5 EA ________ ________ Program (TAMP) Benefit Extension Second-Level Reviews (Section C paragraph 6.5.4) Fixed price per review. Not to exceed:

1015 Option Year 1 Standard of Care (SOC) Reviews 300 EA ________ ________ (Section C paragraph 6.5.5) (Direct Care) Fixed price per review. Not to exceed:

1016 Option Year 1 Quality of Care (QOC) Reviews 6 EA ________ ________ (Section C paragraph 6.5.6) Fixed price per review. Not to exceed:

1017 Option Year 1 Clinical Quality Improvement 500 HR ________ ________ Administrative Studies(Section C paragraph 6.6.1) Fixed price per hour. Not to exceed:

1018 Option Year 1 Clinical Quality Improvement 4,000 EA ________ ________ Abstraction Studies(Fewer than 2,000 Charts) (Section C paragraph 6.6.1) Fixed price per chart. Not to exceed:

1019 Option Year 1 Clinical Quality Improvement 6,000 EA ________ ________ Abstraction Studies (2000 or more charts) (Section C paragraph 6.6.1) Fixed price per chart. Not to exceed:

1020 Option Year 1 Annual Autism Care Demonstration 2,000 EA ________ ________ (ACD) Study (Section C paragraph 6.6.2) Fixed price per chart. Not to exceed:

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1021 Option Year 1 Long Assessment of Evolving 6 EA ________ ________ Practices, Devices, Medicines, Treatements, and Procedures (Section C paragraph 6.7) Fixed price per assessment. Not to exceed:

1022 Option Year 1 Short Assessment of Evolving 6 EA ________ ________ Practices, Devices, Medicines, Treatements, and Procedures (Section C paragraph 6.7) Fixed price per assessment. Not to exceed:

1023 Option Year 1 Quality Communcations (Section C 12 MO ________ ________ paragraph 6.8) FFP per month.

1024 Option Year 1 Meeting Attendance (Section C 7,500 EA $1.00 $7,500.00 paragraph 6.1.13) Cost-reimbursed (no fee) for each meeting attendance. Not to exceed:

1025 Option Year 1 Travel (Section C paragraph 9.0) 100,000 EA $1.00 $100,000.00 Cost-reimbursed (no fee) for travel. Not to exceed:

1026 Option Year 1 Deliverables (DD Forms 1423-1, 1 LO NSP Contract Data Requirements List (CDRLS)). Not separately priced (Not Separately Priced)

1027 Option Year 1 Transition-out (Section C, 1 LO ________ ________ paragraph 6.2.2) Firm, fixed-price.

TQMC Option Year 2.

THE SCHEDULE QUANTITIES ARE ESTIMATED EXCEPT FOR

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CLINs 2001, 2002, 2003, 2023, 2024, 2025, 2026 and 2027.

Option Year 2 Period of Performance: 10/01/2016 to 09/30/2017.

2001 Option Year 2 Health Plan Clinical Quality 12 MO ________ ________ Measures (Section C paragraph 6.3.1) FFP per month.

2002 Option Year 2 Annual NCQA HEDIS® Validation Audit 1 LO ________ ________ (Section C paragraph 6.3.1.4) FFP.

2003 Option Year 2 National Hospital Quality Measures 4 EA ________ ________ (NHQM) (Section C paragraph 6.3.2) FFP per quarter.

2004 Option Year 2 Joint Commission ORYX® Hospital Quality Measures

Informational CLIN

2004AA Option Year 2 Joint Commission ORYX® Chart 95,000 EA ________ ________ Abstraction (Section C paragraph 6.3.3.1) Fixed price per chart. Not to exceed:

2004AB Option Year 2 Joint Commission ORYX® Data 4 EA ________ ________ Submission (Section C paragraphs 6.3.3.2-6.3.3.7) FFP per quarterly submission.

2005 Option Year 2 Institute for Healthcare 14,040 EA ________ ________ Improvement (IHI) Global Trigger Tool (GTT) (Section C paragraph 6.3.4 ) Fixed price per chart. Not to exceed:

2006 Option Year 2 Reviews of Behavioral Health 80 EA ________ ________ Facility Applications for Certification (Section

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C paragraph 6.4 ) Fixed price per application.

