GENERAL INFORMATION - Veterans Affairs



TABLE OF CONTENTS TOC \o "1-3" \h \z \u 1.0GENERAL INFORMATION PAGEREF _Toc447732939 \h 51.1Definitions PAGEREF _Toc447732940 \h 51.2Title of Project PAGEREF _Toc447732941 \h 91.3Scope of Work PAGEREF _Toc447732942 \h 91.4Background PAGEREF _Toc447732943 \h 102.0PROJECT MANAGEMENT PAGEREF _Toc447732944 \h 102.1Kickoff Meeting PAGEREF _Toc447732945 \h 102.2Project Management Plan (PMP) PAGEREF _Toc447732946 \h 112.2.1Implementation Strategy PAGEREF _Toc447732947 \h 122.2.2Deployment Approach PAGEREF _Toc447732948 \h 122.3Risk Management Plan (RMP) PAGEREF _Toc447732949 \h 132.4Contractor Operations PAGEREF _Toc447732950 \h 132.5Quality Assurance Surveillance Plan & Project Management Reporting Requirements PAGEREF _Toc447732951 \h 142.5.1Quality Control Plan (QCP) PAGEREF _Toc447732952 \h 142.5.2Supplemental Project Management Reporting Requirements PAGEREF _Toc447732953 \h 142.6Community Care Network (CCN) Communications Plan PAGEREF _Toc447732954 \h 152.7Accreditation PAGEREF _Toc447732955 \h 153.0HIGH-PERFORMING NETWORK PAGEREF _Toc447732956 \h 163.1Network Establishment and Maintenance PAGEREF _Toc447732957 \h 163.2Provider Networks PAGEREF _Toc447732959 \h 183.2.1CCN Healthcare Services Network PAGEREF _Toc447732960 \h 183.2.2CCN Complementary and Integrative Health Services (CIHS) Network PAGEREF _Toc447732961 \h 193.3Identification of High-Performing Providers PAGEREF _Toc447732963 \h 193.3.1Institutional Centers of Excellence PAGEREF _Toc447732964 \h 193.3.2Group Practice Providers PAGEREF _Toc447732965 \h 203.3.3Individual Providers PAGEREF _Toc447732966 \h 203.4Community Care Network (CCN) Regions PAGEREF _Toc447732967 \h 203.5Network Adequacy Management PAGEREF _Toc447732968 \h 223.6Network Credentialing PAGEREF _Toc447732969 \h 233.6.1Interim Network Credentialing Requirements PAGEREF _Toc447732970 \h 233.6.2Network Credentialing Requirements upon Accreditation PAGEREF _Toc447732972 \h 244.0CCN HEALTH BENEFIT PACKAGE PAGEREF _Toc447732973 \h 244.1CCN Healthcare Services PAGEREF _Toc447732974 \h 244.1.1CCN Healthcare Service Exceptions PAGEREF _Toc447732975 \h 254.2CCN Complementary and Integrative Health Services PAGEREF _Toc447732976 \h 264.3Excluded CCN Healthcare Services PAGEREF _Toc447732977 \h 265.0ELIGIBILITY VERIFICATION AND ENROLLMENT PAGEREF _Toc447732978 \h 275.1Eligibility Data PAGEREF _Toc447732979 \h 275.1.1Eligibility Verifications PAGEREF _Toc447732980 \h 275.1.1.1Eligibility Verification and Enrollment: Time-Eligible Veterans PAGEREF _Toc447732981 \h 275.1.1.2Eligibility Verification and Enrollment: Distance-Eligible Veterans PAGEREF _Toc447732982 \h 275.2Enrollment PAGEREF _Toc447732983 \h 285.3Veterans Choice Cards PAGEREF _Toc447732984 \h 285.3.1Veterans Choice Cards Production and Distribution PAGEREF _Toc447732985 \h 285.3.2Veterans Choice Card Handling PAGEREF _Toc447732986 \h 296.0CUSTOMER SERVICE PAGEREF _Toc447732987 \h 306.1VA Support Call Center Function:? Time-Eligible and Distance-Eligible PAGEREF _Toc447732988 \h 316.2CCN Provider Call Center Function PAGEREF _Toc447732989 \h 316.3Call Center Function: After Hours Support PAGEREF _Toc447732990 \h 326.4Mailing Ad Hoc Correspondence PAGEREF _Toc447732991 \h 326.5Contractor Customer Service Technology PAGEREF _Toc447732992 \h 326.6Veteran Complaints and Grievances and Customer Service Procedure PAGEREF _Toc447732993 \h 326.7Congressional and VA Inquiries PAGEREF _Toc447732994 \h 326.8Contractor Customer Service Performance Standards PAGEREF _Toc447732995 \h 326.8.1Call Center Operational Performance Measures PAGEREF _Toc447732996 \h 336.8.2Customer Service Technology Performance Measures PAGEREF _Toc447732997 \h 336.8.3Complaints and Grievances Performance Measures PAGEREF _Toc447732998 \h 347.0REFERRALS AND PRIOR AUTHORIZATIONS PAGEREF _Toc447732999 \h 347.1Notification of Emergency Care PAGEREF _Toc447733000 \h 347.2Referrals from VA to Community Care Network Provider PAGEREF _Toc447733001 \h 357.3Referrals from a Community Care Network Provider for VA PAGEREF _Toc447733002 \h 357.4Prior Authorizations PAGEREF _Toc447733003 \h 367.5Referrals and Prior Authorization Reports PAGEREF _Toc447733004 \h 378.0Scheduling of Appointments PAGEREF _Toc447733005 \h 379.0Medical Documentation PAGEREF _Toc447733006 \h 389.1Medical Documentation Submission Process PAGEREF _Toc447733007 \h 389.2Medical Documentation Data Elements PAGEREF _Toc447733008 \h 389.3Medical Documentation Submission Timeframes PAGEREF _Toc447733009 \h 399.4Medical Documentation Submission Format PAGEREF _Toc447733010 \h 3910.0TRAINING PAGEREF _Toc447733011 \h 3910.1Training Plan PAGEREF _Toc447733012 \h 3910.1.1Training Program for Contractor CCN Providers, Contractor Personnel and VA Staff Training Program PAGEREF _Toc447733013 \h 4010.1.2Contractor CCN Provider and Contractor Personnel Outreach and Education Program PAGEREF _Toc447733014 \h 4010.1.3Contractor-Provided VA Staff Training Sessions PAGEREF _Toc447733015 \h 4110.2Contractor Training Materials PAGEREF _Toc447733016 \h 4111.0MEDICAL MANAGEMENT PAGEREF _Toc447733017 \h 4211.1Discharge Planning PAGEREF _Toc447733018 \h 4211.2Optional Task: Disease Management Program Administration PAGEREF _Toc447733019 \h 4311.2.1Disease Management: Time-Eligible and Distance Eligible Veterans PAGEREF _Toc447733020 \h 4311.3 Case Management Program Administration PAGEREF _Toc447733021 \h 4311.3.1 Case Management: Time-Eligible Veterans and Distance Eligible Veterans PAGEREF _Toc447733022 \h 4412.0CLAIMS Processing and ADJUDICATION FOR CCN HEALTHCARE SERVICES RENDERED PAGEREF _Toc447733023 \h 4412.1Claims Processing System Functions PAGEREF _Toc447733024 \h 4412.1.1Claims Adjudication and Payment Rules PAGEREF _Toc447733026 \h 4512.2Paper Claims PAGEREF _Toc447733027 \h 4612.3Signature Requirements PAGEREF _Toc447733028 \h 4712.3.1Signature on File Procedure PAGEREF _Toc447733029 \h 4712.3.2Network Provider Signature on Claims PAGEREF _Toc447733030 \h 4712.4Claims Submission and Processing Timeframes PAGEREF _Toc447733031 \h 4712.5Issuance of Explanations of Benefits (EOB) PAGEREF _Toc447733032 \h 4712.6Issuance of Remittance Advice PAGEREF _Toc447733033 \h 4812.7Coordination of Benefits PAGEREF _Toc447733034 \h 4812.7.1Other Health Insurance PAGEREF _Toc447733035 \h 4912.8Claims for Services Rendered Outside of the Assigned CCN Region PAGEREF _Toc447733036 \h 5012.9Claims Auditing PAGEREF _Toc447733037 \h 5012.9.1Claims Audit Reporting PAGEREF _Toc447733038 \h 5112.10Claims Reporting PAGEREF _Toc447733039 \h 5112.11Federal Codes and Regulations PAGEREF _Toc447733040 \h 5213.0Veteran Appeals AND PROVIDER RECONSIDERATIONS PAGEREF _Toc447733041 \h 5213.1Veterans Appeals PAGEREF _Toc447733042 \h 5213.2Provider Reconsiderations PAGEREF _Toc447733043 \h 5214.0CLINICAL QUALITY MONITORING PAGEREF _Toc447733044 \h 5314.1Clinical Quality Monitoring Plan (CQMP) PAGEREF _Toc447733045 \h 5314.1.1Clinical Quality Initiative Component of the CQMP PAGEREF _Toc447733046 \h 5314.1.2Clinical Quality Improvement Component of the CQMP PAGEREF _Toc447733047 \h 5314.2Clinical Quality Issues Identification PAGEREF _Toc447733048 \h 5414.3Peer Review of Identified Quality Issues PAGEREF _Toc447733049 \h 5414.4VA Participation in Peer Review Committees PAGEREF _Toc447733050 \h 5415.0PHARMACY PAGEREF _Toc447733051 \h 5515.1Urgent/Emergent Prescriptions PAGEREF _Toc447733053 \h 5515.2Routine Prescriptions: Time-Eligible Veterans and Distance-Eligible PAGEREF _Toc447733054 \h 5715.3Urgent/Emergent Prescription Network Adequacy PAGEREF _Toc447733056 \h 5815.3.1Urgent/Emergent Prescription Performance Metrics PAGEREF _Toc447733057 \h 5816.0Durable Medical Equipment, Medical Devices, Orthotic and Prosthetic items PAGEREF _Toc447733058 \h 5816.1Urgent/Emergent Prescriptions for DME and Medical Devices: Time-Eligible Veterans and Distance-Eligible Veterans PAGEREF _Toc447733059 \h 5916.2Other Prescriptions for DME, Medical Devices, Orthotics and Prosthetics: Time-Eligible Veterans and Distance-Eligible Veterans PAGEREF _Toc447733060 \h 5916.3Optional Task: Eyeglasses: Time-Eligible and Distance-Eligible PAGEREF _Toc447733061 \h 6017.0DENTAL PAGEREF _Toc447733062 \h 6117.1Dental Network Adequacy PAGEREF _Toc447733063 \h 6117.2Dental Network Credentialing PAGEREF _Toc447733064 \h 6117.3Dental Network Compliance PAGEREF _Toc447733065 \h 6117.4Dental Referrals PAGEREF _Toc447733066 \h 6217.5Return of Dental Records PAGEREF _Toc447733067 \h 6217.5.1Time-Eligible Veterans PAGEREF _Toc447733068 \h 6217.5.2Distance-Eligible Veterans PAGEREF _Toc447733069 \h 6217.6Dental Care Authorizations PAGEREF _Toc447733070 \h 6218.0TECHNOLOGY PAGEREF _Toc447733071 \h 6318.1Continuity of Operations PAGEREF _Toc447733072 \h 6318.2Contractor System Access PAGEREF _Toc447733073 \h 6418.3IT Customer Service PAGEREF _Toc447733074 \h 6518.4Portal PAGEREF _Toc447733075 \h 6518.5Submission of EDI Transactions PAGEREF _Toc447733076 \h 6518.6Submission of OHI PAGEREF _Toc447733077 \h 6618.7Provider File Submission PAGEREF _Toc447733078 \h 6618.8VA System Integration Requirements PAGEREF _Toc447733079 \h 6718.9Contractor Software Configuration Management Requirements PAGEREF _Toc447733080 \h 6719.0DATA ANALYTICS PAGEREF _Toc447733081 \h 6719.1Data Elements PAGEREF _Toc447733082 \h 6719.2Interactive Dashboard PAGEREF _Toc447733083 \h 6819.3Data Repository PAGEREF _Toc447733084 \h 6820.0Schedule of Deliverables PAGEREF _Toc447733085 \h 6921.0ACRONYMS AND DEFINITIONS PAGEREF _Toc447733086 \h 75GENERAL INFORMATIONDefinitionsTermDefinitionActive VeteranA Veteran who has a Community Care claim paid during the billing month.Approved ReferralDepartment of Veterans Affairs (VA)-approved referral constitutes an order under this contract.Associated Referral DocumentationSpecific services requested, diagnosis, referring provider and contact information, special requests from provider, timeframe for services to be rendered.Average Speed of AnswerThe average amount of time it takes for the call to be answered by an agent or the Automatic Call Distributor (ACD).Average Wait TimeThe average amount of time callers wait in call queues before an agent responds.Blockage RateAll lines or trunks to the call center are in use; Veteran receives a busy signal.Blockage RatesThe percentage of callers that received a busy tone when they call.Call Abandonment RatesThe percentage of callers who hang up before reaching an agent.Case ManagementTerminally ill, chronic disease states, multiple comorbidities, high-cost, traumatic injuries, repeated hospitalizations, discharge planning.Levels of Case Management:1.?????? Education and Literature2.?????? Intervention3.?????? Case ManagementCase management programs target “high-risk” patients--those at high-risk of suffering costly hospitalizations and adverse health outcomes because of complex social and medical vulnerabilities. These high-risk patients tend to have diverse combinations of health, functional, and social problems.Catchment AreaThe geographical area served by an institution.Clean ClaimA claim that contains all the required data elements necessary for adjudication without requesting supplemental information from the submitter.CQMPContractor’s plan to monitor patient safety, clinical quality assurance, clinical quality improvement, and peer review plan.Critical FindingThose findings or results that require immediate evaluation by a health care provider such that failure to take immediate appropriate action might result in death, significant morbidity, or serious adverse consequences to the Veteran.DaysAll days within the Performance Work Statement (PWS) are calendar days unless otherwise noted. When “business day” is noted, business day is defined as Monday through Friday, excluding standard Federal Holidays and any other day specifically declared to be a national holiday.Discharge Planning LiaisonCase Management Liaison that focuses on Discharge Planning.Distance-EligibleVeterans who meet specific requirements as determined by the VA to be eligible for community care due to geographic reasons. Distance-Eligible and Special-Circumstances Veterans (hereinafter referred to as “Distance-Eligible” Veterans) are Veterans who meet specific requirements as determined by the VA to be eligible for community care due to geographic reasons. Disease ManagementDisease management programs target patients whose main health problem is a single diagnosis. Even though most patients also have comorbid conditions, patients whose main problem is a specific diagnosis tend to have a relatively standard but perhaps complete set of needs related to that diagnosis.Durable Medical EquipmentDurable Medical Equipment (DME) is equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of an illness or injury, and is appropriate for use in the home.Eligible VeteranAny Veteran who is eligible to receive care in the community due to either time-eligibility or distance-eligibility.Emergent CareMedical care required as a result of an Emergent Need; required within twenty-four (24) hours or less to evaluate and stabilize conditions;Or:Care that if not provided will likely result in unacceptable morbidity/pain when there is significant delay in evaluation or treatment.Emergent NeedConditions that may result in the loss of life, limb, or vision, or result in unacceptable morbidity/pain when there is significant delay in evaluation or treatment.Enrolled VeteranAny Veteran who is enrolled in VA’s patient enrollment system and is eligible to receive health care benefits.Episode of CareA set of clinically related health care services for a specific unique illness or medical condition (diagnosis and/or procedure) provided by an authorized provider during a defined authorized period of time not to exceed one year.ExceptionsServices that will not be provided under this contract.First Call ResolutionThe percentage of calls where the agent resolves the caller’s issue without escalating, transferring or returning the call.Highly Rural“Highly rural” is defined as a sparsely populated area — as an area located in a county that has fewer than seven individuals residing in that county per square mile.Medical DeviceMedical device is an instrument, apparatus, implement, machine, contrivance, or other similar or related article, including a component part, or accessory which is intended for use in the cure, mitigation, or treatment of disease or compensates for a person’s loss of mobility or other bodily functional abilities and function as a direct and active component of the person’s treatment and rehabilitation.Medical DocumentationMedical Documentation includes the following:1.?????? Medical records from the Network Providers2.?????? Case management3.?????? Disease management4.?????? Utilization review and management5.?????? Medical necessity reviews6.?????? Reconsideration and appeals7.?????? Complaints and grievancesMedical ManagementVA Care CoordinationNon-service Connected CareMedical care and services provided for a Veteran who has been discharged from active military duty and does not have a VA adjudicated illness or injury incurred in or aggravated by military service.Pre-AuthorizationsA request and process which introduces the veteran to obtain care from additional resources in the community. Upon approval a referral number is generated.ReferralA request and process which introduces the veteran to obtain care from additional resources in the community. Upon approval, a referral number is generated.Response AccuracyThe percentage of calls where the response provided by the Call Center is accurate and complete according to the terms of the contract.RuralRural is defined as areas not designed as urban or highly rural.Service Connected CareMedical care and services provided for a Veteran who has an illness or injury incurred in or aggravated by military service as determined by VASolutionAll components of the Contractor’s response and planned execution of the High-Performing Network, claims processing, medical management, customer service, and technology components.Start of Health Care DeliveryThe beginning of healthcare delivery at a site or location within an awarded CCN Region.Service AvailabilityServices and applications being available, whether it is during abnormal system operation or software upgrade regardless of hardware or software failure.Service Unavailability“Service Unavailability” consists of the number of hours that the systems were not available.? Calculation of service unavailability shall not include any time the service is unavailable due to scheduled maintenance.Time-EligibleVeterans who are unable to schedule an appointment for hospital care, medical services or dental services with the VA within the wait-time goals of the Veterans Health Administration (VHA) for such care or services or the period determined by a VA provider to be clinically necessary for such care or services, whichever is shorter. This includes when such care or services are not provided within a medical facility of VA that is accessible to the Veteran. This also includes when there is a compelling reason that the Veteran needs to receive the care or service outside of a medical facility of VA. Unique MembersFor the initial contract year, “Unique Members” is defined as Time-Eligible Veterans and Distance-Eligible Veterans who have accessed Community Care. For each contract year going forward, “Unique Members” is defined as Time-Eligible Veterans and Distance-Eligible Veterans who have accessed Community Care at least once during the prior contract year.UrbanCensus Bureau-defined urbanized area, which is any block or block group having a population density of at least 1000 people per square mile.Utilization ManagementThe evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan.Urgent CareProvision of immediate medical service offering outpatient care for the treatment of acute and chronic illness or injury.VA Community Care Regional OfficeVA regional office designated to support each CCN Region under this contract.Veterans Choice Card Veterans Access, Choice, and Accountability Act of 2014 (VACAA) requires the Department of Veterans Affairs (VA) to issue a Veterans Choice Card to all enrolled Veterans that can be used to obtain care in the community when such care is not available due to long wait-times or distance hardships.Wait Time GoalsNot more than thirty (30) days from the date on which a Veteran requests an appointment for hospital care or medical services from the VA.Warm Transfer A?warm transfer?is when the agent who is currently speaking with the caller (and wishes to?transfer?them) speaks with the new agent before the call is?transferred and introduces the caller to the new agent.Title of ProjectCommunity Care Network (CCN), purchased under the authority of 38 United States Code (U.S.C.) § 8153, “Sharing of Healthcare Resources.” Scope of Work The Contractor shall provide a CCN per the requirements defined in this Performance Work Statement (PWS). The CCN shall consist of licensed healthcare providers as well as healthcare practitioners to provide medical, surgical, complementary and integrative services, durable medical equipment, pharmacy and dental services. The Contractor shall upload and maintain enrollment and eligibility information. The Contractor shall maintain referrals and authorizations. The Contractor shall establish and maintain a network of high-performing licensed healthcare providers as well as healthcare practitioners to deliver patient-centered care. The Contractor shall provide (i) exemplary customer service; (ii) monitor and manage quality outcomes; (iii) use data and performance metrics to improve services, and (iv) process and pay claims in order to enhance Veterans’ healthcare experiences. The Contractor shall deliver healthcare services through the use of tools and practices that drive efficiencies, costs savings, and a positive Veteran