J-10_CLIN0002CostProposalTemplate.xls

XLS spreadsheet 495 KB Posted Aug 31, 2007

Attached to: A/B MAC CYCLE 2 JURISDICTION 6
Solicitation number: RFP-CMS-2007-0013
Issued by: Department of Health and Human Services Centers for Medicare and Medicaid Services

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J-10 CLIN 0002 Template

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File	Type	Posted
1_Amendment6-0013.pdf	PDF	Nov 29, 2007
2_RFP-CMS-2007-0013_Amendment5.zip	ZIP file	Nov 6, 2007
1_Amendment4.ZIP	ZIP file	Oct 25, 2007
1_0013Amendment000003.zip	ZIP file	Oct 19, 2007
RFP-CMS-2007-0013Amendment2.pdf	PDF	Oct 5, 2007
1_SF33RFP-CMS-2007-0013.pdf	PDF	Sep 25, 2007
J-17_WEDIAcknowledgementRecommendation(2).pdf	PDF	Sep 6, 2007
J-05_SmallBusinessSubcontractingPlan(2).pdf	PDF	Sep 5, 2007
J-07_BillingInstructions.doc	DOC document	Aug 31, 2007
J-16_NonDisclosureStatement.doc	DOC document	Aug 31, 2007
J-09_CLIN0001CostProposalTemplate.xls	XLS spreadsheet	Aug 31, 2007
J-12_CLIN0008CostProposalTemplate.xls	XLS spreadsheet	Aug 31, 2007
J-02_CategoriesOfBenefitsAndProviderTypes.doc	DOC document	Aug 31, 2007
J-08_CostProposalInstructions.xls	XLS spreadsheet	Aug 31, 2007
J-04_ProviderBankruptcyChecklist.doc	DOC document	Aug 31, 2007
J-14_ProposalChecklist.doc	DOC document	Aug 31, 2007
CycleTwoRFP2rfpcoverletter(2).doc	DOC document	Aug 31, 2007
J-11_CLIN0007CostProposalTemplate.xls	XLS spreadsheet	Aug 31, 2007
J-03_RequirementsForPerformingSAS70Audit.doc	DOC document	Aug 31, 2007
J-01_AB_MAC_Statement_of_WorkAppendicesRFP-CMS-2007-0013.doc	DOC document	Aug 31, 2007
SF33RFP-CMS-2007-0013.pdf	PDF	Aug 31, 2007
J-01_AB_MAC_Statement_of_WorkRFP-CMS-2007-0013083107.doc	DOC document	Aug 31, 2007
J-15_DirectionsToCentralOffice.pdf	PDF	Aug 31, 2007
CycleTwoRFP2FINALJ6J11J14J15.doc	DOC document	Aug 31, 2007
J-06_Reserved.doc	DOC document	Aug 31, 2007
J-13_StaffPlanTemplate.xls	XLS spreadsheet	Aug 31, 2007

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CLIN-0002

COST TEMPLATE - SAMPLE Attachment J-10
(Provide a cost spreadsheet for each CLIN proposed)
CLIN 0002		SLIN 0002AA			SLIN 0002AB			SLIN 0002AC			SLIN 0002AD
A/B SERVICES/BASE YEAR	Total FTEs	Part A/Program Management (PM)			Part A/Medicare Integrity Program (MIP)			Part B/Program Management (PM)			Part B/Medicare Integrity Program (MIP)			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	$0.00
		0		$0	0		$0	0		$0	0		$0	0	$0.00
		0		$0	0		$0	0		$0	0		$0	0	$0.00
		0		$0	0		$0	0		$0	0		$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)		0		$0	0		$0	0		$0	0		$0	0	$0.00
		0		$0	0		$0	0		$0	0		$0	0	$0.00
		0		$0	0		$0	0		$0	0		$0	0	$0.00
		0		$0	0		$0	0		$0	0		$0	0	$0.00
		0		$0	0		$0	0		$0	0		$0	0	$0.00
		0		$1	0		$0	0		$0	0		$0	0	$1.00
Subtotal Direct Labor		0		$0	0		$0	0		$0	0		$0	0	$0.00
Fringe Benefits (at ____%)				$0		0.00%	$0		0.00%	$0		0.00%	$0	0.00%	$0
Total Direct Labor				$0			$0			$0			$0		$0
Travel (See separate schedule. Total should match)				$0			$0			$0			$0		$0.00
SUBCONTRACTORS															$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Total Subcontractor		0		$0	0		$0	0		$0	0		$0	0	$0.00
Other Direct Costs (See separate schedule. Total should match.)				$0			$0			$0			$0		$0.00
SUBTOTAL ALL DIRECT COSTS				$0			$0			$0			$0		$0.00
Indirect Costs (at ______ %)				$0			$0			$0			$0		$0.00
SUBTOTAL COSTS BEFORE FEE				$0			$0			$0			$0		$0.00
Base Fee (at ____%)				$0			$0			$0			$0		$0.00
Award Fee (at ______%)				$0			$0			$0			$0		$0.00
TOTAL COSTS				$0			$0			$0			$0		$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.
TOTAL COSTS

