Form CMS-718-721 Business Proposal Forms
Business Proposal Forms For Quality Improvement Organizations (QIOs) (CMS-718-721)
BP Forms.XLSX
Business Proposal Forms For Quality Improvement Organizations (QIOs)
OMB: 0938-0579
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0579 can be found here:
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QIO F719
QIO F720
QIO F721
QIO STAFFING
QIOSubconts 1
QIOSubconts 2
QIO Staff Sum
QIO ODC
BFCC Sup Sch
Travel Detail Form
Overview
F718 BP SUMQIO F719
QIO F720
QIO F721
QIO STAFFING
QIOSubconts 1
QIOSubconts 2
QIO Staff Sum
QIO ODC
BFCC Sup Sch
Travel Detail Form
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 | $0 | $0 | $0 | #DIV/0! | ||||||||
| c. Fringe Benefits | $0 | $0 | $0 | #DIV/0! | ||||||||
| SUBTOTAL - Leave/Fringe | $0 | $0 | $0 | #DIV/0! | ||||||||
| d. Subcontractors | ||||||||||||
| 1. Physician Reviewers/ Phys.Advisors | $0 | $0 | $0 | #DIV/0! | ||||||||
| 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 | $0 | $0 | $0 | #DIV/0! | ||||||||
| g. Indirect Costs | $0 | $0 | $0 | #DIV/0! | ||||||||
| h. Pass-thru Costs | $0 | $0 | $0 | #DIV/0! | ||||||||
| TOTAL COSTS | $0 | $0 | $0 | #DIV/0! | ||||||||
| i. Fee | $0 | $0 | $0 | #DIV/0! | ||||||||
| TOTAL COST WITH FEE | $0 | $0 | $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. Reviewed By: | |||||||||||
| Indirect Leave Rate | ||||||||||||
| 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 | ||||||||||||||||||||||||||||
| TOTAL | ||||||||||||||||||||||||||||
| MEDICARE COSTS | ||||||||||||||||||||||||||||
| HOURS | COSTS | HOURS | COSTS | HOURS | COSTS | HOURS | COSTS | HOURS | COSTS | HOURS | COSTS | HOURS | COSTS | HOURS | COSTS | 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 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 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 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 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 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 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 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $- | ||
| SUBTOTAL - Direct Labor | 0.0 | $0 | 0.0 | $0 | 0.0 | $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 | $- | ||
| b. Leave | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $- | ||
| c. Fringe Benefits | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $- | |||||||||||||||
| SUBTOTAL - Leave / Fringe | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $- | ||
| d. Subcontracts: | ||||||||||||||||||||||||||||
| 1. Physician Reviewers / Phys. Advisors | 0.0 | $0 | 0.0 | $- | ||||||||||||||||||||||||
| 2. Other Consultants | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $- | |||||||||||||||
| 3. Other Subcontractors | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $- | |||||||||||||||
| SUBTOTAL - Subcontracts | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $- | ||
| e. Travel | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $- | |||||||||||||||
| f. Other Direct Costs | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $- | |||||||||||||||
| SUBTOTAL - DIRECT | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | ||
| g. Indirect Costs | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $- | |||||||||||||||
| h. Pass-thru Costs | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $- | |||||||||||||||
| TOTAL COSTS | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | ||
| i. Fee | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $- | |||||||||||||||
| TOTAL COSTS WITH FEE | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $- | |||||||||||||||
Sheet 3: QIO F720
| FRINGE BENEFIT PROPOSAL | ||||||||||||||
| QUALITY IMPROVEMENT ORGANIZATION 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 5-YR | Total | Total 5-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 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 5yr. | Medicare | Medicare 5yr | Medicare | Medicare 5yr | ||
| 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
| 17. Average | 18. Total 5yr | INDIRECT | DIRECT LEAVE | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| 5. Proposed | 7. Proposed | 9. Proposed | 11. Proposed | 13. Proposed | 15. Average | 16. Total 5yr | 19. Average | 20. Total 5yr | 21. Average | 22. Total 5yr | 23. Average | 24. Total 5yr | 25. Average | 26. Total 5yr | 27. Average | 28. Total 5yr | 29. Average | 30. Total 5yr | 31. Average | 32. Total 5yr | 33. Average | 34. Total 5yr | 35. Average | 36. Total 5yr. | 37. Average | 38. Total 5yr | 39. Average | 40. Total 5yr | 41. Average | Prof. Hours | 42. Total 5yr | 43. Average | 44. Total | 45. Average | 46. Total 5yr | Prof. Labor | 47. Average | 48. Total 5yr | 49. Average Total | 50. Leave as a | 51. Total 5yr | 52. Average Total | 53. Total 5yr | |||||||||||||
