J-11_CLIN_0002_Cost_Proposal_Templates_Base_Period.xls

XLS spreadsheet 417 KB Posted Jan 28, 2010

Attached to: DME MAC Jurisdiction A Federal contract opportunity
Solicitation number: RFP-CMS-2010-0004
Issued by: Department of Health and Human Services Centers for Medicare and Medicaid Services

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J-11_CLIN_0002_Cost_Proposal_Templates_Base_Period.xls

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Other files attached to DME MAC Jurisdiction A, newest first.
File	Type	Posted
J-16_CLIN_0007_Cost_Proposal_Templates_Close_Out_Period.xls	XLS spreadsheet	Jan 28, 2010
J-14_CLIN_0005_Cost_Proposal_Templates_Option_Period_3.xlsx	XLSX spreadsheet	Jan 28, 2010
J-5_GFP-GFI_DME_MAC JA.xlsx	XLSX spreadsheet	Jan 28, 2010
Amendment 000002 JA.docx	DOCX document	Jan 28, 2010
J-14_CLIN_0005_Cost_Proposal_Templates_Option_Period_3.xls	XLS spreadsheet	Jan 28, 2010
J-16_CLIN_0007_Cost_Proposal_Templates_Close_Out_Period.xlsx	XLSX spreadsheet	Jan 28, 2010
J-02_Deliverables_DME_MAC_redline.xlsx	XLSX spreadsheet	Jan 28, 2010
Amendment 00002.pdf	PDF	Jan 28, 2010
J-01_Statement_of_Work_redline.docx	DOCX document	Jan 28, 2010
Attachment J-19 Implementation Handbook redline.doc	DOC document	Jan 28, 2010
J-15_CLIN_0006_Cost_Proposal_Templates_Option_Period_4.xlsx	XLSX spreadsheet	Jan 28, 2010
J-13_CLIN_0004_Cost_Proposal_Templates_Option_Period_2.xls	XLS spreadsheet	Jan 28, 2010
J-13_CLIN_0004_Cost_Proposal_Templates_Option_Period_2.xlsx	XLSX spreadsheet	Jan 28, 2010
J-15_CLIN_0006_Cost_Proposal_Templates_Option_Period_4.xls	XLS spreadsheet	Jan 28, 2010
J-11_CLIN_0002_Cost_Proposal_Templates_Base_Period.xlsx	XLSX spreadsheet	Jan 28, 2010
J-12_CLIN_0003_Cost_Proposal_Templates_Option_Period_1.xlsx	XLSX spreadsheet	Jan 28, 2010
J-10_CLIN_0001_Cost_Proposal_Templates_Implementation.xls	XLS spreadsheet	Jan 28, 2010
RFP-CMS-2010-0004_DME MAC Juris A RFP Q As_ 01_28_10.xls	XLS spreadsheet	Jan 28, 2010
J-12_CLIN_0003_Cost_Proposal_Templates_Option_Period_1.xls	XLS spreadsheet	Jan 28, 2010
J-10_CLIN_0001_Cost_Proposal_Templates_Implementation.xlsx	XLSX spreadsheet	Jan 28, 2010
Amendment 00001 JA.docx	DOCX document	Jan 6, 2010
RFP-CMS-2010-0004_Jurisdiction A_SF30_Amendment 1.pdf	PDF	Jan 6, 2010
J-25_TravelTemplate JA.xlsx	XLSX spreadsheet	Jan 6, 2010
J-13 CLIN 0004 Cost Proposal Templates Option Period 2.xlsx	XLSX spreadsheet	Dec 30, 2009
J-01 Statement of Work 12-22-09.docx	DOCX document	Dec 30, 2009
J-09_Cost Proposal Instructions.xls	XLS spreadsheet	Dec 30, 2009
J-08 PastPerformanceQuestionnaire.doc	DOC document	Dec 30, 2009
J-18 NonDisclosure Statement.doc	DOC document	Dec 30, 2009
J-16 CLIN 0007 Cost Proposal Templates Close Out Period.xlsx	XLSX spreadsheet	Dec 30, 2009
J-04 Billing Instructions.doc	DOC document	Dec 30, 2009
J-01AA Base Reports PSCs ZPICs Need.xlsx	XLSX spreadsheet	Dec 30, 2009
J-21 Corporate Experience Attestation.doc	DOC document	Dec 30, 2009
J-14 CLIN 0005 Cost Proposal Templates Option Period 3.xlsx	XLSX spreadsheet	Dec 30, 2009
J-17 Proposal Checklist.doc	DOC document	Dec 30, 2009
J-20 Information Security Attestation.docx	DOCX document	Dec 30, 2009
J-19 Implementation Handbook.doc	DOC document	Dec 30, 2009
J-22 Contractors Guide for Gov Property 12 09 08.pdf	PDF	Dec 30, 2009
J-01A MAC Shared System BaseNonbase.doc	DOC document	Dec 30, 2009
J-24_DirectionsToCentralOffice.pdf	PDF	Dec 30, 2009
J-12 CLIN 0003 Cost Proposal Templates Option Period 1.xlsx	XLSX spreadsheet	Dec 30, 2009
Solicitation DME MAC A_coverletter.docx	DOCX document	Dec 30, 2009
RFP-CMS-2010-0004_Jurisdiction A_SF33.pdf	PDF	Dec 30, 2009
J-11 CLIN 0002 Cost Proposal Templates Base Period.xlsx	XLSX spreadsheet	Dec 30, 2009
J-07 Basis of Estimate.xlsx	XLSX spreadsheet	Dec 30, 2009
J-02 Deliverables_DME MAC.xlsx	XLSX spreadsheet	Dec 30, 2009
J-01B SoW appendices.doc	DOC document	Dec 30, 2009
J-10 CLIN 0001 Cost Proposal Templates Implementation.xlsx	XLSX spreadsheet	Dec 30, 2009
J-05 GFP-GFI_DME MAC.xlsx	XLSX spreadsheet	Dec 30, 2009
J-03 SmallBusinessSubcontractingPlan.doc	DOC document	Dec 30, 2009
DME MAC JA Section B thru M 12-30-09.docx	DOCX document	Dec 30, 2009