Not to exceed:

2007 Option Year 2 Onsite Reviews of Behavioral Health 20 EA ________ ________ Facility Certifications (Section C paragraph 6.4 ) Fixed price per review. Not to exceed:

2008 Option Year 2 Quality and Utilization Reviews 6,500 EA ________ ________ (Purchased care) (Section C paragraph 6.5.1) Fixed price per chart. Not to exceed:

2009 Option Year 2 Medical Necessity Reconsideration 400 EA ________ ________ Reviews (Second Level Appeals) (Section C paragraph 6.5.2) Fixed price per review. Not to exceed:

2010 Option Year 2 Appeals & Hearings Internal Reviews 6 EA ________ ________ (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:

2011 Option Year 2 Appeals & Hearings Urgent External 16 EA ________ ________ Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:

2012 Option Year 2 Appeals & Hearings Routine External 300 EA ________ ________ Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:

2013 Option Year 2 Appeals & Hearings Support.

(Section C, paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per hour.

Informational CLIN

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2013AA Option Year 2 Pre-Hearing Preparations. Fixed 10 HR ________ ________ price per hour. Not to exceed:

2013AB Option Year 2 Hearing Appearance. Fixed price 50 HR ________ ________ per hour. Not to exceed:

2013AC Option Year 2 Post Hearing. Fixed price per hour. 10 HR ________ ________ Not to exceed:

2013AD Option Year 2 Transcription. Fixed price per 5 HR ________ ________ hour. Not to exceed:

2014 Option Year 2 Transition Assistance Management 5 EA ________ ________ Program (TAMP) Benefit Extension Second-Level Reviews (Section C paragraph 6.5.4) Fixed price per review. Not to exceed:

2015 Option Year 2 Standard of Care (SOC) Reviews 300 EA ________ ________ (Section C paragraph 6.5.5) (Direct Care) Fixed price per review. Not to exceed:

2016 Option Year 2 Quality of Care (QOC) Reviews 6 EA ________ ________ (Section C paragraph 6.5.6) Fixed price per review. Not to exceed:

2017 Option Year 2 Clinical Quality Improvement 500 HR ________ ________ Administrative Studies(Section C paragraph 6.6.1) Fixed price per hour. Not to exceed:

2018 Option Year 2 Clinical Quality Improvement 4,000 EA ________ ________ Abstraction Studies (Fewer than 2,000 charts) (Section C paragraph 6.6.1) Fixed price per

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(A) (B) (C) (D) (E) (F) chart. Not to exceed:

2019 Option Year 2 Clinical Quality Improvement 6,000 EA ________ ________ Abstraction Studies(2000 or more charts) (Section C paragraph 6.6.1) Fixed price per chart. Not to exceed:

2020 Option Year 2 Annual Autism Care Demonstration 2,000 EA ________ ________ (ACD) Studies (Section C paragraph 6.6.2) Fixed price per chart. Not to exceed:

2021 Option Year 2 Long Assessment of Evolving 6 EA ________ ________ Practices, Devices, Medicines, Treatements, and Procedures (Section C paragraph 6.7) Fixed price per assessment. Not to exceed:

2022 Option Year 2 Short Assessment of Evolving 6 EA ________ ________ Practices, Devices, Medicines, Treatements, and Procedures (Section C paragraph 6.7) Fixed price per assessment. Not to exceed:

2023 Option Year 2 Quality Communcations (Section C 12 MO ________ ________ paragraph 6.8) FFP per month.

2024 Option Year 2 Meeting Attendance (Section C 7,500 EA $1.00 $7,500.00 paragraph 6.1.13) Cost-reimbursed (no fee) for each meeting attendance. Not to exceed:

2025 Option Year 2 Travel (Section C paragraph 9.0) 75,000 EA $1.00 $75,000.00 Cost-reimbursed (no fee) for travel. Not to exceed:

2026 Option Year 2 Deliverables (DD Forms 1423-1, 1 LO NSP Contract Data Requirements List (CDRLS))

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Not Separately Priced (Not Separately Priced)

2027 Option Year 2 Transition-out (Section C paragraph 1 LO ________ ________

6.2.2)FFP.

TQMC Option Year 3.

THE SCHEDULE QUANTITIES ARE ESTIMATED EXCEPT FOR

CLINs 3001, 3002, 3003, 3023, 3024, 3025, 3026 and 3027.