experience. The Contractor shall serve as a third-party administrator (TPA) with responsibility to perform the requirements herein. BackgroundVA is committed to providing Veterans timely, accessible, and high-quality care. VA intends to accomplish this by improving performance, promoting a positive culture of service, increasing operational effectiveness and accountability, advancing healthcare innovation through research, and training future clinicians.VA recognizes that while the healthcare landscape is constantly changing, VA’s unique population and broad geographic demands will continue to require community based care for Veterans. A Veteran enrolled in the patient enrollment system of the VA established and operated under 38 U.S.C. § 1705 may receive services under this contract. Healthcare services will be provided in a state as defined in 38 U.S.C. § 101(20). Congress requested that VA create and present a plan explaining how VA intends to provide care in the community to Veterans in the future. Accordingly, VA published its “Plan to Consolidate Programs of the Department of Veterans Affairs to Improve Access to Care” in November of 2015: (). VA identified within the plan its proposed future integrated healthcare delivery system which must provide high-quality, effective, and coordinated care, both within VA and in the community. The future VA healthcare delivery system must operate efficiently, adopt technological advances, and develop and maintain relationships with strategic partners to support an equivalent Veterans’ experience inside and outside of VA. To reach this desired state, VA plans to use a “system of systems” approach to enhance five functional areas as part of the larger VA healthcare transformation initiative. In the plan to consolidate VA-identified requirements, five systems are necessary to VA healthcare and the New Veterans Choice Program: Integrated Customer Service Systems Integrated Care Coordination Systems Integrated Administrative Systems (Eligibility, Patient Referral, Authorization, and Billing and Reimbursement) High-Performing Network Management Systems Integrated Operations Systems (Enterprise Governance, Analytics, and Reporting) PROJECT MANAGEMENT Kickoff MeetingThe Contractor shall participate in a kickoff meeting within thirty (30) days after contract award. The Contractor shall create a Kickoff Meeting Presentation to present the details of the approach to delivering all services under this contract in a Project Management Plan (PMP) as defined in Section 2.2, “Project Management Plan (PMP).” The Contractor shall coordinate with the Contracting Officer (CO) to establish dates, location, and agenda for the kickoff meeting. The Contractor shall take meeting minutes, which shall be provided to all attendees within five (5) days after the meeting. Deliverables:Kickoff Meeting PresentationMeeting MinutesProject Management Plan (PMP)The Contractor shall be responsible for project management and performance of the requirements of this contract. The Contractor shall create a PMP to be approved by VA to capture all elements of managing the CCN. The PMP shall be submitted thirty (30) days after the kickoff meeting and updated monthly thereafter. As part of the PMP, the Contractor shall create an Integrated Master Schedule (IMS) that depicts the implementation and deployment of the CCN pursuant to the contract. The PMP shall include the following: The Contractor shall create and maintain a Work Breakdown Structure (WBS) to a minimum of 3-levels to define the activities, tasks, and outcomes.The Contractor shall identify and include all applicable project milestones in the IMS. The Contractor shall identify and document discrete events necessary to complete the project, identify and document the definition of the relationship between and among these events, determine the expected duration of each event and resources required for each. The Contract shall then create a schedule that depicts this information as a cohesive whole in the IMS. The Contractor shall deliver a detailed-level schedule, critical path depiction, and a what-if analysis, with breakouts of subsections for individual groups/teams. When data are provided/entered that create overall critical path slippage, the Contractor shall notify the Project Manager (PM) within one (1) business day. The notification should occur by email and phone. The Contractor shall ensure that a fully resource-loaded and baselined schedule in Microsoft Project is in place as part of the submission of the initial PMP. The Contractor shall generate schedule reports containing the planned versus actual program/project performance against the PMP and updated critical path information for the project. The Contractor’s schedule reports shall also include identification and documentation of project risks that may jeopardize any imminent milestones or the overall project timeline. The reports shall be provided to, and accepted by, VA.The Contractor shall create and maintain a Change Control Process Plan to address any schedule variance. The Contractor shall adhere to VA direction for changing dates related to baselined dates.The Contractor shall deliver a Project-Level Communications Plan to outline the communications required to manage the overall CCN project. The Contractor shall include, as part of the Project Level Communications Plan, an approach to communicating action items and issues that require immediate response.Deliverables: Project Management PlanImplementation StrategyThe CCN shall be fully operational no later than twelve (12) months after the contract award date. The Contractor shall develop an Implementation Strategy to detail how the CCN shall be implemented within the awarded CCN Region(s). The Implementation Strategy shall outline the strategy for integrating the following:VA health benefits into the Contractor’s system that manages health benefitsEnrollment and eligibility data exchanges Referral and authorization system and process Medical management processesThe provider network, including identification of high-performing providers Provider education Credentialing new and existing CCN providersData exchanges to maintain the VA Master Provider File referenced in Section 19, “Data Analytics”Claims processingBilling for administrative services Veterans Choice Card Distribution (cards to be distributed thirty (30) days prior to the Start of Healthcare Delivery (SHCD))The Implementation Strategy shall also outline the strategy for fulfilling the customer service and data analytics requirements under this contract. The Implementation Strategy shall also contain a high-level phased implementation schedule to achieve network adequacy within the first twelve (12) months. Acceptable strategies include, but are not limited to, initial operational capability (IOC) within six (6) months, with full operational capability (FOC) within twelve (12) months after contract award. For IOC, the minimum schedule requirement includes full implementation for one (1) urban site and one (1) rural site per awarded CCN Region. VA will approve the selection of the urban and rural site for IOC. For FOC, the minimum schedule requirement includes full implementation of all sites within the awarded CCN Region. Deliverable:Implementation StrategyDeployment ApproachThe Contractor shall develop a CCN Deployment Approach to describe the strategy and procedures associated with deploying the CCN by region, VA Medical Center (VAMC), and VAMC catchment construct identified in Attachment J, “VA Medical Center Catchment Area by CCN Region.”The CCN Deployment Approach shall contain details on the Contractor’s method to: Activate provider networks to achieve FOCPrepare for deployment Complete training requirements Identify additional documentation requirements for CCNProvide a series of risks and mitigation strategies specific to CCN deploymentDeliverable:CCN Deployment ApproachRisk Management Plan (RMP)The Contractor shall create and adhere to a Risk Management Plan (RMP), which will consist of a set of risk and issue management processes. The Contractor shall report risks and issues to VA for all CCN activities.The RMP shall identify circumstances that create a negative impact on the CCN. The RMP shall also describe these impacts and describe measures to either minimize or eliminate the potential impact on the CCN. The Contractor shall submit updated risk responses and actions to include mitigation strategies for each Quarterly Progress Report (QPR).The Contractor shall track and manage risks and issues and report them to VA in the contractor-created Project Risk Registry throughout the period of performance. The Contractor shall also collaborate with VA to establish the priority, scope, bounds, and resources for managing project risks and issues, and/or assess the courses of action related to them. The Contractor shall inform VA of relevant deliberations and recommendations to mitigate and resolve project risks and issues as they are identified. The Project Risk Registry shall be updated as necessary and provided to VA. Deliverables: Risk Management PlanProject Risk Registry Contractor OperationsThe Contractor shall ensure that all necessary medical documentation and other Veteran care-specific information is provided to other CCN Contractor(s) when a Veteran receives services in each CCN Region(s) covered under another contract. Quality Assurance Surveillance Plan & Project Management Reporting RequirementsQuality Control Plan (QCP)The Contractor shall establish and maintain a Quality Control Plan. The Contractor’s Quality Control Plan shall demonstrate how the Contractor’s performance will adhere to the Quality Assurance Surveillance Plan (QASP) (See Attachment L, “Quality Assurance Surveillance Plan”). VA will utilize the QASP to monitor the quality of the Contractor’s performance. The oversight provided for in the QASP will help to ensure that service levels reach and maintain the required levels throughout the contract term. Further, the QASP provides the COR with a proactive way to avoid unacceptable or deficient performance, and provides verifiable input for the required Past Performance Information Assessments. The QASP will be finalized upon award and a copy provided to the Contractor after award. The QASP is a living document and may be updated by VA as necessary and executed upon bilateral agreement with the Contractor. The Contractor shall meet performance targets established by the QASP. To provide for changing quality assurance and quality performance conditions, either VA or the Contractor may request changes to the components of QASP measurement and reporting. The Contractor shall address all QASP performance metrics and whether the performance threshold has been met and/or exceeded for each standard in a Section entitled “QASP Summary Report” within its Monthly Progress Report (MPR) (See Section 2.5.2, Supplemental Project Management Reporting Requirements). Deliverable:Quality Control Plan Supplemental Project Management Reporting RequirementsThe Contractor shall establish and maintain Quarterly Progress Reports (QPR). The Contractor shall provide the designated PM and Contracting Officer’s Representative (COR) with QPR in electronic form in Microsoft Word, Project, or Excel formats as directed by the COR. The QPR shall include:QASP Summary ReportHigh Level Cost SummaryHigh Level Schedule SummaryHigh Level Risks and Issues SummaryCorrective Actions and ImprovementsPlanned activities for Next QuarterThese reports shall reflect data as of the last day of the preceding quarter. The Contractor shall participate in quarterly Program Management Reviews (PMR) with VA to support the presentation of information contained in the QPR.The Contractor shall create Monthly Progress Reports (MPR). The Contractor shall provide the COR with MPR in electronic form in Microsoft Word and Project formats. The report shall include detailed instructions/explanations for each required data element in this section. The report shall also identify any performance problems that arose and a description of how those problems were resolved.?If problems have not been completely resolved, the Contractor shall provide an explanation, including their plan and timeframe for resolving the issue. The Contractor shall keep in communication with VA so issues that arise are transparent to both parties to prevent escalation. The Contractor shall participate in ad hoc project related meetings with VA. The MPR shall reflect the data as of the last day of the preceding month. The MPR shall identify the sources from which the data is pulled, and include notifications when updates to technical documents are made. Deliverables:Quarterly Progress ReportMonthly Progress ReportCommunity Care Network (CCN) Communications PlanThe Contractor shall develop a CCN Communications Plan to document the Contractor’s approach to communicating with Community Care (CC) stakeholders throughout the period of performance:Note: A comprehensive list of Community Care (CC) stakeholders will be provided for reference, and as applicable, in the final version of the RFP.The CCN Communications Plan shall also detail the key messages thatshall be articulated to the CC stakeholders, as well as the timing associated with the delivery of those messages. The CCN Communications Plan shall also contain the desired outcomes for the communications, as well as the vehicles for communications distribution.Deliverable:CCN Communications Plan AccreditationExcept as described in Section 3.6.1, “Interim Network Credentialing Requirements,” healthcare delivery shall not commence until the CCN meets accreditation standards set forth herein. The CCN shall be accredited by a nationally-recognized accrediting organization. The contractor shall ensure that all services, facilities and providers are in compliance with the accrediting organizations standards prior to serving Veterans under this contract. National certification, in lieu of accreditation, is insufficient to meet this requirement. In the event that this contract and the accrediting organization have different standards for the same activity, the more stringent standard shall apply for the services under this contract. The Contractor shall maintain accreditation on the following components or programs of the CCN:Provider Network or Health Network: accredited prior to the SHCD and within twelve (12) months from date of award. Certificates to be provided within twelve (12) months from date of award Credentialing Process: Certificates to be provided no later than date of awardMedical Management Process: Certificates to be provided no later than date of award and within thirty (30) days of exercise of Option;Optional Task: Disease ManagementOptional Task: Case ManagementThe Contractor shall maintain documentation of all accreditation, certification, credentialing, privileging, and licensing for its accredited components or programs and providers performing services under this contract. The Contractor shall provide a copy of its accreditation certificates at time of award or upon receipt, as applicable, and upon renewal thereafter. VA reserves the right to perform random reviews of the accreditation, certification, credentialing, privileging/competency measures, and licensing files for the accredited programs and providers within the CCN. The Contractor shall provide access to these files within five (5) business days of notification of such an audit. Deliverable:Accreditation DocumentationHIGH-PERFORMING NETWORKNetwork Establishment and Maintenance The Contractor shall provide a CCN. The CCN shall consist of a comprehensive network of qualified healthcare providers and practitioners to provide services set forth in Section 4.0, “CCN Healthcare Benefits Package.” Additional requirements for the Pharmacy component of the CCN are contained in Section 15, “Pharmacy.” Additional requirements for the Durable Medical Equipment (DME) component of the CCN are contained in Section 16, “Durable Medical Equipment, Medical Devices, and Orthotic and Prosthetic items.” Additional requirements for the Dental component of the CCN are contained in Section 17, “Dental.” The Contractor shall maintain a network of providers and practitioners that will extend across the entirety of each CCN Region and must be sufficient in numbers and types of providers, practitioners, and facilities to ensure that all services will be accessible within the time frames outlined in this section below. Network adequacy will be determined by two factors: (i) geographic accessibility and (ii) travel distance. Where access is inadequate as determined by VA, the Contractor shall be required to recruit providers and practitioners to participate in the CCN. In essence, the CCN shall: Include individual providers, practitioners and institutional facilitiesCoordinate with the care and services provided by VAMonitor quality and cost-effective care; andBe adequate in size, scope and capacity to ensure Veterans receive timely access to careThe size, scope and capacity of a CCN – to ensure timely access to care – shall be set up in accordance with the minimum standards for each VAMC service area found in the tables below:Table 3.1A Maximum Drive TimesDrive TimesPrimary CareUrbanThirty (30) minutesRuralForty-five (45) minutesHighly RuralSixty (60) minutesGeneral CareUrbanForty-five (45) minutesRuralOne hundred (100) minutesHighly RuralOne hundred eighty (180) minutes*Note: Drive Times calculations are in Section 3.5, “Network Adequacy Management.”Table 3.1B Maximum Appointment Availability TimesAppointment AvailabilityEmergentUrgentRoutineUrbanTwenty-four (24) hoursForty-eight (48) hoursThirty (30) DaysRuralTwenty-four (24) hoursForty-eight (48) hoursThirty (30) DaysHighly RuralTwenty-four (24) hoursForty-eight (48) hoursThirty (30) DaysAny deviations from these minimum standards must be requested in writing by the Contractor and submitted to the COR. Written requests must include a detailed explanation of the circumstances that justify a deviation. Written requests will be reviewed by the COR and a determination will be provided by the Contracting Officer. Provider NetworksThe Contractor shall be responsible for contacting, negotiating, and contracting with hospitals, physicians, and other healthcare professionals and practitioners within the awarded CCN Regions (See Section 3.4, CCN Regions). The Contractor shall use the most recent utilization data available to determine which providers and practitioners should be considered for CCN contracting. VA will provide Fiscal Year 2015 (FY15) utilization data on or before the date of the kickoff meeting. VA has attached FY15 Summary Demand Data identifying the volume by categories of care by CCN Region (See Attachment A, “Summary Demand Data”) and FY15 Active Veteran counts by CCN Region (See Attachment B, “Projected Active Veterans”).The Contractor shall report monthly to the referring provider or practitioner and VA any appointments not kept by Veterans. The Contractor shall inform all Health Services Network providers and Complementary and Integrative Health Systems (CIHS) practitioners that it is impermissible to charge any Veteran for not keeping a scheduled appointment. The Contractor shall include a process for Veterans to rate their providers and practitioners based on satisfaction of services rendered and include such ratings in the Contractor’s monitoring of cost and quality. The Contractor shall provide to VA a Veteran Feedback Plan to VA for approval prior to implementation that describes the process Veterans will use to rate CCN providers on the services they receive under this contract. Deliverable: Veteran Feedback PlanCCN Healthcare Services NetworkThe CCN Healthcare Services Network shall be comprised of a comprehensive network of licensed healthcare providers to deliver the