Business Proposal Forms For Quality Improvement Organizations (QIOs)

Business Proposal Forms For Quality Improvement Organizations (QIOs) (CMS-718-721)

BPInstructions

Business Proposal Forms For Quality Improvement Organizations (QIOs)

OMB: 0938-0579

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BUSINESS PROPOSAL FORMAT
FOR UTILIZATION AND QUALITY CONTROL
QUALITY IMPROVEMENT ORGANIZATIONS
FORMS AND INSTRUCTIONS

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
BALTIMORE, MARYLAND

Table of Contents
I. INTRODUCTION .......................................................................................................................................... 4
PURPOSE ................................................................................................................................................... 4
SCOPE ........................................................................................................................................................ 4
METHOD OF SUBMISSION ........................................................................................................................ 4
II. GENERAL INSTRUCTIONS .......................................................................................................................... 5
III. ADDITIONAL EXPLANATION AND JUSTIFICATION FOR BUSINESS PROPOSAL .......................................... 5
General ...................................................................................................................................................... 5
Full Time Equivalents (FTEs) and Salaries ................................................................................................. 6
Leave ......................................................................................................................................................... 6
Fringe Benefits .......................................................................................................................................... 6
Other Consultants/Subcontracts .............................................................................................................. 6
Travel......................................................................................................................................................... 8
Other Direct Costs ..................................................................................................................................... 8
Grand Total ............................................................................................................................................... 8
Indirect Costs ............................................................................................................................................ 9
Pass‐thru Costs .......................................................................................................................................... 9
IV. BUSINESS PROPOSAL FORMS AND INSTRUCTIONS ............................................................................... 10
INSTRUCTIONS FOR CMS FORM 718 BP BUSINESS PROPOSAL SUMMARY ............................................ 10
INSTRUCTIONS FOR CMS FORM 719 BP ................................................................................................. 11
INSTRUCTIONS FOR CMS FORM 720 BP (FRINGE) .................................................................................. 13
INSTRUCTIONS FOR CMS FORM 721 BP INDIRECT AND OTHER DIRECT COSTS ..................................... 15
INSTRUCTIONS FOR PERSONNEL LOADING CHARTS STAFFING PROPOSAL FORM ................................. 18
INSTRUCTIONS FOR CMS FORM SC 1 (SUBCONTRACTS) ........................................................................ 23
INSTRUCTIONS FOR CMS FORM SC 2 (OTHER SUBCONTRACTS) ............................................................ 26
INSTRUCTIONS FOR CMS FORM STAFFING SUMMARY PROPOSAL ........................................................ 28
INSTRUCTIONS FOR OTHER DIRECT COSTS SUPPLEMENTAL SCHEDULE ................................................ 32
INSTRUCTIONS FOR BENEFICIARY AND FAMILY CENTERED CARE SUPPLEMENTAL SCHEDULE ............. 33
INSTRUCTIONS FOR TRAVEL DETAIL ....................................................................................................... 36
V. APPENDIX DEFINITIONS AND GUIDELINES ............................................................................................. 38
I. GENERAL. ............................................................................................................................................. 38
II. LINE ITEM CATEGORIES. ...................................................................................................................... 39
i.

FEE .............................................................................................................................................. 45

III. COST CENTER COLUMN CATEGORIES ................................................................................................ 45

I. INTRODUCTION
PURPOSE
This guideline package will assist you in preparing the standardized business proposal forms
used to award Medicare Quality Improvement Organization (QIO) contracts.
SCOPE
Offerors must use the electronic file that CMS provides to prepare and submit the business
proposal. This guideline package provides instructions for completing the various business
proposal forms in the CMS electronic file.
Business proposals are required to include the appropriate supporting information, crossreferenced to the related column, line item, and form. The supporting information should be
detailed and, as appropriate, fully explain calculations, bases for estimates, etc. Failure to
supply the supportive documentation for all proposed costs may be grounds of rejection
and the proposal will be returned accordingly. Examples include:
a. Quotes and estimates from vendors;
b. Market surveys;
c. Historical data;
d. Specific calculations used to estimate proposed costs and an explanation;
e. Catalog prices; and
f. Previous billing statements/ expense vouchers.
METHOD OF SUBMISSION
CMS is providing you with the business proposal forms in an Excel spreadsheet file titled _____.
You should enter your cost data in the Excel files and submit your completed business
proposal in electronic format.
The cost information in the electronic version of your completed business proposal must be in
Excel format. The narrative supporting information can be in Excel or Word format.

II. GENERAL INSTRUCTIONS
The following general instructions for the completion and submission of the business proposal
forms are in addition to those instructions contained in the RFP issued by CMS to all offerors
and in addition to the attached Section III – ADDITIONAL EXPLANATION AND
JUSTIFICATION FOR BUSINESS PROPOSAL.
1.

The CMS-provided electronic file and the specified Excel and Word versions are the only
acceptable format for your cost proposal submission. Proposals received in any other
format will be considered unacceptable.
The business proposal spreadsheets are formatted to accept one decimal place for entries
relating to hours and whole dollars for entries relating to costs. However, where
appropriate (e.g., hourly rates), the formatting will permit 2 decimal places for costs.

As used in this cost proposal process, the term "QIO" refers to both present QIO and
potential QIO organizations.

A QIO organization proposing a Medicare contract in more than one QIO area must
complete a separate business proposal for each QIO area.

All blocks on the forms that are shaded are filled out by formulae from within the form or
from other forms or are for CMS use only, and they should not be filled out by the
submitting QIO. Please fill out, as appropriate, only the unshaded blocks.

OMB INSTRUCTIONS REQUIRE THE FOLLOWING BURDEN DISCLOSURE
NOTICE TO BE INCORPORATED ON ALL COLLECTIONS OF INFORMATION
OR THE ACCOMPANYING INSTRUCTIONS.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-0579 (Expiration Date:
XX/XX/XXXX). The time required to complete this information collection is estimated to
average 40 hours per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do
not send applications, claims, payments, medical records or any documents containing
sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the
associated OMB control number listed on this form will not be reviewed, forwarded, or
retained. If you have questions or concerns regarding where to submit your documents,
please contact Benjamin Bernstein 410-786-6570.

III. ADDITIONAL EXPLANATION AND JUSTIFICATION FOR
BUSINESS PROPOSAL
General
As a general rule you should explain how you calculated all items in your business proposal,
5

with the exceptions provided below. ALL COSTS MUST BE VERIFIABLE. With the
exception of salaries, which are discussed below, the QIO should not inflate any line item for a
year to year increase of greater than ___% without providing further justification. The QIO
should also make sure to indicate what rate of increase it is using on all non-salary line items,
even when they are at or below the ___% rate of increase per year. Note: The escalation rate is
based on current market conditions and the rate used in FY____ budget assumptions.
Full Time Equivalents (FTEs) and Salaries
FTEs proposed should be proposed on the basis of the most efficient method of performing each
sub-task. The total direct labor hours, and their distribution across labor categories (e.g.
professional, support staff) proposed for each sub-task should be justified on the basis of the
information provided in the technical proposal and/or capability.
All proposed labor rates shall be supported with matching rates or formal salary survey
information conducted by your organization from an acceptable source {i.e.
www.salary.com, www.indeed.com, or etc.}. Escalation of salaries should not exceed ___%
based on current market conditions. QIOs shall also explain organizational salary increases. The
organizational salary increase will be determined each year by the “Grand Total Percent Change”
cell on the Person Loading Chart – Staffing (i.e. for the year 1 over the current year it is cell “O
112” on the Form Staffing).
Leave
Please summarize your leave policy. Also, explain any increase in your leave rate as a
percentage of direct labor cost. All leave should be reported as part of the Fringe Benefit
Category or in your approved Indirect Leave Rate.
Fringe Benefits
For Fringe Benefits, if you have an approved provisional rate, it can serve as the justification for
the Fringe Benefit expense. If you do not have an approved provisional rate or you do not believe
that this rate is correct for your three-year budget, please justify the rate requested, with
emphasis on the major items of increase.
Other Consultants/Subcontracts
Form SC 1 requests information on the number of reviews, the time per review and the hourly
rate for Physician Reviewers/Advisors. Please explain how you determined these factors and
why and how they are different from the current year. The Form SC 1is provided for Beneficiary
Protection and Special Studies. For all other tasks, enter Physician Reviewers/Advisors costs
directly into the appropriate cell on the Form 719BP fully justify the need for Physician
Reviewers/Advisors cost for these tasks and explain the basis for the amount entered. If the
Physician Reviewers/Advisors cost for these other tasks is based on the number of reviews
performed, you should provide the detail in the same format as on the Form SC 1.
For Consultants and Other Subcontracts, please justify the purpose of each proposed Consultant
and Subcontract. Explain the methodology used to formulate each Consultant Service or
Subcontract cost, including hourly rates and number of hours requested for the Consultants or for
the personnel employed in the Subcontract. The QIO’s cost detail shall also include the
6

determination if the rates are fully loaded, travel costs [number of trips, purpose, per diem,
airfare, mileage, means of travel, number of days and nights, lodging, & any miscellaneous
costs/fees], volumes and unit costs for all Other Direct Costs, etc. For all Subcontracts, you shall
use the subcontractor’s business proposal as supporting documentation. Essentially, the
Consultant(s)/Subcontractor(s) must complete the same level of detail as the Prime. If the
Consultant(s)/Subcontractor(s) are not comfortable with submitting their proposal to the
Prime, they may send it to CMS directly. Note: with the exception of the Physician
Reviewers, Subcontract consent (submission of the required Request for Consent - Section
J Attachment __) must be submitted for each Subcontract/Consultant proposed according
to the thresholds provided in Section I of the RFP.
Example (for a Consultant):
Name

