J-13 CLIN 0004 Cost Proposal Template - OptionYear2_RRB_SMAC.xlsx

XLSX spreadsheet 164 KB Posted Feb 11, 2011

Attached to: Solicitation RRB11R001 - RRB Specialty MAC
Solicitation number: RRB11R001
Issued by: Railroad Retirement Board

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Solicitation RRB11R001 Attachment J13 Option Year Two Cost Proposal Template

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Other files

File	Type	Posted
J-15 CLIN 0006 Cost Proposal Template - Opt Year_4_RRB_SMAC_Rev_A5.xlsx	XLSX spreadsheet	Mar 18, 2011
J-11 CLIN 0002 Cost Proposal Template - Base Year_RRB_SMAC_Rev_A5.xlsx	XLSX spreadsheet	Mar 18, 2011
J-14 CLIN 0005 Cost Proposal Template - Opt Year_3_RRB_SMAC_Rev_A5.xlsx	XLSX spreadsheet	Mar 18, 2011
J-13 CLIN 0004 Cost Proposal Template - Opt Year_2_RRB_SMAC_Rev_A5.xlsx	XLSX spreadsheet	Mar 18, 2011
A5 RRB SMAC SF-30 pages 1 thru 4.pdf	PDF	Mar 18, 2011
J-12 CLIN 0003 Cost Proposal Template - Opt Year_1_RRB_SMAC_Rev_A5.xlsx	XLSX spreadsheet	Mar 18, 2011
SMAC A4.pdf	PDF	Mar 14, 2011
J-15 CLIN 0006 Cost Proposal Template - Opt Year_4_RRB_SMAC_Rev_A2.xlsx	XLSX spreadsheet	Mar 11, 2011
J-12 CLIN 0003 Cost Proposal Template - Opt Year_1_RRB_SMAC_Rev_A2.xlsx	XLSX spreadsheet	Mar 11, 2011
J-11 CLIN 0002 Cost Proposal Template - Base Year_RRB_SMAC_Rev_A2.xlsx	XLSX spreadsheet	Mar 11, 2011
J-14 CLIN 0005 Cost Proposal Template - Opt Year_3_RRB_SMAC_Rev_A2.xlsx	XLSX spreadsheet	Mar 11, 2011
J-13 CLIN 0004 Cost Proposal Template - Opt Year_2_RRB_SMAC_Rev_A2.xlsx	XLSX spreadsheet	Mar 11, 2011
SMAC A3.pdf	PDF	Mar 11, 2011
Amendment_A-2_RRB01R001_Q A FINAL.docx	DOCX document	Mar 10, 2011
J-07_Basis of Estimate_Rev_A2.xlsx	XLSX spreadsheet	Mar 10, 2011
SMAC SF30 Amendment A2.pdf	PDF	Mar 10, 2011
RRB11R001 RRB Specialty MAC Amendment A1 February 17 2011.pdf	PDF	Feb 17, 2011
J-22_ContractingGuideforContractofGovProperty_12_09_08.pdf	PDF	Feb 11, 2011
J-12 CLIN 0003 Cost Proposal Template - OptionYear1_RRB_SMAC.xlsx	XLSX spreadsheet	Feb 11, 2011
J-14 CLIN 0005 Cost Proposal Template - OptionYear3_RRB_SMAC.xlsx	XLSX spreadsheet	Feb 11, 2011
J-09_CostProposalInstructions.xlsx	XLSX spreadsheet	Feb 11, 2011
J-18_NonDisclosureStatement.docx	DOCX document	Feb 11, 2011
J-10A Cost Template Summary Sheet_RRB_SMAC.xlsx	XLSX spreadsheet	Feb 11, 2011
J-15 CLIN 0006 Cost Proposal Template - OptionYear4_RRB_SMAC.xlsx	XLSX spreadsheet	Feb 11, 2011
J-11 CLIN 0002 Cost Proposal Template - Base Year_RRB_SMAC.xlsx	XLSX spreadsheet	Feb 11, 2011
J-17_ProposalChecklist.docx	DOCX document	Feb 11, 2011
RRB11R001_SF 33.pdf	PDF	Feb 11, 2011
RRB_RFP_RRB11R001(SMAC)_SOW_ATT_J01_2-11-11.docx	DOCX document	Feb 11, 2011
J-01AA Base Reports PCSs_ZPICs Need.xlsx	XLSX spreadsheet	Feb 11, 2011
J-03_SmallBusinessSubcontractingPlan.docx	DOCX document	Feb 11, 2011
J-24 Proposal Assumptions Template.xlsx	XLSX spreadsheet	Feb 11, 2011
J-08_PastPerformanceQuestionnaire.doc	DOC document	Feb 11, 2011
J-25 Compliance Attestation.docx	DOCX document	Feb 11, 2011
J-01A_Fee-for-Service-Shared-System-Base-Functions.doc	DOC document	Feb 11, 2011
J-06 Award Fee Sample.docx	DOCX document	Feb 11, 2011
J-16 CLIN 0007 Cost Proposal Template - Closeout_RRB_SMAC.xlsx	XLSX spreadsheet	Feb 11, 2011
J-19A Workload Implementation HandbookM Legacy to MAC.docx	DOCX document	Feb 11, 2011
J-23_Contractor Furnished Property.docx	DOCX document	Feb 11, 2011
J-02_RRB SMAC_Deliverables.xlsx	XLSX spreadsheet	Feb 11, 2011
J-05_Government Furnished Property.docx	DOCX document	Feb 11, 2011
J-20 Information Security Attestation.docx	DOCX document	Feb 11, 2011
J-21 Corporate Experience Attestation.docx	DOCX document	Feb 11, 2011
J-06A Award Fee template.docx	DOCX document	Feb 11, 2011
RRB_RFP_RRB11R001_Sects_B-M.docx	DOCX document	Feb 11, 2011
J-10B CLIN 0001 Cost Proposal Template - Implementation_RRB_SMAC.xlsx	XLSX spreadsheet	Feb 11, 2011
J-19 Workload Implementation Handbook.docx	DOCX document	Feb 11, 2011
J-19C Outgoing AB MAC Implementation Handbook.docx..docx	DOCX document	Feb 11, 2011
J-07_Basis of Estimate.xlsx	XLSX spreadsheet	Feb 11, 2011
J-01B SOW appendices.docx	DOCX document	Feb 11, 2011
J-04_Billing_Instructions.docx	DOCX document	Feb 11, 2011