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CLIN-0002

COST TEMPLATE - SAMPLE Attachment J-11
(Provide a cost spreadsheet for each CLIN proposed)
CLIN 0002		SLIN 000XAA			SLIN 000XAB			SLIN 000XAC
DME SERVICES/Option YEAR	Total FTEs	Program Management (PM)			Medicare Integrity Program (MIP)			RAC Operations Support			GRAND TOTAL
		Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Total
COST ELEMENTS
Direct Labor
		0		$0	0		$0	0		$0	0	$0
		0		$0	0		$0	0		$0	0	$0
		0		$0	0		$0	0		$0	0	$0
		0		$0	0		$0	0		$0	0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)		0		$0	0		$0	0		$0	0	$0
		0		$0	0		$0	0		$0	0	$0
		0		$0	0		$0	0		$0	0	$0
		0		$0	0		$0	0		$0	0	$0
		0		$0	0		$0	0		$0	0	$0
		0		$0	0		$0	0		$0	0	$0
Subtotal Direct Labor		0		$0	0		$0	0		$0	0	$0
Fringe Benefits (at ____%)				$0			$0			$0		$0
Total Direct Labor				$0			$0			$0		$0
Travel				$0			$0			$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0		$0	0		$0	0		$0	0	$0
Other Direct Costs		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 (insert & list applicable elements below)				$0			$0			$0		$0
SUBTOTAL ALL DIRECT COSTS				$0			$0			$0		$0
Indirect Costs (at ______ %)				$0			$0			$0		$0
TOTAL OTHER BEFORE FEES				$0			$0			$0		$0
Base Fee (at ____%)				$0			$0			$0		$0
Award Fee (at ______%)				$0			$0			$0		$0
TOTOAL OTHER AFTER FEES				$0			$0			$0		$0
Complementary Credits				$0								$0
Note: comp.credit information will be provided by CMS prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL				$0			$0			$0		$0

&C&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0004&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number&KFF0000 Attachment J-11&C &R&P

ODC Schedule

COST TEMPLATE - SAMPLE Attachment J-11
(Provide an ODC Spreadsheet for each CLIN Proposed)
CLIN 0001 DME SERVICES
Cost Element	TOTAL
Add costs by category
TOTAL ODCs	$0.00

&L&"Arial,Bold"&12CMS-RFP-2010-0004 Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) &LAttachment J-11 CLIN 0002 Cost Proposal Template&R&P

SLIN-0002AA

	COST TEMPLATE - SAMPLE Attachment J-11
	(Provide a cost spreadsheet for each CLIN proposed)
	SLIN 0002AA		C.2			C.3			C.4			C.5			C.6			C.7			C.8			C.9			D.1			D.2			D.3			D.4			D.5			D.6			F			H
	DME SERVICES/Option YEAR	Total FTEs	Infrastructure Requirements			Administrative Requirements			Change Management Process Requirements			FM of Trust Fund Dollars			Contract Award & Monthly Requirements			Task Directives			FOIA Requests			Access to Systems			Bills/Claims Payment			Appeals			Reopenings			Paper Claims Adjustment Editing			Provider Customer Service Program			Medicare Beneficiary Ombudsman			Interface Requirements			Quality Assurance Requirements
(enter positive number)			AWARD FEE			GRAND TOTAL
	Program Management		Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates
	COST ELEMENTS
	Direct Labor
			0	$0.00	$0	0		$0	0	$0.00	$0	0		$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	0	$0.00	$0	0	$0.00	$0	0	$0.00
			0	$0.00	$0	0		$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	0		$0	0		$0	0	$0.00	$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
			0	$0.00	$0	0		$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	0		$0	0		$0	0	$0.00	$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
			0	$0.00	$0	0		$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	0		$0	0		$0	0	$0.00	$0	0		$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	0	$0.00	$0	0		$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	0	$0.00	$0	0	$0.00	$0	0	$0.00
			0	$0.00	$0	0		$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	0		$0	0		$0	0	$0.00	$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
			0	$0.00	$0	0		$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	0		$0	0		$0	0	$0.00	$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
			0	$0.00	$0	0		$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	0		$0	0		$0	0	$0.00	$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
			0	$0.00	$0	0		$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	0		$0	0		$0	0	$0.00	$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
			0	$0.00	$0	0		$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	0		$0	0		$0	0	$0.00	$0	0		$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	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0
	Fringe Benefits (at ____%)			0.00%	$0			$0		0.00%	$0			$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0			$0			$0			$0		0.00%	$0			$0		0.00%	$0		0.00%	$0		0.00%
	Total Direct Labor				$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0
	Travel				$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0
	SUBCONTRACTORS
	Subcontractor Name	(insert for each subcontractor, if applicable)	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0
	Other Direct Costs		0		$0	0		$0	0		$0	0		$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
	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
	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
	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
	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
	Other Direct Costs (insert & list applicable elements below)				$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0
	SUBTOTAL ALL DIRECT COSTS				$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0
	Indirect Costs (at ______ %)			0.00%	$0			$0		0.00%	$0			$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0			$0			$0			$0		0.00%	$0			$0		0.00%	$0		0.00%	$0		0.00%
	TOTAL OTHER BEFORE FEES				$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0
	Base Fee (at ____%)			0.00%	$0			$0		0.00%	$0			$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0			$0			$0			$0		0.00%	$0			$0		0.00%	$0		0.00%	$0		0.00%
	Award Fee (at ______%)
	TOTAL OTHER AFTER FEES				$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.
	GRAND TOTAL