Cost

Description

Dr. John
Doe

$15,000

These are the costs for Dr. John Doe to provide 150 hours of program
management time over the course of the contract for case review related
activity. Additionally Dr. Doe is an internist by training and bills at a
consultant hourly rate of $100.

Travel
All QIOs are required to explain how you calculated your Travel costs by Task. The QIO’s
travel justification should include, but are not limited to, the following for each trip: (1) trip title,
description, & purpose, (2) means of travel (air, car, bus, train) and its cost, (3) locations (origin
and destination), (4) lodging, (5) number of travelers, (6) mileage and the rate used, (7) number
of rental cars, if needed, (8) daily rental car rate, (9) miscellaneous costs per person – includes
parking, gas, taxi, etc. and explain each cost in great detail, (10) number of days and nights, and
(11) meals and incidentals. Furthermore, QIOs are asked to provide printouts with matching
price quotes from a reliable source and/or historical data (including billing statements/expense
vouchers, etc.). CMS will use the Federal Travel Regulations as a means to determine reasonable
travel costs.
Other Direct Costs
Explain how you calculated all Other Direct Costs (ODC) by showing unit costs, volume details,
and explain rationale of how the QIO determined the ODCs. CMS must be able to crosswalk the
proposed costs to the supporting documentation and proposed rationale. QIOs are asked to
provide, but are not limited to:
 Specific price quotes;
 Market surveys;
 Historical data;
 Specific calculations used to estimate proposed costs and an explanation;
 Previous billing statements/expense vouchers; and/or
 Catalog prices.
For example, your Reproduction and Printing justification should show the number of specific
items that you expect to print and the cost per item. If you report Rent under Other Direct Costs,
please provide the details of how many square feet are currently rented, and the number of
square feet you propose to rent under the new contract. Also, provide the cost per square foot in
the prior year and each year of the proposed contract.
Example:Reproduction and Printing
Description

Purpose

Frequency

Cost Estimate/
unit cost

Basis of
Estimate

Yr 1 costs

Printing:
400 Copies

Brochures/Handouts for
Physician Collaboration
Annual Meeting

3 annual
meetings

$0.50 a brochure/
$200 per meeting

Price quote

$600

Printing:
500 Copies

Presentation for
Regional Meeting

4 regular
meetings
per year

$0.05 per page
printing, 40 pages
per presentation.
$1,000 per meeting

Estimate
from
previous
year cost

$4,000

Grand Total

$4,600

Indirect Costs
For Indirect Costs, if you have an approved provisional Indirect Rate it can serve as the
justification for this cost. However, you should always explain how you calculated Rent. For
rent, please provide the details of how many square feet are currently rented, the number of
square feet you propose to rent under the new contract, and the cost per square foot in the prior
year and each year of the proposed contract. In addition, if you report AHQA dues, make sure
that you report the amount per year and how the amount was determined. If you report Board of
Directors fees, please detail your basis of compensation per board meeting or for travel
performed on behalf of the organization.
If you do not have an approved provisional rate, or you do not believe that this rate is
correct for your three-year budget, please fill out all the line items on Form 721 and justify
the rate requested, with emphasis on the major items of increase.
Pass-thru Costs
Explain how you calculated Pass-thru Costs, indicating how many records are involved, how the
QIO projected the number of records, and the cost per record.

IV. BUSINESS PROPOSAL FORMS AND INSTRUCTIONS
INSTRUCTIONS FOR CMS FORM 718 BP BUSINESS PROPOSAL SUMMARY
QUALITY IMPROVEMENT ORGANIZATION
ITEM
1.

Name and Address of QIO Organization. Enter the name and address of the
organization submitting the proposal (make sure the information is entered in the
boxes shown at cells A3, A4 and A5)

QIO Area. Enter the State or other area that the proposed QIO contract will
cover (make sure the information is entered in the box shown at cell C7).

RFP Number. Enter the CMS RFP number for the proposed QIO contract (make
sure the information is entered in the box shown at cell J3.)

Proposed Contract Period. Enter the beginning and ending dates of the
proposed QIO contract (make sure the information is entered in the boxes shown
at cells K7 and K9.)

Total Proposed Costs. This column contains your total proposed costs for the 5year contract period. The proposed costs are listed for each line item category.
No entries are required because the proposed costs automatically flow from Form
719 BP.

CMS Recommended Costs. No entries required. For CMS internal use only.

$ Difference. No entries required. For CMS internal use only.

% Difference. No entries required. For CMS internal use only.

Fringe, Indirect, and Other Rates. QIOs should enter their approved fringe
benefit rate and indirect cost rate in the appropriate spaces. Leave the fringe and
indirect rate spaces blank if you are a new QIO and do not have approved rates.

10.

Signature of Authorized Official. The appropriate official of the organization
submitting the business proposal should sign here.

11.

Type Name and Title. Insert the name and title of the official signing in item 10.

12.

Date. Enter the date the business proposal is submitted.

13.

Telephone #. Enter the organization’s phone number, starting with the area code.

14.

For CMS use only.

15.

For CMS use only.

16.

For CMS use only.
10

INSTRUCTIONS FOR CMS FORM 719 BP
QUALITY IMPROVEMENT ORGANIZATION BUSINESS PROPOSAL
ITEM
1.

RFP#. No entry required. This information automatically flows from Form 718 BP.

Name and Address of QIO Organization. No entry required. This information
automatically flows from Form 718 BP.

QIO Area. No entry required. This information automatically flows from Form 718 BP.

Proposed Contract Period. No entry required. This information automatically flows
from Form 718 BP.

COST CENTER COLUMNS
THE NEXT COLUMNS SERVES AS THE COST CENTERS FOR THE
SPECIFIED SOW:
Note: For direct contract costs that cannot be attributed to
provided costs centers, the QIO/Offeror shall allocate those
direct costs to each of the cost centers, using an allocation
method consistent with organization practice. This does not
include costs related to governance. These costs benefit the
entire organization and should be included in indirect.
LINE ITEMS
a.1- a.4

Labor. No entry required. The hours and costs for each direct labor category are
automatically calculated from the Staffing Proposal Summary sheet (Form SUM).

Leave. Note: include all paid time off (leave) in Fringe Benefit pool unless your
organization has an approved separate Indirect Leave Rate (ILR). If your
organization has an approved ILR, enter the appropriate hours and cost for each
category for the 5-year contract period.

Fringe Benefits. Enter the fringe benefits cost for the 5-year contract period that
applies to the particular column cost center. Include all paid time off (leave)
unless your organization has an approved separate indirect leave rate.

d.1- d.3

Subcontracts. No entry required. The hours and costs for each category are
automatically calculated from the Subcontracts Proposal sheets (Forms SC 1 and
SC 2). However, if you have costs for Physician Reviewers/Advisors in any task
other than Beneficiary Protection and Special Projects, you should enter the cost
for the 5-year contract period that applies to the particular column cost center.

Travel. Enter the travel cost for the 5-year contract period that applies to the
particular column cost center. Furnish detailed supporting documentation to
11

explain these costs.
f.

Other Direct Costs. No entry required. The costs for each column cost center
are automatically calculated from the QIO ODC sheet. Furnish detailed
supporting documentation to explain these costs.

Indirect Costs. Enter the indirect costs for the 5-year contract period that applies
to the particular column cost center.

Pass-thru Costs. Enter the pass-thru costs for the 5-year contract period that
apply to the particular column cost center. Furnish detailed supporting
documentation to explain these costs.

Fee. Enter the appropriate portion of the total fee in each column cost center.

Total Proposed Providers. Enter the total number of proposed providers for the
5-year contract period that apply to the particular column cost center.