&C&"Arial,Bold"&12RFP-CMS-2007-0013 PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number

Attachment J-10&C&A&R&P

ODC

ODC SCHEDULE - SAMPLE
(Provide an ODC Spreadsheet for each CLIN Proposed)
CLIN 0002 A/B SERVICES	SLIN 0002AA	SLIN 0002AB	SLIN 0002AC	SLIN 0002AD	GRAND
Cost Element	Amount	Amount	Amount	Amount	TOTAL
Add costs by category					$0.00
					$0.00
					$0.00
					$0.00
					$0.00
					$0.00
TOTAL ODCs	$0.00	$0.00	$0.00	$0.00	$0.00

&C&"Arial,Bold"&12RFP-CMS-2007-0013 PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number

Attachment J-10&C&A&R&P

TRAVEL

TRAVEL SCHEDULE - SAMPLE
(Provide a Travel Spreadsheet for each CLIN)
CLIN	Enter Purpose Here				Enter Purpose Here				Enter Purpose Here				Enter Purpose Here				Enter Purpose Here				Enter Purpose Here				Enter Purpose Here				Enter Purpose Here				Enter Purpose Here				GRAND TOTAL
	No.	#			No.	#			No.	#			No.	#			No.	#			No.	#			No.	#			No.	#			No.	#
Travel to: (Destination/Purpose)	People (A)	Trips/Days (B)	Amount (C)	TOTAL ((A) X (B)) X (C)	People (A)	Trips/Days (B)	Amount (C)	TOTAL ((A) X (B)) X (C)	People (A)	Trips/Days (B)	Amount (C)	TOTAL ((A) X (B)) X (C)	People (A)	Trips/Days (B)	Amount (C)	TOTAL ((A)X(B)) X (C)	People (A)	Trips/Days (B)	Amount (C)	TOTAL ((A)X(B)) X (C)	People (A)	Trips/Days (B)	Amount (C)	TOTAL ((A)X(B)) X (C)	People (A)	Trips/Days (B)	Amount (C)	TOTAL ((A)X(B)) X (C)	People (A)	Trips/Days (B)	Amount (C)	TOTAL ((A)X(B)) X (C)	People (A)	Trips/Days (B)	Amount (C)	TOTAL ((A)X(B)) X (C)	TOTAL TRAVEL COSTS
Airfare				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00	$0.00
Per Diem(SUM OF HOTEL/M&I)				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00	$0.00
Hotel
Meals and Incidentals(M&I)
Car Rental				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00	$0.00
Local Trips				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00	$0.00
Mileage				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00	$0.00
Parking, Taxis, Other				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00				$0.00	$0.00
Total Travel	0	0	0	$0.00	0	0	0	$0.00	0	0	0	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00

&C&"Arial,Bold"&12RFP-CMS-2007-0013 PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number

