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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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Health administration services
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Consulting Services. Years 1-5 and Renewal Term. $225.00 per hour.
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Fixed Fee / Unit Rate
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| Major Deliverable: Consulting Services. Years 1-5 and Renewal Term. $225.00 per hour.
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| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: The Contractor shall provide Consulting Services as requested by the DRM by the mutually agreed upon date. If no written work product is provided for acceptance in accordance with Section 6 of Attachment 1, Standard Terms and Conditions, the Department shall accept the Consulting Services in writing after the Consulting Services have been provided.
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| Financial Consequences: One hundred dollars ($100.00) for each Business Day beyond the mutually agreed upon date that Consulting Services are not provided.
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| Source Documentation Page Reference: Attachment 3, Pages 1-5, Section 4.I.d |
| Deliverable Number: |
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Health administration services
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Completion of MSA Proposal. Years 1-5 and Renewal Term. $1,500.00 per claim.
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Fixed Fee / Unit Rate
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| Major Deliverable: Completion of MSA Proposal. Years 1-5 and Renewal Term. $1,500.00 per claim.
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| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: The Contractor’s MSA proposals and their delivery to the DRM and the CMS shall meet the requirements set forth in Section 4.II.a., Completion of MSA Proposals.
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| Financial Consequences: One hundred dollars ($100.00) for each Business Day: 1. the initial submission of the MSA proposal to the DRM, is submitted beyond ten (10) Business Days after the Date of Assignment, or 2. the MSA proposal is submitted to the CMS beyond five (5) Business Days after the submission request is made by the DRM, or 3. beyond twenty (20) Business Days after the date the initial MSA proposal was rejected that the MSA Proposal is not resubmitted.
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| Source Documentation Page Reference: Attachment 3, Pages 1-5, Section 4.II.a |
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Health administration services
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Completion of Expedited MSA Proposal. Years 1-5 and Renewal Term. $1,700.00 per claim
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Fixed Fee / Unit Rate
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| Major Deliverable: Completion of Expedited MSA Proposal. Years 1-5 and Renewal Term. $1,700.00 per claim
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| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: The Contractor’s MSA Proposals and their delivery to the DRM shall meet the requirements set forth in Section 4.II.b., Completion of Expedited MSA Proposals.
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| Financial Consequences: Two hundred dollars ($200.00) for each Business Day: 1. the initial submission of the expedited MSA Proposal to the DRM, is submitted beyond five (5) Business Days after the Date of Assignment, or 2. the expedited MSA Proposal is submitted to the CMS beyond five (5) Business Days after the submission request is made by the DRM, or 3. beyond twenty (20) Business Days after the date the initial MSA Proposal was rejected that the MSA Proposal is not resubmitted.
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| Source Documentation Page Reference: Attachment 3,Pages 1-5, Section 4.II.b |
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Health administration services
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MSA Updates within six (6) months since original MSA. Years 1-5 and Renewal Term. No Cost per claim...
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No Cost
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| Major Deliverable: MSA Updates within six (6) months since original MSA. Years 1-5 and Renewal Term. No Cost per claim
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| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: The Contractor shall, if requested by the DRM, complete MSA Updates, which shall meet the requirements set forth in Section 4.II.a., Completion of MSA Proposals, and Section 4.II.b., Completion of Expedited MSA Proposals.
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| Financial Consequences: Financial Consequences for this deliverable shall be the same as the financial consequences set forth in: 1. Deliverable 5., Completion of MSA Proposal; and 2. Deliverable 6., Expedited MSA Proposals.
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| Source Documentation Page Reference: Attachment 3,Pages 1-5, Section 4.II.c |
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Health administration services
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MSA Updates over six (6) months over original MSA. Years 1-5 and Renewal Term. $500.00 per claim.
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Fixed Fee / Unit Rate
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| Major Deliverable: MSA Updates over six (6) months over original MSA. Years 1-5 and Renewal Term. $500.00 per claim.
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| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: The Contractor shall, if requested by the DRM, complete MSA Updates, which shall meet the requirements set forth in Section 4.II.a., Completion of MSA Proposals, and Section 4.II.b., Completion of Expedited MSA Proposals.
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| Financial Consequences: Financial Consequences for this deliverable shall be the same as the financial consequences set forth in: 1. Deliverable 5., Completion of MSA Proposal; and 2. Deliverable 6., Expedited MSA Proposals.
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| Source Documentation Page Reference: Attachment 3,Pages 1-5 , Section 4.II.c |
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Health administration services
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MSA Updates over 2 years since original MSA. Years 1-5 and Renewal Term. $1,500.00 per claim.
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Fixed Fee / Unit Rate
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| Major Deliverable: MSA Updates over 2 years since original MSA. Years 1-5 and Renewal Term. $1,500.00 per claim.
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| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: The Contractor shall, if requested by the DRM, complete MSA Updates, which shall meet the requirements set forth in Section 4.II.a., Completion of MSA Proposals, and Section 4.II.b., Completion of Expedited MSA Proposals.
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| Financial Consequences: Financial Consequences for this deliverable shall be the same as the financial consequences set forth in: 1. Deliverable 5., Completion of MSA Proposal; and 2. Deliverable 6., Expedited MSA Proposals.
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| Source Documentation Page Reference: Attachment 3, Pages 1-5, Section 4.II.c |
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Health administration services
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MSA Amended Review. Years 1-5 and Renewal Term. $250.00 per claim (plus applicable MSA update rate...
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Fixed Fee / Unit Rate
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| Major Deliverable: MSA Amended Review. Years 1-5 and Renewal Term. $250.00 per claim (plus applicable MSA update rate per claim)
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| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: The Contractor shall, if requested by the DRM, complete MSA Amended Review, which shall meet the requirements set forth in Section 4.II.a., Completion of MSA Proposals, and Section 4.II.b., Completion of Expedited MSA Proposals.