&C&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0004&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number&KFF0000 Attachment J-11&C &R&P

C.3

COST TEMPLATE - SAMPLE Attachment J-11
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AA - C.3		C.3.1			C.3.2			C.3.3			C.3.4			C.3.5
DME SERVICES/Option YEAR	Total FTEs	Security			Compliance Program			Internal Controls			Business Continuity Planning and Disaster Recovery			Participation in Conferences, Meetings and Work Groups			GRAND TOTAL
		Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Total
COST ELEMENTS
Direct Labor
		0	$0.00	$0	0	$0.00	$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
		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
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
		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
		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
			$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0
Subtotal Direct Labor		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
Total Direct Labor				$0			$0			$0			$0			$0		$0
Travel				$0			$0			$0			$0			$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0
Other Direct Costs		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
Subcontractor Name		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
Subcontractor Name		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
Other Direct Costs (insert & list applicable elements below)				$0			$0			$0			$0			$0		$0
SUBTOTAL ALL DIRECT COSTS				$0			$0			$0			$0			$0		$0
Indirect Costs (at ______ %)			0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		$0
TOTAL OTHER BEFORE FEES				$0			$0			$0			$0			$0		$0
Base Fee (at ____%)			0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		$0
TOTAL OTHER AFTER FEES				$0			$0			$0			$0			$0		$0

&C&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0004&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number&KFF0000 Attachment J-11&C &R&P

C.5

COST TEMPLATE - SAMPLE Attachment J-11
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AA - C.5		C.5.1			C.5.2			C.5.3			C.5.4		C.5.5			C.5.7
DME SERVICES/Option YEAR	Total FTEs	Trust Fund			Banking Relations			Debt Collection			Overpayments		Debt Referral			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	0	$0.00	$0	0	$0.00	$0	0	$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
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	0	$0.00	$0	0	$0.00	$0	0	$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
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$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	0	$0.00	$0	0	$0.00	$0	0	$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
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$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	0	$0.00	$0	0	$0.00	$0	0	$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
Subtotal Direct Labor		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		0.00%	$0		0.00%	$0		$0
Total Direct Labor				$0			$0			$0		$0			$0			$0		$0
Travel				$0			$0			$0		$0			$0			$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0		$0	0		$0	0		$0	0	$0	0		$0	0		$0	0	$0
Other Direct Costs		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
Subcontractor Name		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
Subcontractor Name		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
Other Direct Costs (insert & list applicable elements below)				$0			$0			$0		$0			$0			$0		$0
SUBTOTAL ALL DIRECT COSTS				$0			$0			$0		$0			$0			$0		$0
Indirect Costs (at ______ %)			0.00%	$0		0.00%	$0		0.00%	$0		$0		0.00%	$0		0.00%	$0		$0
TOTAL OTHER BEFORE FEES				$0			$0			$0		$0			$0			$0		$0
Base Fee (at ____%)			0.00%	$0		0.00%	$0		0.00%	$0		$0		0.00%	$0			$0		$0
TOTAL OTHER AFTER FEES				$0			$0			$0		$0			$0			$0		$0

&C&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0004&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number&KFF0000 Attachment J-11&C &R&P

C.5.4

COST TEMPLATE - SAMPLE Attachment J-11
(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
DME SERVICES/Option YEAR	Total FTEs	Identify Overpayment Cause			ERP Applications			Limitation on Recoupment			Overpayment Related to Bankruptcy			Administrative Freeze Payments			Closed Bankruptcy Case			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
		0	$0.00	$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
		0	$0.00	$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
		0	$0.00	$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
		0	$0.00	$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
			$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0
Subtotal Direct Labor		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
Total Direct Labor				$0			$0			$0			$0			$0			$0		$0
Travel				$0			$0			$0			$0			$0			$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0
Other Direct Costs		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
Subcontractor Name		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
Subcontractor Name		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
Other Direct Costs (insert & list applicable elements below)				$0			$0			$0			$0			$0			$0		$0
SUBTOTAL ALL DIRECT COSTS				$0			$0			$0			$0			$0			$0		$0
Indirect Costs (at ______ %)			0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		$0
TOTAL OTHER BEFORE FEES				$0			$0			$0			$0			$0			$0		$0
Base Fee (at ____%)			0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		$0
TOTAL OTHER AFTER FEES				$0			$0			$0			$0			$0			$0		$0