Attachment J-10&C&A&R&P

SLIN-0002AA

COST TEMPLATE - SAMPLE Attachment J-10
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AA		C.1.4.4			C.5.3			C.5.4			C.5.5			C.5.6			C.5.7			C.5.8			C.5.9			C.5.10			C.5.11			C.5.18			C.5.19			C.5.20			C.5.22			C.5.23			C.5.24
A/B SERVICES/OPTION YEAR 1	Total FTEs	Home Health and Hospice Requirments (J6, J11, J14, and J15 Only)			Infrastructure			Administration			Provider Enrollment			LCDs			Provider Customer Service			Claims Processing			Reopenings of Initial Claims Determinations			Appeals of Initial Claims Determinations			FM of Trust Fund			Freestanding RHCs			FQHCs			Foreign Claims			Shipboard/Foreign Travel			PM Office			Medicare Contractor Provider Satisfaction Survey
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	Total
COST ELEMENTS
Direct Labor
		0		$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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0
		0		$0	0		$0	0		$0	0	$0.00	$0	0	$0.00	$0	0		$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	$0.00	$0
		0		$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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0
		0		$0	0		$0	0		$0	0	$0.00	$0	0	$0.00	$0	0		$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	$0.00	$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	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	$0.00	$0
		0		$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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0
		0		$0	0		$0	0		$0	0	$0.00	$0	0	$0.00	$0	0		$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	$0.00	$0
		0		$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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0
		0		$0	0		$0	0		$0	0	$0.00	$0	0	$0.00	$0	0		$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	$0.00	$0
		0		$1	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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$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
Fringe Benefits (at ____%)			0%	$0		0%	$0		0%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0
Total Direct Labor				$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
SUBCONTRACTORS
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
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
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
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
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
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
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
Other Direct Costs				$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
Indirect Costs (at ______ %)			0%	$0		0%	$0		0%	$0		0%	$0		0%	$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0
SUBTOTAL COSTS BEFORE FEE				$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
Award Fee (at ______%)			$0	$0		$0	$0		$0	$0		0.00%	$0		0.00%	$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0
TOTAL COSTS				$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$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.
TOTAL COSTS

&C&"Arial,Bold"&12RFP-CMS-2007-0013 PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number

Attachment J-10&C&A&R&P

C.5.3

COST TEMPLATE - SAMPLE Attachment J-10
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AA - C.5.3		C.5.3.1			C.5.3.2			C.5.3.3			C.5.3.4
A/B SERVICES	Total FTEs	EDC			Telecommunications			Telephone Service			Audits/Reviews			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	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
			$0.00	$0		$0.00	$0		$0.00	$0		$1.00	$0	0	$0.00
Subtotal Direct Labor		0		$0	0		$0	0		$0	0		$0	0	$0.00
Fringe Benefits (at ____%)			0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0	0.00%	$0
Total Direct Labor				$0			$0			$0			$0		$0
Travel (See separate schedule)				$0			$0			$0			$0		$0.00
SUBCONTRACTORS															$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Total Subcontractor		0		$0	0		$0	0		$0	0		$0	0	$0.00
Other Direct Costs				$0			$0			$0			$0		$0.00
SUBTOTAL ALL DIRECT COSTS				$0			$0			$0			$0		$0.00
Indirect Costs (at ______ %)			0%	$0		0%	$0		0%	$0		0%	$0		$0.00
SUBTOTAL COSTS BEFORE FEE				$0			$0			$0			$0		$0.00
Base Fee (at ____%)				$0			$0			$0			$0		$0.00
Award Fee (at ______%)				$0			$0			$0			$0		$0.00
TOTAL COSTS				$0			$0			$0			$0		$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.
TOTAL COSTS

&C&"Arial,Bold"&12RFP-CMS-2007-0013 PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number

