VDOL WC Medical Fee Schedule

Revised: July 19, 2023 Page 1 of 17 Vermont Department of Labor 133 State Street, 5th Floor | Montpelier VT 05633-8000 802-828-2211 phone |802-828-2222 fax http://bgs.vermont.gov/purchasing SEALED BID REQUEST FOR PROPOSAL Workers’ Compensation Medical Fee Schedule ISSUE DATE March 18, 2024 QUESTIONS DUE March 29, 2024 - 4:30 (EST) RFP RESPONSES DUE BY April 12, 2024 – 4:30 PM (EST) PLEASE BE ADVISED THAT ALL NOTIFICATIONS, RELEASES, AND ADDENDUMS ASSOCIATED WITH THIS RFP WILL BE POSTED AT: http://www.bgs.state.vt.us/pca/bids/bids.php THE STATE WILL MAKE NO ATTEMPT TO CONTACT INTERESTED PARTIES WITH UPDATED INFORMATION. IT IS THE RESPONSIBILITY OF EACH BIDDER TO PERIODICALLY CHECK THE ABOVE WEBPAGE FOR ANY AND ALL NOTIFICATIONS, RELEASES AND ADDENDUMS ASSOCIATED WITH THIS RFP. STATE CONTACT: Dirk Anderson, Director

of Workers’ Compensation TELEPHONE: (802)595-5436 E-MAIL: dirk.anderson@vermont.gov 1. OVERVIEW: 1.1. SCOPE AND BACKGROUND: The Vermont Department of Labor is seeking to establish a contract with a vendor that can provide a medical fee schedule to establish reimbursement rates for health care providers who provide services covered by a workers’ compensation insurance policy, and to update the fee schedule annually for an additional four years. 1.2. CONTRACT PERIOD: Contracts arising from this RFP will be for a period of five years with an option to renew for up to two additional twelve-month periods. The State anticipates the start date for such contract(s) will be May 1, 2024. 1.3. SINGLE POINT OF CONTACT: All communications concerning this RFP are to be addressed in writing to the State Contact listed on the front page of this RFP. Actual or attempted contact with any other individual from the State concerning this RFP is strictly prohibited and may result in disqualification. 1.4. BIDDERS’ CONFERENCE: A bidders’ conference will not be held. http://bgs.vermont.gov/purchasing http://www.bgs.state.vt.us/pca/bids/bids.php Revised: July 19, 2023 Page 2 of 17 1.5. QUESTION AND ANSWER PERIOD: Any bidder requiring clarification of any section of this RFP or wishing to comment on any requirement of the RFP must submit specific questions in writing no later than the deadline for questions indicated on the first page of this RFP. Questions may be e-mailed to the point of contact on the front page of this RFP. Questions or comments not raised in writing on or before the last day of the question period are thereafter waived. At the close of the question period a copy of all questions or comments and the State's responses will be posted on the State’s webpage, http://www.bgs.state.vt.us/pca/bids/bids.php . Every effort will be made to post this information as soon as possible after the question period ends, contingent on the number and complexity of the questions. 1.6. CHANGES TO THIS RFP: Any modifications to this RFP will be made in writing by the State through the issuance of an Addendum to this RFP and posted online at http://www.bgs.state.vt.us/pca/bids/bids.php . Modifications from any other source are not to be considered. 2. DETAILED REQUIREMENTS/DESIRED OUTCOMES: 2.1. The State of Vermont is interested in obtaining bids to meet the following business needs: The establishment and annual amendment, for an additional four years, of two workers’ compensation medical fee schedules: one for hospitals and ambulatory surgical centers, and one for medical practitioners. 2.2. See Attachment A: Statement of Work for more details. 2.3. Vendor Qualification Requirements : The Vendor MUST: 1. Possess a thorough understanding of American Medical Association (AMA) CPT®, HCPCS, ICD-9-CM and ICD-10-CM codes; IPPS, OPPS, and PPS payment systems; 2. At no cost to the Department, possess and maintain for the duration of the contract period, the required AMA CPT® license from the American Medical Association, valid for the duration of this contract, including but not limited to: a. Vendor shall obtain or hold any and all licenses and authorizations from the AMA for the inclusion of AMA CPT® codes and descriptions, including abbreviated descriptions, in the Fee Schedule and for the right of Vendor to reproduce, publish and distribute; and having AMA CPT® codes and descriptions (including any and all royalty fees and other payments); b. Vendor shall obtain any renewals and extensions of said licenses and/or authorizations from the AMA as may be necessary for the term of this contract; and c. Royalty payments shall be a matter solely between Vendor and the AMA; the State of Vermont and the Department of Labor shall be held harmless for any issues regarding payment or lack thereof. 