CC High-Performing Network



20955000DEPARTMENT OF VETERANS AFFAIRSCommunity Care NetworkDRAFT PERFORMANCE WORK STATEMENT (PWS)Veterans Health Administration Office of Community CareDate: February 2016Version: Draft Posting[This is a Draft Performance Work Statement for VA’s Community Care Network requirement. The purpose is to receive feedback from the industry on the VA’s draft requirement. Please review the draft PWS in its entirety. THIS IS NOT A REQUEST FOR PROPOSAL. No contract will be awarded from this announcement.]TABLE OF CONTENTS TOC \o "1-3" \h \z \u 1.0GENERAL INFORMATION PAGEREF _Toc441838093 \h 71.1TITLE OF PROJECT PAGEREF _Toc441838094 \h 71.2SCOPE OF WORK PAGEREF _Toc441838095 \h 71.3BACKGROUND PAGEREF _Toc441838096 \h 72.0PROJECT MANAGEMENT PAGEREF _Toc441838097 \h 92.1CONTRACTOR OPERATIONAL GUIDE PAGEREF _Toc441838098 \h 92.2KICKOFF MEETING PAGEREF _Toc441838099 \h 102.3PROJECT MANAGEMENT REPORTING REQUIREMENTS PAGEREF _Toc441838100 \h 102.4PROJECT MANAGEMENT PLAN PAGEREF _Toc441838101 \h 112.4.1IMPLEMENTATION STRATEGY PAGEREF _Toc441838102 \h 112.4.2DEPLOYMENT PLAN PAGEREF _Toc441838103 \h 112.4.3COMMUNICATIONS PLAN PAGEREF _Toc441838104 \h 122.5TRAINING PLAN PAGEREF _Toc441838105 \h 122.6QUALITY MANAGEMENT PLAN PAGEREF _Toc441838106 \h 122.6.1SCHEDULE MANAGEMENT PLAN PAGEREF _Toc441838107 \h 122.7RISK MANAGEMENT PLAN PAGEREF _Toc441838108 \h 132.8ACCREDITATION PAGEREF _Toc441838109 \h 143.0HEALTH BENEFIT PACKAGE PAGEREF _Toc441838110 \h 143.1HEALTHCARE SERVICES PAGEREF _Toc441838111 \h 143.2COMPLEMENTARY SERVICES PAGEREF _Toc441838112 \h 143.3EXCLUDED HEALTHCARE SERVICES PAGEREF _Toc441838113 \h 153.4HEALTHCARE SERVICE EXCEPTIONS PAGEREF _Toc441838114 \h 164.0HIGH-PERFORMING NETWORK PAGEREF _Toc441838115 \h 164.1NETWORK ESTABLISHMENT AND MAINTENANCE PAGEREF _Toc441838116 \h 164.2TIERED PROVIDER NETWORK PAGEREF _Toc441838117 \h 164.3NETWORK ADEQUACY MONITORING PAGEREF _Toc441838118 \h 174.4CREDENTIALING PAGEREF _Toc441838119 \h 185.0ELGIBILITY VERIFICATION AND ENROLLMENT PAGEREF _Toc441838120 \h 195.1ELIGIBILITY VERIFICATION PAGEREF _Toc441838121 \h 195.1.1ELIGIBILITY COMMUNICATION INTERFACE PAGEREF _Toc441838122 \h 195.1.2ELIGIBILITY DATA EXCHANGE PAGEREF _Toc441838123 \h 195.1.2.1TIME-ELIGIBLE PAGEREF _Toc441838124 \h 195.1.2.2DISTANCE-ELIGIBLE PAGEREF _Toc441838125 \h 195.1.3ELIGIBILITY VERIFICATIONS PAGEREF _Toc441838126 \h 195.2ENROLLMENT PAGEREF _Toc441838127 \h 205.3VETERANS CHOICE CARDS PAGEREF _Toc441838128 \h 205.3.1VETERANS CHOICE CARDS PRODUCTION AND DISTRIBUTION PAGEREF _Toc441838129 \h 205.3.2VETERANS CHOICE CARD HANDLING PAGEREF _Toc441838130 \h 216.0REFERRALS AND PRE-AUTHORIZATIONS PAGEREF _Toc441838131 \h 226.1REFERRALS PAGEREF _Toc441838132 \h 226.1.1TIME-ELIGIBLE PAGEREF _Toc441838133 \h 236.1.1.1TIME-ELIGIBLE: REFERRALS FROM VA TO A COMMUNITY PROVIDER PAGEREF _Toc441838134 \h 236.1.1.2TIME-ELIGIBLE: REFERRALS FROM A COMMUNITY PROVIDER TO ANOTHER COMMUNITY PROVIDER OR BACK TO VA PAGEREF _Toc441838135 \h 236.1.2DISTANCE-ELIGIBLE PAGEREF _Toc441838136 \h 236.1.2.1DISTANCE-ELIGIBLE: REFERRALS FROM A COMMUNITY PROVIDER TO A COMMUNITY PROVIDER PAGEREF _Toc441838137 \h 236.2PRE-AUTHORIZATIONS PAGEREF _Toc441838138 \h 246.2.1TIME-ELIGIBLE PAGEREF _Toc441838139 \h 246.2.2DISTANCE-ELIGIBLE PAGEREF _Toc441838140 \h 256.3PRE-AUTHORIZATION SERVICES PAGEREF _Toc441838141 \h 256.4REFERRALS AND PRE-AUTHORIZATION REPORTs PAGEREF _Toc441838142 \h 257.0MEDICAL MANAGEMENT (VA CARE COORDINATION) PAGEREF _Toc441838143 \h 267.1MEDICAL DOCUMENTATION SUBMISSION PROCESS PAGEREF _Toc441838144 \h 277.1.1TIME-ELIGIBLE PAGEREF _Toc441838145 \h 277.1.2DISTANCE-ELIGIBLE PAGEREF _Toc441838146 \h 287.1.3MEDICAL DOCUMENTATION DATA POINTS PAGEREF _Toc441838147 \h 287.1.4MEDICAL DOCUMENTATION SUBMISSION TIMEFRAMES PAGEREF _Toc441838148 \h 287.2DISEASE MANAGEMENT PROGRAM ADMINISTRATION PAGEREF _Toc441838149 \h 297.2.1TIME-ELIGIBLE PAGEREF _Toc441838150 \h 297.2.2DISTANCE-ELIGIBLE PAGEREF _Toc441838151 \h 297.3CASE MANAGEMENT PROGRAM ADMINISTRATION PAGEREF _Toc441838152 \h 297.3.1TIME-ELIGIBLE PAGEREF _Toc441838153 \h 307.3.2DISTANCE-ELIGIBLE PAGEREF _Toc441838154 \h 307.4DISCHARGE PLANNING PAGEREF _Toc441838155 \h 307.4.1TIME-ELIGIBLE PAGEREF _Toc441838156 \h 307.4.2DISTANCE-ELIGIBLE PAGEREF _Toc441838157 \h 318.0CLAIMS ADJUDICATION FOR HEALTHCARE SERVICES RENDERED PAGEREF _Toc441838158 \h 318.1CLAIMS PROCESSING SYSTEM FUNCTIONS PAGEREF _Toc441838159 \h 318.2CLAIMS ADJUDICATION AND PAYMENT RULES PAGEREF _Toc441838160 \h 328.3CLAIMS SUBMISSION AND PROCESSING TIMEFRAMES PAGEREF _Toc441838161 \h 328.4ISSUANCE OF EXPLANATIONS OF BENEFITS (EOB) PAGEREF _Toc441838162 \h 328.5ISSUANCE OF REMITTANCE ADVICE PAGEREF _Toc441838163 \h 338.6OTHER HEALTH INSURANCE PAGEREF _Toc441838164 \h 338.7VETERAN APPEALS PAGEREF _Toc441838165 \h 338.8PROVIDER RECONSIDERATIONS PAGEREF _Toc441838166 \h 348.9CLAIMS AUDITING PAGEREF _Toc441838167 \h 348.9.1CLAIMS AUDIT REPORTING PAGEREF _Toc441838168 \h 358.9.1.1QUARTERLY FRAUD AND ABUSE WORKLOAD SUMMARY REPORT PAGEREF _Toc441838169 \h 358.9.1.2UTILIZATION REPORT PAGEREF _Toc441838170 \h 358.9.1.3COST AVOIDANCE AND RECOVERY/RECOUPMENTS REPORT PAGEREF _Toc441838171 \h 358.10CLAIMS REPORTING PAGEREF _Toc441838172 \h 369.0CONTRACTOR INVOICING AND REIMBURSEMENT PAGEREF _Toc441838173 \h 379.1MONTHLY INVOICES PAGEREF _Toc441838174 \h 379.1.1CONTRACT LINE ITEMS FOR MONTHLY ADMINISTRATIVE FEES: PER MEMBER PER MONTH PAGEREF _Toc441838175 \h 379.1.2CONTRACT LINE ITEMS FOR MONTHLY ADMINISTRATIVE FEES: IMPLEMENTATION COSTS PAGEREF _Toc441838176 \h 389.2CONTRACTOR INVOICES FOR HEALTHCARE CLAIMS REIMBURSEMENT PAGEREF _Toc441838177 \h 389.3CONTRACTOR REJECTED AND DENIED INVOICES PAGEREF _Toc441838178 \h 399.3.1CONTRACTOR REJECTED INVOICES PAGEREF _Toc441838179 \h 399.3.2CONTRACTOR DENIED INVOICE RESUBMISSION PAGEREF _Toc441838180 \h 3910.0QUALITY MONITORING PAGEREF _Toc441838181 \h 3910.1ESTABLISHMENT OF A PATIENT SAFETY, QUALITY ASSURANCE, QUALITY IMPROVEMENT AND PEER REVIEW PLAN PAGEREF _Toc441838182 \h 3910.2QUALITY INITIATIVE COMPONENT OF THE QA/QI PLAN PAGEREF _Toc441838183 \h 3910.3QUALITY IMPROVEMENT COMPONENT OF THE QA/QI PLAN PAGEREF _Toc441838184 \h 4010.4POTENTIAL AND IDENTIFIED QUALITY ISSUES PAGEREF _Toc441838185 \h 4010.5PEER REVIEW OF IDENTIFIED QUALITY ISSUES PAGEREF _Toc441838186 \h 4110.6VA PARTICIPATION PAGEREF _Toc441838187 \h 4111.0CUSTOMER SERVICE PAGEREF _Toc441838188 \h 4111.1CONTRACTOR VETERAN CALL CENTER FUNCTION – TIME-ELIGIBLE AND DISTANCE-ELIGIBLE PAGEREF _Toc441838189 \h 4211.2NETWORK PROVIDER CALL CENTER FUNCTION – TIME-ELIGIBLE AND DISTANCE-ELIGIBLE PAGEREF _Toc441838190 \h 4211.3CONTRACTOR CUSTOMER SERVICE TECHNOLOGY PAGEREF _Toc441838191 \h 4311.4CONTRACTOR VETERAN COMPLAINTS/GRIEVANCES AND CUSTOMER SERVICE PROCEDURE PAGEREF _Toc441838192 \h 4411.5VA AND CONGRESSIONAL INQUIRIES PAGEREF _Toc441838193 \h 4411.6CONTRACTOR CUSTOMER SERVICE PERFORMANCE MEASURES PAGEREF _Toc441838194 \h 4411.6.1CALL CENTER FUNCTIONALITY PERFORMANCE MEASURES PAGEREF _Toc441838195 \h 4411.6.2CUSTOMER SERVICE TECHNOLOGY PERFORMANCE MEASURES PAGEREF _Toc441838196 \h 4511.6.3COMPLAINTS AND GRIEVANCES PERFORMANCE MEASURES PAGEREF _Toc441838197 \h 4512.0TECHNOLOGY PAGEREF _Toc441838198 \h 4512.1CONTINUITY OF OPERATIONS PAGEREF _Toc441838199 \h 4612.2CONTRACTOR SYSTEM ACCESS PAGEREF _Toc441838200 \h 4612.3VA SYSTEM INTEGRATION REQUIREMENTS PAGEREF _Toc441838201 \h 4712.4INFORMATION SECURITY & PRIVACY PAGEREF _Toc441838202 \h 4712.4.1INFORMATION SYSTEM SECURITY REQUIREMENTS FOR CONTRACTOR SYSTEMS THAT WILL CONTAIN VA INFORMATION PAGEREF _Toc441838203 \h 4712.4.2TECHNOLOGY DOCUMENTS PAGEREF _Toc441838204 \h 4812.4.3CONTRACTOR ACCESS TO VA SYSTEMS PAGEREF _Toc441838205 \h 4812.4.4INFORMATION SYSTEM HOSTING, OPERATION, MAINTENANCE, OR USE PAGEREF _Toc441838206 \h 4913.0DATA ANALYTICS PAGEREF _Toc441838207 \h 5113.1DATA ELEMENTS PAGEREF _Toc441838208 \h 5113.2DATA ANALYTICS PAGEREF _Toc441838209 \h 5313.3DATA REPOSITORY PAGEREF _Toc441838210 \h 5314.0TRAINING PAGEREF _Toc441838211 \h 5414.1TRAINING PLAN PAGEREF _Toc441838212 \h 5414.1.1CONTRACTOR PERSONNEL AND VA STAFF TRAINING PAGEREF _Toc441838213 \h 5414.1.2PROVIDER NETWORK MAINTENANCE AND TRAINING PAGEREF _Toc441838214 \h 5414.1.3TRAINING MATERIALS PAGEREF _Toc441838215 \h 5514.1.4TRAINING SESSIONS PAGEREF _Toc441838216 \h 5515.0PHARMACY PAGEREF _Toc441838217 \h 5615.1ROUTINE PRESCRIPTIONS – TIME-ELIGIBLE AND DISTANCE-ELIGIBLE PAGEREF _Toc441838218 \h 5615.2URGENT/EMERGENT PRESCRIPTIONS – TIME-ELIGIBLE AND DISTANCE-ELIGIBLE PAGEREF _Toc441838219 \h 5715.2.1URGENT/EMERGENT PRESCRIPTION CLAIMS AND INVOICING PAGEREF _Toc441838220 \h 5816.0DURABLE MEDICAL EQUIPMENT AND MEDICAL DEVICES PAGEREF _Toc441838221 \h 5916.1URGENT/EMERGENT PRESCRIPTIONS PAGEREF _Toc441838222 \h 5916.2NON-URGENT/EMERGENT PRESCRIPTIONS FOR DME/MEDICAL DEVICES PAGEREF _Toc441838223 \h 5917.0DENTAL PAGEREF _Toc441838224 \h 5917.1OUTPATIENT DENTAL SERVICES PAGEREF _Toc441838225 \h 6017.2DENTAL MANAGEMENT PAGEREF _Toc441838226 \h 6017.3DENTAL NETWORK ADEQUACY PAGEREF _Toc441838227 \h 6017.4DENTAL CREDENTIALING AND COMPLIANCE PAGEREF _Toc441838228 \h 6117.5DENTAL APPOINTMENT SCHEDULING PAGEREF _Toc441838229 \h 6117.5.1TIME-ELIGIBLE VETERAN PAGEREF _Toc441838230 \h 6117.5.2DISTANCE-ELIGIBLE VETERAN PAGEREF _Toc441838231 \h 6117.6RETURN OF DENTAL RECORDS PAGEREF _Toc441838232 \h 6217.6.1TIME-ELIGIBLE VETERAN PAGEREF _Toc441838233 \h 6217.6.2DISTANCE-ELIGIBLE VETERAN PAGEREF _Toc441838234 \h 6217.7DENTAL CLAIMS PROCESSING PAGEREF _Toc441838235 \h 6217.8DENTAL MONTHLY REPORT PAGEREF _Toc441838236 \h 6218.0PERFORMANCE METRICS PAGEREF _Toc441838237 \h 6319.0SCHEDULE FOR DELIVERABLES PAGEREF _Toc441838238 \h 64GENERAL INFORMATIONTITLE OF PROJECTCommunity Care Network, purchased under the authority of 38 U.S. Code (U.S.C.) § 8153, Sharing of Healthcare Resources. SCOPE OF WORK The Contractor shall provide a Community Care Network per the requirements defined in this PWS and the Community Care Network Operations Manual, hereinafter referred to as the “Operations Manual”. The network shall consist of providers for medical and surgical inpatient and outpatient services as defined in Section 3. The Contractor’s community care network will include a network of high-performing healthcare providers, deliver patient-centered care, monitor and manage quality, use data and performance metrics to improve services, pay and process claims, and enhance Veterans’ healthcare experiences. The Contractor shall deliver healthcare through the use of tools and practices that drive efficiencies, cost savings, and a positive Veteran experience. The Contractor shall serve as a third-party administrator with oversight responsibility for the requirements herein.All days within the 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.BACKGROUNDVA is committed to providing Veterans accessible, timely, and high-quality care. VA’s mission includes commitments to 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. As set forth in 38 Code of Federal Regulation (C.F.R.) 17.1510(b), which may be amended, eligible Veteranits may receive healthcare services through this contract. For the purpose of this contract the following categories of eligibility apply unless otherwise modified: Time-Eligible and Service Not Available Veterans (hereinafter referred to as “Time-Eligible” Veterans): Veterans who attempt, or have attempted, to schedule an appointment with a VA healthcare provider, but VA is unable to schedule an appointment for the Veteran within:The wait-time goals of the Veterans Health Administration; orWith respect to such care or services that are clinically indicated, the period VA determines necessary for such care or services if such period is shorter than the wait-time goals of the Veterans Health Administration.Distance-Eligible and Special Circumstances Veterans (hereinafter referred to as “Distance-Eligible Veterans”): Veterans whose residence is more than 40 miles from a VA medical facility that is closest to the Veteran’s residence.Veterans whose residence is both:In a state without a VA medical facility that provides hospital care, emergency medical services, and surgical care having a surgical complexity of standard; andMore than 20 miles from such a VA medical facility Veterans whose residence is in a location, other than Guam, American Samoa, or the Republic of the Philippines, which is 40 miles or less from a VA medical facility and the Veteran:Must travel by air, boat, or ferry to reach such a VA medical facility; orFaces an unusual or excessive burden in traveling to such a VA medical facility based on geographical challenges, such as the presence of a body of water (including moving water and still water) or a geologic formation that cannot be crossed by road; environmental factors, such as roads that are not accessible to the general public, traffic, or hazardous weather; a medical condition that affects the ability to travel; or other factors, as determined by VA, including but not limited to:The nature or complexity of the hospital care or medical services the Veteran requires;The frequency required for such hospital care or medical services; andThe need for an attendant, defined as a person who provides required aid and/or physical assistance, for a Veteran to travel to a VA medical facility for hospital care or medical services.VA’s future integrated healthcare delivery system must provide high-quality, effective, and coordinated care, both at 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 that will address the enterprise-wide challenges to meeting the unique needs of Veterans. In the report titled “Plan to Consolidate Programs of Department of Veterans Affairs to Improve Access to Care,” VA identified requirements of five systems 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 CONTRACTOR OPERATIONAL GUIDEThe Contractor shall create and deliver a Contract Operational Guide (COG) that details the Contractor’s approach, timeline, and tools to be used in execution of the contract. The COG shall be delivered in both narrative and graphic format that displays the schedule, milestones, risks and resource support. The COG shall also include how the Contractor will coordinate and execute planned, routine, and ad hoc data collection reporting requests as identified within the PWS. The initial baseline COG shall be concurred upon by VA and updated as required or requested by VA. The Contractor shall update and maintain the VA-approved COG throughout the period of performance. The Contractor shall provide all necessary information to other Community Care Network contractor(s) when a Veteran receives services in a region covered under this contract and a region or regions covered under another contract. The Contractor shall provide all necessary information to other Community Care Network contractor(s) when a Veteran receives services in a region covered by another contract. Deliverables: Contract Operational GuideKICKOFF MEETINGThe Contractor shall participate in a kickoff meeting within ten (10) days after contract award. The Contractor shall present, for review and approval by the VA, the details of the approach, work plan, and project schedule. The Contractor shall collaborate with the Contracting Officer to establish dates, locations, and agenda. The Contractor shall take meeting minutes which shall be provided to all attendees within three (3) business days after the meeting. Deliverables:Kickoff Meeting PresentationMeeting MinutesPROJECT MANAGEMENT REPORTING REQUIREMENTSThe Contractor shall provide the designated VA Project Manager (PM) and Contracting Officer’s Representative with Executive Level Quarterly Progress Reports (QPR) in electronic form in Microsoft Word and Project formats. The report shall include:Performance Summary Contract Quality Assurance Objectives and MetricsHigh Level Cost SummaryHigh Level Schedule SummaryHigh Level Risks and Issues SummaryCorrective Actions and ImprovementsRequirement PerformancePlanned activities for next quarterRecommendationsThese reports shall reflect data as of the last day of the preceding quarter. The Contractor shall participate in quarterly Program Management Reviews (PMRs) with VA.? ?The Contractor shall provide the COR with Monthly Progress Reports (MPRs) in electronic form in Microsoft Word and Project formats. The report shall include detailed instructions/explanations for each required data element in this Section REF _Ref440461300 \r \h \* MERGEFORMAT 2.3 to ensure that the report is