Attachment J-10&C&A&R&P

C.5.4

COST TEMPLATE - SAMPLE Attachment J-10
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AA - 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			C.5.4.8			C.5.4.9			C.5.4.10			C.5.4.11			C.5.4.12
A/B SERVICES	Total FTEs	Key Personnel			Reserved for (Background Checks)			Security			Quality Control and Improve			Public Relations			Congress Inquiries			Conferences/Meetings			Change Management			BCP/Disaster Recovery			Internal Control			Compliance Program			Chain Provider Orgs			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	$0.00	$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
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
		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
		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
		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
			$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$1.00	$0		$1.00	$0		$1.00	$0		$1.00	$0		$1.00	$0		$1.00	$0		$1.00	$0		$1.00	$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
Fringe Benefits (at ____%)			0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0	0	$0
Total Direct Labor				$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
SUBCONTRACTORS
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
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
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
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
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
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
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
Other Direct Costs				$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
Indirect Costs (at ______ %)			0%	$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 COSTS BEFORE FEE				$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
Award Fee (at ______%)				$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0		$0
TOTAL COSTS				$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0		$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.
TOTAL COSTS

&C&"Arial,Bold"&12RFP-CMS-2007-0013 PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number

Attachment J-10&C&A&R&P

C.5.7

COST TEMPLATE - SAMPLE Attachment J-10
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AA - C.5.7		C.5.7.1			C.5.7.2			C.5.7.3
A/B SERVICES	Total FTEs	Provider Education & Outreach			Provider Contact Center			Provider Technology			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	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0		$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0		$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0		$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)		0	$0.00	$0	0	$0.00	$0	0		$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0		$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0		$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0		$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0		$0	0	$0.00
			$0.00	$0		$0.00	$0	0		$0	0	$0.00
Subtotal Direct Labor		0		$0	0		$0	0		$0	0	$0.00
Fringe Benefits (at ____%)			0.00%	$0		0.00%	$0		0.00%	$0	0.00%	$0
Total Direct Labor				$0			$0			$0		$0
Travel				$0			$0			$0		$0
SUBCONTRACTORS
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
Subcontractor Name		0		$0	0		$0	0		$0	0	$0
Total Subcontractor		0		$0	0		$0	0		$0	0	$0
Other Direct Costs				$0			$0			$0		$0.00
SUBTOTAL ALL DIRECT COSTS				$0			$0			$0		$0.00
Indirect Costs (at ______ %)			0%	$0		0%	$0		0%	$0		$0.00
SUBTOTAL COSTS BEFORE FEE				$0			$0			$0		$0.00
Base Fee (at ____%)				$0			$0			$0		$0.00
Award Fee (at ______%)				$0			$0		0.00%	$0		$0.00
TOTAL COSTS				$0			$0			$0		$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.
TOTAL COSTS

&C&"Arial,Bold"&12RFP-CMS-2007-0013 PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number

Attachment J-10&C&A&R&P

C.5.7.3

COST TEMPLATE - SAMPLE Attachment J-10
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AA - C.5.7.3		C.5.7.3.1
A/B SERVICES	Total FTEs	Interactive Voice Response
		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
		0	$0.00	$0
		0	$0.00	$0
		0	$0.00	$0
Subtotal Direct Labor		0		$0
Fringe Benefits (at ____%)			0.00%	$0
Total Direct Labor				$0
Travel				$0
SUBCONTRACTORS
Subcontractor Name		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				$0
SUBTOTAL ALL DIRECT COSTS				$0
Indirect Costs (at ______ %)			0%	$0
SUBTOTAL COSTS BEFORE FEE				$0
Base Fee (at ____%)				$0
Award Fee (at ______%)			0.00%	$0
TOTAL COSTS				$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.
TOTAL COSTS

&C&"Arial,Bold"&12RFP-CMS-2007-0013 PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number