6. Possess the required permission from the American Society of Anesthesiologists, Inc. to use ASA base value units and concomitant licensing with the American Medical Association for AMA CPT® codes related thereto, valid for the duration of this contract; 7. Possess the required knowledge and experience necessary to develop methodology to produce medical fees and billing guidelines consistent with 21 V.S.A. §640(d); 8. Possess the required knowledge and experience necessary to develop methodology to produce hospital and ambulatory surgical center fees and billing guidelines consistent with 21 V.S.A. §640(d); 9. Possess understanding and expert knowledge of laws and regulations of the State of Vermont pertaining to medical, physician/medical provider, hospital, and ambulatory surgical center fee assessments; 10. Possess understanding and expert knowledge of federal laws and regulations pertaining to medical, physician/medical provider, hospital, and ambulatory surgical center fee assessments; 11. Possess expert knowledge and experience in workers’ compensation medical, hospital and ambulatory surgical center billing codes and practices; 12. Possess expert knowledge and experience in Medicare billing practices with specific expertise in Medicare fee schedule and coding systems utilizing RBRVS methodology; and IPPS, OPPS, and PPS methodologies; http://www.bgs.state.vt.us/pca/bids/bids.php http://www.bgs.state.vt.us/pca/bids/bids.php Revised: July 19, 2023 Page 3 of 17 13. Possess prior experience in developing medical fee schedules in which RBRVS methodologies; and IPPS, OPPS, and PPS methodologies are employed; 14. Possess knowledge and resources to develop relative values and conversion factors for services where there are no established Medicare RBRVS methodologies; 15. Possess prior experience in formulating and producing annual revisions to Fee Schedules for medical practitioners and hospitals and ambulatory surgical centers who treat injured workers; 16. Possess expert knowledge and comprehension of Vermont’s Workers’ Compensation laws and regulations; 17. Possess expert knowledge, understanding, and experience necessary to draft a “User’s Manual” for use by hospitals, medical practitioners, and bill reviewers; said manual to be written in clear, concise, and comprehensible language and with step-by-step instructions for coding, submitting, analyzing, repricing, and/or paying bills in accordance with the applicable fee schedule. 18. Possess financial stability; and 19. Employ adequate personnel to develop the Annual Updates to the “Vermont Workers’ Compensation Fee Schedule for Hospitals and Ambulatory Surgical Centers” and the “Vermont Workers’ Compensation Medical Practitioner Fee Schedule” and demonstrate to the Department’s satisfaction existence of same. 3. GENERAL REQUIREMENTS: 3.1. PRICING: Bidders must price the terms of this solicitation at their best pricing. Any and all costs that Bidder wishes the State to consider must be submitted for consideration. If applicable, all equipment pricing is to include F.O.B. delivery to the ordering facility. No request for extra delivery cost will be honored. All equipment shall be delivered assembled, serviced, and ready for immediate use, unless otherwise requested by the State. 3.1.1. Prices and/or rates shall remain firm for the initial term of the contract. The pricing policy submitted by Bidder must (i) be clearly structured, accountable, and auditable and (ii) cover the full spectrum of materials and/or services required. 3.1.2. Cooperative Agreements. Bidders that have been awarded similar contracts through a competitive bidding process with another state and/or cooperative are welcome to submit the pricing in response to this solicitation. 3.1.3. Retainage. In the discretion of the State, a contract resulting from this RFP may provide that the State withhold a percentage of the total amount payable for some or all deliverables, such retainage to be payable upon satisfactory completion and State acceptance in accordance with the terms and conditions of the contract. 3.2. STATEMENT OF RIGHTS: The State shall have the authority to evaluate Responses and select the Bidder(s) as may be determined to be in the best interest of the State and consistent with the goals and performance requirements outlined in this RFP. The State of Vermont reserves the right to obtain clarification or additional information necessary to properly evaluate a proposal. Failure of bidder to respond to a request for additional information or clarification could result in rejection of that bidder's proposal. To secure a project that is deemed to be in the best interest of the State, the State reserves the right to accept or reject any and all bids, in whole or in part, with or without cause, and to waive technicalities in submissions. The State also reserves the right to make purchases outside of the awarded contracts where it is deemed in the best interest of the State. 3.2.1. Best and Final Offer (BAFO). At any time after submission of Responses and prior to the final selection of Bidder(s) for Contract negotiation or execution, the State may invite Bidder(s) to provide a BAFO. The state reserves the right to request BAFOs from only those Bidders that meet the minimum qualification requirements and/or have not been eliminated from consideration during the evaluation process. 