Average 5-year Cost Per Provider. Enter the average 5-year cost per provider
for the 5-year contract period that applies to the particular column cost center.

TOTAL
No entry required. This column automatically calculates the total hours and costs for each line
item category from the entries in the cost center columns.

INSTRUCTIONS FOR CMS FORM 720 BP (FRINGE)
FRINGE BENEFIT PROPOSAL
QUALITY IMPROVEMENT ORGANIZATION BUSINESS PROPOSAL
ITEM
1.

Name and Address of QIO Organization. No entry required. This information
automatically flows from Form 718 BP.

QIO Area. No entry required. This information automatically flows from Form 718 BP.

RFP#. No entry required. This information automatically flows from Form 718 BP.

Proposed Contract Period. No entry required. This information automatically flows
from Form 718 BP.

NOTE:

The total cost entries that you make in column 7 and 9 should include both direct
and indirect costs. Also, an established QIO that has an approved provisional
fringe benefit rate and which determines that this approved rate will accurately
reflect projected 5-yr fringe benefit costs, does not have to complete the
individual line items on Form 720 BP. Instead, enter the fringe benefit rate on
Line m.
If the QIO does not believe that the approved rate is appropriate for projecting 5yr costs or it is a new QIO that does not have an approved provisional rate, the
QIO should complete the individual line items in columns 7 and 9, as explained
below.

COLUMN 6. - Prior Year Total Organization Costs
LINE
a. - l.

Individual line item categories. Disregard these line items. No entries should
be made on these lines in column 6.

Fringe Benefit Rate. Enter the fringe benefit rate for the latest 12-month period
completed, for which cost data is available. Identify this 12-month period in your
supporting documentation and explain the base (i.e., denominator) used to
calculate this rate.

COLUMN 7 - Projected Total 5-yr Organization Costs
LINE
a. - k.

Individual line item categories. (See note, above) On each line item, enter the
fringe benefit cost projected for your organization for the 5-year period that the
QIO contract would be operating. However, make an entry on line j. (Leave) only
if you include leave in the fringe benefit pool.
Your supporting documentation should explain, in detail, any amount you enter
on line item k. The supporting documentation should also fully explain the
13

assumptions and bases you used for your organization’s projection, including
appropriate cost projection schedules.
l.

Total Fringe Benefits. No entry required. This line item automatically
calculates the total of line items a. thru k.

Fringe Benefit Rate. Enter the fringe benefit rate that is applicable to the amount
on line item l., Total Fringe Benefits. In your supporting documentation, give a
detailed explanation of the method used to calculate this rate. It is necessary to
provide the Fringe Benefit Rate even if you do not have to fill out lines a. thru l.

COLUMN 8 - Prior Year Total Medicare Costs
LINE
a. - l.

Individual line item categories. Disregard these line items. No entries should
be made on these lines in column 8.

m.
Fringe Benefit Rate. Enter the fringe benefit rate for the latest 12-month period
completed, for which cost data is available. Identify this 12-month period in your supporting
documentation and explain the base (i.e., denominator) used to calculate this rate.
COLUMN 9 - Projected Total 5-yr Medicare Costs
LINE
a. - k.

Individual line item categories. (See note above) On each line item, enter the
portion of the corresponding line item cost in column 7. (Projected Total 5-yr
Organization Costs) allocated to the proposed Medicare QIO contract.
Your supporting documentation should explain, in detail, any amount you entered
on line item k. The supporting documentation should also fully explain the
assumptions and bases you used to allocate a portion of your organization’s total
projected fringe benefits cost to the proposed Medicare QIO contract.

Total Fringe Benefits. No entry required. This line item automatically
calculates the total of line items a. thru k.

INSTRUCTIONS FOR CMS FORM 721 BP INDIRECT AND OTHER DIRECT COSTS
QUALITY IMPROVEMENT ORGANIZATION BUSINESS PROPOSAL
ITEM
1.

Name and Address of QIO Organization. No entry required. This information
automatically flows from Form 718 BP.

QIO Area. No entry required. This information automatically flows from Form 718 BP.

RFP#. No entry required. This information automatically flows from Form 718 BP.

Proposed Contract Period. No entry required. This information automatically flows
from Form 718 BP.

Note: If a QIO has an approved provisional indirect cost rate and the QIO determines that this
approved rate will accurately reflect projected 5-year indirect costs, it is not necessary to
complete the individual line items on Form 721 BP pertaining to indirect costs. Instead,
enter the indirect cost rate on Line ee.
If the QIO believes that the approved rate is not appropriate for projecting 5-year costs,
the QIO should complete the individual line items in columns 6 and 8, as explained
below. In any case, as explained in “Section 3 - Additional Explanation and Justification
for Business Proposal” you should explain all rental costs, AHQA dues, or Board of
Directors fees in that section.
COLUMN 5 - Prior Year Total Indirect Costs
LINE
a. - dd.

Individual line item categories. Disregard these line items. No entries should
be made on these line items in column 5.

ee.

Indirect Cost Rate. Enter the indirect cost rate for the latest 12-month period
completed, for which cost data is available. Identify this 12-month period in your
supporting documentation and explain the base (i.e., denominator) used to
calculate this rate.

COLUMN 6 - Projected Total 5-yr Indirect Costs
LINE
a. - cc.

Individual line item categories. On each line item, enter the indirect cost
projected for your organization for the 5-year period that the QIO contract would
be operating.
Your supporting documentation should explain, in detail, any amount you entered
on line item cc. The supporting documentation should also fully explain the
assumptions and bases you used for your organization’s projection, including
appropriate cost projection schedules.
15

dd.

Total. No entry required. This line item automatically calculates the total of line
items a. thru cc.

ee.

Indirect Cost Rate. Enter the indirect cost rate that applies to the amount on line
item dd. (Total). In your supporting documentation, give a detailed explanation
of the method used to calculate this rate.

COLUMN 7 - Prior Year Medicare Indirect Costs
LINE
a. - ee.

Individual line item categories. Disregard these line items. No entries should
be made on these lines in column 7.

COLUMN 8 - Projected Medicare 5-yr Indirect Costs
LINE
a. & b.

Indirect Labor and Indirect Leave. No entry required.
The amounts on these line items flow directly from the Staffing Proposal
Summary Sheet (Form QIO Staff Sum).

c. - cc.

Individual line item categories. On each line item, enter the portion of the
corresponding line item cost in column 6. (Projected Total 5-yr Indirect Costs)
allocated to the proposed Medicare QIO contract.
Your supporting documentation should explain, in detail, any amount you entered
on line item cc. The supporting documentation should also fully explain the
assumptions and bases you used to allocate a portion of your organization’s total
projected indirect costs to the proposed Medicare QIO contract.

dd.

Total. No entry required. This line item automatically calculates the total of line
items a. thru cc.

ee.

Indirect Cost Rate. No entry required, as the indirect rate that applies has already
been provided in column 6.

COLUMN 9 - Prior Year Medicare Other Direct Costs
LINE
a. - c.

Indirect Labor, Indirect Leave, and Indirect Fringe. No entries required.
These line items are not applicable to this column.

d. - cc.

Individual line item categories. If applicable, on each line item, enter the other
direct cost for the current Medicare QIO contract for the latest 12-month period
completed.
16

Identify this 12-month period in your supporting documentation. Your supporting
documentation should also explain, in detail, any amount you entered on line item
cc.
Line item o. Consultants does not apply to this column.
Line item q. Travel does not apply to this column.
dd.

Total. No entry required. This line item automatically calculates the total of line
items d. thru cc.

COLUMN 10 - Projected Medicare 5-yr Other Direct Costs
LINE
a. - c.

Indirect Labor, Indirect Leave, and Indirect Fringe. No entries required.
These line items do not apply to this column.

d. - cc.

Individual line item categories. No entry required.
The amounts on these line items flow directly from the Other Direct Costs
Supplemental Schedule (QIO ODC).

dd.

Total. No entry required. This line item automatically calculates the total of line
items d. thru cc.

INSTRUCTIONS FOR PERSONNEL LOADING CHARTS STAFFING PROPOSAL
FORM
These instructions apply to the personnel loading charts for all four labor categories. It is
preferable that positions should be listed in the following order: (1) Corporate Management, (2)
Professional, (3) Information Systems, and (4) Support Staff. You should not list each type of
labor category on a separate sheet. Positions will be sorted by labor category based on the labor
category code (see col. 3 below). The form will automatically summarize information by labor
category under the Grand Total line. Please note that all entries for employees concerning
proposed hours for labor and leave, whether direct or indirect, must be based on a work year of
2,080 hours.
COLUMN
1.

