AB MAC CLIN 0003 Cost Proposal Template Option Year1.xlsx

XLSX spreadsheet 362 KB Posted Feb 10, 2012

Attached to: Award: A/B MAC Jurisdiction L - RFP-CMS-2012-0003 Federal contract opportunity
Solicitation number: RFP-CMS-2012-0003
Issued by: Department of Health and Human Services Centers for Medicare and Medicaid Services

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AB MAC CLIN 0003 Cost Proposal Template Option Year1

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Other files for this federal contract opportunity

Other files attached to Award: A/B MAC Jurisdiction L - RFP-CMS-2012-0003, newest first.
File	Type	Posted
RFP Amd 1 02-10-2012 Final.docx	DOCX document	Feb 10, 2012
JL AB MAC Offeror's RFP Questions and Answers.FINAL.xlsx	XLSX spreadsheet	Feb 10, 2012
J-02 Deliverable Schedule JL_02032012.xlsx	XLSX spreadsheet	Feb 10, 2012
JL SF30 Amd1signed.pdf	PDF	Feb 10, 2012
J-03 Small Business Subcontracting Plan.doc	DOC document	Feb 10, 2012
RFP Amd 1 02-10-2012 Redlined.docx	DOCX document	Feb 10, 2012
J-08 Past Performance Questionnaire.docx	DOCX document	Feb 10, 2012
J-01 Statement of Work_JL_FINAL_FEB-03-2012.docx	DOCX document	Feb 10, 2012
AB MAC CLIN 0002 Cost Proposal Template Base Year.xlsx	XLSX spreadsheet	Feb 10, 2012
JL RFP Attachments 01_05_12.zip	ZIP file	Jan 5, 2012

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CLIN-0003

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

CLIN 0003

SLIN 0003AA

SLIN 0003AB

SLIN 0003AC

SLIN 0003AD

SLIN 0003AE

SLIN 0003AF

SLIN 0003AG

SLIN 0003AH

SLIN 0003AJ

A/B SERVICES/oPTION PERIOD

Total FTEs

Part A/Program Management (PM)

Part A/Medicare Integrity Program (MIP)

Part B/Program Management (PM)

Part B/Medicare Integrity Program (MIP)

VA Remittance Advice Project Part A (JH only)

VA Remittance Advice Project Part B (JH only)

Part A/Support of Recovery Audit Program Operations

Part B/Support of Recovery Audit Program Operations

HITECH Incentive Payments Resulting from ARRA

GRAND 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	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$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	$0.00

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

Total Direct Labor $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Travel (See separate schedule. Total should match)		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs (See separate schedule. Total should match.) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

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

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Complementary Credits	$0		$0							$0.00
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	$0	$0	$0	$0	$0	$0.00
v.1.11 2/1/2012

&"Arial,Bold"&12RFP-CMS-2012-0003&K000000

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P v.1.11 02/1/2012

TRAVEL

COST TEMPLATE - SAMPLE Attachment J-13

TRAVEL SUMMARY

CLIN 0003

	Purpose of Trip	SOW WBS
Crosswalk	Labor Category Taking Trip	Trip Origin	Destination	# People
(A)	# Trips
(B)	# Days
(C)	# Nights
(D)	Lodging Rate
(E)	Lodging
(F=EDA)	M&IE
(G)	Total Lodging

and M&IE

(H=F+G)	Airfare
(I)	Car Rental
(J)	Misc
(K)	Local

Mileage

(L)	Total Per Trip
(M=H+I+J+K+L)	Total For All Trips

(N=M*B )

$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -
$ -	$ -	$ -	$ -

TOTAL TRAVEL $ -

Travel Assumptions:

&"Arial,Bold"&12RFP-CMS-2012-0003&K000000

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

ODC

COST TEMPLATE - SAMPLE Attachment J-13
(Provide an ODC Spreadsheet for each CLIN Proposed)
CLIN 0003 A/B SERVICES/oPTION PERIOD	SLIN 0003AA	SLIN 0003AB	SLIN 0003AC	SLIN 0003AD	SLIN 0003AE	GRAND
Cost Element	Amount	Amount	Amount	Amount	Amount	TOTAL