Option Year 3 Period of Performance: 10/01/2018 to 09/30/2019.

3001 Option Year 3 Health Plan Clinical Quality 12 MO ________ ________ Measures (Section C paragraph 6.3.1) FFP per month.

3002 Option Year 3 Annual NCQA HEDIS® Validation Audit 1 LO ________ ________ (Section C paragraph 6.3.1.4) FFP.

3003 Option Year 3 National Hospital Quality Measures 4 EA ________ ________ (NHQM) (Section C paragraph 6.3.2) FFP per quarter.

3004 Option Year 3 Joint Commission ORYX® Hospital Quality Measures

Informational CLIN

3004AA Option Year 3 Joint Commission ORYX® Chart 95,000 EA ________ ________ Abstraction (Section C paragraph 6.3.3.1) Fixed price per chart. Not to exceed:

3004AB Option Year 3 Joint Commission ORYX® Data 4 EA ________ ________

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Submission (Section C paragraphs 6.3.3.2-6.3.3.7) Fixed price per quarterly submission.

3005 Option Year 3 Institute for Healthcare 14,040 EA ________ ________ Improvement (IHI) Global Trigger Tool (GTT) (Section C paragraph 6.3.4 ) Fixed price per chart. Not to exceed:

3006 Option Year 3 Reviews of Behavioral Health 80 EA ________ ________ Facility Applications for Certification (Section C paragraph 6.4 ) Fixed price per application.

Not to exceed:

3007 Option Year 3 Onsite Reviews of Behavioral Health 20 EA ________ ________ Facility Certifications (Section C paragraph 6.4 ) Fixed price per review. Not to exceed:

3008 Option Year 3 Quality and Utilization Reviews 6,500 EA ________ ________ (Purchased care) (Section C paragraph 6.5.1) Fixed price per chart. Not to exceed:

3009 Option Year 3 Medical Necessity Reconsideration 400 EA ________ ________ Reviews (Second Level Appeals) (Section C paragraph 6.5.2) Fixed price per review. Not to exceed:

3010 Option Year 3 Appeals & Hearings Internal Reviews 6 EA ________ ________ (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:

3011 Option Year 3 Appeals & Hearings Urgent External 16 EA ________ ________ Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:

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3012 Option Year 3 Appeals & Hearings Routine External 300 EA ________ ________ Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:

3013 Option Year 3 Appeals & Hearings Support.

(Section C, paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per hour.

Informational CLIN

3013AA Option Year 3 Pre-Hearing Preparations. Fixed 10 HR ________ ________ price per hour. Not to exceed:

3013AB Option Year 3 Hearing Appearance. Fixed price 50 HR ________ ________ per hour. Not to exceed:

3013AC Option Year 3 Post Hearing. Fixed price per hour. 10 HR ________ ________ Not to exceed:

3013AD Option Year 3 Transcription. Fixed price per 5 HR ________ ________ hour. Not to exceed:

3014 Option Year 3 Transition Assistance Management 5 EA ________ ________ Program (TAMP) Benefit Extension Second-Level Reviews (Section C, paragraph 6.5.4) Fixed price per review. Not to exceed:

3015 Option Year 3 Standard of Care (SOC) Reviews 300 EA ________ ________ (Section C paragraph 6.5.5) (Direct Care) Fixed price per review. Not to exceed:

3016 Option Year 3 Quality of Care (QOC) Reviews 6 EA ________ ________

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(Section C paragraph 6.5.6) Fixed price per review. Not to exceed:

3017 Option Year 3 Clinical Quality Improvement 500 HR ________ ________ Administrative Studies (Section C paragraph 6.6.1) Fixed price per hour. Not to exceed:

3018 Option Year 3 Clinical Quality Improvement 4,000 EA ________ ________ Abstraction Studies (Fewer than 2,000 charts) (Section C paragraph 6.6.1) Fixed price per chart. Not to exceed:

3019 Option Year 3 Clinical Quality Improvement 6,000 EA ________ ________ Abstraction Studies(2000 or more charts) (Section C paragraph 6.6.1) Fixed price per chart. Not to exceed:

