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Deliverable Number
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Commodity/Service Type
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Major Deliverable
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Method of Payment
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Vocational rehabilitation services
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Vocational evaluation report - Background, Medical, Educational, Work History, Behavioral Observati...
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Fixed Fee / Unit Rate
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| Major Deliverable: Vocational evaluation report - Background, Medical, Educational, Work History, Behavioral Observations, Test Results, Transferrable Skills Analysis, Summary - $1,050.00 per face-to-face vocational evaluation report and $950 for virtual.
Assign the Referral to the Provider and notify the Department of the Provider's name via the Contract Services Module within five (5) Business Days as specified.
(1st renewal years; Jan 4, 2021 - Jan 3, 2022)
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| Deliverable Price: $0.00 |
| Non Price Justification: Rate Agreement |
| Performance Metrics: As specified in Contract;The Division will compare the substance of the written report with the records provided to Momentum Healthcare, Inc.
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| Financial Consequences: Provider Assignment - Failure to acknowledge the Referral via the Contract Services Module as specified will result in a $25.00 reduction from the initial invoices for that injured employee for each Business Day past the due date until the Referral is acknowledged.
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| Source Documentation Page Reference: pg 48-49; Attachment 3 |
| Deliverable Number: |
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Vocational rehabilitation services
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Vocational evaluation report - Background, Medical, Educational, Work History, Behavioral Observati...
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Fixed Fee / Unit Rate
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| Major Deliverable: Vocational evaluation report - Background, Medical, Educational, Work History, Behavioral Observations, Test Results, Transferrable Skills Analysis, Summary - $1,099.00 per face-to-face vocational evaluation report and $999.00 for virtual.
Assign the Referral to the Provider and notify the Department of the Provider's name via the Contract Services Module within five (5) Business Days as specified.
(2nd & 3rd renewal years; Jan 4, 2022 - Jan 3, 2024)"
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| Deliverable Price: $0.00 |
| Non Price Justification: Rate Agreement |
| Performance Metrics: As specified in Contract; The Division will compare the substance of the written report with the records provided to Momentum Healthcare, Inc.
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| Financial Consequences: Provider Assignment - Failure to acknowledge the Referral via the Contract Services Module as specified will result in a $25.00 reduction from the initial invoices for that injured employee for each Business Day past the due date until the Referral is acknowledged.
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| Source Documentation Page Reference: pg. 48-49; Attachment 3 |
| Deliverable Number: |
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Vocational rehabilitation services
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Vocational evaluation report - Background, Medical, Educational, Work History, Behavioral Observati...
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Fixed Fee / Unit Rate
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| Major Deliverable: Vocational evaluation report - Background, Medical, Educational, Work History, Behavioral Observations, Test Results, Transferrable Skills Analysis, Summary - $1,099.00 per face-to-face vocational evaluation report and $999.00 for virtual.
Prepare the written Vocational Evaluation Report and submit it via the Conrract Services Module as specified.
(2nd & 3rd renewal years; Jan 4, 2022 - Jan 3, 2024)"
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| Deliverable Price: $0.00 |
| Non Price Justification: Rate Agreement |
| Performance Metrics: As specified in Contract; The Division will compare the substance of the written report with the records provided to Momentum Healthcare, Inc.
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| Financial Consequences: Report - Initial Report due 45 days/acknowledgement of assignment, Additional Reports due 30 days/thereafter. Failure to submit the written reemployment Services Report to the Department as specified will result in a $75.00 reduction from the invoice for each Business Day past the due date until the Report is submitted.
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| Source Documentation Page Reference: pg. 48-49 |
| Deliverable Number: |
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Vocational rehabilitation services
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Vocational evaluation report - Background, Medical, Educational, Work History, Behavioral Observati...
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Fixed Fee / Unit Rate
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| Major Deliverable: Vocational evaluation report - Background, Medical, Educational, Work History, Behavioral Observations, Test Results, Transferrable Skills Analysis, Summary - $1,099.00 per face-to-face vocational evaluation report and $999.00 for virtual.
Acknowledge the Referral via the Contract Service Module no later than three (3) Business Days as specified.
(2nd & 3rd enewal years; Jan 4, 2022 - Jan 3, 2024)"
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| Deliverable Price: $0.00 |
| Non Price Justification: Rate Agreement |
| Performance Metrics: As specified in Contract; The Division will compare the substance of the written report with the records provided to Momentum Healthcare, Inc.
