Get documents about "Keyboard Enterable Version of R0944901R2 - Broward County
Document Sample
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
Table of Contents
Procurement Authority ...................................................................................................................... 4
Scope of Service ................................................................................................................................ 5
Submittal Instructions ....................................................................................................................... 6
Required Forms ............................................................................................................................... 7
For Additional Project Information Contact ....................................................................................... 8
Selection Process .............................................................................................................................. 8
Review Responses .......................................................................................................................... 8
Short Listing..................................................................................................................................... 8
Cone of Silence ............................................................................................................................... 9
Demonstrations................................................................................................................................ 9
Pricing ............................................................................................................................................. 9
Public Art and Design Program ........................................................................................................ 9
Presentations/Interviews/Ranking .................................................................................................. 10
Negotiation and Award................................................................................................................... 10
Posting of Solicitation and Proposed Contract Awards................................................................... 10
Vendor Protest ............................................................................................................................... 10
Rejection of Responses ................................................................................................................. 11
Public Records and Exemptions .................................................................................................... 11
Copyrighted Materials .................................................................................................................... 12
Right of Appeal .............................................................................................................................. 12
Projected Schedule........................................................................................................................ 12
Responsiveness Criteria ................................................................................................................. 14
Definition of a Responsive Bidder: ................................................................................................. 14
1. Office of Economic and Small Business Development Program ....................................... 14
2. Domestic Partnership Act ................................................................................................. 15
3. Joint Venture Enterprises ................................................................................................. 15
Responsibility Criteria..................................................................................................................... 16
Definition of Responsible Bidder .................................................................................................... 16
1. Financial Information ........................................................................................................ 16
2. Litigation History .............................................................................................................. 16
3. Electronic Data Interchange Submitter ............................................................................. 16
Employment Verification Program (E-Verify) .............................................................................. 17
Evaluation Criteria ........................................................................................................................... 17
Project-Specific Criteria ................................................................................................................. 17
Company Profile ............................................................................................................................ 22
Legal Requirements ....................................................................................................................... 25
Tiebreaker Criteria ......................................................................................................................... 28
Required Forms to be Returned ..................................................................................................... 31
Attachment “G” - Domestic Partnership Certification .................................................................... 32
Attachment “H” - Lobbyist Registration – Certification .................................................................. 33
Attachment “J” - Litigation History ................................................................................................ 34
Attachment “K” - Insurance Requirements ................................................................................... 35
Attachment “L” - Cone of Silence Certification.............................................................................. 36
Attachment “N” - Drug Free Workplace Policy Certification .......................................................... 37
Rev. 6.4.12 Page 2 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
Attachment “O” - Non-Collusion Statement Form ......................................................................... 38
Attachment “P” - Scrutinized Companies List Certification ........................................................... 39
Attachment “Q” - Local Vendor Certification ................................................................................. 40
Attachment “R” - Volume of Work Over Five Years ...................................................................... 41
Exhibits ............................................................................................................................................ 42
EXHIBIT 1 - File Format for the First Report of Injury (FNOI) Data File ........................................ 43
Header Record .............................................................................................................................. 43
EXHIBIT 1 - File Format for the First Report of Injury (FNOI) Data File ........................................ 44
Detail Record ................................................................................................................................. 44
EXHIBIT 1 - File Format for the First Report of Injury (FNOI) Data File ........................................ 49
Trailer Record ................................................................................................................................ 49
EXHIBIT 1 - File Format for the First Report of Injury (FNOI) Data File ........................................ 50
NCCI CAUSE CODES THAT MUST BE USED ............................................................................. 50
EXHIBIT 1 - File Format for the First Report of Injury (FNOI) Data File ........................................ 52
NCCI NATURE OF INJURY CODES THAT MUST BE USED ....................................................... 52
EXHIBIT 1 - File Format for the First Report of Injury (FNOI) Data File ........................................ 54
NCCI BODY PART CODES THAT MUST BE USED ..................................................................... 54
EXHIBIT 2 - File Layout and Mapping .......................................................................................... 56
EXHIBIT 3 - FILE HEADER RECORD ......................................................................................... 58
EXHIBIT 3 - BILL HEADER RECORD ......................................................................................... 59
EXHIBIT 3 - BILLING PROVIDER RECORD ............................................................................... 61
EXHIBIT 3 - BILL TRAILER RECORD ......................................................................................... 62
EXHIBIT 3 - FILE TRAILER RECORD ......................................................................................... 63
EXHIBIT 3 - REQUIRED BILL TYPE CODES .............................................................................. 64
EXHIBIT 4 - Other EDI & Technical Requirements ...................................................................... 65
EXHIBIT 5 - EDI TESTING FOR ALL SHORTLISTED FIRMS ..................................................... 67
EXHIBIT 6 - WC “STATS” FOR MEDICAL CARE SVCS RLI ........................................................ 71
Rev. 6.4.12 Page 3 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
Request for Letters of Interest (RLI)
RLI Number: R0944901R2
RLI Name: Workers’ Compensation Medical Cost Containment and Case
Management Services
Procurement Authority
Unchecked boxes do not apply to this solicitation.
Pursuant to the Broward County Procurement Code, the Broward County Commission invites qualified
firms to submit Letters of Interest for consideration to provide services on the following project:
Standard Request for Letters of Interest
Construction General Contractor: Two-Step Process - (Step 1) Issue RLI to Short list firms -
(Step 2) Issue Invitation for Bids to Shortlisted firms to obtain bids
Establish Library of Firms for Services
Pursuant to the Broward County Procurement Code, the Broward County Commission invites qualified
firms to submit Letters of Interest for consideration to provide Construction Manager at Risk Services on
the following project.
Standard Construction Manager at Risk
Construction Manager at Risk (Modified): Two Step Process - (Step 1) Issue RLI to Short list
firms (Step 2) Issue Invitation for Bids to Shortlisted firms to obtain bids
Pursuant to Florida Statutes, Chapter 287.055 (Consultants’ Competitive Negotiation Act), the
Broward County Commission invites qualified firms to submit Letters of Interest for consideration to provide
Professional Consulting Services on the following project.
Non-Continuing Contract: (Check only one box)
Professional services needed for a construction project where the construction costs
exceed $ 325,000
Professional services needed for a planning or study activity where the fee for the
professional services exceed $ 35,000
Continuing Contract :( Check only one box)
Professional services needed for projects in which construction costs do not to exceed $2
million
Professional services needed for study activities when the fee for such professional
service does not exceed $ 200,000
Professional services needed for work of a specified nature
Rev. 6.4.12 Page 4 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
Design-Build: (Check only one box)
Qualification - Based with a Guaranteed Maximum Price and a Guaranteed Completion
Date
Two-Step process - (Step 1) Issue RLI to Short list firms - (Step 2) Issue Request for
Proposals or Invitation for Bid to Shortlisted firms to obtain proposals
Scope of Service
The Risk Management Division seeks a qualified Workers’ Compensation Medical Cost Containment and
Case Management Service company to provide professional medical cost containment/case management
services (hereinafter referred to as “MCMS”). The MCMS provider will have the primary responsibility in
assisting Broward County’s self-administered, self-insured workers’ compensation program (Broward
County’s Self Insured Workers’ Compensation Program may also include, but is not limited to: Broward
Sheriff’s Office; Property Appraisers Office; Performing Arts Center; Clerk of Courts, Supervisor of
Elections and other constitutional offices) in providing employees workers’ compensation medical cost
containment/case management services designed to control and reduce overall medical costs, at the same
time assuring that injured employees receive prompt, high quality and efficient medical care. BSO is
expected to leave the County’s Workers’ Compensation program on or about July 2, 2012.
The services to be provided include but are not limited to: 24/7/365 telephone intake of First Notice Injury
Reports (FNOI) with triage; transmission of bill information and First Notice of Injury to the County’s claims
system electronically; telephonic and field medical case management; vocational rehabilitation services
and return to work programs; other medical case management services such as: utilization review/peer
review, medical bill review and re-pricing; serve as the Medical Bill Electronic Data Interchange (EDI)
Submitter, on behalf of the County, for all paid medical and pharmacy bills to the State of Florida in
accordance with current and future requirements of Rule 69L-7.602; preferred provider networks (PPO) for
medical services (maintenance of a preferred provider list of physicians/doctors that are trained and
certified in Florida workers’ compensation to include cardiologists with experience treating claimants/injured
workers that fall under the Heart and Lung Presumption); prescription drugs/prescription RX program
(PBM); durable medical supplies, diagnostic testing; pre-certification, in-patient/out-patient hospital
services; state reporting, provide the County with electronic copies (PDF) of all scanned medical bills, notes
and Explanation of Benefits (EOB) forms.
The County is committed to providing all statutory workers’ compensation benefits provided by State Law;
however, the County also desires to control costs to the greatest possible extent, and continually seek new
techniques and practices to assist in this regard.
See Exhibit 6 for a summary of the County’s workers compensation Statistical activity. The County currently
monitors its workers’ compensation claims utilizing CS Stars claims management system.
Rev. 6.4.12 Page 5 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
Submittal Instructions
Unchecked boxes do not apply to this solicitation.
Only interested firms from the Sheltered Market may respond to this solicitation.
This solicitation is open to the general marketplace.
Interested firms may supply requested information in the “Evaluation Criteria” section by typing right into the
document using Microsoft Word. Firms may also prepare responses and any requested ancillary forms
using other means but following the same order as presented herein.
Submit ten (10) CDs, containing the following files:
CD or DVD discs included in the submittal must be finalized or closed so that no changes can be
made to the contents of the discs.
IT IS IMPORTANT THAT EACH CD BE LABELED WITH THE COMPANY NAME, RLI NUMBER
AND TITLE, AND THEN PLACED IN AN INDIVIDUAL DISC ENVELOPE.
1. A single PDF file that contains your entire response with each page of the response in the order as
presented in the RFP/RLI document, including any attachments.
2. Responses to the Evaluation Criteria questions are to be provided in the following formats:
a. Microsoft Word for any typed responses.
b. Microsoft Excel for any spreadsheets
Submit Seven (7) total printed copies (hard copies) of your response.
It is the responsibility of each firm to assure that the information submitted in both its written response and
CDs are consistent and accurate. If there is a discrepancy, the information provided in the written response
shall govern.
This is of particular importance in the implementation of the County's tiebreaker criteria. As set forth in
Section 21.31.d of the Procurement Code, the tiebreaker criteria shall be applied based upon the
information provided in the firm's response to the solicitation. Therefore, in order to receive credit for any
tiebreaker criterion, complete and accurate information must be contained in the written submittal.
Rev. 6.4.12 Page 6 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
Required Forms
This Request for Letter of Interest requires the following CHECKED forms to be returned:
(Please initial each Attachment being returned)
Documents submitted to satisfy responsiveness requirement(s) indicated with an (R) must be attached to the
RLI submittal and returned at the time of the opening deadline.
Verification of return
(Please Initial)
Attachment A Bidders Opportunity List Removed – Not Included
Attachment B Letter of Intent (CBE) Removed – Not Included
Attachment C Schedule of (CBE) Participation Removed – Not Included
Attachment D CBE Unavailability Report Removed – Not Included
Attachment E Vendor’s List
(Non-Certified Subcontractors and
Suppliers Information) Removed – Not Included
Attachment F Contractors Assurance Statement Removed – Not Included
Attachment G Domestic Partnership Certification _________________
Attachment H Lobbyist Registration – Certification _________________
Attachment I Employment Eligibility Verification
Program Contractor Certification Removed – Not Included
Attachment J Litigation History _________________
Attachment K Insurance Requirements _________________
Attachment L Cone of Silence Certification _________________
Attachment M Living Wage Ordinance Removed – Not Included
Attachment N Drug Free Workplace Policy Certification _________________
Attachment O Non-Collusion Statement Form _________________
Attachment P Scrutinized Companies List Certification _________________
Attachment Q Local Vendor Certification _________________
Attachment R Volume of Work Over Five Years _________________
Rev. 6.4.12 Page 7 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
Send all requested materials to:
Broward County Purchasing Division
115 South Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
RE: RLI Number: R0944901R2
The Purchasing Division must receive submittals no later than 5:00 pm on July 9, 2012. Purchasing will not
accept electronically transmitted, late, or misdirected submittals. If fewer than three interested firms
respond to this solicitation, the Director of Purchasing may extend the deadline for submittal by up to four
(4) weeks. Submittals will only be opened following the final submittal due date.
For Additional Project Information Contact:
Project Manager: Danielle French
Phone: 954-357-7219
Email: dfrench@broward.org
Selection Process
A Selection Committee (SC) will be responsible for recommending the most qualified firms and ranking
them for negotiation. The process for this procurement may proceed in the following manner:
Review Responses
The Purchasing Division delivers the submittals to agency staff for summarization for the Selection
Committee members. The Office of Economic and Small Business Development staff evaluates submittals
to determine compliance with the Office of Economic and Small Business Development Program
requirements, if applicable. Agency staff will prepare an analysis report which includes a matrix of
responses submitted by the firms. This may include a technical review, if applicable.
Staff will also identify any incomplete responses. The Director of Purchasing will review the information
provided in the matrix and will make a recommendation to the Selection Committee as to each firm’s
responsiveness to the requirements of the RLI. The final determination of responsiveness rests solely on
the decision of the Selection Committee.
Short Listing
The SC will meet to create a short list of the most qualified firms. The matrix and staff analysis report is a
tool that the SC may use in its decision-making process. The County will not consider oral or written
communications, prior to the conclusion of short-listing the firms, which may vary the terms of the
submittals.
Rev. 6.4.12 Page 8 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
Cone of Silence
At the time of the Selection Committee appointment (which is typically prior to the advertisement of the
solicitation document) in this RLI process, a Cone of Silence will be imposed. Section 1-266, Broward
County Code of Ordinances as revised, provides that after Selection Committee appointment, potential
vendors and their representatives are substantially restricted from communicating regarding this RLI with
the County Administrator, Deputy and Assistants to the County Administrator and their respective support
staff, or any person appointed to evaluate or recommend selection in this RLI process. For communication
with County Commissioners and Commission staff, the Cone of Silence allows communication until the
Shortlist Meeting of the Selection Committee. After the application of the Cone of Silence, inquiries
regarding this RLI should be directed to the Director of Purchasing or designee.
