47_Section_L_Exhibit_L-11_Price_Proposal_Template_5-19-15.xlsx

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TRICARE Quality Monitoring Contract (TQMC)
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HT9402-15-R-0005
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Section L Exhibit L-11

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Price Proposal Template

TQMC HT9402-15-0005
Section L Exhibit L-11 Price Proposal Template
OFFEROR:
Price Proposal by CLIN
PeriodCLIN/ SLINCLIN DescriptionUnit of IssueQuantityPrice EachPrice Total
Transition-in0001Transition-in (Section C paragraph 6.2.1 Transition-in). Firm-fixed-price (FFP).LO1$0.00
0002Deliverables (DD Forms 1423-1, Contract Data Requirements List (CDRLS)) Not separately priced (NSP)NSP
Base totalTotal$0.00
Option Year 11001Option Year 1 Health Plan Clinical Quality Measures (Section C paragraph 6.3.1) FFP per month.MO12$0.00
1002Option Year 1 Annual NCQA HEDIS® Validation Audit (Section C paragraph 6.3.1.4) FFP.LOT1$0.00
1003Option Year 1 National Hospital Quality Measures (NHQM) (Section C paragraph 6.3.2) FFP per Quarter.EA4$0.00
1004Option Year 1 Joint Commission ORYX® Hospital Quality Measures (Section C paragraph 6.3.3)$0.00
1004AAOption Year 1Joint Commission ORYX® Hospital Quality Chart Abstraction (Section C paragraph 6.3.3.1) Fixed price per chart. Not to exceed:EA95,000$0.00
1004ABOption Year 1 Joint Commission ORYX® Data Submission (Section C paragraph 6.3.3.2-6.3.3.7) FFP per quarterly submission.EA4$0.00
1005Option Year 1 Institute for Healthcare Improvement (IHI) Global Trigger Tool (GTT) (Section C paragraph 6.3.4 ) Fixed price per chart. Not to exceed:EA14,040$0.00
1006Option Year 1 Reviews of Behavioral Health Facility Applications for Certification (Section C paragraph 6.4 ) Fixed price per application. Not to exceed:EA80$0.00
1007Option Year 1 On-Site Reviews of Behavioral Health Facility Certifications (Section C paragraph 6.4 ) Fixed price per onsite review. Not to exceed:EA20$0.00
6.5 MEDICAL REVIEWS
1008Option Year 1 Quality and Utilization Reviews (Section C paragraph 6.5.1) Fixed price per chart. Not to exceed:EA6,500$0.00
1009Option Year 1 Medical Necessity Reconsideration Reviews (Second Level Appeals) (Section C paragraph 6.5.2) Fixed price per review. Not to exceed:EA400$0.00
1010Option Year 1 Appeals & Hearings Internal Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per internal review. Not to exceed:EA6$0.00
1011Option Year 1 Appeals & Hearings Urgent External Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per urgent external review. Not to exceed:EA16$0.00
1012Option Year 1 Appeals & Hearings Routine External Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per routine external review. Not to exceed:EA300$0.00
1013Option Year 1 Appeals & Hearings Support (Section C, paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per hour. Not to exceed:$0.00
1013AAPre-Hearing PreparationsHR10$0.00
1013ABHearing AppearanceHR50$0.00
1013ACPost HearingHR10$0.00
1013ADTranscriptionHR5$0.00
1014Option Year 1 Transition Assistance Management Program (TAMP) Benefit Extension Second-Level Reviews (Section C, paragraph 6.5.4) Fixed price per review. Not to exceed:EA5$0.00
1015Option Year 1 Standard of Care (SOC) Reviews (Section C paragraph 6.5.5) Fixed price per review. Not to exceed:EA300$0.00
1016Option Year 1 Quality of Care (QOC) Reviews (Section C paragraph 6.5.6) (Direct and Purchased Care): Fixed price per QOC review. Not to exceed:EA6$0.00