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| Financial Consequences: Acknowledgement of Assignment - Failure to acknowledge the Referral via the Contract Services Module as specified will result in a $25.00 reduction from the initial invoices for that injured employee for each Business Day past the due date until the Referral is acknowledged.
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| Source Documentation Page Reference: pg. 48-49; Attachment 3 |
| Deliverable Number: |
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Vocational rehabilitation services
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Reemployment Services - Summary of reemployment services; Work products from the requested services ...
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Fixed Fee / Unit Rate
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| Major Deliverable: Reemployment Services - Summary of reemployment services; Work products from the requested services - $84.00 per hour (face-to-face and virtual).
Prepare the written Reemployment Services Report and submit it via the Contract Services Module as specified.
(2nd & 3rd renewal years; Jan 4, 2022 - Jan 3, 2024)
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| Deliverable Price: $0.00 |
| Non Price Justification: Rate Agreement |
| Performance Metrics: As specified in Contract; The Division will compare the substance of the written report with the records provided to Momentum Healthcare, Inc.
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| Financial Consequences: Report - Initial Report due 45 days/acknowledgement of assignment, Additional Reports due 30 days/thereafter. Failure to completed all services identified on the Referral Form as specified will result in a $75.00 reduction on the invoice for that injured employee.
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| Source Documentation Page Reference: pg. 48-49; Attachment 3 |
| Deliverable Number: |
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Vocational rehabilitation services
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"Reemployment Services - Summary of reemployment services; Work products from the requested services...
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Fixed Fee / Unit Rate
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| Major Deliverable: "Reemployment Services - Summary of reemployment services; Work products from the requested services - $84.00 per hour (face-to-face and virtual).
Completed all services identified on the Referral form as specified.
(2nd & 3rd renewal years; Jan 4, 2022 - Jan 3, 2024)
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| Deliverable Price: $0.00 |
| Non Price Justification: Rate Agreement |
| Performance Metrics: As specified in Contract; The Division will compare the substance of the written report with the records provided to Momentum Healthcare, Inc.
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| Financial Consequences: Report - Initial Report due 45 days/acknowledgement of assignment, Additional Reports due 30 days/thereafter. Failure to completed all services identified on the Referral Form as specified will result in a $75.00 reduction on the invoice for that injured employee.
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| Source Documentation Page Reference: pg. 49; Attachment 3 |
| Deliverable Number: |
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Vocational rehabilitation services
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Reemployment Services - Summary of reemployment services; Work products from the requested services ...
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Fixed Fee / Unit Rate
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| Major Deliverable: Reemployment Services - Summary of reemployment services; Work products from the requested services - $84.00 per hour (face-to-face and virtual).
Assign the Referral to the Provider and notify the Department of the Provider's name via the Contract Services Module within five (5) Business Days as specified.
(2nd & 3rd renewal years; Jan 4, 2022 - Jan 3, 2024)
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| Deliverable Price: $0.00 |
| Non Price Justification: Rate Agreement |
| Performance Metrics: As specified in Contract; The Division will compare the substance of the written report with the records provided to Momentum Healthcare, Inc.
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| Financial Consequences: Provider Assignment - Failure to assign the Referral to the Provider and notify the Department of the Provider's name via the Contract Services Module as specified will result in a $25.00 reduction from the initial invoice for that injured employee for each Business Day past the due date until the Referral is assigned.
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| Source Documentation Page Reference: pg. 49; Attachment 3 |
| Deliverable Number: |
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Vocational rehabilitation services
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Reemployment Services - Summary of reemployment services; Work products from the requested services ...
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Fixed Fee / Unit Rate
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| Major Deliverable: Reemployment Services - Summary of reemployment services; Work products from the requested services - $84.00 per hour (face-to-face and virtual).
Acknowledge the Referral via the Contract Service Module no later than three (3) Business Days as specified.
(2nd & 3rd renewal years; Jan 4, 2022 - Jan 3, 2024)
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| Deliverable Price: $0.00 |
| Non Price Justification: Rate Agreement |
| Performance Metrics: As specified in Contract; The Division will compare the substance of the written report with the records provided to Momentum Healthcare, Inc.
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| Financial Consequences: Acknowledgement of Assignment - Failure to acknowledge the Referral via the Contract Services Module as specified will result in a $25.00 reduction from the initial invoices for that injured employee for each Business Day past the due date until the Referral is acknowledged.
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| Source Documentation Page Reference: pg. 49; Attachment 3 |
| Deliverable Number: |
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Vocational rehabilitation services
|
Vocational evaluation report - Background, Medical, Educational, Work History, Behavioral Observati...