The Cone of Silence terminates when the County Commission or other awarding authority takes action
which ends the solicitation.
Demonstrations
If this box is checked, then this project will lend itself to an additional step where short-listed firms
demonstrate the nature of their offered solution. After the Short List Meeting, short-listed firms will be
notified of the desired demonstration. A copy of the demonstration (hard copy, DVD, CD or a combination
of both) should be given to the Purchasing Agent at the meeting to retain in the Purchasing files.
In lieu of an on-site demonstration, short-listed firms are asked to provide sample data files for the
various EDI Requirements as specified in Exhibits Nos. 1 thru 5 for testing and evaluation by
County staff approximately two weeks after short listing and prior to Presentation/Ranking. In
addition, short listed firms may be asked to answer another questionnaire with additional detailed
questions prior to the Presentations/Ranking meeting.
Pricing
Unchecked boxes do not apply to this solicitation.
Price may be considered in the final evaluation and ranking of the short-listed firms. If the SC will
consider price, staff will provide each short-listed firm with a pricing submittal instrument and
instructions for its preparation and delivery.
Price will not be a factor in evaluating or ranking the interested firms.
County staff and the top ranked firm will negotiate fees for pre-construction services during the
Negotiation Phase of this process. Generally, the Parties negotiate a Guaranteed Maximum Price
(GMP) for construction services during the course of pre-construction services.
Public Art and Design Program
Unchecked boxes do not apply to this solicitation.
Section 1-88, as amended, of the Broward County Code (of Ordinances) contains the requirements
for the Broward County’s Public Art and Design Program.
Rev. 6.4.12 Page 9 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
It is the intent of Broward County to functionally integrate art, when applicable, into capital projects
and integrate artists’ design concepts into this improvement project. The bidder may be required to
collaborate with the artist(s) on design development within the scope of this request. Artist(s) shall
be selected by Broward County through an independent process. (For additional information
contact Mary Becht at (954) 357-7456).
Presentations/Interviews/Ranking
Each of the short-listed firms will have an opportunity to make an oral presentation to the SC on the firm’s
approach to this project and the firm’s ability to perform. The SC may provide a list of subject matter for the
discussion. The firms will have equal time to present but the question-and-answer time may vary. A copy
of the presentation (hard copy, DVD, CD or a combination of both) should be given to the Purchasing Agent
at the meeting to retain in the Purchasing files. The SC will rank the firms and post its recommendation for
three days as a “Proposed Recommendation of Ranking”. Following this three-day period, if no objections
to the proposed ranking have been received in writing by the Director of Purchasing, a Final
Recommendation of Ranking will be posted and presented to the Board for approval. At the discretion of
the Board, presentations to the Board of County Commissioners by the ranked firms may be required.
Negotiation and Award
The Purchasing Negotiator, assisted by County staff, will attempt to negotiate a contract with the first
ranked firm. If an impasse occurs, the County ceases negotiation with the firm and begins negotiations
with the next-ranked firm. The final negotiated contract will be forwarded by the Purchasing Negotiator to
the Selection Committee for approval, if required by the committee, or to the awarding authority for
approval.
Posting of Solicitation and Proposed Contract Awards
The Broward County Purchasing Division's website is the official location for the County's posting of all
solicitations and contract award results. It is the obligation of each vendor to monitor the website in order to
obtain complete and timely information. The website is located at
http://www.broward.org/Purchasing/Pages/SolicitationResult.aspx
Vendor Protest
Sections 21.118 and 21.119 of the Broward County Procurement Code set forth procedural requirements
that apply if a vendor intends to protest a solicitation or proposed award of a contract and state in part the
following:
(a) Any protest concerning the bid or other solicitation specifications or requirements must be made and
received by the County within seven (7) business days from the posting of the solicitation or addendum on
the Purchasing Division’s website. Such protest must be made in writing to the Director of Purchasing.
Failure to timely protest bid specifications or requirements is a waiver of the ability to protest the
specifications or requirements.
Rev. 6.4.12 Page 10 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
(b) Any protest concerning a solicitation or proposed award above the award authority of the Director of
Purchasing, after the bid opening, shall be submitted in writing and received by the County within five (5)
business days from the posting of the recommendation of award on the Purchasing Division's website.
(c) Any actual or prospective bidder or offeror who has a substantial interest in and is aggrieved in
connection with the proposed award of a contract which does not exceed the amount of the award
authority of the Director of Purchasing, may protest to the Director of Purchasing. The protest shall be
submitted in writing and received within three (3) business days from the posting of the recommendation
of award on the Purchasing Division's website.
(d) For purposes of this section, a business day is defined as Monday through Friday between 8:30 a.m.
and 5:00 p.m. Failure to timely file a protest within the time prescribed for a solicitation or proposed
contract award shall be a waiver of the vendor's right to protest.
(e) Protests arising from the decisions and votes of a Selection Committee or Evaluation Committee
shall be limited to protests based upon the alleged deviations from established Committee procedures
set forth in the Broward County Procurement Code and existing written Guidelines. Any allegations of
misconduct or misrepresentation on the part of a competing vendor shall not be considered a protest.
(f) As a condition of initiating any RLI protest, the protestor shall present the Director of Purchasing a
nonrefundable filing fee in accordance with the table below.
Estimated Contract Amount Filing Fee
$30,000 - $250,000 $ 500
$250,001 - $500,000 $1,000
$500,001 - $5 million $3,000
Over $5 million $5,000
If no contract bid amount was submitted, the estimated contract amount shall be the County’s estimated
contract price for the project. The County may accept cash, money order, certified check, or cashier’s
check, payable to Broward County Board of Commissioners.
Rejection of Responses
The Selection Committee may recommend to reject all proposals in the best interests of the County. The
rejection shall be made by the Director of Purchasing except when a solicitation was approved by the
Board, in which case the rejection shall be made by the Board.
Public Records and Exemptions
Upon receipt, all response submittals become "public records" and shall be subject to public
disclosure consistent with Chapter 119, Florida Statutes.
Any firm that intends to assert any materials to be exempted from public disclosure under Chapter
119, Florida Statutes must submit the document(s) in a separate bound document labeled "Name of
Firm, Attachment to Proposal Package, RLI# - Confidential Matter".
Rev. 6.4.12 Page 11 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
The firm must identify the specific statute that authorizes the exemption from the Public Records
Law. CD or DVD discs included in the submittal must also comply with this requirement and
separate any materials claimed to be confidential.
Failure to provide this information at the time of submittal and in the manner required above may
result in a recommendation by the Director of Purchasing that the response is non-responsive.
Furthermore, proposer’s failure to provide the information as instructed may lead for the
information to become public.
Any claim of confidentiality on materials that the firm asserts to be exempt and placed elsewhere in the
submittal will be considered waived by the firm upon submission, effective after opening. Please note that
the financial statement exemption provided for in Section 119.071(1) c, Florida Statutes only applies to
submittals in response to a solicitation for a "public works" project.
Please be aware that submitting confidential material may impact full discussion of your submittal
by the Selection/Evaluation Committee because the Selection/Evaluation Committee will be unable
to talk about the details of the confidential material(s) at the public Selection/Evaluation Committee
meeting. Please note that the financial statement exemption provided for in Section 119.071(1) c,
Florida Statutes only applies to submittals in response to a solicitation for a "public works" project.
Copyrighted Materials
Copyrighted material will be accepted as part of a submittal only if accompanied by a waiver that will allow
the County to make paper and electronic copies necessary for the use of County staff and agents. It is
noted that copyrighted material is not exempt from the Public Records Law, Chapter 119, Florida Statutes.
Therefore, such material will be subject to viewing by the public, but copies of the material will not be
provided to the public.
Right of Appeal
Pursuant to Section 21.83 of the Broward County Procurement Code, any vendor that has a substantial
interest in the matter and is dissatisfied or aggrieved in connection with the Selection Committee's
determination of responsiveness may appeal the determination pursuant to Section 21.120 of the Code.
The appeal must be in writing and sent to the Director of Purchasing within ten (10) calendar days of the
determination by the Selection Committee to be deemed timely.
As required by Section 21.120, the appeal must be accompanied by an appeal bond by a person having
standing to protest and must comply with all other requirements of this section. The institution and filing of
an appeal is an administrative remedy to be employed prior to the institution and filing of any civil action
against the County concerning the subject matter of the appeal.
Projected Schedule
Open Date: July 9, 2012
Short list Date: August 13, 2012
Presentations: August 29, 2012
First Negotiation Meeting: September 10, 2012
Rev. 6.4.12 Page 12 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
Second Negotiation Meeting, if needed: September 17, 2012
If three (3) or fewer responses are received, a combination Short List and Presentation/Ranking meeting
may be held on August 29, 2012.
http://www.broward.org/Commission/Pages/SunshineMeetings.aspx
Please check the above website for any changes to the above tentative schedule.
Balance of Page Left Blank Intentionally
Rev. 6.4.12 Page 13 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
Responsiveness Criteria
Definition of a Responsive Bidder:
In accordance with Broward County Procurement Code Section 21.8.b.66, a Responsive
Bidder means a person who has submitted a bid which conforms in all material respects to a
solicitation. A bid or proposal of a Responsive Bidder must be submitted on the required
forms, which contain all required information, signatures, notarizations, insurance, bonding,
security, or other mandated requirements required by the bid documents to be submitted at
the time of bid opening.
Failure to provide the information required below, at the time of submittal opening may result in a
recommendation of non-responsive by the Director of Purchasing. The Selection Committee will
determine whether the firm is responsive to the requirements specified herein. The County reserves
the right to waive minor technicalities or irregularities as is in the best interest of the County in
accordance with Section 21.30.f.1(c) of the Broward County Procurement Code.
***NOTICE TO PROPOSERS***
Proposers are invited to pay strict attention to the following requirements of this RLI. The
information being requested in this section is going to be used by the Selection Committee
during the selection/evaluation process and further consideration for contract award. Please
be aware that proposers have a continuing obligation to provide the County with any material
changes to the information being requested in this RLI.
1. Office of Economic and Small Business Development Program
(See Office of Economic and Small Business Development Program requirements below).
Office of Economic and Small Business Development Program Requirements
The Broward County Business Opportunity Act of 2004 and the County Business Enterprise (CBE) Act of
2009 establish the County’s policies for participation by small business enterprises, county business
enterprises, and federal disadvantaged business enterprises in all County contracts and in other selected
activities.
In accordance with the Acts, participation for this contract is as follows:
There is No County Business Enterprise (CBE) participation goal for this project.
The County uses the interested firm’s submittal to this section of the RLI to determine the
firm’s “responsiveness.” The County only considers “responsive” submittals for short-listing.
To be considered responsive requires the following actions.
Rev. 6.4.12 Page 14 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
2. Domestic Partnership Act
The Broward County Domestic Partnership Act (Section 16-1/2 – 157 of the Broward County
Code of Ordinances, as amended) requires that, for projects where the initial contract term is
more than $100,000, that at the time of RLI submittal, the vendor shall certify that the vendor
currently complies or will comply with the requirements of the Domestic Partnership Act by
providing benefits to Domestic Partners of its employees on the same basis as it provides
benefits to employee’s spouses.
The Domestic Partnership Certification Form (Attachment G) should be completed, for all
submittals over $100,000, and returned with the RLI Submittal Response at the time of the
opening deadline, but no later than five (5) business days from request of the Purchasing
agent. Failure to meet this requirement shall render your submittal non-responsive.
3. Joint Venture Enterprises
Unchecked boxes do not apply to this solicitation.
Construction Licensing
A Joint Venture is required to provide evidence with its response that the Joint Venture, or at
least one of the Joint Venture partners, holds the specified Construction License issued either
by the State of Florida or Broward County. If not with its response, the Joint Venture is
required to provide evidence prior to contract execution that the Joint Venture holds the
specified Construction License issued either by the State of Florida or Broward County. A Joint
Venture is also required to provide with its response a Statement of Authority indicating that
the individual submitting the Joint Venture’s proposal has the legal authority to bind the Joint
Venture. Failure to provide any of this information to the County at the required time may be
cause for the response to the solicitation to be deemed non-responsive.
Florida Registration
A Joint Venture is required to provide evidence with its response that the Joint Venture, or at
least one of the Joint Venture partners, holds a Certificate of Authority from the Florida
Department of State, Division of Corporations to transact business in Florida. If not with its
response, the Joint Venture is required to provide evidence prior to contract execution that the
Joint Venture exists by providing the County with a copy of the Joint Venture Agreement.
Failure to provide any of this information to the County at the required time may be cause for
the response to the solicitation to be deemed non-responsive.
4. Lobbyist Registration – Certification
A vendor who has retained a lobbyist(s) to lobby in connection with a competitive solicitation
shall be deemed non-responsive unless the firm, in responding to the competitive solicitation,
certifies, see Attachment H, that each lobbyist retained has timely filed the registration or
amended registration required under Section 1-262, Broward County Code of Ordinances. If,
after awarding a contract in connection with the solicitation, the County learns that the
certification was erroneous, and upon investigation determines that the error was willful or
intentional on the part of the vendor, the County may, on the basis, exercise any contractual
right to terminate the contract for convenience.
Rev. 6.4.12 Page 15 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
The Lobbyist Registration Certification Form (Attachment H) should be completed and
returned at the time of the RLI opening deadline and included within the submittal document.
If not included with the RLI submittal at the time of the RLI opening deadline, the Lobbyist
Certification Form must be completed and returned prior to contract award at a date and time
certain established by the County.
Responsibility Criteria
Definition of Responsible Bidder
In accordance with Broward County Procurement Code Section 21.8.b.65, a Responsible Bidder or
Offeror means an offeror who has the capability in all respects to perform the contract requirements,
and the integrity and reliability which will assure good faith performance.