1017Option Year 1 Clinical Quality Improvement Administrative Study (Section C 6.6.1). Fixed price per hour. Not to exceed:HR500$0.00
1018Option Year 1 Clinical Quality Improvement Abstraction Study (Fewer than 2,000 Records) (Section C paragraph 6.6.1) Fixed price per chart. Not to exceed:EA4,000$0.00
1019Option Year 1 Clinical Quality Improvement Chart Abstraction Study (2000 or more charts) (Section C paragraph 6.6.1) Fixed price per chart. Not to exceed:EA6,000$0.00
1020Option Year 1 Annual Autism Care Demonstration (ACD) Study (Section C paragraph 6.6.2) Fixed price per chart. Not to exceed:EA2,000$0.00
1021Option Year 1 Long Assessment of Evolving Practices, Devices, Medicines, Treatements, and Procedures (Section C paragraph 6.7) Fixed price per assessment. Not to exceed:EA6$0.00
1022Option Year 1 Short Assessment of Evolving Practices, Devices, Medicines, Treatements, and Procedures (Section C paragraph 6.7) Fixed price per assessment. Not to exceed:EA6$0.00
1023Option Year 1 Quality Communcations (Section C paragraph 6.8) FFP per month.MO12$0.00
1024Option Year 1 Meeting Attendance (Section C paragraph 6.1.13) This CLIN establishes a cost-reimbused (no fee) amount for meeting attendance. Not to exceed:EA7,500$1.00$7,500.00
1025Option Year 1 Travel (Section C paragraph 9.0) This CLIN establishes a cost-reimbused (no fee) amount for travel. Not to exceed:EA100,000$1.00$100,000.00
1026Deliverables (DD Forms 1423-1, Contract Data Requirements List (CDRLS)) Not separately priced (NSP)NSP
1027Option Year 1 Transition-out. (Section C paragraph 6.2.2 and FAR 52.237-3) FFP.LO1$0.00
Option Year 1 Total$107,500.00
Option Year 22001Option Year 2 Health Plan Clinical Quality Measures (Section C paragraph 6.3.1) FFP per month.MO12$0.00
2002Option Year 2 Annual NCQA HEDIS® Validation Audit (Section C paragraph 6.3.1.4).LO1$0.00
2003Option Year 2 National Hospital Quality Measures (NHQM) (Section C paragraph 6.3.2) FFP Quarterly.EA4$0.00
2004Option Year 2 Joint Commission ORYX® Hospital Quality Measures (Section C paragraph 6.3.3)$0.00
2004AAOption Year 1 Joint Commission ORYX® Hospital Quality Measures (Section C paragraph 6.3.3.1) Chart Abstraction. Fixed price per chart. Not to exceed:EA95,000$0.00
2004ABOption Year 1 Joint Commission ORYX® Data Submission (Section C paragraphs 6.3.3.2-6.3.3.7) FFP per quarterly submission.EA4$0.00
2005Option Year 2 Institute for Healthcare Improvement (IHI) Global Trigger Tool (GTT) (Section C paragraph 6.3.4 ) Fixed price per chart. Not to exceed:EA14,040$0.00
2006Option Year 2 Reviews of Behavioral Health Facility Applications for Certification (Section C paragraph 6.4 ) Fixed price per application. Not to exceed:EA80$0.00
2007Option Year 2 On-Site Reviews of Behavioral Health Facility Certifications (Section C paragraph 6.4 ) Fixed price per onsite review. Not to exceed:EA20$0.00
6.5 MEDICAL REVIEWS
2008Option Year 2 Quality and Utilization Reviews (Section C paragraph 6.5.1) Fixed price per chart. Not to exceed:EA6,500$0.00
2009Option Year 2 Medical Necessity Reconsideration Reviews (Second Level Appeals) (Section C paragraph 6.5.2) Fixed price per review. Not to exceed:EA400$0.00
2010Option Year 2 Appeals & Hearings Internal Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:EA6$0.00
2011Option Year 2 Appeals & Hearings Urgent External Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:EA16$0.00
2012Option Year 2 Appeals & Hearings Routine External Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:EA300$0.00
2013Option Year 2 Appeals & Hearings Support. (Section C, paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per hour. Individual task order. Not to Exceed$0.00