cross-cutting, accurate and consistent. The report shall also identify any problems that arose and a description of how the 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 report performance against requirements by reporting successes and non-successes. The Contractor shall monitor performance against the Quality Assurance Surveillance Plan (QASP) and COG and report any deviations. It is expected that the Contractor shall keep in communication with VA so that issues that arise are transparent to both parties to prevent escalation of outstanding issues. The Contractor shall participate with designated VA personnel at any periodic or intermittent project-related meetings. The MPR shall reflect the data, including the source of the data, as of the last day of the preceding Month. The MPR shall include notifications when updates to technical documents are made. Deliverables:Executive-Level QPRMonthly Progress ReportPROJECT MANAGEMENT PLANIMPLEMENTATION STRATEGYThe Contractor’s network shall be fully operational not later than 12 months after the post award kickoff meeting. The Contractor shall develop a High-Performing Network Implementation Strategy to detail how the Contractor’s network solution shall be implemented within the VA regions referenced in Section REF _Ref441819489 \r \h \* MERGEFORMAT 4.1. The Implementation Plan shall outline the strategy for establishing the provider network, provider education, credentialing new and existing Veteran providers, establishing a provider directory to initialize the operational capability of the high-performing network. The Implementation Strategy shall also contain a high-level implementation schedule, with network adequacy in the first twelve (12) months and fifteen (15) months for quality and network tiering (see section REF _Ref441819524 \r \h \* MERGEFORMAT 4.2) based on the IMS created in the COG. Acceptable concepts include, but are not limited to, full immediate availability at a certain point, phased approaches, rolling availability of services across the region.? Deliverables:1. Implementation Plan2. Project Plan including the overall project management strategy DEPLOYMENT PLANThe Contractor shall develop a High-Performing Network Deployment Approach to describe the strategy and procedures associated with deploying the High-Performing Network in the regional, VAMC, and catchment construct identified in PWS Section 4.The High-Performing Network Deployment Approach shall contain details on the Contractor’s plan to (i) prepare for deployment, training requirements, and documentation requirements, and (ii) provide a series of High-Performing Network deployment scenarios. The Deployment Approach shall also contain a high-level deployment schedule based on the IMS created in the COG.Deliverable:High-Performing Network Deployment Approach COMMUNICATIONS PLAN TBDDeliverables: WBS and UpdatesIntegrated Master Schedule (IMS) and UpdatesSchedule ReportsCritical Path Reports and UpdatesWhat-if Analyses and Updates QUALITY MANAGEMENT PLAN SCHEDULE MANAGEMENT PLANThe Contractor shall create an Integrated Master Schedule (IMS) that depicts the implementation and deployment of the high performing network solution pursuant to the PWS. The Contractor shall create, maintain, analyze, and report integrated schedules, as defined below: The Contractor shall create and maintain a Work Breakdown Structure (WBS) to a minimum of 3 levels.The IMS schedule shall identify and include all applicable project milestones for identifying and documenting discrete events necessary to complete the project, definition of relationship (dependency) between and among these events, determination of the expected duration of each event, resources required for each, and creation of a schedule that depicts this information as a cohesive whole. The Contractor shall ensure that a fully resource-loaded and baselined schedule in Microsoft Project (or other product as directed by VA such as Primavera, Jira, etc.) is in place within twenty (20) business days of receiving baselined requirements. The Contractor shall maintain the schedule, generating weekly schedule reports containing at a minimum the planned versus actual program/project performance and updated critical path information for the project. The reports shall be provided to and accepted by VA.The Contractor shall follow the established 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 detail-level schedule, critical path depiction, and 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 PM within one (1) business day, by email and phone. RISK MANAGEMENT PLANThe Contractor shall adhere to risk and issue management processes and report risks and issues to VA for all Community Care High-Performing Network activities.The Contractor shall also populate a project Risk Management Plan (RMP) to identify circumstances that create a negative impact on the network solution. The RMP shall also describe impacts and assert measures to either reduce/eliminate their potential or minimize their impact. The Contractor shall provide a presentation to VA of updated risk responses and actions to include mitigation strategies at each QPR.The Contractor shall track and manage risks/issues and report them to VA. The Contractor shall also collaborate with project partners to establish the priority, scope, bounds, and resources for managing project risks and issues and assess the courses of action related to them. The Contractor shall inform VA of relevant deliberations and recommendations and work with the development team to mitigate and resolve project risks and issues as they are identified.In accordance with requirements outlined in the OIG’s Compliance Program Guidance for Hospitals () and USSC Sentencing Guidelines (), all services, facilities, and providers shall have a compliance program in place that includes the seven elements of an effective compliance program.Deliverables: Risk Management Initial Content and Updates Project Risk Registry and Updates Action Item/Issue Log and Updates ACCREDITATIONThe Contractor’s network shall be accredited by a nationally recognized accrediting organization. All services, facilities and providers shall be 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 body have different standards for the same activity, the more stringent standard shall apply for the Contractor’s solution. The Contractor shall maintain accreditation on the following components of its solution:Provider Network: accredited prior to Veteran access or within 12 months from date of awardCredentialing: Included at date of awardMedical Management: Included at date of awardDisease ManagementCase ManagementUtilization ManagementThe Contractor shall maintain documentation of all accreditation, certification, credentialing, privileging, and licensing for its accredited programs and network providers performing services under this Contract. The Contractor shall provide a copy of its Accreditation Certifications at time of award or upon receipt, as applicable, and upon renewal thereafter. VA reserves the right to perform random inspections of the accreditation, certification, credentialing, privileging/competency measures, and licensing files for its accredited programs and providers within the Contractor’s network for performance of this contract within 5 business days of notification. Deliverable:Network Accreditation CertificateHEALTH BENEFIT PACKAGEHEALTHCARE SERVICESThe Contractor shall include the following healthcare services as described in 38 C.F.R. 17.38 as part of the services provided under this contract:Health BenefitCoverageBasic Medical Benefits Package, includesPreventive CareHospital ServicesAncillary ServicesMental HealthHome HealthcareGeriatricsOutpatient Diagnostic and Treatment ServicesInpatient Diagnostic and Treatment ServicesAll eligible VeteransMedicationsAll eligible Veterans Contractor will only provide pharmacy services for urgent and emergent drugs.DentalRequires special eligibilityUrgent/Emergent CareUnder certain conditionsDurable Medical EquipmentUnder certain conditionsNote: Healthcare services may include rehabilitative therapies provided by non-licensed practitioners (e.g. blind therapy; driver rehabilitation services; recreational therapy)COMPLEMENTARY SERVICES Complementary Services are Veteran services that are covered under the VA Health Benefits Package pursuant to 38 C.F.R. 17.38. For the following Complementary Services, the Contractor shall only provide customer service and claims processing services: National ClinicList CodeNameACUPACUPUNCTUREBIOFBIOFEEDBACKCBHTCOGNITIVE BEHAVIORAL THERAPY GIMAGUIDED IMAGERYHYPNHYPNOTHERAPYMANTMANTRAM REPETITIONMBSRMINDFULNESS BASED STRESS REDUCTIONMDTNMEDITATIONMSGTMASSAGE THERAPYNAHLNATIVE AMERICAN HEALINGPILAPILATESREIKREIKI ALTERNATIVE THERAPYRFLXREFLEXOLOGYRLXTRELAXATION TECHNIQUESTAICTAI CHITPHTTHERAPEUTIC OR HEALING TOUCHYOGAYOGAEXCLUDED HEALTHCARE SERVICESExcluded Healthcare Services are services not covered by the VA Health Benefit Package pursuant to 38 C.F.R. 17.38. The Contractor shall exclude the following healthcare services from the Community Care Network customer services and claims processing: 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 clubsHEALTHCARE SERVICE EXCEPTIONSHealthcare Service Exceptions are services covered by the VA Health Benefit Package pursuant to 38 C.F.R. 17.38; however, they are not eligible for reimbursement under the terms of this contract. The Contractor shall not be required to provide services under this contract for the following items:Long Term Acute Care Hospitals (LTAC)Nursing home careChronic dialysis treatmentsCompensation and pension examinationsPediatric servicesHIGH-PERFORMING NETWORKNETWORK ESTABLISHMENT AND MAINTENANCE The Contractor shall establish and maintain a tiered network of qualified healthcare professionals to include individual providers and institutional facilities, that (i) is coordinated with the care and services provided by VA, (ii) produces the best quality clinical outcomes, and (iii) is adequate in size, scope and capacity to ensure Veterans receive timely access to care in accordance with the following standards, at a minimum, for each VAMC service area. Appointment AvailabilityDistanceEmergentUrgentRoutineUrbanSame Day24 Hours30 Days40 milesRuralSame Day24 Hours30 Days40 milesHighly RuralSame Day24 Hours30 Days40 milesProvider to Unique Member RatiosPrimary Care Physicians1 primary care physician per 1,200 Unique MembersSpecialists1 specialist, by type, per 5,000 Unique MembersHospitals1 hospital within 40 miles of each county covered under this contractTIERED PROVIDER NETWORKThe Contractor’s network shall include three tiers in the following priority ranked highest to lowest: (i) Tier 1 (academic affiliates and Federally-Qualified Health Centers), (ii) Tier 2 and (iii) Tier 3. The Contractor shall base its Tier 2 and Tier 3 network participation on quality measures, reporting capability, timeliness of medical documentation submission, referrals to the VA Core Network, and cost as set forth in the Operations Manual. The Contractor shall define the process for maintaining a tiered provider network based on quality and performance criteria and shall collaborate with VA to identify opportunities to introduce value-based reimbursement models into the tiered provider network.The Contractor shall establish its tiered provider network in accordance with PWS Section 3.2 based on “Unique Members” and using the data provided by VA in Demand Data Attachment for the applicable VAMC service areas for the region(s) set forth in Table 1: “VA Community Care Regions.” For the initial contract year, “Unique Members” is defined as Time-Eligible Veterans and Distance-Eligible Veterans who have accessed Community Care as set forth in Demand Data Attachment. 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. Table 1 VA Community Care Network RegionsRegion 1Region 2Region 3Region 4MaineOhioOklahomaTexasNew HampshireKentuckyArkansasNew MexicoVermontIndianaLouisianaArizonaMassachusettsIllinoisTennesseeCaliforniaConnecticutMissouriMississippiNevadaRhode IslandKansasAlabamaUtahNew YorkNebraskaGeorgiaColoradoNew JerseyIowaSouth CarolinaWyomingDelawareWisconsinFloridaIdahoMarylandMichiganPuerto RicoOregonPennsylvaniaMinnesotaWashingtonDCNorth DakotaMontanaWest VirginiaSouth DakotaAlaskaVirginiaHawaiiNorth CarolinaNorthern Mariana IslandsGuamAmerican SamoaPhilippinesNETWORK ADEQUACY ManagementThe Contractor shall detail its approach for creating and maintaining an adequate network in a Network Adequacy Plan. The network shall be tailored to individual catchment areas associated with each VAMC. 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 its performance against the network adequacy standards set forth in this Section as part of a Network Adequacy Plan. The Contractor shall record its performance and submit the performance record to VA. The Contractor shall correct any network adequacy deficiencies. The Contractor shall develop and submit to VA a Network Corrective Action Plan to resolve any deficiency identified by the Contractor or VA within 10 days of its discovery. The Contractor’s Network Corrective Action Plan shall include the reason for the deficiency and timeline for correcting it. The Contractor shall meet on a weekly basis with local VA to evaluate network performance and needs, including, but not limited to, the following: (i) network implementation; (ii) network access and/or adequacy needs and/or deficiencies; (iii) VA Core Network capabilities; (iv) after hours care; (v) utilization data; (vi) enrollment processes; (vii) referrals and authorizations; (viii) utilization management; (ix) clinical quality management; (x) provider education and customer service; (xi) population health improvement processes; (xii) operational issue resolution; and (xiii) any other areas falling under the scope of this contract. Deliverables:Network Adequacy PlanNetwork Corrective Action PlanCREDENTIALINGThe Contractor shall confirm that providers and facilities within its high-performing network solution shall be credentialed in accordance with the requirements set forth by the nationally-recognized accrediting body for the Contractor’s credentialing program.The Contractor shall confirm that all services, facilities, and providers shall be in compliance with all applicable federal and state laws, statutes, and regulatory requirements. The Contractor shall confirm that any provider on the Centers for Medicare and Medicaid Services (CMS) exclusionary list shall be prohibited from network participation. The Contractor shall confirm that all licensed independent and dependent providers have all active and unrestricted licenses required by their applicable state and federal licensing boards, to provide the services covered under this contract. The Contractor shall confirm that its network providers honor appointments made for authorized services, unless an appointment is canceled by the Veteran or due to circumstances out of the network provider’s control.ELGIBILITY VERIFICATION AND ENROLLMENTELIGIBILITY VERIFICATIONELIGIBILITY INFORMATION The 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. The Contractor shall receive, process, and store eligibility records electronically in a format provided by VA. ELIGIBILITY DATA EXCHANGEThe Contractor shall receive, process, and store these electronic transmissions in the formats outlined in Chapter 4 of the Operations Manual.The Contractor shall receive, process, and store an initial load containing data for Veterans who are currently eligible for care in the community. After receipt of the initial load, the Contractor shall receive, process, and store real-time updates showing Veterans whose eligibility status has changed (begins, changes, extends, or terminates).TIME-ELIGIBLEThe Contractor shall receive and manage eligibility data for Time-Eligible Veterans. The eligibility data provided by VA will include a period of eligibility, with start and end dates for the episode of care.DISTANCE-ELIGIBLEThe Contractor shall receive and manage eligibility data for Distance-Eligible Veterans. The period of eligibility will not be time limited, and eligibility will be reevaluated and updated.ELIGIBILITY VERIFICATIONSThe Contractor shall provide community providers and Veterans access to eligibility information electronically and via telephone. The Contractor shall ensure that providers verify patient eligibility for healthcare services at the time of