Attachment J-10&C&A&R&P

C.5.8

COST TEMPLATE - SAMPLE Attachment J-10
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AA - C.5.8		C.5.8.1			C.5.8.2			C.5.8.3			C.5.8.4			C.5.8.5			C.5.8.6			C.5.8.7
A/B SERVICES	Total FTEs	Paper Remittance Advice			General Claims Processing			Suspended Claims			Back-End Processing			Opt-out Payments			Physician Payments			CAP			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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		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
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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00	$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
			$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0.00
Subtotal Direct Labor		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Fringe Benefits (at ____%)			0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0	0.00%	$0.00
Total Direct Labor				$0			$0			$0			$0			$0			$0			$0		$0.00
Travel (See separate schedule)				$0			$0			$0			$0			$0			$0			$0		$0.00
SUBCONTRACTORS
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Total Subcontractor		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Other Direct Costs (See separate schedule)				$0			$0			$0			$0			$0			$0			$0		$0.00
SUBTOTAL ALL DIRECT COSTS				$0			$0			$0			$0			$0			$0			$0		$0.00
Indirect Costs (at ______ %)			0%	$0		0%	$0		0%	$0		0%	$0		0%	$0		0%	$0		0%	$0		$0.00
SUBTOTAL COSTS BEFORE FEE				$0			$0			$0			$0			$0			$0			$0		$0.00
Base Fee (at ____%)				$0			$0			$0			$0			$0			$0			$0		$0.00
Award Fee (at ______%)				$0			$0			$0			$0			$0			$0			$0		$0.00
TOTAL COSTS				$0			$0			$0			$0			$0			$0			$0		$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.
TOTAL COSTS

&C&"Arial,Bold"&12RFP-CMS-2007-0013 PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number

Attachment J-10&C&A&R&P

C.5.10

COST TEMPLATE - SAMPLE Attachment J-10
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AA - C.5.10		C.5.10.1			C.5.10.2			C.5.10.3			C.5.10.4
A/B SERVICES	Total FTEs	Reterminations			Appeal Decision Effectuation			MSR on Appeals			Quality Improvement / Data Analysis			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	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
			$0.00	$0		$0.00	$0		$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor		0		$0	0		$0	0		$0	0		$0	0	$0.00
Fringe Benefits (at ____%)			0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0	0.00%	$0
Total Direct Labor				$0			$0			$0			$0		$0
Travel				$0			$0			$0			$0		$0.00
SUBCONTRACTORS
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Total Subcontractor		0		$0	0		$0	0		$0	0		$0	0	$0.00
Other Direct Costs				$0			$0			$0			$0		$0.00
SUBTOTAL ALL DIRECT COSTS				$0			$0			$0			$0		$0.00
Indirect Costs (at ______ %)			0%	$0		0%	$0		0%	$0		0%	$0		$0.00
SUBTOTAL COSTS BEFORE FEE				$0			$0			$0			$0		$0.00
Base Fee (at ____%)				$0			$0			$0			$0		$0.00
Award Fee (at ______%)				$0			$0			$0			$0		$0.00
TOTAL COSTS				$0			$0			$0			$0		$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.
TOTAL COSTS

&C&"Arial,Bold"&12RFP-CMS-2007-0013 PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number

Attachment J-10&C&A&R&P

C.5.11

COST TEMPLATE - SAMPLE Attachment J-10
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AA - C.5.11		C.5.11.1			C.5.11.2			C.5.11.4			C.5.11.5			C.5.11.6			C.5.11.7			C.5.11.8			C.5.11.9
A/B SERVICES	Total FTEs	Use of Trust Fund			Banking Relations			Non-MSP Overpay			Non-MSP Debt Collection			Non-Medicare Secondary Payer Debt Referral			Reserved for (Refund Request)			Overpay Bankruptcy			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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		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
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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00	$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
Subtotal Direct Labor		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Fringe Benefits (at ____%)			0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		$0.00
Total Direct Labor				$0			$0			$0			$0			$0			$0			$0			$0		$0.00
Travel				$0			$0			$0			$0			$0			$0			$0			$0		$0.00
SUBCONTRACTORS																											$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Total Subcontractor		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Other Direct Costs				$0			$0			$0			$0			$0			$0			$0			$0		$0.00
SUBTOTAL ALL DIRECT COSTS				$0			$0			$0			$0			$0			$0			$0			$0		$0.00
Indirect Costs (at ______ %)			0%	$0		0%	$0		0%	$0		0%	$0		0%	$0		0%	$0		0%	$0		0%	$0		$0.00
SUBTOTAL COSTS BEFORE FEE				$0			$0			$0			$0			$0			$0			$0			$0		$0.00
Base Fee (at ____%)				$0			$0			$0			$0			$0			$0			$0			$0		$0.00
Award Fee (at ______%)			0%	$0		0%	$0		0%	$0		0%	$0		0%	$0		0%	$0		0%	$0		0%	$0		$0.00
TOTAL COSTS				$0			$0			$0			$0			$0			$0			$0			$0		$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.
TOTAL COSTS