2013AAPre-Hearing PreparationsHR10$0.00
2013ABHearing AppearanceHR50$0.00
2013ACPost HearingHR10$0.00
2013ADTranscriptionHR5$0.00
2014Option Year 2 Transition Assistance Management Program (TAMP) Benefit Extension Second-Level Review (Section C, paragraph 6.5.4) Fixed price per review. Not to exceed:EA4$0.00
2015Option Year 2 Standard of Care (SOC) Review (Section C paragraph 6.5.5) Fixed price per review. Not to exceed:EA300$0.00
2016Option Year 2 Quality of Care (QOC) Reviews (Section C paragraph 6.5.6) Fixed price per review. Not to exceed:6$0.00
2017Option Year 2 Clinical Quality Improvement Administrative Study (Section C 6.6.1) Fixed price per hour. Not to exceed:HR500$0.00
2018Option Year 2 Clinical Quality Improvement Administrative Study (Fewer than 2,000 Records) (Section C paragraph 6.6.1) (Direct care). Fixed price per chart. Not to exceed:EA4,000$0.00
2019Option Year 2 Clinical Quality Improvement Chart Abstraction Study (2000 or more charts) (Section C paragraph 6.6.1) Fixed price per chart. Not to exceed:EA6,000$0.00
2020Option Year 2 Annual Autism Care Demonstration (ACD) Study (Section C paragraph 6.6.2) Fixed price per chart. Not to exceed:EA2,000$0.00
2021Option Year 2 Long Assessment of Evolving Practices, Devices, Medicines, Treatements, and Procedures(Section C paragraph 6.7) Fixed price per assessment. Individual task order. Not to Exceed6$0.00
2022Option Year 2 Short Assessment of Evolving Practices, Devices, Medicines, Treatements, and Procedures(Section C paragraph 6.7) Fixed price per assessment. Individual task orders. Not to exceed:6$0.00
2023Option Year 2 Quality Communcations (Section C paragraph 6.8) FFP per month.MO12$0.00
2024Option Year 2 Meeting Attendance (Section C paragraph 6.1.13) This CLIN establishes a cost-reimbused (no fee) amount for meeting attendance. Not to exceed:EA7,500$1.00$7,500.00
2025Option Year 2 Travel (Section C paragraph 9.0) This CLIN establishes a cost-reimbused (no fee) amount for travel. Not to exceed:EA75,000$1.00$75,000.00
2026Deliverables (DD Forms 1423-1, Contract Data Requirements List (CDRLS)) Not separately priced (NSP).NSP
2027Option Year 2 Transition-out. (Section C paragraph 6.2.2 and FAR 52.237-3) (Direct and purchased care): FFP.LOT1$0.00
Option Year 2 Total$82,500.00
Option Year 33001Option Year 3 Health Plan Clinical Quality Measures (Section C paragraph 6.3.1) FFP per month.MO12$0.00
3002Option Year 3 Annual NCQA HEDIS® Validation Audit (Section C paragraph 6.3.1.4). FFPLO1$0.00
3003Option Year 3 National Hospital Quality Measures (NHQM) (Section C paragraph 6.3.2) FFP per quarter.EA4$0.00
3004Option Year 3 Joint Commission ORYX® Hospital Quality Measures (Section C paragraph 6.3.3).$0.00
3004AAOption Year 3 Joint Commission ORYX® Hospital Quality Measures (Section C paragraph 6.3.3.1) Chart Abstraction. Fixed price per chart. Not to exceed:EA95,000$0.00
3004ABOption Year 3 Joint Commission ORYX® Data Submission (Section C paragraphs 6.3.3.2-6.3.3.7) FFP per quarterly submission.EA4$0.00
3005Option Year 3 Institute for Healthcare Improvement (IHI) Global Trigger Tool (GTT) (Section C paragraph 6.3.4 ). Fixed price per chart. Not to exceed:EA14,040$0.00
3006Option Year 3 Reviews of Behavioral Health Facility Applications for Certification
(Section C paragraph 6.4 ). Fixed price per application. Not to exceed:EA80$0.00
3007Option Year 3 Onsite Reviews of Behavioral Health Facility Certifications (Section C paragraph 6.4 ). Fixed price per onsite review. Not to exceed:EA20$0.00
6.5 MEDICAL REVIEWS