Add costs by category	$0.00
	$0.00
	$0.00
	$0.00
	$0.00
	$0.00

TOTAL ODCs $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

SLIN-0003AA

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA

C.1.4.4

C.5.3

C.5.4

C.5.5

C.5.7

C.5.8

C.5.9

C.5.10

C.5.11

C.5.23

C.6

C.7

A/B SERVICES/oPTION PERIOD

Total FTEs

RESERVED

Infrastructure Requirements

Administrative Requirements

Provider Enrollment

Provider Customer Service Program

Claims Processing

Reopenings of Medicare Initial Claims Determinations

Appeals of Medicare Initial Claims Determinations

FM of Trust Fund Dollars

Program Management Office

Interface Requirements

Jurisdiction Specific Requirements

CREDITS

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

Total

COST ELEMENTS
Direct Labor
	0	$0.00	$0.00	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	0	$0.00
	0	$0.00	$0.00	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	0	$0.00
	0	$0.00	$0.00	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	0	$0.00
	0	$0.00	$0.00	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0.00	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	0	$0.00
	0	$0.00	$0.00	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	0	$0.00
	0	$0.00	$0.00	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	0	$0.00
	0	$0.00	$0.00	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	0	$0.00
	0	$0.00	$0.00	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	0	$0.00
	0	$0.00	$0.00	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	0	$0.00
Subtotal Direct Labor	0	$0.00	$0.00	0	$0	0	$0	0		$0	0	$0	0	$0	0		$0	0	$0	0	$0	0		$0	0		$0	0	$0.00	0	$0.00

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

Total Direct Labor $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00 $0.00

Travel		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0.00		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0.00	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	0	$0.00
Subcontractor Name	0	$0.00	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	0	$0.00
Subcontractor Name	0	$0.00	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	0	$0.00
Subcontractor Name	0	$0.00	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	0	$0.00
Subcontractor Name	0	$0.00	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	0	$0.00
Subcontractor Name	0	$0.00	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	0	$0.00
Total Subcontractor	0	$0.00	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00 $0.00

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

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00 $0 $0 $0.00

Complementary Credits													0		$0.00
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	$0	$0	$0	$0	$0	$0	$0	$0.00	$0	$0	$0.00

&"Arial,Bold"&12RFP-CMS-2012-0003&K000000

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

C.5.3

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AA - C.5.3		C.5.3.1			C.5.3.2
A/B SERVICES/oPTION PERIOD	Total FTEs	EDC			Telecommunications			GRAND TOTAL
Program Management		Hours	Rates	Total	Hours	Rates	Total	Hours	Total
COST ELEMENTS

Direct Labor
	0	$0	0	$0.00	$0	0	$0.00
	0	$0	0	$0.00	$0	0	$0.00
	0	$0	0	$0.00	$0	0	$0.00
	0	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0	0	$0.00	$0	0	$0.00
	0	$0	0	$0.00	$0	0	$0.00
	0	$0	0	$0.00	$0	0	$0.00
	0	$0	0	$0.00	$0	0	$0.00
	0	$0	0	$0.00	$0	0	$0.00
	0	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0	$0	0		$0	0	$0.00

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

Total Direct Labor $0 $0 $0.00

Travel (See separate schedule)		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0.00

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

TOTAL OTHER AFTER FEE $0 $0 $0.00

GRAND TOTAL $0 $0 $0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

C.5.4

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - C.5.4

C.5.4.3

C.5.4.4

C.5.4.5

C.5.4.6

C.5.4.7

C.5.4.8

C.5.4.10

C.5.4.11

A/B SERVICES/oPTION PERIOD

Total FTEs

Security

Quality Assurance Requirements

Public Relations

Congressional Inquiries

Participation in Conferences, Meetings & Work Groups

Participation in Change Management Process

Internal Controls

Compliance Program

GRAND TOTAL

Program Management

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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	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
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	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00	$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
		$0.00	$0		$0.00	$0	0	$0		$1.00	$0		$1.00	$0		$1.00	$0		$1.00	$0		$1.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0		$0	0	$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00

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

Total Direct Labor $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Travel		$0		$0		$0		$0		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0 $0 $0 $0 $0.00

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

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0 $0 $0 $0.00

GRAND TOTAL $0 $0 $0 $0 $0 $0 $0 $0 $0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

C.5.4.5

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AA - C.5.4.5		C.5.4.5.3
A/B SERVICES/oPTION PERIOD	Total FTEs	Responding to Complex Beneficiary Inquiries
Program Management		Hours	Rates	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
Subtotal Direct Labor	0		$0

Fringe Benefits (at ____%) $0

Total Direct Labor $0

Travel (See separate schedule)		$0
SUBCONTRACTORS
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Total Subcontractor	0	$0