&C&"Arial,Bold"&12RFP-CMS-2007-0013 PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number

Attachment J-10&C&A&R&P

SLIN-0002AB

COST TEMPLATE - SAMPLE Attachment J-10
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AB		C.1.4.4			C.5.7			C.5.11			C.5.12			C.5.13			C.5.14
A/B SERVICES/BASE YEAR	Total FTEs	Home Health and Hospice Requirements (J6, J11, J14, and J15 Only)			Provider Customer Service			FM of Trust Fund			Medical Review			Coordination with PSCs			MSP			GRAND TOTAL
Medicare Integrity Program		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	0	$0.00	$0	0		$0	0	$0.00
		0		$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	$0.00	$0	0		$0	0	$0.00
		0		$0	0		$0	0		$0	0		$0	0	$0.00	$0	0		$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)		0		$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	$0.00	$0	0		$0	0	$0.00
		0		$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	$0.00	$0	0		$0	0	$0.00
		0		$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	$0.00	$0	0		$0	0	$0.00
Subtotal Direct Labor		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Fringe Benefits (at ____%)			0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0	0.00%	$0.00
Total Direct Labor				$0			$0			$0			$0			$0			$0		$0.00
Travel				$0			$0			$0			$0			$0			$0		$0.00
SUBCONTRACTORS
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Total Subcontractor		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Other Direct Costs				$0			$0			$0			$0			$0			$0		$0.00
SUBTOTAL ALL DIRECT COSTS				$0			$0			$0			$0			$0			$0		$0.00
Indirect Costs (at ______ %)				$0			$0			$0			$0		0%	$0			$0		$0.00
SUBTOTAL COSTS BEFORE FEE				$0			$0			$0			$0			$0			$0		$0.00
Base Fee (at ____%)				$0			$0			$0			$0			$0			$0		$0.00
Award Fee (at ______%)				$0			$0			$0			$0		0%	$0			$0		$0.00
TOTAL COSTS				$0			$0			$0			$0			$0			$0		$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.
TOTAL COSTS

&C&"Arial,Bold"&12RFP-CMS-2007-0013 PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number

Attachment J-10&C&A&R&P

C.5.7-2

COST TEMPLATE - SAMPLE Attachment J-10
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AB - C.5.7		C.5.7.1
A/B SERVICES	Total FTEs	Provider Education & Outreach
		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
		0	$0.00	$0
		0	$0.00	$0
		0	$0.00	$0
Subtotal Direct Labor		0		$0
Fringe Benefits (at ____%)			0.00%	$0
Total Direct Labor				$0
Travel				$0
SUBCONTRACTORS
Subcontractor Name		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				$0
SUBTOTAL ALL DIRECT COSTS				$0
Indirect Costs (at ______ %)			0%	$0
SUBTOTAL COSTS BEFORE FEE				$0
Base Fee (at ____%)				$0
Award Fee (at ______%)			0%	$0
TOTAL COSTS				$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.
TOTAL COSTS

&C&"Arial,Bold"&12RFP-CMS-2007-0013 PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number

Attachment J-10&C&A&R&P

C.5.11-2

COST TEMPLATE - SAMPLE Attachment J-10
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AB - C.5.11		C.5.11.3
A/B SERVICES	Total FTEs	Cost Reporting
		Hours	Rates	Total
COST ELEMENTS
Direct Labor
		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
Subtotal Direct Labor		0		$0
Fringe Benefits (at ____%)			0.00%	$0
Total Direct Labor				$0
Travel				$0
SUBCONTRACTORS
Subcontractor Name		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				$0
SUBTOTAL ALL DIRECT COSTS				$0
Indirect Costs (at ______ %)			0%	$0
SUBTOTAL COSTS BEFORE FEE				$0
Base Fee (at ____%)				$0
Award Fee (at ______%)			0%	$0
TOTAL COSTS				$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.
TOTAL COSTS