3008Option Year 3 Quality and Utilization Reviews(Section C paragraph 6.5.1). Fixed price per review. Not to exceed:EA6,500$0.00
3009Option Year 3 Medical Necessity Reconsideration Reviews (Second Level Appeals) (Section C paragraph 6.5.2) Fixed price per review. Not to exceed:EA400$0.00
3010Option Year 3 Appeals & Hearings Internal Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:EA6$0.00
3011Option Year 3 Appeals & Hearings Urgent External Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:EA16$0.00
3012Option Year 3 Appeals & Hearings Routine External Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:EA300$0.00
3013Option Year 3 Appeals & Hearings Support (Section C, paragraph 6.5.3 and Section J, Attachment J-6)$0.00
301301Pre-Hearing PreparationsHR10$0.00
301302Hearing AppearanceHR50$0.00
301303Post HearingHR10$0.00
301304TranscriptionHR5$0.00
3014Option Year 3 Transition Assistance Management Program (TAMP) Benefit Extension Second-Level Review (Section C, paragraph 6.5.4) Fixed price per review. Not to exceed:EA5$0.00
3015Option Year 3 Standard of Care (SOC) Review (Section C paragraph 6.5.5) Fixed price per review. Not to exceed:EA300$0.00
3016Option Year 3 Quality of Care (QOC) Reviews (Section C paragraph 6.5.6) Fixed price per review. Not to exceed:6$0.00
3017Option Year 3 Clinical Quality Improvement Administrative Study (Section C 6.6.1) Fixed price per hour. Not to exceed:HR500$0.00
3018Option Year 3 Clinical Quality Improvement Administrative Study (Fewer than 2,000 Records) (Section C paragraph 6.6.1) (Direct care). Fixed price per chart. Not to exceed:EA4,000$0.00
3019Option Year 3 Clinical Quality Improvement Chart Abstraction Study (2000 or more Charts) (Section C paragraph 6.6.1) Fixed price per chart. Not to exceed:EA6,000$0.00
3020Option Year 3 Annual Autism Care Demonstration (ACD) Study (Section C paragraph 6.6.2) Fixed price per chart. Not to exceed:EA2,000$0.00
3021Option Year 3 Long Assessment of Evolving Practices, Devices, Medicines, Treatements, and Procedures (Section C paragraph 6.7) Fixed price per assessment. Individual task order. Not to exceed:6$0.00
3022Option Year 3 Short Assessment of Evolving Practices, Devices, Medicines, Treatements, and Procedures (Section C paragraph 6.7) (Direct and Purchased Care): Fixed price per assessment. Individual task order. Not to exceed:6$0.00
3023Option Year 3 Quality Communcations (Section C paragraph 6.8) FFP per month.MO12$0.00
3024Option Year 3 Meeting Attendance (Section C paragraph 6.1.13) This CLIN establishes a cost-reimbused (no fee) amount for meeting attendance. Not to exceed:EA7,500$1.00$7,500.00
3025Option Year 3 Travel (Section C paragraph 9.0) This CLIN establishes a cost-reimbused (no fee) amount for travel. Not to exceed:EA50,000$1.00$50,000.00
3026Deliverables (DD Forms 1423-1, Contract Data Requirements List (CDRLS)) Not separately priced(NSP)NSP
3027Option Year 3 Transition-out. (Section C paragraph 6.2.2 and FAR 52.237-3) FFP.LOT1$0.00
Option Year 3 Total$57,500.00
Option Year 44001Option Year 4 Health Plan Clinical Quality Measures (Section C paragraph 6.3.1) FFP per month.MO12$0.00
4002Option Year 4 Annual NCQA HEDIS® Validation Audit (Section C paragraph 6.3.1.4). FFP.LOT1$0.00
4003Option Year 4 National Hospital Quality Measures (NHQM) (Section C paragraph 6.3.2) FFP per quarter.EA4$0.00
4004Option Year 4 Joint Commission ORYX® Hospital Quality Measures (Section C paragraph 6.3.3).$0.00
4004AAOption Year 4 Joint Commission ORYX® Hospital Quality Measures (Section C paragraph 6.3.3.1) Chart Abstraction. Fixed price per chart. Not to exceed:EA95,000$0.00