services identified in Section 4.1, “CCN Healthcare Services,” and to meet the network adequacy standards in Section 3.1, “Network Establishment and Maintenance.” The Contractor shall make every reasonable attempt to ensure access to Academic Teaching Facilities and Federally Qualified Healthcare Centers as part of the CCN Healthcare Services Network. The Contractor shall make every reasonable attempt to also include Tribal Health Services in the CCN Healthcare Services Network after December 31, 2017.The Contractor shall make every reasonable attempt to allow Veterans to remain with their existing providers by contracting with those providers to be in the CCN.The Contractor shall ensure that all appointments for healthcare services are honored for authorized services by their network providers, unless an appointment is canceled by the Veteran or due to circumstances outside of the CCN Healthcare Services Network provider’s control. CCN Complementary and Integrative Health Services (CIHS) Network The Contractor shall provide access to a CCN CIHS Network. The CCN CIHS Network shall be comprised of a comprehensive network of practitioners to deliver the services identified in Section 4.2, “Complementary and Integrative Health Services” and to meet the network adequacy standards of Section 3.1, “Network Establishment and Maintenance.” The Contractor shall confirm that all CCN CIHS Network practitioners are in compliance with all applicable federal and state laws, statutes, and regulatory requirements. The Contractor shall confirm if a CCN CIHS practitioner’s practice area provides for certification. If so, then the CCN CIHS practitioner must hold such certification. The Contractor shall require that all appointments for CCN CIHS are honored for authorized services, unless an appointment is canceled by the Veteran or due to circumstances outside of the CCN CIHS Network provider’s control. Identification of High-Performing ProvidersThe Contractor shall identify and designate high-performing Health Services Network Quality and Performance Criteria Thresholds based on the criteria agreed to by VA during the Implementation Phase (See Attachment C, “Quality and Performance Criteria”). For the purpose of identifying and designating a provider as described in this section, the Contractor may use any internal CCN provider performance data that are applicable to that provider. The Contractor shall be responsible for monitoring and reviewing the performance of CCN providers and taking corrective action when necessary. The Contractor shall provide a monthly Network Monitoring Report (See Section 3.5, “Network Adequacy Management”) to identify (i) utilization and cost trends; (ii) potential quality issues; (iii) failure to comply with medical management protocols, and (iv) to develop and implement corrective action plans.Deliverable:Health Services Network Quality and Performance Criteria Thresholds Institutional Centers of ExcellenceThe Contractor shall identify and designate high-performing institutional providers as Centers of Excellence (CoE). Any designation of an institution as a CoE must be based on the Health Services Network Quality and Performance Criteria Thresholds as agreed to by VA, as referenced in Section 3.3, “Identification of High-Performing Providers.” The Contractor shall provide the CoE designation in all provider data transmitted to VA.Group Practice ProvidersThe Contractor shall identify and designate Health Services Network group practice providers as high-performing providers based on the combined group practice performance against the Health Services Network Quality and Performance Criteria Thresholds agreed to by VA as referenced in Section 3.3, “Identification of High-Performing Providers.” The Contractor shall provide the high-performing provider designation in all provider data transmitted to VA. Individual ProvidersThe Contractor shall identify and designate Health Services Network individual providers as high-performing providers based on the individual provider’s performance against the Health Services Network Quality and Performance Criteria Thresholds agreed to by VA as referenced in Section 3.3, “Identification of High-Performing Providers.” The Contractor shall provide the high-performing provider designation in all provider data transmitted to VA. Community Care Network (CCN) Regions For the purposes of this contract, the CCN Regions are as follows:[THIS SPACE INTENTIONALLY LEFT BLANK]Table 3.4 VA CCN RegionsCCN Region 1CCN Region 2CCN Region 3CCN Region 4MaineOhioOklahomaTexasNew HampshireKentuckyArkansasNew MexicoVermontIndianaLouisianaArizonaMassachusettsIllinoisTennesseeCaliforniaConnecticutMissouriMississippiNevadaRhode IslandKansasAlabamaUtahNew YorkNebraskaGeorgiaColoradoNew JerseyIowaSouth CarolinaWyomingDelawareWisconsinFloridaIdahoMarylandMichiganPuerto RicoOregonPennsylvaniaMinnesotaUS Virgin IslandsWashingtonDCNorth DakotaMontanaWest VirginiaSouth DakotaAlaskaVirginiaHawaiiNorth CarolinaNorthern Mariana IslandsGuamAmerican SamoaNetwork Adequacy ManagementThe Contractor shall detail the approach for creating and maintaining an adequate CCN in a Network Adequacy Plan. The CCN shall be customized for each VAMC service area per Attachment J, “VA Medical Center Catchment Area by CCN Region.” The Contractor shall obtain approval of the Network Adequacy Plan from VA at least thirty (30) days prior to the delivery of healthcare services.The Contractor shall monitor CCN performance against the network adequacy standards set forth in Section 3.1, “Network Establishment and Maintenance,” as part of the Network Adequacy Plan. The Contractor shall create a Network Adequacy Performance Report. The Contractor shall record performance, including any performance deficiencies, and submit the performance record as part of a Network Adequacy Performance Report to VA during status update meetings to occur no less frequently than monthly. VA maintains the ability to request ad hoc meetings with the Contractor to discuss identified issues. The Network Adequacy Performance Report shall include the following elements: (i) average drive time calculated by Google Maps between Veteran zip code and provider zip code without factoring in allocations for traffic conditions per claim received; (ii) average appointment wait time using referral issuance data and actual appointment date on the first claim associated with that referral; and (iii) further analysis that takes into account any Veteran or CCN provider complaint data received regarding drive time or appointment availability standards. The Contractor shall develop and submit to VA a Network Adequacy Corrective Action Plan for contractor resolution of any performance deficiencies identified by the Contractor or VA within ten (10) days of its discovery. The Contractor’s Network Adequacy Corrective Action Plan shall include the reason(s) for the performance deficiency and timeline for the Contractor to correct the deficiency. The Contractor shall meet periodically with VA to evaluate network performance.The Contractor shall establish and maintain a Network Monitoring Report. The Contractor’s monthly Network Monitoring Report shall (i) identify utilization and cost trends; (ii) potential quality issues; (iii) failure to comply with medical management protocols; and (iv) to develop and implement corrective action plans.Deliverables:Network Adequacy PlanNetwork Adequacy Performance ReportNetwork Adequacy Corrective Action PlanNetwork Monitoring ReportNetwork CredentialingInterim Network Credentialing RequirementsThe Contractor may commence healthcare delivery prior to network accreditation for the CCN Healthcare Services Network so long as the contractor complies with the interim network credentialing requirements set forth in this section. Upon the Contractor’s receipt of accreditation, the credentialing requirements set forth in Section 3.6.2, “Network Credentialing Requirements upon Accreditation,” shall apply.The Contractor shall confirm that all services, facilities, and providers are in compliance with all applicable federal and state regulatory requirements. Any provider on the U.S. Health and Human Services (HHS) Office of the Inspector General (OIG) exclusionary list shall be prohibited from network participation. See: , for further detail.In accordance with requirements outlined in the OIG’s Compliance Program Guidance for Hospitals () and USSC Sentencing Guidelines (), the Contractor shall confirm that all services, facilities, and providers have a compliance program in place that includes the seven elements of an effective compliance program.The Contractor shall be responsible for ensuring that CCN Healthcare Services Network providers: Have an active, unrestricted license in the state in which the service is performed;Have a current National Provider Identifier (NPI) number;Whose names appear on the Centers for Medicare & Medicaid Services (CMS) exclusionary list shall be prohibited from providing services;Who prescribe have a Drug Enforcement Agency (DEA) number; Provide documentation to allow verification of the highest of the three levels of education and training; and Are participating in Medicare or Medicaid programs. The facility accreditation requirement may be waived by the CO, who will coordinate with the CO and facility, for facilities that do not have a preexisting requirement for accreditation due to federal or state requirements. In cases in which this requirement is waived, the Contractor shall note the omission and submit proposed alternative qualification standards so as to ensure a like standard of quality to the CO and COR. If a provider is or has been licensed, registered, or certified in more than one state, the Contractor shall confirm that the provider certifies that none of those states has terminated such license, registration, or certification for cause, and that the provider has not voluntarily relinquished such license, registration, or certification in any of those states after being notified in writing by that state of potential termination for cause.The Contractor shall confirm that the provider notifies the Contractor within fifteen (15) days if any state in which the provider is licensed, registered, or certified terminates such license, registration, or certification for cause, or if the provider voluntarily relinquishes such license, registration, or certification after being notified in writing by that state of potential termination for cause. Such termination or relinquishment is cause for immediate removal from the CCN.The Contractor shall ensure that all Veteran appointments are honored for authorized services by network providers, unless an appointment is canceled by the Veteran or due to circumstances outside of the provider’s control. Network Credentialing Requirements upon AccreditationThe Contractor shall confirm that CCN Healthcare Services Network providers and facilities are credentialed in accordance with the requirements set forth by the nationally-recognized accrediting organization for the Contractor’s credentialing program. The Contractor shall incorporate an annual review of provider credentials into its credentialing program. The Contractor shall ensure that all Veteran appointments are honored for authorized services by network providers, unless an appointment is canceled by the Veteran or due to circumstances outside of the provider’s N HEALTH BENEFIT PACKAGECCN Healthcare ServicesThe Contractor shall include the following CCN Healthcare Services as described in 38 Code of Federal Regulations (C.F.R.) § 17.38 as part of the services provided under this contract:Table STYLEREF 1 \s 4. SEQ Table \* ARABIC \s 1 1 CCN Healthcare ServicesHealth BenefitCoverageBasic Medical Benefits Package, includesPreventive CareComprehensive Rehabilitative ServicesHospital ServicesAncillary ServicesMental Health (to include professional counseling)Residential CareHome Healthcare (Skilled and Unskilled)Hospice /Palliative Care/RespiteGeriatricsOutpatient Diagnostic and Treatment ServicesInpatient Diagnostic and Treatment ServicesLong Term Acute CareAcupunctureAll eligible VeteransPharmacyAll eligible Veterans; Contractor shall only provide pharmacy services for urgent and emergent prescriptionsDentalRequires special eligibility (See Section 15, “Dental”) Emergent CareUnder certain conditions pursuant to 38 C.F.R. § 17.38Durable Medical Equipment, Medical Devices, Orthotics and ProstheticsUnder certain conditions pursuant to 38 C.F.R. § 17.38Reconstructive Surgery Under certain conditions pursuant to 38 C.F.R. § 17.38ImmunizationsUnder certain conditions pursuant to 38 C.F.R. § 17.38ImplantsWhen provided as part of an authorized surgical or medical procedureUrgent CareOptional service to be exercised by VANote: CCN Healthcare Services may include rehabilitative therapies provided by non-licensed practitioners (e.g. blind therapy; driver rehabilitation services; recreational therapy).CCN Healthcare Service ExceptionsCCN Healthcare Service Exceptions are services covered by the CCN Health Benefit Package pursuant to 38 C.F.R. § 17.38, but shall not be provided under this contract. The Contractor shall not be reimbursed for the Administrative Fees or the Cost of Medical Care if any services for the following items are provided to an Active Veteran:Beneficiary TravelMedical and rehabilitative evaluation for artificial limbs and specialized devices such as adaptive sports and recreational equipmentNursing home care including State Veterans’ Home per diemChronic dialysis treatmentsCompensation and pension examinationsCCN Complementary and Integrative Health Services CCN CIHS are Veteran services that are covered under the VA Health Benefits Package pursuant to 38 C.F.R. 17.38. The Contractor shall provide the following CCN CIHS and require all practitioners to submit claims using the appropriate Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) code. If a CPT or HCPCS code is unavailable, the CCN CIHS practitioner shall use VA National Clinic List Codes identified in the table below as CPT codes or HCPCS codes. Table 4.2 VA National Clinic List CodesVA National Clinic List CodeNameCoverageBIOFBiofeedbackUnder certain conditions pursuant to 38 C.F.R. § 17.38HYPNHypnotherapyMSGTMassage TherapyNAHLNative American HealingRLXTRelaxation TechniquesTAICTai ChiExcluded CCN Healthcare ServicesExcluded CCN Healthcare Services are services not covered by the CCN Health Benefit Package pursuant to 38 C.F.R. § 17.38. The Contractor shall exclude the following healthcare services from the CCN Health Benefit Package: Abortion or abortion counselingIn vitro fertilization (medically indicated diagnostic testing or treatments related to in vitro fertilization are covered benefits)Drugs, biologicals, and medical devices not approved by the Food and Drug Administration unless used under approved clinical research trialsGender alterations (medically indicated diagnostic testing or treatments related to gender alterations are covered benefits)Hospital and outpatient care for a Veteran who is either a patient or inmate in an institution of another government agency if that agency has a duty to give the care or servicesMembership in spas or health clubs Out-of-network services without a referral ELIGIBILITY VERIFICATION AND ENROLLMENTEligibility DataThe Contractor shall confirm eligibility with VA for all Veterans who choose community care. The Contractor shall not be responsible for eligibility determinations. The Contractor shall verify Veteran eligibility using data provided by VA via an EDI 278 transaction. Eligibility VerificationsIn order to be eligible, a Veteran must be both enrolled in the VA Healthcare System and have an Approved Referral for care in the community. The Contractor shall respond to requests for eligibility data from community providers and Veterans electronically and/or via telephone. The Contractor shall ensure Veteran eligibility for services covered under this contract is verified at the time of arrival for an appointment. Contractors shall include in provider training that Choice Cards do not guarantee eligibility or payment for services and that enrollment alone does not indicate eligibility or payment for services.The Contractor shall verify eligibility of Veterans via electronic transmissions in the formats outlined in the Eligibility Verification and Enrollment Data Exchange (See Attachment D, “Eligibility Verification and Enrollment Data Exchange”).Eligibility Verification and Enrollment: Time-Eligible VeteransTime-Eligible Veterans and Service Not Available Veterans (hereinafter referred to as “Time-Eligible” Veterans) are Veterans who are unable to schedule an appointment for hospital care, medical services or dental services with the VA within the wait-time goals of the Veterans Health Administration (VHA) for such care or services or the period determined by a VA provider to be clinically necessary for such care or services, whichever is shorter. This includes when such care or services are not provided within a medical facility of VA that is accessible to the Veteran. This also includes when there is a compelling reason that the Veteran needs to receive the care or service outside of a medical facility of VA.Eligibility Verification and Enrollment: Distance-Eligible VeteransDistance-Eligible and Special-Circumstances Veterans (hereinafter referred to as “Distance-Eligible” Veterans) are Veterans who meet specific requirements as determined by the VA to be eligible for community care due to geographic reasons. Distance-Eligible Veterans who are enrolled in the VA Healthcare System and who have chosen a primary care provider in the community will have an Approved Referral for primary care services for a period not to exceed one (1) year and shall be eligible to receive those services without requesting additional referrals from VA. For services other than primary care services, Distance-Eligible Veterans must receive an approved referral for those specific services from VA in order to be considered eligible for those services. Distance-Eligible Veterans must have an Approved Referral for any other services other than primary care. The Contractor shall ensure eligibility is confirmed for Distance-Eligible Veterans. VA will provide a real time eligibility inquiry service through EDI 270/271 transaction(s). Enrollment The Contractor shall maintain an accurate and up-to-date enrollment system based on information provided by VA. The Contractor shall receive, process, and store electronic transmissions of the initial load of Veteran information from VA and ongoing updates. VA will provide a list of all Enrolled Veterans. Enrolled Veterans may include Veterans who do not currently utilize the VA but may elect to at any point after their enrollment date. The Contractor shall load all Enrolled Veterans in their system for production and distribution of Veterans Choice Cards (See Section 5.3, “Veterans Choice Cards”). The Contractor shall identify Time-Eligible Veterans and Distance-Eligible Veterans in the enrollment system. The Contractor shall receive, process, and store an initial load containing data for Veterans who are currently enrolled in the VA Healthcare System. After receipt of the initial load, the Contractor shall receive, process, and store real-time updates showing Veterans whose enrollment status have changed, to include new enrollments, changes of enrollment status, extensions, or terminations.The Contractor shall use the VA-provided Electronic Data Interchange Patient Identifier (EDIPI) as the unique identification number to each enrolled Veteran. The Contractor shall provide VA with real-time, read-only access to the enrollment system.Veterans Choice CardsVeterans Choice Cards Production and DistributionThe Contractor shall produce all Veterans Choice Cards for Enrolled Veterans in the CCN