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Fixed Fee / Unit Rate
|
| Major Deliverable: Vocational evaluation report - Background, Medical, Educational, Work History, Behavioral Observations, Test Results, Transferrable Skills Analysis, Summary - $1,050.00 per face-to-face vocational evaluation report and $950 for virtual.
Prepare the written Vocational Evaluation Report and submit it via the Contract Services Module as specified.
(1st renewal years; Jan 4, 2021 - Jan 3, 2022)"
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| Deliverable Price: $0.00 |
| Non Price Justification: Rate Agreement |
| Performance Metrics: As specified in Contract; The Division will compare the substance of the written report with the records provided to Momentum Healthcare, Inc.
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| Financial Consequences: Report - Initial Report due 45 days/acknowledgement of assignment, Additional Reports due 30 days/thereafter. Failure to submit the written reemployment Services Report to the Department as specified will result in a $75.00 reduction from the invoice for each Business Day past the due date until the Report is submitted.
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| Source Documentation Page Reference: pg. 48-49; Attachment 3 |
| Deliverable Number: |
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Vocational rehabilitation services
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Vocational evaluation report - Background, Medical, Educational, Work History, Behavioral Observati...
|
Fixed Fee / Unit Rate
|
| Major Deliverable: Vocational evaluation report - Background, Medical, Educational, Work History, Behavioral Observations, Test Results, Transferrable Skills Analysis, Summary - $1,050.00 per face-to-face vocational evaluation report and $950 for virtual.
Acknowledge the Referral via the Contract Service Module no later than three (3) Business Days as specified.
(1st renewal years; Jan 4, 2021 - Jan 3, 2022)
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| Deliverable Price: $0.00 |
| Non Price Justification: Rate Agreement |
| Performance Metrics: As specified in Contract; The Division will compare the substance of the written report with the records provided to Momentum Healthcare, Inc.
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| Financial Consequences: Acknowledgement of Assignment - Failure to acknowledge the Referral via the Contract Services Module as specified will result in a $25.00 reduction from the initial invoices for that injured employee for each Business Day past the due date until the Referral is acknowledged.
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| Source Documentation Page Reference: pg. 48-49; Attachment 3 |
| Deliverable Number: |
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Vocational rehabilitation services
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Reemployment Services - Summary of reemployment services; Work products from the requested services ...
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Fixed Fee / Unit Rate
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| Major Deliverable: Reemployment Services - Summary of reemployment services; Work products from the requested services - $83.00 per hour (Face-To-Face and Virtual).
Prepare the written Reemployment Services Report and submit it via the Contract Services Module as specified.
(1st renewal years; Jan 4, 2021 - Jan 3, 2022)
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| Deliverable Price: $0.00 |
| Non Price Justification: Rate Agreement |
| Performance Metrics: As specified in Contract;The Division will compare the substance of the written report with the records provided to Momentum Healthcare, Inc.
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| Financial Consequences: Report - Initial Report due 45 days/acknowledgement of assignment, Additional Reports due 30 days/thereafter. Failure to completed all services identified on the Referral Form as specified will result in a $75.00 reduction on the invoice for that injured employee.
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| Source Documentation Page Reference: pg. 48-49; Attachment 3 |
| Deliverable Number: |
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Vocational rehabilitation services
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Reemployment Services - Summary of reemployment services; Work products from the requested services ...
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Fixed Fee / Unit Rate
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| Major Deliverable: Reemployment Services - Summary of reemployment services; Work products from the requested services - $83.00 per hour (Face-To-Face and Virtual).
Complete all services identified on the Referral form as specified.
(1st renewal years; Jan 4, 2021 - Jan 3, 2022)
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| Deliverable Price: $0.00 |
| Non Price Justification: Rate Agreement |
| Performance Metrics: As specified in Contract; The Division will compare the substance of the written report with the records provided to Momentum Healthcare, Inc.
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| Financial Consequences: Report - Initial Report due 45 days/acknowledgement of assignment, Additional Reports due 30 days/thereafter. Failure to completed all services identified on the Referral Form as specified will result in a $75.00 reduction on the invoice for that injured employee.
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| Source Documentation Page Reference: Pg 49; Attachment 3 |
| Deliverable Number: |
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Vocational rehabilitation services
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Reemployment Services - Summary of reemployment services; Work products from the requested services ...
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Fixed Fee / Unit Rate
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| Major Deliverable: Reemployment Services - Summary of reemployment services; Work products from the requested services - $83.00 per hour (Face-To-Face and Virtual).
Acknowledge the Referral via the Contract Service Module no later than three (3) Business Days as specified.