The Selection Committee will recommend to the awarding authority a determination of a firm’s
responsibility. At any time prior to award, the awarding authority may find that an offeror is not
responsible to receive a particular award. The following criteria shall be evaluated in making a
determination of responsibility:
1. Financial Information
Although the review of a vendor's financial information is an issue of responsibility, the
failure to either provide the financial documentation or correctly assert a confidentiality
claim pursuant the Florida Public Records Law and the solicitation requirements as stated
in the Evaluation Criteria and Public Record and Exemptions sections may result in a
recommendation of non-responsive by the Director of Purchasing.
2. Litigation History
Although the review of a vendor's litigation history is an issue of responsibility, the failure to
provide litigation history as required in the Evaluation Criteria may result in a
recommendation of non-responsive by the Director of Purchasing.
3. Electronic Data Interchange Submitter
Vendor should provide with the RLI Submittal documentation from the Florida Department
of Financial Services showing status as a State approved EDI Submitter for all paid
medical and pharmacy bills to the State of Florida in accordance with current and future
requirements of Rule 69L-7.602, Florida Workers’ Compensation Medical Services Billing,
Filing, and Report Rule and the State’s Medical EDI Implementation Guide (MEIG).
Rev. 6.4.12 Page 16 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
Additionally, the awarding authority may consider the following factors, without limitation: debarment
or removal from the authorized vendors list or a final decree, declaration or order by a court or
administrative hearing officer or tribunal of competent jurisdiction that the offeror has breached or
failed to perform a contract, claims history of the offeror, performance history on a County contract(s),
an unresolved concern, or any other cause under this code and Florida law for evaluating the
responsibility of an offeror.
Employment Verification Program (E-Verify)
Unchecked boxes do not apply to this solicitation.
This service is funded by the State of Florida. Therefore, you are required to complete
and return the “Employment Eligibility Verification Program Contractor Certification” –
(Attachment I).
Evaluation Criteria
With regard to the Evaluation criteria, each firm has a continuing obligation to provide the
County with any material changes to the information requested. The County reserves the right
to obtain additional information from interested firms.
Evaluation Criteria – Provide answers below. If you are
submitting a response as a joint
venture, you must respond to each
Project-Specific Criteria question for each entity forming the
joint venture. When an entire response
cannot be entered, a summary,
followed with a page number reference
where a complete response can be
found is acceptable.
1. Does your firm have the capability to
electronically transmit to the County CS Yes ☐ ☐ No
STARS system the First Notice of Injury (If yes, provide reference contact name
(FNOI) information in the data file format and phone numbers for other clients that
defined in Exhibit 1? your firm provided electronic FNOI Files
to.)
2. Does your firm have the capability to
electronically transmit to the County CS Yes ☐ ☐ No
STARS system all processed and audited (If yes, provide reference contact name
medical and pharmacy bills in the data file and phone numbers for other clients that
format defined in Exhibit 3? your firm provided electronic medical and
pharmacy bill files to.)
3. Does your firm provide online access to case
management activity, medical review/audit Yes ☐ ☐ No
services, and bill authorization? (If yes, provide Brief overview)
Rev. 6.4.12 Page 17 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
4. Provide at least 5 years of experience as a
workers’ compensation medical cost
containment and case management provider
in Florida, providing all of the services as
described in the “scope of services” for
governmental entities or other self-insured
employers.
5. How many accounts does your firm currently
provide cost containment and case
management services for based on the
following average number of employees?
__________ Up to 999
__________ 1,000 to 4,999
__________ 5,000 to 9,999
__________ 10,000 or more
6. Provide a list of the 3 largest governmental
entities or self-insured employers (based on
number of employees) for which your firm has
provided services in the last five years.
Please specify what services were
provided along with the length of
time and any other applicable
information.
Provide references for the above,
name, phone number, location and
e mail address.
7. Identify the Service Team which will be
assigned to the County’s account.
Identify the Service Team Leader,
primary servicing office; and
provide number of years in
business. Include names, titles,
related workers’ compensation
experience and professional
designations of all assigned team
members.
Service team members should only
include employees of the proposing
firm. (Include Resumes)
8. Provide specific and brief descriptions of your
firm’s program/process as it relates to First
Report Of Injury Intake/Triage services
Is the intake center operational
24/7/365?
Is a toll free number available for
Rev. 6.4.12 Page 18 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
telephonic FNOI intake?
9. Provide specific and brief descriptions of your
firm’s program/process as it relates to
Telephonic Case Management and Field
Case Management Services
Include the process for handling
Heart and Lung claims
10. Provide specific and brief descriptions of
your firm’s program/process as it relates to
Preferred Provider Network services.
Including the geographic coverage
Include the number of physicians
for the following specialties:
___ Cardiologists ___ Electro-physiologists
___ Psychiatrists ___ Neuropsychologists
___ Pulmonologists ___ Infectious disease
___ Ear/Nose/Throat ___ Gastroenterologists
___ Plastic Surgeons ___ Rheumatologists
___ Endocrinologists
11. Provide specific and brief descriptions of
your firm’s program/process as it relates to
Medical Bill review/audit services.
Does your firm have the capacity and
capability to receive all the County’s
medical bills directly at your firm’s
designated work location?
Include a list of your 3 largest accounts
served by your firm’s office, with
corresponding average monthly bill
volume.
Include capability of your firm
processing and re-pricing systems’
ability to create and maintain two
separate business sections or units.
Include the capability to re-price in
accordance with State of Florida fee
schedule, and any available PPO
discounts.
For medical bills which have been
untimely filed with the state, is your firm
willing to reimburse the County for
assessed late fees?
Handling of send-backs.
Rev. 6.4.12 Page 19 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
12. Provide specific and brief descriptions of
your firm’s program/process as it relates to
Utilization/Peer review services
Include how Utilization Review
decisions are defended
13. Provide specific and brief descriptions of
your firm’s program/process as it relates to
Pharmacy Benefit management services
Include how your firm’s system
manages the following:
Early Refill
Potential adverse reactions
Duplicate prescriptions
Drugs not commonly associated
with workers’ compensation
injuries
Over utilization
Lack of medical necessity
Chronic pain
Include possible solutions enacted by
Florida clients addressing physicians
dispensing drugs directly to injured
workers.
14. Provide specific and brief descriptions of
your firm’s program/process as it relates to
Vocational Rehabilitation / Return to Work
services.
15. Provide information if your firm contracts
with a 3rd party vendor in regards to any
duties as outlined in the “scope of
services”. Identify with specificity:
The vendor(s)
Length of business relationship
Type of business relationship
Specific service duties
16. Does your firm have written procedures to
assume or continue operations in the event
of a hurricane, other natural disaster, or
other emergency to ensure continued
uninterrupted medical cost containment
and case management services? If so,
provide a copy of those procedures.
Rev. 6.4.12 Page 20 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
17. Would your company be able to
accommodate Broward County Workers’
Compensation Staff at your facility in the
event that the Governmental Center office
building is not operational during any given
emergency?
18. What are the methods and procedures by
which your firm stays abreast of new
medical cost containment / case
management strategies?
19. Provide three (3) specific examples where
you have achieved significant savings for
your client(s).
20. What is the single most important reason
the County should consider awarding this
contract to your firm?
21. Should the County implement a new
claims management system(s), does your
organization commit to remaining
compatible to the County’s claims
administration system at no additional cost
to the County?
22. Does your firm have the ability to receive
an electronic “new claim” file from the
County in the file format defined in Exhibit
2 to update your firm’s system(s) with the
County’s assigned claim number and
County adjuster’s name?
23. Does your firm have the ability to receive
an electronic data file from the County’s
CS STARS system that will contain the
County’s “date paid” on all medical bills in
the file format defined in Exhibit 4 to
update your firm’s system(s) in order to
meet the State’s medical bill EDI
requirements (which include the date paid
on all medical bill EDI submissions)?
24. Does your firm have the ability to meet all
of the additional EDI requirements detailed
in Exhibit 4? Indicate any of these
requirements that your firm cannot meet.
25. Does or will your firm provide a secured
FTP site for the transfer of the various EDI
files back and forth between your
system(s) and the County’s claims
administration system?
Rev. 6.4.12 Page 21 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
Evaluation Criteria – Provide answers below. If you are
submitting a response as a joint
venture, you must respond to each
Company Profile
question for each entity forming the
joint venture. When an entire response
cannot be entered, a summary,
followed with a page number reference
where a complete response can be
found is acceptable.
1. Supply legal firm name, headquarters address,
local office addresses, state of incorporation,
and key firm contact names with their phone
numbers and e-mail addresses.
2. Supply the interested firm’s federal ID number
and Dun and Bradstreet number.
3. Is the interested firm legally authorized,
pursuant to the requirements of the Florida
YES NO
Statutes, to do business in the State of
Florida?
4. All firms are required to provide Broward
County the firm's financial statements at the
time of submittal in order to demonstrate the
firm's financial capabilities. Failure to provide
this information at the time of submittal may
result in a recommendation by the Director of
Purchasing that the response is non-
responsive. Each firm shall submit its most
recent two (2) years of financial statements for
review. The financial statements are not
required to be audited financial statements.
With respect to the number of years of
financial statements required by this RLI, the
firm must fully disclose the information for all
years available; provided, however, that if the
firm has been in business for less than the
required number of years, then the firm must
disclose for all years of the required period that
the firm has been in business, including any
partial year-to-date financial statements. The
County may consider the unavailability of the
most recent year’s financial statements and
whether the firm acted in good faith in
disclosing the financial documents in its
evaluation.
Rev. 6.4.12 Page 22 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
Any claim of confidentiality on financial
statements should be asserted at the time of
submittal. (see below)
*****ONLY “IF” claiming Confidentiality*****
The financial statements should be submitted
in a separate bound document labeled "Name
of Firm, Attachment to Proposal Package, RLI#
- Confidential Matter". The firm must identify
the specific statute that authorizes the
exemption from the Public Records Law. CD or
DVD discs included in the submittal must also
comply with this requirement and separate any
materials claimed to be confidential.
Failure to provide this information at the time
of submittal and in the manner required above
may result in a recommendation by the
Director of Purchasing that the response is
non-responsive. Furthermore, proposer’s
failure to provide the information as instructed
may lead to the information becoming public.
Please note that the financial statement
exemption provided for in Section 119.071(1)
c, Florida Statutes only applies to submittals
in response to a solicitation for a "public
works" project.
5. Litigation History Requirement:
The County will consider a vendor's litigation
history information in its review and
determination of responsibility. All vendors are
required to disclose to the County all "material"
cases filed, pending, or resolved during the
last three (3) years prior to the solicitation
response due date, whether such cases were
brought by or against the vendor, any parent
or subsidiary of the vendor, or any
predecessor organization. If the vendor is a
joint venture, the information provided should
encompass the joint venture (if it is not newly-
formed for purposes of responding to the
solicitation) and each of the entities forming
the joint venture.
Rev. 6.4.12 Page 23 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
For purpose of this disclosure requirement, a
“case” includes lawsuits, administrative
hearings and arbitrations. A case is considered
to be "material" if it relates, in whole or in part,
to any of the following:
1. A similar type of work that the vendor is
seeking to perform for the County under the
current solicitation;
2. An allegation of negligence, error or
omissions, or malpractice against the vendor
or any of its principals or agents who would be
performing work under the current solicitation;
3. A vendor's default, termination, suspension,
failure to perform, or improper performance in
connection with any contract;
4. The financial condition of the vendor,
including any bankruptcy petition (voluntary
and involuntary) or receivership; or
5. A criminal proceeding or hearing concerning
business-related offenses in which the vendor
or its principals (including officers) were/are
defendants.
Notwithstanding the descriptions listed in
paragraphs 1 – 5 above, a case is not
considered to be "material" if the claims raised
in the case involve only garnishment, auto
negligence, personal injury, workers'
compensation, foreclosure or a proof of claim
filed by the vendor.
For each material case, the vendor is required
to provide all information identified, on the
“Litigation History” form. (Attachment J)
Failure to disclose any material case, or to
provide all requested information in
connection with each such case, may result
in the vendor being deemed non-
responsive. Prior to making such
determination, the vendor will have the
ability to clarify the submittal and to explain
why an undisclosed case is not material.
Rev. 6.4.12 Page 24 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
6. Has the interested firm, its principals, officers,
or predecessor organization(s) been debarred
YES NO
or suspended from bidding by any government
during the last three (3) years? If yes, provide
details.
7. Has your company ever failed to complete any YES NO
work awarded to you? If so, where and why?
8. Has your company ever been terminated from YES NO
a contract? If so, where and why?
9. Insurance Requirements: Refer to the
sample Certificate of Insurance
Attachment K. It reflects the insurance
requirements deemed necessary for this
project. It is not necessary to have this level of
insurance in effect at the time of submittal but
it is necessary to submit certificates indicating
that the firm currently carries the insurance or
to submit a letter from the carrier indicating
upgrade availability.
Evaluation Criteria – Provide answers below. If you are
submitting a response as a joint
Legal Requirements venture, you must respond to each
question for each entity forming the
joint venture. When an entire response
cannot be entered, a summary,
followed with a page number reference
where a complete response can be
found is acceptable.
1. Standard Agreement Language:
Identify any standard terms and conditions
YES (Agree)
with which the interested firm cannot agree.
The standard terms and conditions for the NO
resulting contract can be located at: If no, you need to specifically identify
http://www.broward.org/Purchasing/Document the terms and conditions with which
s/caf101.pdf you are taking exception since they
will be discussed with the Selection
If you do not have computer access to the
Committee. Please be aware that
internet, call the Project Manager for this RLI
taking exceptions to the County’s
to arrange for mailing, pick up, or facsimile
standard terms and conditions may be
transmission.
viewed unfavorably by the Selection
Committee and ultimately impact the
overall evaluation of your submittal.
Rev. 6.4.12 Page 25 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
2. Cone of Silence: This County’s ordinance
prohibits certain communications among
vendors, county staff, and selection committee
members. Identify any violations of this
ordinance by any members of the responding
firm or its joint venturers. The firm(s)
submitting is expected to sign and notarize the
Cone of Silence Certification (Attachment L).