3.2.2. Presentation. An in-person or webinar presentation by the Bidder may be required by the State if it will help the State’s evaluation process. The State will factor information presented during Revised: July 19, 2023 Page 4 of 17 presentations into the evaluation. Bidders will be responsible for all costs associated with providing the presentation. 3.3. WORKER CLASSIFICATION COMPLIANCE REQUIREMENTS: In accordance with Section 32 of The Vermont Recovery and Reinvestment Act of 2009 (Act No. 54), Bidders must comply with the following provisions and requirements. 3.3.1. Self Reporting: For bid amounts exceeding $250,000.00, Bidder shall complete the appropriate section in the attached Certificate of Compliance for purposes of self-reporting information relating to past violations, convictions, suspensions, and any other information related to past performance relative to coding and classification of workers. The State is requiring information on any violations that occurred in the previous 12 months. 3.3.2. Subcontractor Reporting: For bid amounts exceeding $250,000.00, Bidders are hereby notified that upon award of contract, and prior to contract execution, the State shall be provided with a list of all proposed subcontractors and subcontractors’ subcontractors, together with the identity of those subcontractors’ workers’ compensation insurance providers, and additional required or requested information, as applicable, in accordance with Section 32 of The Vermont Recovery and Reinvestment Act of 2009 (Act No. 54). This requirement does not apply to subcontractors providing supplies only and no labor to the overall contract or project. This list MUST be updated and provided to the State as additional subcontractors are hired. A sample form is available online at http://bgs.vermont.gov/purchasing-contracting/forms. The subcontractor reporting form is not required to be submitted with the bid response. 3.4. EXECUTIVE ORDER 05-16: CLIMATE CHANGE CONSIDERATIONS IN STATE PROCUREMENTS: For bid amounts exceeding $25,000.00 Bidders are requested to complete the Climate Change Considerations in State Procurements Certification, which is included in the Certificate of Compliance for this RFP. After consideration of all relevant factors, a bidder that demonstrates business practices that promote clean energy and address climate change as identified in the Certification, shall be given favorable consideration in the competitive bidding process. Such favorable consideration shall be consistent with and not supersede any preference given to resident bidders of the State and/or products raised or manufactured in the State, as explained in the Method of Award section. But, such favorable consideration shall not be employed if prohibited by law or other relevant authority or agreement. 3.5. METHOD OF AWARD: Awards will be made in the best interest of the State. The State may award one or more contracts and reserves the right to make additional awards to other compliant bidders at any time if such award is deemed to be in the best interest of the State. All other considerations being equal, preference will be given first to resident bidders of the state and/or to products raised or manufactured in the state, and then to bidders who have practices that promote clean energy and address climate change, as identified in the applicable Certificate of Compliance. 3.5.1. Evaluation Criteria: Consideration shall be given to the Bidder’s project approach and methodology, qualifications and experience, ability to provide the services within the defined timeline, cost, and/or success in completing similar projects, as applicable, and to the extent specified below. 3.5.2. Criteria: The following table outlines the scoring criteria for bids. Scoring Criteria Weighted Point % Proposed approach (thoughtful, comprehensive, clearly structured, easy to understand) 35% Experience (demonstrated experience creating similar medical fee schedules, ideally in rural states) 30% Price (reasonable, clearly structured, detailed, accountable, comprehensive) 25% Response includes the required content and format (see Section 4.) 10% Revised: July 19, 2023 Page 5 of 17 3.6. CONTRACT NEGOTIATION: Upon completion of the evaluation process, the State may select one or more bidders with which to negotiate a contract, based on the evaluation findings and other criteria deemed relevant for ensuring that the decision made is in the best interest of the State. In the event the State is not successful in negotiating a contract with a selected bidder, the State reserves the option of negotiating with another bidder, or to end the proposal process entirely. 