4004ABOption Year 4 Joint Commission ORYX® Data Submission (Section C paragraphs 6.3.3.2-6.3.3.7) Fixed price per quarterly submission.EA4$0.00
4005Option Year 4 Institute for Healthcare Improvement (IHI) Global Trigger Tool (GTT) (Section C paragraph 6.3.4 ) Fixed price per chart. Not to exceed:EA14,040$0.00
4006Option Year 4 Reviews of Behavioral Health Facility Applications for Certification (Section C paragraph 6.4 ). Fixed price per application. Not to exceed:EA80$0.00
4007Option Year 4 Onsite Reviews of Behavioral Health Facility Certifications (Section C paragraph 6.4 ) Fixed price per onsite review. Not to exceed:EA20$0.00
6.5 MEDICAL REVIEWS
4008Option Year 4 Quality and Utilization Reviews (Section C paragraph 6.5.1). Fixed price per chart. Not to exceed:EA6,500$0.00
4009Option Year 4 Medical Necessity Reconsideration Reviews (Second Level Appeals) (Section C paragraph 6.5.2) Fixed price per review. Not to exceed:EA400$0.00
4010Option Year 4 Appeals & Hearings Internal Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6). Fixed price per review. Not to exceed:EA6$0.00
4011Option Year 4 Appeals & Hearings Urgent External Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6). Fixed price per review. Not to exceed:EA16$0.00
4012Option Year 4 Appeals & Hearings Routine External Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:EA300$0.00
4013Option Year 4 Appeals & Hearings Support. (Section C, paragraph 6.5.3 and Section J, Attachment J-6) Fixed rate per hour. Individual task order. Not to exceed:$0.00
401301Pre-Hearing PreparationsHR10$0.00
401302Hearing AppearanceHR50$0.00
401303Post HearingHR10$0.00
401304TranscriptionHR5$0.00
4014Option Year 4 Transition Assistance Management Program (TAMP) Benefit Extension Second-Level Review (Section C, paragraph 6.5.4) Fixed price per review. Not to exceed:EA5$0.00
4015Option Year 4 Standard of Care (SOC) Review (Section C paragraph 6.5.5) (Direct Care) Fixed price per review. Not to exceed:EA300$0.00
4016Option Year 4 Quality of Care (QOC) Reviews (Section C paragraph 6.5.6) Fixed price per review. Not to exceed:6$0.00
4017Option Year 4 Clinical Quality Improvement Administrative Study (Section C paragraph 6.6.1) FFP per hour. Not to exceed:HR500$0.00
4018Option Year 4 Clinical Quality Improvement Chart Abstraction Study (fewer than 2000 Charts) (Section C paragraph 6.6.1) Fixed price per chart. Not to exceed:EA4,000$0.00
4019Option Year 4 Clinical Quality Improvement Chart Abstraction Study (2000 or more Charts) (Section C paragraph 6.6.1) Fixed price per chart. Not to exceed:EA6,000$0.00
4020Option Year 4 Annual Autism Care Demonstration (ACD) Study (Section C paragraph 6.6.2) Chart Abstraction Study (2000 or more Charts). Fixed price per chart. Not to exceed:EA2,000$0.00
4021Option Year 4 Long Assessment of Evolving Practices, Devices, Medicines, Treatements, and Procedures (Section C paragraph 6.7) Fixed price per assessment. Individual task order. Not to exceed:6$0.00
4022Option Year 4 Short Assessment of Evolving Practices, Devices, Medicines, Treatements, and Procedures (Section C paragraph 6.7) Fixed price per assessment. Individual task orders Not to exceed:6$0.00
4023Option Year 1 Quality Communcations (Section C paragraph 6.8) (Direct and Purchased Care): FFP per month.MO12$0.00
4024Option Year 4 Meeting Attendance (Section C paragraph 6.1.13) This CLIN establishes a cost-reimbused (no fee) amount for meeting attendance. Not to exceed:EA7,500$1.00$7,500.00