3020 Option Year 3 Annual Autism Care Demonstration 2,000 EA ________ ________ (ACD) Studies (Section C paragraph 6.6.2) Fixed price per chart. Not to exceed:

3021 Option Year 3 Long Assessment of Evolving 6 EA ________ ________ Practices, Devices, Medicines, Treatements, and Procedures (Section C paragraph 6.7) Fixed price per assessment. Not to exceed:

3022 Option Year 3 Short Assessment of Evolving 6 EA ________ ________ Practices, Devices, Medicines, Treatements, and Procedures (Section C paragraph 6.7) Fixed price per assessment. Not to exceed:

3023 Option Year 3 Quality Communcations (Section C 12 MO ________ ________ paragraph 6.8) FFP per month.

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3024 Option Year 3 Meeting Attendance (Section C 7,500 EA $1.00 $7,500.00 paragraph 6.1.13) Cost-reimbursed (no fee) for each meeting attendance. Not to exceed:

3025 Option Year 3 Travel (Section C paragraph 9.0) 50,000 EA $1.00 $50,000.00 Cost-reimbursed (no fee) for travel. Not to exceed:

3026 Option Year 3 Deliverables (DD Forms 1423-1, 1 LO NSP Contract Data Requirements List (CDRLS)) (Not Separately Priced)

3027 Option Year 3 Transition-out (Section C, 1 LO ________ ________ paragraph 6.2.2)FFP.

TQMC Option Year 4.

THE SCHEDULE QUANTITIES ARE ESTIMATED EXCEPT FOR

CLINs 4001, 4002, 4003, 4023, 4024, 4025, 4026 and 4027.

Option Year 4 Period of Performance: 10/01/2018 to 09/30/2019.

4001 Option Year 4 Health Plan Clinical Quality 12 MO ________ ________ Measures (Section C paragraph 6.3.1) FFP per month.

4002 Option Year 4 Annual NCQA HEDIS® Validation Audit 1 LO ________ ________ (Section C paragraph 6.3.1.4) FFP.

4003 Option Year 4 National Hospital Quality Measures 4 EA ________ ________ (NHQM) (Section C paragraph 6.3.2) FFP per quarter.

4004 Option Year 4 Joint Commission ORYX® Hospital

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Quality Measures

Informational CLIN

4004AA Option Year 4 Joint Commission ORYX® Chart 95,000 EA ________ ________ Abstraction (Section C paragraph 6.3.3.1) Fixed price per chart. Not to exceed:

4004AB Option Year 4 Joint Commission ORYX® Data 4 EA ________ ________ Submission (Section C paragraphs 6.3.3.2-6.3.3.7) Fixed price per quarterly submission.

4005 Option Year 4 Institute for Healthcare 14,040 EA ________ ________ Improvement (IHI) Global Trigger Tool (GTT) (Section C paragraph 6.3.4 ) Fixed price per chart. Not to exceed:

4006 Option Year 4 Reviews of Behavioral Health 80 EA ________ ________ Facility Applications for Certification (Section C paragraph 6.4 ) Fixed price per application.

Not to exceed:

4007 Option Year 4 Onsite Reviews of Behavioral Health 20 EA ________ ________ Facility Certifications (Section C paragraph 6.4 ) Fixed price per review. Not to exceed:

4008 Option Year 4 Quality and Utilization Reviews 6,500 EA ________ ________ (Purchased care) (Section C paragraph 6.5.1) Fixed price per chart. Not to exceed:

4009 Option Year 4 Medical Necessity Reconsideration 400 EA Reviews (Second Level Appeals) (Section C paragraph 6.5.2) Fixed price per review. Not to exceed:

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4010 Option Year 4 Appeals & Hearings Internal Reviews 6 EA ________ ________ (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:

4011 Option Year 4 Appeals & Hearings Urgent External 16 EA ________ ________ Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:

4012 Option Year 4 Appeals & Hearings Routine External 300 EA ________ ________ Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:

4013 Option Year 4 Appeals & Hearings Support.

(Section C, paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per hour.