3.7. COST OF PREPARATION: Bidder shall be solely responsible for all expenses incurred in the preparation of a response to this RFP and shall be responsible for all expenses associated with any presentations or demonstrations associated with this request and/or any proposals made. 3.8. CONTRACT TERMS: The selected bidder(s) will be expected to sign a contract with the State, including the Standard Contract Form and Attachment C as attached to this RFP for reference. If IT Attachment D is included in this RFP, terms may be modified based upon the solution proposed by the Bidder, subject to approval by the Agency of Digital Services. 3.8.1. Business Registration. To be awarded a contract by the State of Vermont a bidder (except an individual doing business in his/her own name) must be registered with the Vermont Secretary of State’s office https://sos.vermont.gov/corporations/registration/ and must obtain a Contractor’s Business Account Number issued by the Vermont Department of Taxes http://tax.vermont.gov/ . 3.8.2. The contract will obligate the bidder to provide the services and/or products identified in its bid, at the prices listed. 3.8.3. Payment Terms. Percentage discounts may be offered for prompt payments of invoices; however, such discounts must be in effect for a period of 30 days or more in order to be considered in making awards. 3.8.4. Quality. If applicable, all products provided under a contract with the State will be new and unused, unless otherwise stated. Factory seconds or remanufactured products will not be accepted unless specifically requested by the purchasing agency. All products provided by the contractor must meet all federal, state, and local standards for quality and safety requirements. Products not meeting these standards will be deemed unacceptable and returned to the contractor for credit at no charge to the State. 4. CONTENT AND FORMAT OF RESPONSES: The content and format requirements listed below are the minimum requirements for State evaluation. These requirements are not intended to limit the content of a Bidder’s proposal. Bidders may include additional information or offer alternative solutions for the State’s consideration. However, the State discourages overly lengthy and costly proposals, and Bidders are advised to include only such information in their response as may be relevant to the requirements of this RFP. 4.1. The bid should include a Cover Letter and Technical Response and Price Schedule. 4.2. COVER LETTER: 4.2.1. Confidentiality. To the extent your bid contains information you consider to be proprietary and confidential, you must comply with the following requirements concerning the contents of your cover letter and the submission of a redacted copy of your bid (or affected portions thereof). 4.2.2. All responses to this RFP will become part of the contract file and will become a matter of public record under the State’s Public Records Act, 1 V.S.A. § 315 et seq. (the “Public Records Act”). If your response must include material that you consider to be proprietary and confidential under the Public Records Act, your cover letter must clearly identify each page or section of your response that you consider proprietary and confidential. Your cover letter must also include a written explanation for each marked section explaining why such material should be considered exempt from public disclosure in the event of a public records request, pursuant to 1 V.S.A. § 317(c), including the prospective harm to the competitive position of the bidder if the identified material were to be released. Additionally, you must include a redacted copy of your response for portions that are considered proprietary and confidential. Redactions must be limited so that the reviewer may understand the nature of the information being withheld. It is typically inappropriate to redact entire pages, or to redact the titles/captions of tables and figures. Under no circumstances may your entire response be marked confidential, and the State reserves the right to disqualify responses so marked. https://sos.vermont.gov/corporations/registration/ http://tax.vermont.gov/ Revised: July 19, 2023 Page 6 of 17 4.2.3. Exceptions to Contract Terms and Conditions. If a Bidder wishes to propose an exception to any terms and conditions set forth in the Standard Contract Form and its attachments, such exceptions must be included in the cover letter to the RFP response. Failure to note exceptions when responding to the RFP will be deemed to be acceptance of the State contract terms and conditions. If exceptions are not noted in the response to this RFP but raised during contract negotiations, the State reserves the right to cancel the negotiation if deemed to be in the best interests of the State. Note that exceptions to contract terms may cause rejection of the proposal. 4.3. TECHNICAL RESPONSE. In response to this RFP, a Bidder shall: 4.3.1. Provide details concerning your form of business organization, company size and resources. 4.3.2. Describe your capabilities and particular experience relevant to the RFP requirements. 4.3.2.1. Identify all current or past State projects. 