Staff Name. For each labor category, enter the last name and first initial of each
employee that you have identified as a staff person under the guideline definitions in the
Appendix. If the position title listed in column 2. is not assigned to anyone, enter vacant
instead of an employee’s name.

Position Title. Enter the employee’s position for the 5-year Medicare QIO contract.

Labor Category Code. Enter the employee’s Labor Category code: P for Professional; I
for Information Systems; C for Corporate Management; S for Support Staff.

Current Hourly Rate. Enter the employee’s current hourly rate of pay.

Proposed Year 1 Hourly Rate. Enter the employee’s hourly pay rate for year 1 of the
proposed Medicare QIO contract.

Percent Change. No entry required. This column automatically calculates the
percentage change in the hourly pay rate from the current rate to the year 1 rate of the
proposed Medicare QIO contract.

Proposed Year 2 Hourly Rate. Enter the employee’s hourly pay rate for year 2 of the
proposed Medicare QIO contract.

Percent Change. No entry required. This column automatically calculates the
percentage change in the hourly pay rate from year 1 of the proposed Medicare QIO
contract to year 2.

Proposed Year 3 Hourly Rate. Enter the employee’s hourly pay rate for year 3 of the
proposed Medicare QIO contract.

10.

Percent Change. No entry required. This column automatically calculates the
percentage change in the hourly pay rate from year 2 of the proposed Medicare QIO
contract to year 3.

11.

Proposed Year 4 Hourly Rate. Enter the employee’s hourly pay rate for year 4 of the
proposed Medicare QIO contract.
18

12.

Percent Change. No entry required. This column automatically calculates the
percentage change in the hourly pay rate from year 3 of the proposed Medicare QIO
contract to year 4.

13.

Proposed Year 5 Hourly Rate. Enter the employee’s hourly pay rate for year 5 of the
proposed Medicare QIO contract.

14.

Percent Change. No entry required. This column automatically calculates the
percentage change in the hourly pay rate from year 4 of the proposed Medicare QIO
contract to year 5.

15.

Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the
employee would devote to _______ during the 5-year Medicare QIO contract period.

16.

Total 5-yr ______ Labor Costs. No entry required. This column automatically
calculates the total direct labor costs for ________ based on the amounts you entered in
the previous columns. The calculation assumes that an employee has the same direct
labor hours for each of the 5 contract years based on your column 11 entry.

17.

Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the
employee would devote to _______ during the 5-year Medicare QIO contract period.

18.

19.

Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the
employee would devote to _______ during the 5-year Medicare QIO contract period.

20.

21.

Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the
employee would devote to _______ during the 5-year Medicare QIO contract period.

22.

23.

Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the
employee would devote to _______ during the 5-year Medicare QIO contract period.

24.

25.

Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the
employee would devote to _______ during the 5-year Medicare QIO contract period.

26.

27.

Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the
employee would devote to _______ during the 5-year Medicare QIO contract period.

28.

29.

Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the
employee would devote to _______ during the 5-year Medicare QIO contract period.

30.

31.

Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the
employee would devote to _______ during the 5-year Medicare QIO contract period.

32.

33.

Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the
employee would devote to _______ during the 5-year Medicare QIO contract period.

34.

35.

Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the
employee would devote to _______ during the 5-year Medicare QIO contract period.

36.

37.

Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the
employee would devote to _______ during the 5-year Medicare QIO contract period.
20

38.

Total 5-yr ____ Labor Costs. No entry required. This column automatically calculates
the total direct labor costs for ____ based on the amounts you entered in the previous
columns. The calculation assumes that an employee has the same direct labor hours for
each of the 5 contract years based on your column 33 entry.

39.

Average Total Direct Labor Hours Per Year. No entry required. The amounts in this
column are automatically calculated from your previous entries in the individual cost
center columns dealing with average direct labor hours per year.

40.

Total 5-yr Direct Labor Costs. No entry required. The amounts in this column are
automatically calculated from the entries in the individual cost center columns dealing
with 5-yr labor costs.

41.

Average Indirect Labor Hours Per Year. Enter one-third of the total indirect labor
hours estimated for the employee during the 5-year Medicare QIO contract period.

42.

Total 5-yr Indirect Labor Costs. No entry required. This column is automatically
calculated based on the amounts you entered in the previous columns. The calculation
assumes that an employee has the same indirect labor hours for each of the 5 contract
years based on your column 37 entry.

43.

Average Total Labor Hours Per Year. No entry required. This column is
automatically calculated based on your previous entries for average direct and indirect
labor hours per year.

44.

Total 5-yr Labor Costs. No entry required. This column automatically combines the
amounts entered for total direct labor costs and total indirect labor costs in previous
columns.

45.

Average Direct Leave Hours Per Year. Not Applicable. Include all paid time off
(leave) in Fringe Benefits unless your organization has an approved separate Indirect
Leave Rate.

46.

Total 5-yr Direct Leave Costs. Not Applicable. Include all paid time off (leave) in
Fringe Benefits unless your organization has an approved separate indirect leave rate.

47.

Average Indirect Leave Hours Per Year. Enter one-third of the total indirect leave
hours estimated for the employee during the 5-year Medicare QIO contract period.

48.

Total 5-yr Indirect Leave Costs. No entry required. This column is automatically
calculated based on the amounts you entered in the previous columns. The calculation
assumes that an employee has the same indirect leave hours for each of the 5 contract
years based on your column 43 entry.

49.

Average Total Leave Hours Per Year. No entry required. This column is
automatically calculated based on your previous entries for average indirect leave hours
per year.

50.

Leave as a % of Hours Worked. No entry required. This column calculates
automatically based on amounts you entered in previous columns.
21

51.

Total 5-yr Leave Costs. No entry required. This column automatically combines the
amounts entered for total indirect leave costs in previous columns.

52.

Average Total Labor and Leave Hours Per Year. No entry required. This column
automatically combines the amounts for average yearly direct and indirect labor and
leave hours in previous columns.

53.

Total 5-yr Labor/Leave Costs. No entry required. This column automatically
calculates the total 5-yr cost of your proposed contract for labor and leave combined.

54.

FTE Per Year. No entry required. This column automatically calculates the average
yearly FTE for each employee. The calculation considers all employee hours -- labor,
leave, direct, and indirect.
Your proposed hours for labor and leave must be based on a work year of 2,080 hours

INSTRUCTIONS FOR CMS FORM SC 1 (SUBCONTRACTS)
SUBCONTRACTS PROPOSAL – PHYSICIAN REVIEWERS
NOTE:

This form should reflect the aggregate cost information for the total number of
physician reviewers/advisors that you estimate will be used. Information entered
into this form will input hours and costs to the respective tasks on the 719 form
automatically. However, the form is set up only for Beneficiary and Family
Centered Care and Special Project. If you have Physician Reviewer cost for any
other sub-task, you should provide the information in the same format as on the
Form SC1 and input the totals directly in the appropriate block on the 719.

Physician Reviewer Cost for Beneficiary and Family Center Care (Benef. and FCC) - Blocks
1 through 17.
1. Current Physician Reviewer Hourly Rate. Enter the current average hourly rate for
your physician reviewers/advisors in beneficiary and family center care.
2. Year 1 Number of Reviews. Enter your estimate of the number of reviews for year 1 of
beneficiary and family center care proposed Medicare QIO contract.
3. Year 1 Hours Per Review. Enter your estimate of the average time it takes for a
Physician Reviewer/Advisor to complete a case review. This estimate should include all
the time that it takes a Physician Reviewer/Advisor to complete such a review.
4. Year 1 Hours Per Year. No entry is required. This column automatically calculates the
total number of review hours for the first year of the contract based on the amounts you
entered in the previous columns.
5. Year 1 Physician Reviewer Hourly Rate. Enter the average hourly rate for your
Physician Reviewers/Advisors for Year 1 of the proposed Medicare QIO contract.
6. Year 1 Benef. and FCC Review Costs. No entry is required. This column automatically
calculates the total Physician costs for beneficiary protection review based on the amounts
you entered in the previous columns.
7. Year 2 Number of Reviews. Enter your estimate of the number of beneficiary protection
reviews for year 2 of the proposed Medicare QIO contract.
8. Year 2 Hours Per Review. Enter your estimate of the average time it takes for a
Physician Reviewer/Advisor to complete a beneficiary protection review. This estimate
should include all the time that it takes a Physician Reviewer/Advisor to complete such a
review.
9. Year 2 Hours Per Year. No entry is required. This column automatically calculates the
total number of beneficiary protection review hours for the second year of the contract
based on the amounts you entered in the previous columns.
10. Year 2 Physician Reviewer Hourly Rate. Enter the average hourly rate for your
beneficiary protection Physician Reviewers/Advisors for Year 2 of the proposed Medicare
QIO contract.
23