Other Direct Costs $0

SUBTOTAL ALL DIRECT COSTS $0

Indirect Costs (at ______ %) $0

TOTAL OTHER BEFORE FEE $0

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

TOTAL OTHER AFTER FEE $0

GRAND TOTAL $0

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

C.5.7

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - C.5.7

C.5.7.1

C.5.7.2

C.5.7.3

C.5.7.4

A/B SERVICES/oPTION PERIOD

Total FTEs

Provider Outreach & Education

Provider Contact Center

Provider Self-Service Technology

PCSP Staff Training

GRAND TOTAL

Program Management

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	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$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	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0	0	$0.00	$0	0	$0.00
		$0.00	$0	0	$0	0	$0		$0.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0	$0	0	$0	0		$0	0	$0.00

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

Total Direct Labor $0 $0 $0 $0 $0.00

Travel		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0.00

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

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0.00

Complementary Credits
Note: comp.credit information will be provided by CMS prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0	$0	$0.00

&"Arial,Bold"&12RFP-CMS-2012-0003&K000000

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

C.5.7.2

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - C.5.7.2

C.5.7.2.1

C.5.7.2.2

C.5.7.2.3

C.5.7.2.4

A/B SERVICES/oPTION PERIOD

Total FTEs

Telephone Inquiries

Written Inquiries

Provider Relations Research Specialist

Inquiry Tracking System

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0	$0.00

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

Total Direct Labor $0 $0 $0 $0 $0.00

Travel		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0.00

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

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0.00

GRAND TOTAL $0 $0 $0 $0 $0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

C.5.7.3

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - C.5.7.3

C.5.7.3.1

C.5.7.3.2

C.5.7.3.3

C.5.7.3.4

A/B SERVICES/oPTION PERIOD

Total FTEs

Interactive Voice Response

Web Technology

Provider Listserv

Provider Internet Portal

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0	$0.00

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

Total Direct Labor $0 $0 $0 $0 $0.00

Travel		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0.00

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

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0.00

GRAND TOTAL $0 $0 $0 $0 $0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

C.5.8

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - C.5.8

C.5.8.1

C.5.8.2

C.5.8.3

C.5.8.4

A/B SERVICES/oPTION PERIOD

Total FTEs

Standard Paper Remittance Advice Transactions

General Claims Processing

Development of Suspended Claims

Back-End Processing

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0	$0.00

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

Total Direct Labor $0 $0 $0 $0 $0.00

Travel (See separate schedule)		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs (See separate schedule) $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0.00

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

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0.00

GRAND TOTAL $0 $0 $0 $0 $0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

C.5.10

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - C.5.10

C.5.10.1

C.5.10.2

C.5.10.3

C.5.10.5

A/B SERVICES/oPTION PERIOD

Total FTEs

Redermination Requests

Appeal Decision Effectuation

MSR on Reopenings & Appeals Activty

Administrative Law Judge (ALJ) Hearings

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		$0.00	$0		$0.00	$0		$0.00	$0		$0.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0	$0.00

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

Total Direct Labor $0 $0 $0 $0 $0.00

Travel		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0.00

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

TOTAL COSTS $0 $0 $0 $0 $0.00

GRAND TOTAL $0 $0 $0 $0 $0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

C.5.11

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - C.5.11

C.5.11.1

C.5.11.2

C.5.11.3

C.5.11.4

C.5.11.5

C.5.11.6

C.5.11.8

C.5.11.9

A/B SERVICES/oPTION PERIOD

Total FTEs

Use of Trust Fund

Banking Relations

Cost Reporting and Reimbursement Payment Policy

Non-MSP Overpayment

Non-MSP Debt Collection Activities

Non-MSP Debt Referral

Overpayment Related to Bankruptcy

Financial Reporting & Accounting

GRAND TOTAL

Program Management

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	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0		$0	0	$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00

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

Total Direct Labor $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Travel		$0		$0		$0		$0		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0 $0 $0 $0 $0.00

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

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0 $0 $0 $0.00

GRAND TOTAL $0 $0 $0 $0 $0 $0 $0 $0 $0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

C.5.11.3

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AA - C.5.11.3		C.5.11.3.3			C.5.11.3.5
A/B SERVICES/oPTION PERIOD	Total FTEs	Provider Reimbursement			Provider Based Determinations			GRAND TOTAL
Program Management		Hours	Rates	Total	Hours	Rates	Total	Hours	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0		$0	0	$0.00

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

Total Direct Labor $0 $0 $0.00

Travel		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0.00

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

TOTAL OTHER AFTER FEE $0 $0 $0.00

GRAND TOTAL $0 $0 $0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

C.7

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AA - C.7

C.7.1

C.7.2

C.7.8

C.7.9

C.7.10

C.7.22

C.7.24

C.7.27

C.7.29

C.7.30

A/B SERVICES/oPTION PERIOD

Total FTEs

Centralized Billing for Mass Immunizers (JH, J5 only)