&C&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0004&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number&KFF0000 Attachment J-11&C &R&P

D.1

COST TEMPLATE - SAMPLE Attachment J-11
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AA - D.1		D.1.1			D.1.2			D.1.3			D.1.4			D.1.5			D.1.6
DME SERVICES	Total FTEs	Medicare Front End Processing			General Claims Processing			Back-end Processing			Common Working File			DMEPOS Fee Schedule			ASCA Reviews			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	0		$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
		0		$0	0		$0	0		$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	0		$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
		0		$0	0		$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
		0		$0	0		$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
		0		$0	0		$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
		0		$0	0		$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
		0		$0	0		$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
		0		$0	0		$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
		0		$0	0		$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
Subtotal Direct Labor		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	0
Fringe Benefits (at ____%)				$0			$0			$0		0.00%	$0		0.00%	$0		0.00%	$0		0
Total Direct Labor				$0			$0			$0			$0			$0			$0		0
Travel				$0			$0			$0			$0			$0			$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	0
Other Direct Costs		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
Subcontractor Name		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
Subcontractor Name		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
Other Direct Costs (insert & list applicable elements below)				$0			$0			$0			$0			$0			$0		0
SUBTOTAL ALL DIRECT COSTS				$0			$0			$0			$0			$0			$0		0
Indirect Costs (at ______ %)				$0			$0			$0		0.00%	$0		0.00%	$0		0.00%	$0		0
TOTAL OTHER BEFORE FEES				$0			$0			$0			$0			$0			$0		0
Base Fee (at ____%)				$0			$0			$0		0.00%	$0		0.00%	$0		0.00%	$0		0
TOTAL OTHER AFTER FEES				$0			$0			$0			$0			$0			$0		0

&C&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0004&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number&KFF0000 Attachment J-11&C &R&P

D.1.1

COST TEMPLATE - SAMPLE Attachment J-11
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AA - D.1.1		D.1.1.1			D.1.1.2			D.1.1.3			D.1.1.4			D.1.1.5
DME SERVICES	Total FTEs	Electronic Data Interchange			Front-end for Paper Claims and SPRs			Misidrected Claims			Transition Support			Electronic Funds Transfer Authorization Agreement			GRAND TOTAL
		Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Total
COST ELEMENTS
Direct Labor
		0	$0.00	$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0		$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	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
			$0.00	$0	0		$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0
Subtotal Direct Labor		0		$0	0		$0	0		$0	0		$0	0		$0	0	$0
Fringe Benefits (at ____%)			0.00%	$0			$0		0.00%	$0		0.00%	$0		0.00%	$0		$0
Total Direct Labor				$0			$0			$0			$0			$0		$0
Travel				$0			$0			$0			$0			$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0
Other Direct Costs		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
Subcontractor Name		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
Subcontractor Name		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
Other Direct Costs (insert & list applicable elements below)				$0			$0			$0			$0			$0		$0
SUBTOTAL ALL DIRECT COSTS				$0			$0			$0			$0			$0		$0
Indirect Costs (at ______ %)			0.00%	$0			$0		0.00%	$0		0.00%	$0		0.00%	$0		$0
TOTAL OTHER BEFORE FEES				$0			$0			$0			$0			$0		$0
Base Fee (at ____%)			0.00%	$0			$0		0.00%	$0		0.00%	$0		0.00%	$0		$0
TOTAL OTHER AFTER FEES				$0			$0			$0			$0			$0		$0

&C&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0004&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number&KFF0000 Attachment J-11&C &R&P

D.1.1.2

COST TEMPLATE - SAMPLE Attachment J-11
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AA - D.1.1.2		D.1.1.2.1			D.1.1.2.2
DME SERVICES	Total FTEs	Manage Paper Bills/Claims			EDI Support Related to Front-End paper Claims and Transactions			GRAND 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	$0.00	$0	0	$0
		0	$0.00	$0	0	$0.00	$0	0	$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
		0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0	$0.00	$0	0	$0
			$0.00	$0		$0.00	$0	0	$0
Subtotal Direct Labor		0		$0	0		$0	0	$0
Fringe Benefits (at ____%)			0.00%	$0		0.00%	$0		$0
Total Direct Labor				$0			$0		$0
Travel				$0			$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0		$0	0		$0	0	$0
Other Direct Costs		0		$0	0		$0	0	$0
Subcontractor Name		0		$0	0		$0	0	$0
Subcontractor Name		0		$0	0		$0	0	$0
Subcontractor Name		0		$0	0		$0	0	$0
Subcontractor Name		0		$0	0		$0	0	$0
Total Subcontractor		0		$0	0		$0	0	$0
Other Direct Costs (insert & list applicable elements below)				$0			$0		$0
SUBTOTAL ALL DIRECT COSTS				$0			$0		$0
Indirect Costs (at ______ %)			0.00%	$0		0.00%	$0		$0
TOTAL OTHER BEFORE FEES				$0			$0		$0
Base Fee (at ____%)			0.00%	$0		0.00%	$0		$0
TOTAL OTHER AFTER FEES				$0			$0		$0