arrival for an appointment. In response to eligibility requests from community providers, the Contractor shall provide Veteran eligibility information in accordance with the Veterans’ Health Benefit Plans as specified in the Operations Manual.ENROLLMENT The Contractor shall populate their enrollment system with Veteran enrollment data to include eligibility data. The Contractor shall maintain accurate and up-to-date enrollment data based on eligibility information provided by VA. The Contractor shall receive, process, and store electronic transmissions of not only the initial load of Veteran information from VA but also ongoing updates. The Contractor shall assign a unique identification number to each enrolled Veteran. The unique ID shall contain the alphanumeric prefix followed by a standard nine digit ID number. The Contractor’s enrollment database shall include a mapping between the Contractor’s unique ID and VA’s [ID number]. The Contractor shall provide VA with real-time read only access to the enrollment database which shall also include a download capability. VETERANS CHOICE CARDSVETERANS CHOICE CARDS PRODUCTION AND DISTRIBUTIONThe Contractor shall produce all Choice Cards for Veterans in the regions in which their network services are provided. The Veteran’s Choice Cards shall include information required by VACAA, and any future amendments. The Contractor shall develop an Implementation Plan for Card Issuance. The Implementation Plan for Card Issuance shall contain a schedule for an initial distribution of cards for all eligible Veterans. The Implementation Plan for Card Issuance shall include a process for handling replacement cards for any Veteran who reports their card as lost. The Implementation Plan for Card Issuance shall define the process for distributing cards to new enrollees after the initial distribution of Veteran’s Choice Cards. The Contractor shall ensure newly identified Veterans, who are eligible for the Veterans Choice program, receive their cards within fourteen (14) calendar days of notification of eligibility by VA. The Contractor shall provide and distribute replacement cards and participation information within fourteen (14) calendar days of request.Each card issued shall be known as a ‘‘Veteran’s Choice Card’’ (name of the card) and shall include the following information:The name of the VeteranAn identification number for the Veteran that is not the social security number of the VeteranThe contact information for healthcare providers to confirm that care or services under this section are authorized for the VeteranContact information and other relevant information for the submittal of claims or bills for the furnishing of care or servicesVA Branding, website address, and phone number Contractors shall propose a Veteran’s Choice Card design and type that includes the information specified and considers cost and value. VA will choose and approve the final design.Deliverables:Implementation Plan for Card IssuanceFinal Design for Veteran’s Choice CardVETERANS CHOICE CARD HANDLINGVeterans Choice Cards shall be mailed to valid postal addresses through the United States Postal Service (USPS).The Contractor shall receive and handle all returned mail associated with the distribution of Veteran’s Choice Cards. When the USPS returns the mail as undeliverable, the Contractor shall take the appropriate action based on the reason provided:If the card was undeliverable due to an invalid postal address that can be corrected without Veteran contact, then the Contractor shall correct the error and resend. If the card was undeliverable due to an incorrect address or the Veteran does not reside at that location, then the Contractor shall validate current Veteran address through direct contact with Veteran. If the mail is successfully delivered, but the Contactor receives a forwarding address notification from the USPS, the Contractor shall notify VA of the new address in accordance with the Operations Manual. When new address is validated, the Contractor shall notify VA and resend the undelivered mail to the Veteran’s new address. The Contractor shall resolve invalid addresses and resend the card 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, address, and type of document that was mailed (i.e., Veteran’s Choice Card, etc.). The Contractor shall retain undeliverable mail for a period of ninety (90) days, unless an updated address is received before the 90 days expire and the returned mail resent. If the mail is still undeliverable at the end of 90 days, the Contractor shall destroy the card in accordance with VA policy. The Contractor shall provide weekly a detailed report and a summary report to VA on all card processing outcomes (e.g., cards mailed, returned). These reports shall be delivered in the electronic format described in the Operations Manual. Deliverables:Card Processing Summary ReportCard Processing Detailed ReportREFERRALS AND PRE-AUTHORIZATIONSThe Contractor shall facilitate the ability for designated VA staff to schedule appointments directly with its network providers. The Contractor shall administer and maintain a referral and pre-authorization management process in accordance with the Chapter X, Section X.X, of the Community Care Network. The Contractor shall leverage their existing referral and pre-authorization management system to enable a bi-directional interface with the VA Referral Management System (RMS) in accordance with the One VA Technical Reference Model, and HIPAA. The Contractor’s process shall include a mechanism to inform community care providers of services requiring referrals and/or pre-authorizations before each Veteran’s scheduled appointment. The Contractor shall use the referral and pre-authorization data to properly adjudicate claims (see section REF _Ref441822580 \r \h \* MERGEFORMAT 8.0). The Contractor must maintain an automated referral system so that claims are processed consistent with referral authorizations. The Contractor shall verify that the referral number, Veteran, provider, and service or supply information submitted on the claim are consistent with data which were authorized on the referral. The Veteran must be “held harmless” in cases where the community care provider fails to request a referral and the Contractor denies payment. If the referral involves services rendered by a non-network provider, “hold harmless” cannot apply, as “hold harmless” only applies to network providers. Once the Veteran is evaluated by the specialist, the Contractor may require an authorization before the services are provided or the procedure is performed. In those instances where a Contractor requires authorization of services in addition to those listed in Section REF _Ref441822725 \r \h \* MERGEFORMAT 3.1, such authorization must be available to and appealable by all Veterans.The Contractor’s medical necessity review for referrals and pre-authorizations shall be in accordance with VA business rules. REFERRALSThe Contractor’s referral process shall include processing for the following referral scenarios as described:TIME-ELIGIBLETIME-ELIGIBLE: REFERRALS FROM VA TO A COMMUNITY PROVIDERThe Contractor shall receive the referral number and associated referral documentation electronically and shall store this information in their referral and pre-authorization management system. TIME-ELIGIBLE: REFERRALS FROM A COMMUNITY PROVIDER TO ANOTHER COMMUNITY PROVIDER OR BACK TO VAThe Contractor shall receive, process, and respond to HIPAA-compliant referral requests from referring community providers electronically as well as all other approved communication methods.For any rejected or returned referrals, the Contractor shall provide a narrative explanation that describes the reason why the referral is being rejected and returned, and what action the community provider should take to correct the referral before resubmitting the request. The Contractor shall report all rejected and returned referrals to VA in a Denied and Rejected Referral Report. The Denied and Rejected Referral Report shall include details describing the reasons why the referral was rejected or returned. The Contractor shall review and forward all referral requests for “Time-Eligible” Veterans to VA for referral review, approval, and scheduling within one (1) day of receipt.The Contractor shall receive the referral determination from VA electronically through the RMS interface. The Contractor shall provide the referral determination to the requesting community provider.If the referral is scheduled in the community, the Contractor shall receive the referral number and associated referral documentation electronically and shall store this information in the Contractor’s referral and pre-authorization management system. Deliverable:Denied and Rejected Referral ReportDISTANCE-ELIGIBLEDISTANCE-ELIGIBLE: REFERRALS FROM A COMMUNITY PROVIDER TO A COMMUNITY PROVIDERThe Contractor shall receive, process, and respond to HIPAA-compliant referral requests from referring community providers electronically as well as all other approved communication methods.For any rejected or returned referrals, the Contractor shall provide a narrative explanation that describes the reason why the referral is being rejected and returned, and what action the community provider should take to correct the referral before resubmitting the request. The Contractor shall report all rejected and returned referrals to VA in the Denied and Rejected Referral Report referenced in PWS Section REF _Ref441823301 \r \h \* MERGEFORMAT 6.1.1.2. The Denied and Rejected Referral Report shall include details describing the reasons why the referral was rejected or returned. The Contractor shall review all requests for referrals. If it is determined that the services being requested are not a VA benefit, the Contractor shall inform the Veteran and the community provider that the services are excluded from coverage and will not be paid by VA. The Contractor shall review and forward all referral requests for services on the Exception list in PWS Section 3.4 to VA for referral review and consideration within one (1) day of receipt.The Contractor shall provide the referral determination to the requesting community provider and to the Veteran within two (2) days of receipt for emergent/urgent and seven (7) days for routine. The written notice to the Veteran shall contain the referral number and a description of the service that they are authorized to obtain. The Contractor shall issue the notice to the Veteran within two (2) days of referral determination.When services are denied, the Contractor shall satisfy the requirements in Section REF _Ref441823854 \r \h \* MERGEFORMAT 8.7, “Veteran Appeals.” PRE-AUTHORIZATIONSThe Contractor shall perform pre-authorization when required for care to all Veterans who reside within its region. The Contractor shall process all requests for pre-authorizations from providers.TIME-ELIGIBLE The Contractor shall receive, review, and forward HIPAA-compliant pre-authorization requests from community care providers electronically, as well as all other approved communication methods.The Contractor shall forward all pre-authorization requests for “Time-Eligible” Veterans to VA for pre-authorization review and consideration within one (1) day of receipt.The Contractor shall receive the pre-authorization determination from VA electronically through the RMS interface. The Contractor shall provide the pre-authorization determination to the requesting community provider.The Contractor shall receive the pre-authorization number, and pre-authorization information (medical codes, effective date, termination date, date generated) electronically and shall store this information in the Contractor’s referral and pre-authorization management system. DISTANCE-ELIGIBLE The Contractor shall receive, process, and respond to HIPAA-compliant pre-authorization requests from community care providers electronically, as well as all other approved communication methods.The Contractor shall make a determination on pre-authorization requests within two (2) days of receipt. The Contractor shall notify VA and seek approval for pre-authorization for services as defined by VA or where charges for the episode of care are expected to exceed $50,000.00. Pre-authorization is required for DME and medical devices exceeding $1,000.00 or other certain equipment and devices determined by VA. The Contractor shall use VA-provided issuance criteria to approve or deny pre-authorizations for DME or medical devices.The Contractor shall ensure that the pre-authorization has an effective date and an expiration date. The Contractor shall limit a pre-authorization length of stay for inpatient healthcare as medically indicated and for no more than seven (7) continuous days.The Contractor shall generate pre-authorization numbers and include a creation date for all pre-authorization requests. This information shall be used to validate claims data in the automated claims adjudication process.The Contractor shall inform the Veteran, community care provider, and VA of all pre-authorization determinations.If a pre-authorization request is denied, the Contractor shall notify the Veteran and the Community Provider, and the Contractor shall advise them of their right to appeal in accordance with PWS Section REF _Ref441824479 \r \h \* MERGEFORMAT 8.7, “Veteran Appeals.” SERVICES THAT REQUIRE PRE-AUTHORIZATIONThe Contractor shall review pre-authorization requests to be performed for all care and procedures listed below. When the Contractor is acting as a secondary payer any authorization requests shall be performed on a retrospective basis.Pre-authorizations?will be required for all inpatient admissions; complex procedures and interventions, testing, imaging and/or therapies; restorative and rehabilitative services; all transplants,?and any services determined by VA.REFERRALS AND PRE-AUTHORIZATION REPORTs The Contractor shall provide a monthly Referral Statistics Report to include summary and daily statistics as follows:Summary StatisticsAverage processing timesMonthly totals for all referralsRequests by specialty including the number of requests, denials, and approvalsDaily StatisticsSize of referral request processing queues for each specialtyOldest referral requests in each queueNumber of referral requests denied, approved, and awaiting Contractor response at the end of each day The Contractor shall provide a monthly Pre-Authorization Statistics Report to include summary and daily statistics as follows:Summary StatisticsAverage processing timesMonthly totals for all pre-authorizationsRequests by specialty including the number of requests, denials, and approvalsDaily StatisticsSize of pre-authorization request processing queues for each specialtyOldest pre-authorization requests in each queueNumber of pre-authorization requests sent to VA, denied, approved, and awaiting Contractor response at the end of each day The monthly Referrals and Pre-Authorization Reports are defined in more detail in the Operations Manual. The Contractor shall provide all EDI 278 transaction data in accordance with Chapter X, Section X.X, of the Operations Manual. Deliverable:Referral Statistics ReportPre-Authorization Statistics ReportMEDICAL MANAGEMENT (VA CARE COORDINATION)The Contractor shall establish and maintain disease management programs, case management programs, and care coordination programs for Veterans in accordance in Chapter X, Section X.X, of the Operations Manual. For each program, the Contractor shall provide access to its program information and data to VA upon request. The Contractor shall provide a Medical Management Plan to describe all processes, procedures, criteria, staff and staff qualifications, patient selection criteria, and information and data collection activities and requirements that the Contractor shall use in conducting medical documentation submission management, disease management, case management, utilization management, and other care coordination activities. The Contractor’s plan shall be reviewed and accepted by VA at least ninety (90) days prior to the delivery of healthcare services and at least thirty (30) days prior to the effective date of any material change.The Contractor shall provide a Medical Management Report to document the medical management activities executed by the Contractor in the areas of medical documentation submission management, disease management, case management, utilization management and other care coordination activities. Specifically, the Contractor’s Medical Management Report shall include the following:Medical Document Submission Management: compliance with Contractor-developed medical documentation submission process Disease Management: document participation in the program and the types of analytic tools utilized to define at-risk groups, evaluate participation, monitor adherence to interventions, and assess outcomes Case Management: outpatient as well as inpatient case management and discharge planning activities Utilization Management: the evaluation of the medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities under the provisions of the applicable health benefits planOther care coordination activitiesDELIVERABLES:Medical Management Plan Medical Management ReportMEDICAL DOCUMENTATION SUBMISSION PROCESS The Contractor shall ensure that medical documentation is provided to the referring provider for services rendered to Veterans in accordance with this Section 7.TIME-ELIGIBLEFor Time-Eligible Veterans, the Contractor shall submit a process to confirm for the submission of medical documentation to the referring provider, the primary care provider if different from the referring provider, and to VA if VA is not the referring provider or primary care provider. 