| 1. Staff | 2. Position | 3. Labor | 4. Current | Year 1 | 6. Percent | Year 2 | 8. Percent | Year 3 | 10. Percent | Year 4 | 12. Percent | Year 5 | 14. Percent | Total Direct Labor | Direct | Indirect Labor | per year | Indirect | Total Labor | 5yr | Direct Leave | Direct Leave | costs/yr | Leave | Leave | Leave Hours | % of Hours | Leave | Labor and Leave | Labor/ | 54. FTE | |||||||||||||||||||||||||
| Name | Title | Category Code | Hourly Rate | Hourly Rate | Change | Hourly Rate | Change | 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 | 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 | avg | Labor Costs | Hours Per Year | Labor Costs | Hours Per Year | Costs | avg | Hours Per Year | Costs | Per Year | Worked | Costs | Hours Per Year | Leave Costs | Per Year | |
| 1 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 2 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 3 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 4 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 5 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 6 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 7 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 8 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 9 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 10 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 11 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 12 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 13 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 14 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 15 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 16 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 17 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 18 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 19 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 20 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 21 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 22 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 23 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
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| 82 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 83 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 84 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 85 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 86 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 87 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 88 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 89 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 90 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 91 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 92 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 93 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 94 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 95 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 96 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 97 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 98 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 99 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 100 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 101 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 102 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 103 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 104 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 105 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 106 | #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 | #DIV/0! | $0 | 0 | $0 | 0.00 | ||||||||||||||||||||||||
| 107 | #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 | #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! | #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 | $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 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| P=Professional | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #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 | $- | 0.0 | $- | 0.0 | #DIV/0! | $- | 0 | $- | 0 | |||||
| I=Info Systems | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #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 | $- | 0.0 | $- | 0.0 | #DIV/0! | $- | 0 | $- | 0 | |||||
| C=Corp Mgmt | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #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 | $- | 0.0 | $- | 0.0 | #DIV/0! | $- | 0 | $- | 0 | |||||
| S=Support Staff | #DIV/0! | #DIV/0! | #DIV/0! | #DIV/0! | #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 | $- | 0.0 | $- | 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 | $- | 0 | $- | 0.0 | $- | 0.0 | $- | 0.0 | $- | 0.0 | $- | 0.0 | $- | 0.0 | #DIV/0! | $- | 0 | $- | 0.00 | ||||||||||||||||
| Averaging | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Counts | 0 | 0 | 0 | 0 | 0 |
Sheet 6: QIOSubconts 1
| Physician Reviewer Cost for Beneficiary & Family Centered Care Activities | |||||
| 1. Current | 2 | 3 | 4 | 5 | 6. |
| Phys. Reviewer | Number of | Hours | Hours | Phys. Reviewer | Benef. and FCC |