&C&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0004&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number&KFF0000 Attachment J-11&C &R&P

D.1.2

COST TEMPLATE - SAMPLE Attachment J-11
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AA - D.1.2		D.1.2.1			D.1.2.2			D.1.2.3			D.1.2.4			D.1.2.5			D.1.2.6			D.1.2.7
DME SERVICES	Total FTEs	Run Systems			EDI Support Related to General Claims Processing			Report Claims Processing Problems			Handling Incomplete or Invalid Claims			Resolve Claims Transaction Replies and Unsolicited Responses from CWF			Processing Claims			NPI			GRAND TOTAL
		Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Total
COST ELEMENTS
Direct Labor
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0		$0	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	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	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	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	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	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	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	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	0	$0.00	$0	0	$0
			$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0	0		$0		$0.00	$0	0	$0
Subtotal Direct Labor		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0
Fringe Benefits (at ____%)			0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0			$0		0.00%	$0		$0
Total Direct Labor				$0			$0			$0			$0			$0			$0			$0		$0
Travel				$0			$0			$0			$0			$0			$0			$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0
Other Direct Costs		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
Subcontractor Name		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
Subcontractor Name		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
Other Direct Costs (insert & list applicable elements below)				$0			$0			$0			$0			$0			$0			$0		$0
SUBTOTAL ALL DIRECT COSTS				$0			$0			$0			$0			$0			$0			$0		$0
Indirect Costs (at ______ %)			0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0			$0		0.00%	$0		$0
TOTAL OTHER BEFORE FEES				$0			$0			$0			$0			$0			$0			$0		$0
Base Fee (at ____%)			0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0			$0		0.00%	$0		$0
TOTAL OTHER AFTER FEES				$0			$0			$0			$0			$0			$0			$0		$0

&C&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0004&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number&KFF0000 Attachment J-11&C &R&P

D.1.2.6

COST TEMPLATE - SAMPLE Attachment J-11
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AA - D.1.2.6		D.1.2.6.1			D.1.2.6.2			D.1.2.6.3
DME SERVICES	Total FTEs	Bills/Claims Determination			Payment of Claims			Payment of Claims outside of CWF			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
		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
		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
		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
		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
			$0.00	$0		$0.00	$0		$0.00	$0	0	0
Subtotal Direct Labor		0		$0	0		$0	0		$0	0	0
Fringe Benefits (at ____%)			0.00%	$0		0.00%	$0		0.00%	$0		0
Total Direct Labor				$0			$0			$0		0
Travel				$0			$0			$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0		$0	0		$0	0		$0	0	0
Other Direct Costs		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 (insert & list applicable elements below)				$0			$0			$0		0
SUBTOTAL ALL DIRECT COSTS				$0			$0			$0		0
Indirect Costs (at ______ %)			0.00%	$0		0.00%	$0		0.00%	$0		0
TOTAL OTHER BEFORE FEES				$0			$0			$0		0
Base Fee (at ____%)			0.00%	$0		0.00%	$0		0.00%	$0		0
TOTAL OTHER AFTER FEES				$0			$0			$0		0

&C&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0004&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number&KFF0000 Attachment J-11&C &R&P

D.1.3

COST TEMPLATE - SAMPLE Attachment J-11
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AA - D.1.3		D.1.3.1			D.1.3.2
DME SERVICES	Total FTEs	Generate & Deliver SPRs and MSNs			Transfer Claims Info to COBC			GRAND 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	$0.00	$0	0	$0
		0	$0.00	$0	0	$0.00	$0	0	$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
		0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0	$0.00	$0	0	$0
			$0.00	$0		$0.00	$0	0	$0
Subtotal Direct Labor		0		$0	0		$0	0	$0
Fringe Benefits (at ____%)			0.00%	$0		0.00%	$0		$0
Total Direct Labor				$0			$0		$0
Travel				$0			$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0		$0	0		$0	0	$0
Other Direct Costs		0		$0	0		$0	0	$0
Subcontractor Name		0		$0	0		$0	0	$0
Subcontractor Name		0		$0	0		$0	0	$0
Subcontractor Name		0		$0	0		$0	0	$0
Subcontractor Name		0		$0	0		$0	0	$0
Total Subcontractor		0		$0	0		$0	0	$0
Other Direct Costs (insert & list applicable elements below)				$0			$0		$0
SUBTOTAL ALL DIRECT COSTS				$0			$0		$0
Indirect Costs (at ______ %)			0.00%	$0		0.00%	$0		$0
TOTAL OTHER BEFORE FEES				$0			$0		$0
Base Fee (at ____%)			0.00%	$0		0.00%	$0		$0
TOTAL OTHER AFTER FEES				$0			$0		$0

&C&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0004&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number&KFF0000 Attachment J-11&C &R&P