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 Community Care referring facility and/or providers, and the roles, responsibilities and points of contact for the process. The Contractor’s process shall be approved by VA prior to execution.DISTANCE-ELIGIBLEFor Distance-Eligible Veterans, the Contractor shall submit a process to confirm for the submission of medical documentation to the referring provider, the primary care provider if different from the referring provider, and to VA if VA is not the referring provider or primary care provider and requests such 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 Community Care referring facility and/or providers, and the roles, responsibilities and points of contact for the process. The Contractor’s process shall be approved by VA prior to execution.MEDICAL DOCUMENTATION DATA POINTSThe Contractor shall confirm that medical documentation provides a chronological report of the patient’s course of care and should reflect any change in condition and the results of treatment. The Contractor shall confirm that all significant information pertaining to a patient is incorporated into the patient’s medical record and maintained through its contracted provider’s administration and medical staff. The Contractor shall confirm that its contracted providers maintain legible medical records to (i) substantiate that specific care was actually furnished and medically necessary and appropriate and (ii) identify the individual(s) who provided the care. These requirements apply to all medical records environments, both paper-based and electronic. The Contractor shall confirm that its contracted provider’s minimum requirements for medical documentation meet these requirements and any additional requirements set forth by: (i) 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. If more than one of the three enumerated standards applies, then the more stringent standards apply.The Contractor shall confirm that all medical documentation being sent to VA includes: Contractor-generated identification number, Veteran name, sex, date of birth, referral number and the medical documentation pertaining to the encounter being sent.MEDICAL DOCUMENTATION SUBMISSION TIMEFRAMESThe Contractor shall confirm that medical documentation for any authorized episode of outpatient care is submitted after the completion of the appointment within the earlier of: (i) 24 hours for emergent care; (ii) 48 hours for urgent care, (iii) 30 days for routine care; or (iv) the clinically appropriate date.The Contractor shall confirm that medical documentation for any authorized episode of inpatient care is submitted by the earlier of: (i) 3 days after discharge or (ii) the clinically appropriate date. The Contractor shall confirm that clinical information regarding a Veteran’s inpatient and outpatient episode of care is also communicated via telephone when clinically appropriate.The Contractor shall also confirm that medical records requested by the VA are delivered within the applicable timeframes for outpatient care and inpatient care as set forth in this Section.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. TIME-ELIGIBLEThe Contractor’s Disease Management Program shall be available to all Time-Eligible Veterans with a community primary care provider.DISTANCE-ELIGIBLEThe Contractor’s Disease Management Program is available to all Distance-Eligible Veterans under the care of a community primary care provider. If a Distance-Eligible Veteran receives care from a VAMC, then VA physicians should be incorporated in all management plans.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. TIME-ELIGIBLEThe Contractor’s Case Management Program shall be available to all Time-Eligible Veterans with a community primary care provider.DISTANCE-ELIGIBLEThe Contractor’s Case Management Program is available to all Distance-Eligible Veterans under the care of a community primary care provider. If a Distance-Eligible Veteran receives care from a VAMC, then VA physicians should be incorporated in all management plans.DISCHARGE PLANNINGThe Contractor shall establish and administer a discharge planning program for eligible inpatient Veterans.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 prior to execution.TIME-ELIGIBLEThe Contractor’s Discharge Planning Program shall be applied to all inpatient Time-Eligible Veterans.For inpatient Time-Eligible Veterans, the Contractor shall establish a Discharge Planning Liaison function to facilitate the hand off of information from the Contractor to the 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 and from the VA back to the Discharge Planning Liaison. The Contractor shall provide VA with visibility via real-time system access to all case management and discharge planning assignment information for Time-Eligible 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 dashboard shall be made accessible to authorized VA users, mutually agreed to between VA and the Contractor, on a continual (24/7) basis except for scheduled downtime for system maintenance. The Contractor shall transfer patients in accordance with the VHA Directive 2007-015 “Inter-Facility Transfer Policy.” DISTANCE-ELIGIBLEThe Contractor’s Discharge Planning Program shall be applied to all inpatient Distance-Eligible Veterans.The Contractor shall transfer patients in accordance with the VHA Directive 2007-015 “Inter-Facility Transfer Policy.” CLAIMS ADJUDICATION FOR HEALTHCARE SERVICES RENDERED The Contractor shall receive, process, and adjudicate claims for healthcare services for both Time-Eligible and Distance-Eligible Veterans. The Contractor shall process and adjudicate all claims submitted by (i) providers contracted directly with the Contractor; (ii) out-of-network providers that provide services to a Veteran within the Contractor’s service area, (iii) providers affiliated with VA and (iv) non-licensed practitioners providing complementary and alternative medical services as outlined in PWS Section REF _Ref441827744 \r \h \* MERGEFORMAT 3.0 .CLAIMS PROCESSING SYSTEM FUNCTIONSThe Contractor shall utilize an existing automated claims processing system to process and adjudicate claims. The Contractor shall process claims in accordance with the policies, business rules and Federal requirements. The Contractor shall utilize a software solution that is configurable to allow for changes to be tested, accepted, and implemented by the effective date mutually agreed to in the Contractor’s Operational Guide.The Contractor shall validate eligibility and enrollment data, referral and pre-authorization data, and associated referral documentation to properly adjudicate claims. The Contractor shall also adjudicate claims in accordance with the terms and conditions provided by VA for VA affiliated providers, complementary and alternative medicine practitioners, and in accordance with the Contractor’s policies and procedures for claims adjudication.The Contractor shall validate that the referral number, pre-authorization number, name of Veteran, provider, and service or supply information submitted on the claim are consistent with that authorized and that the care was accomplished within the authorized time period. CLAIMS ADJUDICATION AND PAYMENT RULESThe Contractor shall deliver a data dictionary that includes all requirements for auto-adjudication, rejection, return, and denial of a claim.The Contractor shall exclude co-pay calculations from the claims adjudication rules. The Contractor shall reimburse network providers in accordance with the Veteran’s eligibility and reimbursement rates included in their network agreements. The Contractor shall reimburse out-of-network providers in their service area in accordance with the applicable reimbursement rates provided by VA.The Contractor shall reimburse (i) providers affiliated with VA and (ii) non-licensed practitioners providing complementary and alternative medical services in accordance with the applicable reimbursement rates provided by VA.Deliverable:Claims Processing Data DictionaryCLAIMS 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 Contractor shall be solely responsible for any late payments incurred in accordance with the Prompt Payment Act. The Contractor shall deny claims for healthcare services that are submitted by providers more than 180 days from the date of service.ISSUANCE OF EXPLANATIONS OF BENEFITS (EOB) The Contractor shall issue an Explanation of Benefits (EOB) to Veterans pursuant to the Contractor’s standard practice. The EOB shall be easily understood and appropriately describe the action taken for each claim processed to a final determination. 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 written agreement to receive the EOB electronically. The EOB shall be available in a paper monthly summary upon request. The EOB shall comply with the requirements of 38 U.S.C. 7332, 38 CFR Section 1.460-1.496, and VHA Handbook 1605.1, Privacy and Release of Information. The EOB shall include language describing the process for the Veteran to appeal a claim that is denied in whole or in part. The Contractor shall include in its proposal its processes and methodologies for ensuring compliance with 38 U.S.C. 7332, 38 CFR Section 1.460-1.496, and VHA Handbook 1605.1, Privacy and Release of Information. ISSUANCE OF REMITTANCE ADVICEThe Contractor shall issue a remittance advice in an EDI 835 Transaction File 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 to Providers HIPAA-compliant Electronic Funds Transfers (EFTs) and Electronic Remittance Advice (ERA). The Contractor shall transmit a daily file of all claims processed that day to VA.Deliverable:EDI 835 Transaction FileOTHER HEALTH INSURANCEThe Contractor shall use commercial or publically-available Other Health Insurance (OHI) data sources to identify and update OHI for Veterans. 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 approved by VA. VETERAN APPEALS The Contractor shall include in any pre-authorization denial or referral denial notice a description of the Veteran’s right to appeal such denial to VA., The Contractor shall use the form and content of such description provided by VA to create the pre-authorization or referral denial notice.In the event that the Contractor denies a claim and the Veteran has a financial liability 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 use the form and content of such description provided by VA to create the notice of denial to the Veteran.PROVIDER RECONSIDERATIONSThe Contractor shall establish and maintain a provider reconsideration process for all (i) Distance-Eligible referral requests, (ii) referral and pre-authorization requests, and (iii) claims that are denied, in whole or in part. The Contractor shall notify the provider, in writing, of any such denial, the reason for the denial, and the provider’s right to request reconsideration.For initial referral and pre-authorization denial determinations made by VA, the Contractor’s reconsideration process shall include a provision to submit to VA any request for reconsideration of a pre-authorization or referral denial for review and disposition. The Contractor shall communicate VA’s response to the requested determination to the Community Provider in accordance with the notice requirements set forth in its reconsideration process.The Contractor shall submit a written reconsideration process to VA for approval 90 days prior to the date on which healthcare service delivery commences under the contract. The Contractor shall provide an updated description of its reconsideration process to VA for approval at least 30 days prior to any material change. CLAIMS AUDITINGThe Contractor shall establish and maintain a process for reviewing claims for improper payment in accordance with prevailing industry standards and Improper Payments Elimination and Recovery Act (IPERIA). The Contractor shall attempt recovery of any improper payments for services rendered to Veterans or for persons who were not eligible to receive a benefit. The VA is not responsible for reimbursing any claims that were adjudicated improperly.The Contractor shall develop a Healthcare Fraud Detection and Prevention Plan and submit it to VA at least 90 days prior to start of healthcare delivery. The Contractor shall provide an updated Healthcare Fraud Detection and Prevention Plan at least 30 days prior to the effective date of any material change. Deliverable: Healthcare Fraud Detection and Prevention PlanCLAIMS AUDIT REPORTINGQUARTERLY FRAUD AND ABUSE WORKLOAD SUMMARY REPORTThe Contractor shall compile and submit Workload Summary to VA in a Quarterly Fraud and Abuse Workload Summary Report within 30 days following the last day of each calendar quarter. The Contractor shall promptly identify, aggressively pursue, and quickly resolve instances of fraud and abuse. The Contractor shall appropriately identify and refer to VA potential cases of fraud and/or abuse. The Contractor shall provide support in VA’s investigation and resolution of potential fraud and/or abuse cases, including provider exclusions, suspensions, termination, and reinstatements. UTILIZATION REPORTThe Contractor shall generate a Utilization Report as an addendum to the Quarterly Fraud and Abuse Workload Summary Report. This report shall include a brief description of the software listing the analytical techniques used for fraud detection, a utilization rate for the use of this software for both pre-pay and post-pay claims, and the rate or impact of false positives on fraud detection through the use of the software.? COST AVOIDANCE AND RECOVERY/RECOUPMENTS REPORTThe Contractor shall report to VA the cost avoidance and recoveries/recoupments achieved as a result of the activities of their anti-fraud investigative unit and other units contributing to healthcare fraud detection and prevention. The Contractor’s Quarterly Cost Avoidance and Recovery/Recoupments Report shall contain information detailing: (i) cost avoidance, recoveries, and recoupments; along with the cost associated with all program integrity activities; information on eligibility reviews, recoupments initiated, collected, or transferred to VA; (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; (iii) provide a summary analysis to be included in the fourth quarter Fraud and Abuse Summary Report 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 30 days following the last day of the quarter. Deliverables:Fraud and Abuse Workload Summary ReportCost Avoidance and Recovery/Recoupments ReportUtilization ReportCLAIMS REPORTINGThe Contractor shall capture and report to VA all Community Care Encounter Data related to claim adjudication that includes all EDI 837 transaction data daily. The Contractor shall provide VA Daily Claim Payment reports that include all EDI 835 transaction data. The Contractor shall commence sending Daily Claim Payment reports at the start of claim processing, and they are due for each payment cycle. The report will list all payments issued for each cycle or each approved manual release. Voided/Stale dated payments must also be reported as negative amounts in this same format. The Contractor shall provide VA Weekly Claim Processing reports that include all EDI 835 transaction data. The Contractor shall commence sending Weekly Claim Processing reports at the start of claim processing, and they are due at the end of each week (Sun-Sat). The Contractor shall include totals for: open claims, pended claims, newly received claims, adjustments, transfers, claims processed, adjustments processed, closing of pending claims, and closing of adjusted claims. The Contractor shall sort all categories by the age of the claim, i.e. 0-10, 11-30, 31-60, 61-90, 90+ days, and total each category.The Contractor shall provide quarterly Claim Audit reports. The Contractor shall commence sending Claim Audit reports 30 days after the end of the first quarter following the start of healthcare delivery, and subsequent reports shall be submitted within 30 days after the end of each quarter thereafter. The Contractor’s Claim Audit reports shall be consistent with the Healthcare Fraud Detection and Prevention Plan Contractor submitted to VA and summarize the findings of Contractor audits during the quarter. The Contractor shall generate individual file folders labeled with identifying information and all supporting documentation data.The Contractor shall provide quarterly Claims Audit and Fraud and Abuse Summary reports. The Contractor shall commence sending Fraud and Abuse Summary reports 30 days after the end of the first quarter following the start of healthcare delivery, and subsequent reports shall be submitted within 30 days after the end of each quarter thereafter. The Contractors Fraud and Abuse Summary report shall include a Quarterly Program Integrity Cost Avoidance and Recovery/Recoupments Report; a Quarterly Program Integrity Eligibility Recoupment Status Report. The Contractor shall provide back-up data to support all savings reported during quarter (e.g. Veterans’ names, claim numbers, payment verification, accounting data, etc.) upon request.