11. Year 2 Benef. and FCC Review Costs. No entry is required. This column automatically
calculates the total Physician costs for beneficiary protection review based on the amounts
you entered in the previous columns.
12. Year 3 Number of Reviews. Enter your estimate of the number of beneficiaryprotection
reviews for year 3 of the proposed Medicare QIO contract.
13. Year 3 Hours Per Review. Enter your estimate of the average time it takes for a
Physician Reviewer/Advisor to complete a beneficiary protection review. This estimate
should include all the time that it takes a Physician Reviewer/Advisor to complete such a
review.
14. Year 3 Hours Per Year. No entry is required. This column automatically calculates the
total number of beneficiary protection review hours for the third year of the contract based
on the amounts you entered in the previous columns.
15. Year 3 Physician Reviewer Hourly Rate. Enter the average hourly rate for your
beneficiary protection Physician Reviewers/Advisors for Year 3 of the proposed Medicare
QIO contract.
16. Year 3 Benef. and FCC Review Costs. No entry is required. This column automatically
calculates the total Physician costs for beneficiary protection reviews based on the
amounts you entered in the previous columns
17. Year 4 Number of Reviews. Enter your estimate of the number of beneficiary protection
reviews for year 4 of the proposed Medicare QIO contract.
18. Year 4 Hours Per Review. Enter your estimate of the average time it takes for aPhysician
Reviewer/Advisor to complete a beneficiary protection review. This estimate should
include all the time that it takes a Physician Reviewer/Advisor to complete such a review.
19. Year 4 Hours Per Year. No entry is required. This column automatically calculates the
total number of beneficiary protection review hours for the fourth year of the contract
based on the amounts you entered in the previous columns.
20. Year 4 Physician Reviewer Hourly Rate. Enter the average hourly rate for your
beneficiary protection Physician Reviewers/Advisors for Year 4 of the proposed Medicare
QIO contract.
21. Year 4 Benef. and FCC Review Costs. No entry is required. This column automatically
calculates the total Physician costs for beneficiary protection reviews based on the
amounts you entered in the previous columns
22. Year 5 Number of Reviews. Enter your estimate of the number of beneficiary protection
reviews for year 5 of the proposed Medicare QIO contract.
23. Year 5 Hours Per Review. Enter your estimate of the average time it takes for a
Physician Reviewer/Advisor to complete a beneficiary protection review. This estimate
should include all the time that it takes a Physician Reviewer/Advisor to complete such a
review.
24

24. Year 5 Hours Per Year. No entry is required. This column automatically calculates the
total number of beneficiary protection review hours for the fifth year of the contract based
on the amounts you entered in the previous columns.
25. Year 5 Physician Reviewer Hourly Rate. Enter the average hourly rate for your
beneficiary protection Physician Reviewers/Advisors for Year 5 of the proposed Medicare
QIO contract.
26. Year 5 Benef. and FCC Review Costs. No entry is required. This column automatically
calculates the total Physician costs for beneficiary protection reviews based on the
amounts you entered in the previous columns.
27. Total 5 Year Benef. and FCC Review Costs. No entry is required. This column
automatically calculates based on the costs for all five years of the contract.

INSTRUCTIONS FOR CMS FORM SC 2 (OTHER SUBCONTRACTS)
SUBCONTRACTS PROPOSAL - OTHER
NOTE:

Please enter the requested cost information separately for each other consultant in
Section 1 and each other subcontractor in Section 2. If you have more than 10
entries for Section 1 or 2, provide the additional consultant/subcontractor
information on an attachment and carry the attachments subtotals to line k.

COLUMN
1.

Name. Enter the first initial and last name of the subcontractor, when appropriate. If it is
more appropriate to identify the subcontractor by a company or organizational name, enter
this name instead of an individual’s name. Enter TBD If you are proposing a particular
subcontracting activity for the 5-year Medicare contract but have not yet identified a
particular subcontractor.

Total 5-yr _______ Costs. For each consultant/subcontractor, enter the total costs that
you propose for ______ costs during the 5-year Medicare QIO contract period.

Total 5-yr _______ Costs. For each consultant/subcontractor, enter the total costs that
you propose for ______ costs during the 5-year Medicare QIO contract period

Total 5-yr _______ Costs. For each consultant/subcontractor, enter the total costs that
you propose for ______ costs during the 5-year Medicare QIO contract period.

Total 5-yr _______ Costs. For each consultant/subcontractor, enter the total costs that
you propose for ______ costs during the 5-year Medicare QIO contract period

Total 5-yr _______ Costs. For each consultant/subcontractor, enter the total costs that
you propose for ______ costs during the 5-year Medicare QIO contract period.

Total 5-yr _______ Costs. For each consultant/subcontractor, enter the total costs that
you propose for ______ costs during the 5-year Medicare QIO contract period

10.

Total 5-yr _______ Costs. For each consultant/subcontractor, enter the total costs that
you propose for ______ costs during the 5-year Medicare QIO contract period.

11.

Total 5-yr _______ Costs. For each consultant/subcontractor, enter the total costs that
you propose for ______ costs during the 5-year Medicare QIO contract period.

12.

Total 5-yr _______ Costs. For each consultant/subcontractor, enter the total costs that
you propose for ______ costs during the 5-year Medicare QIO contract period.

13.

Total 5-yr Costs. No entry required. The amounts in this column are automatically
calculated from the entries in the individual cost center columns.
26

14.

Current Activity. If applicable, enter a short description of the work that the
consultant/subcontractor is currently performing. Otherwise, enter NA.

15.

Proposed Activity. Enter a short description of the work that the consultant/subcontractor
would perform during the 5-year Medicare QIO contract. Provide a detailed explanation of
the activity in your supporting documentation.

INSTRUCTIONS FOR CMS FORM STAFFING SUMMARY PROPOSAL
NOTE:

This form summarizes hour and cost information by labor category and cost center.
No entries are required, as all information is automatically calculated from the
individual personnel loading charts for each labor category.

COLUMN
1.

Average Current Hourly Rate. For each labor category, this amount corresponds to the
related current hourly rate for that labor category. This amount is an average of the
individual entries in the loading chart column.

Proposed Average Year 1 Hourly Rate. For each labor category, this amount
corresponds to the total Proposed Year 1 Hourly Rate for that labor category. This amount
is an average of the individual entries in the loading chart column.

Percent Change. For each labor category, this amount reflects the percentage change in
the average hourly pay rate from the current average rate to the average rate for year 1 of
the proposed Medicare QIO contract.

Proposed Average Year 2 Hourly Rate. For each labor category, this amount
corresponds to the total Proposed Year 2 Hourly Rate for that labor category. This amount
is an average of the individual entries in the loading chart column.

Percent Change. For each labor category, this amount reflects the percentage change in
the average hourly pay rate from year 1 of the proposed Medicare QIO contract to year 2.

Proposed Average Year 3 Hourly Rate. For each labor category, this amount
corresponds to the total Proposed Year 3 Hourly Rate for that labor category. This amount
is an average of the individual entries in the loading chart column.

Percent Change. For each labor category, this amount reflects the percentage change in
the average hourly pay rate from year 2 of the proposed Medicare QIO contract to year 3.

Percent Change. For each labor category, this amount reflects the percentage change in
the average hourly pay rate from year 3 of the proposed Medicare QIO contract to year 4.

10.

Proposed Average Year 5 Hourly Rate. For each labor category, this amount
corresponds to the total Proposed Year 5 Hourly Rate for that labor category. This amount
is an average of the individual entries in the loading chart column

11.

Percent Change. For each labor category, this amount reflects the percentage change in
the average hourly pay rate from year 4 of the proposed Medicare QIO contract to year 5.

12.

Total _______ Hours. For each labor category, this amount is the total direct labor hours
proposed for ________ activities during the 5-year Medicare QIO contract period.
28

13.

Total _______ Labor Costs. For each labor category, this amount is the total direct labor
cost proposed for _______ activities during the 5-year Medicare QIO contract period.

14.

Total _______ Hours. For each labor category, this amount is the total direct labor hours
proposed for ________ activities during the 5-year Medicare QIO contract period.

15.

Total _______ Labor Costs. For each labor category, this amount is the total direct labor
cost proposed for _______ activities during the 5-year Medicare QIO contract period.

16.

Total _______ Hours. For each labor category, this amount is the total direct labor hours
proposed for ________ activities during the 5-year Medicare QIO contract period.

17.

Total _______ Labor Costs. For each labor category, this amount is the total direct labor
cost proposed for _______ activities during the 5-year Medicare QIO contract period.

18.