Regions in which services are provided. The Veterans Choice Cards shall include information required by the Veterans Access, Choice, and Accountability Act of 2014 (VACAA), and any future amendments. The Contractor shall develop an Implementation Plan for Veterans Choice Card Issuance. The Implementation Plan for Veterans Choice Card Issuance shall contain a schedule for an initial distribution of cards for all eligible Veterans during the implementation phase. The Implementation Plan for Veterans Choice Card Issuance shall include a process for handling replacement cards for any Veteran who reports their card as lost. The Contractor shall provide and distribute replacement cards within fourteen (14) days of request.The Implementation Plan for Veterans Choice Card Issuance shall define the process for distributing cards to newly enrolled Veterans after the initial distribution of Veterans Choice Cards. The Contractor shall ensure newly enrolled Veterans receive their cards within fourteen (14) days of notification of eligibility by VA. Each card issued shall be known as a ‘‘Veterans Choice Card’’ and shall include information required by VACAA, as well as the following information:The name of the Veteran, including suffixThe Veteran’s EDIPI Veterans eligibility dataThe Contractor's contact informationWhatever contact information is provided shall allow healthcare providers to confirm eligibility for care or services, and other relevant information for the submittal of claims for the provision of care or servicesContact information for emergency care/hospital admission notificationVA Logo, website address, and phone number Veterans Choice Cards shall not contain the Social Security number (SSN) of the Veteran.The Contractor shall be required to reissue Veterans Choice Cards in the event of a change to the contact information or other relevant information for the submittal of claims for the furnishing of care or services.The Contractor shall submit a proposed Veterans Choice Card design and type that includes the information specified herein and considers cost and value. In order to maintain continuity across the system, the Contractor shall base card design on existing Veterans Choice Cards and federal legislative requirements found in 38 U.S.C. § 17. (See “Southern Arizona VA Health Care System,” as an example of existing Choice Cards: ()). VA will select and approve the final design.Deliverables:Implementation Plan for Veterans Choice Card IssuanceProposed/Final Design for Veterans Choice CardVeterans Choice Card HandlingVeterans Choice Cards shall be mailed to valid postal addresses through the United States Postal Service (USPS). Contractors shall include up to an additional two (2) pages of explanatory information with the Veterans Choice Card. The content and format for these pages will be provided to the Contractor by VA. The Contractor shall provide a Veterans Choice Card Processing Summary Report and a Veterans Choice Card Processing Detailed Report to VA on all card processing outcomes weekly (e.g. cards mailed, returned). The formats for these reports are outlined in Attachment D, “Eligibility Verification and Enrollment Data Exchange.” The Contractor shall receive and handle all returned mail associated with the distribution of Veterans Choice Cards. When the USPS returns the mail as undeliverable, the Contractor shall take the appropriate action based on the reason provided:If the mail is returned and the error can be corrected by the contractor without contacting the Veteran, the Contractor shall correct the error and resend If the mail is returned and the error cannot be corrected by the contractor without contacting the Veteran, then the Contractor shall verify current Veteran address through direct contact with the Veteran When a new address is obtained through any means, the Contractor shall notify VA of the new address in the Veterans Choice Card Processing Detailed Report. The Contractor shall not update address changes in their enrollment system until the address changes have been processed by VA and provided via an eligibility update. When the new address is verified and updated by VA, the Contractor shall notify VA and resend the undelivered mail to the Veteran’s new address. The Contractor shall resolve invalid addresses within thirty (30) days.If unable to deliver the card or contact the Veteran, the Contractor shall notify VA of any undeliverable mail, including name, and address as part of the Veterans Choice Card Processing Detailed Report. The Contractor shall retain undeliverable mail for a period of ninety (90) days, unless an updated address is received before the ninety (90) days expire and the returned mail resent. If the mail is still undeliverable at the end of ninety (90) days, the Contractor shall destroy the card in accordance with VA policy. Deliverables:Veterans Choice Card Processing Summary ReportVeterans Choice Card Processing Detailed ReportCUSTOMER SERVICEThe Contractor shall establish and maintain customer service capabilities in support of the CCN.?These capabilities, detailed in Sections 6.1-6.8, shall include:Establishing and maintaining standards for call centers functionality, Staffing and supporting call centers functionality in compliance with the standards established, Maintaining system interfaces and websites for Veterans, CCN providers and VA, Managing Veteran complaints and grievances based on established procedures, Providing monthly reporting to VA and maintaining communication between VA and the Contractor on performance in all areas of customer service, and,Managing correspondence, including Congressional and VA inquiries.VA Support Call Center Function:? Time-Eligible and Distance-EligibleThe Contractor shall establish and maintain a VA Support Call Center function.?The Contractor shall maintain online service, local telephone service and toll-free telephone lines.?These services shall be available from 7AM to 7PM Monday through Friday, in the local time zones for each CCN Region. The VA Support Call Center will address inquiries made by VA regarding information on community care services, provider directories, eligibility, pharmacy, scheduled appointments, referral/authorization status, claim status, complaints, and grievances. The Contractor shall provide an escalation process for VA to facilitate prompt resolution of customer service issues. The Contractor shall provide VA a warm transfer phone number so that VA can warm transfer a Veteran immediately to the appropriate Contractor customer service representative.?The Contractor shall demonstrate call center capabilities no later than one-hundred twenty (120) days prior to the SHCD, and shall continue to demonstrate call center capabilities throughout performance of this contract. Training documents and response scripts shall be available for review and approval by VA prior to implementation.? CCN Provider Call Center FunctionThe Contractor shall establish and maintain standards for CCN Provider Call Center functionality and toll-free telephone lines, from 7AM to 7PM Monday through Friday in the local time zones for the Contractor’s assigned CCN Region(s), to respond to online and telephonic inquiries related to the following categories:Status of ReferralsAuthorization statusProvider Status for ReferralsClaims StatusClaims IssuesEligibilityPharmacyProvider EnrollmentComplaintsBenefits Issues Online and telephonic inquiries shall be addressed in a timely, accurate, and consistent manner.? The Contractor shall demonstrate provider call center capabilities no later than one hundred twenty (120) days prior to the SHCD, and shall continue to demonstrate provider call center capabilities throughout this contract. Training documents and response scripts shall be available for review by VA prior to implementation.? Call Center Function: After Hours Support The Contractor shall provide after-hours call center support when VA issues a task order for a specified period of time.?The Contractor will have a minimum of five (5) business days to start delivery of services upon execution of a task order. Mailing Ad Hoc CorrespondenceThe Contractor shall perform ad hoc mailing of correspondence directed to Veterans and/or CCN providers when services are ordered through a task order. VA will provide all materials for any ad hoc mailing. When needed, VA will issue a task order for this requirement.Contractor Customer Service TechnologyThe Contractor shall maintain a website/online service for Veterans, VA personnel, and providers related to, at a minimum, Veteran benefits lookup, access via a link to the VA master provider directory search function, eligibility and enrollment, referrals, authorizations, medical management, claims, information on the appeals and grievance processes, and provider manual. The Contractor shall provide access to customer service via a real-time chat function for the VA Support Call Center and the CCN Provider Call Center. Veteran Complaints and Grievances and Customer Service ProcedureThe Contractor shall forward all Veteran Complaints and Grievances received to VA within two (2) business days.?The Contractor shall work with VA to resolve any complaints within three (3) business days. Congressional and VA InquiriesThe Contractor shall forward all inquiries received directly from a Congressional office that are associated with services under this contract to VA within one (1) business day of receipt.VA reserves the right to request information relating to customer service at any time.? When VA requests information from the Contractor, the Contractor shall confirm receipt of the request within one (1) business day. ?The Contractor shall provide the full written response within three (3) business days or as negotiated with VA.Contractor Customer Service Performance StandardsThe Contractor’s customer service performance standards shall include Veteran satisfaction derived from call center functionality statistics and healthcare experience feedback.?The Contractor shall conduct Veteran Satisfaction Surveys on an ongoing basis.?The results of the Veteran Satisfaction Surveys shall be provided to VA on a quarterly basis.Deliverable:Veteran Satisfaction Survey Results? Call Center Operational Performance MeasuresThe Contractor shall provide a VA Support and Provider Call Center Report on a monthly basis.? The report shall include detailed information in the following categories:? ?Blockage RatesCall Abandonment Rates Average Speed of Answer Average Wait Time First Call Resolution Response Accuracy Acknowledgement to VA Of Receipt Of InquiryThe Contractor shall provide a monthly report summarizing all call center inquiries, performance statistics, open issues, and trends.?The Contractor shall include in this report all unexpected downtime events related to the Contractor Customer Service Technology performance (See Section 6.8.2, Customer Service Technology Performance Measures).? The Contractor shall meet with VA quarterly. During these meetings, the Contractor shall review current customer services, activities, call center performance metrics, and Veteran satisfaction survey results to maintain an effective customer service relationship between the Contractor and VA.?The frequency of these meetings may be altered at the discretion of VA.Deliverable:VA Support and Provider Call Center ReportCustomer Service Technology Performance MeasuresThe Contractor shall provide website service availability of 99.9 %.The Contractor shall create and provide an Availability Status Report to VA monthly. The Availability Status Report shall calculate the service’s unavailability for each calendar month.?Calculation of service unavailability shall not include any time the service is unavailable due to scheduled maintenance.?The Contractor shall notify the VA COR 48 hours prior to performance of any non-emergency maintenance.If service availability falls below 99.9%, the Contractor shall conduct root cause analyses and provide findings and recommendations to the COR within three (3) business days of detection.?The Contractor shall provide the COR with a schedule to resolve the issues within two (2) business days of completion of the root cause analysis.The Contractor shall provide real-time communication of metrics concerning unexpected system downtime.?This shall include web/online services and call center functionality.Deliverable:Availability Status Report Complaints and Grievances Performance MeasuresThe Contractor shall submit all Veteran complaints about any aspect of care provided under this contract to VA within one (1) business day of receipt.REFERRALS AND PRIOR AUTHORIZATIONSThe Contractor shall create, administer and maintain a referral and prior authorization management system or process that meets the requirements defined in this section.All services, other than primary care for Distance Eligible Veterans, require an approved referral from VA. Primary Care for Distance Eligible Veterans is authorized based on the VA eligibility data and such referral shall not exceed a period of one (1) year. Veterans may submit a request to VA for mental health services independently of a referral from a primary care provider. The Contractor shall direct all requests for referrals to VA for appropriate disposition and scheduling of the appointment. The Contractor shall leverage an existing referral and prior authorization management system to communicate with VA through an EDI 278 transaction(s) (for requests and responses) through the VA clearinghouse in accordance with the One VA Technical Reference Model () and Health Insurance Portability and Accountability Act (HIPAA). The Contractor shall establish a mechanism to inform CCN providers of services requiring referrals, prior authorizations, and emergency notification requirements. Notification of Emergency CareThe Contractor shall contact VA if a Veteran requires emergency management and/or admission for coordination of care within three (3) hours after the Veteran is clinically stabilized. The Contractor shall notify VA of all emergent requests for care within seventy-two (72) hours. The Contractor shall process these requests as a post-service request for approval by VA. The Contractor shall notify VA within seventy-two (72) hours that a Veteran presented for care in an emergency room. The Contractor shall send VA the notification through an EDI 278 request transaction within one (1) business day and shall store this information in their referral and prior authorization management system.Referrals from VA to Community Care Network ProviderThe Contractor shall adhere to the process represented in the following table:Table 7.2 Referral Process and ActionsStep NumberAction1VA creates an EDI 278 transaction, including attachments2VA sends an EDI 278 transaction, including attachments, to the referred CCN provider3Referred CCN provider receives the EDI 278 transaction, including attachments4VA sends a copy of the EDI 278 transaction to the Contractor5Contractor receives copy of the EDI 278 transaction and stores for claims adjudicationVA will provide the referral number for all services requiring a referral. VA will also maintain the capability to send and receive referral information via secure email, fax and telephone when the provider lacks the capability to electronically transmit referral requests as described in this section. VA will approve or deny all referral requests.Referrals from a Community Care Network Provider for VAThe Contractor shall adhere to the process represented in the following table:Table STYLEREF 1 \s 7.3 Process for Transmitting Referrals from a CCN Provider for VAStep NumberAction1Referring CCN provider creates an EDI 278 transaction, including attachments2Referring CCN provider sends an EDI 278 transaction, including attachments, to VA3VA receives the EDI 278 transaction, including attachments4VA makes a determination5VA sends EDI 278 transaction to referring community provider6Referring CCN provider receives EDI 278 transaction determination from VA7VA sends a copy of the EDI 278 determination to the Contractor8Contractor receives copy of the EDI 278 determination and stores for claims adjudicationVA will provide the referral number for all services requiring a referral. VA will also maintain the capability to send and receive referral information via secure email, fax and telephone when the provider lacks the capability to electronically transmit referral requests as described in this section. VA will approve or deny all referral requests. The Contractor shall inform all CCN providers that Distance Eligible Veterans have an open referral for primary care and that the plan number contained in the eligibility information will be utilized as the referral number for claims processing purposes. Prior AuthorizationsAttachment M, “Prior Authorization List,” contains a list of services that are pre-authorized under this contract. The Contractor shall ensure all prior authorization requests for CCN healthcare services, when required, are submitted to VA for all Veterans who reside within its CCN Region(s). VA will provide to the Contractor an updated list of services requiring prior authorization and associated business rule guidance during the implementation phase. The Contractor shall update the Pre-Authorization List and associated business rule guidance in their claims adjudication system within thirty (30) days upon receipt of revisions from VA.The Contractor shall ensure all prior authorization requests are submitted to the VA in an electronic format, where available. The Contractor shall ensure all CCN providers who do not have the capability to submit EDI 278 transactions shall submit prior authorization requests via secure email, fax, or telephone. VA will approve or deny all prior authorization requests. The Contractor shall conduct retrospective reviews of all prior authorization requests when the Contractor is acting as a secondary payer.The Contractor shall ensure transmission of the prior authorization number and associated referral documentation can be achieved through an EDI 278 transaction, including attachments. following the same process in Table 7.2 and Table 7.3 above. The Contractor shall ensure a copy of the prior authorization number and prior authorization information (medical codes, effective date, termination date, date generated) is stored electronically in the Contractor’s referral and prior authorization management system. This information shall be used to validate claims data in the automated claims adjudication process.The Contractor shall notify the Veteran and the CCN provider if the prior authorization request is denied and shall advise them of their right to appeal in accordance with Section 13.1, “Veterans Appeals,” and Section 13.2, “Provider Reconsiderations.” Referrals and Prior Authorization Reports The Contractor shall provide a monthly Referral Summary Report and a monthly Prior Authorizations Summary Report that are to include referral or prior authorization requests received from VA. The reports shall include the Veteran EDIPI, Provider Information, Medical Service Request, Request Date, and summary of requests to VA that remain open. The Contractor shall provide a monthly Referral Statistics and Prior Authorization Statistics Report to include Referral Summary Statistics, and Prior Authorization Summary Statistics as follows:Referral Summary StatisticsMonthly totals for all referrals – The following totals are to be included: The sum of all referral requests received The sum of all referrals forwarded to VA for review The sum of all referrals processed by the ContractorRequests by specialty– The following totals are to be included: The sum of all referral requests received from community providers by referred-to specialty; within the referred-to specialty:the sum of the referrals approved the sum of the