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 business days. The Contractor shall have search capabilities built into its systems.Deliverables:Claims Performance Data and Metrics Report38 U.S.C. 7332, 38 CFR Section 1.460-1.496, and VHA Handbook 1605.1, Privacy and Release of Information EOB compliance processes.Note: The invoicing and reimbursement will not be in the PWS; the information below is a combination of invoicing instructions and the schedule of services.CONTRACTOR INVOICING AND REIMBURSEMENTThe Contractor shall submit invoices monthly to VA for healthcare claims reimbursement and administrative fees as prescribed in the sections below. MONTHLY INVOICESCONTRACT LINE ITEMS FOR MONTHLY ADMINISTRATIVE FEES: PER MEMBER PER MONTHThe Contractor shall submit invoices monthly on an inclusive Eligible, Enrolled and Active Veteran per member per month fee (PMPM) in accordance with the instructions provided in FAR 52.212-4(g). The Contractor shall submit the invoice based on the actual number of Eligible, Enrolled and Active Veterans in the Community Care Network in a given month. The Contractor shall invoice for Veterans that are active by the 25th of the month, if not the Veteran will be included in the next month's invoice.The Contractor shall propose a tiered PMPM fee based on the number of Active Veterans. The tiered PMPM should accommodate for low Active Veteran volumes but also to reduce as active Veteran volumes increase. The Contractor shall divide the PMPM fee into the following categories:Network ManagementEligibility and EnrollmentReferrals and Pre-AuthorizationsCare CoordinationCustomer ServiceClaims ProcessingAdministrative FeesTable SEQ Table \* ARABIC 2 - PMPM Fee TableActive VeteransPMPM Cost1,000,001+????????? XX PMPM750,001 – 1,000,000XX PMPM500,001 – 750,000XX PMPM250,001 – 500,000XX PMPM100,001 – 250,000XX PMPM0 – 100,000XX PMPMWhen a non-traditional/unlicensed practitioner utilizes the service, the Contractor shall invoice for a PMPM that includes Customer Service and Claims Processing. Concurrently, the Contractor shall submit an electronic copy of the supporting documentation for the invoiced PMPM fees. The supporting documentation, submitted monthly in an electronic format, shall include the vendor tax identification number, VA-provided obligation number, date of service, VA-provided Veteran ID, Veteran VAMC, Veteran eligibility date (start), Veteran eligibility type and associated billing CLIN.Deliverable:Supporting Documentation for Invoiced PMPM FeesCONTRACT LINE ITEMS FOR MONTHLY ADMINISTRATIVE FEES: IMPLEMENTATION COSTSThe Contractor shall submit invoices monthly for administrative fees that are associated with implementation costs in accordance with the instructions provided in FAR 52.212-4(g). In addition to the FAR, the Contractor shall invoice implementation costs in accordance with Performance Payment Milestone Schedule proposed in the Contractor’s Implementation Strategy. The invoice shall include, but not be limited to, vendor tax ID, VA-provided obligation number, implementation milestone met, implementation milestone date completed, and implementation amount being billed.Concurrently, the Contractor shall submit an electronic copy of the supporting documentation for implementation invoices. The supporting documentation shall include, but not be limited to, the vendor tax identification number, VA-provided obligation number, and date of completed service, associated billing CLIN, and milestone completion proof. CONTRACTOR INVOICES FOR HEALTHCARE CLAIMS REIMBURSEMENTThe Contractor shall submit healthcare claims reimbursement invoices daily in accordance with the instructions provided in FAR 52.212-4(g) and within 30 days of Contractor’s claim adjudicated date. The invoice shall include the vendor tax ID, VA-provided obligation number, claim number, VA-provided Veteran ID, Veteran VAMC, referral number, rendering provider National Provider Identifier (NPI), billing entity NPI, place of service code, medical service category, and CLIN associated to billing.The Contractor shall submit healthcare claims reimbursement invoices for which all claims data for the corresponding claims referenced in the invoices have been reported to VA. The claims data must include all claims received by the Contractor (EDI 837 transactions) and the payment and remittance advice data (EDI 835 transactions) generated as described in Section REF _Ref441829708 \r \h \* MERGEFORMAT 8.10, “Claims Reporting.” CONTRACTOR REJECTED AND DENIED INVOICESCONTRACTOR REJECTED INVOICESThe Contractor shall submit complete and accurate invoices to the VA. When an invoice is considered incomplete and requires additional information for processing, it will be rejected and returned for correction and re-submission. Reasons for rejected invoices may include at a minimum: missing VA required data as specified above, the need for additional supporting documentation, and correction and explanation of discrepancies on the claims data. CONTRACTOR DENIED INVOICE RESUBMISSIONThe Contractor shall resubmit an invoice for reconsideration within 12 months from the denied invoice date. QUALITY MONITORINGESTABLISHMENT OF A PATIENT SAFETY, QUALITY ASSURANCE, QUALITY IMPROVEMENT AND PEER REVIEW PLANThe Contractor shall develop a written patient safety, quality assurance, quality improvement and peer review plan (QA/QI Plan). The Contractor’s QA/QI plan shall include a detailed description of the purpose, methods, proposed goals and objectives designed to meet the intent of the program. The Contractor shall provide a copy of its QA/QI Plan to VA upon contract award and no later than 30 days prior to the effective date of any material change. Deliverable: QA/QI PlanQUALITY INITIATIVE COMPONENT OF THE QA/QI PLANThe Contractor’s QA/QI Plan 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.QUALITY IMPROVEMENT COMPONENT OF THE QA/QI PLANThe Contractor’s QA/QI Plan shall include a quality improvement program (QIP) component, defined as a set of related activities designed to achieve measurable improvement in processes and outcomes of clinical care. The Contractor’s QIP 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) by serving as a valid proxy for Veterans who are high-risk or high-volume users of services. The Contractor’s QIP 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 QIP with the following common elements: (i) description and purpose of activity; (ii) description of the population; (iii) rationale for selection of the QIP baseline data; (iv) description of data collection; (v) goals and time frames for achieving them; (vi) action plans and interventions; and (vii) periodic re-measurements and outcomes.POTENTIAL AND IDENTIFIED QUALITY ISSUES The Contractor shall identify, track, trend, and report interventions to resolve any “potential quality issues” (PQI) or “identified quality issues” (IQI) using the most current National Quality Forum (NQF) Serious Reportable Events (SREs), Centers for Medicare and Medicaid Services (CMS) Hospital Acquired Conditions (HACs), Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs). A PQI is defined as a clinical or system variance, warranting further review and investigation to determine whether an IQI has occurred. An IQI is defined as a verified deviation, as determined by a qualified reviewer, from accepted standard of practice or standard of care as a result of some process, individual, or institutional component of the healthcare system. The Contractor shall apply appropriate medical judgment, evidence based medicine, and best medical practices when identifying, evaluating, and reporting on all PQIs and IQIs. The Contractor shall process to completion 95% of all PQIs and IQIs within ninety (90) calendar days from date of identification and 100% within 180 calendar days of identification. The Contractor shall report aggregated and de-identified IQI and PQI data to VA on a quarterly basis.The Contractor shall implement appropriate IQI interventions using evidence based medicine and best medical practices to address and resolve each IQI. When the Contractor confirms an IQI 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 IQIs, 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 QA/QI 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 The Contractor shall allow VA staff, as mutually agreed upon between Contractor and VA, to actively participate, as non-voting members, on the Contractor’s QA/QI Plan committees, quality management committees, peer review committees, and credentialing committees for each 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.CUSTOMER SERVICEThe Contractor shall establish and maintain customer service capabilities in support of VA’s Community Care Program. These capabilities, detailed in the following sections, shall include:Establishing and maintaining standards for Veteran and network provider call center functionality, Staffing and supporting Veteran and network provider call center functionality in compliance with the standards established, Maintaining system interfaces and websites for Veterans, network 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 Congressional and VA inquiries.CONTRACTOR VETERAN CALL CENTER FUNCTION – TIME-ELIGIBLE AND DISTANCE-ELIGIBLEThe Contractor shall establish and maintain a Veteran call center function. The Contractor shall maintain online and local telephone service and toll-free telephone lines from 7AM to 7PM Monday through Friday, local time zones for each Region, for inquiries made by Veterans regarding general information on community care services, as well as provider directories, eligibility, scheduled appointments, referral/authorization status, claim status, complaints, and grievances. The Contractor shall respond to of all inquiries by a Veteran, provider, or their authorized representatives based on performance standards outlined in Section 13.5. The Contractor shall establish a secure, clearly defined and consistent means for identity proofing that meets security and privacy requirements established by the Office of Management and Budget (OMB) regulations and the National Institute of Standards and Technology (NIST) guidelines. The Contractor must design an identity proofing process that confirms the identity of the Veteran or the Veteran’s authorized representatives. VA reserves the right to review the Contractor’s identity proofing process and auditing capabilities. The Contractor shall provide an escalation mechanism to VA to facilitate prompt resolution of customer service issues. The Contractor shall provide to 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 120 days prior to the start of healthcare delivery (SHCD), and shall continue to demonstrate call center capabilities until full operating capability is reached. The Contractor’s Veteran call center capability shall be satisfactorily operational no later than 60 days prior to SHCD. Training documents and response scripts shall be available for review prior to implementation. Deliverable:Warm Transfer CapabilityNETWORK PROVIDER CALL CENTER FUNCTION – TIME-ELIGIBLE AND DISTANCE-ELIGIBLEThe Contractor shall establish and maintain standards for provider call center functionality. The Contractor shall maintain a provider call center functionality to respond to online and telephonic inquiries related to status of referrals, authorization status, eligibility, provider, claims status, claims issues, eligibility, provider enrollment, complaints, and benefits issues in a timely, accurate, and consistent manner as outlined in Section 11.5 below. The Contractor shall develop and maintain local telephone service and toll-free telephone lines from 7AM to 7PM Monday through Friday, local time zones for each Region, for telephonic inquiries made by Providers.The Contractor shall demonstrate provider call center capabilities no later than 120 days prior to the start of healthcare delivery (SHCD), and shall continue to demonstrate provider call center capabilities until full operating capability is reached. The Contractor’s Veteran call center capability shall be satisfactorily operational no later than 60 days prior to SHCD. Training documents and response scripts shall be available for review at each of the Contractor demonstration events referenced in the PWS Section X. CONTRACTOR CUSTOMER SERVICE TECHNOLOGYThe Contractor shall maintain a website/online services for Veterans and Providers related to at least Veteran benefits lookup, provider directory search function, eligibility and enrollment, referrals, authorizations, medical management, claims, information on the appeals and grievance processes, and provider manual. The on-line provider directory shall be in the form of a master provider database that contains correct and up-to-date information for all of the following data elements: (i) provider name; (ii) organization name; (iii) address(es); (iv) phone number(s); (v) email address; (vi) facsimile number(s); (vii) NPI; (viii) tax identification number; (ix) license type (MD, DO, RN, etc.); (x) license number(s) and state(s); (xi) specialty and sub-specialty; (xii) gender; (xiii) language(s) spoken; and (xiv) whether the provider is accepting new patients.? The data in (xiv) will not be included for the accuracy rate calculation.??The information in the on-line network provider directory shall be current and refreshed no less frequently than once every twenty-four (24) hours. The on-line network provider directory shall be made accessible to users on a continual (24 hours/7 days a week) basis except for scheduled downtime for system maintenance. To the maximum extent practicable, the Contractor shall schedule system maintenance windows during weekends or non-peak hours to minimize disruption of services to Veterans. These requirements for refreshing the data and data accuracy are not applicable to the on-line directory of VA-contracted core providers; however, the Contractor shall refresh the data contained in VA-contracted core provider’s provider directory no less than semi-annually.??CONTRACTOR VETERAN COMPLAINTS/GRIEVANCES AND CUSTOMER SERVICE PROCEDUREThe Contractor shall maintain a complaint/grievance procedure and provide adequate staff and forms for Veterans who seek assistance. The Contractor shall perform customer service functions with knowledgeable, courteous and responsive staff. The Contractor shall have customer service support available from 7 AM to 7 PM, Monday through Friday, in the local time zone in each Community Care Region via a toll-free number to address Veteran complaints/grievances. The Contractor