4.3.3. Identify the names of all subcontractors you intend to use, the portions of the work the subcontractors will perform, and address the background and experience of the subcontractor(s), as per RFP section 4.3.2 above. 4.4. REFERENCES. Provide the names, addresses, and phone numbers of at least three companies with whom you have transacted similar business in the last 12 months. You must include contact names who can talk knowledgeably about performance. 4.5. REPORTING REQUIREMENTS: Provide a sample of any reporting documentation that may be applicable to the Detailed Requirements of this RFP. 4.6. PRICE SCHEDULE: Bidders shall submit their pricing information in the Price Schedule attached to the RFP. 4.7. CERTIFICATE OF COMPLIANCE: This form must be completed and submitted as part of the response for the proposal to be considered valid. 5. SUBMISSION INSTRUCTIONS: 5.1. CLOSING DATE: Bids must be received by the State by the due date specified on the front page of this RFP. Late bids will not be considered. 5.1.1. The State may, for cause, issue an addendum to change the date and/or time when bids are due. If a change is made, the State will inform all bidders by posting at the webpage indicated on the front page of this RFP. 5.1.2. There will not be a public bid opening. However, the State will record the name, city, and state for any and all bids received by the due date. This information will be posted as promptly as possible following the due date online at: https://bgs.vermont.gov/content/opc-bid-tabulation-sheets-0 . Bidders are hereby notified to review the information posted after the bid opening deadline to confirm receipt of bid by the State. Any bidder that submitted a bid, and is not listed on the bid tabulation sheet, shall promptly notify the State Contact listed on the front page of this RFP. Should a bidder fail to notify the State Contact listed on the front page of this RFP within two weeks of posting the bid tabulation sheet, the State shall not be required to consider the bid. 5.2. BID DELIVERY INSTRUCTIONS: Only electronic bids will be accepted. Bids will be accepted via email submission to the email specified on the front page of this RFP. Bids must consist of a single email with a single, digitally searchable PDF attachment containing all components of the bid. Multiple emails and/or multiple attachments will not be accepted. There is an attachment size limit of 40 MB. It is the Bidder’s responsibility to compress the PDF file containing its bid if necessary in order to meet this size limitation. 6. BID SUBMISSION CHECKLIST:  Cover Letter https://bgs.vermont.gov/content/opc-bid-tabulation-sheets-0 Revised: July 19, 2023 Page 7 of 17  Technical Response  Redacted Technical Response, if applicable  References  Price Schedule  Signed Certificate of Compliance 7. ATTACHMENTS: 7.1. Certificate of Compliance 7.2. Price Schedule 7.3. Worker Classification Compliance Requirement; Subcontractor Reporting Form 7.4. Standard State Contract with its associated attachments, including but not limited to, Attachment C: Standard State Provisions for Contracts and Grants (December 15, 2017) Revised: July 19, 2023 Page 8 of 17 RFP/PROJECT: DATE: Page 1 of 3 CERTIFICATE OF COMPLIANCE For a bid to be considered valid, this form must be completed in its entirety, executed by a duly authorized representative of the bidder, and submitted as part of the response to the proposal. A. NON-COLLUSION: Bidder hereby certifies that the prices quoted have been arrived at without collusion and that no prior information concerning these prices has been received from or given to a competitive company. If there is sufficient evidence to warrant investigation of the bid/contract process by the Office of the Attorney General, bidder understands that this paragraph might be used as a basis for litigation. B. CONTRACT TERMS: Bidder hereby acknowledges that is has read, understands and agrees to the terms of this RFP, including Attachment C: Standard State Contract Provisions, and any other contract attachments included with this RFP. C. WORKER CLASSIFICATION COMPLIANCE REQUIREMENT: In accordance with Section 32 of The Vermont Recovery and Reinvestment Act of 2009 (Act No. 54), the following provisions and requirements apply to Bidder when the amount of its bid exceeds $250,000.00. Self-Reporting. Bidder hereby self-reports the following information relating to past violations, convictions, suspensions, and any other information related to past performance relative to coding and classification of workers, that occurred in the previous 12 months. Summary of Detailed Information Date of Notification Outcome Subcontractor Reporting. Bidder hereby acknowledges and agrees that if it is a successful bidder, prior to execution of any contract resulting from this RFP, Bidder will provide to the State a list of all proposed subcontractors and subcontractors’ subcontractors, together with the