J.6 Appendix F - WCRC Cost Template.xlsx
XLSX spreadsheet 16 KB Posted
- Attached to
- Workers' Compensation Review Contractor (WCRC) Federal contract opportunity
- Solicitation number
- 75FCMC23R0010
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| J.7-Contractor-Business-Ethics-COI-and-Compliance-Program-Requirements Jan 2019.docx | DOCX document | |
| J.9-Past Performance Questionnaire.docx | DOCX document | |
| Solicitation RFP 75FCMC23R0010.pdf | ||
| J.1 Appendix A - Statement of Work 2022 (final).docx | DOCX document | |
| J.4 Appendix D - Q&A Template.xlsx | XLSX spreadsheet | |
| J.8-Contractor Offeror Conflict of Interest.docx | DOCX document |
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Sheet1 Base Year Transition (April 4, 2023-July 3, 2023). Quantity (# of Proposal Submissions) Unit Price (Per Recomm) Total FFP Instructions: This table represents the format related to proposals. The value of guaranteed and optional reviews is already populated. Only the total value of all transition activities and unit price may be altered. Please include the price of any non-review activities within the unit price for review (i.e. potential travel). This project is funded from two sources with an expectation that approximately 67% of effort comes from medical review activities and 33% of effort come from medication review activities. Transition activities include those items necessary for ensuring adequate infrastructure, staffing, internal SOP development, and staff education. They are to be priced as a single total in the Total FFP column and corresponding Transition Activities line in the Base Year.
| CLIN0001 | Price Per WCMSA Recommendation | |
| SLIN 0001AA | Transition Activities* | $ - 0 |
Base Year (July 4, 2023 – April 3, 2024). Quantity (# of Proposal Submissions) Unit Price (Per Recomm) Total FFP
| CLIN0002 | Price Per WCMSA Recommendation | |||
| SLIN 0002AA | WCMSA Recommendations - MIP | 14,400 | $ - 0 | $ - 0 |
| SLIN 0002AB | WCMSA Recommendations - Part D | 14,000 | $ - 0 | $ - 0 |
| SLIN 0002AC | Optional WCMSA Recomm Additional Quantity - MIP | 3,000 | $ - 0 | $ - 0 |
| SLIN 0002AD | Optional WCMSA Recomm Additional Quantity - Part D | 3,000 | $ - 0 | $ - 0 |
| SLIN 0002AE | Optional WCMSA Recomm Additional Quantity - MIP | 3,000 | $ - 0 | $ - 0 |
| SLIN 0002AF | Optional WCMSA Recomm Additional Quantity - Part D | 3,000 | $ - 0 | $ - 0 |
| Total | $ - 0 |
CLIN 0003 Option Year 1 (April 4, 2024- April 3, 2025). Quantity (# of Proposal Submissions) Unit Price (Per Recomm) Total FFP
| CLIN0003 | Price Per WCMSA Recommendation | |||
| SLIN 0003AA | WCMSA Recommendations - MIP | 19,200 | $ - 0 | $ - 0 |
| SLIN 0003AB | WCMSA Recommendations - Part D | 19,200 | $ - 0 | $ - 0 |
| SLIN 0003AC | Optional WCMSA Recomm Additional Quantity - MIP | 3,000 | $ - 0 | $ - 0 |
| SLIN 0003AD | Optional WCMSA Recomm Additional Quantity - Part D | 3,000 | $ - 0 | $ - 0 |
| SLIN 0003AE | Optional WCMSA Recomm Additional Quantity - MIP | 3,000 | $ - 0 | $ - 0 |
| SLIN 0003AF | Optional WCMSA Recomm Additional Quantity - Part D | 3,000 | $ - 0 | $ - 0 |
| Optional NGHP Price Per LMSA Recommendation | ||||
| SLIN 0003AK | Optional LMSA & NFMSA Recomm - MIP | 1,000 | $ - 0 | $ - 0 |
| SLIN 0003AL | Optional LMSA & NFMSA Recomm- Part D | 1,000 | $ - 0 | $ - 0 |
| SLIN 0003AM | Optional LMSA & NFMSA Recomm Additional Quantity - MIP | 3,000 | $ - 0 | $ - 0 |
| SLIN 0003AN | Optional LMSA & NFMSA Recomm Additional Quantity- Part D | 3,000 | $ - 0 | $ - 0 |