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| Financial Consequences: Financial Consequences for this deliverable shall be the same as the financial consequences set forth in: 1. Deliverable 5., Completion of MSA Proposal; and 2. Deliverable 6., Expedited MSA Proposals.
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| Source Documentation Page Reference: Attachment 3,Pages 1-5, Section 4.II.d |
| Deliverable Number: |
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Health administration services
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Future Medical Cost Projection (FMCP). Years 1-5 and Renewal Term. $2,450.00 per claim.
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Fixed Fee / Unit Rate
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| Major Deliverable: Future Medical Cost Projection (FMCP). Years 1-5 and Renewal Term. $2,450.00 per claim.
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| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: The Contractor shall, if requested by the DRM, provide a FMCP Report, which shall meet the requirements set forth in Section 4.II.e.ii., FMCP.
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| Financial Consequences: One hundred dollars ($100.00) for each Business Day beyond the fifteen (15) Business Days after the DRM’s request until the FMCP Report is submitted.
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| Source Documentation Page Reference: Attachment 3, Pages 1-5, Section 4.II.e.ii |
| Deliverable Number: |
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Health administration services
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Initial Conditional Payment Verification. Years 1-5 and Renewal Term. $225.00 per claim.
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Fixed Fee / Unit Rate
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| Major Deliverable: Initial Conditional Payment Verification. Years 1-5 and Renewal Term. $225.00 per claim.
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| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: The Contractor shall, if requested by the DRM, provide Initial Conditional Payments Verification, which shall meet the requirements set forth in Section 4.II.g.i., Conditional Payments.
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| Financial Consequences: Fifty dollars ($50.00) for each Business Day beyond the ten (10) Business Days after the DRM’s request until the Initial Conditional Payments Verification is submitted.
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| Source Documentation Page Reference: Attachment 3,Pages 1-5, Section 4.II.g.i |
| Deliverable Number: |
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Health administration services
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Medicare Conditional Payment Services. Hourly rate. Years 1-5 and Renewal Term. $100.00 per hour
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Fixed Fee / Unit Rate
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| Major Deliverable: Medicare Conditional Payment Services. Hourly rate. Years 1-5 and Renewal Term. $100.00 per hour
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| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: The Contractor shall, within ten (10) Business Days of receiving the final resolution document for the case identification number, provide a copy to the DRM.
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| Financial Consequences: One hundred dollars ($100.00) for each Business Day beyond the ten (10) Business Days the final resolution document is not provided..
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| Source Documentation Page Reference: Attachment 3,Pages 1-5, Section 4.II.g.ii |
| Deliverable Number: |
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Health administration services
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Lein Resolution Services. Hourly rate. Years 1-5 and Renewal Term. $100.00 per hour
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Fixed Fee / Unit Rate
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| Major Deliverable: Lein Resolution Services. Hourly rate. Years 1-5 and Renewal Term. $100.00 per hour
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| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: The Contractor shall, within ten (10) Business Days, provide the DRM (via email) with a copy of the initial Lien Inquiry and the date it was submitted to the lien entity.
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| Financial Consequences: One hundred dollars ($100.00) for each Business Day beyond the ten (10) Business Days the Initial Lien Inquiry and the date it was submitted to the lien entity is not provided.
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| Source Documentation Page Reference: Attachment 3,Pages 1-5, Section 4.II.h |
| Deliverable Number: |
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Health administration services
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Snapshot MSA Report. Years 1-5 and Renewal Term. $750.00 per claim.
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Fixed Fee / Unit Rate
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| Major Deliverable: Snapshot MSA Report. Years 1-5 and Renewal Term. $750.00 per claim.
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| Deliverable Price: $0.00 |
| Non Price Justification: Price cannot be determined until the work has been completed |
| Performance Metrics: The Contractor shall, if requested by the DRM, provide a Snapshot MSA Report, which shall meet the requirements set forth in Section 4.II.f., Snapshot MSA Report.
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| Financial Consequences: One hundred dollars ($100.00) for each Business Day beyond the ten (10) Business Days after the DRM’s request until the Snapshot MSA Report is submitted.
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| Source Documentation Page Reference: Attachment 3, Pages 1-5, Section 4.II.f |
| Deliverable Number: |
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Health administration services
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Section 111 Reporter
(annual fee)
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Fixed Fee / Unit Rate
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| Major Deliverable: Section 111 Reporter
(annual fee) |
| Deliverable Price: $6,750.00 |
| Non Price Justification: |
| Performance Metrics: The Contractor shall submit Section 111 quarterly reporting
to CMS and/or its contractors at a frequency determined by the guidelines outlined in the most current MMSEA NGHP User Guide, or a mutually agreeable alternative timeline is
established and agreed to, in writing, by the Division’s
Contract Manager. |
| Financial Consequences: Failure to submit the required Section 111 quarterly reporting to the CMS by the required submission filing window, when attributed solely to Contractor error, the Contractor shall be assessed one hundred dollars ($100.00) for each Business Day until the required Section 111 quarterly reporting is submitted to the CMS. |
| Source Documentation Page Reference: SOW Section V(c)(iv) |
| Deliverable Number: |
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Health administration services
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Section 111 Implementation Fee
(one-time fee)
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Fixed Price - Lump Sum
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| Major Deliverable: Section 111 Implementation Fee
(one-time fee)
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| Deliverable Price: $500.00 |
| Non Price Justification: |
| Performance Metrics: Provision of Implementation Service |
| Financial Consequences: Non-payment |
| Source Documentation Page Reference: SOW Section V(c) |
| Deliverable Number: |
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