4025Option Year 4 Travel (Section C paragraph 9.0) This CLIN establishes a cost-reimbused (no fee) amount for travel. Not to exceed:EA25,000$1.00$25,000.00
4026Option Year 4 Deliverables (DD Forms 1423-1, Contract Data Requirements List (CDRLS)) Not separately priced (NSP).NSP
4027Option Year 4 Transition-out. (Section C paragraph 6.2.2 and FAR 52.237-3) FFP.LOT1$0.00
Option Year 4 Total$32,500.00
Option Year 55001Option Year 5 Health Plan Clinical Quality Measures (Section C paragraph 6.3.1) FFP per month.MO12$0.00
5002Option Year 5 Annual NCQA HEDIS® Validation Audit (Section C paragraph 6.3.1.4). FFP.LOT1$0.00
5003Option Year 5 National Hospital Quality Measures (NHQM) (Section C paragraph 6.3.2) FFP per quarter.EA4$0.00
5004Option Year 5 Joint Commission ORYX® Hospital Quality Measures (Section C paragraph 6.3.3).$0.00
5004AAOption Year 4 Joint Commission ORYX® Hospital Quality Measures (Section C paragraph 6.3.3.1) Chart Abstraction. Fixed price per chart. Not to exceed:EA95,000$0.00
5004ABOption Year 5 Joint Commission ORYX® Data Submission (Section C paragraphs 6.3.3.2-6.3.3.7) FFP per quarterly submission.EA4$0.00
5005Option Year 5 Institute for Healthcare Improvement (IHI) Global Trigger Tool (GTT) (Section C paragraph 6.3.4 ) Fixed price per chart. Not to exceed:EA14,040$0.00
5006Option Year 5 Reviews of Behavioral Health Facility Applications for Certification
(Section C paragraph 6.4 ). Fixed price per application. Not to exceed:EA80$0.00
5007Option Year 5 Onsite Reviews of Behavioral Health Facility Certifications (Section C paragraph 6.4 ). Fixed price per onsite review. Not to exceed:EA20$0.00
6.5 MEDICAL REVIEWS
5008Option Year 5 Quality and Utilization Reviews (Purchased care) (Section C paragraph 6.5.1). Fixed price per review. Not to exceed:EA6,500$0.00
5009Option Year 5 Medical Necessity Reconsideration Reviews (Second Level Appeals) (Section C paragraph 6.5.2) Fixed price per review. Not to exceed:EA400$0.00
5010Option Year 5 Appeals & Hearings Internal Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:EA6$0.00
5011Option Year 5 Appeals & Hearings Urgent External Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6). Fixed price per review. Not to exceed:EA16$0.00
5012Option Year 5 Appeals & Hearings Routine External Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per review. Not to exceed:EA300$0.00
5013Option Year 5 Appeals & Hearings Support. (Section C, paragraph 6.5.3 and Section J, Attachment J-6)$0.00
5013AAPre-Hearing PreparationsHR10$0.00
5013ABHearing AppearanceHR50$0.00
5013ACPost HearingHR10$0.00
5013ADTranscriptionHR5$0.00
5014Option Year 5 Transition Assistance Management Program (TAMP) Benefit Extension Second-Level Review (Section C, paragraph 6.5.4) Fixed price per review. Not to exceed:EA5$0.00
5015Option Year 5 Standard of Care (SOC) Review (Section C paragraph 6.5.5) Fixed price per review. Not to exceed:EA300$0.00
5016Option Year 5 Quality of Care (QOC) Reviews (Section C paragraph 6.5.6) Fixed price per review. Not to exceed:6$0.00
5017Option Year 5 Clinical Quality Improvement Administrative Study (Section C 6.6.1) Fixed price per hour. Not to exceed:HR500$0.00
5018Option Year 5 Clinical Quality Improvement Chart Abstraction Study(Fewer than 2,000 charts) (Section C paragraph 6.6.1) Fixed price per chart. Not to exceed:EA4,000$0.00
5019Option Year 5 Clinical Quality Improvement Chart Abstraction Study (2000 or more Charts) (Section C paragraph 6.6.1) Fixed price per chart. Not to exceed:EA6,000$0.00
5020Option Year 5 Annual Autism Care Demonstration (ACD) Study (Section C paragraph 6.6.2) Fixed price per chart. Not to exceed:EA2,000$0.00