Indian Health Services (JH only)

Provider Internet Portal (JF Only)

Frontier Extended Stay Clinic (JH only)

Pay for Performance Check-Writing (J5, JH only)

Medicare Coordinated Care Demo (JK only)

Environmental Health Hazards Pilot Project (JF only)

ICD10 - NCD Project (J5 only)

Medicare Essential Hospital Payment Program (JF only)

FQHC Demo (JF only)

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

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	0
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

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

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

Travel		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		0
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	0
Subcontractor Name	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
Subcontractor Name	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
Subcontractor Name	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

Other Direct Costs $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

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 0

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 0

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

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 0

GRAND TOTAL $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 0

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

SLIN-0003AB

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AB

C.1.4.4

C.5.4

C.5.6

C.5.7

C.5.11

C.5.12

C.5.13

C.5.14

C.5.15

C.7

A/B SERVICES/oPTION PERIOD

Total FTEs

RESERVED

Administrative Requirements

LCDs

Provider Customer Service Program

FM of Trust Fund Dollars

Medical Review

Coordination with PSCs/ZPICs

MSP

Provider Oversight

Jurisdiction Specific 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

Total

COST ELEMENTS
Direct Labor
	0	$0.00	$0.00	0	$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	$0.00
	0	$0.00	$0.00	0	$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	$0.00
	0	$0.00	$0.00	0	$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	$0.00
	0	$0.00	$0.00	0	$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	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0.00	0	$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	$0.00
	0	$0.00	$0.00	0	$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	$0.00
	0	$0.00	$0.00	0	$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	$0.00
	0	$0.00	$0.00	0	$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	$0.00
	0	$0.00	$0.00	0	$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	$0.00
	0	$0.00	$0.00	0	$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	$0.00
Subtotal Direct Labor	0		$0.00	0	$0	0		$0	0	$0	0	$0	0	$0	0		$0	0	$0	0		$0	0	$0.00	0	$0.00

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

Total Direct Labor $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00 $0.00

Travel		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0.00		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00 $0.00

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

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00 $0 $0.00

Complementary Credits
Note: comp.credit information will be provided by CMS prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0.00	$0	$0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

C.5.4(2)

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AB - C.5.4		C.5.4.5
A/B SERVICES/oPTION PERIOD	Total FTEs	Public Relations			GRAND TOTAL
Medicare Integrity Program		Hours	Rates	Total	Hours	Total
COST ELEMENTS

Direct Labor
	0	$0	0	$0.00
	0	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0	0	$0.00
	0	$0	0	$0.00
	0	$0	0	$0.00
	0	$0	0	$0.00
	0	$0	0	$0.00
	0	$0	0	$0.00
	0	$0	0	$0.00
	0	$0	0	$0.00
Subtotal Direct Labor	0	$0	0	$0.00

Fringe Benefits (at ____%) $0 $0.00

Total Direct Labor $0 $0.00

Travel		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	$0	$0	0	$0.00
Subcontractor Name	$0	$0	0	$0.00
Subcontractor Name	$0	$0	0	$0.00
Subcontractor Name	$0	$0	0	$0.00
Subcontractor Name	$0	$0	0	$0.00
Subcontractor Name	$0	$0	0	$0.00
Total Subcontractor	$0	$0	0	$0.00

Other Direct Costs $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0.00

Indirect Costs (at ______ %) $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0.00

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

TOTAL OTHER AFTER FEE $0 $0.00

GRAND TOTAL $0 $0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

C.5.4.5(2)

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AB - C.5.4.5		C.5.4.5.3
A/B SERVICES/oPTION PERIOD	Total FTEs	Responding to Complex Beneficiary Inquiries
Medicare Integrity Program		Hours	Rates	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
Subtotal Direct Labor	0		$0

Fringe Benefits (at ____%) $0

Total Direct Labor $0

Travel (See separate schedule)		$0
SUBCONTRACTORS
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Total Subcontractor	0	$0

Other Direct Costs $0

SUBTOTAL ALL DIRECT COSTS $0

Indirect Costs (at ______ %) $0

TOTAL OTHER BEFORE FEE $0

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

TOTAL OTHER AFTER FEE $0

GRAND TOTAL $0

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

C.5.7(2)

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AB - C.5.7		C.5.7.1
A/B SERVICES/oPTION PERIOD	Total FTEs	Provider Outreach & Education
Medicare Integrity Program		Hours	Rates	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
Subtotal Direct Labor	0		$0