&C&"Arial,Bold"&12RFP-CMS-2007-0013 PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number

Attachment J-10&C&A&R&P

C.5.11.3

COST TEMPLATE - SAMPLE Attachment J-10
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AB - C.5.11.3		C.5.11.3.1			C.5.11.3.2			C.5.11.3.3
A/B SERVICES	Total FTEs	Medicare Cost Report			Audit of Cost Reports			Provider Reimbursement			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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor		0		$0	0		$0	0		$0	0	$0.00
Fringe Benefits (at ____%)			0.00%	$0		0.00%	$0		0.00%	$0	0.00%	$0.00
Total Direct Labor				$0			$0			$0		$0.00
Travel				$0			$0			$0		$0.00
SUBCONTRACTORS
Subcontractor Name		0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0	$0.00
Total Subcontractor		0		$0	0		$0	0		$0	0	$0.00
Other Direct Costs				$0			$0			$0		$0.00
SUBTOTAL ALL DIRECT COSTS				$0			$0			$0		$0.00
Indirect Costs (at ______ %)			0%	$0		0%	$0		0%	$0		$0.00
SUBTOTAL COSTS BEFORE FEE				$0			$0			$0		$0.00
Base Fee (at ____%)				$0			$0			$0		$0.00
Award Fee (at ______%)			0%	$0		0%	$0		0%	$0		$0.00
TOTAL COSTS				$0			$0			$0		$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.
TOTAL COSTS

&C&"Arial,Bold"&12RFP-CMS-2007-0013 PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number

Attachment J-10&C&A&R&P

C.5.12

COST TEMPLATE - SAMPLE Attachment J-10
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AB - C.5.12		C.5.12.1
A/B SERVICES	Total FTEs	Develop Strategy
		Hours	Rates	Total
COST ELEMENTS
Direct Labor
		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
		0	$0.00	$0
		0	$0.00	$0
		0	$0.00	$0
		0	$0.00	$0
		0	$0.00	$0
Subtotal Direct Labor		0		$0
Fringe Benefits (at ____%)			0.00%	$0
Total Direct Labor				$0
Travel				$0
SUBCONTRACTORS
Subcontractor Name		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				$0
SUBTOTAL ALL DIRECT COSTS				$0
Indirect Costs (at ______ %)			0%	$0
SUBTOTAL COSTS BEFORE FEE				$0
Base Fee (at ____%)				$0
Award Fee (at ______%)			0%	$0
TOTAL COSTS				$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.
TOTAL COSTS

&C&"Arial,Bold"&12RFP-CMS-2007-0013 PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number

Attachment J-10&C&A&R&P

C.5.14

COST TEMPLATE - SAMPLE Attachment J-10
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AB - C.5.14		C.5.14.1			C.5.14.2			C.5.14.3			C.5.14.4			C.5.14.5			C.5.14.6
A/B SERVICES	Total FTEs	MSP Operations			Electronic Coorespondence Referral System			Identify and Adjudicate			Transfer to COBC			Hospital Audits			MSP Post-Pay Recovery			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	$0.00
		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
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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Fringe Benefits (at ____%)			0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0	0.00%	$0.00
Total Direct Labor				$0			$0			$0			$0			$0			$0		$0.00
Travel				$0			$0			$0			$0			$0			$0		$0.00
SUBCONTRACTORS
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Total Subcontractor		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00
Other Direct Costs				$0			$0			$0			$0			$0			$0		$0.00
SUBTOTAL ALL DIRECT COSTS				$0			$0			$0			$0			$0			$0		$0.00
Indirect Costs (at ______ %)			0%	$0		0%	$0		0%	$0		0%	$0		0%	$0		0%	$0		$0.00
SUBTOTAL COSTS BEFORE FEE				$0			$0			$0			$0			$0			$0		$0.00
Base Fee (at ____%)				$0			$0			$0			$0			$0			$0		$0.00
Award Fee (at ______%)			0%	$0		0%	$0		0%	$0		0%	$0		0%	$0		0%	$0		$0.00
TOTAL COSTS				$0			$0			$0			$0			$0			$0		$0.00
Complementary Credits
Note: comp.credit information will be provided by CMS prior to final proposal revision. Offerors should not propose amounts at this time.
TOTAL COSTS