3. Public Entity Crimes Statement: A person
or affiliate who has been placed on the
convicted vendor list following a conviction for
a public entity crime may not submit an offer to
perform work as a consultant or contract with
a public entity, and may not transact business
with Broward County for a period of 36 months
from the date of being placed on the convicted
vendor list. Submit a statement fully
describing any violations of this statute by
members of the interested firm or its joint
venturers.
4. No Contingency Fees: By responding to this
solicitation, each firm warrants that it has not
and will not pay a contingency fee to any
company or person, other than a bona fide
employee working solely for the firm, to secure
an agreement pursuant to this solicitation. For
Breach or violation of this provision, County
shall have the right to reject the firm’s
response or terminate any agreement
awarded without liability at its discretion, or to
deduct from the agreement price or otherwise
recover the full amount of such fee,
commission, percentage, gift, or consideration.
Submit an attesting statement warranting that
the Responder has not and will not pay a
contingency fee to any company or person,
other than a bona fide employee working
solely for the firm, to secure an agreement
pursuant to this solicitation.
5. If this box is checked, then the provisions
of the Broward County Living Wage Ordinance
2008-45, as amended, (“Living Wage
Ordinance”) will apply to this agreement.
Rev. 6.4.12 Page 26 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
6. DRUG FREE WORKPLACE:
1. Do you have a drug free workplace policy?
1. YES NO
2. If so, please provide a copy of your drug
free workplace policy in your proposal.
3. Does your drug free workplace policy 3. YES NO
comply with Section 287.087 of the Florida
Statutes?
4. If your drug free workplace policy complies 4. YES NO
with Section 287.087 of the Florida Statutes,
please complete the Drug Free Workplace
Policy Certification Form. Attachment N
5. If your drug free workplace policy does not
comply with Section 287.087 of the Florida 5. YES NO
Statutes, does it comply with the drug free
workplace requirements pursuant to Section
21.31.a.2 of the Broward County Procurement
Code?
6. If so, please complete the attached Drug
Free Workplace Policy Certification Form.
7. If your drug free workplace policy does not 7. YES NO
comply with Section 21.31.a.2 of the Broward
County Procurement Code, are you willing to
comply with the requirements Section
21.31.a.2 of the Broward County Procurement
Code?
8. If so, please complete the attached Drug
Free Workplace Policy Certification Form.
(Attachment N)
Failure to provide a notarized Certification
Form in your proposal indicating your
compliance or willingness to comply with
Broward County's Drug Free Workplace
requirements as stated in Section 21.31.a.2
of the Broward County Procurement Code
may result in your firm being ineligible to
be awarded a contract pursuant to Broward
County's Drug Free Workplace Ordinance
and Procurement Code
7. Non-Collusion Statement: By responding to
this solicitation, the vendor certifies that this
offer is made independently and free from
collusion. Vendor shall disclose on the “Non-
Collusion Statement Form” (Attachment O)
to their best knowledge, any Broward County
officer or employee, or any relative of any
such officer or employee as defined in Section
112.3135(1) (c), Florida Statutes (1989),
Rev. 6.4.12 Page 27 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
who is an officer or director of, or had a
material interest in, the vendor’s business,
who is in a position to influence this
procurement. Any Broward County officer or
employee who has any input into the writing of
specifications or requirements, solicitation of
offers, decision to award, evaluation of offers,
or any other activity pertinent to this
procurement is presumed, for purposes
hereof, a person has a material interest if they
directly or indirectly own more than 5 percent
of the total assets or capital stock of any
business entity, or if they otherwise stand to
personally gain if the contract is awarded to
this vendor. Failure of a vendor to disclose
any relationship described herein shall be
reason for debarment in accordance with the
provisions of the Broward County
Procurement Code.
8. Scrutinized Companies List Certification:
Any company, principals, or owners on the
Scrutinized Companies with Activities in
Sudan List or on the Scrutinized Companies
with Activities in the Iran Petroleum Energy
Sector List is prohibited from submitting a bid,
proposal or response to a Broward County
solicitation for goods or services in an amount
equal to or greater than $1 million. Therefore,
if applicable, each company submitting a bid,
proposal or response to a solicitation must
certify to the County that it is not on either list
at the time of submitting a bid, proposal or
response. The certification form is referenced
as “Scrutinized Companies List Certification”
(Attachment P) and should be completed
and submitted with your proposal but must be
completed and submitted prior to award.
Evaluation Criteria – Provide answers below. If you are
submitting a response as a joint
Tiebreaker Criteria venture, you must respond to each
question for each entity forming the
joint venture. Furthermore, to receive
credit for a tiebreaker criterion, each
Rev. 6.4.12 Page 28 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
entity forming the joint venture must
meet the tiebreaker criteria. When an
entire response cannot be entered, a
summary, followed with a page number
reference where a complete response
can be found is acceptable.
LOCATION in BROWARD COUNTY
1. YES NO
1. Is your firm located in Broward County?
2. Does your firm have a valid current Broward 2. YES NO
County Local Business Tax Receipt? 3. YES NO
3. Has your firm (a) been in existence for at least
six (6) months prior to the proposal opening (b)
providing services on a day to day basis (c) at a
business address physically located within the
limits of Broward County (d) in an area zoned for
such business and (e) the services provided from
this location are substantial component of the
services offered in the firm's proposal?
If so, please provide the interested firm's business
address in Broward County, telephone number(s),
email address, evidence of the Broward County
Local Business Tax Receipt and complete the
Local Vendor Certification Form (Attachment Q)
Failure to provide a valid Broward County
Local Business Tax Receipt and the attached
notarized Certification Form in your proposal
shall prevent your firm from receiving credit
under Broward County's tiebreaker criteria of
Section 21.31.d of the Broward County
Procurement Code and, if applicable, shall
prevent your firm from receiving any
preference(s) allowed under Broward County's
Local Preference Ordinance.
Domestic Partnership Act -
The requirements of the Broward County
Domestic Partnership Act (Section 16-1/2 – 157 of
the Broward County Code of Ordinances, as
amended) do not apply to solicitations resulting in
a contract for goods or services valued at
$100,000 or less.
Rev. 6.4.12 Page 29 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
However, firms providing domestic partnership
benefits may receive credit in a tie breaker
circumstance pursuant to Section 21.31.d of the
Broward County Procurement Code. Therefore,
please note the following:
The attached Domestic Partnership Certification
Form (Attachment G) must be completed and
returned with the RLI Submittal Response at the
1. YES NO
time of the opening deadline.
1. Do you have a domestic partnership benefit
program?
2. If so, please provide a copy of your domestic
partnership benefit program in your proposal and
complete Attachment G “Domestic Partnership
Benefit Certification Form.” 3. YES NO
3. Does your domestic partnership benefit
program provide benefits which are the same or
substantially equivalent to those benefits offered
to other employees in compliance with the
Broward County Domestic Partnership Act of
2011, Broward County Ordinance # 2011-26, as
amended?
VOLUME OF WORK OVER FIVE YEARS
$
Vendor that has the lowest dollar volume of work
previously awarded by the County over a five (5)
year period from the date of the submittal will
receive the tie break preference. The work shall
include any amount awarded to any parent or
subsidiary of the vendor, any predecessor
organization and any company acquired by the
vendor over the past five (5) years. If the vendor is
a joint venture, the information provided should
encompass the joint venture and each of the
entities forming the joint venture.
If applicable complete Attachment R.
(Report only amounts awarded as Prime Vendor)
To be considered for the Tie Break preference,
this completed Attachment R must be included
with the RLI Submittal Response at the time of the
opening deadline.
Rev. 6.4.12 Page 30 of 71
Broward County Purchasing Division
115 S. Andrews Avenue, Room 212
Fort Lauderdale, FL 33301
(954) 357-6065 FAX (954) 357-8535
Required Forms to be Returned
Balance of Page Left Blank Intentionally
Rev. 6.4.12 Page 31 of 71
Attachment “G” - Domestic Partnership Certification
(RESPONSIVE CRITERIA FORM)
The Vendor, by virtue of the signature below, certifies that it is aware of the requirements of Broward County’s Domestic
Partnership Act, (Section 16-1/2 -157 of the Broward County Code of Ordinances, as amended); and certifies the following:
(Please check only one below).
1. The Vendor currently complies with the requirements of the County’s Domestic Partnership Act and provides benefits
to Domestic Partners of its employees on the same basis as it provides benefits to employees’ spouses
2. The Vendor will comply with the requirements of the County’s Domestic Partnership Act at time of contract award and
provide benefits to Domestic Partners of its employees on the same basis as it provides benefits to employees’ spouses
3. The Vendor will not comply with the requirements of the County’s Domestic Partnership Act at time of award
4. The Vendor does not need to comply with the requirements of the County’s Domestic Partnership Act at time of
award because the following exemption(s) applies: (Please check only one below).
The Vendor’s price bid for the initial contract term is $100,000 or less.
The Vendor employs less than five (5) employees.
The Vendor is a governmental entity, not-for-profit corporation, or charitable organization.
The Vendor is a religious organization, association, society, or non-profit charitable or educational institution.
The Vendor does not provide benefits to employees’ spouses.
The Vendor provides an employee the cash equivalent of benefits. (Attach an affidavit in compliance with the
Act stating the efforts taken to provide such benefits and the amount of the cash equivalent.)
The Vendor cannot comply with the provisions of the Domestic Partnership Act because it would violate the
laws, rules or regulations of federal or state law or would violate or be inconsistent with the terms or conditions of a
grant or contract with the United States or State of Florida. Indicate the law, statute or regulation. (State the law,
statute or regulation and attach explanation of its applicability.)
I, ____________________________, _______________________________ of __________________________________________
(Name) (Title) (Vendor)
hereby attests that I have the authority to sign this notarized certification and certify that the above-referenced information
is true, complete and correct.
__________________________________
Signature
__________________________________
Print Name
SWORN TO AND SUBSCRIBED BEFORE ME this ________day of ____________________, 20___
STATE OF ______________________ COUNTY OF ___________________
_________________________________ My commission expires: _________________________ (SEAL)
Notary Public
(Print, type or stamp commissioned name of Notary Public)
Personally Known ________ or Produced Identification _________ Type of Identification Produced: ______________
Rev. 6.4.12 Page 32 of 71
Attachment “H” - Lobbyist Registration – Certification
(RESPONSIVE CRITERIA FORM)
This certification form should be completed and submitted with your proposal. If not included with the RLI
submittal at the time of the RLI opening deadline, the Lobbyist Certification Form must be completed and
returned by a date and time certain established by the County.
The Vendor, by virtue of the signature below, certifies that:
a. It understands if it has retained a lobbyist(s) to lobby in connection with a competitive solicitation, it shall
be deemed non-responsive unless the firm, in responding to the competitive solicitation, certifies that
each lobbyist retained has timely filed the registration or amended registration required under Section 1-
262, Broward County Code of Ordinances; and
b. It understands that if, after awarding a contract in connection with the solicitation, the County learns that
the certification was erroneous, and upon investigation determines that the error was willful or intentional
on the part of the vendor, the County may, on that basis, exercise any contractual right to terminate the
contract for convenience.
Based upon these understandings, the vendor further certifies that: (Check One)
1.______It has not retained a lobbyist(s) to lobby in connection with this competitive solicitation.
2.______It has retained a lobbyist(s) to lobby in connection with this competitive solicitation and certified that
each lobbyist retained has timely filed the registration or amended registration required under Section
1-262, Broward County Code of Ordinances.
_____________________________________
(Vendor Signature)
____________________________________
STATE OF __________________ (Print Vendor Name)
COUNTY OF ________________
The foregoing instrument was acknowledged before me this ____day of ________________, 20___, by
_________________________________________________ as _________________________ of
(Name of person who's signature is being notarized) (Title)
__________________________________ known to me to be the person described herein, or who produced
(Name of Corporation/Company)
____________________________________________ as identification, and who did/did not take an oath.
(Type of Identification)
NOTARY PUBLIC:
____________________________________ My commission expires: _______________________
(Signature)
_______________________
(Print Name)
Rev. 6.4.12 Page 33 of 71
Attachment “J” - Litigation History
Vendor : ______________________________________________
RLI#:______________
Vendor’s Parent Company:________________________________
MATERIAL CASE
SYNOPSIS Vendor’s Subsidiary Company:_____________________________
Vendor’s Predecessor Organization: _________________________
Party Plaintiff Defendant
Case Name
Case Number
Date Filed
Name of Court or other
tribunal
Civil Administrative/Regulatory
Type of Case
Criminal Bankruptcy
Claim or Cause of Action
and Brief description of
each Count
Brief description of the
Subject Matter and
Project Involved
Disposition of Case Pending Settled Dismissed
Judgment Vendor’s Favor
(Attach copy of any
applicable Judgment,
Settlement Agreement Judgment Against Vendor
and Satisfaction of
Judgment.)
If Judgment Against, is Judgment Satisfied? Yes No
Name:
Email:
Opposing Counsel
Phone number:
NAME OF COMPANY: ______________________________________________
Rev. 6.4.12 Page 34 of 71
Attachment “K” - Insurance Requirements
Rev. 6.4.12 Page 35 of 71
Attachment “L” - Cone of Silence Certification
The undersigned vendor hereby certifies that:
1. _____ the vendor has read Broward County's Cone of Silence Ordinance, Section 1-266,
Article xiii, Chapter 1 as revised of the Broward County Code; and
2. _____ the vendor understands that the Cone of Silence for this competitive solicitation shall
be in effect beginning upon the appointment of the Evaluation Committee (for Requests for
Proposals - RFPs) or Selection Committee (for Request for Letters of Interest - RLIs) for
communication regarding this RFP/RLI with the County Administrator, Deputy and Assistants
to the County Administrator and their respective support staff or any person, including
Evaluation or Selection Committee members, appointed to evaluate or recommend selection in
this RFP/RLI process. For Communication with County Commissioners and Commission
staff, the Cone of Silence allows communication until the initial Evaluation or Selection
Committee Meeting.
3.______the vendor agrees to comply with the requirements of the Cone of Silence Ordinance.