Informational CLIN

4013AA Option Year 4 Pre-Hearing Preparations. Fixed 10 HR ________ ________ price per hour. Not to exceed:

4013AB Option Year 4 Hearing Appearance. Fixed price 50 HR ________ ________ per hour. Not to exceed:

4013AC Option Year 4 Post Hearing. Fixed price per hour. 10 HR ________ ________ Not to exceed:

4013AD Option Year 4 Transcription. Fixed price per 5 HR ________ ________ hour. Not to exceed:

4014 Option Year 4 Transition Assistance Management 5 EA ________ ________ Program (TAMP) Benefit Extension Second-Level

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Reviews (Section C, paragraph 6.5.4) Fixed price per review. Not to exceed:

4015 Option Year 4 Standard of Care (SOC) Reviews 300 EA ________ ________ (Section C paragraph 6.5.5) (Direct Care) Fixed price per review. Not to exceed:

4016 Option Year 4 Quality of Care (QOC) Reviews 6 EA ________ ________ (Section C paragraph 6.5.6) Fixed price per review. Not to exceed:

4017 Option Year 4 Clinical Quality Improvement 500 HR ________ ________ Administrative Studies (Section C paragraph 6.6.1) Fixed price per hour. Not to exceed:

4018 Option Year 4 Clinical Quality Improvement 4,000 EA ________ ________ Abstraction Studies(Fewer than 2,000 charts) (Section C paragraph 6.6.1) Fixed price per chart. Not to exceed:

4019 Option Year 4 Clinical Quality Improvement 6,000 EA ________ ________ Abstraction Studies (2000 or more charts) (Section C paragraph 6.6.1) Fixed price per chart. Not to exceed:

4020 Option Year 4 Annual Autism Care Demonstration 2,000 EA ________ ________ (ACD) Studies (Section C paragraph 6.6.2) Fixed price per chart. Not to exceed:

4021 Option Year 4 Long Assessment of Evolving 6 EA ________ ________ Practices, Devices, Medicines, Treatements, and Procedures (Section C paragraph 6.7) Fixed price per assessment. Not to exceed:

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4022 Option Year 4 Short Assessment of Evolving 6 EA ________ ________ Practices, Devices, Medicines, Treatements, and Procedures (Section C paragraph 6.7) Fixed price per assessment. Not to exceed:

4023 Option Year 4 Quality Communcations (Section C 12 MO ________ ________ paragraph 6.8) FFP per month.

4024 Option Year 4 Meeting Attendance (Section C 7,500 EA $1.00 $7,500.00 paragraph 6.1.13) Cost-reimbursed (no fee) for each meeting attendance. Not to exceed:

4025 Option Year 4 Travel (Section C paragraph 9.0) 25,000 EA $1.00 $25,000.00 Cost-reimbursed (no fee) for travel. Not to exceed:

4026 Option Year 4 Deliverables (DD Forms 1423-1, 1 LO NSP Contract Data Requirements List (CDRLS)) (Not Separately Priced)

4027 Option Year 4 Transition-out (Section C, 1 LO ________ ________ paragraph 6.2.2) FFP>

TQMC Option Year 5.

THE SCHEDULE QUANTITIES ARE ESTIMATED EXCEPT FOR

CLINs 5001, 5002, 5003, 5023, 5024, 5025, 5026 and 5027.

Option Year 5 Period of Performance: 10/01/2019 to 09/30/2020.

5001 Option Year 5 Health Plan Clinical Quality 12 MO ________ ________ Measures (Section C paragraph 6.3.1) FFP per month.

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5002 Option Year 5 Annual NCQA HEDIS® Validation Audit 1 LO ________ ________ (Section C paragraph 6.3.1.4) FFP.

5003 Option Year 5 National Hospital Quality Measures 4 EA ________ ________ (NHQM) (Section C paragraph 6.3.2) FFP per quarter.

5004 Option Year 5 Joint Commission ORYX® Hospital Quality Measures

Informational CLIN

5004AA Option Year 5 Joint Commission ORYX® Chart 95,000 EA ________ ________ Abstraction (Section C paragraph 6.3.3.1) Fixed price per chart. Not to exceed:

5004AB Option Year 5 Joint Commission ORYX® Data 4 EA ________ ________ Submission (Section C paragraphs 6.3.3.2-6.3.3.7) Fixed price per quarterly submission.

5005 Option Year 5 Institute for Healthcare 14,040 EA ________ ________ Improvement (IHI) Global Trigger Tool (GTT) (Section C paragraph 6.3.4 ) Fixed price per chart. Not to exceed:

5006 Option Year 5 Reviews of Behavioral Health 80 EA ________ ________ Facility Applications for Certification (Section C paragraph 6.4 ) Fixed price per application.

