J-11 CLIN 0002 Cost Proposal Templates Base Period.xlsx

XLSX spreadsheet 210 KB Posted Dec 30, 2009

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

About this file

From the source

J-11 CLIN 0002 Cost Proposal Templates Base Period

View the file

Other files for this federal contract opportunity

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-11_CLIN_0002_Cost_Proposal_Templates_Base_Period.xls	XLS spreadsheet	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-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

Show all 50

DME MAC Jurisdiction A has more files on GovTribe.

On GovTribe

Work with this file on GovTribe

Download the original file
Contacts named in this file
Similar government files
Ask GovTribe AI about this file

Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

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

&"Arial,Bold"&12&KFF0000RFP-CMS-2010-0004&K000000 DME MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)&"Arial,Regular"&10

SLIN = Sub Line Item Number

&KFF0000

Attachment J-06 &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

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	$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	0	$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	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	$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	0	$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	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	$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	0	$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	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	$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	0	$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	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	$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	0	$0	0	$0	0	$0.00	$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	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% $0 $0

Total Direct Labor $0 $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		$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	$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	$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	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	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	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	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	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 $0 $0

SUBTOTAL ALL DIRECT COSTS $0 $0 $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% $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $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%	$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 $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

Attachment J-06 &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

Attachment J-06 &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

Attachment J-06 &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

Attachment J-06 &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

Attachment J-06 &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

Attachment J-06 &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

Attachment J-06 &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

Attachment J-06 &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

Attachment J-06 &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

Attachment J-06 &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

Medicare Appeals System

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

Attachment J-06 &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

Attachment J-06 &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

Attachment J-06 &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

Attachment J-06 &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

Attachment J-06 &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

D.5.3.4

DME SERVICES/Option YEAR

Total FTEs

Interactive Voice Response

Web Technology

Provider Listserv

Provider Internet Portal

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
	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
	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
	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
	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
		$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

Fringe Benefits (at ____%) 0.00% $0 0.00% $0 0.00% $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 0.00% $0 0.00% $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0

Base Fee (at ____%) 0.00% $0 0.00% $0 0.00% $0 0.00% $0 $0

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0

Attachment J-06 &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

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

Attachment J-06 &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

Attachment J-06 &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

Attachment J-06 &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

Attachment J-06 &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
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

Attachment J-06 &P

E.3

COST TEMPLATE - SAMPLE Attachment J-11
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0002AB - E.3		E.3.1			E.3.2
DME SERVICES	Total FTEs	MSP Pre-Payment			MSP Post Payment Recovery			GRAND 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
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
Subtotal Direct Labor	0	$0	0	$0	0	$0

Fringe Benefits (at ____%) $0 $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 $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $0

Base Fee (at ____%) $0 $0 $0

TOTAL OTHER AFTER FEES $0 $0 $0

Attachment J-06 &P

E.3.1

COST TEMPLATE - SAMPLE Attachment J-11

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002AB - E.3.1

E.3.1.1

E.3.1.2

E.3.1.3

E.3.1.4

DME SERVICES

Total FTEs

MSP Claim w/Complete EOB: Update CWF

Incomplete EOB: Possible MSP Claim, possible MSP Situation, or CWF Exclusion: Forward to COBC

ECRS Status Inquiry

Identification & Adjudication of MSP Claims, Applying Benefits & Application of MSP Processing Formula

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	0	$0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$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
	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	$0.00	$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	$0.00	$0	0	$0	0	$0
		$0.00	$0		$0.00	$0		$0.00	$0	0	$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 0.00% $0 $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 0.00% $0 $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0

Base Fee (at ____%) 0.00% $0 0.00% $0 0.00% $0 $0 $0

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0

Attachment J-06 &P

E.3.1.4

COST TEMPLATE - SAMPLE Attachment J-11

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002AB - E.3.1.4

E.3.1.4.1

E.3.1.4.2

E.3.1.4.3

E.3.1.4.4

DME SERVICES

Total FTEs

MSP Claims Determindations

MSP Claims Adjudication & Validation

MSP Claims Inquiries

Tranference of Documentation & Phone Calls to COBC

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
	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
	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
	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
	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
		$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

Fringe Benefits (at ____%) 0.00% $0 0.00% $0 0.00% $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 0.00% $0 0.00% $0 $0

TOTAL OTHER BEFORE FEES $0 $0 $0 $0 $0

Base Fee (at ____%) 0.00% $0 0.00% $0 0.00% $0 0.00% $0 $0

TOTAL OTHER AFTER FEES $0 $0 $0 $0 $0

Attachment J-06 &P

E.3.2

COST TEMPLATE - SAMPLE Attachment J-11

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0002AB - E.3.2

E.3.2.1

E.3.2.2

E.3.2.3

DME SERVICES

Total FTEs

Supplier Duplicate Primary Payments

Mis-Routed MSP Recovery Checks

Mis-Routed MSP Recovery Correspondence

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		$0
SUBCONTRACTORS

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.