_____________________________________
(Vendor Signature)
_____________________________________
(Print Vendor Name)
STATE OF __________________
COUNTY OF ________________
The foregoing instrument was acknowledged before me this ____day of ________________, 20___, by
_________________________________________________ as _________________________ of
(Name of person who's signature is being notarized) (Title)
____________________________________________ known to me to be the person described herein, or who produced
(Name of Corporation/Company)
____________________________________________ as identification, and who did/did not take an oath.
(Type of Identification)
NOTARY PUBLIC:
________________________________
(Signature)
_______________________________ My commission expires: _______________________
(Print Name)
Rev. 6.4.12 Page 36 of 71
Attachment “N” - Drug Free Workplace Policy
Certification
THE UNDERSIGNED VENDOR HEREBY CERTIFIES THAT:
1. _____ THE VENDOR HAS A DRUG FREE WORKPLACE POLICY AS IDENTIFIED IN THE COMPANY POLICY ATTACHED TO THIS CERTIFICATION.
AND/OR
2. _____ THE VENDOR HAS A DRUG FREE WORKPLACE POLICY THAT IS IN COMPLIANCE WITH SECTION 287.087 OF THE FLORIDA STATUTES.
AND/OR
3. _____ THE VENDOR HAS A DRUG FREE WORKPLACE POLICY THAT IS IN COMPLIANCE WITH THE BROWARD COUNTY DRUG FREE WORKPLACE
ORDINANCE # 1992-08, AS AMENDED, AND OUTLINED AS FOLLOWS:
(a) Publishing a statement notifying its employees that the unlawful manufacture, distribution, dispensing, possession, or use of a
controlled substance is prohibited in the offeror's workplace, and specifying the actions that will be taken against employees for
violations of such prohibition;
(b) Establishing a continuing drug-free awareness program to inform its employees about:
(i) The dangers of drug abuse in the workplace;
(ii) The offeror's policy of maintaining a drug-free workplace;
(iii) Any available drug counseling, rehabilitation, and employee assistance programs; and
(iv) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;
(c) Giving all employees engaged in performance of the contract a copy of the statement required by subparagraph (a);
(d) Notifying all employees, in writing, of the statement required by subparagraph (a), that as a condition of employment on a covered
contract, the employee shall:
(i) Abide by the terms of the statement; and
(ii) Notify the employer in writing of the employee's conviction of, or plea of guilty or nolo contendere to, any violation of Chapter 893,
Florida Statutes, or of any controlled substance law of the United States or of any state, for a violation occurring in the workplace
NO later than five (5) days after such conviction.
(e) Notifying Broward County government in writing within 10 calendar days after receiving notice under subdivision (d) (ii) above, from
an employee or otherwise receiving actual notice of such conviction. The notice shall include the position title of the employee;
(f) Within 30 calendar days after receiving notice under subparagraph (d) of a conviction, taking one of the following actions with
respect to an employee who is convicted of a drug abuse violation occurring in the workplace:
(i) Taking appropriate personnel action against such employee, up to and including termination; or
(ii) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes
by a federal, state, or local health, law enforcement, or other appropriate agency;
(g) Making a good faith effort to maintain a drug-free workplace program through implementation of subparagraphs (a) through (f).
OR
4.____ THE VENDOR DOES NOT CURRENTLY HAVE A DRUG FREE WORKPLACE POLICY BUT IS WILLING TO COMPLY WITH THE REQUIREMENTS AS
SPECIFIED IN NO. 3
______________________________________
(VENDOR SIGNATURE)
______________________________________
(PRINT VENDOR NAME)
STATE OF __________________
COUNTY OF ________________
The foregoing instrument was acknowledged before me this ____day of ________________, 20___, by
_________________________________________________ as _________________________ of
(Name of person who's signature is being notarized) (Title)
____________________________________________ known to me to be the person described herein, or who produced
(Name of Corporation/Company)
____________________________________________ as identification, and who did/did not take an oath.
(Type of Identification)
NOTARY PUBLIC:
________________________________
(Signature)
________________________________ My commission expires: _______________________
(Print Name)
Rev. 6.4.12 Page 37 of 71
Attachment “O” - Non-Collusion Statement Form
By signing this offer, the vendor certifies that this offer is made independently and free from collusion.
Vendor shall disclose below, to their best knowledge, any Broward County officer or employee, or any
relative of any such officer or employee as defined in Section 112.3135 (1) (c), Fla. Stat. (1989), who
is an officer or director of, or has a material interest in, the vendor’s business, who is in a position to
influence this procurement. Any Broward County officer or employee who has any input into the
writing of specifications or requirements, solicitation of offers, decision to award, evaluation of offers,
or any other activity pertinent to this procurement is presumed, for purposes hereof, to be in a position
to influence this procurement. For purposes hereof, a person has a material interest if they directly or
indirectly own more than 5 percent of the total assets or capital stock of any business entity, or if they
otherwise stand to personally gain if the contract is awarded to this vendor.
Failure of a vendor to disclose any relationship described herein shall be reason for
debarment in accordance with the provisions of the Broward County Procurement Code.
NAME RELATIONSHIP
_______________________________ ____________________________________
_______________________________ ____________________________________
_______________________________ ____________________________________
_______________________________ ____________________________________
_______________________________ ____________________________________
_______________________________ ____________________________________
_______________________________ ____________________________________
__________________________________________
(Vendor Signature)
__________________________________________
(Print Vendor Name)
In the event the vendor does not indicate any names, the County shall interpret this to mean
that the vendor has indicated that no such relationships exist.
(Form is to be signed even if no names are listed)
Rev. 6.4.12 Page 38 of 71
Attachment “P” - Scrutinized Companies List
Certification
This certification form should be completed and submitted with your proposal but must be
completed and submitted prior to award.
The Vendor, by virtue of the signature below, certifies that:
a. The Vendor, owners, or principals are aware of the requirements of Section 287.135,
Florida Statutes, regarding Companies on the Scrutinized Companies with Activities in
Sudan List or on the Scrutinized Companies with Activities in the Iran Petroleum Energy
Sector List; and
b. The Vendor, owners, or principals, are eligible to participate in this solicitation and not
listed on either the Scrutinized Companies with Activities in Sudan List or on the
Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List; and
c. If awarded the Contract, the Vendor, owners, or principals will immediately notify the
COUNTY in writing if any of its principals are placed on the Scrutinized Companies with
Activities in Sudan List or on the Scrutinized Companies with Activities in the Iran
Petroleum Energy Sector List.
_________________________________________
(Authorized Signature)
_________________________________________
(Print Name and Title)
____________________________________________
(Name of Firm)
STATE OF ___________________
COUNTY OF _________________
The foregoing instrument was acknowledged before me this day of ___________, 20___, by
____________________________ (name of person whose signature is being notarized) as
______________________________ (title) of ______________________ (name of corporation/entity),
known to me to be the person described herein, or who produced _____________________________
(type of identification) as identification, and who did/did not take an oath.
NOTARY PUBLIC:
__________________________ State of ___________________ at Large (SEAL)
(Signature)
__________________________ My commission expires: _______________
(Print name)
Rev. 6.4.12 Page 39 of 71
Attachment “Q” - Local Vendor Certification
Tiebreaker Criteria
(or Local Preference if Applicable)
THE UNDERSIGNED VENDOR HEREBY CERTIFIES THAT:
1. _____ THE VENDOR IS A LOCAL VENDOR IN BROWARD COUNTY AND HAS A VALID BROWARD COUNTY LOCAL
BUSINESS TAX RECEIPT WHICH IS ATTACHED TO THIS CERTIFICATION
AND
2. _____ THE VENDOR IS A LOCAL VENDOR IN BROWARD COUNTY AND:
(a) Has been in existence for at least six (6) months prior to the proposal opening;
(b) Provides services on a day to day basis at a business address physically located within the limits of
Broward County and in an area zoned for such business; and
(c) The services provided from this location are a substantial component of the services offered in the
vendor's proposal.
AND/OR
3. _____ THE VENDOR IS A LOCAL VENDOR IN BROWARD OR MIAMI-DADE COUNTY AND HAS A VALID CORRESPONDING COUNTY
LOCAL BUSINESS TAX RECEIPT WHICH IS ATTACHED TO THIS CERTIFICATION AND:
(a) Has been in existence for at least ONE YEAR prior to the proposal opening;
(b) Provides services on a day to day basis at a business address physically located within the limits of
Broward County and in an area zoned for such business; and
(c) The services provided from this location are a substantial component of the services offered in the
vendor's proposal.
______________________________________
(VENDOR SIGNATURE)
______________________________________
(PRINT VENDOR NAME)
STATE OF __________________
COUNTY OF ________________
The foregoing instrument was acknowledged before me this ____day of ________________, 20___, by
_________________________________________________ as _________________________ of
(Name of person who's signature is being notarized) (Title)
____________________________________________ known to me to be the person described herein, or who produced
(Name of Corporation/Company)
____________________________________________ as identification, and who did/did not take an oath.
(Type of Identification)
NOTARY PUBLIC:
________________________________
(Signature)
________________________________ My commission expires: _______________________
(Print Name)
Rev. 6.4.12 Page 40 of 71
Attachment “R” - Volume of Work Over Five Years
Tie Breaker Criteria
Broward County Projects
The work shall include any amount awarded to any parent or subsidiary of the vendor, any predecessor
organization and any company acquired by the vendor over the past five (5) years. If the vendor is a
joint venture, the information provided should encompass the joint venture and each of the entities
forming the joint venture. (Report only amounts awarded as a Prime Vendor)
Solicitation Broward
Contract County
Item Project Title Date Awarded Awarded
Number Bid – Department
No. Dollar
Quote – RLI - or Division
Amount
RFP
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Grand Total
Rev. 6.4.12 Page 41 of 71
Exhibits
Balance of Page Left Blank Intentionally
Rev. 6.4.12 Page 42 of 71
EXHIBIT 1 - File Format for the First Report of Injury
(FNOI) Data File
Header Record
REQUIRED BY BROWARD COUNTY’S STARS SYSTEM
The FNOI data file is be generated and placed on the FTP site twice per day(M-F) at
9 am and 2pm.
Note: All data elements required for the Header Record
Element Name Data Type & Positions MCMS Instructions
Size
Record Type C2 1-2 Must equal 01
File Extraction C27 3-30 Broward_FNOI_YYYYMMDDHHMMSS
Identifier
Broward_FNOI _ always followed by the year,
month, day & time of the file extraction
Filler 31-2400 Use spaces
Rev. 6.4.12 Page 43 of 71
EXHIBIT 1 - File Format for the First Report of Injury
(FNOI) Data File
Detail Record
REQUIRED BY BROWARD COUNTY’S STARS SYSTEM
FNOI Data Record from MCMS – One record for each FNOI
Data Element(Field) Data Type Field Positions Req’d MCMS STARS DATA
Name and Size Data Instructions ELEMENT
Element
Record_type C2 01 - 02 Yes Must be hard
coded to 02
First Name C15 03 - 17 Yes Contact 1, Name 1
Middle Initial C1 18 - 18 Yes Contact 1, Name 1
Last Name C20 19 - 38 Yes Contact 1, Name 1
Social Security C11 39 - 49 Yes No Dashes SSN
Date of Accident N8 50 - 57 Yes (mmddyyyy) Loss Date
Time of Accident C10 58 - 67 Yes (hh:mm AM/PM)
Home Address: Street C40 68 - 107 Yes Contact 1.Address1
Home Address: City C30 108 - 137 Yes Contact 1.City
Home address: state C2 138 - 139 Yes Contact 1.St
Home address: zip C5 140 - 144 Yes Contact 1.zip
Home telephone C18 145 - 162 Yes No Dashes Rolodex.Phone(1)
Employee's Description C254 163 - 416 Yes Description
of Accident: How
injured
Employee's Description C254 417 - 670 Yes
of Accident: Cause of
injury
Occupation C50 671 – 720 Yes MiscDesc(8) *but
doesn’t look like
STARS is
populating as it is
picking up from
the HR file. Else
Anita keys it.
Date of birth N8 721 – 728 Yes (mmddyyyy) MiscDate (31)
729 – 731 Yes SA(1)
Sex C3
Injury/illness that 732 – 985 Yes
occurred C254
Part of body affected C254 986 – 1239 Yes
Rev. 6.4.12 Page 44 of 71
Data Element (Field) Data Type Field Position Req’d MCMS STARS DATA
Name and Size Data Instructions ELEMENT
Element
Company C50 1240 – 1289 Yes STARS creates a
Loc “Note” with
this information
D.b.a.: C20 1290 - 1309 Yes STARS creates a
Loc “Note”
Street: C40 1310-1349 Yes STARS creates a
Loc “Note” with
this information
City: C30 1350 - 1379 Yes STARS creates a
Loc “Note” with
this information
State C2 1380 – 1381 Yes STARS creates a
Loc “Note” with
this information
Zip C5 1382 - 1386 Yes STARS creates a
Loc “Note” with
this information
Telephone number: C18 1387 – 1404 Yes No Dashes MiscDesc(9)
Federal id number (fein) C10 1405 - 1414 No Can use spaces N/A
Date first reported to 1415 - 1422 Yes (mmddyyyy) Report Date
the County N8
Nature of business C50 1423 - 1472 No Can use spaces N/A
Policy/member number C50 1473 - 1522 No Can use spaces N/A
Date employed N8 1523 - 1530 Yes (mmddyyyy) MiscDate(8)
Paid for date of injury C3 1531 - 1533 No Can use spaces SA(56) STARS hard
codes as “Y” on all
Employer's Location N/A
Address (if different)
Street C40 1534 - 1573 Yes N/A
City C30 1574 - 1603 Yes N/A
State C2 1604 - 1605 Yes N/A
Zip C5 1606 - 1610 Yes N/A
Location # C15 1611 - 1625 No Can use spaces N/A
Last date employee 1626 – 1633 Yes (mmddyyyy) N/A
worked
N8
Will you continue to pay C3 1634 - 1636 No Can use spaces N/A
wages instead of
workers’ comp?
