CMS-718-721 CMS-718-721.J-8a 9th SOW Patient Pathways Spreadsheet

Business Proposal Forms For Quality Improvement Organizations (QIOs)

CMS-718-721.J-8a 9th SOW Patient Pathways Spreadsheet.xlsx

Business Proposal Forms For Quality Improvement Organizations (QIOs)

OMB: 0938-0579

Document [xlsx]
Download: xlsx | pdf

Overview

F718 BP SUM
QIO F719
QIO F720
QIO F721
QIO STAFFING
QIOSubconts 2
QIO Staff Sum
QIO ODC

Sheet 1: F718 BP SUM














1. Name and Address of QIO Organization







3. RFP #





































4: Proposed Contract Period















2. QIO Area (State):







From:
























To:





























Medicare


5. Total Proposed

6. CMS Recommended
7. $
8. %

Contract


Costs

Costs
Difference
DIfference













Direct Cost
























a. LABOR:











1. Professional



$0

$0
$0
#DIV/0!
2. Information Systems



$0

$0
$0
#DIV/0!
3. Corporate Management



$0

$0
$0
#DIV/0!
4. Support Staff



$0

$0
$0
#DIV/0!













SUBTOTAL - Direct Labor



$0

$0
$0
#DIV/0!













b. Leave



#DIV/0!

$0
#DIV/0!
#DIV/0!
c. Fringe Benefits



$0

$0
$0
#DIV/0!













SUBTOTAL - Leave/Fringe



#DIV/0!

$0
#DIV/0!
#DIV/0!













d. Subcontractors











1. Physician Reviewers/ Phys.Advisors











2. Other Consultants



$0

$0
$0
#DIV/0!
3. Other Subcontracts



$0

$0
$0
#DIV/0!













SUBTOTAL - Subcontractors



$0

$0
$0
#DIV/0!













e. Travel



$0

$0
$0
#DIV/0!
f. Other Direct Costs



$0

$0
$0
#DIV/0!













SUBTOTAL - DIRECT



#DIV/0!

$0
#DIV/0!
#DIV/0!













g. Indirect Costs



$0

$0
$0
#DIV/0!
h. Pass-thru Costs



$0

$0
$0
#DIV/0!













TOTAL COSTS



#DIV/0!

$0
#DIV/0!
#DIV/0!













i. Fee



$0

$0
$0
#DIV/0!













TOTAL COST WITH FEE



#DIV/0!

$0
#DIV/0!
#DIV/0!













9.















10. Signature of Authorized Official:




CMS USE ONLY

Fringe Rate




















14. Proposal Receipt Date:


Indirect Rate


11. Type or Print Name and Title:




















Other Rate







15. Review By:
































12. DATE:
13. Telephone #














16. Signature/Title:




























Sheet 2: QIO F719

1. RFP Number: 2. Name and Address of QIO Organization:


3. QIO Area (State):
4. Contract Period




0 0




From: 12/30/1899




0



0 To: 12/30/1899




0











5. Community Provider/ Recruitment Selection 6. Interventions 7. Monitoring/Reports 8. Evaluation 9. Total


Theme: Patient Pathways Theme: Patient Pathways Theme: Patient Pathways Theme: Patient Pathways




HOURS COSTS HOURS COSTS HOURS COSTS HOURS COSTS HOURS COSTS

a. LABOR:











1. Professional 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $-

2. Information Systems 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $-

3. Corporate Management 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $-

4. Support Staff 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $-

SUBTOTAL - Direct Labor 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $-














b. Leave #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

c. Fringe Benefits
$0
$0
$0
$0
$-

SUBTOTAL - Leave / Fringe #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!














d. Subcontracts:











1. Physician Reviewers / Phys. Advisors











2. Other Consultants
$0
$0
$0
$0
$-

3. Other Subcontractors
$0
$0
$0
$0
$-

SUBTOTAL - Subcontracts 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $-














e. Travel
$0
$0
$0
$0
$-

f. Other Direct Costs
$0
$0
$0
$0
$-

SUBTOTAL - DIRECT #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!














g. Indirect Costs
$0
$0
$0
$0
$-














h. Pass-thru Costs
$0
$0
$0
$0
$-














TOTAL COSTS #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

i. Fee
$0
$0
$0
$0
$-














TOTAL COSTS WITH FEE
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!