| Hourly Rate | Reviews | Per Review | Per Year | Hourly Rate | Review Costs |
| 0.0 | $0 | ||||
| 7 | 8 | 9 | 10 | 11. | |
| Number of | Hours | Hours | Phys. Reviewer | Benef. and FCC | |
| Reviews | Per Review | Per Year | Hourly Rate | Review Costs | |
| 0.0 | $0 | ||||
| 12 | 13 | 14 | 15 | 16 | |
| Number of | Hours | Hours | Phys. Reviewer | Benef. and FCC | |
| Reviews | Per Review | Per Year | Hourly Rate | Review Costs | |
| 0.0 | $0 | ||||
| 17 | 18 | 19 | 20 | 21 | |
| Number of | Hours | Hours | Phys. Reviewer | Benef. and FCC | |
| Reviews | Per Review | Per Year | Hourly Rate | Review Costs | |
| 0.0 | $0 | ||||
| 22 | 23 | 24 | 25 | 26 | 27. Total |
| Number of | Hours | Hours | Phys. Reviewer | Benef. and FCC | Benef. and FCC |
| Reviews | Per Review | Per Year | Hourly Rate | Review Costs | Review Costs |
| 0.0 | $0 | $0 | |||
Sheet 7: QIOSubconts 2
| 2. Total 5 Years | 3. Total 5 Years | 4. Total 5 Years | 5. Total 5 Years | 6. Total 5 Years | 7. Total 5 Years | 8. Total 5 Years | 9. Total 5 Years | 10. Total 5 Years | 11. Total 5 Years | 12. Total 5 Years | 13. Total 5 Years | 14. | ||||
| 1. | Total | 15 | 16. | |||||||||||||
| Name | 5 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 | $0 | $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 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
Sheet 8: QIO Staff Sum
| Labor Category | 1. Average | 2. Proposed | 4. Proposed | 6. Proposed | 8. Proposed | 10. Proposed | 12. Total | 13. Total | 14. Total | 15. Total | 16. Total | 17. Total | 18. Total | 19. Total | 20. Total | 21. Total | 22. Total | 23. Total | 24. Total | 25. Total | 26. Total | 27. Total | 28. Total | 29. Total | 30. Total | 31. Total | 32. Total | 33. Total | 36. Total | 37. Total | 38. Total | 39. Total | 40. Total | 41. Total | 42. Total | 43. Total | 44. Total | 45. Total | 46. Total | 47. Leave as a | 48. Total | 49. Total | 50.. Total | ||||||||
| Current | Average Year 1 | 3. Percent | Average Year 2 | 5. Percent | Average Year 3 | 7. Percent | Average Year 4 | 9. Percent | Average Year 5 | 11. Percent | 34. Total | 35. Total | Direct Labor | Direct Labor | Indirect Labor | Indirect Labor | Labor | Labor | Direct Leave | Direct Leave | Leave | Leave | Leave | % of Hours | Leave | Labor and Leave | Labor and Leave | 51. Total FTE | |||||||||||||||||||||||
| Hourly Rate | Hourly Rate | Change | Hourly Rate | Change | Hourly Rate | Change | Hourly Rate | Change | Hourly Rate | Change | Hours | Labor Costs | Hours | Labor Costs | Hours | Labor Costs | Hours | Labor Costs | Hours | Labor Costs | Hours | Labor Costs | Hours | Labor Costs | Hours | Labor Costs | Hours | Labor Costs | Hours | Labor Costs | Hours | Labor Costs | Hours | Labor Costs | 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! | #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 | $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! | #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 | $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! | #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 | $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! | #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 | $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! | #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 | $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 9: QIO ODC
| OTHER DIRECT COST | |||||||||||||||
| QUALITY IMPROVEMENT ORGANIZATION 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 | Total Projected Medicare - 5yr Other Direct Costs | ||||||||||||||
| d. Rent | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| e. Storage | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| f. Utilities | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| g. Maintenance & Repairs | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| h. Depreciation | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| i. Data Processing | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| j. Equipment Leasing & Rental | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| k. Office Supplies | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| l. Reproduction & Printing | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| m. Telephone | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| n. Postage & Express Mail | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| o. Consultants | |||||||||||||||
| p. Meeting & Conferences | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| q. Travel | |||||||||||||||
| r. Training | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| s. Garage & Parking Spaces | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| t. Dues & Subscriptions | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| u. Recruiting | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| v. Temporary Help | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| w. Continuing Education | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| x. Legal Fees | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| y. Accounting/Audit Fees | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| z. Board of Directors Fees | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| aa. Insurance | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| bb. Bank Charges | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| cc. Other - see attached | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