Returned to work 1637 - 1639 Yes N/A
(Yes/No) C3
Last day wages will be N8 1640 - 1647 No (mmddyyyy) or N/A
paid instead of workers’ use spaces
comp
Rev. 6.4.12 Page 45 of 71
Data Element (Field) Data Type Field Position Req’d MCMS STARS DATA
Name and Size Data Instructions ELEMENT
Element
If Return to Work = Yes, N8 1648 - 1655 Yes (mmddyyyy) or N/A Currently but
give date use space will need in near
future for Claims
EDI to State
Rate of pay D(10,2) 1656 - 1665 Yes Decimal point MiscNum(1)
must be included
Wage Period C3 1666 - 1668 Yes BWK - Bi-week N/A
(hr/wk/day/mo) DAY - Day
HLY – Hour,
MNY - Month
OTH – Other,
WKY - Week
YRY – Year
Place of Accident:
Street C40 1669 – 1708 Yes Other Descr
City C30 1709 – 1738 Yes Other Descr
State C2 1739 – 1740 Yes Other Descr
Zip C5 1741 – 1745 Yes MiscDesc(12)
County of Accident: C30 1746 – 1775 Yes
Date Of Death (If N8 1776 – 1783 Yes, if (mmddyyyy) Date(1)
applicable) applicabl
e
Number of hours per 1784 – 1785 Yes SA(32)
day N2
Number of hours per 1786 – 1788 Yes No Decimal point SA(33)
week N3
Number of days per 1789 – 1790 Yes SA(34)
week N2
Physician Prefix C10 1791 – 1800 No Can use spaces N/A
Physician First Name C15 1801 – 1815 No Can use spaces N/A
Physician Middle Initial C1 1816 – 1816 No Can use spaces N/A
1817 – 1836 No Can use spaces N/A
Physician Last Name C20
1837 – 1846 No Can use spaces N/A
Physician Suffix C10
No Can use spaces N/A
Physician Address:
1847 – 1886 No Can use spaces N/A
Street C40
1887 – 1916 No Can use spaces N/A
City C30
1917 – 1918 No Can use spaces N/A
State C2
Rev. 6.4.12 Page 46 of 71
Data Element (Field) Data Type Field Position Req’d MCMS STARS DATA
Name and Size Data Instructions ELEMENT
Element
1919 – 1923 No Can use spaces N/A
Zip C5
1924 – 1941 No Can use spaces N/A
Physician telephone C18
Hospital or Clinic Name C50 1942 – 1991 Yes If employee If STARS reads No
refused treatment Treatment then
then the MCMS coverage = 15 else
must enter the coverage =10
following: No
Treatment in the
Hospital/Clinic
Name Field
Hospital/Clinic Address:
1992 - 2031 Yes Leave blank if No N/A
Treatment
Street C40
City C30 2032 - 2061 Yes Leave blank if No N/A
Treatment
State C2 2062 - 2063 Yes Leave blank if No N/A
Treatment
Zip C5 2064 – 2068 Yes Leave blank if No N/A
Treatment
Reported by C20 2069 – 2088 Yes First & Last Name MiscDesc(11)
Reported date to the 2089 – 2096 Yes (mmddyyyy) MiscDesc(7)
MCMS N8
Insurer code C6 2097 – 2102 No Can use spaces N/A
Employee's risk class 2103 – 2122 No Can use spaces N/A
code C20
Insurer NAIC code C4 2123 – 2126 No Can use spaces N/A
Claim Handling Entity C50 2127 – 2176 No Can use spaces N/A
Name
Address: No Can use spaces N/A
Street C40 2177 – 2216 No Can use spaces N/A
City C30 2217 – 2246 No Can use spaces N/A
State C2 2247 – 2248 No Can use spaces N/A
Zip C5 2249 – 2253 No Can use spaces N/A
N/A
Service co/tpa code # C20 2254 – 2273 No Can use spaces
Rev. 6.4.12 Page 47 of 71
Data Element (Field) Data Type Field Position Req’d MCMS STARS DATA
Name and Size Data Instructions ELEMENT
Element
Claim Handling file # C10 2274 – 2283 No Can use spaces N/A
Is employer self- C3 2284 - 2286 No Can use spaces N/A
insured?
Vendor’s FNOI Unique N9 2287 - 2295 Yes Vendor must MiscDesc(3)
ID provide a unique *mapped in Admin
record ID # for NOTE: STARS
each FNOI record already has ID#s
in the file. 48955-99967 &
NOTE: The 100011-207254 .
beginning record Therefore to
prevent “dups”
ID# must begin at new vendor should
or exceed 300000 begin with 300000.
(three hundred All of the current
thousand) and vendor’s FNOI #s
then incremented begin with the
letter N.
consecutively by
one for each
additional new
FNOI record. Or if
the Med Care
provider is using
an alpha/numeric
numbering
scheme it must
NOT start with the
letter N.
Nature of Injury Code N3 2296-2298 Yes Must use NCCI SA(26)
codes –see
attached
Cause of Injury Code N3 2299-2301 Yes Must use NCCI Cause
codes – see
attached
Body Part Code N3 2302-2304 Yes Must use NCCI SA(24)
codes – see
attached
Filler C96 2305-2400 Yes Use spaces
Rev. 6.4.12 Page 48 of 71
EXHIBIT 1 - File Format for the First Report of
Injury (FNOI) Data File
Trailer Record
REQUIRED BY BROWARD COUNTY’S STARS SYSTEM
All Data Elements are Required
Element Name Data Type & Positions MCMS Special Notes
Size
Record Type C2 1–2 MCMS to hard code to 03
Number of Records N8 3 – 10 # Of ‘FNOI’ Records sent
in this file transmission
File Naming Convention of the First Report of Injury Export File
Broward 7 Broward
_(underscore) 1 Underscore
FNOI 4 FNOI
Year 4 YYYY
_(underscore) 1 Underscore
Month 2 MM
Day 2 DD
_(underscore) 1 Underscore
Hours (military time) 2 HH
Minutes 2 MM
File Extension 3 Text
Based on the above description, file name would be for a file created on May 2, 2006 @ 11:00 am :
Broward_FNOI_20060502_1100.txt.
Rev. 6.4.12 Page 49 of 71
EXHIBIT 1 - File Format for the First Report of
Injury (FNOI) Data File
NCCI CAUSE CODES THAT MUST BE USED – AS OF June 17, 2011
REQUIRED BY BROWARD COUNTY’S STARS SYSTEM
01 BURN OR SCALD--DUE TO CHEMICALS
02 BURN OR SCALD--HOT OBJECT/SUBSTANCES
03 BURN OR SCALD--TEMPERATURE EXTREMES
04 BURN OR SCALD-FIRE OR FLAME
05 BURN OR SCALD-STEAM OR HOT FLUIDS
06 BURN OR SCALD-DUST, GASES,FUMES OR VAPOR
07 BURN OR SCALD-WELDING OPERATIONS
08 BURN OR SCALD-RADIATION
09 BURN OR SCALD-CONTACT WITH, NOC
10 CAUGHT IN,UNDER , BETWEEN-MACHINERY
11 BURN OR SCALD-COLD OBJECTS OR SUBSTANCES
12 CAUGHT IN,UNDER OR BETWEEN-OBJ HANDLED
13 CAUGHT IN, UNDER OR BETWEEN - NOC
14 BURN OR SCALD-ABNORMAL AIR PRESSURE
15 CUT,PUNCT,SCRAPE , INJ BY - BROKEN GLASS
16 CUT,PUNCT,SCRPE BY-HAND TOOL-NON POWER
17 CUT,PUNCT,SCRAPE BY -OBJ LIFTED/HANDLED
18 CUT,PUNCT,SCRPE-POWER HAND TOOL/APPL
19 CUT,PUNCTURE,SCRAPE, NOC
20 CAUGHT IN, UNDER -COLLAPSING MATERIALS
25 FALL/SLIP/TRIP-FROM DIFFERENT LEVEL
26 FALL/SLIP/TRIP-FROM LADDER OR SCAFFOLDIN
27 FALL/SLIP/TRIP-FROM LIQUID/GREASE SPILL
28 FALL/SLIP/TRIP-INTO OPENINGS(SHAFTS, ETC
29 FALL/SLIP/TRIP-ON SAME LEVEL
30 FALL/SLIP/TRIP-SLIPPED, DID NOT FALL
31 FALL/SLIP/TRIP-NOC
32 FALL/SLIP/TRIP-ON ICE OR SNOW
33 FALL/SLIP/TRIP - ON STAIRS
40 MOTOR VEH - CRASH OF WATER VEHICLE
41 MOTOR VEH-CRASH OF RAIL VEHICLE
45 MOTOR VEH-COLLISION/SIDESWIPE W/OV
46 MOTOR VEH-COLLISION W/FIXED OBJECT
47 MOTOR VEH-CRASH OF AIRPLANE/HELICOPTER
48 MOTOR VEH-VEHICLE UPSET-OVERTURNED
50 MOTOR VEHICLE, NOC
Rev. 6.4.12 Page 50 of 71
52 STRAIN OR INJURY BY - CONTINUAL NOISE
53 STRAIN OR INJURY BY - TWISTING
54 STRAIN OR INJURY BY - JUMPING
55 STRAIN OR INJ BY - HOLDING OR CARRYING
56 STRAIN OR INJURY BY – LIFTING
57 STRAIN OR INJURY BY - PUSHING OR PULLING
58 STRAIN OR INJURY BY - REACHING
59 STRAIN OR INJ BY - USING TOOL OR MACHINE
60 STRAIN OR INJURY BY - NOC
61 STRAIN OR INJ BY - WIELDING OR THROWING
65 STRKNG AGNST/STEP'G ON-MOV'G MACH PARTS
66 STRKNG AGNST/STEP'G ON-OBJ LIFTED/HANDLE
67 STRKNG AGNST/STEP'G ON-SANDING/SCRAPING/CLEANING OPS
68 STRKNG AGNST/STEP'G ON-STATIONARY OBJECT
69 STRKNG AGNST/STEP'G ON-SHARP OBJECT
70 STRKNG AGNST/STEP'G ON- NOC
74 STRUCK/INJ'D BY- CO WORKER OR PATIENT
75 STRUCK/INJ'D BY - FALLING/FLYING OBJECT
76 STRUCK/INJ'D BY - HAND TOOL/MACH IN USE
77 STRUCK/INJURED BY - MOTOR VEHICLE
78 STRUCK/INJ'D BY - MOVING MACHINE PARTS
79 STRUCK/INJ'D BY- OBJECT LIFTED/HANDLED
80 STRUCK/INJ'D BY-OBJ HANDLED BY OTHERS
81 STRUCK/INJ'D, NOC(KICK'D, STAB'D, BIT)
82 MISC-ABSORPTION/INGESTION/INHALED, NOC
84 BURN OR SCALD-ELECTRICAL CURRENT
85 STRUCK/INJ'D BY-ANIMAL OR INSECT
86 STRUCK/INJ'D BY-EXPLOSION/FLARE BACK
87 MISC-FOREIGN BODY IN EYE(S)
88 NATURAL DISASTERS
89 MISC-PERSON IN ACT OF CRIME-ROBBERY, ETC
90 MISC-OTHER THAN PHYSICAL CAUSE OF INJURY
91 MOLD
94 RUBBED/ABRADED BY-REPETITIVE MOTION
95 RUBBED/ABRADED, NOC
96 TERRORISM
97 STRAIN OR INJURY BY - REPETITIVE MOTION
98 MISC-CUMULATIVE, NOC- ALL OTHER
99 MISC-OTHER, NOC
Rev. 6.4.12 Page 51 of 71
EXHIBIT 1 - File Format for the First Report of Injury
(FNOI) Data File
NCCI NATURE OF INJURY CODES THAT MUST BE USED – AS OF June 17, 2011
REQUIRED BY BROWARD COUNTY’S STARS SYSTEM
01 No Physical Injury
02 Amputation
03 Angina Pectoris
04 Burn - Heat, chemical,acid
07 Concussion
10 Contusion
13 Crushing
16 Dislocation
19 Electric Shock
22 Enucleation
25 Foreign Body
28 Fracture
30 Freezing
31 Hearing Loss or Impairment
32 Heat Prostration
34 Hernia
36 Infection
37 Inflammation
40 Laceration
41 Myocardial Infarction
42 Poisoning (Not OD or Cumulative Injury)
43 Puncture
46 Rupture
47 Severance
49 Sprain
52 Strain
53 Syncope
54 Asphyxiation
55 Vascular
58 Vision Loss
59 All Other Specific Injuries, NOC
60 Dust Disease NOC (Other Pneumoconiosis)
61 Asbestosis
62 Black Lung
63 Byssinosis
64 Silicosis
65 Respiratory Disorder-Gases, Fumes, Chems
66 Poisoning - Chemcial (Other than Metals)
67 Poisoning - Chemcial - Metals
68 Dermatitis
Rev. 6.4.12 Page 52 of 71
69 Mental Disorder
70 Radiation
71 All Other Occupational Disease Inj NOC
72 Loss of Hearing
73 Contagious Disease
74 Cancer
75 AIDS
76 VDT Related Disease
77 Mental Stress
78 Carpal Tunnel Syndrome
79 Hepatitis C
80 All Other Cumulative Injuries NOC
90 Multiple Physical Injuries Only
91 Mult Inj's Incl Physical & Psychological
Rev. 6.4.12 Page 53 of 71
EXHIBIT 1 - File Format for the First Report of Injury
(FNOI) Data File
NCCI BODY PART CODES THAT MUST BE USED – AS OF June 17, 2011
REQUIRED BY BROWARD COUNTY’S STARS SYSTEM
10 Head - Multiple Head Injury
11 Head - Skull
12 Head - Brain
13 Head - Ear(s)
14 Head - Eye(s)
15 Head - Nose
16 Head - Teeth
17 Head - Mouth
18 Head - Soft Tissue
19 Head - Facial Bones
20 Neck - Multiple Neck Injury
21 Neck - Vertebrae
22 Neck - Disc
23 Neck - Spinal Cord
24 Neck - Larynx
25 Neck - Soft Tissue
26 Neck - Trachea
30 Upper Extremities - Multiple Upper Extremities
31 Upper Extremities - Upper Arm
32 Upper Extremities - Elbow
33 Upper Extremities - Lower Arm
34 Upper Extremities - Wrist
35 Upper Extremities - Hand
36 Upper Extremities - Finger(s)
37 Upper Extremities - Thumb
38 Upper Extremities - Shoulder(s)
39 Upper Extremities - Wrist(s) & Hand(s)
40 Trunk - Multiple Trunk
41 Trunk - Upper Back Area
42 Trunk - Lower Back Area
43 Trunk - Disc
44 Trunk - Chest
45 Trunk - Sacrum and Coccyx
46 Trunk - Pelvis
47 Trunk - Spinal Cord
48 Trunk - Internal Organs
49 Trunk - Heart
Rev. 6.4.12 Page 54 of 71
50 Lower Extremities - Multiple Lower Extremities
51 Lower Extremities - Hip
52 Lower Extremities - Upper Leg
53 Lower Extremities - Knee
54 Lower Extremities - Lower Leg
55 Lower Extremities - Ankle
56 Lower Extremities - Foot
58 Lower Extremities - Great Toe
60 Trunk - Lungs
61 Trunk - Abdomen
62 Trunk - Buttocks
63 Trunk - Lumbar & or Sacral Vertebrae (Vertebra NOC trunk)
64 Multiple Body Parts - Artificial Appliance
65 Multiple Body Parts - Insufficient Info to Properly Identify - Unclassified
66 Multiple Body Parts - No Physical Injury
90 Multiple Body Parts - Multiple Body Parts (Including Body Systems & Parts)
91 Body Systems and Multiple Body Systems
99 Whole Body
Rev. 6.4.12 Page 55 of 71
EXHIBIT 2 - File Layout and Mapping
Information for Broward’s New Claim File Exports back to the MCMS
The primary purpose of Broward sending the “new claim” files back to the MCMS on a weekly basis is
so that Broward’s claim number can be added to the MCMS’s system(s) including the MCMS’s
medical bill repricing system as all electronic medical bills sent to Broward must contain Broward’s
correct claim number. All other information provided to the MCMS in this file can be ignored if the
provider so chooses. Also, please note that Header & Trailer records are not generated. This is
simply a fixed length text file with a detail record for each new claim that was created in Broward’s
STARS system when the MCMS’s 1St Notice of Injury data file was imported and processed in
STARS.