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CLIN-0004

COST TEMPLATE - SAMPLE Attachment J-13		OFFERORS SHALL COMPLETE THESE PART B CLINS BY
(Provide a cost spreadsheet for each CLIN proposed)		COMPLETING COSTS IN SUBWORKSHEETS TO THE RIGHT
CLIN 0004		SLIN 0004AC			SLIN 0004AD
Part B SERVICES/Option Year 2	Total FTEs	Part B/Program Management (PM)			Part B/Medicare Integrity Program (MIP)			GRAND TOTAL
		Hours	Rates	Total	Hours	Rates	Total	Hours	Total
COST ELEMENTS

Direct Labor
	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0.00
	0	$0	0	$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. Total should match)		$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 (See separate schedule. Total should match.) $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 ______%)	$0	$0	$0.00

TOTAL OTHER AFTER FEE $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	$0.00

&"Arial,Bold"&12RFP - RRB-11-R001

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = 0004

Attachment J-13 &P

ODC

ODC SCHEDULE - SAMPLE
(Provide an ODC Spreadsheet for each CLIN Proposed)
CLIN 0004 PART B SERVICES	SLIN 0004AC	SLIN 0004AD	GRAND
Cost Element	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

&"Arial,Bold"&12RFP-RRB11R001

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

SLIN = 0004

Attachment J-13 &P

TRAVEL

TRAVEL SUMMARY

CLIN 0004

	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"&14RFP - RRB-11-R001

PART B SPECIALTY MAC

Attachment J-13 &P

SLIN-0004AC

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004AC

C.5.3

C.5.4

C.5.11.2

C.5.11.1

C.5.8

C.5.9

C.5.10

C.5.13

C.5.12

C.6

PART B SERVICES/Option Year 2

Total FTEs

Infrastructure

Administrative Requirements

Beneficiary Customer Service Program

Provider Customer Service Program

Claims Processing

Reopenings of Initial Claims Determinations

Appeals of Initial Claims Determinations

FM of Trust Fund

Provider Enrollment

Interface 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

Total

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

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

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

Travel		$0		$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	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	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	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	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	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	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	0	$0.00