Total _______ Hours. For each labor category, this amount is the total direct labor hours
proposed for ________ activities during the 5-year Medicare QIO contract period.

19.

Total _______ Labor Costs. For each labor category, this amount is the total direct labor
cost proposed for _______ activities during the 5-year Medicare QIO contract period.

20.

Total _______ Hours. For each labor category, this amount is the total direct labor hours
proposed for ________ activities during the 5-year Medicare QIO contract period.

21.

Total _______ Labor Costs. For each labor category, this amount is the total direct labor
cost proposed for _______ activities during the 5-year Medicare QIO contract period.

22.

Total _______ Hours. For each labor category, this amount is the total direct labor hours
proposed for ________ activities during the 5-year Medicare QIO contract period.

23.

Total _______ Labor Costs. For each labor category, this amount is the total direct labor
cost proposed for _______ activities during the 5-year Medicare QIO contract period.

24.

Total _______ Hours. For each labor category, this amount is the total direct labor hours
proposed for ________ activities during the 5-year Medicare QIO contract period.

25.

Total _______ Labor Costs. For each labor category, this amount is the total direct labor
cost proposed for _______ activities during the 5-year Medicare QIO contract period.

26.

Total _______ Hours. For each labor category, this amount is the total direct labor hours
proposed for ________ activities during the 5-year Medicare QIO contract period.

27.

Total _______ Labor Costs. For each labor category, this amount is the total direct labor
cost proposed for _______ activities during the 5-year Medicare QIO contract period.

28.

Total _______ Hours. For each labor category, this amount is the total direct labor hours
proposed for ________ activities during the 5-year Medicare QIO contract period.

29.

Total _______ Labor Costs. For each labor category, this amount is the total direct labor
cost proposed for _______ activities during the 5-year Medicare QIO contract period.
29

30.

Total _______ Hours. For each labor category, this amount is the total direct labor hours
proposed for ________ activities during the 5-year Medicare QIO contract period.

31.

Total _______ Labor Costs. For each labor category, this amount is the total direct labor
cost proposed for _______ activities during the 5-year Medicare QIO contract period.

32.

Total _______ Hours. For each labor category, this amount is the total direct labor hours
proposed for ________ activities during the 5-year Medicare QIO contract period.

33.

Total _______ Labor Costs. For each labor category, this amount is the total direct labor
cost proposed for _______ activities during the 5-year Medicare QIO contract period.

34.

Total _______ Hours. For each labor category, this amount is the total direct labor hours
proposed for ________ activities during the 5-year Medicare QIO contract period.

35.

Total _______ Labor Costs. For each labor category, this amount is the total direct labor
cost proposed for _______ activities during the 5-year Medicare QIO contract period.

36.

Total Direct Labor Hours. For each labor category, this amount is the total direct labor
hours proposed for all activities during the 5-year Medicare QIO contract period.

37.

Total Direct Labor Costs. For each labor category, this amount is the total direct labor
costs proposed for all activities during the 5-year Medicare QIO contract period.

38.

Total Indirect Labor Hours. For each labor category, this amount is the total indirect
labor hours you propose to apply to the 5-year Medicare QIO contract period.

39.

Total Indirect Labor Costs. For each labor category, this amount is the total indirect
labor costs you propose to apply to the 5-year Medicare QIO contract period.

40.

Total Labor Hours. For each labor category, this amount is the total direct and indirect
labor hours you propose for the 5-year Medicare QIO contract period.

41.

Total Labor Costs. For each labor category, this amount is the total direct and indirect
labor costs you propose for the 5-year Medicare QIO contract period.

42.

Total Direct Leave Hours. Not Applicable. Include all paid time off (leave) in Fringe
Benefits unless your organization has an approved separate Indirect Leave Rate.

43.

Total Direct Leave Costs. Not Applicable. Include all paid time off (leave) in Fringe
Benefits unless your organization has an approved separate Indirect Leave Rate.

44.

Total Indirect Leave Hours. For each labor category, this amount is the total indirect
leave hours you propose to apply to the 5-year Medicare QIO contract period.

45.

Total Indirect Leave Costs. For each labor category, this amount is the total indirect
leave costs you propose to apply to the 5-year Medicare QIO contract period.

46.

Total Leave Hours. For each labor category, this amount is the total direct and indirect
leave hours you propose for the 5-year Medicare QIO contract period.
30

47.

Leave as a % of Hours Worked. For each labor category, this amount provides the
percentage relationship of leave hours to labor hours. It is based on the entries you made
on the individual personnel loading charts for each labor category regarding direct and
indirect labor and leave hours.

48.

Total Leave Costs. For each labor category, this amount is the total direct and indirect
leave costs you propose for the 5-year Medicare QIO contract period.

49.

Total Labor and Leave Hours. For each labor category, this amount is the total labor and
leave hours (indirect) you propose for the 5-year Medicare QIO contract period.

50.

Total Labor and Leave Costs. For each labor category, this amount is the total labor and
leave costs (indirect) you propose for the 5-year Medicare QIO contract period.

51.

Total FTE Per Year. For each labor category, this amount is the full-time equivalent per
year. It is based on total labor and leave hours (direct and indirect) and a work year of
2,080 hours.

INSTRUCTIONS FOR OTHER DIRECT COSTS SUPPLEMENTAL SCHEDULE
QUALITY IMPROVEMENT ORGANIZATION BUSINESS PROPOSAL
Projected Medicare 5-yr Other Direct Costs
LINE
d. - cc.

Individual line item categories. On each line item, enter the other direct cost
projected for the proposed 5-year QIO contract.
Your supporting documentation should explain, in great detail, any amount
you entered on line items d - cc. The supporting documentation should also
fully explain the assumptions and bases you used for your projection,
including appropriate supporting schedules.
Line item o. Consultants does not apply to this column. Enter direct costs related
to consultants on Form SC-2 (Excel tab: QIO Subconts2).
Line item q. Travel does not apply to this column. Enter direct costs related to
travel on Form 719 BP, line e.

dd.

Total. No entry required. This line item automatically calculates the total of line
items d. thru cc.

INSTRUCTIONS FOR BENEFICIARY AND FAMILY CENTERED CARE
SUPPLEMENTAL SCHEDULE
QUALITY IMPROVEMENT ORGANIZATION
BUSINESS PROPOSAL
ITEM
1.

Name and Address of QIO Organization. No entry required. This information
automatically flows from Form 718 BP.

QIO Area. No entry required. This information automatically flows from Form 718 BP.

Proposed Contract Period. No entry required. This information automatically flows
from Form 718 BP.

COST CENTER COLUMNS – For each cost center column (4-10), enter the amounts, both
hours and costs (a-j), on average for each case.
4.

QUALITY OF CARE REVIEWS COST PER CASE - This column is used for all costs
directly attributable to quality of care review activities as described in the under
Beneficiary and Family Centered Care.

HOSPITAL BASED NOTICE APPEALS COST PER CASE - This column is used for
all cost directly attributable to hospital based notice appeals activities as described in the
under Beneficiary and Family Centered Care.

FEE-FOR SERVICE (FFS) EXPEDITED APPEALS COST PER CASE - This
column is used for all cost directly attributable to fee-for service expedited appeal
activities as described in the under Beneficiary and Family Centered Care.

MEDICARE ADVANTAGE (MA) FAST TRACK APPEALS COST PER CASE This column is used for all cost directly attributable to Medicare Advantage fast track
appeal activities as described in the under the Beneficiary and Family Centered Care.

EMTALA: 5-DAY REVIEWS - COST PER REVIEW – This column is used for all
cost directly attributable to the Emtala 5-day review activities as described in the under
Beneficiary and Family Centered Care.

EMTALA: 60-DAY REVIEWS - COST PER REVIEW – This column is used for all
cost directly attributable to the Emtala 60-day review activities as described in the under
Beneficiary and Family Centered Care.

10.

HIGHER WEIGHTED DRG – COST PER REVIEW – This column is used for all
cost directly attributable to higher weighted DRG activities as described in the under
Beneficiary and Family Centered Care.

COST CENTER COLUMNS – For each cost center column (11-15), enter total cost at these
activities for the three year period.
11.

QUALITY IMPROVEMENT INTERVENTIONS (QII)/ TECHNICAL
ASSISTANCE COSTS – This column is used for all cost directly attributable to quality
33

improvement interventions/ technical assistance activities as described in the under
Beneficiary and Family Centered Care.
12.

SANCTION ACTIVITIES – This column is used for all cost directly attributable to
sanction activities as described in the under Beneficiary and Family Centered Care.

13.

COLLABORATION– This column is used for all cost directly attributable to
collaboration activities as described in the under Beneficiary and Family Centered Care.

14.