(1st renewal years; Jan 4, 2021 - Jan 3, 2022)
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| Deliverable Price: $0.00 |
| Non Price Justification: Rate Agreement |
| Performance Metrics: As specified in Contract. The Division will compare the substance of the written report with the records provided to Momentum Healthcare, Inc.
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| Financial Consequences: Acknowledgement of Assignment - Failure to acknowledge the Referral via the Contract Services Module as specified will result in a $25.00 reduction from the initial invoices for that injured employee for each Business Day past the due date until the Referral is acknowledged.
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| Source Documentation Page Reference: pg 49 and Attachment 3 |
| Deliverable Number: |
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Vocational rehabilitation services
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Reemployment Services - Summary of reemployment services; Work products from the requested services ...
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Fixed Fee / Unit Rate
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| Major Deliverable: Reemployment Services - Summary of reemployment services; Work products from the requested services - $83.00 per hour (Face-To-Face and Virtual).
Assign the Referral to the Provider and notify the Department of the Provider's name via the Contract Services Module within five (5) Business Days as specified.
(1st renewal year; Jan 4, 2021 - Jan 3, 2022)
|
| Deliverable Price: $0.00 |
| Non Price Justification: Rate Agreement |
| Performance Metrics: As specified in Contract; The Division will compare the substance of the written report with the records provided to Momentum Healthcare, Inc.
|
| Financial Consequences: Provider Assignment - Failure to assign the Referral to the Provider and notify the Department of the Provider's name via the Contract Services Module as specified will result in a $25.00 reduction from the initial invoice for that injured employee for each Business Day past the due date until the Referral is assigned.
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| Source Documentation Page Reference: pg 49 and Attachment 3 |
| Deliverable Number: |
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Job evaluation service
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Vocational evaluation report - Background, Medical, Educational, Work History, Behaviorial Observat...
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Fixed Fee / Unit Rate
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| Major Deliverable: Vocational evaluation report - Background, Medical, Educational, Work History, Behaviorial Observations, Test Results, Transferrable Skills Analysis, Summary - $1,050.00 per vocational evaluation report.
Prepare the written Vocational Evaluation Report and submit it via the Conrract Services Module as specified.
(Initial contract years; Jan 2, 2019 - Jan 1, 2021) |
| Deliverable Price: $0.00 |
| Non Price Justification: Rate Agreement |
| Performance Metrics: The Division will compare the substance of the written report with the records provided to Momentum Healthcare, Inc. |
| Financial Consequences: Report - Initial Report due 45 days/acknowledgement of assignment, Additional Reports due 30 days/thereafter. Failure to submit the written reemployment Services Report to the Department as specified will result in a $75.00 reduction from the invoice for each Business Day past the due date until the Report is submitted. |
| Source Documentation Page Reference: pg 48-49; 1718-27 RCP WC |
| Deliverable Number: |
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Job evaluation service
|
Vocational evaluation report - Background, Medical, Educational, Work History, Behaviorial Observat...
|
Fixed Fee / Unit Rate
|
| Major Deliverable: Vocational evaluation report - Background, Medical, Educational, Work History, Behaviorial Observations, Test Results, Transferrable Skills Analysis, Summary - $1,050.00 per vocational evaluation report.
Assign the Referral to the Provider and notify the Department of the Provider's name via the Contract Services Module within five (5) Business Days as specified.
(Initial contract years; Jan 2, 2019 - Jan 1, 2021) |
| Deliverable Price: $0.00 |
| Non Price Justification: Rate Agreement |
| Performance Metrics: The Division will compare the substance of the written report with the records provided to Momentum Healthcare, Inc. |
| Financial Consequences: Provider Assignment - Failure to acknowledge the Referral via the Contract Services Module as specified will result in a $25.00 reduction from the initial invoices for that injured employee for each Business Day past the due date until the Referral is acknowledged. |
| Source Documentation Page Reference: pg 48-49; 1718-27 RCP WC |
| Deliverable Number: |
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Job evaluation service
|
Vocational evaluation report - Background, Medical, Educational, Work History, Behaviorial Observat...
|
Fixed Fee / Unit Rate
|
| Major Deliverable: Vocational evaluation report - Background, Medical, Educational, Work History, Behaviorial Observations, Test Results, Transferrable Skills Analysis, Summary - $1,050.00 per vocational evaluation report.
Acknowledge the Referral via the Contract Service Module no later than three (3) Business Days as specified.