referrals deniedPrior Authorization Summary StatisticsMonthly totals for all prior authorizations - The following totals are to be included: The sum of all prior authorization requests receivedThe sum of all prior authorization forwarded to VA for reviewThe sum of all prior authorization processed by the ContractorRequests by specialty - The following totals are to be included: The sum of all prior authorization requests received from community providers by specialty; within the specialty:the sum of the prior authorizations approvedthe sum of the prior authorizations deniedDeliverables:Referral Summary Statistics ReportPrior Authorization Statistics ReportScheduling of AppointmentsThe VA is responsible for scheduling all appointments for Veterans who receive CCN healthcare services referenced in Section 4.0, “CCN Health Benefit Package,” under this contract. The Contractor shall direct all requests for referrals to VA for appropriate disposition and scheduling of the appointment. Medical DocumentationMedical Documentation Submission Process The Contractor shall ensure that medical documentation is delivered to VA and the referring provider, if not VA, for services rendered to Veterans under this contract. The Contractor shall provide a Medical Documentation Submission Plan to describe all processes, procedures, criteria, information and data collection activities and requirements that the Contractor shall use in conducting medical documentation submission management. The Contractor shall provide a Medical Document Submission Report. This report shall demonstrate, at a minimum, compliance with Contractor’s developed medical documentation submission process.The Contractor shall submit a process to confirm the submission of medical documentation to VA when: (i) VA is the referring provider; (ii) VA is the primary care provider or (iii) VA requests medical documentation. The process shall include an operational definition of medical record submission compliance, actions the Contractor will take to encourage compliance, and thresholds of non-compliance that will evoke action by the Contractor. The Contractor shall also provide a process to receive information regarding non-compliant providers from VA and CCN referring facility and/or provider, and the roles, responsibilities and points of contact for the process. The Contractor’s process shall be approved by VA prior to execution.Deliverables:Medical Documentation Submission Plan Medical Documentation Submission ReportMedical Documentation Data ElementsThe Contractor shall require medical documentation to be submitted in a legible format and include, at a minimum, the following data elements: Encounter notes to include any procedures performed and recommendations for further testing or follow-up (e.g. discharge summary for inpatient)In lieu of encounter notes, a clinical summary may be provided for ancillary services when appropriate (e.g. physical therapy, occupational therapy, speech and language pathology, and nutrition services). Results of community testing or imaging such as MRI, CT scanActual results of any ancillary studies/procedures which would impact recommended follow up such as biopsy results (e.g. biopsy results from GI provider who recommends a follow up such as surgery); andAny recommended prescriptions, medical devices, supplies, or equipment, and treatment plans. The Contractor shall ensure all medical documentation is maintained in accordance with: (i) the requirements of the provider’s applicable state licensing authority; (ii) applicable standard of practice in the state in which the provider is located; and/or (iii) The Joint Commission standards ().If more than one of the three enumerated standards applies, then the more stringent standards apply.The Contractor shall ensure all medical documentation includes the following data when sent to VA: VA EDIPI NumberVeteran full name, including suffix, sex, date of birth, and referral numberMedical Documentation Submission TimeframesExcept as stated in Section 17.5, “Return of Dental Records,” and Section 16.0. “Durable Medical Equipment, Medical Devices, Orthotic and Prosthetic Items,” initial medical documentation is medical documentation associated with the first appointment of an Episode of Care. Final medical documentation is medical documentation that covers the entire Episode of Care.? Initial medical documentation for outpatient care shall be returned within thirty (30)days of the initial appointment. Final outpatient medical documentation shall be returned within thirty (30) days of the completion of the Episode of Care.Medical documentation shall be returned within thirty (30) business days for inpatient care and consist of a discharge summary.? Critical findings shall be communicated to VA within two (2) business days. Communications shall be either verbal or written. The contractor shall ensure that the Veteran and VA are notified of test results within fourteen (14) days of the authorized episode of care.Medical Documentation Submission FormatThe Contractor shall ensure medical records are submitted directly to VA via electronic submission, where available. The Contractor shall ensure that medical documentation is submitted via a Continuity of Care Document Architecture (CCDA) electronic EDI X12-275 transaction(s), version 5010, secure email, or fax. VA will provide notice to the Contractor in the event VA adopts an updated version, and the Contractor shall notify their providers of such updates within forty-five (45) days of receipt of notice from VA. TRAININGTraining PlanThe Contractor shall provide a Training Plan that will include all training programs and activities as described in Section 10, “Training.” The Contractor’s Training Plan shall outline the methods, schedule, role-specific training requirements, scope of training, and outcome measurements to be provided. The Contractor shall review, update, and submit the Training Plan on a quarterly basis to VA for approval.Deliverable:Training PlanTraining Program for Contractor CCN Providers, Contractor Personnel and VA Staff Training ProgramThe Contractor shall develop a Training Program that shall include training for CCN providers, Contractor personnel and identified VA staff in the following areas: VA Support Call Center; CCN Provider Call Center; Systems, system interfaces, and system access; andAny other areas identified by VA or the Contractor related to services required under this contract. The Contractor shall provide training at least sixty (60) days prior to the SHCD and provide updated training within thirty (30) of implementing any material system changes.The Contractor shall review and update the Training Program at a minimum on an annual basis. Deliverable:Annual Training Program and Updates Contractor CCN Provider and Contractor Personnel Outreach and Education ProgramThe Contractor shall develop and implement an initial and ongoing outreach and education program for CCN providers and personnel to execute the requirements under this contract. The Contractor’s outreach and education program shall be documented in the Training Plan that outlines the methods, schedule, role-specific training requirements, scope of training, and outcome measurements to be provided. The Contractor’s outreach and education program shall include at a minimum: VA program requirements, policies, and procedures related to the requirements under this contract; Veterans’ healthcare benefits that are administered through this contract referenced in Section 4.0, “CCN Health Benefit Package;”Referral and prior authorization processes (including emergency notification, and referrals back to VA);Claims submission processes; Encouraging the use of a certified health information exchange to facilitate the exchange of information between the provider and VA; Compliance with medical documentation submission requirements set forth in this contract; and Any other areas identified by VA or the Contractor related to services required under this contract. Contractor-Provided VA Staff Training SessionsThe Contractor shall conduct the following training sessions for VA staff:Customer Service (50 trainees):Training Method: Web-based or virtual, as agreed uponTarget Staff: VA Customer Service Personnel – the purpose of this training is to provide “Train the Trainer” for VA Customer Service personnel Training Focus: Full Scope of Contractor’s Operations for Customer Service supportContractor-Specific Systems Training for designated VA data analytics users (50 trainees):Training Method: In-person, web-based or virtual, as agreed uponTarget Staff: Designated Community Care VA users who will have access to Contractor systems Training Focus: Contractor systems training to allow VA users to effectively access interpret and utilize Contractor dataVA CCN Field Operations Training (254 trainees)Training Method: In-person, web-based, or virtual, as agreed uponTarget Staff: Designated CCN Field Operations StaffCCN Regional Offices – 50VA Program Offices – 30VISN Staff – 21VAMC Staff - 153 Training Focus: Full scope of Contractor’s operational components Contractor Training MaterialsThe Contractor shall deliver Training Materials that are compliant with the commercial standard Shareable Content Object Reference Model (SCORM) to VA to facilitate all required training. The Contractor shall utilize VA terms in its Training Materials or provide a glossary to allow trainees to understand the meaning of terms. VA shall maintain the right to modify and reproduce both printed and electronic Training Materials during and after the period of performance. The Contractor shall obtain VA approval of all Training Materials prior to the execution of the Training Sessions referenced in Section 10.1.3, “Contractor-Provided VA Staff Training Sessions.”Deliverable:Training MaterialsMEDICAL MANAGEMENT The Contractor shall establish and maintain a discharge planning program for eligible Veterans. The Contractor shall provide access to its program information and data to VA upon request. The Contractor shall create a Medical Management Plan. The Medical Management Plan shall describe the following: All processes, procedures, criteria;Staff and staff qualifications;Patient selection criteria; Information and data collection activities; andRequirements that the Contractor shall use for Distance-Eligible Veterans and all Time-Eligible Veterans with a CCN primary care provider. The Contractor’s Medical Management Plan shall be reviewed and accepted by VA at least ninety (90) days prior to SHCD and must be reviewed and accepted again at least thirty (30) days prior to the effective date of any material change.Deliverables:Medical Management Plan Discharge PlanningThe Contractor shall establish and administer a discharge planning program for inpatient Veterans authorized to receive care under this contract.The Contractor shall submit a Discharge Planning Plan to include the program design for managing inpatient discharges. The Contractor shall submit the Discharge Planning Plan to VA for approval thirty (30) days prior to execution.The Contractor’s Discharge Planning Program shall be applied to all inpatient Veterans.The Contractor shall establish Discharge Planning Liaison positions to facilitate the transfer of information from the Contractor to VA. The Contractor’s Discharge Planning Liaisons are not required to be co-located in VAMCs; however, specific contact information for each Discharge Planning Liaison shall be provided to VA.The Contractor shall provide VA with visibility via real-time system, read only access to all case management and discharge planning assignment information for Veterans. At a minimum, this information shall provide notification to VA whenever a Veteran is assigned to the Contractor’s discharge planning program, and include the contact information for the specific care coordinator(s) assigned to the Veterans. Information that is available via the dashboard shall be current and refreshed no less frequently than once every twenty-four (24) hours. The Contractor shall transfer Veterans in accordance with the “VHA Directive 2007-015 Inter-Facility Transfer Policy” () or its replacement directive.Deliverables:Discharge Planning Plan Optional Task: Disease Management Program AdministrationThe Contractor shall administer a disease management program for eligible Veterans. The Contractor shall utilize its analytic tools to promote health, identify at-risk individuals and populations, treat chronic diseases (to include, for example, cancer, heart disease, diabetes, asthma, chronic obstructive pulmonary disease (COPD), serious mental health disorders, obesity, hypertension, chronic kidney disease, and dementia) and shall demonstrate to VA its methods to engage Veterans, their family/caregivers, and their healthcare providers in appropriate care and treatment. The Contractor shall submit a Disease Management Program, to be included within the Medical Management Plan, and will include the program design, all eligible conditions that are recommended to be included in their program, and supporting metrics to demonstrate effectiveness and outcomes. Disease Management: Time-Eligible and Distance Eligible VeteransThe Contractor’s Disease Management Program is available to all Time-who have a CCN primary care provider and all Distance Eligible Veterans. The Contractor shall include all VA providers in the management plans for any Veteran who also receives care from a VAMC. All Veterans must opt in to the Disease Management Program in order to be eligible. Case Management Program AdministrationThe Contractor shall establish and administer a case management program to identify and manage the healthcare of Veterans with high-cost conditions or with specific diseases or comorbid conditions which benefit from evidence-based clinical management and coordination.The Case Management Program shall include a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet the Veteran’s and family's comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes.The Contractor shall submit a Case Management Program, to be included within the Medical Management Plan, and will include the program design, eligible conditions that are recommended to be included in their program, and supporting metrics to demonstrate effectiveness and outcomes. Case Management: Time-Eligible Veterans and Distance Eligible VeteransThe Contractor’s Case Management Program is available to all Time-Eligible Veterans who have a CCN primary care provider and all Distance-Eligible Veterans. The Contractor shall include all VA providers in the management plans for any Veteran who also receives care from a VAMC. All Veterans must opt in to the Disease Management Program in order to be eligible.CLAIMS Processing and ADJUDICATION FOR CCN HEALTHCARE SERVICES RENDERED The Contractor shall receive, process, and adjudicate claims for all services provided pursuant to this contract for both Time-Eligible Veterans and Distance-Eligible Veterans. Claims Processing System FunctionsThe Contractor shall utilize an existing automated claims processing system to process and adjudicate claims. The Contractor’s claims processing system shall determine if a claim is ready for processing by ensuring the claim contains all the standard requirements of an EDI 837 transaction(s), as well as those fields required for VA claims processing. The Contractor’s claims processing system shall reject and notify the provider via an EDI 267 or EDI 277 transaction(s) if the claim has missing or incorrect information. The Contractor’s claims processing system shall send the provider claim status information to the community provider via EDI 267 or EDI 277 transactions. The Contractor shall process claims in accordance with all applicable Federal and state statutes, and regulations. The Contractor shall accept electronic claims in EDI 837P, EDI 837I and EDI 837D format transactions. The Contractor shall identify each claim by issuing an Internal Control Number (ICN) containing the Julian date, indicating the actual date of receipt for all claims (hardcopy or electronic). The Contractor shall stamp the ICN on the face of each hardcopy claim, and enter the claim into the automated system within five (5) business days of actual date of receipt. The Contractor shall ensure claims not processed to completion and any associated supporting documentation will be retrievable by Veteran’s name, EDIPI, and ICN. The Contractor’s claims adjudication system shall validate eligibility and enrollment data, referral and prior authorization data, and any other data needed to properly adjudicate claims. The Contractor’s claims adjudication system shall validate that the referral number, prior authorization number, name of Veteran, provider, and service or supply information submitted on the claim are consistent with the care authorized and that the care was accomplished within the authorized time period. Claims Adjudication and Payment RulesThe Contractor shall deliver a Claims Processing Data Dictionary that includes all capabilities for auto-adjudication, rejection, return, and denial of a claim. The Contractor’s claims processing system shall include standard business rules and edits in its Claims Processing Data Dictionary. The Contractor’s claims processing system shall be capable of adding rules and edits based on information from VA. When VA requests a change, the Contractor shall implement the change within thirty (30) days. The Contractor’s claims processing system shall include adjudication rules for the following requirements:Administrative Charges: The Contractor’s claims processing system shall classify any administrative charges imposed by the provider related to completing and submitting the applicable claim form or any other related information as non-covered and denied. Duplicate Claims: The Contractor’s claims processing system shall deny, as a duplicate claim, any claim that was previously submitted by a provider for the same service provided to a particular individual on a specified date of service. Benefits: The Contractor’s claims processing system shall deny, as not being a covered benefit, any claims submitted for a medical service that is not included as part of the Veteran’s benefit plan.Claim Forms: The Contractor shall reject any claims submitted on unapproved claims forms. When an unapproved claim form is submitted, the Contractor shall notify the claimant in writing that in order to be considered for payment the claim must be submitted on approved claim forms and that any additional information, if required, must be submitted and received by the Contractor within the timely filing deadline. Emergency Services: The Contractor shall suspend claims for emergency services that do not include a referral number and submit those claims and supporting documentation sufficient for VA to determine whether to issue a retroactive referral to VA. In the event that VA issues denial of a retroactive authorization for an emergency service claim to the Contractor, then the Contractor shall deny that claim. Out-of-Network Providers: The Contractor will only reimburse out-of-network providers with a valid referral number and services included in the episode of care with a valid referral number, and in accordance with the applicable reimbursement rates provided by VA. The Contractor shall deny all claims from out-of-network providers without a referral. National Provider Identifier (NPI) Claims: The Contractor shall use the National Provider Identifier (NPI) to process claims from covered entities. The Contractor shall deny claim transactions received that do not include a valid NPI. Non-NPI Claims: The Contractor shall use the tax identification number to process claims for providers who are not eligible to receive an NPI. The Contractor shall deny claim transactions received from providers