5021Option Year 5 Long Assessment of Evolving Practices, Devices, Medicines, Treatements, and Procedures (Section C paragraph 6.7) Fixed price per assessment. Individual task order. Not to exceed:EA6$0.00
5022Option Year 1 Short Assessment of Evolving Practices, Devices, Medicines, Treatements, and Procedures (Section C paragraph 6.7) Fixed price per assessment. Individual task order. Not to exceed:EA6$0.00
5023Option Year 5 Quality Communcations (Section C paragraph 6.8) FFP per month.MO12$0.00
5024Option Year 5 Meeting Attendance (Section C paragraph 6.1.13) This CLIN establishes a cost-reimbused (no fee) amount for meeting attendance. Not to exceed:EA7,500$1.00$7,500.00
5025Option Year 5 Travel (Section C paragraph 9.0) This CLIN establishes a cost-reimbused (no fee) amount for travel. Not to exceed:EA25,000$1.00$25,000.00
5026Deliverables (DD Forms 1423-1, Contract Data Requirements List (CDRLS)) Not Separately priced (NSP).NSP
5027Option Year 5 Transition-out. (Section C paragraph 6.2.2 and FAR 52.237-3) (Direct and purchased care) FFP.LOT1$0.00
Option Year 5 Total$32,500.00
Total all option years$312,500.00
6 month extension of servicesOY 5 x 0.5$16,250.00
Total Evaluated Price$328,750.00

&"Times New Roman,Regular"Exhibit L-11 Price Proposal Template

TQMC HT9402-15-R-0005,Section L Exhibit L-11 Page &P of &N

Summary by CLIN, Option Yr

TQMC HT9402-15-0005
Section L Exhibit L-11 Price Proposal Template
OFFEROR:
Totals by Option YearTotal by
Price Proposal by CLIN by Option PeriodBaseOY 1OY 2OY 3OY 4OY 5CLIN
0001Transition-in (Section C paragraph 6.2.1 Transition-in). Fixed price0
0002Deliverables (DD Forms 1423-1, Contract Data Requirements List (CDRLS)) Not separately priced (NSP)
X001Health Plan Clinical Quality Measures (Section C paragraph 6.3.1) Firm, fixed price per month.$0.00$0.00$0.00$0.00$0.00$0.00
X002Annual NCQA HEDIS® Validation Audit (Section C paragraph 6.3.1.4) Firm, fixed price.$0.00$0.00$0.00$0.00$0.00$0.00
X003National Hospital Quality Measures (NHQM) (Section C paragraph 6.3.2) Fixed price. Quarterly.$0.00$0.00$0.00$0.00$0.00$0.00
X004Joint Commission ORYX® Hospital Quality Measures (Section C paragraph 6.3.3)
X004AAJoint Commission ORYX® Hospital Quality Chart Abstraction (Section C paragraph 6.3.3.1) Fixed price per chart. Not to exceed:$0.00$0.00$0.00$0.00$0.00$0.00
X004ABJoint Commission ORYX® Data Submission (Section C paragraphs 6.3.3.2-6.3.3.7) Fixed price per quarterly submission.$0.00$0.00$0.00$0.00$0.00$0.00
X005Institute for Healthcare Improvement (IHI) Global Trigger Tool (GTT) (Section C paragraph 6.3.4 ) Fixed price per chart. Not to exceed:$0.00$0.00$0.00$0.00$0.00$0.00
X006Reviews of Behavioral Health Facility Applications for Certification (Section C paragraph 6.4 ) Fixed price per application. Not to exceed:$0.00$0.00$0.00$0.00$0.00$0.00
X007Onsite Reviews of Behavioral Health Facility Certifications (Section C paragraph 6.4 ) Fixed price per onsite review. Not to exceed:$0.00$0.00$0.00$0.00$0.00$0.00
6.5 MEDICAL REVIEWS
X008Quality and Utilization Reviews (Section C paragraph 6.5.1) Fixed price per chart. Not to exceed:$0.00$0.00$0.00$0.00$0.00$0.00
X009Medical Necessity Reconsideration Reviews (Second Level Appeals) (Section C paragraph 6.5.2) Fixed price per review. Not to exceed:$0.00$0.00$0.00$0.00$0.00$0.00
X010Appeals & Hearings Internal Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per internal review. Not to exceed:$0.00$0.00$0.00$0.00$0.00$0.00
X011Appeals & Hearings Urgent External Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per urgent external review. Not to exceed:$0.00$0.00$0.00$0.00$0.00$0.00