NOTE: The MCMS will be required to set up Broward Sheriff’s Office (BSO) as a separate business
unit/company in all of their systems due to reporting requirements of BSO.
DETAIL “NEW” CLAIM RECORD FILE FORMAT
Field
# Position Length Description Comment/Notes STARS Field Mapping
1 1 - 2 2 Blanks N/A
2 3 - 4 2 State FL STARS Hard coded
3 5 - 5 1 Claim Code A=Add STARS Hard coded to “A”
Claim.ClaimNumber (13-15
4 6 - 27 22 STARS Claim # characters)
STARS Hard coded – just
5 28 - 37 10 Defaults to “588001” IGNORE IGNORE
6 38 - 41 4 BLANKS
MCMS’s Unique FNOI
7 42 - 59 18 number Claim.MiscDesc3 (FNOLID)
8 60 - 68 9 Claimant’s SSN No Dashes Claim.SocialSecurityNumber
9 69 - 76 8 Date of Injury mmddyyyy Claim.LossDate
10 77 - 94 18 BLANKS N/A
11 95 - 95 1 BLANKS N/A
12 96 - 110 15 BLANKS N/A
13 111 - 125 15 BLANKS N/A
14 126 - 128 3 Line of Business Code WC = Workers Comp STARS Hard coded to WC
15 129 - 133 5 Adjuster Code IGNORE Claim.UserMisc(1)
Adjuster First
16 134 - 141 8 Initial/Lastname UserName of User in UserMisc(1)
17 142 - 143 2 BLANKS N/A
18 144 - 145 2 BLANKS N/A
19 146 - 147 2 BLANKS N/A
20 148 - 149 2 BLANKS N/A
21 150 - 150 1 BLANKS N/A
22 151 - 250 100 BLANKS N/A
23 251 - 259 9 BLANKS N/A
24 260 - 271 12 BLANKS N/A
Claimant’s
25 272 - 280 9 SocSecNum No Dashes Claim.SocialSecurityNumber
26 281 - 310 30 Claimant Name LastName,First Claim.ClaimName1
27 311 - 318 8 Claimant DOB MMDDYYYY Claim.MiscDate(31) (DOB)
28 319 - 319 1 Claimant Sex Claim.SpecialAnalysis(1)
29 320 - 349 30 Employing Division Location.LocationName
30 350 - 379 30 Claimant Address Claim.Contact(1).Address1
31 380 - 395 16 Claimant City Claim.Contact(1).City
32 396 - 397 2 Claimant State Claim.Contact(1).State
Rev. 6.4.12 Page 56 of 71
Field
# Position Length Description Comment/Notes STARS Field Mapping
33 398 - 406 9 Claimant Zip Claim.Contact(1).PostalCode
34 407 - 426 20 Claimant LastName Claim.Contact(1).LastName
35 427 - 446 20 Claimant FirstName Claim.Contact(1).FirstName
36 447 - 447 1 Claimant MidInit Claim.Contact(1).MiddleInitial
37 448 - 450 3 BLANKS N/A
38 451 - 456 6 BLANKS N/A
39 457 - 465 9 BLANKS N/A
40 466 - 474 9 BLANKS N/A
41 475 - 504 30 BLANKS Appears to be blank in the file
Employing Division
42 505 - 534 30 Address Line 1 Location.Street1
Employing Division
43 535 - 564 30 Address Line 2 Location.Street2
Employing Division
44 565 - 584 20 City Location.City
Employing Division
45 585 - 586 2 State Location.State
Employing Division
46 587 - 595 9 ZipCode Location.ZipCode
Last Name of User in
47 596 - 615 20 Adjuster Last Name Adjuster Last Name Claim.UserMisc(1)
First Name of User in
48 616 - 630 15 Adjuster First Name Adjuster First Name Claim.UserMisc(1)
Doesn’t look like STARS has the
49 631 - 640 10 BLANKS ph#
50 641 - 645 5 BLANKS N/A
51 646 - 653 8 AddDate mmddyyyy Claim.CreateDate
52 654 - 661 8 Updated mmddyyyy Claim.LastModNonFinancialsDate
53 662 - 669 8 ALL ZEROS IGNORE N/A
54 670 - 719 50 AttorneyFirmName Attorney Firm Name Claim.Contact(2).Company
55 720 - 739 20 AttorneyLastName Attorney Last Name Claim.Contact(2).LastName
56 740 - 754 15 AttorneyFirstName Attorney First Name Claim.Contact(2).FirstName
57 755 - 804 50 AttorneyAddress Attorney Address Claim.Contact(2).Address1
58 805 - 834 30 AttorneyCity Attorney City Claim.Contact(2).City
59 835 - 836 2 AttorneyState Attorney State Claim.Contact(2).State
60 837 - 841 5 AttorneyZipCode Attorney Zip Code Claim.Contact(2).PostalCode
61 842 - 845 4 BLANKS N/A
Claim.Contact(2).Phone – But
STARS has the dashes so the
last two digits of the phone #
62 846 - 855 10 AttorneyPhone IGNORE are cut off
63 856 - 956 101 Filler
Rev. 6.4.12 Page 57 of 71
EXHIBIT 3 - FILE HEADER RECORD
REQUIRED FILE FORMAT FOR THE MCMS’S MEDICAL BILL EXPORT
FILE FOR BROWARD COUNTY
Separate files are to be generated for pharmacy bills and for all other medical bills daily and placed
on the FTP site no later than 9 am (M-F).
One File Header Record per each medical bill file transmission to Broward County Risk Mgt
Element Name Starting Length Required MCMS Instructions
Position
MCMS's File 1 8 Yes Must be a unique #, pad with leading
Extract ID zeros and the number used in the
file header record must be used in all
of the record types found in the same
file transmission.
FILLER 9 15 Yes Use Spaces or zeros
Record Type 24 2 Yes Record Type must = 00 for the file
header
Date of Data File Extract 26 8 Yes YYYYMMDD
Time of Data File Extract 34 6 Yes hhmmss
Extract Format Version 40 3 Yes 001 = 1st run, 002 = 2nd run, etc.
Name of Data File Extract 43 50 Yes Must be comprised of the file title
either “Broward” or “BrowardRX”
followed by the date & time of the file
extract, the extract ID#. For example:
Broward_020060428_150427_123441.txt
FILLER 93 358 Yes Use Spaces or zeros
TOTAL RECORD LENGTH 450
Rev. 6.4.12 Page 58 of 71
EXHIBIT 3 - BILL HEADER RECORD
REQUIRED FILE FORMAT FOR THE MCMS’S MEDICAL BILL EXPORT
FILE FOR BROWARD COUNTY
One Bill Header Record for each medical bill included in the data file transmission to Broward County
Risk Mgt is required.
Data Element Starting Length Req’d MCMS Provider STARS Notes
Position Instructions/Notes
MCMS’s 1 8 Yes Must be = to the extract # in
File Extract ID The File Header record
FILLER 9 3 Yes Use spaces or zeros
MCMS’s 12 8 Yes Pad with leading zeros to STARS(Trans Misc
Unique Bill make this field 8 characters, Desc1) captures
Number(EOB) i.e. 00630000. Cannot the bill number
exceed 8 characters. Must plus seq # and
be unique for each bill and uses this to check
must be equal or greater for incoming
than 00630000 as not to duplicates which
conflict with existing are rejected if
numbers in Broward’s encountered in
STARS system. Or if the the file
MCMS is using an
alpha/numeric numbering
scheme then it must NOT
start with the letter L.
FILLER 21 3 Yes Use Spaces or zeros N/A
Record Type = 10 for 24 2 Yes Record Type must = 10 for
bill header records medical bill header records
FILLER 26 30 Yes Use Spaces or zeros
MCMS’s 56 8 Yes YYYYMMDD
Received Date
Rev. 6.4.12 Page 59 of 71
Data Element Starting Length Req’d MCMS Provider STARS Notes
Position Instructions/Notes
MCMS’s Processed 64 8 Yes YYYYMMDD
Date
Broward’s Claim # 72 40 Yes This is Broward's assigned
claim number that is sent to
the MCMS in the new claim
file that Broward will
transmit to the MCMS and
must be included in the
electronic medical bill file
and on all of the hard copy
EOB's as well
FILLER 112 3 Yes Use spaces or zeros
Date of Injury 115 8 Yes YYYYMMDD
FILLER 123 4 Yes Use spaces or zeros
Claimant’s Account# 127 20 Yes STARS Invoice ID
With the medical (different from
provider the STARS system
generated Invoice
#!)
From Date of Service 147 8 Yes YYYYMMDD STARS Invoice Svc
From Date
Thru Date of Service 155 8 Yes YYYYMMDD STARS Invoice Svc
Thru Date
Provider’s Date of Bill 163 8 Yes YYYYMMDD Need for future
use in STARS
FILLER 171 60 Yes Use spaces or zeros
Date that the MCMS 231 8 Yes YYYYMMDD STARS Trans Date
received the bill from & Invoice Date
the provider
FILLER 239 92 Yes Use spaces or zeros
Bill Type Code & this 331 3 Yes See Required Code Mapping STARS Trans Type
must be included on for this field and left justify & Financial
RX bills as well Bucket
FILLER 334 117 Yes Use spaces of zeros
TOTAL RECORD 450
LENGTH
Rev. 6.4.12 Page 60 of 71
EXHIBIT 3 - BILLING PROVIDER RECORD
REQUIRED FILE FORMAT FOR THE MCMS’S
MEDICAL BILL EXPORT FILE FOR BROWARD
COUNTY
One Billing Provider Record for each medical bill included in the data file transmission to Broward
County Risk Mgt is required. In addition, the Billing Provider Record must immediately follow the
corresponding bill header record in the data file.
Data Element Starting Length Req’d MCMS Provider STARS Notes
Position Instructions/Notes
MCMS’s 1 8 Yes Must be = to the extract # in
File Extract ID The File Header record
FILLER 9 3 Yes Use spaces or zeros
Bill Number 12 8 Yes Must match the bill ID# used
in the bill header record
Bill Sequence 20 1 Yes Must match the bill ID seq #
used in the bill header
record
FILLER 21 3 Yes Use spaces or zeros
Record Type = 16 for 24 2 Yes Record Type must = 16 for
billing provider record billing provider record
FILLER 26 1 Yes Use spaces or zeros
Provider’s Federal Tax 27 10 Yes No Dashes Uses for the
ID # Rolodex lookup
FILLER 37 53 Yes Use spaces or zeros
Pay To Name 90 50 Yes Uses for the
Rolodex lookup
Provider Last Name 140 20 Yes Required if Pay To Name is Uses for the
blank Rolodex lookup
Provider First Name 160 15 Yes Required if Pay To Name is Uses for the
blank Rolodex lookup
FILLER 175 62 Yes Use spaces or zeros
Provider Billing 237 50 Yes Uses for the
Address Rolodex lookup
Provider Billing City 287 30 Yes Uses for the
Rolodex lookup
Provider Billing State 317 2 Yes Uses for the
Rolodex lookup
Provider Billing Zip 319 9 Yes
FILLER 328 123 Yes Use spaces or zeros
TOTAL RECORD 450
LENGTH
Rev. 6.4.12 Page 61 of 71
EXHIBIT 3 - BILL TRAILER RECORD
REQUIRED FILE FORMAT FOR THE MCMS’S MEDICAL BILL EXPORT
FILE FOR BROWARD COUNTY
One Bill Trailer Record for each medical bill included in the data file transmission to Broward County
Risk Mgt is required. In addition, the Bill Trailer Record must immediately follow the corresponding
billing provider record in the data file.