without their tax identification number.Eligibility and Enrollment: The Contractor shall deny claims for Veterans who were not eligible and enrolled on the date of service. Referrals and Prior Authorizations: The Contractor shall deny, for lack of authorizations, any claim that does not contain a valid referral and any required prior authorization number. The Contractor shall deny claims for lack of authorization if the referral and/or prior authorization number are missing, incorrect, or inconsistent. Timely Filing Deadline: The Contractor shall deny, for passing the timely filing deadline, claims not submitted within one hundred eighty (180) days from the date of service.Secondary Payer: The Contractor shall grant additional time to the claims filing deadline requirements for Veterans with other health insurance (OHI) when the provider first submits the claim to the primary payer, and the adjudication occurred past the VA filing deadline. The Contractor shall ensure claims for services denied by another insurer include the Explanations of Benefits (EOB) or remittance advice statement indicating the dates of service, amount of the claim, and reason(s) for denial. The Contractor shall deny all OHI claims submitted beyond ninety (90) days from the date of the other insurer’s adjudication. Co-Pay Calculations: The Contractor shall exclude co-pay calculations from the claims adjudication rules. The Contractor shall use the referral and prior authorization data to properly adjudicate claims. The Contractor shall maintain an automated and integrated system so that claims are processed consistent with referrals and prior authorizations. The Contractor shall verify that the referral number and prior authorization number (if required), Veteran name, provider, and service, or supply information submitted on the claim are consistent with data which were authorized on the referral. The Contractor shall retain all claims, and claims processing information to allow processing to completion. VA reserves the right to audit all claims as required. The Contractor shall retain the claims and sufficient information on all claims to permit audits pursuant to the record retention requirements contained in HIPAA privacy regulations (45 C.F.R. § 160, 162 and 164).Deliverable:Claims Processing Data DictionaryPaper ClaimsThe Contractor shall only accept the latest mandated version of the following forms for medical claims: the CMS 1500 Claim Form, and the CMS 1450 UB-04 for all providers submitting paper claims. The Contractor shall only accept the American Dental Association (ADA) claim forms for the processing and payment of adjunctive dental claims. The Contractor shall convert all relevant claims data into the standard EDI 835 and EDI 837 transaction data. This data will be included in the EDI 835 and EDI 837 transaction(s) that is transmitted to the VA. The Contractor shall establish a billing and claims adjudication process using the fields of CMS-1500 claim form for Complementary and Integrative Health Services claims shown in Attachment N, “CMS-1500 Claim Form”.Signature RequirementsSignature on File ProcedureThe Contractor shall submit to VA its Signature on File Procedure for providers to indicate providers are authorized to submit a claim on behalf of the Veteran at least ninety (90) days prior to SCHD for review and approval. The Contractor shall provide an updated Signature on File Procedure at least thirty (30) days prior to the effective date of any material change. Deliverable:Signature On File ProcedureNetwork Provider Signature on ClaimsThe Contractor shall follow its normal business operations to verify signature of physician on all claim submissions for services provided under this contract. Claims Submission and Processing TimeframesThe Contractor shall process and adjudicate ninety-eight percent (98%) of all Clean Claims within thirty (30) days of receipt. The Contractor shall return claims, other than Clean Claims, to the provider with a clear explanation of deficiencies within thirty (30) days of original receipt. The Contractor shall process corrected claims within thirty (30) days of resubmission receipt. The Contactor shall confirm the actual date of receipt is entered into the ICN and all required claims aging and inventory controls are applied for all claims. The Contractor shall count the actual date of receipt as day one. Issuance of Explanations of Benefits (EOB)The Contractor shall issue an Explanation of Benefits (EOB) to Veterans. The EOB shall be available through electronic means, including but not limited to a web-based portal. The EOB shall be mailed in hardcopy, unless the Veteran has provided verbal or written agreement to receive the EOB electronically. EOBs shall be available in a paper monthly summary upon request. The EOB shall comply with the requirements of 38 U.S.C. § 7332, 38 C.F.R. § 1.460-1.496, and VHA Handbook 1605.1, Privacy and Release of Information. For further information, see the following:VHA Handbook 1605.1, Privacy and Release of information: VHA Directive 1605, VHA Privacy Program; Transmittal Sheet, dated April 11, 2012, see: U.S.C. § 7332, 38 C.F.R. § 1.460-1.496 (as applicable);38 C.F.R. § 1.460-1.461: C.F.R. § 1.461-1.464: EOB shall include language describing the process for the Veteran to appeal a claim that is denied in whole or in part. Issuance of Remittance AdviceThe Contractor shall issue a remittance advice in an EDI 835 transaction to providers. The Contractor shall issue a remittance advice containing sufficient information to identify each Veteran and explain the payment for each line item on each claim. The Contractor shall send Electronic Remittance Advice (ERA) to providers. The Contractor shall include all adjustment codes, adjustment code reasons, and dollar values in the remittance advices and EDI 835 transaction required by VA and CCN providers to process claims payments. The Contractor shall transmit a daily EDI 835 Transaction File of all claims processed that day to VA.Deliverable:EDI 835 Transaction File Coordination of BenefitsIn situations where VA would be the secondary payer, the Contractor shall:Develop and execute a program to coordinate benefits for CCN healthcare services determined by VA to not be related to a service connected disability for Veterans with OHI. The Contractor shall develop a National Association of Insurance Commissioners (NAIC) compliant Coordination of Benefits Plan and submit it to VA for review and approval at least ninety (90) days prior to SHCD. The Contractor shall provide an updated Coordination of Benefits Plan at least thirty (30) days prior to the effective date of any material change. Obtain a copy of the OHI Explanation of Benefits (EOB) from the community provider and submit the OHI EOB in addition to health care claim reimbursement invoices. This includes cases where there will be no additional payment required as the secondary payer by the Contractor to the CCN provider.Deny any claims when an eligible Veteran who has OHI is receiving medical care for services that are determined by VA to not be related to a service connected disability and the Veteran’s OHI is not billed by the provider prior to the Contractor invoicing VA. Upon completion of OHI billing, the Contractor shall submit, with every healthcare EDI claim to VA, an EOB determined by VA to not be related to a service connected disability or special authority care. The?healthcare and OHI prior payment information, including payments made by the Veteran,?shall be submitted to VA with each claim. This includes all claims, including those that have been satisfied and/or paid in full by the primary insurance. The Contractor shall provide VA the amounts paid by the Veteran at the point of service. The Contractor shall ensure that Veterans are held harmless and cannot be billed for any services denied for failure to obtain a referral and any required prior authorizations. In situations where VA would be a secondary payer, the Veteran must be held harmless in cases where the CCN provider fails to meet the OHI prior authorization requirements of the OHI and receives a denial.The Contractor shall ensure that VA is the primary payer for any CCN healthcare services related to or associated with any claim against a (i) workers’ compensation carrier; (ii) auto liability insurance carrier; (iii) medical malpractice; or (iv) any other situation where a third party is responsible for the cost of CCN healthcare services. The Contractor shall ensure that payment to the provider under this contract is deemed as payment in full. In situations where the VA would be a secondary payer, the Contractor shall have the ability to receive, process and store service connection, non-service connection determinations. The service connection, non-service connection determinations will be sent with each referral, and the information shall be stored in the Contractor’s system to be able to adjudicate claims in accordance with the claims business rules for primary and secondary payer adjudication.Deliverable: Coordination of Benefits PlanOther Health InsuranceThe Contractor shall use commercial or publically-available OHI data sources to: (i) validate Veteran OHI provided by VA to the Contractor as part of the initial eligibility file (See Section 5, “Eligibility Verification and Enrollment”); (ii) identify OHI for Veterans that VA has no documented OHI information; and (iii) update as necessary the Veteran’s OHI insurance information. The Contractor shall electronically transmit OHI data to VA monthly. For those Veterans whose OHI cannot be confirmed through commercially or publically available data, the Contractor may obtain such information from the Veteran only in accordance with a process pre-approved by VA. The Contractor shall develop an OHI Verification and Retrieval Plan and submit it to VA for review and approval at least ninety (90) days prior to SHCD. The Contractor shall provide an updated OHI Verification and Retrieval Plan at least thirty (30) days prior to the effective date of any material change. Deliverable: Other Health Insurance Verification and Retrieval PlanClaims for Services Rendered Outside of the Assigned CCN RegionAs applicable, the Contractor shall provide to other CCN Contractors any supplemental information necessary to process claims for Veterans assigned to the Contractor’s CCN Region(s) who receive services outside of their assigned CCN Region(s). The Contractor shall designate a Point of Contact (POC) to VA who will be responsible for providing pricing information and rendering provider information. The POC shall provide the requested information necessary to process claims within five (5) business days after receipt of such requests. Claims AuditingThe Contractor shall create and submit an Improper Payment Review Plan and submit it to VA at least thirty (30) days prior to SHCD. The Improper Payment Review Plan shall establish and maintain a process for reviewing claims for improper payment in accordance with prevailing industry standards to include identification of healthcare fraud, waste, and abuse. The Contractor shall make every reasonable attempt to recover all improper payments for services rendered to Veterans or for persons who were not eligible to receive a benefit. Unless improper adjudication was a result of VA error, the Contractor is solely responsible and financially liable for reimbursing VA for any claims that were improperly adjudicated, including those due to provider or practitioner fraud or Contractor error. In situations where VA would be the secondary payer, the Contractor shall verify that the primary payer adjudicated the claim properly. VA shall not be held responsible when the primary payer fails to properly adjudicate the claim. The Contractor shall provide an updated Improper Payment Review Plan at least thirty (30) days prior to the effective date of any material change. Deliverable: Improper Payment Review PlanClaims Audit ReportingThe Contractor shall create a Quarterly Cost Avoidance and Recovery/Recoupments Report to include the cost avoidance and recoveries/recoupments achieved as a result of the improper payment reviews. The Report shall contain information detailing: (i) cost avoidance, recoveries, and recoupments and (ii) a variance analysis for any reporting category with a greater than 15% increase or decrease from the current quarterly report to the last report, to include any unusual activity even if it does not exceed the percentage.The final quarterly summary report shall include analysis of the full Period of Performance (PoP) to reflect unusual activity that persists throughout all four quarters. The Contractor shall submit a Quarterly Cost Avoidance and Recovery/Recoupments Report to VA within thirty (30) days following the last day of the quarter. Deliverable:Quarterly Cost Avoidance and Recovery/Recoupments ReportClaims ReportingThe Contractor shall transmit a daily EDI 837 Transaction File of all claims processed that day to VA.The Contractor shall provide Weekly Claims Processing Reports to VA that summarizes all claim activity. The Contractor shall commence sending Weekly Claims Processing Reports at the start of claims processing. The Contractor shall run the Weekly Claims Processing Reports and include all claims activities from Sunday through close of business on Saturday, and shall be received by VA no later than 11 PM Eastern Time each Sunday. The Contractor shall include totals for: open claims, pended claims, newly received claims, adjustments, and transfers, claims processed, adjustments processed, closing of pending claims, and closing of adjusted claims. The Contractor shall include the following categories by the age of the claim, and provide a total for each category: 0-10, 11-30, 31-60, 61-90, and 90+ days.The Contractor shall provide Quarterly Claims Audit Reports. The Contractor shall commence sending Claims Audit reports 30 days after the end of the first quarter following the SHCD, and subsequent reports shall be submitted within (thirty) 30 days after the end of each quarter thereafter. The Contractor’s Claims Audit Reports shall be consistent with the Improper Payment Review Plan. The Contractor shall generate individual file folders labeled with identifying information and all supporting documentation data.The Contractor shall provide ad hoc reports, standardized reports, and special reports that satisfy request requirements within mutually agreed upon timelines, but no later than five (5) business days. The Contractor shall have search capabilities built into its systems.Deliverables:EDI 837 Transaction File Weekly Claims Processing ReportsQuarterly Claims Audit ReportsClaims Performance Data and Metrics ReportFederal Codes and Regulations38 U.S.C. Chapter 17 and 38 C.F.R. Part 17 the authorities which govern VA’s payment for health care services. The Contractor shall ensure the claims processing system and any associated business rules and processes incorporate and maintain VA statutory and regulatory authorities, including any subsequent changes thereto.Veteran Appeals AND PROVIDER RECONSIDERATIONSVeterans AppealsThe Contractor shall include in any referral denial or prior authorization denial notice a statement indicating that the decision may be reviewed by VA upon request of the Veteran. In the event that the Contractor denies a claim and the Veteran has a financial liability (e.g. denied emergency service claims) for that denied claim, the Contractor shall provide a notice of the denial to the Veteran with a description of the Veteran’s right to appeal such denial to VA. The Contractor shall include “VA Form 4107VHA” () with the notice of denial to the Veteran.Provider ReconsiderationsThe Contractor shall establish and maintain a provider reconsideration process for all denied referral and prior authorization requests and all claims that are denied, either in whole or in part. The Contractor shall notify the CCN provider, in writing, of any such denial, the reason for the denial, and the provider’s right to request reconsideration. The Contractor shall ensure all requests for reconsiderations are submitted to VA within ninety (90) days from the date of denial. The Contractor shall create and submit a Provider Reconsideration Process. The Provider Reconsideration Process shall be submitted to VA for approval ninety (90) days prior to SCHD under the contract. The Contractor shall provide an updated description of its reconsideration process to VA for approval at least thirty (30) days prior to any material change. Deliverable: Provider Reconsideration ProcessCLINICAL QUALITY MONITORINGClinical Quality Monitoring Plan (CQMP)The Contractor shall develop and submit a written Clinical Quality Monitoring Plan (CQMP) to VA. The CQMP shall include an articulation of the quality monitoring activities for patient safety, clinical quality assurance, clinical quality improvement, and peer review. The Contractor’s CQMP shall include a detailed description of the purpose, methods, proposed goals and objectives designed to ensure the highest quality clinical care under this contract. The Contractor shall provide a copy of its CQMP to VA no later than forty-five (45) days following contract award and no later than thirty (30) days prior to the effective date of any material change. Deliverable: Clinical Quality Monitoring Plan (CQMP)Clinical Quality Initiative Component of the CQMPThe Contractor’s CQMP shall include a quality initiative component to improve processes internal to the Contractor, comprised of initiatives to improve clinical administrative processes and program related issues. The Contractor shall evaluate and update the quality initiative component periodically to adopt new methods for accomplishing desired outcomes.Clinical Quality Improvement Component of the CQMPThe Contractor’s CQMP shall include a Clinical Quality Improvement Program (CQIP) component, defined as a set of related activities designed to achieve measurable improvement in processes and outcomes of clinical care. The Contractor’s CQIP component shall achieve improvements: (i) through activities that target healthcare providers, practitioners, plans, and Veterans; (ii) by addressing administrative processes, Veteran health, error reduction and safety improvement, Veteran functional status, Veteran and provider satisfaction, and program related issues; and (iii) for Veterans who are high-risk or high-volume users of services. The Contractor’s CQIP component shall be structured with appropriate elements, including clearly defined sample sizes and inclusion and exclusion criteria, and developed using relevant and rigorous scientific methodology. The Contractor shall appropriately document the CQIP with the following common elements:Description and purpose of activity;Description of the population; Rationale for selection of the CQIP baseline data;Description of data collection; Goals and time frames for achieving them; Action plans and interventions; and Periodic measurements and outcomes.Clinical Quality Issues IdentificationThe Contractor shall identify, track, trend, and report interventions to resolve any potential quality issues or identified quality issues using the most current National Quality Forum (NQF) Serious Reportable Events (SREs), Centers for Medicare and Medicaid Services (CMS) Hospital Acquired Conditions (HAC), and Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSI). The Contractor shall apply appropriate medical judgment, evidence based medicine, and best medical practices when identifying, evaluating, and reporting on all potential quality issues and identified quality issues. The Contractor shall process to completion 95% of all potential quality issues and identified quality issues within ninety (90) days from date of identification and 99% within one hundred eighty (180) days of