shall attempt to resolve complaints at the lowest level without escalation to VA. The Contractor shall work with VA to resolve any escalated complaints. The Contractor shall provide monthly logs and records of all oral and written complaints, resolution of complaints, and time to resolution for VA auditing. The Contractor shall temporarily refrain from referring Veterans to providers where VA has notified the Contractor of significant concerns or issues with that provider until such time when that concern has been resolved. Deliverable:Complaint LogsVA AND CONGRESSIONAL 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.The Contractor shall provide timely responses to VA inquiries regarding customer service for Veterans, providers, and VA. The Contractor shall confirm receipt of the inquiry within one (1) business day to all inquiries related to VA, Veterans, and/or Congressional Representatives that are sent to the Contractor from VA. ?The Contractor shall provide the full written response within three (3) business days or as negotiated with VA.CONTRACTOR CUSTOMER SERVICE PERFORMANCE MEASURESCALL CENTER FUNCTIONALITY PERFORMANCE MEASURESThe Contractor’s customer service performance measures shall include Veteran satisfaction derived from call center functionality statistics and healthcare experience feedback. Veteran satisfaction surveys shall be conducted by the Contractor on an ongoing basis with results reported to the VA quarterly. The Contractor’s Veteran and provider call center function metrics shall be reported monthly and include, at a minimum: Blockage Rates less than 1%Call Abandonment Rates less than 5%Average Speed of Answer less than 45 secondsAverage Wait Time less than 30 seconds 95% of the timeFirst Call Resolution 85% of the timeResponse accuracy 90% (response provided by Call Center shall be accurate and complete according to the terms of the contract)The Contractor shall provide a monthly report summarizing all Veteran and Provider call center function inquiries, performance statistics, and trends or open issues. The Contractor shall include in this report all unexpected downtime events related to the Customer Service interface performance. The Contractor shall meet with VA at least quarterly. During these meetings, the Contractor shall review current Contractor 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:Veteran and Provider Call Center Monthly ReportCUSTOMER SERVICE TECHNOLOGY PERFORMANCE MEASURESThe Contractor’s on-line directory of network providers shall be updated daily with a minimum of 95% data accuracy, including network participation status.The Contractor shall provide real-time communication of metrics concerning unexpected system downtime. This shall include web/online services and call center functionality. COMPLAINTS AND GRIEVANCES PERFORMANCE MEASURESThe Contractor shall submit all escalated Veteran complaints about any aspect of care to VA within one (1) business day of receipt.TECHNOLOGYThe Contractor shall provide information management and information technology support as needed to accomplish the stated functional and operational requirement of the Community Care Network. The Contractor shall be responsible to certify their systems meet all the requirements for information security, system certifications, and privacy according to the security requirements listed in Section REF _Ref441831686 \r \h \* MERGEFORMAT 12.5. The Contractor’s information technology solutions shall be in compliance with the One-VA Technical Reference Model (TRM). The Contractor shall provide customer service support to assist VA users during normal business hours for all local time zone in each Community Care Region.CONTINUITY OF OPERATIONSThe Contractor shall develop a Continuity of Operations Plan that demonstrates the process for the continuous operation of their Information Technologies (IT) systems and data support of the Community Care Network. The Continuity of Operations Plan shall be submitted to VA at least annually and due 30 days after the incorporation of a material change to the plan. The plan 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 region. The plan shall also include a plan for temporary system unavailability, and the process and 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.To the maximum extent practicable, the Contractor shall schedule system maintenance windows during weekends or non-peak hours to minimize disruption of services to VA users. DeliverableContinuity of Operations PlanCONTRACTOR SYSTEM ACCESSThe Contractor shall provide VA real-time read-only access to the following Contractor’s systems: Claims Processing System, Referral and Management System, Enrollment System, Utilization Management System, Case Management System, Disease Management System, Discharge Planning System and Customer Service Systems for all required VA personnel. The systems shall be made accessible to authorized (VA users, mutually agreed to between VA and the Contractor, on a continual (24/7) basis except for scheduled downtime for system maintenance. System access authorizations shall be as follows:SystemRegion 1Region 2Region 3Region 4Claims Process SystemReferral and Management SystemEnrollment SystemUtilization Management SystemCase Management SystemDisease Management SystemDischarge Planning System (if separate)Customer Service System The Contractor shall make available an additional thirty (30) authorizations to be assigned at the discretion of the VA.VA SYSTEM INTEGRATION REQUIREMENTSThe Contractor shall be prepared to integrate its technical solutions in a secure manner with VA’s systems.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 a VA system.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). Contractor shall comply with VA Handbook 6500.3 – Authorization to Operate RMATION SECURITY & PRIVACYINFORMATION SYSTEM SECURITY REQUIREMENTS FOR CONTRACTOR SYSTEMS THAT WILL CONTAIN VA INFORMATIONThe Contractor’s information systems shall meet National Institute for Standards and Technology (NIST) Special Publication 800-53. The Contractor's information systems shall comply with the Federal Information Security Management Act (FISMA) of 2002, and with the requirements of Federal Information Processing Standard (FIPS) 200. The Contractor’s information systems shall comply with the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as implemented by the HIPAA Privacy, Security, Breach, and Enforcement Rules (collectively, the HIPAA Rules). The Contractor’s information systems shall comply with the Privacy Act of 1974. When there is HIPAA or Privacy Act Breach, the Contractor shall notify the VA within 24 hours.The Contractor’s information systems shall comply with all VA Security and Privacy Directives. The Contractor shall complete a Privacy Impact Assessment (PIA), and be provided to VA for review, comment, and approval prior to operation. The PIA shall be in accordance with Directive 6508, VA Privacy Impact Assessment.Contractor Information Systems shall receive, gather, store, back up, maintain, use, disclose and dispose of VA information only in compliance with the terms of the contract and applicable Federal and VA information confidentiality and security laws, regulations and policies.The Contractor shall store, transport, or transmit VA sensitive information in an encrypted form, using VA-approved encryption tools that are, at a minimum, FIPS 140-2 validated.Contractors, Contractor personnel, Sub-Contractors, and Sub-Contractor personnel shall be subject to the same Federal laws, regulations, standards, and VA Directives and Handbooks as VA and VA personnel regarding information and information system security.TECHNOLOGY DOCUMENTSThe Contractor shall prepare and submit the following security documents to VA for review, comment, and acceptance: System Security Plan (SSP), Risk Assessment (IT-RA), Configuration Management Plan (CMP), Incident Response plan (IRP), Information System Contingency plan (ISCP), Disaster Recovery plan (DRP), ISCP test, DRP test, any necessary ISAMOUs, Code review scans through Fortify, NSOC Web Application Security Assessment (WASA) tests, Nessus operating system scans and NSOC DB scans. CONTRACTOR ACCESS TO VA SYSTEMSA Contractor shall request logical (technical) or physical access to VA information and VA information systems for their employees, Sub-Contractors, and affiliates only to the extent necessary to perform the services specified in the contract, agreement, or task order.The Contractor shall confirm that VA systems are to be used in accordance with the VA Handbook 6500, VA Information Security Program. The Contractor shall comply with all VA information security program policies, procedures, and practices. The Contractor shall complete VA security awareness training on at least an annual RMATION SYSTEM HOSTING, OPERATION, MAINTENANCE, OR USEFor information systems that are hosted, operated, maintained, or used on behalf of VA at non-VA facilities, Contractors/Sub-Contractors are fully responsible and accountable for ensuring compliance with all HIPAA, Privacy Act, FISMA, NIST, FIPS, and VA security and privacy directives and handbooks. This includes conducting compliant risk assessments, routine vulnerability scanning, system patching and change management procedures, and the completion of an acceptable contingency plan for each system. The Contractor’s security control procedures must be equivalent, to those procedures used to secure VA systems. A Privacy Impact Assessment (PIA) must also be provided to the COR and approved by VA Privacy Service prior to operational approval. All external Internet connections to VA network involving VA information must be reviewed and approved by VA prior to implementation.Adequate security controls for collecting, processing, transmitting, and storing of Personally Identifiable Information (PII), as determined by the VA Privacy Service, must be in place, tested, and approved by VA prior to hosting, operation, maintenance, or use of the information system, or systems by or on behalf of VA. These security controls are to be assessed and stated within the PIA and if these controls are determined not to be in place, or inadequate, a Plan of Action and Milestones (POA&M) must be submitted and approved prior to the collection ofOutsourcing (Contractor facility, Contractor equipment or Contractor staff) of systems or network operations, telecommunications services, or other managed services requires certification and accreditation (authorization) (C&A) of the Contractor’s systems in accordance with VA Handbook 6500.3, Certification and Accreditation and/or the VA OCS Certification Program Office. Government-owned (Government facility or Government equipment) Contractor-operated systems, third party or business partner networks require memorandums of understanding and interconnection agreements (MOU-ISA) which detail what data types are shared, who has access, and the appropriate level of security controls for all systems connected to VA networks.The Contractor/Sub-Contractor’s system must adhere to all FISMA, FIPS, and NIST standards related to the annual FISMA security controls assessment and review and update the PIA. Any deficiencies noted during this assessment must be provided to the VA contracting officer and the ISO for entry into the VA POA&M management process. The Contractor/Sub-Contractor must use the VA POA&M process to document planned remedial actions to address any deficiencies in information security policies, procedures, and practices, and the completion of those activities. Security deficiencies must be corrected within the timeframes approved by the Government. Contractor/Sub-Contractor procedures are subject to periodic, unannounced assessments by VA officials, including the VA Office of Inspector General. The physical security aspects associated with Contractor/Sub-Contractor activities must also be subject to such assessments. If major changes to the system occur that may affect the privacy or security of the data or the system, the C&A of the system may need to be reviewed, retested and re-authorized per VA Handbook 6500.3. This may require reviewing and updating all of the documentation (PIA, System Security Plan, and Contingency Plan). The Certification Program Office can provide guidance on whether a new C&A would be necessary.The Contractor/Sub-Contractor must conduct an annual self-assessment on all systems and outsourced services as required. Both hard copy and electronic copies of the assessment must be provided to the COR. The Government reserves the right to conduct such an assessment using Government personnel or another Contractor/Sub-Contractor. The Contractor/Sub-Contractor must take appropriate and timely action (this can be specified in the contract) to correct or mitigate any weaknesses discovered during such testing, generally at no additional cost.VA prohibits the installation and use of personally-owned or Contractor/Sub-Contractor owned equipment or software on the VA network. If non-VA owned equipment must be used to fulfill the requirements of a contract, it must be stated in the service agreement, SOW or contract. All of the security controls required for Government furnished equipment (GFE) must be utilized in approved other equipment (OE) and must be funded by the owner of the equipment. All remote systems must be equipped with, and use, a VA-approved antivirus (AV) software and a personal (host-based or enclave based) firewall that is configured with a VA approved configuration. Software must be kept current, including all critical updates and patches. Owners of approved OE are responsible for providing and maintaining the anti-viral software and the firewall on the non-VA owned OE.All electronic storage media used on non-VA leased or non-VA owned IT equipment that is used to store, process, or access VA information must be handled in adherence with VA Handbook 6500.1, Electronic Media Sanitization upon: (i) completion or termination of the contract or (ii) disposal or return of the IT equipment by the Contractor/Sub-Contractor or any person acting on behalf of the Contractor/Sub-Contractor, whichever is earlier. Media (hard drives, optical disks, CDs, back-up tapes, etc.) used by the Contractors/Sub-Contractors that contain VA information must be returned to VA for sanitization or destruction or the Contractor/Sub-Contractor must self-certify that the media has been disposed of per 6500.1 requirements. This must be completed within 30 days of termination of the contract.Bio-Medical devices and other equipment or systems containing media (hard drives, optical disks, etc.) with VA sensitive information must not be returned to the vendor at the end of lease, for trade-in, or other purposes. The options are:Vendor must accept the system without the drive;VA’s initial medical device purchase includes a spare drive which must be installed in place of the original drive at time of turn-in; orVA must reimburse the company for media at a reasonable open market replacement cost at time of purchase.Due to the highly specialized and sometimes proprietary hardware and software associated with medical equipment/systems, if it is not possible for VA to retain the hard drive, then;The equipment vendor must have an existing BAA if the device being traded in has sensitive information stored on it and hard drive(s) from the system are being returned physically intact; andAny fixed hard drive on the device must be non-destructively sanitized to the greatest extent possible without negatively impacting system operation. Selective clearing down to patient data folder level is recommended using VA approved and validated overwriting technologies/methods/tools. Applicable media sanitization specifications need to be preapproved and described in the purchase order or contract.A statement needs to be signed by the Director (System Owner) that states that the drive could not be removed and that (a) and (b) controls above are in place and completed. The ISO needs to maintain the documentation.DATA ANALYTICS DATA ELEMENTSThe Contractor shall provide an episodic data for the following data set. VHA parent facility (station number & sub-station alpha indicator if exists - VistA instance number e.g. AZ649 may be AZ649AB). If parent facility does not exist for a Veteran eligible under the 40 mile rule then preferred facility, received on the 40 mile list of eligible from VA shall be used.Patient nameFull SSNDOBReports needs