Not to exceed:

5007 Option Year 5 Onsite Reviews of Behavioral Health 20 EA ________ ________ Facility Certifications (Section C paragraph 6.4 ) Fixed price per review. Not to exceed:

5008 Option Year 5 Quality and Utilization Reviews 6,500 EA ________ ________

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(Purchased care) (Section C paragraph 6.5.1) Fixed price per chart. Not to exceed:

5009 Option Year 5 Medical Necessity Reconsideration 400 EA ________ ________ Reviews (Second Level Appeals) (Section C paragraph 6.5.2) Fixed price per review. Not to exceed:

5010 Option Year 5 Appeals & Hearings Internal Reviews 6 EA ________ ________ (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:

5011 Option Year 5 Appeals & Hearings Urgent External 16 EA ________ ________ Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:

5012 Option Year 5 Appeals & Hearings Routine External 300 EA ________ ________ Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:

5013 Option Year 5 Appeals & Hearings Support.

(Section C, paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per hour.

Informational CLIN

5013AA Option Year 5 Pre-Hearing Preparations. Fixed 10 HR ________ ________ price per hour. Not to exceed:

5013AB Option Year 5 Hearing Appearance. Fixed price 50 HR ________ ________ per hour. Not to exceed:

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5013AC Option Year 5 Post Hearing. Fixed price per hour. 10 HR ________ ________ Not to exceed:

5013AD Option Year 5 Transcription. Fixed price per 5 HR ________ ________ hour. Not to exceed:

5014 Option Year 5 Transition Assistance Management 5 EA ________ ________ Program (TAMP) Benefit Extension Second-Level Reviews (Section C, paragraph 6.5.4) Fixed price per review. Not to exceed:

5015 Option Year 5 Standard of Care (SOC) Reviews 300 EA ________ ________ (Section C paragraph 6.5.5) (Direct Care) Fixed price per review. Not to exceed:

5016 Option Year 5 Quality of Care (QOC) Reviews 6 EA ________ ________ (Section C paragraph 6.5.6) Fixed price per review. Not to exceed:

5017 Option Year 5 Clinical Quality Improvement 500 HR ________ ________ Administrative Studies (Section C paragraph 6.6.1) Fixed price per hour. Not to exceed:

5018 Option Year 5 Clinical Quality Improvement 4,000 EA ________ ________ Abstraction Studies(Fewer than 2,000 charts) (Section C paragraph 6.6.1) Fixed price per chart. Not to exceed:

5019 Option Year 5 Clinical Quality Improvement 6,000 EA ________ ________ Abstraction Studies(2000 or more charts) (Section C paragraph 6.6.1) Fixed price per chart. Not to exceed:

5020 Option Year 5 Annual Autism Care Demonstration 2,000 EA ________ ________

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(ACD) Studies (Section C paragraph 6.6.2) Fixed price per chart. Not to exceed:

5021 Option Year 5 Long Assessment of Evolving 6 EA ________ ________ Practices, Devices, Medicines, Treatements, and Procedures (Section C paragraph 6.7) Fixed price per assessment. Not to exceed:

5022 Option Year 5 Short Assessment of Evolving 6 EA ________ ________ Practices, Devices, Medicines, Treatements, and Procedures (Section C paragraph 6.7) Fixed price per assessment. Not to exceed:

5023 Option Year 5 Quality Communcations (Section C 12 MO ________ ________ paragraph 6.8) FFP per month.

5024 Option Year 5 Meeting Attendance (Section C 7,500 EA $1.00 $7,500.00 paragraph 6.1.13) Cost-reimbursed (no fee) for each meeting attendance. Not to exceed:

5025 Option Year 5 Travel (Section C paragraph 9.0) 25,000 EA $1.00 $25,000.00 Cost-reimbursed (no fee) for travel. Not to exceed:

5026 Option Year 5 Deliverables (DD Forms 1423-1, 1 LO NSP Contract Data Requirements List (CDRLS)) (Not Separately Priced)

5027 Option Year 5 Transition-out (Section C, 1 LO paragraph 6.2.2) FFP.