Technology Implementation Fees

							                   Vendor Name
               Contact Information
                 Application Name
                Application Version
                 5010 Initial Assessment Questions
  Currently or Planned Usage of 4010 format in
               current version (Y/N)
     Planned Version Upgrade to 5010 Date
                  New Version ID
         Planned Modifications Included
  Departments/ Resources using system or data
   Will upgrade require contract modification
    Will upgrade increase maintenance fees
               Additional Questions
              5010 Detailed Assessment Questions
  Process Steps to Upgrade/Implement System
      Application Links (Networks/Servers)

Software/Hardware Dependencies with Timelines

Timeline for Completing Upgrade/Implementation
          Technology Requirements for
            Upgrade/Implementation
      Technology Requirements for Testing
       Resource Requirements for Testing
  Documentation for Upgrade/Implementation
     Functionality will include 4010 and 5010
                 accommodation
    Date 4010 Transaction Processing will End
   Date 5010 Transaction Processing will Start
  How long will dual processing be supported, if
                    applicable
   Cost Estimate for Upgrade/Implementation
Supportive Service Process and Availability During
            Upgrade/Implementation
               Additional Questions
               ICD-10 Initial Assessment Questions
  Currently or Planned Usage of ICD-9 format in
               current version (Y/N)
    Planned Version Upgrade to ICD-10 Date
                 New Version ID
         Planned Modifications Included
  Departments/ Resources using system or data
   Will upgrade require contract modification
    Will upgrade increase maintenance fees
              Additional Questions
            ICD-10 Detailed Assessment Questions
  Process Steps to Upgrade/Implement System
      Application Links (Networks/Servers)

Timeline for Completing Upgrade/Implementation
          Technology Requirements for
             Upgrade/Implementation
            Interface Requirements for
             Upgrade/Implementation

  Dependancies for Implementation with Timeline
       Technology Requirements for Testing
   Planned Usage of CMS GEM Files in Upgrade
    Planned Usage of CMS DRG Mapping Files in
                       Upgrade
        Resource Requirements for Testing
   Documentation for Upgrade/Implementation
Functionality will include ICD-9 and ICD-10 code set
                   accommodation
 How long will dual processing of ICD-9 and ICD-10
             be supported, if applicable
    Cost Estimate for Upgrade/Implementation
 Supportive Service Process and Availability During
             Upgrade/Implementation
                Additional Questions
Software Vendor Assessment Questionnaire