identification. The Contractor shall report aggregated and de-identified / identified quality issues and potential quality issues data to VA on a quarterly basis.The Contractor shall implement appropriate identified quality issues interventions using evidence based medicine and best medical practices to address and resolve each identified quality issues. When the Contractor confirms an identified quality issues or determines there is deviation in the standard of practice or care, the determination shall include assignment of an appropriate severity level and/or sentinel event, and describe the actions taken to resolve the quality problem. Peer Review of Identified Quality IssuesThe Contractor shall ensure that all identified quality issues, regardless of the source, are reviewed and confirmed by a qualified peer review committee to determine deviations from standards of care, severity levels, recommending interventions to include Corrective Action Plans (CAPs), reporting to licensure boards, and follow-up monitoring through resolution. The Contractor’s CQMP Plan shall describe the peer review committee(s) composition, qualifications, quorum of voting members to conduct peer review and frequency of the meetings.The Contractor’s peer review committee shall be responsible for ensuring that all identified issues are documented, tracked, trended, patterns identified, reported to committee and appropriately addressed until resolution is achieved.VA Participation in Peer Review CommitteesThe Contractor shall allow VA staff, as mutually agreed upon between Contractor and VA, to actively participate, as non-voting members, on the Contractor’s CQIP committees, clinical quality management committees, clinical peer review committees, and credentialing committees for each CCN Region covered under this contract.The Contractor shall take the necessary steps as directed by VA to safeguard the safety of Veterans when VA identifies a patient safety issue where Veterans are, or could be, at risk.The Contractor shall conduct a clinical quality review and case investigation as directed by VA and report their findings to VA when VA identifies clinical quality concerns regarding the care rendered to a Veteran. Contractor shall report findings to VA clinical staff who participate on the Contractor’s peer review committee. All proceedings, deliberations, findings and outcomes of the peer review committee are confidential and protected under peer review regulations. PHARMACYThe Contractor’s Health Services Network shall include a Pharmacy component. The Pharmacy component shall provide pharmacy benefits to Veterans through the use of a Pharmacy Benefits Management (PBM) function that has a retail pharmacy network to provide prescription fulfillment services for urgent and emergent prescriptions from CCN providers and VA providers when a VA Pharmacy is not available for prescription fulfillment of the urgent and emergent prescriptions. The Contractor shall require all routine scripts be forwarded to VA for processing and fulfillment.Urgent/Emergent Prescriptions The Contractor shall establish a retail pharmacy network to fill urgent/emergent prescriptions received from CCN providers and VA providers when a VA pharmacy is not available for prescription fulfillment of urgent and emergent prescriptions. An urgent/emergent prescription is available for a maximum 14-day supply of medication. The Contractor shall have retail pharmacies covering all geographic areas of the CCN Region and meet the adequacy standards described in Section 15.3, “Urgent/Emergent Prescription Network Adequacy.”The Contractor shall establish procedures to include instructions for prescribing a maximum 14-day supply of medication, without refills, when it is determined medically appropriate by the CCN or VA provider. The Contractor’s procedures shall also instruct the Veteran to go to a local pharmacy in the retail network established by the Contractor’s PBM. ?The Contractor shall provide all applicable Veteran eligibility information and network prescribing provider information to facilitate Veterans’ receipt of their urgent/emergent prescriptions through the participating retail pharmacies.The Contractor shall train all CCN providers to generate a second prescription for medications beyond the urgent/emergent 14-day supply and submit the prescription to VA by fax or other agreed-upon electronic method within 1 hour of issuance for processing. Incomplete prescriptions will not be processed and will be returned to the prescribing provider to resubmit to VA for processing once completed. The Contractor shall instruct its CCN providers to use the medication that is medically acceptable and the least cost if there is no medication on the VA Urgent and Emergent National Formulary (subject to routine updates) (Attachment F, “VA Urgent and Emergent National Formulary”) If a medication from the VA Urgent/Emergent National Formulary or VA National Formulary is not acceptable, the Contractor shall communicate to the retail pharmacy a VA Urgent or Emergent National Formulary drug in the same drug class for the VA National Formulary non-formulary drug that was prescribed. If a second prescription is required, it shall be requested using VA’s non-formulary request process, referenced in VHA Handbook 1108.08, “VHA Formulary Management Process” (See ).Prescriptions shall be for generic medications whenever a generic medication is available and there are no verifiable clinical reasons to use a branded product. The Contractor’s retail pharmacies shall follow established clinical protocol for registration of new patients to determine a Veteran’s allergy and previous drug history. The Contractor shall provide training on pharmacy benefits and requirements under this contract to its network provider. This shall include web-based and virtual trainings, as well as written training materials. The Contractor shall provide a monthly electronic urgent/emergent prescription report, as a flat, tab delimited file, to VA to include the following information on each prescription filled:Pharmacy name, store #, address, and phone numberPharmacy prescription numberNational Drug Code number of the drug that was used to fill the prescriptionText description of drugNumber of days’ supply, quantity, and date dispensedDrug ingredient cost, including % off Average Wholesale Price (AWP), AWP at time of charge, and dispensing fee Total amount paid to the retail pharmacyPrescribing provider, who prescribed the medication, including NPI and DEA number (if required for prescription)Veteran unique identifier of person who received the prescriptionDiagnosis associated with the prescription Provider status (i.e. CCN Provider or VA Provider)The monthly report shall also provide details on urgent/emergent fill performance metrics, as referenced in Section 15.3, “Urgent/Emergent Prescription Network Adequacy.”VA shall transmit a list of all VA providers who are eligible to prescribe urgent or emergent prescriptions to Veterans when a VA pharmacy is not available to dispense the prescription within thirty (30) days of contract award date. The Contractor shall have a process in place where new VA providers may be active to prescribe urgent or emergent prescriptions within four (4) hours of being provided the information. When VA communicates the deletion of VA provider from the network, the change shall occur immediately in the Contractor’s retail pharmacy network.Deliverable:Monthly Electronic Urgent/Emergent Prescription Report in National Council for Prescription Drug Programs (NCPDP) formatRoutine Prescriptions: Time-Eligible Veterans and Distance-EligibleVA healthcare benefits include providing Veterans with prescription medications, medical/surgical supplies and nutritional products. The Contractor’s CCN providers may prescribe medications to be processed by the VA pharmacy where they are enrolled for care as part of the authorized CCN healthcare services under this contract. The Contractor shall provide the following information from the prescribing CCN provider for each prescription for fulfillment:Provider Name (Family, Given, Middle Suffix)Provider Name Suffix, Example (Sr., Jr., II., III., etc.)Provider Gender NPI of the Provider Tax-ID of the Provider Provider’s PERSONAL DEA Number and Expiration Date (not a generic facility number) Provider’s Office Address of the Provider Providers Office Phone and Additional Phone Number Provider’s Fax Number (if applicable) Provider’s discipline (i.e., physician, physician assistant, nurse practitioner, etc.) The Contractor shall transmit to VA a list of all CCN providers with prescribing privileges, thirty (30) calendar days prior to the SHCD.?The Contractor shall transmit the list of providers with prescribing privileges in an electronic format with the data fields required above to be agreed upon with VA.?The Contractor shall update this list upon the credentialing of new providers, or change in credentials of an existing provider, after the initial load every ninety (90))) days.? The Contractor shall instruct its CCN providers that prescriptions must be prescribed in accordance with VA’s National Formulary, which includes provisions for requesting non-formulary drugs (). In addition to the online formulary, an online formulary search tool is available at: (). This application provides formulary alternatives to non-formulary drugs in the same VA drug class. The Contractor shall instruct its CCN providers to utilize this application to prescribe appropriate formulary medications. Prescriptions shall be for generic medications whenever a generic medication is available and there are no verifiable clinical reasons to use a branded product. Prescriptions shall be transmitted?by fax or other agreed-upon electronic method to VA for processing within 1 hour of issuance. Incomplete prescriptions will not be processed and will be returned to the prescribing provider to re-submit to VA for re-processing once completed.Urgent/Emergent Prescription Network AdequacyThe Contractor shall ensure that a retail pharmacy network is established and in place that is adequate in size, scope and capacity to ensure Veterans receive timely access to urgent/emergent prescription services in accordance with the following standards, at a minimum, for each VA Health Care System service area. These include:Urban: 90% of Veterans have access to network pharmacies within two (2) miles of their residenceRural: 90% of Veterans have access within five (5) miles of their residenceHighly-Rural: 70% of Veterans have access within twenty (20) miles of their residenceThe Contractor shall obtain approval of the pharmacy adequacy plan from VA at least thirty (30) days prior to the SHCD.Urgent/Emergent Prescription Performance MetricsThe Contractor shall, on a monthly basis, report performance towards the defined performance metric goals for all urgent/emergent prescriptions handled by the retail pharmacy network. These goals and metrics are:95% overall conformance with VA Urgent/Emergent Formulary for Community Network providers95% overall conformance with VA Urgent/Emergent Formulary for VA providers 90% generic dispensing for VA Urgent/Emergent prescriptions for Community Network Providers90% generic dispensing for VA Urgent/Emergent Prescriptions for VA providersThese performance metrics shall include the ability to drill down to prescribing provider including contact information, and retail pharmacy location including contact information.Durable Medical Equipment, Medical Devices, Orthotic and Prosthetic itemsThe Contractor shall provide urgent and emergent Durable Medical Equipment (DME), medical devices, orthotic and prosthetic items to eligible Veterans. Urgent/Emergent Prescriptions for DME and Medical Devices: Time-Eligible Veterans and Distance-Eligible VeteransThe Contractor shall provide DME and medical devices to eligible Veterans for an urgent or emergent medical condition. Urgent or emergent DME items include: splints, crutches, canes, slings, soft collars, walkers, and manual wheelchairs. All other DME and medical device prescriptions shall be sent to VA for the items to be purchased by VA. The Contractor shall provide all DME and medical devices to meet the urgent/emergent needs of the Veteran at the time of service or time of discharge.Other Prescriptions for DME, Medical Devices, Orthotics and Prosthetics: Time-Eligible Veterans and Distance-Eligible VeteransThe Contractor’s shall ensure all prescriptions for non-Urgent and Emergent DME, medical devices, orthotic and prosthetic items for eligible Veterans are sent to VA for fulfilment.? The Contractor shall ensure these DME prescriptions contain the following information:Date or requestPatient’s namePatient’s date of birthPatient’s social security numberPrescribing provider’s namePrescribing provider’s addressPrescribing provider’s phone numberPrescribing provider’s fax numberDiagnosis and ICD-10 Code(s)Description and Healthcare Common Procedure Coding System (HCPCS) code for each prescribed itemDetailed information (brand, make, model, part number, etc.) and medical justification of the prescribed item, if a specific brand/model/product is prescribedItem delivery location/address and expected delivery dateThe Contractor shall ensure all DME requests are submitted on VA-provided order forms or templates. All VA forms or templates for DME, along with instructions for use, will be provided to the Contractor during the implementation phase.The Contractor shall ensure all requests for hearing aids are submitted to VA for review and fulfillment. For hearing aids, the Contractor shall provide initial testing results related to potential hearing aid needs within two (2) business days of completion of the initial testing. No hearing aids shall be purchased or provided under this contract by the Contractor or the Contractor’s CCN providers. The Contractor shall ensure all necessary follow up care including patient education and training for the prescribed item, as well as fitting and adjustment is provided. VA will procure and send the prescribed item to the prescribing network provider location for the prescribing network provider to provide the item(s) to the Veteran. Optional Task: Eyeglasses: Time-Eligible and Distance-EligibleThe Contractor shall provide the capability for Time-Eligible and Distance-Eligible Veterans to receive eyeglasses through a retail vendor. Only Time-Eligible and Distance-Eligible Veterans who received an eye care examination and have an eyeglass prescription from their CCN eye care provider shall be referred to a CCN eyeglass vendor. Eyeglasses provided to Veterans shall meet the following:Provision of a pair of eyeglasses shall include a case for eyeglasses at no cost to VA or Veteran.Provision of a pair of eyeglasses shall include fitting and dispensing of the eyeglasses. Fees for the lenses and frames shall be inclusive of the fees for fitting and dispensing services.All lenses shall have ultra-violet (UV) protection. If UV is manufactured directly in the lenses, UV coating shall not be billed separately.Necessary Veteran education regarding the proper care and cleaning of eyeglasses at no cost to VA or Veteran.The following four types of lenses may be prescribed or provided:Single Vision Lenses;Bifocal Lenses;Trifocal Lenses; and Progressive Lenses.No additional features or “upgrades” desired by the Veteran that are not included in the community eye care provider’s (optometrist or ophthalmologist) prescription shall be allowed or authorized.The quality of materials and fabrication requirements for prescription ophthalmic lenses and frames and their assembly into a pair of eyeglasses must meet current American National Standards Institute (ANSI) Z80 Standards, including “American National Standard for Prescription Ophthalmic Lenses - Recommendations” ANSI Z80.1, and “American National Standard Requirements for Ophthalmic Frames” ANSI Z80.5. In addition, all ophthalmic lenses shall be in accordance with Food and Drug Administration (FDA) Regulation (2) CFR, Parts 3 and 4 for impact resistance.Eyeglasses provided under this contract shall be warranted / guaranteed against defective material and/or workmanship for a minimum of one year from the date of receipt. The eyeglass provider shall agree to furnish, without additional cost to VA, all labor and materials necessary to correct defects that were detected during the guarantee period. These conditions do not apply to adjustments incidental to the wearing of eyeglasses, adjustments required by physical change of the wearer, or where there is evidence of deliberate misuse or alteration by anyone other than the eyeglass provider.DENTALThe Contractor shall establish and maintain a network of dental providers to provide outpatient dental care to all Veterans that satisfy the dental eligibility requirements of 38 U.S.C. § 1710(c) and 1712 and 38 C.F.R. § 17.93 and 17.160-17.166. Dental Network AdequacyThe dental network shall include both general and specialized dental care. Specialized dental services include all recognized American Dental Association (ADA) specialties except for pediatric dentistry. Minimum network standards for Veteran access are as follows:Table 17.1 Dental Network Density StandardsMinimum Network Density Standards for Access to General Dentist98% of urban enrollees shall have access to a general dentistry network provider within ten (10) driving miles of their primary residence.90% of rural enrollees shall have access to a general dentistry network provider within fifty (50) driving miles of their primary residence.90% of highly rural enrollees shall have access to a general dentistry network provider within one hundred fifty (150) driving miles of their primary residence.Table 17.1.A Dental Network Access StandardsMinimum Network Standards for Access to General DentistryUrbanThirty (30) minutesRuralForty-five (45) minutesHighly RuralSixty (60) minutesMinimum Network Standards for Access to Specialized DentistryUrbanForty-five (45) minutesRuralOne hundred (100) minutesHighly RuralOne hundred eighty (180) minutesDental Network CredentialingThe Contractor shall apply and utilize the credentialing process discussed in Section 3.6, “Network Credentialing,” to establish and maintain a network of credentialed dentists. Dental Network ComplianceThe Contractor shall be compliant with the most current version of the Code on Dental Procedures and Nomenclature published in the American Dental Association's (ADA) Current Dental Terminology (CDT) manual throughout the period of performance. The Contractor shall develop quality initiatives that address, but are not limited to, the following: patient complaints, excessive remakes of prosthesis, retreatment rates, patient dissatisfaction with care, and post-treatment issues identified by VA personnel. Dental ReferralsThe Contractor shall establish, administer and maintain a CCN dental referral and prior authorization process for all eligible Veterans.The Contractor’s processes shall require that, except as described in the following paragraph, after an initial dental referral is completed, all recommended treatment be reviewed and approved by VA prior to the Veteran receiving care. VA will provide the Contractor an initial list of dental services as part of Attachment M, “Prior Authorization List,” that do not require prior authorization and associated business rule guidance during the implementation phase. The Contractor shall update the list and associated business rule guidance within thirty (30) days of receipt of revisions from VA.Return of Dental RecordsThe Contractor shall return dental records to VA. The exchange of dental records through health information exchange or Direct Trust is encouraged. Time-Eligible VeteransThe Contractor shall establish, implement and monitor processes which require that dental