D.2

COST TEMPLATE - SAMPLE Attachment J-11
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AA - D.2		D.2.1			D.2.2			D.2.3			D.2.4			D.2.5			D.2.6			D.2.7
DME SERVICES	Total FTEs	Appeals of Medicare Initial Claims Determinations			Appeal Decision Effectuation			QICs			Incomplete Redetermination Requests			Part B Quality Improvement/ Data Analysis			Document Imaging			ALJ Hearings			GRAND TOTAL
		Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Total
COST ELEMENTS
Direct Labor
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0	$0.00	$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
		0	$0.00	$0	0	$0.00	$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
		0	$0.00	$0	0	$0.00	$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
		0	$0.00	$0	0	$0.00	$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
			$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0
Subtotal Direct Labor		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0
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
Total Direct Labor				$0			$0			$0			$0			$0			$0			$0		$0
Travel				$0			$0			$0			$0			$0			$0			$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0
Other Direct Costs		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
Subcontractor Name		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
Subcontractor Name		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
Other Direct Costs (insert & list applicable elements below)				$0			$0			$0			$0			$0			$0			$0		$0
SUBTOTAL ALL DIRECT COSTS				$0			$0			$0			$0			$0			$0			$0		$0
Indirect Costs (at ______ %)			0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		$0
TOTAL OTHER BEFORE FEES				$0			$0			$0			$0			$0			$0			$0		$0
Base Fee (at ____%)			0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		0.00%	$0		$0
TOTAL OTHER AFTER FEES				$0			$0			$0			$0			$0			$0			$0		$0

&C&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0004&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number&KFF0000 Attachment J-11&C &R&P

D.3

COST TEMPLATE - SAMPLE Attachment J-11
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AA - D.3		D.3.1			D.3.3
DME SERVICES	Total FTEs	Clerical Error Reopenings			Telephone Reopenings			GRAND 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	$0.00	$0	0	$0
		0	$0.00	$0	0	$0.00	$0	0	$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
		0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0	$0.00	$0	0	$0
			$0.00	$0		$0.00	$0	0	$0
Subtotal Direct Labor		0		$0	0		$0	0	$0
Fringe Benefits (at ____%)			0.00%	$0		0.00%	$0		$0
Total Direct Labor				$0			$0		$0
Travel				$0			$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0		$0	0		$0	0	$0
Other Direct Costs		0		$0	0		$0	0	$0
Subcontractor Name		0		$0	0		$0	0	$0
Subcontractor Name		0		$0	0		$0	0	$0
Subcontractor Name		0		$0	0		$0	0	$0
Subcontractor Name		0		$0	0		$0	0	$0
Total Subcontractor		0		$0	0		$0	0	$0
Other Direct Costs (insert & list applicable elements below)				$0			$0		$0
SUBTOTAL ALL DIRECT COSTS				$0			$0		$0
Indirect Costs (at ______ %)			0.00%	$0		0.00%	$0		$0
TOTAL OTHER BEFORE FEES				$0			$0		$0
Base Fee (at ____%)			0.00%	$0		0.00%	$0		$0
TOTAL OTHER AFTER FEES				$0			$0		$0

&C&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0004&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number&KFF0000 Attachment J-11&C &R&P

D.5

COST TEMPLATE - SAMPLE Attachment J-11
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AA - D.5		D.5.1			D.5.2			D.5.3			D.5.4			D.5.5
DME SERVICES	Total FTEs	Provider Outreach & Education			Provider Contact Center			Provider Self-Service Technology			PCSP Training			MCPSS			GRAND TOTAL
		Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Total
COST ELEMENTS
Direct Labor
		0	$0.00	$0	0		$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0		$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0		$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0		$0	0		$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	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0		$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0		$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0		$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0		$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0
			$0.00	$0	0		$0	0		$0	0	$0.00	$0	0	$0.00	$0	0	$0
Subtotal Direct Labor		0		$0	0		$0	0		$0	0		$0	0		$0	0	$0
Fringe Benefits (at ____%)			0.00%	$0			$0			$0		0.00%	$0		0.00%	$0		$0
Total Direct Labor				$0			$0			$0			$0			$0		$0
Travel				$0			$0			$0			$0			$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0
Other Direct Costs		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
Subcontractor Name		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
Subcontractor Name		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
Other Direct Costs (insert & list applicable elements below)				$0			$0			$0			$0			$0		$0
SUBTOTAL ALL DIRECT COSTS				$0			$0			$0			$0			$0		$0
Indirect Costs (at ______ %)			0.00%	$0			$0			$0		0.00%	$0		0.00%	$0		$0
TOTAL OTHER BEFORE FEES				$0			$0			$0			$0			$0		$0
Base Fee (at ____%)			0.00%	$0			$0			$0		0.00%	$0		0.00%	$0		$0
TOTAL OTHER AFTER FEES				$0			$0			$0			$0			$0		$0

&C&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0004&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number&KFF0000 Attachment J-11&C &R&P