| TOTAL | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||
Sheet 10: BFCC Sup Sch
| 1. Name and Address of QIO Organization: | 2. QIO Area (State): | 3. Contract Period | |||||||||||||||||||||||||
| 0 | 0 | From: | 12/30/1899 | ||||||||||||||||||||||||
| 0 | To: | 12/30/1899 | |||||||||||||||||||||||||
| 0 | |||||||||||||||||||||||||||
| 4. Quality of Care Reviews Cost Per Case | 5. Hospital Based Notice Appeals Cost Per Case | 6. Fee-for-Service (FFS) Expedited Appeals Cost Per Case | 7. Medicare Advantage (MA) Fast Track Appeals Cost Per Case | 8. EMTALA: 5-day Reviews Cost Per Review | 9. EMTALA: 60-day Reviews Cost Per Review | 10. Higher Weighted DRG Cost Per Case | 11. Quality Improvement Interventions (QII)/ Technical Assistance Costs | 12. Sanction Activities | 13. Collaboration | 14. Transparency Through Reporting | 15. Other Non-Review Activities | 16. Total | |||||||||||||||
| HOURS | COSTS | HOURS | COSTS | HOURS | COSTS | HOURS | COSTS | HOURS | COSTS | HOURS | COSTS | HOURS | COSTS | HOURS | COSTS | HOURS | COSTS | HOURS | COSTS | HOURS | COSTS | HOURS | COSTS | HOURS | COSTS | ||
| a. LABOR: | |||||||||||||||||||||||||||
| 1. Professional | 0.0 | $- | |||||||||||||||||||||||||
| 2. Information Systems | 0.0 | $- | |||||||||||||||||||||||||
| 3. Corporate Management | 0.0 | $- | |||||||||||||||||||||||||
| 4. Support Staff | 0.0 | $- | |||||||||||||||||||||||||
| SUBTOTAL - Direct Labor | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $- | |
| b. Leave | 0.0 | $- | |||||||||||||||||||||||||
| c. Fringe Benefits | $- | ||||||||||||||||||||||||||
| SUBTOTAL - Leave / Fringe | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $- | |
| d. SUBCONTRACTS: | |||||||||||||||||||||||||||
| 1. Physician Reviewers / Phys. Advisors | 0.0 | $- | |||||||||||||||||||||||||
| 2. Other Consultants | $- | ||||||||||||||||||||||||||
| 3. Other Subcontractors | $- | ||||||||||||||||||||||||||
| SUBTOTAL - Subcontracts | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $- | |
| e. Travel | $- | ||||||||||||||||||||||||||
| f. Other Direct Costs | $- | ||||||||||||||||||||||||||
| SUBTOTAL - DIRECT | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | |
| g. Indirect Costs | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $- | ||||||||||||||
| h. Pass-thru Costs | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $- | ||||||||||||||
| TOTAL COSTS | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | 0.0 | $0 | |
| i. Fee | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $- | ||||||||||||||
| TOTAL COSTS WITH FEE | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $- | ||||||||||||||
| Projected Volume - # of cases for: | |||||||||||||||||||||||||||
| Year 1 | |||||||||||||||||||||||||||
| Year 2 | |||||||||||||||||||||||||||
| Year 3 | |||||||||||||||||||||||||||
| Year 4 | |||||||||||||||||||||||||||
| Year 5 | |||||||||||||||||||||||||||
| GRAND TOTAL: | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ||||||||||||||
| ** Please note, the totals for these activities DO NOT roll into the column BENEFICIARY & FAMILY CENTERED CARE on the form "QIO F719". | |||||||||||||||||||||||||||
Sheet 11: Travel Detail Form
| TRAVEL DETAIL | |||||||||||||||||||
| QUALITY IMPROVEMENT ORGANIZATION BUSINESS PROPOSAL | |||||||||||||||||||
| CENTERS FOR MEDICARE & MEDICAID SERVICES | |||||||||||||||||||
| 1. RFP Number: | 2. Name and Address of QIO Organization: | 3. QIO Area (State): | 4. Contract Period | ||||||||||||||||
| 0 | 0 | 0 | From: | 12/30/1899 | |||||||||||||||
| 0 | To: | 12/30/1899 | |||||||||||||||||
| 0 | |||||||||||||||||||
| 5. Mileage Rate: | |||||||||||||||||||
| 6. Area | 7. Trip Title & Description/Purpose | 8. # of Days per Trip | 9. # of Nights per Trip | 10. # of Travelers per Trip | 11. Airfare per Person | 12. Departing from: | 13. Arriving to: | 14. FTR Meals & Inc. Daily Rate | 15. FTR Lodging per Night | 16. # of Trips | 17. Total # of miles per trip | 18. # of Rental Cars Per Trip | 19. Daily Rental Car Rate | 20. Misc. Cost per Person per Trip (includes parking, gas, taxi, etc.) | 21. TOTAL | 22. Notes | |||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| $0 | |||||||||||||||||||
| 23. GRAND TOTAL: | $0 | ||||||||||||||||||
| ** Please note, the totals for these activities DO NOT roll into the TRAVEL line item listed on the forms entitled, "QIO F719", "QIO ODC", or "BFCC Sup Sch". | |||||||||||||||||||
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |
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