| Total | $ - 0 |
CLIN 0004 Option Year 2 (April 4, 2025- April 3, 2026). Quantity (# of Proposal Submissions) Unit Price (Per Recomm) Total FFP
| CLIN0004 | Price Per WCMSA Recommendation | |||
| SLIN 0004AA | WCMSA Recommendations - MIP | 19,200 | $ - 0 | $ - 0 |
| SLIN 0004AB | WCMSA Recommendations - Part D | 19,200 | $ - 0 | $ - 0 |
| SLIN 0004AC | Optional WCMSA Recomm Additional Quantity - MIP | 3,000 | $ - 0 | $ - 0 |
| SLIN 0004AD | Optional WCMSA Recomm Additional Quantity - Part D | 3,000 | $ - 0 | $ - 0 |
| SLIN 0004AE | Optional WCMSA Recomm Additional Quantity - MIP | 3,000 | $ - 0 | $ - 0 |
| SLIN 0004AF | Optional WCMSA Recomm Additional Quantity - Part D | 3,000 | $ - 0 | $ - 0 |
| Optional NGHP Price Per LMSA Recommendation | ||||
| SLIN 0004AK | Optional LMSA & NFMSA Recomm - MIP | 1,000 | $ - 0 | $ - 0 |
| SLIN 0004AL | Optional LMSA & NFMSA Recomm- Part D | 1,000 | $ - 0 | $ - 0 |
| SLIN 0004AM | Optional LMSA & NFMSA Recomm Additional Quantity - MIP | 3,000 | $ - 0 | $ - 0 |
| SLIN 0004AN | Optional LMSA & NFMSA Recomm Additional Quantity- Part D | 3,000 | $ - 0 | $ - 0 |
| Total | $ - 0 | |||
| CLIN 0005 Option Year 3 (April 4, 2026- April 3, 2027). | Quantity (# of Proposal Submissions) | Unit Price (Per Recomm) | Total FFP |
| CLIN0005 | Price Per WCMSA Recommendation | |||
| SLIN 0005AA | WCMSA Recommendations - MIP | 19,200 | $ - 0 | $ - 0 |
| SLIN 0005AB | WCMSA Recommendations - Part D | 19,200 | $ - 0 | $ - 0 |
| SLIN 0005AC | Optional WCMSA Recomm Additional Quantity - MIP | 3,000 | $ - 0 | $ - 0 |
| SLIN 0005AD | Optional WCMSA Recomm Additional Quantity - Part D | 3,000 | $ - 0 | $ - 0 |
| SLIN 0005AE | Optional WCMSA Recomm Additional Quantity - MIP | 3,000 | $ - 0 | $ - 0 |
| SLIN 0005AF | Optional WCMSA Recomm Additional Quantity - Part D | 3,000 | $ - 0 | $ - 0 |
| Optional NGHP Price Per LMSA Recommendation | ||||
| SLIN 0005AK | Optional LMSA & NFMSA Recomm - MIP | 1,000 | $ - 0 | $ - 0 |
| SLIN 0005AL | Optional LMSA & NFMSA Recomm- Part D | 1,000 | $ - 0 | $ - 0 |
| SLIN 0005AM | Optional LMSA & NFMSA Recomm Additional Quantity - MIP | 3,000 | $ - 0 | $ - 0 |
| SLIN 0005AN | Optional LMSA & NFMSA Recomm Additional Quantity- Part D | 3,000 | $ - 0 | $ - 0 |
| Total | $ - 0 | |||
| CLIN 0006 Option Year 4 (April 4, 2027- April 3, 2028). | Quantity (# of Proposal Submissions) | Unit Price (Per Recomm) | Total FFP |
| CLIN0006 | Price Per WCMSA Recommendation | |||
| SLIN 0006AA | WCMSA Recommendations - MIP | 19,200 | $ - 0 | $ - 0 |
| SLIN 0006AB | WCMSA Recommendations - Part D | 19,200 | $ - 0 | $ - 0 |
| SLIN 0006AC | Optional WCMSA Recomm Additional Quantity - MIP | 3,000 | $ - 0 | $ - 0 |
| SLIN 0006AD | Optional WCMSA Recomm Additional Quantity - Part D | 3,000 | $ - 0 | $ - 0 |
| SLIN 0006AE | Optional WCMSA Recomm Additional Quantity - MIP | 3,000 | $ - 0 | $ - 0 |
| SLIN 0006AF | Optional WCMSA Recomm Additional Quantity - Part D | 3,000 | $ - 0 | $ - 0 |
| Optional NGHP Price Per LMSA Recommendation | ||||
| SLIN 0006AK | Optional LMSA & NFMSA Recomm - MIP | 1,000 | $ - 0 | $ - 0 |
| SLIN 0006AL | Optional LMSA & NFMSA Recomm- Part D | 1,000 | $ - 0 | $ - 0 |
| SLIN 0006AM | Optional LMSA & NFMSA Recomm Additional Quantity - MIP | 3,000 | $ - 0 | $ - 0 |
| SLIN 0006AN | Optional LMSA & NFMSA Recomm Additional Quantity- Part D | 3,000 | $ - 0 | $ - 0 |
| Total | $ - 0 |
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