D.5.2

COST TEMPLATE - SAMPLE Attachment J-11
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AA - D.5.2		D.5.2.1			D.5.2.2			D.5.2.3			D.5.2.4
DME SERVICES	Total FTEs	Telephone Inquiries			Written Inquiries			Provider Relations Research Specialists			Inquiry Tracking System			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	$0
		0	$0.00	$0	0	$0.00	$0	0		$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	0	$0.00	$0	0	$0
		0	$0.00	$0	0	$0.00	$0	0		$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0	$0.00	$0	0		$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0	$0.00	$0	0		$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0	$0.00	$0	0		$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0	$0.00	$0	0		$0	0	$0.00	$0	0	$0
		0	$0.00	$0	0	$0.00	$0	0		$0	0	$0.00	$0	0	$0
			$0.00	$0		$0.00	$0	0		$0		$0.00	$0	0	$0
Subtotal Direct Labor		0		$0	0		$0	0		$0	0		$0	0	$0
Fringe Benefits (at ____%)			0.00%	$0		0.00%	$0			$0		0.00%	$0		$0
Total Direct Labor				$0			$0			$0			$0		$0
Travel				$0			$0			$0			$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0		$0	0		$0	0		$0	0		$0	0	$0
Other Direct Costs		0		$0	0		$0	0		$0	0		$0	0	$0
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0
Subcontractor Name		0		$0	0		$0	0		$0	0		$0	0	$0
Total Subcontractor		0		$0	0		$0	0		$0	0		$0	0	$0
Other Direct Costs (insert & list applicable elements below)				$0			$0			$0			$0		$0
SUBTOTAL ALL DIRECT COSTS				$0			$0			$0			$0		$0
Indirect Costs (at ______ %)			0.00%	$0		0.00%	$0			$0		0.00%	$0		$0
TOTAL OTHER BEFORE FEES				$0			$0			$0			$0		$0
Base Fee (at ____%)			0.00%	$0		0.00%	$0			$0		0.00%	$0		$0
TOTAL OTHER AFTER FEES				$0			$0			$0			$0		$0

&C&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0004&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number&KFF0000 Attachment J-11&C &R&P

D.5.2.3

COST TEMPLATE - SAMPLE Attachment J-11
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AA - D.5.2.3		D.5.2.3.1
DME Services	Total FTEs	Responding to Complex Beneficiary Inquiries
		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
			$0.00	$0
Subtotal Direct Labor		0		$0
Fringe Benefits (at ____%)			0.00%	$0
Total Direct Labor				$0
Travel				$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0		$0
Other Direct Costs		0		$0
Subcontractor Name		0		$0
Subcontractor Name		0		$0
Subcontractor Name		0		$0
Subcontractor Name		0		$0
Total Subcontractor		0		$0
Other Direct Costs (insert & list applicable elements below)				$0
SUBTOTAL ALL DIRECT COSTS				$0
Indirect Costs (at ______ %)			0.00%	$0
TOTAL OTHER BEFORE FEES				$0
Base Fee (at ____%)			0.00%	$0
TOTAL OTHER AFTER FEES				$0

&C&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0004&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number&KFF0000 Attachment J-11&C &R&P

D.5.3

COST TEMPLATE - SAMPLE Attachment J-11
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AA - D.5.3		D.5.3.1			D.5.3.2			D.5.3.3
DME SERVICES/Option YEAR	Total FTEs	Interactive Voice Response			Web Technology			Provider Listserv			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
		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
		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
		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
		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
			$0.00	$0		$0.00	$0		$0.00	$0	0	$0
Subtotal Direct Labor		0		$0	0		$0	0		$0	0	$0
Fringe Benefits (at ____%)			0.00%	$0		0.00%	$0		0.00%	$0		$0
Total Direct Labor				$0			$0			$0		$0
Travel				$0			$0			$0		$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0		$0	0		$0	0		$0	0	$0
Other Direct Costs		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 (insert & list applicable elements below)				$0			$0			$0		$0
SUBTOTAL ALL DIRECT COSTS				$0			$0			$0		$0
Indirect Costs (at ______ %)			0.00%	$0		0.00%	$0		0.00%	$0		$0
TOTAL OTHER BEFORE FEES				$0			$0			$0		$0
Base Fee (at ____%)			0.00%	$0		0.00%	$0		0.00%	$0		$0
TOTAL OTHER AFTER FEES				$0			$0			$0		$0

&C&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0004&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number&KFF0000 Attachment J-11&C &R&P