Other Direct Costs $0 $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 $0.00

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

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

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

&"Arial,Bold"&12RFP - RRB-11-R-001

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

SLIN = 0004AC

Attachment J-13 &P

C.5.3(2)

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0004AC - C.5.3		C.5.3.1			C.5.3.2
PART B SERVICES/Option Year 2	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		$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

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

&"Arial,Bold"&12RFP - RRB-11-R-001

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

Attachment J-13 &P

C.5.4(3)

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004AC - C.5.4

C.5.4.1

C.5.4.2

C.5.4.3

C.5.4.4

C.5.4.5

C.5.4.6

C.5.4.7

C.5.4.8

C.5.4.10

C.5.4.11

PART B SERVICES/Option Year 2

Total FTEs

Key Personnel

Program Management Office Functions

Security

Quality Assurance Req.

Public Relations

Congressional Inquiries and Outreach

Participation in Conferences, Meetings & Work Groups

Participation in Change Management Process

Internal Controls

Compliance Program

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	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	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	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	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	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	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	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	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	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	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

SUBTOTAL COSTS 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

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	0

&"Arial,Bold"&12RFP - RRB-11-R-001

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

Attachment J-13 &P

C.5.11.2.5(3)

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0004AC - C.5.11.2.5		C.5.11.2.5
PART B SERVICES/Option Year 2	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

&"Arial,Bold"&12RFP - RRB-11-R-001

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

Attachment J-13 &P

C.5.11.1(3)

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004AC - C.5.11.1

C.5.11.1.2

C.5.11.1.5

C.5.11.1.8

C.5.11.1.10

PART B SERVICES/Option Year 2

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	$0.00	$0	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 - RRB-11-R-001

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

Attachment J-13 &P

C.5.11.1.5(2)

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004AC - C.5.11.1.5

C.5.11.1.5.1

C.5.11.1.5.2

C.5.11.1.6

C.5.11.1.7

PART B SERVICES/Option Year 2

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

&"Arial,Bold"&12RFP - RRB-11-R-001

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

Attachment J-13 &P

C.5.11.1.8

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004AC - C.5.11.1.8

C.5.11.1.8.1

C.5.11.1.8.2

C.5.11.1.9

C.5.11.1.8.2

PART B SERVICES/Option Year 2

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

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

Travel		$0		$0		$0		$0		$0
SUBCONTRACTORS
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
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 $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

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

&"Arial,Bold"&12RFP - RRB-11-R-001

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

Attachment J-13 &P

C.5.8(2)

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004AC - C.5.8

C.5.8.1

C.5.8.2

C.5.8.4

C.5.8.5

C.5.8.7

PART B SERVICES/Option Year 2

Total FTEs

Standard Paper Remittance Advice Transactions

General Claims Processing

Development of Suspended Claims

Back-End Processing

Incentive Payments

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	$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
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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00

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

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

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

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

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

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

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

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

TOTAL OTHER AFTER FEE $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	$0.00

&"Arial,Bold"&12RFP - RRB-11-R-001

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

Attachment J-13 &P

C.5.10(2)

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004AC - C.5.10

C.5.10.1

C.5.10.2

C.5.10.3

PART B SERVICES/Option Year 2

Total FTEs

Redetermination Requests

Appeal Decision Effectuation

MSR on Appeals

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

Fringe Benefits (at ____%) $0 $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 - RRB-11-R-001

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

Attachment J-13 &P

C.5.13(3)

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004AC - C.5.13

C.5.13.1

C.5.13.2

C.5.13.4

C.5.13.5

C.5.13.6

C.5.13.8

C.5.13.9

PART B SERVICES/Option Year 2

Total FTEs

Use of Trust Fund

Banking Relations

Non-MSP Overpay

Non-MSP Debt Collection Activities

Non-MSP Debt Referral

Overpay Related to Bankruptcy

Financial Reporting & Accounting

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

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

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

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

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

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

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

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

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

TOTAL OTHER AFTER FEE $0 $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	$0.00