Sheet 3: QIO F720





FRINGE BENEFIT PROPOSAL












QUALITY IMPROVEMENT ORGANIZATION 9th SOW - PATIENT PATHWAYS BUSINESS PROPOSAL













CENTERS FOR MEDICARE & MEDICAID SERVICES







































1. Name and Address of QIO Organization







3. RFP #




0







0




0













0







4: Proposed Contract Period



















2. QIO Area (State):
0





From: 12/30/1899



























To: 12/30/1899























6. Prior Year

7. Projected

8. Prior Year

9. Projected

DETAIL COSTS


Total

Total 3-YR

Total

Total 3-YR




Organization Costs

Organization Costs


Medicare Costs

Medicare Costs
Fringe Benefits













a. Employer's FICA Expense






$0




$0
b. Federal Unemployment Insurance






$0




$0
c. State Unemployment Insurance






$0




$0
d. Disability Insurance






$0




$0
e. Pension Expense






$0




$0
f. Workers Compensation






$0




$0
g. Group Health Insurance






$0




$0
h. Group Life Insurance






$0




$0
i. Empl. Relations & Welfare






$0




$0
j. Leave






$0




$0
k. Other - see attached






$0




$0















l. Total Fringe Benefits






$0




$0
m. Fringe Benefit Rate



0.00%

0.00%

0.00%

0.00%















Sheet 4: QIO F721


INDIRECT AND OTHER DIRECT COST







QUALITY IMPROVEMENT ORGANIZATION 9th SOW - PATIENT PATHWAYS BUSINESS PROPOSAL







CENTERS FOR MEDICARE & MEDICAID SERVICES














1. Name and Address of QIO Organization



3. RFP #


0



0


0







0



4: Proposed Contract Period











2. QIO Area (State):
0

From: 12/30/1899















To: 12/30/1899













5. Prior Year 6. Projected 7. Prior Year 8. Projected 9. Prior Year 10. Projected

DETAIL COSTS
Total Total 3yr. Medicare Medicare 3yr Medicare Medicare 3yr



Indirect Costs Indirect Costs Indirect Costs Indirect Costs Other Direct. Other Direct.


















a. Indirect Labor


$0
$0

b. Indirect Leave


$0
$0

c. Indirect Fringe


$0
$0

d. Rent


$0
$0 $0 $0
e. Storage


$0
$0 $0 $0
f. Utilities


$0
$0 $0 $0
g. Maintenance & Repairs


$0
$0 $0 $0
h. Depreciation


$0
$0 $0 $0
i. Data Processing


$0
$0 $0 $0
j. Equipment Leasing & Rental


$0
$0 $0 $0
k. Office Supplies


$0
$0 $0 $0
l. Reproduction & Printing


$0
$0 $0 $0
m. Telephone


$0
$0 $0 $0
n. Postage & Express Mail


$0
$0 $0 $0
o. Consultants


$0
$0

p. Meeting & Conferences


$0
$0 $0 $0
q. Travel


$0
$0

r. Training


$0
$0 $0 $0
s. Garage & Parking Spaces


$0
$0 $0 $0
t. Dues & Subscriptions


$0
$0 $0 $0
u. Recruiting


$0
$0 $0 $0
v. Temporary Help


$0
$0 $0 $0
w. Continuing Education


$0
$0 $0 $0
x. Legal Fees


$0
$0 $0 $0
y. Accounting/Audit Fees


$0
$0 $0 $0
z. Board of Directors Fees


$0
$0 $0 $0
aa. Insurance


$0
$0 $0 $0
bb. Bank Charges


$0
$0 $0 $0
cc. Other - see attached


$0
$0 $0 $0









dd. ** TOTAL


$0
$0 $0 $0









ee. Indirect Cost Rate

0.00% 0.00%












Sheet 5: QIO STAFFING











11. Average 12. Total 3yr 13. Average 14. Total 3yr 15. Average 16. Total 3yr 17. Average 18. Total 3yr 19. Average 20. Total 3yr




