SLIN-0002AB

COST TEMPLATE - SAMPLE Attachment J-11
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AB		C.5			C.7			C.8			C.9			D.3			D.5			E.1			E.2			E.3			E.4			E.5			F			H			A
DME SERVICES/Option YEAR	Total FTEs	FM of Trust Fund Dollars			Task Directives			FOIA Requests			Access to Systems			Reopenings			Provider Customer Service Program			CERT Program			BI PSC & ZPIC Support Services			MSP			Medicare Review Activities Not in Support of BI			Local Coverage Determinations			Interface Requirements			Quality Assurance Requirements			AWARD FEE			GRAND TOTAL
Medicare Integrity Program		Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Rates	Total	Hours	Total
COST ELEMENTS
Direct Labor
		0		$0	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	$0.00	$0	0	$0.00	$0				0	$0
		0		$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	$0.00	$0	0	$0.00	$0				0	$0
		0		$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	$0.00	$0	0	$0.00	$0				0	$0
		0		$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	$0.00	$0	0	$0.00	$0				0	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)		0		$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	$0.00	$0	0	$0.00	$0				0	$0
		0		$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	$0.00	$0	0	$0.00	$0				0	$0
		0		$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	$0.00	$0	0	$0.00	$0				0	$0
		0		$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	$0.00	$0	0	$0.00	$0				0	$0
		0		$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	$0.00	$0	0	$0.00	$0				0	$0
		0		$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	$0.00	$0	0	$0.00	$0				0	$0
Subtotal Direct Labor		0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0				0	$0
Fringe Benefits (at ____%)				$0		0.00%	$0		0.00%	$0		0.00%	$0			$0			$0		0.00%	$0		0.00%	$0			$0			$0		0.00%	$0		0.00%	$0		0.00%	$0					$0
Total Direct Labor				$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
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0				0	$0
Other Direct Costs		0		$0	0		$0	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
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
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
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
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
Other Direct Costs (insert & list applicable elements below)				$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
Indirect Costs (at ______ %)				$0		0.00%	$0		0.00%	$0		0.00%	$0			$0			$0		0.00%	$0		0.00%	$0			$0			$0		0.00%	$0		0.00%	$0		0.00%	$0					$0
TOTAL OTHER BEFORE FEES				$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0					$0
Base Fee (at ____%)				$0		0.00%	$0		0.00%	$0		0.00%	$0			$0			$0		0.00%	$0		0.00%	$0			$0			$0		0.00%	$0		0.00%	$0		0.00%	$0					$0
Award Fee (at ______%)																																											$0		$0
TOTAL OTHER AFTER FEES				$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0			$0		$0
GRAND TOTAL																																													$0

&C&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0004&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number &KFF0000Attachment J-11&C &R&P

C.5 (2)

COST TEMPLATE - SAMPLE Attachment J-11
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AB - C.5		C.5.4
DME Services	Total FTEs	Overpayments
Medicare Integrity Program		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
Total Direct Labor				$0
Travel				$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0		$0
Other Direct Costs		0		$0
Subcontractor Name		0		$0
Subcontractor Name		0		$0
Subcontractor Name		0		$0
Subcontractor Name		0		$0
Total Subcontractor		0		$0
Other Direct Costs (insert & list applicable elements below)				$0
SUBTOTAL ALL DIRECT COSTS				$0
Indirect Costs (at ______ %)				$0
TOTAL OTHER BEFORE FEES				$0
Base Fee (at ____%)				$0
TOTAL OTHER AFTER FEES				$0

&C&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0004&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number &KFF0000Attachment J-11&C &R&P

C.5.4 (2)

COST TEMPLATE - SAMPLE Attachment J-11
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AB - C.5.4		C.5.4.1
DME SERVICES	Total FTEs	Identify Overpayment Cause
		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
			$0.00	$0
Subtotal Direct Labor		0		$0
Fringe Benefits (at ____%)			0.00%	$0
Total Direct Labor				$0
Travel				$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0		$0
Other Direct Costs		0		$0
Subcontractor Name		0		$0
Subcontractor Name		0		$0
Subcontractor Name		0		$0
Subcontractor Name		0		$0
Total Subcontractor		0		$0
Other Direct Costs (insert & list applicable elements below)				$0
SUBTOTAL ALL DIRECT COSTS				$0
Indirect Costs (at ______ %)			0.00%	$0
TOTAL OTHER BEFORE FEES				$0
Base Fee (at ____%)			0.00%	$0
TOTAL OTHER AFTER FEES				$0

&C&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0004&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number &KFF0000Attachment J-11&C &R&P

D.3(2)

COST TEMPLATE - SAMPLE Attachment J-11
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AB - D.3		D.3.2
DME SERVICES	Total FTEs	Unanswered ADR
		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
			$0.00	$0
Subtotal Direct Labor		0		$0
Fringe Benefits (at ____%)			0.00%	$0
Total Direct Labor				$0
Travel				$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0		$0
Other Direct Costs		0		$0
Subcontractor Name		0		$0
Subcontractor Name		0		$0
Subcontractor Name		0		$0
Subcontractor Name		0		$0
Total Subcontractor		0		$0
Other Direct Costs (insert & list applicable elements below)				$0
SUBTOTAL ALL DIRECT COSTS				$0
Indirect Costs (at ______ %)			0.00%	$0
TOTAL OTHER BEFORE FEES				$0
Base Fee (at ____%)			0.00%	$0
TOTAL OTHER AFTER FEES				$0

&C&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0004&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10 &LSLIN = Sub Line Item Number &KFF0000Attachment J-11&C &R&P

D.5 (2)

COST TEMPLATE - SAMPLE Attachment J-11
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AB - D.5		D.5.1
DME SERVICES	Total FTEs	Provider Outreach & Education
		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
			$0.00	$0
Subtotal Direct Labor		0		$0
Fringe Benefits (at ____%)			0.00%	$0
Total Direct Labor				$0
Travel				$0
SUBCONTRACTORS
Subcontractor Name	(insert for each subcontractor, if applicable)	0		$0
Other Direct Costs		0		$0
Subcontractor Name		0		$0
Subcontractor Name		0		$0
Subcontractor Name		0		$0

This is the start of the file's text. The full file is on GovTribe.

File details come from the government source that posted it. Updated Nov 14, 2017.