TRANSPARENCY THROUGH REPORTING – This column is used for all cost
directly attributable to transparency though reporting activities as described in the under
Beneficiary and Family Centered Care.

15.

OTHER NON-REVIEW ACTIVITIES – This column is used for all cost directly
attributable to other non-review activities as described in the Beneficiary and Family
Centered Care, but not in any other cost columns.
Examples:
- Training,
- General oversight and review activities,
- Beneficiary and provider education,
- ‘On-call time for appeals review when no review is underway and meetings
associated with these appeal reviews,
- Training attended by QIO staff in order to conduct review of MA or FFS
appeals,
- On-call time during which no review activity is conducted,
- Appeals-related administrative duties not associated with a specific MA or
FFS appeal review,
- Appeals-related time spent by Review Coordinators (communicating with
providers, beneficiaries and Physician Reviewers not associated with a
specific review),
- Appeals-related time spent by Physician Reviewers (communicating with
providers, beneficiaries to research guidelines and regulations not
associated with a specific review),
- Appeals-related conference calls, and
- General discussions of appeals with beneficiaries on site.
LINE ITEMS

a.1- a.4

Labor. Enter the labor cost for each case to the particular column cost center.

Leave. Enter the leave cost for each case to the particular column cost center.

Fringe Benefits. Enter the fringe benefit cost for each case to the particular
column cost center.

d.1- d.3

Subcontracts. Enter the subcontracts cost for each case to the particular column
cost center.

Travel. Enter the travel cost for each case to the particular column cost center.
34

Furnish detailed supporting documentation to explain these costs.
g.

Other Direct Costs. Enter the other direct costs for each case to the particular
column cost center. Furnish detailed supporting documentation to explain
these costs.

Indirect Costs. Enter the indirect costs for each case to the particular column cost
center.

Pass-thru Costs. Enter the pass-thru costs for each case that apply to the
particular column cost center. Furnish detailed supporting documentation to
explain these costs.

Fee. Enter the appropriate portion of the total fee in each column cost center.

TOTAL - No entry required. This line item automatically calculates the total hours and costs for
each line item category from the entries in the costs center columns.
PROJECTED VOLUME - # OF CASES FOR (AS APPLY):
YEAR 1: Enter the projected volume of cases in each column cost center.
YEAR 2: Enter the projected volume of cases in each column cost center.
YEAR 3: Enter the projected volume of cases in each column cost center.
YEAR 4: Enter the projected volume of cases in each column cost center.
YEAR 5: Enter the projected volume of cases in each column cost center.
GRAND TOTAL: No entry required. This line item automatically calculates the total cost for all
5 years based on the projected volumes in each costs center column.
NOTE: PLEASE PROVIDE YOUR ASSUMPTIONS IN DETERMINING YOUR
ESTIMATES, INCLUDING VOLUME ESTIMATES.

INSTRUCTIONS FOR TRAVEL DETAIL
BUSINESS PROPOSAL
ITEM
1.

RFP Number. No entry required. This information automatically flows from Form 718
BP.

Name and Address of QIO Organization. No entry required. This information
automatically flows from Form 718 BP.

QIO Area. No entry required. This information automatically flows from Form 718 BP.

Proposed Contract Period. No entry required. This information automatically flows from
Form 718 BP.

Mileage Rate. Enter the current Federal Travel Regulation mileage rate.

Area. Enter the quality improvement element the proposed trip relates to.

Trip Title and Description/Purpose. Enter the trip title and provide a brief
description/purpose of the trip.

# of Days per Trip. Enter the number of days the trip will occur.

# of Night per Trip. Enter the number of nights the trip will occur.

10.

# of Travelers per Trip. Enter the number of travelers, per trip, in whole figures.

11.

Airfare per Person. Enter airfare amount per person.

12.

Departing From. Enter the city and state the travelers are departing from.

13.

Arriving To. Enter the city and state the travelers will arrive to.

14.

FTR Meals and Incidentals Daily Rate. Enter the current Federal Travel Regulations
(FTR) Meals and Incidental Rate for the location. Note: The formula in the Total column
will calculate the max Per Diem rate for the first and last day of travel based on the
number of days reported.

15.

FTR Lodging per Night. Enter the current the current Federal Travel Regulations (FTR)
maximum Lodging Rate (excluding taxes) for the Primary Destination for each trip. Note:
The formula in the Total column will calculate the lodging costs based on the nights
reported previously.

16.

# of Trips. Enter the number of trips for the respective year.

17.

Mileage per Traveler per Trip. Enter the roundtrip mileage per trip, if applicable.

18.

# of Rental Car(s) per Trip. Enter the number of rental cars needed for each trip.
36

19.

Daily Rental Car Rate. Enter the proposed daily rental car rate.

20.

Miscellaneous Costs per Person per Trip. Enter the miscellaneous cost per person per
trip. You may include parking fees, gas, taxi, metro fees, and the like.

21.

Total. No entry required. This line item automatically calculates the total travel costs for
the listed trip.

22.

Notes. Provide a detailed explanation of the miscellaneous cost calculations (what and how
your organization reached the proposed figures – i.e.: $20 taxi & $3 airport parking).
Grand Total. No entry required. This line item automatically calculates the total travel
costs for all 5 years.

23.

** Shaded cells represent no entry required and 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".

V. APPENDIX DEFINITIONS AND GUIDELINES
I. GENERAL.
The forms that you need to complete your business proposal are forwarded electronically in an
Excel spreadsheet file. (Sample forms are also included in the hardcopy version of this guideline
package.) Upon opening the Excel file, the forms are accessible by clicking the various tabs at
the bottom of your screen. Each tab represents one of the hardcopy business proposal forms.
The forms and their related tab titles are as follows:
Form

Tab Title

Description

718 BP

F718 BP SUM

Business proposal summary

719 BP

QIO F719

5-year proposed costs by cost center

720 BP

QIO F720

Fringe benefit proposal

721 BP

QIO F721

Indirect and Other Direct Cost

Staffing

QIO Staff

Personnel loading chart for all QIO
Staff

SC 1

QIO Subconts1

Calculation of cost for Physician
Reviewers and Physician Advisors

SC 2

QIO Subconts2

Personnel loading chart for other
consultants and other subcontractors

Sum

QIO Staff Sum

Personnel loading chart summary

QIO ODC

Other Direct Costs

BFCC Sup Sch

Travel Detail Form

Beneficiary and Family Centered Care –
Supplemental Schedule
Travel Detail Form

Most of the cost information is entered on the individual Personnel Loading Charts and the
Subcontracts Proposal form. The information you enter on these forms flows to the Form 719
BP. There are only a few line items on Form 719 BP that require your direct entry. Cells that do
not require your entry are blocked. For specific data entry instructions, please see Section IV of
the Table of Contents.

II. LINE ITEM CATEGORIES.
The following information is provided in a format consistent with the line item categories on
CMS Form 719 BP. This information also applies to similar terms on other forms and
worksheets used for the business proposal end for the Financial Information and Vouchering
System (FIVS).
a.

LABOR. Direct labor hours and costs, excluding leave and fringe benefit costs, are to be
proposed and reported in the following four labor categories:
1.
2.
3.
4.

Professional
Information Systems
Corporate Management
Support Staff

Specified tasks within the Scope of Work require certain core competencies for the
individuals performing the task. Since job titles are not always indicative of the type of
work performed, the following chart should be used as a guide in deciding what labor
category is appropriate for specific employees. Examples of various job titles are also
included in the chart for each of the four labor categories.
These examples are not all inclusive, nor are they suggestions or requirements for QIOs
to have jobs similarly titled. The title of a particular job at one QIO can be different from
the title of a job covering similar work at another QIO. Examples of the different job
titles that QIOs might use to cover similar work are: (1) Director/Manager/Supervisor
and (2) Clerk/Assistant. QIOs should continue to use job titles specific to their
organization.

Labor
Category
Professional

Core
Competencies
Medicine,
Nursing and
related
medical/clinical
disciplines.

Definition

Job Title Examples

Physicians (MD and DO), RNs,
LPNs/LVNs, RRAs, ARTs, whose
medical/clinical degrees or certifications
are considered necessary to fulfill SOW
requirements. Work includes design,
implementation, monitoring, and/or
management activities relating to
medical case review, HCQIP, pattern
analysis/surveillance and program
integrity.

Abstractor
Associate Clinical
Coordinator
Associate Medical
Director
DRG Coordinator
Epidemiologist
HCQIP Director
Medical Director
Nurse, RRA, ART
Project Coordinator
Nurse Reviewer
Principal Clinical
Coordinator
Review Director

Epidemiology,
statistics, survey
research, data
analysis, related
empirical and
analytic
disciplines.