5. Proposed
7. Proposed
9. Proposed
Community Provider/Recruitment Selection Community Provider/Recruitment Selection Interventions Interventions Monitoring/Reports Monitoring/Reports Evaluation Evaluation BLANK BLANK 21. Average 22. Total 3yr 23. Average 24. Total 3yr 25. Average
27. Average 28. Total 3yr 29. Average 30. Total 3yr 31. Average Total 32. Leave as a 33. Total 3yr 34. Average Total 35. Total 3yr

1. Staff 2. Position 3. Labor 4. Current Year 1 6. Percent Year 2 8. Percent Year 3 10. Percent Total Direct Labor Direct Indirect Labor Indirect Total Labor 26. Total 3yr Direct Leave Direct Leave Indirect Leave Indirect Leave Leave Hours % of Hours Leave Labor and Leave Labor/ 36. FTE

Name Title Category Code Hourly Rate Hourly Rate Change Hourly Rate Change Hourly Rate Change Hours Per Year Labor Costs Hours Per Year Labor Costs Hours Per Year Labor Costs Hours Per Year Labor Costs Hours Per Year Labor Costs Hours Per Year Labor Costs Hours Per Year Labor Costs Hours Per Year Labor Costs Hours Per Year Costs Hours Per Year Costs Per Year Worked Costs Hours Per Year Leave Costs Per Year
1




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
2




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
3




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
4




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
5




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
6




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
7




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
8




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
9




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
10




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
11




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
12




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
13




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
14




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
15




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
16




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
17




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
18




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
19




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
20




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
21




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
22




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
23




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
24




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
25




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
26




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
27




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
28




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
29




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
30




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
31




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
32




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
33




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
34




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
35




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
36




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
37




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
38




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
39




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
40




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
41




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
42




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
43




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
44




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
45




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
46




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
47




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
48




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
49




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
50




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
51




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
52




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
53




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
54




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
55




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
56




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
57




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
58




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
59




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
60




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
61




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
62




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
63




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
64




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
65




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
66




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
67




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
68




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
69




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
70




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
71




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
72




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
73




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
74




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
75




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
76




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
77




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
78




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
79




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
80




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
81




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
82




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
83




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
84




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
85




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
86




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
87




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
88




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
89




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
90




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
91




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
92




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
93




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
94




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
95




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
96




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
97




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
98




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
99




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
100




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
101




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
102




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
103




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
104




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
105




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
106




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
107




#DIV/0!
#DIV/0!
#DIV/0!
$0
$0
$0
$0
$0 0.0 $0
$0 0.0 $0
$0
$0 0.0 #DIV/0! $0 0 $0 0.00
Grand Total N/A N/A N/A #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 #DIV/0! $0 0 $0 0.00
By Category



















0.0














P=Professional


#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 #DIV/0! $- 0 $- 0
I=Info Systems


#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 #DIV/0! $- 0 $- 0
C=Corp Mgmt


#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 #DIV/0! $- 0 $- 0
S=Support Staff


#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 #DIV/0! $- 0 $- 0
Check Cell for Columns: Sum of 114 through 117 should equal value in 112









0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 $- 0.0 #DIV/0! $- 0 $- 0.00









































Averaging



































Counts 0

0 0


























Sheet 6: QIOSubconts 2












2. Community Provider/Recruitment Selection 3. Interventions 4. Monitoring/Reports 5. Evaluation BLANK 6.


1. Total 7. 8.

Name 3 YR Costs Current Activity Proposed Activity










1 Other Consultants:







a





$0

b





$0

c





$0

d





$0

e





$0

f





$0

g





$0

h





$0

i





$0

j





$0

k (See Attached)




$0


Subtotal - Other Consultants $0 $0 $0 $0 $0 $0











2 Other Subcontractors:







a





$0

b





$0

c





$0

d





$0

e





$0

f





$0

g





$0

h





$0

i





$0

j





$0

k (See Attached)