X012Appeals & Hearings Routine External Reviews (Section C paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per routine external review. Not to exceed:$0.00$0.00$0.00$0.00$0.00$0.00
X013Appeals & Hearings Support (Section C, paragraph 6.5.3 and Section J, Attachment J-6) Fixed price per hour. Not to exceed:
X013AAPre-Hearing Preparations$0.00$0.00$0.00$0.00$0.00$0.00
X013ABHearing Appearance$0.00$0.00$0.00$0.00$0.00$0.00
X013ACPost Hearing$0.00$0.00$0.00$0.00$0.00$0.00
X013ADTranscription$0.00$0.00$0.00$0.00$0.00$0.00
X014Transition Assistance Management Program (TAMP) Benefit Extension Second-Level Reviews (Section C, paragraph 6.5.4) Fixed price per review. Not to exceed:$0.00$0.00$0.00$0.00$0.00$0.00
X015Standard of Care (SOC) Reviews (Section C paragraph 6.5.5) Fixed price per review. Not to exceed:$0.00$0.00$0.00$0.00$0.00$0.00
X016Quality of Care (QOC) Reviews (Section C paragraph 6.5.6) (Direct and Purchased Care): Fixed price per QOC review. Not to exceed:$0.00$0.00$0.00$0.00$0.00$0.00
X017Clinical Quality Improvement Administrative Study (Section C 6.6.1) Fixed price per hour. Not to exceed:$0.00$0.00$0.00$0.00$0.00$0.00
X018Clinical Quality Improvement Abstraction Study (Fewer than 2,000 Records) (Section C paragraph 6.6.1) Fixed price per chart. Not to exceed:$0.00$0.00$0.00$0.00$0.00$0.00
X019Clinical Quality Improvement Chart Abstraction Study (2000 or more charts) (Section C paragraph 6.6.1) Fixed price per chart. Not to exceed:$0.00$0.00$0.00$0.00$0.00$0.00
X020Annual Autism Care Demonstration (ACD) Study (Section C paragraph 6.6.2) Fixed price per chart. Not to exceed:$0.00$0.00$0.00$0.00$0.00$0.00
X021Long Assessment of Evolving Practices, Devices, Medicines, Treatements, and Procedures (Section C paragraph 6.7) Fixed price per assessment. Not to exceed:$0.00$0.00$0.00$0.00$0.00$0.00
X022Short Assessment of Evolving Practices, Devices, Medicines, Treatements, and Procedures (Section C paragraph 6.7) Fixed price per assessment. Not to exceed:$0.00$0.00$0.00$0.00$0.00$0.00
X023Quality Communcations (Section C paragraph 6.8) Firm, fixed price per month.$0.00$0.00$0.00$0.00$0.00$0.00
X024Meeting Attendance (Section C paragraph 6.1.13) This CLIN establishes a cost-reimbused (no fee) amount for meeting attendance. Not to exceed:$7,500.00$7,500.00$7,500.00$7,500.00$7,500.00$37,500.00
X025Travel (Section C paragraph 9.0) This CLIN establishes a cost-reimbused (no fee) amount for travel. Not to exceed:$100,000.00$75,000.00$50,000.00$25,000.00$25,000.00$275,000.00
X026Deliverables (DD Forms 1423-1, Contract Data Requirements List (CDRLS)) Not separately priced (NSP) Enter Estimated Cost on the CDRL Cost Estimate Worksheet$0.00
X027Transition-out. (Section C paragraph 6.2.2 and FAR 52.237-3) Firm, fixed price for transition-out.$0.00$0.00$0.00$0.00$0.00$0.00
Total per period$0.00$107,500.00$82,500.00$57,500.00$32,500.00$32,500.00$312,500.00
Total all CLINs/Periods$312,500.00
6-month extension of services$16,250.00
Total Evaluated Price$328,750.00

CDRL Cost Estimate

TQMC HT9402-15-0005
Section L Exhibit L-11 Price Proposal Template
OFFEROR:
Estimated Cost for CDRLsBaseOY 1OY 2OY 3OY 4OY 5
0002Deliverables (DD Forms 1423-1, Contract Data Requirements List (CDRLS)) Not separately priced (NSP)
X026Deliverables (DD Forms 1423-1, Contract Data Requirements List (CDRLS)) Not separately priced (NSP)
Total Estimated Cost for CDRLs$0.00$0.00$0.00$0.00$0.00$0.00
Not included in the total evaluated price

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