UEF 2024-001FP.xlsx
XLSX spreadsheet 17 KB Posted
- Solicitation number
- BPM041172
- Issued by
- Maryland
About this file
This document is a Financial Proposal Form for a Request for Proposals (RFP) issued by the Maryland Uninsured Employers' Fund (UEF) for third party administrator services to process, investigate, and administer workers' compensation claims. The contract has a term of 5 years and covers the administration of claims found compensable by the Maryland Workers Compensation Commission where the claimant was employed by an uninsured employer, or where the UEF has been implead as a party to the claim. The RFP solicitation number is UEF 2024-001.
The financial proposal form outlines the fixed administrative fees and unit prices for various claims administration services such as CMS reporting, bill review, and independent medical exams. Pricing is provided for each of the 5 contract years. The total 5-year proposed contract price is $0.00. The RFP states that the State will pay the unit prices per actual services performed and will not guarantee any minimum or maximum claim volume.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| RFP- UEF2024-001.pdf | ||
| Signed fully executed contract UEF.pdf | ||
| loss run-Standard Loss Run.xlsx | XLSX spreadsheet | |
| Amendment 1.pdf | ||
| PPC Attendance List.pdf | ||
| RFP Amendment 2.pdf | ||
| Modification contract pdf 2.5.19 (1).pdf | ||
| Q & A-1.pdf | ||
| Q & A-2.pdf | ||
| Pre Proposal Conference Summary.pdf |
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Text version
Financial Proposal Form
| State of Maryland Uninsured Employers Fund |
| WORKERS’ COMPENSATION THIRD PARTY CLAIMS ADMINISTRATION PROFESSIONAL SERVICES |
| Solicitation No. UEF 2024-001 |
Contract Year 1 Contract Year 2 Contract Year 3 Contract Year 4 Contract Year 5
| Monthly Administrative Fee | |||||
| Total Annual Administrative Fee Price Proposed for each Contract Year | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| 5 Year Subtotal of Fixed Price Administrative Fees | F10 * 12 | $ - 0 |
| Allocated Prices per Service - Contract Year 1 | Average Pharmacy Fee % of Savings | Savings Amount for Evaluation Purposes | Price Per Service | Average Number of Cases per Month * | Subtotal Per Month | Total Per Month | Total Per Contract Year 1 |
| CMS Reporting | 655.10 | $ - 0 | |||||
| Bill Review | 598.90 | $ - 0 | |||||
| IME | 7.50 | $ - 0 | |||||
| In Network % of Savings for Fee Rate ** | $ - 0 | $ - 0 | |||||
| Total Annual Estimated Price for Allocated Prices per Service | $ - 0 | $ - 0 | |||||
| * The annual number of claims is provided for evaluation purposes and does not reflect historical usage. The State will not guarantee any minimum or maximum amount of actual participation. The State will pay the unit price per services times the number of actual claims. **The Average % for the In Network Pharmacy Fee is being used for evaluation purposes only. Each claim will be priced based upon the Offeror's Phamacy Network % Savings. |
| Allocated Prices per Service - Contract Year 2 | Average Pharmacy Fee % of Savings | Savings Amount for Evaluation Purposes | Price Per Service | Average Number of Cases per Month * | Subtotal Per Month | Total Per Month | Total Per Contract Year 2 |
| CMS Reporting | 655.10 | $ - 0 | |||||
| Bill Review | 598.90 | $ - 0 | |||||
| IME | 7.50 | $ - 0 | |||||
| In Network % of Savings for Fee Rate ** | $ - 0 | $ - 0 | |||||
| Total Annual Estimated Price for Allocated Prices per Service | $ - 0 | $ - 0 | |||||
| * The annual number of claims is provided for evaluation purposes and does not reflect historical usage. The State will not guarantee any minimum or maximum amount of actual participation. The State will pay the unit price per services times the number of actual claims. **The Average % for the In Network Pharmacy Fee is being used for evaluation purposes only. Each claim will be priced based upon the Offeror's Phamacy Network % Savings. |
| Allocated Prices per Service - Contract Year 3 | Average Pharmacy Fee % of Savings | Savings Amount for Evaluation Purposes | Price Per Service | Average Number of Cases per Month * | Subtotal Per Month | Total Per Month | Total Per Contract Year 3 |
| CMS Reporting | 655.10 | $ - 0 | |||||
| Bill Review | 598.90 | $ - 0 | |||||
| IME | 7.50 | $ - 0 | |||||
| In Network % of Savings for Fee Rate ** | $ - 0 | $ - 0 | |||||
| Total Annual Estimated Price for Allocated Prices per Service | $ - 0 | $ - 0 | |||||
| * The annual number of claims is provided for evaluation purposes and does not reflect historical usage. The State will not guarantee any minimum or maximum amount of actual participation. The State will pay the unit price per services times the number of actual claims. **The Average % for the In Network Pharmacy Fee is being used for evaluation purposes only. Each claim will be priced based upon the Offeror's Phamacy Network % Savings. |
| Allocated Prices per Service - Contract Year 4 | Average Pharmacy Fee % of Savings | Savings Amount for Evaluation Purposes | Price Per Service | Average Number of Cases per Month * | Subtotal Per Month | Total Per Month | Total Per Contract Year 4 |
| CMS Reporting | 655.10 | $ - 0 | |||||
| Bill Review | 598.90 | $ - 0 | |||||
| IME | 7.50 | $ - 0 | |||||
| In Network % of Savings for Fee Rate ** | $ - 0 | $ - 0 | |||||
| Total Annual Estimated Price for Allocated Prices per Service | $ - 0 | $ - 0 | |||||
| * The annual number of claims is provided for evaluation purposes and does not reflect historical usage. The State will not guarantee any minimum or maximum amount of actual participation. The State will pay the unit price per services times the number of actual claims. **The Average % for the In Network Pharmacy Fee is being used for evaluation purposes only. Each claim will be priced based upon the Offeror's Phamacy Network % Savings. |
| Allocated Prices per Service - Contract Year 5 | Average Pharmacy Fee % of Savings | Savings Amount for Evaluation Purposes | Price Per Service | Average Number of Cases per Month * | Subtotal Per Month | Total Per Month | Total Per Contract Year 5 |
| CMS Reporting | 655.10 | $ - 0 | |||||
| Bill Review | 598.90 | $ - 0 | |||||
| IME | 7.50 | $ - 0 | |||||
| In Network % of Savings for Fee Rate ** | $ - 0 | $ - 0 | |||||
| Total Annual Estimated Price for Allocated Prices per Service | $ - 0 | $ - 0 | |||||
| * The annual number of claims is provided for evaluation purposes and does not reflect historical usage. The State will not guarantee any minimum or maximum amount of actual participation. The State will pay the unit price per services times the number of actual claims. **The Average % for the In Network Pharmacy Fee is being used for evaluation purposes only. Each claim will be priced based upon the Offeror's Phamacy Network % Savings. |
Total 5 Year Proposed Price for Allocated Prices per Service $ - 0
5 Year Proposed Contract Price (Total Evaluated Price) $0.00
| Submitted By: |
| Offeror Name (print or type) |
| Authorized Signature: |
| Authorized Signature: |
| Date: |
| Printed Name and Title: |
| Company Name : |
| Company Address: |
| FEIN: |
| eMM #: |
| Telephone #: |
| Fax #: |
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