Professional non-medical staff with
research and analysis degrees/skills
considered necessary to fulfill SOW
requirements. Work includes
epidemiology, biostatistics, data
analysis and/or health care research to
support medical case review, HCQIP,
pattern analysis/surveillance and/or
program integrity.
Professional non-medical staff
developing educational campaigns, and
intervention strategies. Beneficiary
rights, outreach and education activities,
and the beneficiary hotline. Research
and writing for HCQIP and beneficiary
publications, and survey design. Report
direct labor hours and costs on line a1 of
CMS BP Form 719, FIVS Forms 719 +
719A.

Bio-statistician
Data Analyst
Programmer Analyst
Researcher
Statistician

Database information systems personnel
who support the QualityNet Standard
Data Processing System at the QIO.
Work includes Oracle and MS Access
database administration, maintenance,
backup and support.

DBA
Database Administrator

Health education
and promotion,
public relations,
social marketing
and formative
research,
communications,
social and
behavioral
science
disciplines, CQI.

Information
Systems

Database
Administration
DBA

Beneficiary Outreach
Coordinator
CQI Coordinator
Communications
Director
Health Education
Coordinator
Graphic Designer
Market Researcher
Medical Editor
Medical Librarian
Technical Writer

Labor
Category

Core
Competencies
PC
Desktop/Help
Desk Support

Definition

Job Title Examples

Information systems personnel who
support the QualityNet Standard Data
Processing System at the QIO. Work
includes providing support for
local/remote users with standard MS
Windows workstations/laptop hardware
and SDPS/QualityNet applications. Act
as the first level support for the local
QIO personnel and interface with the
QualityNet Helpdesk on issues that
cannot be resolved locally. Also
responsible for any additional approved
workstation/laptop hardware or software
attached to the SDPS/QualityNet
network.

PC Specialist
Systems/Computer Analyst

Senior
Network/System
Administration

Information systems personnel who
support the QualityNet Standard Data
Processing System at the QIO. Work
includes trouble shooting of local QIO
network problems, working with the
CMS contractors to help resolve LAN
and WAN issues when necessary,
backing up and restoring of data for all
QIO systems platforms, and following
the procedures outlined in the
Operations and Administrator's
Manuals. Responsible for the training
of local QIO users in the proper use of
the applications, LAN environment, and
security requirements for QualityNet.
Information systems personnel who
support the QualityNet Standard Data
Processing System at the QIO. Work
includes backing up and restoring of
data on the local QIO file server and
following the procedures outlined in the
Operations and Administrator's
Manuals.

Senior SystemsAdministrator

Junior
Network/System
Administration

Senior NetworkAdministrator

Junior Systems Administrator
Junior Network Administrator

Labor
Category

Core
Competencies
Technical
Management

QIO Security
Administration

Definition

Job Title Examples

Information systems personnel who
manage and support the QualityNet
Standard Data Processing System at the
QIO. Work includes managing senior
and junior level systems administrators
and IT support staff. Overall
responsibility for backups and restores
of data for the file/print server and all
QIO data. In addition, serves as the
QIO technical liaison or IT
representative to the overall QualityNet
enterprise system through various
workgroups and/or boards. Duties will
also include coordination efforts with
the QualityNet development networks
and lab environments for approved
special study work and/or trade studies.
Systems security personnel who support
the QualityNet Standard Data
Processing System at the QIO and
protect the integrity of the QualityNet
Infrastructure. Work includes:
Managing security, including ensuring
assigned POC perform the necessary
tasks at their individual office locations;
enforcing CMS security rules as
outlined in the QualityNet System
Security Policies Handbook; completing
tasks assigned by the CMS Information
System Security Officer (ISSO); and
ensuring QIO staff are fully trained as
policy states from QualityNet System
Security Policies Handbook. In addition
to these roles, serves as the primary
POC in the event of security incidents
identified from outside sources and
provides first level response to security
incidents identified within the
QualityNet operations; ensures
confidential data are destroyed or stored
as identified within the QualityNet
System Security Policies Handbook,
and maintains the acceptance log for
their QIO site location(s).

IT Manager
CIO
CTO
IT Representative

QIO Security
Administrator

Labor
Category
Corporate
Management

Core
Competencies
Corporate
management and
leadership skills.

Support
Staff

Administrative,
Secretarial and
clerical support

Definition

Job Title Examples

Personnel performing Administrative,
Financial, Human Resource, Training
and Public Relations Management for
the organization as a whole. Activities
are directly identifiable with specific
cost centers of the QIO contract. Report
direct labor hours and costs on line a3 of
CMS BP Form 719, FIVS Forms 719 +
719A.

Chief Executive
Officer
Chief Operating
Officer
Contracts
Administrator
Controller
Corporate Training
Coordinator
Finance Director
Fiscal Analyst
Accountant
Human Resources
Director
Public Relations
Director

Personnel who perform support services
and staff assistance to Professional,
Information Systems, and Corporate
Administration staff for the QIO
contract.

Accounting
Clerk/Assistant
Administrative
Clerk/Assistant
Data Entry Operator
Human Resources
Clerk/Assistant
Mail Room and
Photocopy Clerk
Medical Records Clerk
Receptionist
Secretary

Report direct labor hours and costs on
line a4 of CMS BP Form 719, FIVS
Forms 719 + 719A.

Note: All proposed labor rates shall be supported with matching rates or formal salary survey
information conducted by your organization from an acceptable source {i.e. www.salary.com,
www.indeed.com, or etc.}.

NOTE: The Line designations listed below apply both to the Forms BP719 of the FIVS
719+ 719A
b.

LEAVE. This line item should be completed by all organizations that have an approved
Indirect Leave Rate. This line item includes all indirect leave such as vacation, sick,
holiday, and military leave. Accounting treatment of leave as an indirect cost must be
consistent for all contracts or lines of business.

FRINGE BENEFITS. This line item includes allowances provided by the contractor to its
employees as compensation in addition to regular wages and salaries. The Fringe Benefits
line includes all direct costs such as employer’s share of FICA, federal unemployment tax,
state unemployment insurance, disability insurance, pension expense, workers
compensation, group health insurance, group life insurance, employee relations, and
welfare. It also covers leave costs for those organizations that include these costs in the
fringe benefit pool. This category does not include benefits provided some, but not all, fulltime employees.

SUBCONTRACTS
1.

PHYSICIAN REVIEWERS/ADVISORS. This line item includes all direct
hours and costs related to subcontracts or agreements with physician reviewers or
physician advisors to perform medical case review (and related) activities required
by the statement of work (SOW). This applies to physicians who are not
employees.

OTHER CONSULTANTS. This line item includes all direct costs related to
subcontracts with physician and non-physician consultants (other than the
physician reviewers and physician advisors performing medical case review, noted
above) to perform activities required by the SOW.

OTHER SUBCONTRACTS. This line item is for all direct subcontracting costs
not reportable on lines d.1. or d.2. This includes all direct hours and costs for
subcontract arrangements (including those with universities and other
organizations) meeting the requirements of the FAR, incurred in performance of
the SOW, and not involving consultative services.

TRAVEL. This line item includes all travel directly chargeable to the contract.

OTHER DIRECT COSTS. This line item includes all direct costs applicable to the
Medicare contract that are not reportable on other line items. Accounting treatment of other
direct costs must be applied consistently to all contracts or lines of business and in
accordance with the FAR or OMB Circular A-122.

All direct costs (excluding information services costs) not directly associated with a specific
task should be included in the other direct cost pool and allocated to each task based on an
allocation methodology developed by the offeror. Offerors must provide supporting
documentation describing the proposed allocation method.
g.

INDIRECT COSTS. This line item includes costs allocated to the Medicare contract but
incurred for common or joint objectives. These costs fit in one of the following categories:
1.

Costs that benefit all lines of business.

Costs that directly benefit the Medicare contract but which cannot be readily
allocated to one or more specific cost centers. These costs are also referred to as
general overhead costs of the Medicare contract.

Accounting treatment of indirect costs must be applied consistently to all contracts or lines
of business and in accordance with the FAR and OMB Circular A-122.
h.

PASS‐THRU COSTS. This line item includes payments to providers or vendors as
specified and negotiated in the contract as being pass-thru costs. Examples are
reimbursement for medical record reproduction costs and postage costs for mailing medical
records from the provider to the QIO.
i. FEE. This is the element of potential total compensation that may be received for contract
performance over and above allowable costs and shall not exceed statutory
limitations.

III. COST CENTER COLUMN CATEGORIES
a.

TBD

File Type	application/pdf
File Title	BPInstructions.PDF
Author	CMS
File Modified	2021-02-18
File Created	2021-02-17