records, to include radiographs, for Time-Eligible Veterans be returned to the referring VA within forty-five (45) days after completion of authorized treatment or within forty-five (45) days of request of VA. Distance-Eligible VeteransThe Contractor shall establish, implement and monitor processes which require that dental records, to include radiographs, for Distance-Eligible Veterans be returned to the referring VA within forty-five (45) days of request of VA.Dental Care AuthorizationsThe Contractor shall require all dental treatment provided through CCN dental providers be authorized by VA in advance of treatment. The Contractor shall establish, implement and monitor processes to ensure that all eligible Veterans and their providers receive an Authorization Notification Letter detailing those procedures that VA has authorized prior to treatment. TECHNOLOGYThe Contractor shall provide Information Technology (IT) support as needed to accomplish the stated functional and operational requirements of the CCN. All Contractor Information Technology (IT) systems that interface to VA enterprise systems shall be in compliance with the One-VA Technical Reference Model (TRM). Please see the following link for more details: of OperationsThe Contractor shall develop a Continuity of Operations Plan (COOP) that demonstrates the process for the continuous operation of their Information Technologies (IT) systems, data availability and organizational support of the CCN. The Contractor’s current COOP shall be submitted to VA at the time of the kickoff meeting and within thirty (30) days after the incorporation of any material change. The Contractor shall provide the current COOP on an annual basis thereafter. The COOP shall also provide information specific to all actions that will be taken by the Contractor in order to continue operations should an actual disaster be declared for their CCN Region. The COOP shall describe the process for managing temporary system unavailability and the communication method that will be used to ensure minimal process disruption. The Contractor shall ensure the availability of the system and associated data in the event of hardware, software and/or communications failures.The Contractor shall notify VA of scheduled system maintenance at least two (2) weeks in advance. For unscheduled system maintenance, the Contractor shall notify VA immediately (within 1 hour of being alerted of an issue). The Contractor shall schedule system maintenance windows during weekends or non-peak hours to minimize disruption of services to users. The COOP shall address the following categories:Process for Continuous OperationsSystem Maintenance (Scheduled and Unscheduled)Hardware/Software System FailuresTemporary System UnavailabilityAvailability PerformanceDisaster RecoveryThe COOP shall meet the operational and availability standards, including a downtime process for the following:Table 18.1 Operational/Availability StandardsSystemHours of OperationAvailabilityReturn to Operations (RTO)Referral and Management System24/799.9%12 hoursEnrollment and Eligibility System 24/799.9%12 hoursDischarge Planning System24/799.9%12 hoursCustomer Service Systems24/799.9%12 hoursClaims Processing System 24/799.9%48 hoursUtilization Management System 24/799.9%48 hoursCase Management System (optional)24/799.9%48 hoursDisease Management System (optional)24/799.9%48 hoursData Repository24/799.9%48 hoursPortal24/799.9%48 hoursDeliverable:Continuity of Operations Plan (COOP)Contractor System AccessThe Contractor shall provide VA real-time, read-only access to the following Contractor’s systems: Table 18.2 Contractor Systems (users per Region)SystemCCN Region 1CCN Region 2CCN Region 3CCN Region 4Claims Process System750 750750750Referral and Management System750750750750Enrollment System750750750750Utilization Management System750750750750Case Management System750750750750Disease Management System750750750750Discharge Planning System (if separate)750750750750Customer Service System 750750750750Reporting System750750750750Portal750750750750IT Customer ServiceThe Contractor shall provide customer service support to assist VA users with access to Contractor’s systems and data as defined in this contract. IT Customer Service support shall be available via telephone and email Monday through Friday from 7AM and 7PM in all local time zones in the Contractor’s assigned CCN Region.PortalThe Contractor shall create a portal for VA that will contain the following: a dashboard with the data analytics information as described in Section 19, “Data Analytics,” and access to reporting capabilities that is able to drill down to the Veteran level as required in this PWS.Submission of EDI TransactionsThe Contractor shall leverage their current systems to exchange all EDI transactions as required in this PWS. The Contractor shall transmit these EDI transactions in the current HIPAA compliant standard format as required by HHS, which are listed for reference below:The ASC X12 Standards for EDI TR3 - Health Care Services Review-Request for Review and Response (278), May 2006, ASC X12N/005010X217, and Version 5010 to Health Care Services Review-Request for Review and Response (278), ASC X12 Standards for EDI TR3, April 2008, ASC X12N/005010X217E1, as referenced in § 162.1302.The ASC X12 Standards for Electronic Data Interchange (EDI) TR3 - Health Care Claim: Dental (837), May 2006, ASC X12N/005010X224, and Version 5010 to Health Care Claim Dental (837), ASC X12 Standards for EDI TR3, October 2007, ASC X12N/ 005010X224A1, as referenced in § 162.1102 and § 162.1802.The ASC X12 Standards for EDI TR3 - Health Care Claim: Professional (837), May 2006, ASC X12N/005010X222, as referenced in § 162.1102 and § 162.1802.The ASC X12 Standards for EDI TR3 - Health Care Claim: Institutional (837), May 2006, ASC X12N/005010X223, and Version 5010 to Health Care Claim: Institutional (837), ASC X12 Standards for EDI Technical Report Type 3, October 2007, ASC X12N/ 005010X223A1, as referenced in § 162.1102 and § 162.1802.The ASC X12 Standards for EDI TR3 - Health Care Claim Payment/Advice (835), April 2006, ASC X12N/005010X221, as referenced in § 162.1602.The ASC X12 Standards for EDI TR3 – Additional Information to Support a Health Care Claim or Encounter (275), 2007, ASC X12N/005010X210.American National Standards Institute ASC X12N/005010X279 270/271 Technical Report Type 3 (TR3) for Health Care Eligibility Benefit Inquiry and Response and its associated Errata 005010X279A1.The EDI 275 transaction file shall include a Trace Number (TRN) segment that contains the Provider Attachment Control Number.?The EDI 837 transaction file shall include a Paperwork (PWK) segment that contains the Attachment Control Number.? When additional accompanying EDI Standard Transactions are adopted and mandated by CMS for use at a future date, the Contractor shall comply with those EDI Standard Transactions by the compliance dates as specified by HHS.Submission of OHIThe Contractor shall submit OHI information and OHI EOB information electronically through a secure file transfer monthly. Provider File SubmissionThe Contractor shall submit an initial full network Provider File in a flat text, comma delimited format. The Contractor shall provide a full file replacement daily with an indication of any changes (See Attachment H, “Master Provider File Data Dictionary”).VA System Integration RequirementsThe Contractor shall be prepared to integrate its technical solutions in a secure manner with VA’s systems.The Contractor shall integrate with VA’s Data Access Service (DAS) to provide a standard interface for data access and storage of structured and unstructured data. The Contractor shall be responsible for all documentation to certify their system meets all the requirements for information security, system certifications, and privacy in order to connect to all VA necessary systems.The Contractor shall be responsible for working with the Office of Information and Technology (OIT) to successfully complete the appropriate documentation (such as, but not limited to, Operational Readiness Review [ORR]), in order to secure the approval of the Authority to Operate (ATO). The Contractor shall comply with VA Handbook 6500.3, Assessment, Authorization and Continuous Monitoring of VA Information Systems (). For additional details, please see the following link: ().Contractor Software Configuration Management RequirementsThe Contractor shall utilize a solution to support the requirements herein that is configurable to allow for changes to be tested, accepted, and implemented. When VA requests a change, the Contractor shall implement the change by the mutually agreed upon date. DATA ANALYTICS Data ElementsThe Contractor shall provide all data elements from the monthly reports required incorporated into an interactive dashboard (Section 19.2, “Interactive Dashboard”) and a data repository (Section 19.3, “Data Repository”). The data elements included in the monthly reports are listed and defined in the Reporting Data Definitions (See Attachment I, “Reporting Data Definitions”).The Contractor shall submit a provider listing to VA as part of the Master Provider File Data. The provider listing shall be submitted as a text file, comma-delimited format of all CCN providers. The Contractor shall provide a full file replacement of all CCN providers daily with an indication of any changes. The Contractor shall format the text file in accordance with the format shown in the Master Provider File Data Dictionary (Attachment H, “Master Provider File Data Dictionary”). Deliverable:Master Provider File DataInteractive DashboardThe Contractor shall provide a real-time, interactive dashboard to include all data elements described in Section 19, “Data Analytics.” The data elements incorporated into the dashboard shall be retrievable at each of the following category levels:The Veteran,CCN Region,CCN provider,VISN,VAMC, andStandard geographic area (State, County, and Zip Code).Deliverable:Interactive DashboardData RepositoryThe Contractor shall provide a data repository. The data repository shall contain an analytics component to allow VA-designated personnel to access the Contractor’s data information system/data repository permitting VA to extract data. This requirement does not require access to the Contractor’s production system(s), but a data warehouse or an extract of VA-specific data elements to a separate database that is accessible by the data analytics application. The Contractor shall make available 50 user accounts to be assigned at the discretion of VA. The Contractor shall manage the list of user accounts based on approved users provided by VA COR throughout the period of performance.All data contained in the data repository shall be current and refreshed no less frequently than weekly and accessible to all VA-designated personnel. The data repository shall allow the following item categories to be queried:The Veteran,CCN Region,CCN provider,VISN,VAMC, and Standard geographic area (State, County, and Zip Code). VA access to the data analytics application will be mutually agreed upon by the Contractor and VA and will be included as part of the implementation plan.The Contractor shall provide initial and ongoing training for accessing the Contractor's data analytics application. Web-based training is an acceptable training method.Deliverable:VA Data RepositorySchedule of DeliverablesItemTaskIDDeliverable DescriptionDue DateElectronic submission to:12.1AKickoff Meeting Presentation Five (5) days before scheduled kickoff meetingVA PM, COR, CO22.1BMeeting Minutes Five (5) days after kickoff meetingVA PM, COR, CO32.2AProject Management PlanThirty (30) days after kickoff meeting and updated monthly thereafterVA PM, COR, CO42.2.1AImplementation StrategyFifteen (15) days after kickoff meeting and updated monthly thereafterVA PM, COR, CO52.2.2ACommunity Care Network Deployment ApproachFifteen (15) days after kickoff meeting and updated monthly thereafterVA PM, COR, CO62.3ARisk Management Plan Initial Content and UpdatesFifteen (15) days after kickoff meeting and updated monthly thereafterVA PM, COR, CO72.3BProject Risk Registry and UpdatesFifteen (15) days after kickoff meeting and updated monthly thereafterVA PM, COR, CO82.5.1AQuality Control PlanFifteen (15) days after kickoff meeting and updated monthly thereafter VA PM, COR, CO 92.5.2AQuarterly Progress ReportsQuarterlyVA PM, COR, CO102.5.2BMonthly Progress ReportsMonthlyVA PM, COR, CO112.6ACommunications PlanFifteen (15) days after kickoff meeting and updated monthly thereafter VA PM, COR, CO122.7AAccreditation Certificate(s) Thirty days (30) after accreditation; no later than HCD 133.2AVeteran Feedback PlanThirty (30) days after kickoff meetingVA PM, COR, CO143.3AHealth Services Network Quality and Performance Criteria ThresholdsMonthlyVA PM, COR, CO153.5ANetwork Adequacy PlanFifteen (15) days after kickoff meeting VA PM, COR, CO163.5BNetwork Adequacy Performance ReportMonthlyVA PM, COR, CO173.5CNetwork Adequacy Corrective Action PlanWithin ten (10) days of discovery of performance deficienciesVA PM, COR, CO183.5DNetwork Monitoring ReportMonthlyVA PM, COR, CO195.3.1AImplementation Plan for Card IssuanceThirty (30) days after kickoff meetingVA PM, COR, CO205.3.1BDesign for Veteran Choice Card Proposed design due thirty (30) days after kickoff meeting; Final due ten (10) days after VA approval of proposed designVA PM, COR, CO215.3.2ACard Processing Summary Report Due monthly once card issue begins.VA PM, COR, CO225.3.2BCard Processing Detailed ReportDue monthly once card issue begins.VA PM, COR, CO236.8AVeteran Satisfaction Survey ResultsQuarterly after SCHDVA PM, COR, CO246.8.1AVA Support and Provider Call Center ReportQuarterly after SCHDVA PM, COR, CO256.8.2AAvailability Status ReportWithin three (3) business days of downtime detectionVA PM, COR, CO267.5AReferral Summary Statistics ReportThirty (30) days after SCHD and updated monthly thereafterVA PM, COR, CO277.5BPrior Authorization Summary Statistics ReportThirty (30) days after SCHD and updated monthly thereafterVA PM, COR, CO289.1AMedical Documentation Submission PlanThirty (30) days after kickoff meeting VA PM, COR, CO 299.1BMedical Documentation Submission ReportThirty (30) days after SCHD and updated monthly thereafter VA PM, COR, CO 3010.1ATraining PlanFifteen (15) days after kickoff meeting and updated thirty (30) days prior to the effective date of any material changeVA PM, COR, CO3110.1.1AAnnual Training Program and UpdatesSixty (60) days prior to SHCD and updated thirty (30) days prior to the effective date of any material changeVA PM, COR, CO3210.2ATraining Materials Ninety (90) days prior to SHCD and updated thirty (30) days prior to the effective date of any material changeVA PM, COR, CO3311.0AMedical Management Plan Thirty (30) days after kickoff meeting and at least thirty (30) days prior to the effective date of any material changeVA PM, COR, CO3411.1ADischarge Planning PlanThirty (30) days after kickoff meeting and at least thirty (30) days prior to the effective date of any material changeVA PM, COR, CO3512.1.1AClaims Processing Data DictionaryForty five (45) days after kickoff meeting and updated at least thirty (30) days prior to the effective date of any material changeVA PM, COR, CO3612.3.1ASignature on File ProcedureNinety (90) days prior to SCHD and updated thirty (30) days prior to any changeVA PM, COR, CO3712.6AEDI 835 Transaction FileDaily after payment of first claimVA PM, COR, CO3812.7ACoordination of Benefits PlanNinety (90) days prior to SHCD and updated at least thirty (30) days prior to the effective date of any material changeVA PM, COR, CO3912.7.1AOther Health Insurance Verification and Retrieval PlanNinety (90) days prior to SHCD and updated monthly thereafterVA PM, COR, CO4012.9BImproper Payment Review PlanThirty (30) days prior to SHCD and updated at least thirty (30) days prior to the effective date of any material changeVA PM, COR, CO4112.9.1ACost Avoidance and Recovery/Recoupments ReportNinety (90) days after payment of first claim and updated quarterly thereafterVA PM, COR, CO4212.10AEDI 837 Transaction FileDailyVA PM, COR, CO4312.10BVA Weekly Claims Processing ReportsWeekly after payment of first claimVA PM, COR, CO4412.10CQuarterly Claims Audit ReportsQuarterly after payment of first claimVA PM, COR, CO4512.10DClaims Performance Data and Metrics ReportWeekly after payment of first claimVA PM, COR, CO4613.2AProvider Reconsideration ProcessNinety (90) days prior to SHCD and updated thirty (30) days prior to the effective date of any material changeVA PM, COR, CO4714.1AClinical Quality Monitoring PlanFifteen (15) days after kickoff meeting and updated thirty (30) days prior to the effective date of any material changeVA PM, COR, CO4815.1AMonthly Electronic Urgent/Emergent Prescription Report in National Council for Prescription Drug Programs (NCPDP) formatThirty (30) days after SHCD and updated monthly thereafterVA PM, COR, CO4918.1AContinuity of Operations PlanFifteen (15) days after kickoff meeting and updated thirty (30) days prior to the effective date of any material changeVA PM, COR, CO5019.1AMaster Provider File DataThirty (30) days prior to SHCD and updated within five (5) days as new providers are added to the network VA PM, COR, CO5119.2AInteractive DashboardThirty (30) days prior to SHCDVA PM, COR, CO5219.3AVA Data RepositoryThirty (30) days prior to SHCDVA PM, COR, COACRONYMS AND DEFINITIONSAcronymDefinition ADAAmerican Dental AssociationAHRQAgency for Healthcare Research and Quality ANSIAmerican National Standards InstituteATOAuthority to Operate AWPAverage Wholesale PriceCAPCorrective Action PlanCCCommunity CareCCDAContinuity of Care Document ArchitectureCCNCommunity Care NetworkCDTCurrent Dental Terminology C.F.R.Code of Federal RegulationsCIHSComplimentary and Integrative Health ServicesCMSCenters for Medicare and Medicaid ServicesCOContracting OfficerCOOPContinuity of Operations PlanCOECenters of ExcellenceCOPDChronic Obstructive Pulmonary Disease CORContracting Officer's RepresentativeCPTCurrent Procedural TerminologyCQIPClinical Quality Improvement ProgramCQMPClinical Quality Monitoring PlanDASVA’s Data Access ServiceDEADrug Enforcement AgencyDMEDurable Medical EquipmentEDIElectronic Data InterchangeEDIPIElectronic Data Interchange Patient IdentifierEOBExplanation of Benefits ERAElectronic Remittance Advice FDAFood and Drug AdministrationFOCFull Operation CapabilityFYFiscal YearHACHospital Acquired Conditions HCPCSHealthcare Common Procedure Coding System HHSHealth and Human ServicesHIPAAHealth Insurance Portability and Accountability Act ICNInternal Control NumberIMSIntegrated Master Schedule IOCInitial Operation CapabilityITInformation TechnologyMPRMonthly Progress ReportNAICNational Association of Insurance CommissionersNCPDPNational Council for Prescription Drug ProgramsNPINational Provider IdentifierNQFNational Quality Forum OHIOther Health Insurance OIGOffice of the Inspector General OITOffice of Information and TechnologyORROperational Readiness Review PBMPharmacy Benefits Management PIIPersonally Identifiable Information PMProject Manager PMPProject Management PlanPMRProgram Management ReviewPOCPoint of ContactPOPPeriod of PerformancePSIPatient Safety Indicators PWSPerformance Work StatementQASPQuality Assurance Surveillance Plan QCPQuality Control PlanQPRQuarterly Progress ReportRMPRisk Management PlanRTOReturn to OperationsSCORMShareable Content Object Reference Model SHCDStart of Healthcare Delivery SRESerious Reportable Events TPAThird Party AdministratorTRMTechnical Reference Model USPSUnited States Postal ServiceUSSCUnited States Sentencing CommissionVADepartment of Veterans AffairsVAMCVeterans Administration Medical CenterVHAVeterans Heath AdministrationWBSWork Breakdown Structure ................
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