&"Arial,Bold"&12RFP - RRB-11-R-001

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

Attachment J-13 &P

C.6

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0004AC - C.6		C.6.1			C.6.2
PART B SERVICES/Option Year 2	Total FTEs	Successful Collaboration with Entities Requiring Joint Operating Agreement			Successful Collaboration and Coordination with Other Internal and External Entities			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
	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	$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
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	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
Subcontractor Name	0	$0	0	$0	0	0
Total Subcontractor	0	$0	0	$0	0	0

Other Direct Costs $0 $0 0

SUBTOTAL ALL DIRECT COSTS $0 $0 0

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

TOTAL OTHER BEFORE FEE $0 $0 0

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

TOTAL OTHER AFTER FEE $0 $0 0

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

&"Arial,Bold"&12RFP - RRB-11-R-001

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

Attachment J-13 &P

SLIN-0004AD

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004AD

C.5.4

C.5.11.2

C.5.14

C.5.15

C.5.16

C.5.17

PART B SERVICES/Option Year 2

Total FTEs

Administrative Requirements

Beneficiary Customer Service Program

Medical Review

Benefit Integrity

MSP

Provider Oversight

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

Total

COST ELEMENTS
Direct Labor
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0.00	$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	$0.00	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0.00	$0	0	$0	0	$0	0	$0.00
Subtotal Direct Labor	0	$0	0	$0	0	$0	0		$0	0	$0	0	$0	0	$0.00

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 ______%)							$0	$0.00

TOTAL OTHER AFTER FEE $0 $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	$0.00

&"Arial,Bold"&12RFP - RRB-11-R-001

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = 0004AD

Attachment J-13 &P

C.5.4(4)

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0004AD - C.5.4		C.5.4.5
PART B SERVICES/Option Year 2	Total FTEs	Public Relations
Medicare Integrity Program
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

GRAND TOTAL $0

&"Arial,Bold"&12RFP - RRB11-R-001

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

Attachment J-13 &P

C.5.11.2.5(4)

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0004AD - C.5.11.2.5		C.5.11.2.5
PART B SERVICES/Option Year 2	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

&"Arial,Bold"&12RFP - RRB-11

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

Attachment J-13 &P

C.5.17(4)

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0004AD - C.5.17		C.5.17
PART B SERVICES/Option Year 2	Total FTEs	Provider Outreach & Education (MIP)
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 - RRB-11-R-001

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

Attachment J-13 &P

C.5.14(2)

COST TEMPLATE - SAMPLE Attachment J-13
(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0004AD - C.5.14		C.5.14.2
PART B SERVICES/Option Year 2	Total FTEs	Develop 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 (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 (See separate schedule) $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 - RRB-11-R-001

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

Attachment J-13 &P

C.5.14.1(2)

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004AD - C.5.14.1

C.5.14.3.1

C.5.14.3.2

C.5.14.3.3

C.5.12.3.4

C.5.14.1

PART B SERVICES/Option Year 2

Total FTEs

Medical Review Data:

Data Analysis

Medical Review Data:

Edit Effectiveness

Medical Review Data:

Probe Reviews

Provider Tracking

Medical Review of Claims

GRAND TOTAL

Medicare Integrity Program

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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00

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

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

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

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

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

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

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

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

TOTAL OTHER AFTER FEE $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	$0.00

&"Arial,Bold"&12RFP - RRB-11-R-001

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

Attachment J-13 &P

C.5.16(2)

COST TEMPLATE - SAMPLE Attachment J-13

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004AD - C.5.16

C.5.16.1

C.5.16.2

C.5.16.4

C.5.16.8

C.5.16.9

PART B SERVICES/Option Year 2

Total FTEs

Implementation of MSP Operations

Electronic Correspondence Referral System

Identify and Adjudicate

Transfer to COBC

MSP Post-Pay Recovery

GRAND TOTAL

Medicare Integrity Program

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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00	$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	$0.00

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

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

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

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

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

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

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

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

TOTAL OTHER AFTER FEE $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	$0.00

&"Arial,Bold"&12RFP- RRB-11-R-001

PART B SPECIALTY MEDICARE ADMINISTRATIVE CONTRACTOR (SMAC)

Attachment J-13 &P

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

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