(Initial contract years; Jan 2, 2019 - Jan 1, 2021) |
| Deliverable Price: $0.00 |
| Non Price Justification: Rate Agreement |
| Performance Metrics: The Division will compare the substance of the written report with the records provided to Momentum Healthcare, Inc. |
| Financial Consequences: Acknowledgement of Assignment - Failure to acknowledge the Referral via the Contract Services Module as specified will result in a $25.00 reduction from the initial invoices for that injured employee for each Business Day past the due date until the Referral is acknowledged. |
| Source Documentation Page Reference: pg 48-49; 1718-27 RCP WC |
| Deliverable Number: |
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Vocational rehabilitation services
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Reemployment Services - Summary of reemployment services; Work products from the requested services ...
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Fixed Fee / Unit Rate
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| Major Deliverable: Reemployment Services - Summary of reemployment services; Work products from the requested services - $79.00 per hour.
Prepare the written Reemployment Services Report and submit it via the Conrract Services Module as specified.
(Initial contract years; Jan 2, 2019 - Jan 1, 2021) |
| Deliverable Price: $0.00 |
| Non Price Justification: Rate Agreement |
| Performance Metrics: The Division will compare the substance of the written report with the records provided to Momentum Healthcare, Inc. |
| Financial Consequences: Report - Initial Report due 45 days/acknowledgement of assignment, Additional Reports due 30 days/thereafter. Failure to submit the written reemployment Services Report to the Department as specified will result in a $75.00 reduction from the invoice for each Business Day past the due date until the Report is submitted. |
| Source Documentation Page Reference: pg 48-49; 1718-27 RCP WC |
| Deliverable Number: |
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Vocational rehabilitation services
|
Reemployment Services - Summary of reemployment services; Work products from the requested services ...
|
Fixed Fee / Unit Rate
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| Major Deliverable: Reemployment Services - Summary of reemployment services; Work products from the requested services - $79.00 per hour.
Completed all services indentified on the Referral form as specified.
(Initial contract years; Jan 2, 2019 - Jan 1, 2021) |
| Deliverable Price: $0.00 |
| Non Price Justification: Rate Agreement |
| Performance Metrics: The Division will compare the substance of the written report with the records provided to Momentum Healthcare, Inc. |
| Financial Consequences: Report - Initial Report due 45 days/acknowledgement of assignment, Additional Reports due 30 days/thereafter. Failure to completed all services identified on the Referral Form as specified will result in a $75.00 reduction on the invoice for that injured employee. |
| Source Documentation Page Reference: pg 417189; -27 RCP WC |
| Deliverable Number: |
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Vocational rehabilitation services
|
Reemployment Services - Summary of reemployment services; Work products from the requested services ...
|
Fixed Fee / Unit Rate
|
| Major Deliverable: Reemployment Services - Summary of reemployment services; Work products from the requested services - $79.00 per hour.
Assign the Referral to the Provider and notify the Department of the Provider's name via the Contract Services Module within five (5) Business Days as specified.
(Initial contract years; Jan 2, 2019 - Jan 1, 2021) |
| Deliverable Price: $0.00 |
| Non Price Justification: Rate Agreement |
| Performance Metrics: The Division will compare the substance of the written report with the records provided to Momentum Healthcare, Inc. |
| Financial Consequences: Provider Assignment - Failure to assign the Referral to the Provider and notify the Department of the Provider's name via the Contract Servcies Module as specified will resul in a $25.00 reduction from the intial invoice for that injured employee for each Business Day past the due date unil the Referral is assigned. |
| Source Documentation Page Reference: pg 49; 1718-27 RCP WC |
| Deliverable Number: |
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Vocational rehabilitation services
|
Reemployment Services - Summary of reemployment services; Work products from the requested services ...
|
Fixed Fee / Unit Rate
|
| Major Deliverable: Reemployment Services - Summary of reemployment services; Work products from the requested services - $79.00 per hour.
Acknowledge the Referral via the Contract Service Module no later than three (3) Business Days as specified.
(Initial contract years; Jan 2, 2019 - Jan 1, 2021) |
| Deliverable Price: $0.00 |
| Non Price Justification: Rate Agreement |
| Performance Metrics: The Division will compare the substance of the written report with the records provided to Momentum Healthcare, Inc. |
| Financial Consequences: Acknowledgement of Assignment - Failure to acknowledge the Referral via the Contract Services Module as specified will result in a $25.00 reduction from the initial invoices for that injured employee for each Business Day past the due date until the Referral is acknowledged. |
| Source Documentation Page Reference: pg 49; 1718-27 RCP WC |
| Deliverable Number: |
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