Fringe Benefits (at ____%) $0

Total Direct Labor $0

Travel		$0
SUBCONTRACTORS
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Total Subcontractor	0	$0

Other Direct Costs $0

SUBTOTAL ALL DIRECT COSTS $0

Indirect Costs (at ______ %) $0

TOTAL OTHER BEFORE FEE $0

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

TOTAL OTHER AFTER FEE $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	$0

&"Arial,Bold"&12RFP-CMS-2012-0003&K000000

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

C.5.11(2)

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AB - C.5.11		C.5.11.3
A/B SERVICES/oPTION PERIOD	Total FTEs	Cost Reporting and Reimbursement Payment Policy
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	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Total Subcontractor	0	$0

Other Direct Costs $0

SUBTOTAL ALL DIRECT COSTS $0

Indirect Costs (at ______ %) $0

TOTAL OTHER BEFORE FEE $0

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

TOTAL OTHER AFTER FEE $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	0

&"Arial,Bold"&12RFP-CMS-2012-0003&K000000

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

C.5.11.3(2)

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AB - C.5.11.3

C.5.11.3.1

C.5.11.3.2

C.5.11.3.4

A/B SERVICES/oPTION PERIOD

Total FTEs

Medicare Cost Report

Audit of Institutional Provider Cost Report

Audit/Reimbursement Support Systems - File Maintenance

GRAND TOTAL

Medicare Integrity Program

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	$0.00	$0	0	$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	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0	$0	0		$0	0	$0.00

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

Total Direct Labor $0 $0 $0 $0.00

Travel		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0.00

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

TOTAL OTHER AFTER FEE $0 $0 $0 $0.00

Complementary Credits
Note: comp.credit information will be provided by CMS prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0	$0.00

&"Arial,Bold"&12RFP-CMS-2012-0003&K000000

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

C.5.11.3.2

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AB - C.5.11.3.2

C.5.11.3.2.1

C.5.11.3.2.2

C.5.11.3.2.3

C.5.11.3.2.4

C.5.11.3.2.5

C.5.11.3.2.6

C.5.11.3.2.7

C.5.11.3.2.8

A/B SERVICES/oPTION PERIOD

Total FTEs

Cost Report Acceptance

Tentative Settlements

Desk Reviews

Wage Index

Audits

Final Settelement

Reopenings

Appeals

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

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00

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

Total Direct Labor $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Travel		$0		$0		$0		$0		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0 $0 $0 $0 $0.00

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

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0 $0 $0 $0.00

GRAND TOTAL $0 $0 $0 $0 $0 $0 $0 $0 $0.00

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

C.5.12

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0003AB - C.5.12		C.5.12.1
A/B SERVICES/oPTION PERIOD	Total FTEs	Development of Medical Review Strategy
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	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Total Subcontractor	0	$0

Other Direct Costs $0

SUBTOTAL ALL DIRECT COSTS $0

Indirect Costs (at ______ %) $0

TOTAL OTHER BEFORE FEE $0

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

TOTAL OTHER AFTER FEE $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	$0

&"Arial,Bold"&12RFP-CMS-2012-0003&K000000

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

C.5.12.1

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AB - C.5.12.1

C.5.12.1 .1

C.5.12.1 .2

C.5.12.1 .3

C.5.12.1 .4

C.5.12.1 .5

C.5.12.1 .6

A/B SERVICES/oPTION PERIOD

Total FTEs

Medical Review Data:

Data Analysis

Medical Review Data:

Edit Effectiveness

Medical Review Data:

Probe Reviews

Provider Tracking

Medical Review of Claims

Physician Participation

GRAND TOTAL

Medicare Integrity Program

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00

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

Total Direct Labor $0 $0 $0 $0 $0 $0 $0.00

Travel		$0		$0		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0 $0 $0.00

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

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0 $0.00

Complementary Credits
Note: comp.credit information will be provided by CMS prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0	$0	$0	$0	$0.00

&"Arial,Bold"&12RFP-CMS-2012-0003&K000000

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P

C.5.14

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0003AB - C.5.14

C.5.14.1

C.5.14.2

C.5.14.3

C.5.14.4

C.5.14.5

C.5.14.6

A/B SERVICES/oPTION PERIOD

Total FTEs

Implementation of MSP Operations

Electronic Coorespondence Referral System Status Inquiries

Identification and Adjudication of MSP Claims & Application of Benefits & Processing Formula

Transfer of Documentation and Phone Calls to COBC

MSP Hospital Audits

MSP Post-Pay Recovery

GRAND TOTAL

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.

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