to distinguish Wait Time Eligible – Distance Eligible – can be on one list, but must be identifiable under each scenarioDate of serviceType of service authorized (free text)Category of care (free text field) (same as purchased care has a list) – for example: ORTHO clinic visit: orthopedic procedure; x-ray left knee? Category of care list provided as an attachment. In the case of inpatient care only the words ‘inpatient’ are required in this element with type of service defined in text in element 10.11-Episode of care dates – beginning date + a one-year limitation 12-Provider – (NPI & name)13-OHI – Yes/No (Excludes Medicare and TRICARE, etc.)The Contractor shall provide monthly reports with the following data elements but not limited to:Call Center MetricsCall Center summary to include volume and resolution Complaints and resolutionsTracking of Missed Appointments, Return Authorizations/Referrals, No Shows, cancellationsWait time MetricsClaims Processing MetricsBenefits Management Report Elements Audit Reports Provider Option UtilizationParticipation in VA Choice Program (opt-in and opt-out)Summary eligibility information collected at enrollment (OHI, Addresses temporary and permanent with applicable start and end dates, whether the Veteran opted in or not)Education costs to Veteran (detailed report showing all costs and activities related to educating Veterans)Education costs to Contractor Staff (detailed report showing all costs and activities related to educating staff)Clinical information return metricsSummary reports for OHI determinations and amounts per VAClaims processing Types of care furnishedNumber of participants who receive careQuality MetricsMonthly report of all returned mail to include name, address, and type of document that was mailed (i.e., Veterans Choice Card, EOB, etc.) xxiii. Provider Calls: The Contractor shall address, document, and report specific provider inquiries to include but not limited to the following:status of referrals, referral authorization status, Veteran eligibility, Provider directory,claims status, claims issues, provider enrollment, complaints, andbenefits issues DATA ANALYTICSThe Contractor shall build a real-time, interactive dashboard to include the data elements described in this Section. The data elements should be aggregated at the VAMC level and summarized at all levels above.DATA REPOSITORYThe Contractor shall provide access to the Contractor’s data information system/data repository, or an equivalent data extract, to VA personnel. The Contractor shall make available 50 user accounts to be assigned at the discretion of VA.Data elements shall include, at a minimum, details concerning the provider network, referrals, authorizations, claims processing, program administration, beneficiary satisfaction and services, enrollment, and clinical data (case management, chronic care/disease management, utilization management, and medical management). All data shall be current and refreshed no less frequently than once every 24 hours and accessible to all users identified in the requirement above. The read-only claims data system shall be made accessible to users on a continual (24 hours per day/7 days per week) basis except for scheduled downtime for system maintenance. The data shall available for queries on the following, but not limited to, available for queries on a Veteran, Regional, VAMC, and standard geographic area (State, County, and Zip Code) basis. The data access interface will be mutually agreed upon by the Contractor and the VA and will be included as part of the implementation plan.The Contractor shall provide training accessing the Contractor's data information system/data repository or an equivalent data extract. Web-based training is acceptable. The Contractor shall provide ongoing training as needed. TRAININGTRAINING PLANThe Contractor shall provide a Training Plan to VA for approval that will include training as described in the following subsections. CONTRACTOR PERSONNEL AND VA STAFF TRAININGThe Contractor shall develop a Training Plan to implement an initial and ongoing Training Program for Contractor personnel and VA staff as identified by VA. 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 and update the Training Plan on a quarterly basis.The Contractor’s Training Program shall include training for both Contractor personnel and identified VA staff in the following areas: (i) Veteran Call Center; (ii) Network Provider Call Center; (iii) systems, system interfaces, and system access; and (iv) any other areas identified by VA or Contractor related to services rendered under this contract. The Contractor shall review and update the Training Program on a quarterly basis. Deliverable:Training PlanTraining ProgramPROVIDER NETWORK MAINTENANCE AND TRAININGThe Contractor shall develop a plan to implement an initial and ongoing Provider Training Program as part of the Training Plan for VA Core Network and Contractor’s provider network.The Contractor shall develop and implement an initial and ongoing outreach and education program for providers in the VA Core Network and Contractor’s network 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: (i) VA program requirements, policies, and procedures related to the requirements under this contract; (ii) Veterans’ healthcare benefits that are administered through this contract referenced in PWS Section 3.0, “Benefits,” (including the pharmacy benefit described in in PWS Section REF _Ref441831953 \r \h \* MERGEFORMAT 15.0 and Durable Medical Equipment and Medical Devices benefit described in PWS Section REF _Ref441832170 \r \h \* MERGEFORMAT 16.0 ); (iii) referral and authorization processes; (iv) claims submission processes; (v) encouraging the use of a certified health information exchange to facilitate the exchange of information between the provider and VA; (vi) compliance with medical documentation submission requirements set forth in this contract; and (vii) any other areas identified by VA or Contractor related to services rendered under this contract . 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 in its Training Materials VA terms or provide a glossary to allow trainees to understand the meaning of terms. VA shall maintain the rights 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 Material prior to the execution of the Training Sessions referenced in Section 13.1.4.Deliverable:Training MaterialsTRAINING SESSIONSThe Contractor shall conduct the following training:Remote Training (XX Users)Help Desk Personnel – the purpose of this training is to provide “Train the Trainer” for Help Desk personnel. In-person Training at VA (XX Users, XX Locations)Trainers – the purpose of this training is “Train the Trainer” for all groups of users. Community Care Program Office (XX Users, XX Locations)Program Managers – the purpose of this training is to provide program managers the ability access information they may require to monitor the contract and Community Care ProgramChief Business Office (XX Users, XX Locations)Trainers – the purpose of this training is “Train the Trainer” for all groups of users. Finance Center (XX Users, XX Locations)Trainers – the purpose of this training is “Train the Trainer” for all groups of users. VISNS (XX Users, XX Locations)Trainers – the purpose of this training is “Train the Trainer” for all groups of users. VAMCs (XX Users, XX Locations)Trainers – the purpose of this training is “Train the Trainer” for all groups of users. PHARMACYThe Contractor shall provide pharmacy benefits to Veterans based upon the requirements listed below.? These requirements include the use of a Pharmacy Benefits Management (PBM) company to provide urgent and emergent prescriptions.? ROUTINE PRESCRIPTIONS – TIME-ELIGIBLE AND DISTANCE-ELIGIBLEVA health care benefits include providing Veteran’s with prescription medications, medical/surgical supplies and nutritional products. The Contractor’s network providers may prescribe medications to be processed by the VA pharmacy where they are enrolled for care as part of the authorized healthcare services under this contract. The Contractor shall provide the following information from the prescribing network provider for each prescription:Prescribing provider’s namePrescribing provider’s addressPrescribing provider’s PERSONAL DEA number (NOT a generic facility number)Prescribing provider’s phone numberPrescribing provider’s fax numberPrescribing provider’s National Provider Identifier (NPI) numberPrescribing provider’s date of birthPrescribing provider’s genderprovider’s discipline (i.e, physician, physician assistant, nurse practitioner, etc.) The Contractor shall transmit to the VA a list of all network providers with prescribing privileges [90] calendar days prior to the SHCD.? The Contractor shall transmit the list of providers with prescribing privileges in an electronic format 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.? The Contractor shall instruct its providers that prescriptions must be prescribed in accordance with VA’s National Formulary, which includes provisions for requesting non-formulary drugs . Prescriptions will be for generic medications whenever a generic medication is available and there are no verifiable clinical reasons to use a branded product. Prescriptions must 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.URGENT/EMERGENT PRESCRIPTIONS – TIME-ELIGIBLE AND DISTANCE-ELIGIBLEThe Contractor shall establish a retail pharmacy network to fill urgent/emergent prescriptions as part of the community care program.? The Contractor shall use a Pharmacy Benefits Management (PBM) company to process all urgent/emergent prescriptions as described below .The Contractor’s PBM shall include retail pharmacies covering all geographic areas of the region and will include large retail pharmacy chains.The Contractor shall provide all applicable Veteran eligibility data to the PBM in real-time to facilitate Veterans’ receipt of their urgent/emergent prescriptions through the participating retail pharmacies.The Contractor shall instruct its network providers if a Veteran has an urgent/emergent need to start a medication, they are to write a prescription for up to a 14 day supply (without refills) and instruct the Veteran which local pharmacies are in the retail network established by the PBM.?The Contractor shall instruct its network providers to provide a second prescription for medications beyond the urgent/emergent 14-day supply and submit it to a VA pharmacy or CMOP 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.The contractor will ensure that Veterans who are referred to a retail pharmacy for urgent/emergent prescriptions incur no out-of-pocket expenses.The Contractor shall instruct its network providers if there is no medication on the VA National Formulary that is medically acceptable, they may write the initial 14-day prescription for the least expensive medically acceptable non-formulary drug but, for a second prescription, if required, shall be requested using VA’s non-formulary request process. Prescriptions will 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 training material shall ensure network providers are instructed that a Veteran can receive a prescription for up to a 14-day supply, without refills, when there is an urgent/emergent need to start a medication.? The Contractor’s training material shall include information on participating retail pharmacies.? The Contractor training materials shall instruct providers to submit a second prescription for the remainder of the quantity required to a VA pharmacy for processing if the urgently/emergently needed medication is filled in a non-VA pharmacy and is expected to be continued beyond 14-days.? The Contractor shall provide a monthly urgent/emergent prescription report to the VA to include:By pharmacy, which pharmacy filled the prescriptionBy National Drug Code, which drug was used to fill the prescriptionBy prescription, the drug ingredient cost and the RX processing feeBy prescribing provider, who prescribed what medication, By Veteran, who received what medication, By the diagnosis associated with each prescribed medication, and By provider, prescribed non-formulary medications and corresponding diagnosesThe contractor shall absorb the cost of a non-formulary medication if a VA National Formulary medication could have been prescribed. The contractor shall absorb the prescription cost (difference between the lowest cost drug and the dispensed drug) if the pharmacy does not dispense the most cost effective generic product DELIVERABLE:Monthly Urgent/Emergent Prescription ReportURGENT/EMERGENT PRESCRIPTION CLAIMS AND INVOICINGThe Contractor’s pharmacy solution shall include the ability to receive and process claims payments from the retail pharmacies.? The Contractor shall inform PMB of the VA approved reimbursement described below and will agree to accept this reimbursement as full payment without charge to the Veteran.? The Contractor shall invoice VA for urgent/ emergent medications when these are dispensed by pharmacies in the Contractor's network. VA shall reimburse the Contractor for brand name medication at Wholesale Acquisition Cost (WAC) minus X%, plus a $X.XX dispensing fee, and generic medication at WAC minus XX%, plus a $X.XX dispensing fee.? The Contractor shall provide VA a monthly summary prescription claims report.DELIVERABLE:Monthly Summary Prescription Claims ReportDURABLE MEDICAL EQUIPMENT AND MEDICAL DEVICESThe Contractor shall provide Durable Medical Equipment (DME) and medical device benefit to Veterans under this contract. URGENT/EMERGENT PRESCRIPTIONSThe Contractor shall provide DME and medical devices to patients that are needed urgently or emergently based on the criteria provided by VA.? All non-urgent or non-emergent DME and medical device prescriptions shall be returned to VA for them to be filled by VA. NON-URGENT/EMERGENT PRESCRIPTIONS FOR DME/MEDICAL DEVICESThe Contractor’s network providers may prescribe DME and medical devices for Veterans to be filled at VA as part of the authorized healthcare services under this contract.? All DME and medical device prescription shall have the following information at a minimum: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 prescribed.Item delivery location/address and expected delivery dateThe Contractor shall instruct its network providers to provide all necessary follow up care including patient education and training for the prescribed item and fitting and adjustment. VA shall procure and send the prescribed item to the prescribing network provider location. The Contract shall instruct its network providers to use VA-provided order forms or templates for certain DME and/or medical devices.DENTALThe Contractor shall develop and maintain a network of dental providers to provide outpatient dental care to all eligible Veterans in accordance with 38 U.S.C. 1712(b) and 38 CFR 17.93. See the Dental section of the Operations Manual. OUTPATIENT DENTAL SERVICESThe Contractor shall require care purchased for enrollees from community outpatient dental providers is cost-effective and complementary to the larger VHA system of care. Success is defined as providing the best possible care to Veterans, while establishing accountability and maintaining or improving quality, clinical information sharing, and care coordination. Cost effective, consistent, and competitive pricingQuality outpatient dental community careHigh patient satisfactionImproved exchange of patient care information between community outpatient dental providers and VHA High-quality care and patient safetyImproved coordination of care to maintain continuity of care with VHADENTAL MANAGEMENTThe Contractor shall provide sufficient management to ensure that the work specified in this contract is performed efficiently, accurately, on time, and in compliance with the requirements of this document. The Contractor shall ensure that a Monthly Management Report is submitted. Pricing for dental services shall be reimbursed based on the VA Schedule. DENTAL NETWORK ADEQUACYThe Contractor shall establish and maintain a network of credentialed dentists that meet the network adequacy standards in Section REF _Ref441837649 \r \h \* MERGEFORMAT 4.3. The network shall enable eligible Veterans to access dental care through community dentists. This network will include existing VA dental providers that the VA wants to retain and that wish to continue serving VA patients through the network. The Contractor