identity of those subcontractors’ workers compensation insurance providers, and additional required or requested information, as applicable, in accordance with Section 32 of The Vermont Recovery and Reinvestment Act of 2009 (Act No. 54), and Bidder will provide any update of such list to the State as additional subcontractors are hired. Bidder further acknowledges and agrees that the failure to submit subcontractor reporting in accordance with Section 32 of The Vermont Recovery and Reinvestment Act of 2009 (Act No. 54) will constitute non-compliance and may result in cancellation of contract and/or restriction from bidding on future state contracts. Revised: July 19, 2023 Page 9 of 17 RFP/PROJECT: DATE: Page 2 of 3 D. Executive Order 05 – 16: Climate Change Considerations in State Procurements Certification Bidder certifies to the following (Bidder may attach any desired explanation or substantiation. Please also note that Bidder may be asked to provide documentation for any applicable claims): 1. Bidder owns, leases or utilizes, for business purposes, space that has received:  Energy Star® Certification  LEED®, Green Globes®, or Living Buildings ChallengeSM Certification  Other internationally recognized building certification: ____________________________________________________________________________ 2. Bidder has received incentives or rebates from an Energy Efficiency Utility or Energy Efficiency Program in the last five years for energy efficient improvements made at bidder’s place of business. Please explain: _____________________________________________________________________________ 3. Please Check all that apply:  Bidder can claim on-site renewable power or anaerobic-digester power (“cow-power”). Or bidder consumes renewable electricity through voluntary purchase or offset, provided no such claimed power can be double-claimed by another party.  Bidder uses renewable biomass or bio-fuel for the purposes of thermal (heat) energy at its place of business.  Bidder’s heating system has modern, high-efficiency units (boilers, furnaces, stoves, etc.), having reduced emissions of particulate matter and other air pollutants.  Bidder tracks its energy consumption and harmful greenhouse gas emissions. What tool is used to do this? _____________________  Bidder promotes the use of plug-in electric vehicles by providing electric vehicle charging, electric fleet vehicles, preferred parking, designated parking, purchase or lease incentives, etc..  Bidder offers employees an option for a fossil fuel divestment retirement account.  Bidder offers products or services that reduce waste, conserve water, or promote energy efficiency and conservation. Please explain: ____________________________________________________________________________ ____________________________________________________________________________ 4. Please list any additional practices that promote clean energy and take action to address climate change: _____________________________________________________________________________ ____________________________________________________________________________ _____________________________________________________________________________ Revised: July 19, 2023 Page 10 of 17 RFP/PROJECT: DATE: Page 3 of 3 E. Executive Order 02 – 22: Solidarity with the Ukrainian People  By checking this box, Bidder certifies that none of the goods, products, or materials offered in response to this solicitation are Russian-sourced goods or produced by Russian entities. If Bidder is unable to check the box, it shall indicate in the table below which of the applicable offerings are Russian-sourced goods and/or which are produced by Russian entities. An additional column is provided for any note or comment that you may have. Provided Equipment or Product Note or Comment Bidder Name: Contact Name: Address: Fax Number: Telephone: E-Mail: By: Name: Signature of Bidder (or Representative) (Type or Print) END OF CERTIFICATE OF COMPLIANCE Revised: July 19, 2023 Page 11 of 17 PRICE SCHEDULE Fixed Price Deliverables: Deliverable Description Fixed Price Two draft fee schedules, one for hospitals and ambulatory surgical centers, and one for medical practitioners $ First subsequent annual update to the fee schedules referenced above $ Second subsequent annual update to the fee schedules referenced above $ Third subsequent annual update to the fee schedules referenced above $ Fourth subsequent annual update to the fee schedules referenced above $ A “User’s Manual,” for use by hospitals, medical practitioners, and/or bill reviewers, written in clear, concise, and comprehensible language with step-by-step instructions for coding, submitting, analyzing, repricing, and/or paying bills in accordance with the applicable fee schedule. $ Total Project Cost $ Hourly Labor Rates: Activity Hourly Rate Additional consultation time to review proposed revisions, amendments, and public comments. $ Virtually attend meetings and