&C&"Arial,Bold"&12RFP-CMS-2007-0013 PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number

Attachment J-10&C&A&R&P

SLIN-0002AC

COST TEMPLATE - SAMPLE Attachment J-10
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AC		C.5.3			C.5.4			C.5.5			C.5.6			C.5.7			C.5.8			C.5.9			C.5.10			C.5.11			C.5.16			C.5.17			C.5.18			C.5.19			C.5.20			C.5.21			C.5.22
A/B SERVICES/BASE YEAR	Total FTEs	Infrastructure			Administration			Provider Enrollment			LCDs			Provider Customer Service			Claims Processing			Reopenings of Initial Claims Determinations			Appeals of Initial			FM of Trust Fund			Reserved for (Coordinated Care Benefits Demo)			ESRD Clinical Trial			Freestanding RHCs			FQHCs			Foreign Claims			Lab Competitive Bidding			Shipboard/Foreign Travel
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	Total
COST ELEMENTS
Direct Labor
		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	$0.00	$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	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	$0.00	$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	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	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	$0.00	$0	0	$0.00	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)		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	$0.00	$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	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	$0.00	$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	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	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	$0.00	$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	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	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	$0.00	$0	0	$0.00	$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
Fringe Benefits (at ____%)			0%	$0		0%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0
Total Direct Labor				$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
SUBCONTRACTORS
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
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
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
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
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
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
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
Other Direct Costs				$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
Indirect Costs (at ______ %)			$0	$0		$0	$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0
SUBTOTAL COSTS BEFORE FEE				$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
Award Fee (at ______%)			$0	$0		$0	$0		0.00%	$0		0.00%	$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0
TOTAL COSTS				$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$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.
TOTAL COSTS

&C&"Arial,Bold"&12RFP-CMS-2007-0013 PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number

Attachment J-10&C&A&R&P

C.5.3-2

COST TEMPLATE - SAMPLE Attachment J-10
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AC - C.5.3		C.5.3.1			C.5.3.2			C.5.3.3			C.5.3.4
A/B SERVICES	Total FTEs	EDC			Telecommunications			Telephone Service			Audits/Reviews			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	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor		0		$0	0		$0	0		$0	0		$0	0	$0.00
Fringe Benefits (at ____%)			0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0	0.00%	$0
Total Direct Labor				$0			$0			$0			$0		$0
Travel				$0			$0			$0			$0		$0.00
SUBCONTRACTORS
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0.00
Total Subcontractor		0		$0	0		$0	0		$0	0		$0	0	$0.00
Other Direct Costs				$0			$0			$0			$0		$0.00
SUBTOTAL ALL DIRECT COSTS				$0			$0			$0			$0		$0.00
Indirect Costs (at ______ %)			0%	$0		0%	$0		0%	$0		0%	$0		$0.00
SUBTOTAL COSTS BEFORE FEE				$0			$0			$0			$0		$0.00
Base Fee (at ____%)				$0			$0			$0			$0		$0.00
Award Fee (at ______%)			0%	$0		0%	$0		0%	$0		0%	$0		$0.00
TOTAL COSTS				$0			$0			$0			$0		$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.
TOTAL COSTS

&C&"Arial,Bold"&12RFP-CMS-2007-0013 PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number

Attachment J-10&C&A&R&P

C.5.4-2

COST TEMPLATE - SAMPLE Attachment J-10
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AC - 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			C.5.4.8			C.5.4.9			C.5.4.10			C.5.4.11			C.5.4.12
A/B SERVICES	Total FTEs	Key Personnel			Reserved (Background Checks)			Security			Quality Control and Improve			Public Relations			Congress Inquiries			Conferences/Meetings			Change Management			BCP/Disaster Recovery			Internal Control			Compliance Program			Chain Provider Orgs			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	$0.00	$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

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