shall develop a process which ensures VA dental providers have the right of first refusal. The Contractor’s network shall meet the following standards: Consist of community dentists to meet VA access needs and provide high-quality dental careMaintain dental coverage across contracted region(s), the network shall be adaptable and flexible enough to meet changing VA demandCredentialing and real-time provider status verification The Contractors network management and processes shall be responsive to Veteran needsThe Contractor shall track and monitor appointment completionDENTAL CREDENTIALING AND COMPLIANCEThe Contractor shall be compliant with the most current version of the Code on Dental Procedures and Nomenclature (Code) published in the American Dental Association's (ADA) Current Dental Terminology (CDT) manual throughout the life of the contract. The Contractor shall promptly notify the Contracting Officer whenever a new version of the ADA CDT manual is published. Within 30 calendar days of the release of the new version, the Contractor shall provide the Contracting Officer with a synopsis of the changes that impact the performance of this contract and has any impact on the Operations Manual. The Contractor shall maintain a network that meets the following standards. The Contractor shall credential network dentists in accordance with industry standards and perform periodic re-credentialing of network dentists.Monitor dental services and inquiries to develop integrated quality improvement initiatives for providers.Coordinate with the VA Patient Advocate, as needed, to investigate and resolve complaints, grievances and patient safety issues. The Contractor shall comply with patient safety requirements.Identify and coordinate specialized dental services.Provide VA access to provider credentialing files as requested. Work with QM staff to monitor quality and compliance through ongoing quality assessment program.DENTAL APPOINTMENT SCHEDULINGTIME-ELIGIBLE VETERANAppointment scheduling for Time-Eligible Veterans shall be handled by VA.DISTANCE-ELIGIBLE VETERANThe Contractor shall provide an online dental provider listing and appointment scheduling portal for Distance-Eligible Veteran appointment scheduling. RETURN OF DENTAL RECORDSTIME-ELIGIBLE VETERANDental records to include radiographs for Time-Eligible Veterans shall be returned to the referring VA within 60 days after completion of appointment. DISTANCE-ELIGIBLE VETERANDental records and/or radiographs shall be provided within 45 days of request for Distance-Eligible Veterans. Exchange of dental records through health information exchange is encouraged. DENTAL CLAIMS PROCESSINGThe Contractor shall pay its providers in accordance with the terms and conditions of the Prompt Payment Act.Receive claims from providers in electronic data interchange (EDI) or paper formatVerify services billed are same as VA authorization.If complete information is not received from provider, submit a request for the required information (i.e., clinical information) and suspend claim until information received.Issue payment to provider for authorized services on complete claims on or before the timeframes required in the Prompt Payment Act.Generate payment explanation to provider and explanation of benefit (EOB) to patient.Transmit claims information to VA in HIPAA-compliant EDI file.Respond to provider payment inquiries.Summarize claim processing and payment data in Monthly Report. Work with QM staff to monitor quality and compliance through ongoing quality assessment program.DENTAL MONTHLY REPORTThe Contractor shall submit a Monthly Report that includes the following information:Summary claims data (claims submissions, claims processed, claims payments within 20 days and within 30 days, number of claims submitted, total amount billed, amounts paid to network providers);Dental access data (initial exams, initial appointments, subsequent treatments);Summary of patient complaints/grievances;Summary of patient safety incidents andAnnually, a Credentialing Agreement stating that all credentialing requirements for network providers have been met.DELIVERABLE:Dental Monthly ReportPERFORMANCE METRICSThe table below defines the Performance Standards and Acceptable Performance Levels for Objectives associated with this effort. The Contractor shall monitor performance against the established schedule, milestones, risks and resource support outlined in the approved CPMP. The Contractor shall report any deviations in the Monthly Progress Report. The VA will utilize a Quality Assurance Surveillance Plan (QASP) throughout the life of the task order to ensure that the Contractor is performing the services required by this PWS in an acceptable manner. The VA reserves the right to alter or change the QASP at its own discretion. A Performance Based Service Assessment Survey will be used in combination with the QASP to assist the VA in determining acceptable performance levels. The COR will determine if the performance of the Contractor is below a metric standard and deem it unacceptable. The COR will then notify the Contracting Officer.Section Number / NamePerformance ObjectivesReview FrequencyMethodAcceptable Quality LevelPerformance ThresholdIncentive/Disincentive for Contractor 1: General InformationN/AN/AN/AN/AN/AN/A2: Project Management??????3: Benefits??????4.4: High Performing NetworkContractor providers are credentialedInitial and quarterly thereafterAccreditation CertificateVA participation on Contractor's Credentialing Committee100% compliance by date of healthcare service delivery and ongoing thereafterCompliance on a VAMC service area level?4.4: High Performing NetworkMeet with VA representative(s) to evaluate network performance needsWeeklyEstablish and conduct weekly meetings100% complianceCompliance on a VAMC service area level?4.4: High Performing NetworkProvider directory data accuracy 30 days prior to the delivery of healthcare services and monthly thereafterReceipt of directory transmissionVA ability to schedule Veterans98% compliance by date of healthcare delivery and monthly thereafterCompliance on a regional level?4.1.2: High Performing NetworkProvider training Initial review 30 days prior to the date of delivery of healthcare and monthly thereafterVA review of Training Plan and Training MaterialsReport of number of new and maintenance provider trainings98% compliance by date of healthcare service delivery and monthly thereafterComplete provider training (i) for all existing providers in the network no later than thirty (30) days prior to the delivery of health care services on this contract and (ii) prior to any new provider joining the network?4.2: High Performing NetworkTiered provider network capabilityInitial review 30 days prior to the date of delivery of healthcare and annually thereafterDemonstration of compliance with VA tiring standards by ContractorListing of providers by tier in provider directory VA approvalCompliance on a VAMC service area level?4.2: High Performing NetworkMeet quantitative network adequacy and access standards30 days prior to the delivery of healthcare services and monthly thereafterVA review of Network PlanVA and Contractor's review of Contractor's demand data and analysisVA ability to schedule Time Eligible VeteransAverage number of days from date of referral approval to date of service for Distance Eligible VeteransVA review of Network Corrective Action Plan Submitted to VA within 10 days of an identified deficiency95% compliance for network adequacy and accessCompliance on a VAMC service area level?5.3.1: Veterans Choice Cards Production and Distribution Timely Issuance of Veterans Choice CardsWeeklyAudit of Weekly Card Processing Detailed ReportMeets or exceedsCards for newly enrolled Veterans provided within 14 days of notification of enrollment AND Replacement Cards for newly enrolled Veterans within provided 14 days of notification of loss?5.3.2: Veterans Choice Card Handling Initial Choice Card DistributionWeekly Track to timeline specified in the plan using Weekly Card Processing Summary and Detailed ReportsCompletion of all activities on or before the defined milestonesInitial Choice Card distribution completed in accordance with approved Implementation Plan for Card Issuance ?5.3.2: Veterans Choice Card HandlingChoice Card DistributionWeeklyAudit of Weekly Card Processing Detailed ReportMeets or exceedsResolve invalid addresses and resend cards within 30 days ?5.3.2: Veterans Choice Card Handling Provide Change of Address Information to VAWeeklyAudit of Weekly Card Processing Detailed ReportMeets or exceedsUpdated Addresses provided to VA within 30 days? of when the new address information is made available to the Contractor?6.1.1: Time-Eligible [Referrals] Timely forwarding of Community Provider referrals for Time-Eligible Veterans to VAMonthlyReferral Statistics ReportMeets or exceedsForward all referral requests for “Time-Eligible” Veterans to VA within [1]?day of receipt.?6.1.2: Distance-Eligible [Referrals]Timely determination of Referral requests for Distance-Eligible VeteransMonthlyReferral Statistics ReportMeets or exceedsThe Contractor shall make a determination on referral requests within [two] days of receipt. ?6.2.1: Time Eligible [Pre-authorizations] Timely forwarding of Pre-Authorization requests for Time-Eligible Veterans to the VAMonthlyPre-Authorization Statistics ReportMeets or exceedsForward all pre-authorization requests for “Time-Eligible” Veterans to VA within [1] day of receipt.?6.2.2: Distance-Eligible [Pre-authorizations]Timely determination of Pre-Authorization requests for Distance-Eligible VeteransMonthlyPre-Authorization Statistics ReportMeets or exceedsThe Contractor shall make a determination on pre-authorization requests within [two] days of receipt. ?7: Medical Management Return of medical record documentation within required timeframes and with required documentationOngoingVA confirmation of accurate and timely record submission95% compliance on a VAMC service levelCorrective action by Contractor when deficiencies are identifiedCompliance on a VAMC service area level?8.3: Claims Adjudication for Healthcare Services RenderedTimely and accurate processing and payment of claims in accordance with PWS and Operational Manual standardsWeeklyWeekly Claims Processing Report98% compliance within 90 days of the start of healthcare deliveryCompliance on a regional level?8.3: Claims Adjudication for Healthcare Services Rendered Late payment penaltiesWeeklyWeekly Claims Processing Report100% complianceLate payment penalties shall not exceed 0.5% of the dollar amount of total claims paid on a monthly basis?8.9: Claims Adjudication for Healthcare Services RenderedAdministration of claims auditing program requirements QuarterlyFraud and Abuse SummaryClaims Audit ReportSatisfactoryCompliance with the approved Claims Auditing , Fraud and Abuse plan performance standards?9: Contractor Reimbursement and Invoicing ??????10: QualityAdministration of the QA/QI program OngoingVA review of QA/QI PlanVA participation on QA/QI CommitteeVA participation on Peer Review CommitteeSatisfactoryVA committee representative satisfaction?10: QualityProcessing of PQI and IQI issues OngoingVA participation on QA/QI CommitteeVA participation on Peer Review CommitteeSatisfactoryVA committee representative satisfaction?11: Customer ServiceVA and Congressional InquiriesPeriodicAudit95% ComplianceThe Contractor shall confirm receipt of the inquiry within one (1) business day to all inquiries related to VA, Veterans, and/or Congressional Representatives that are sent to the Contractor from VA. The Contractor shall provide the full written response within three (3) business days or as negotiated with VA.?11: Customer ServiceTimeliness of Patient Complaints/GrievancesPeriodicBy Exception / Monthly ReportsPositive Past Performance RatingForward complaints to VA within one business day 95% of the time.?11: Customer ServiceOn-line provider directory updatesPeriodicAudit, Inspection100% ComplianceContractor’s on-line directory of network providers shall be updated daily with a minimum of 95% data accuracy, including network participation status?11: Customer ServiceCall Center functional performance shall meet the requirements set forth in the PWSPeriodicMonthly Reports / AuditPositive Past Performance Rating100% compliance with PWS requirements?12: Reporting ??????13: Technology??????14: Training??????15: HIPAA??????16: Management ??????17: PharmacyList of Network Providers with prescribing privilegesPeriodicAudit/Inspection 95% ComplianceThe Contractor shall transmit the list of providers with prescribing privileges in an electronic format to be agreed upon with VA. The Contract shall update this list upon the credentialing of new providers, or change in credentials of an existing provider, after the initial load. ?18: Dental??????19: Dual Eligible ?????? SCHEDULE FOR DELIVERABLESNote: Days used in the table below refer to calendar days unless otherwise stated. Deliverables with due dates falling on a weekend or holiday shall be submitted the following Government work day after the weekend or holiday.Note: A ship to address must be provided for all hardware deliverables. Electronic submission of S/W or paper deliverables should be the norm unless otherwise stated. Email address(es) must be provided. Although email addresses are provided below for all POC’s, table must be clear as to who receives the deliverables.SCHEDULE FOR DELIVERABLESNote: Days used in the table below refer to calendar days unless otherwise stated. Deliverables with due dates falling on a weekend or holiday shall be submitted the following Government work day after the weekend or holiday.ItemTaskIDDeliverable DescriptionElectronic submission to:12.1AContract Operational Guide. Due Thirty (30) days after contract (DAC) and updated monthly thereafter. VA PM, COR, CO22.2AExecutive Level QPR. Due One hundred twenty (120) DAC and updated quarterly thereafter. VA PM, COR, CO32.2BMonthly Progress Report. Due Thirty (30) DAC and updated monthly thereafter. VA PM, COR, CO42.3AVA Privacy and Information Security Training Certificates. Due Seven (7) DAC (and/or Seven (7) Days after on-boarding of new employee) and annually as required throughout the period of performance (PoP) for all Contractor employees.VA PM, COR, CO52.4AWBS and Updates. Initial schedules and reports are due Thirty (30) DAC and updated weekly as necessary throughout PoP.VA PM, COR, CO2.4BIntegrated Master Schedule (IMS) and Updates. Initial schedules and reports are due thirty DAC and updated weekly as necessary throughout the PoP. VA PM, COR, CO2.4CSchedule Reports or Agile. Due Thirty (30) DAC and at the end of each sprint throughout the PoP.VA PM, COR, CO2.4DCritical Path Reports and Updates. Due Thirty (30) DAC and updated weekly as necessary throughout the PoP. VA PM, COR, CO2.4EWhat-if analyses and Updates. Due Thirty (30) DAC and at the end of each sprint thereafter. VA PM, COR, CO2.5ARisk Management Initial Content and Updates. Draft package is due Sixty (60) DAC. Updates to each document and artifact identified above are due monthly throughout the PoP. VA PM, COR, CO2.5BProject Risk Registry and Updates. Draft package is due Sixty (60) DAC. Updates due monthly throughout the PoP. VA PM, COR, CO2.5CAction Item/Issue Log and Updates. Draft package is due Sixty (60) DAC. Updates due monthly throughout the period of performance.VA PM, COR, CO4.2.1APlan for Card Issuance. Due 90 DAC. VA PM, COR, CO4.2.1BFinal Design for Veteran Choice Card. Due 90 DAC. VA PM, COR, CO4.2.2AProcessing Outcome Detailed File. Due Weekly once card issue begins.VA PM, COR, CO4.2.2BCard Processing Summary Report. Due Weekly once card issue begins.VA PM, COR, CO3.1AHigh-Performing Network Solution. Due DAC per the Implementation ScheduleVA PM, COR, CO5.0Utilization Management Plan. Due 180 DAC.VA PM, COR, CO5.0Adjudicated Referral Claim Report. Due 60 days after commencement of care delivery.VA PM, COR, CO5.0Contractor Referral Summary Report. Due 60 days after commencement of care delivery.VA PM, COR, CO5.0Un-activated Referral Report. Due 60 days after commencement of care delivery.VA PM, COR, CO5.0Referral and Pre-Authorization Statistics Report. Due 60 days after commencement of care delivery.VA PM, COR, CO5.0Utilization Management Program Accrediting Certificate. Due 60 days after commencement of care delivery.VA PM, COR, CO ................
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