public hearings. $ Name of Bidder: Signature of Bidder: Date: Revised: July 19, 2023 Page 12 of 17 RFP/PROJECT: DATE: SUBCONTRACTOR REPORTING FORM This form must be completed in its entirety and submitted prior to contract execution and updated as necessary and provided to the State as additional subcontractors are hired. The Department of Buildings and General Services in accordance with Act 54, Section 32 of the Acts of 2009 and for total project costs exceeding $250,000.00 requires bidders to comply with the following provisions and requirements. Contractor is required to provide a list of subcontractors on the job along with lists of subcontractor’s subcontractors and by whom those subcontractors are insured for workers’ compensation purposes. Include additional pages if necessary. This is not a requirement for subcontractor’s providing supplies only and no labor to the overall contract or project. Subcontractor Insured By Subcontractor’s Sub Insured By Date: Name of Company: Contact Name: Address: Title: Phone Number: E-mail: Fax Number: By: Name: Failure to adhere to Act 54, Section 32 of the Acts of 2009 and submit Subcontractor Reporting: Worker Classification Compliance Requirement will constitute non-compliance and may result in cancellation of contract and/or forfeiture of future bidding privileges until resolved. Send Completed Form to: Office of Purchasing & Contracting 133 State Street, 5th Floor Montpelier, VT 05633-8000 Revised: July 19, 2023 Page 13 of 17 STANDARD CONTRACT FOR SERVICES 1. Parties. This is a contract for services between the State of Vermont, _____________ (hereinafter called “State”), and _____________, with a principal place of business in _____________, (hereinafter called “Contractor”). Contractor’s form of business organization is _____________. It is Contractor’s responsibility to contact the Vermont Department of Taxes to determine if, by law, Contractor is required to have a Vermont Department of Taxes Business Account Number. 2. Subject Matter. The subject matter of this contract is services generally on the subject of _____________. Detailed services to be provided by Contractor are described in Attachment A. 3. Maximum Amount. In consideration of the services to be performed by Contractor, the State agrees to pay Contractor, in accordance with the payment provisions specified in Attachment B, a sum not to exceed $________.00. 4. Contract Term. The period of Contractor’s performance shall begin on _____________, 20__ and end on _____________, 20__. 5. Prior Approvals. This Contract shall not be binding unless and until all requisite prior approvals have been obtained in accordance with current State law, bulletins, and interpretations. 6. Amendment. No changes, modifications, or amendments in the terms and conditions of this contract shall be effective unless reduced to writing, numbered and signed by the duly authorized representative of the State and Contractor. 7. Termination for Convenience. This contract may be terminated by the State at any time by giving written notice at least thirty (30) days in advance. In such event, Contractor shall be paid under the terms of this contract for all services provided to and accepted by the State prior to the effective date of termination. 8. Attachments. This contract consists of ___ pages including the following attachments which are incorporated herein: Attachment A - Statement of Work Attachment B - Payment Provisions Attachment C – “Standard State Provisions for Contracts and Grants” a preprinted form (revision date 12/15/2017) Attachment D - Other Provisions 9. Order of Precedence. Any ambiguity, conflict or inconsistency between the documents comprising this contract shall be resolved according to the following order of precedence: (1) Standard Contract (2) Attachment D (3) Attachment C (Standard Contract Provisions for Contracts and Grants) (4) Attachment A (5) Attachment B List other attachments, if any, in order of precedence Revised: July 19, 2023 Page 14 of 17 WE THE UNDERSIGNED PARTIES AGREE TO BE BOUND BY THIS CONTRACT By the State of Vermont: By the Contractor: Date: Date: Signature: Signature: Name: Name: Title: Title: Revised: July 19, 2023 Page 15 of 17 ATTACHMENT A – STATEMENT OF WORK Product Definitions and Requirements: For each year of the five-year contract, the Vendor SHALL: 1. Provide the Department with annual reviews of the current “Vermont Workers’ Compensation Fee Schedule for Hospitals and Ambulatory Surgical Centers” and the “Vermont Workers’ Compensation Medical Practitioner Fee Schedule” as follows: review ground rules and general instructions in the Department’s current Fee Schedules and provide recommendations for instructions and rules that may require re-evaluation due to changes in AMA CPT®, HCPCS, and ICD-9-CM and ICD-10-CM codes, Medicare rules, and industry standards, and submit language to be included in the annual Fee Schedules; 2. Develop the Annual Updates to the “Vermont Workers’ Compensation Fee Schedule for Hospitals and Ambulatory Surgical Centers” with AMA CPT®, HCPCS, ICD-9-CM and ICD-10-CM codes, descriptions, rules, and fees maintaining the methodology as statutorily mandated under 21 V.S.A. §640(d) and any future legislative changes that take place during the contract period; 3. Develop the Annual Updates to the “Vermont Workers’ Compensation Medical Practitioner Fee Schedule” with AMA CPT® codes, ICD-9-CM and ICD-10-CM codes, descriptions, rules, and fees maintaining the methodology as statutorily mandated under 21 V.S.A. §640(d) and any future legislative changes that take place during the contract period; 4. Produce deliverables that are consistent with Vermont law and federal law, as well as accepted actuarial practices and methodologies; 5. Produce deliverables that include copyright information and appropriate disclaimers; 6. Provide statements as to the methodologies employed to produce the deliverables in the Annual Updates; 7. At any time during the term of the Contract, the Vendor shall correct in a timely manner any significant errors in the deliverables that have become apparent to either the Vendor or the Department; either party shall give notice to the other of such errors. Vendor shall apprise Department of steps they will take to correct such errors. Such corrections may be released in the form of errata or updates. Any such corrections as per this section shall be at no cost to the Department; 8. Assume all responsibility and liability associated with the development of the final products. 9. By law, the fee schedules must be adopted by the Department through the administrative rulemaking process. The Vendor will therefore be required to consider, in conjunction with the Department, public comment and proposed amendments during the course of the administrative rulemaking process. The Vendor should also be prepared to participate in focus groups, public comment hearings, and potentially legislative hearings, in advance of the adoption of the initial Vermont Workers’ Compensation Fee Schedule for Hospitals and Ambulatory Surgical Centers and Vermont Workers’ Compensation Medical Practitioner Fee Schedule. The Vendor shall be prepared to defend the draft fee schedules for form, content and methodologies. It is anticipated that work of this nature, following the initial submission the draft fee schedules, will be billed by the Vendor at an hourly rate. Revised: July 19, 2023 Page 16 of 17 ATTACHMENT B – PAYMENT PROVISIONS The maximum dollar amount payable under this contract is not intended as any form of a guaranteed amount. The Contractor will be paid for products or services actually delivered or performed, as specified in Attachment A, up to the maximum allowable amount specified on page 1 of this contract. 1. Prior to commencement of work and release of any payments, Contractor shall submit to the State: a. a certificate of insurance consistent with the requirements set forth in Attachment C, Section 8 (Insurance), and with any additional requirements for insurance as may be set forth elsewhere in this contract; and b. a current IRS Form W-9 (signed within the last six months). 2. Payment terms are Net 30 days from the date the State receives an error-free invoice with all necessary and complete supporting documentation. 3. Contractor shall submit detailed invoices itemizing all work performed during the invoice period, including the dates of service, rates of pay, hours of work performed, and any other information and/or documentation appropriate and sufficient to substantiate the amount invoiced for payment by the State. All invoices must include the Contract # for this contract. 4. Contractor shall submit invoices to the State in accordance with the schedule set forth in this Attachment B. Unless a more particular schedule is provided herein, invoices shall be submitted not more frequently than monthly. 5. Invoices shall be submitted to the State via email at Dirk.Anderson@vermont.gov, copying the Department’s Business Office at labor.ap@vermont.gov. 6. The payment schedule for delivered products, or rates for services performed, and any additional reimbursements, are as follows: Fixed Price Deliverables, as described in the Price Schedule: Upon Completion Hourly Rates: Monthly mailto:Dirk.Anderson@vermont.gov mailto:labor.ap@vermont.gov Revised: July 19, 2023 Page 17 of 17 ATTACHMENT C: STANDARD STATE PROVISIONS FOR CONTRACTS AND GRANTS REVISED DECEMBER 15, 2017 “Attachment C: Standard State Provisions for Contracts and Grants” (revision version dated December 15, 2017) constitutes part of this Agreement and is hereby incorporated by reference as if fully set forth herein and shall apply to the purchase of all goods and/or services by the State under this Agreement. A copy of this document is available online at: https://bgs.vermont.gov/purchasing-contracting/forms. https://bgs.vermont.gov/purchasing-contracting/forms