$0


Subtotal - Other Subcontractors $0 $0 $0 $0 $0 $0

Sheet 7: QIO Staff Sum

Labor Category 1. Average 2. Proposed
4. Proposed
6. Proposed
8. Total Community Provider/Recruitment Selection Hours 9. Total Community Provider/Recruitment Selection Labor Costs 10. Total Interventions Hours 11. Total Interventions Labor Costs 12. Total Monitoring/Reports Hours 13. Total Monitoring/Reports Labor Costs 14. Total Evaluation Hours 15. Total Evaluation Labor Costs 16. BLANK 17. BLANK 18. Total 19. Total 20. Total 21. Total 22. Total 23. Total 24. Total 25. Total 26. Total 27. Total 28. Total 29. Leave as a 30. Total 31. Total 32. Total
Current Average Year 1 3. Percent Average Year 2 5. Percent Average Year 3 7. Percent Direct Labor Direct Labor Indirect Labor Indirect Labor Labor Labor Direct Leave Direct Leave Indirect Leave Indirect Leave Leave % of Hours Leave Labor and Leave Labor and Leave 33. Total FTE
Hourly Rate Hourly Rate Change Hourly Rate Change Hourly Rate Change Hours Costs Hours Costs Hours Costs Hours Costs Hours Costs Hours Worked Costs Hours Costs Per Year
Professional #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 #DIV/0! $0 0.0 $0 0.00
Information Systems #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 #DIV/0! $0 0.0 $0 0.00
Corporate Management #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 #DIV/0! $0 0.0 $0 0.00
Support Staff #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 #DIV/0! $0 0.0 $0 0.00
Total #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 #DIV/0! $0 0.0 $0 0.00






































































































Sheet 8: QIO ODC




OTHER DIRECT COST FOR PATIENT PATHWAYS








QUALITY IMPROVEMENT ORGANIZATION 9th SOW BUSINESS PROPOSAL








CENTERS FOR MEDICARE & MEDICAID SERVICES














1. Name and Address of QIO Organization



3. RFP #



0



0



0








0



4: Proposed Contract Period













2. QIO Area (State):
0

From: 12/30/1899

















To: 12/30/1899












DETAIL COSTS 5. Community Provider/Recruitment Selection 6. Interventions 7. Monitoring/Reports 8. Evaluation Total Projected Medicare - 3yr Other Direct Costs





d. Rent

$0 $0 $0 $0 $0

e. Storage

$0 $0 $0 $0 $0

f. Utilities

$0 $0 $0 $0 $0

g. Maintenance & Repairs

$0 $0 $0 $0 $0

h. Depreciation

$0 $0 $0 $0 $0

i. Data Processing

$0 $0 $0 $0 $0

j. Equipment Leasing & Rental

$0 $0 $0 $0 $0

k. Office Supplies

$0 $0 $0 $0 $0

l. Reproduction & Printing

$0 $0 $0 $0 $0

m. Telephone

$0 $0 $0 $0 $0

n. Postage & Express Mail

$0 $0 $0 $0 $0

o. Consultants








p. Meeting & Conferences

$0 $0 $0 $0 $0

q. Travel








r. Training

$0 $0 $0 $0 $0

s. Garage & Parking Spaces

$0 $0 $0 $0 $0

t. Dues & Subscriptions

$0 $0 $0 $0 $0

u. Recruiting

$0 $0 $0 $0 $0

v. Temporary Help

$0 $0 $0 $0 $0

w. Continuing Education

$0 $0 $0 $0 $0

x. Legal Fees

$0 $0 $0 $0 $0

y. Accounting/Audit Fees

$0 $0 $0 $0 $0

z. Board of Directors Fees

$0 $0 $0 $0 $0

aa. Insurance

$0 $0 $0 $0 $0

bb. Bank Charges

$0 $0 $0 $0 $0

cc. Other - see attached

$0 $0 $0 $0 $0











TOTAL

$0 $0 $0 $0 $0





















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