Data Element Starting Length Req’d MCMS Instructions/Notes STARS Notes
Position
MCMS’s 1 8 Yes Must be = to the extract # in
File Extract ID The File Header record
FILLER 9 3 Yes Use spaces or zeros
Bill Number 12 8 Yes Must match the bill ID# used
in the bill header record
Bill Sequence 20 1 Yes Must match the bill ID seq #
used in the bill header
record
FILLER 21 3 Yes Use spaces or zeros
Record Type = 90 for 24 2 Yes Record Type must = 90 for
billing provider record billing provider record
FILLER 26 6 Yes Use spaces or zeros
MCMS Total Fee for 32 6.2 Yes 2 Decimal places(RJ/ZF) Creates a
this bill (i.e. Line Right justify/zero fill separate
changes, percentage transaction for
of savings charges, per payment to the
bill charges, etc. ALL MCMS Provider
totaled together into
one amount)
Total Actual Provider 40 11.2 Yes 2 Decimal places(RJ/ZF) STARS captures in
Charges for this bill the "trans" &
"ctrans" tables
just not displayed
Total State of FL Fee 53 11.2 Yes 2 Decimal places(RJ/ZF) Trans Misc 1
Schedule Reduction
Total PPO Reduction(if 66 11.2 Yes 2 Decimal places(RJ/ZF) Trans Misc 2
any) for this bill
Total Allowed Fee for 79 11.2 Yes 2 Decimal places(RJ/ZF) Trans Amount
this bill(Amount that Paid
BC Risk will be paying
to the provider)
FILLER 92 359 Yes Use Spaces or zeros
Total Record Length 450
Rev. 6.4.12 Page 62 of 71
EXHIBIT 3 - FILE TRAILER RECORD
REQUIRED FILE FORMAT FOR THE MCMS’S MEDICAL BILL EXPORT
FILE FOR BROWARD COUNTY
One File Trailer Record per each medical bill file transmission to Broward County Risk Mgt and it
should be the very last record in the file.
Element Name Starting Length Required MCMS Instructions
Position
MCMS's File 1 8 Yes Must be = to extract # in the File
Extract ID Header record
FILLER 9 15 Yes Use Spaces or zeros
Record Type 24 2 Yes Record Type must = 99 for the file
Trailer
Record Count of Type “10” 26 6 Yes
Record Count of Type “16” 32 6 Yes
Record Count of Type “90” 38 6 Yes
FILLER 44 407 Yes Use Spaces or zeros
TOTAL RECORD LENGTH 450
Rev. 6.4.12 Page 63 of 71
EXHIBIT 3 - REQUIRED BILL TYPE CODES
THE MCMS MUST USE FOR BROWARD COUNTY’S MEDICAL BILL
EXPORT FILE
CODES THAT MUST BE
USED IN "BILL TYPE" STARS TRANS
FIELD IN THE BILL TYPE
HEADER RECORD DESCRIPTION
(starting position 331)
ASC Ambulatory Surgery Center 1P1A
CHI Chiropractor 1P1A
DEN Dentist 1P1A
DME Durable Medical Equipment 1P1I
HI Hospital Inpatient - DWC 90/UB 92 1P1B
HO Hospital Outpatient - DWC 90/UB 92 1P1B
LAB Laboratory 1P1A
ORT Orthopedic 1P1A
OTH Misc Other, i.e. House cleaning, home 1P1G
modifications, autos or anything that does NOT
fit into the other bill type codes
OUT Outpatient Provider 1P1A
PHA Pharmacy 1P1C
PT Physical Therapy 1P1A
SNF Skilled Nursing Facility 1P1E
TRN Transport to medical appts, i.e. Tri Cty or 1P1F
Ambulance Payments
HHC 1P1E
Home Health Care provided by an agency
Rev. 6.4.12 Page 64 of 71
EXHIBIT 4 - Other EDI & Technical Requirements
1) DWC-1 First Report of Injury or Illness in PDF format and emailed to the designated County e-
mail address throughout the day.
2) Copies of each scanned medical bill and the associated medical report/notes in one PDF file
with the County’s full claim number in the beginning of the file name followed by an
underscore then the MCMS’s bill/EOB number then underscore and then the word Bill.
For example: BAR010111888_XYZ12345_Bill .pdf
Copies of each associated Explanation of Benefits (EOB) for the medical bill in one PDF file
with the County’s full claim number in the beginning of the file name followed by an
underscore then the MCMS’s bill/EOB number then underscore and then the word EOB.
For example: BAR010111888_XYZ12345_EOB .pdf
3) Copies of all of the EOBs in one PDF that are in the same exact order as the daily exported EDI
medical bill files (Exhibit # 3). Therefore, there will be two of these EOB PDF files daily, one
for the pharmacy bills and the second one for all other medical bills.
4) After STARS generates the payments for the electronic medical bills that were received from
the MCMS, Broward will generate an Excel data file that is sent back to the MCMS daily that
contains the following data elements: MCMS’s Bill ID/EOB Number; date that the County paid
the bill (which is also the date “mailed”); County’s Claim Number; and the County’s check
number. This data file is used to update the MCMS’s medical bill re-pricing system so that
when the MCMS sends the EDI medical bill information to the State, on the County’s behalf,
that this file will contain the required “date mailed” data element.
5) Monthly Medical Case Management Fees Excel File for payment of all Medical Case
Management Hours billed by the provider. File is to be submitted the first week of the month
for the previous month’s fees. File must contain the following data elements: County claim
number; Claimant Name(Last, First); Loss Date; Service From Date; Service Thru Date; Dollar
Amount; Number of Case Mgt Hours; Type of Claim Indicator(Lost Time; Medical,
Incident(Report Only); and Exposure.
Rev. 6.4.12 Page 65 of 71
6) Monthly Zero Bill Fees Excel File for payment of medical bill re-pricing fees incurred on
Denied bills and bills paid directly to the claimant. File is to be submitted the first week of
the month for the previous month’s fees. File must contain the following data elements:
County claim number; Claimant Name(Last, First); Loss Date; Service From Date; Service Thru
Date; Dollar Amount; EOB number; Type of Claim Indicator(Lost Time; Medical,
Incident(Report Only); and Exposure; and Provider Name.
7) Provide on-line view access to the MCMS’s nurse case management and medical bill re-
pricing system.
8) Ability for County adjusters to review medical bills and all associated medical/doctor’s
reports/notes and apply electronic approvals for payment in the MCMS’s medical bill re-
pricing system.
Ability to receive and process various types of Excel files provided by the County on a weekly basis to
keep the MCMS’s system(s) in sync with the County’s claims administration. Data elements that may
be included are: County’s Claim Number, Date Closed or Re-closed, Date Re-open, MMI Date, County
Adjuster Name, etc. *NOTE: Exact data elements to be exchanged will be determined during
implementation with the selected MCMS vendor
Rev. 6.4.12 Page 66 of 71
EXHIBIT 5 - EDI TESTING FOR ALL SHORTLISTED
FIRMS
Each shortlisted firm will be required to provide the County with sample data files on a CD labeled
“EDI Test Files”. County staff will test the data files and report the findings to the Selection
Committee prior to the ranking meeting.
Instructions and sample fictitious data to be used in the creation of each firm’s sample data files are
described below.
1. Provide an electronic First Notice of Injury Reports (FNOI) data file per the County’s defined
FNOI file layouts in Exhibit # 1 and create hardcopy FNOI Forms in PDF format. Use the FNOI
information provided below for two fictitious claimants.
Fictitious Claimant # 1 Fictitious Claimant # 2
Name: Teresa L. Schmidt Kimberly S. Land
SS#: 111-22-8888 111-22-9999
DOI: 08/01/11 1:00 pm 08/15/11 5:00 pm
Home Address & Ph #: 214 S. Howard Burton Drive 2152 NW 54 St
Ft Lauderdale, FL 33313 Ft. Lauderdale, FL 33309
954-999-8888 954-771-2099
Employee’s Description of While moving archive boxes A work meeting at the main
Accident: that contained very heavy files library and injured left index
felt pull and pain in lower back. finger on a broken chair.
Occupation Recording Clerk Account Clerk
DOB: 6/14/54 11/27/59
SEX: Female Female
Injury that occurred: Low back strain contusion
Part of Body injured: Low back Left index finger
Company Name: BC Board of Commissioners Broward Cty Sheriff(BSO)
Employing Division(DBA): County Records Division BSO
Address: 115 S. Andrews Ave 2601 W Broward Blvd.
Ft. Lauderdale, FL 33301 Ft. Lauderdale, Fl 33312
Employer’s Ph # 954-357-9999 954-357-7000
Employer’s Location (if 1600 W Hillsboro Blvd 2421 NW 16 St
different): Deerfield Beach, FL 33064 Pompano Bch, FL 33069
Place of Accident: 1600 W Hillsboro Blvd 115 S Andrews Ave & 2nd St
Deerfield Beach, FL 33064 Ft Lauderdale, FL 33301
County of Accident: Broward Broward
Date Employed: 1/5/06 12/10/90
Paid for date of injury? Yes Yes
Last date employee worked? 08/01/11 08/15/11
Returned to work? Yes, 08/01/11 No
Rev. 6.4.12 Page 67 of 71
Rate of Pay 12.55 per hour $15.00 per hour
# of hrs worked per day 8 8
# of hrs worked per week 40 40
# of days worked per week 5 5
Name & Address of Does not want treatment at this Broward General Hospital
Physician/Hospital time. 1600 S Andrews Ave
Ft Lauderdale, FL 33316
Reported by: Joe Brown Mary Smith
Insurer Code: 9145 9145
Employers NAICS Code 921120 921120
Insurer Name Broward County Board of Broward County Board of
County Commissioners County Commissioners
Risk Management Division Risk Management Division
Claims Handling Entity Broward County Board of Broward County Board of
County Commissioners County Commissioners
Risk Management Division Risk Management Division
115 S Andrews Ave # 210 115 S Andrews Ave # 210
Ft Lauderdale, FL 33301 Ft Lauderdale, FL 33301
954-357-7200 954-357-7200
NOTE: When creating the electronic FNOI data file be sure to include the correct NCCI codes for
Nature of Injury, Cause of Injury & Body Part for both claims. These codes are all detailed in Exhibit
1. And it the MCMS’s responsibility to ensure that the correct codes are assigned on all County’s
FNOIs and transmitted in the electronic FNOI data file even though these codes currently do not
appear on the paper FNOI form.
2. Provide electronic medical bill data files (one for medical bills and a separate file for the RX
bills) per the County’s defined Medical Bill file layouts as defined in Exhibit # 3 and create
hardcopy Explanation of Benefits Forms in PDF format with the County’s claim number and
the MCMS’s medical bill ID# as the file name. For example LAN0815111234_XZY001_EOB.pdf
3. For testing purposes only use a flat fee of $5.00 per medical bill and $3.00 per pharmacy bill
for the Medical Care Services Provider processing fees.
Rev. 6.4.12 Page 68 of 71
Use the information below for the two fictitious claimants.
Fictitious claimant # 1 Kimberly Land
Claimant Home Addr: 2152 NW 54 St., Ft Laud 33309
SS#: 111-22-9999
DOI: 08/15/11
BC RMD Claim #: Lan0815111234
Patient’s Acct #: 121213
From Date of Svc: 08/15/11
Thru Date of Svc: 08/15/11
Provider’s Bill Date: 08/25/11
MCMS Date Rec’d : 08/30/11
Bill Type: Hospital ER Visit
Provider’s Fed ID: 596012065
Provider: Broward General Medical Center
Provider Address: P.O. Box 932540 Atlanta GA 31193
Prin Diag Code: 8830
68 Code:
69 Code: 9595
70 Code: 7295
75 Admin Diag Code:
77 E Code:
Attending Phys ID: ME0091596 Ian Russinoff
Services Rendered: Use 08/15/11 on all of the below services
Rev CD Description HCPCS/Rates Service Units Total Charges
0320 DX X-Ray 73130LT 1 624.00
0450 Emerg Room 9928325 1 495.00
In addition, there was $300.00 charge for transport to Broward General on 08/15/11. Vendor is
“Medics Ambulance Service” and their Fed Tax ID is 59-2154162. Mailing address is: PO Box 5028
Deerfield Beach, FL 33442.
Rev. 6.4.12 Page 69 of 71
=========================================================================
Fictitious Claimant#2 : Teresa Schmidt
Claimant Home Addr: 214 S Howard Burton Drive Ft Laud 33313
SS#: 111-22-8888
DOI: 08/01/11
BC RMD Claim #: Sch0801111235
Patient’s Acct #: 121211
From Date of Svc: 08/01/11
Thru Date of Svc: 08/01/11
Provider’s Bill Date: 08/10/11
MCMS Date Rec’d: 08/25/11
Bill Type: Outpatient Visit
Provider’s Fed ID: 58-2654983
Provider: U.S. HealthWorks Medical Group FL, Inc.
Provider Address: P.O. Box 404473 Atlanta GA 30384
Prin Diag Code: 847.2
Attending Phys ID: ME77483 Marjorie Lewis, M.D.
Services Rendered: Use 08/01/11 on all of the below services
99204 25 New Pt, Compre/Mod/Mod $158.00
29799 Strapping; Low Back $71.00
72070 X-Ray, spine;thoracic, 2 views$41.00
In addition, there is a pharmacy bill for Naproxen 500MG quality of 40 that was purchased from:
J & H Stores, Inc.
D/B/A Garden Drugs
4400 N Andrews Ave
Ft Lauderdale, FL 33309
Fed Tax ID: 65-0417130
Date of service: 08/01/11
Rev. 6.4.12 Page 70 of 71
EXHIBIT 6 - WC “STATS” FOR MEDICAL CARE
SVCS RLI
WC "STATS" FOR MEDICAL CARE SVCS RLI
Approx Number of Employees covered for WC: 12,559
Total Number of open claims as of 5/10/12: 1,213
Medical Only: 648
Medical w/IIB: 314
Lost Time: 248
Death 3
Number of new Claims Occurring in FY 11: 1,150
Medical Only: 963
Medical w/IIB: 104
Lost Time: 82
Death 1
Number of Report Onlys(Incidents) FY 11 342
Number of Open claims at 9/30/10 874
Number of Open claims at 9/30/09 907
Number of Open claims at 9/30/08 1,067
Number of Open Heart & Lung as of 5/10/12: 129
Number of new Heart & Lung occuring in FY 11 28
Approximate Number of medical bills & RX bills processed in FY 11 27,000
Approximate Number of Pre-Certs FY 11 92
Rev. 6.4.12 Page 71 of 71
