Veterans Affairs



FedBizOppsSources Sought Notice*******CLASSIFICATION CODESUBJECTCONTRACTING OFFICE'SZIP-CODESOLICITATION NUMBERRESPONSE DATE (MM-DD-YYYY)ARCHIVEDAYS AFTER THE RESPONSE DATERECOVERY ACT FUNDSSET-ASIDENAICS CODECONTRACTING OFFICEADDRESSPOINT OF CONTACT(POC Information Automatically Filled fromUser Profile Unless Entered)DESCRIPTIONSee AttachmentAGENCY'S URLURL DESCRIPTIONAGENCY CONTACT'S EMAILADDRESSEMAIL DESCRIPTIONADDRESSPOSTAL CODECOUNTRYADDITIONAL INFORMATIONGENERAL INFORMATIONPLACE OF PERFORMANCE* = Required FieldFedBizOpps Sources Sought NoticeRev. March 2010QNon-VA Third Party Administrator to support theimplementation of the Veterans Access, Choice, andAccountability Act of 2014.80401-5621VA791-14-N-009009-17-201490N524292Department of Veterans AffairsVA Denver Acquisition & Logistics Center(003A4D)555 Corporate CircleGolden CO 80401-5621Kyle Shaffer, Contract SpecialistKyle.Shaffer@Contract SpecialistPURPOSE:The Department of Veterans Affairs Denver Acquisition & Logistics Center (VA DALC), in support of the Veterans Health Administration (VHA) Chief Business Office, Purchased Care Office, is contemplating the issuance of a solicitation for a Third Party Administrator (TPA) (please see details below). The purpose of this Request for Information (RFI) is to provide interested parties the opportunity to inform the VA of their capabilities to perform the services addressed in this RFI. The Department of Veterans Affairs (VA) will host one (1) Industry Day in anticipation of the release of a new solicitation for a Third Party Administrator (TPA). The purpose of the Industry Day is to provide general information on the upcoming solicitation and requirements and to solicit industry feedback. The Industry Day is open to all potential offerors interested in responding to the upcoming solicitation. The location and date are listed below. Attendance is voluntary and is not required in order to propose to future solicitations. The information provided in response to the RFI will assist the VA in understanding standard industry practices and facilitate the VA development of the requirement. THIS IS NOT A SOLICITATION FOR OFFERS AND NO CONTRACT WILL BE AWARDED FROM THIS EVENT. This announcement serves as a request for information and invitation to participate in this vendor event, and as a pre-solicitation notice, issued solely for information and planning purposes. OVERVIEW AND PURPOSE:The VA intends to contract with a qualified vendor to provide Third Party Administrator services across the nation. The contracts will be available for all VA Medical Centers throughout the Veterans Health Administration and will be centrally supported by the VHA Chief Business Office.1.0 Program ObjectiveThe objective of the VHA Chief Business Office’s Third Party Administrator (TPA) procurement is to support VHA in the implementation of the Veterans Access, Choice and Accountability Act of 2014 (Veterans Choice). This includes the creation and distribution of the Veteran’s Choice Card, establishment of a call center to provide education to Veterans and providers on VA Choice program details, respond to Veteran and clinician inquiries, tracking, monitor and provide reporting on Veteran utilization and manage claims adjudication and payment to include receipt of clinical documentation. The TPA will also facilitate and manage patient referrals, establishment of a utilization review department to make Non-Service Connected/Service Connected/Special Authority (NSC/SC/SA) determinations. The TPA will provide Veterans with preferred provider network, internal and/or external to the VA. The TPA may also be asked to provide a pharmacy benefits management (PBM) network.2.0 Statement ObjectivesThe purpose of this Statement of Objectives is to define the responsibility of a Third Party Administrator in support of Title 1 Section 101 of the Veteran Choice Bill.2.1 VA Choice CardsThe TPA may print and distribute VA Choice Cards to all enrolled and eligible Veterans. 2.2 Call CenterThe TPA will be required to establish a Customer Service Call Center to respond to general call from Veterans regarding VA Choice Eligibility and calls from providers. 2.2.1 General Calls from Veterans – The TPA will provide coverage information pertaining to the VA Choice program. The TPA will also provide education to Veterans on out of pocket costs associated with the use of the VA Choice program. 2.2.2 Calls from potential VA Choice eligible Veterans – The TPA will provide education and eligibility information to Veterans. The TPA will assist with and /or schedule VA Choice appointments and will follow-up to confirm receipt of care. The VA Choice Call Center will follow up with providers to ensure documentation is received to ensure continuity of care and timely claims processing.2.2.3 Provider Calls – The TPA will address, document, and report specific provider inquiries to include but not limited to the following. A. Status of claimB. Report of No-showsC. Rescheduled appointmentsD. General Program InformationE. Provide Other Health Insurance CoverageF. Copay Information G. Service Connected/Non-Service Connection Condition Status2.3 Eligibility Determination and EnrollmentThe TPA will determine enrollment in the Choice program based on the requirements of the Veterans Access, Choice, and Accountability Act of 2014 and the Veteran’s decision on choice. A veteran is an eligible veteran for the purposes of this section if— (1)(A) as of August 1, 2014, the veteran is enrolled in the patient enrollment system of the Department of Veterans Affairs established and operated under section 1705 of title 38, United States Code, including any such veteran who has not received hospital care or medical services from the Department and has contacted the Department seeking an initial appointment from the Department for the receipt of such care or services; or (B) the veteran is eligible for hospital care and medical services under section 1710(e)(1)(D) of such title and is a veteran described in section 1710(e)(3) of such title; and (2) the veteran— attempts, or has attempted, to schedule an appointment for the receipt of hospital care or medical services under chapter 17 of title 38, United States Code, but is unable to schedule an appointment within the wait-time. (B) resides more than 40 miles from the medical facility of the Department, including a community-based outpatient clinic, that is closest to the residence of the veteran;(C) resides—(i) in a State without a medical facility of the Department that provides—(I) hospital care;(II) emergency medical services; and (III) surgical care rated by the Secretary as having a surgical complexity of standard; and (ii) more than 20 miles from a medical facility of the Department described in clause (i); or(D)(i) resides in a location, other than a location in Guam, American Samoa, or the Republic of the Philippines, that is 40 miles or less from a medical facility of the Department, including a community-based outpatient clinic; and(ii)(I) is required to travel by air, boat, or ferry to reach each medical facility described inclause (i) that is 40 miles or less from the residence of the veteran; or(II) faces an unusual or excessive burden in accessing each medical facility described in clause that is 40 miles or less from the residence of the veteran due to geographical challenges, as determined by the Secretary.2.4 Referral and Authorization2.4.1 The TPA will gather the required chief complaint from the Veteran and will coordinate the referral and authorization with a provider. The TPA may also be responsible for scheduling the appointment and services related to appointment management. 2.4.2 The TPA is required but not limited to:Estimate the cost of the episode of care and provide to the VA in the format requestedEstimate VA Copay AmountDetermine Service Connection or Special AuthorityCollect and Verify Other Health Insurance (OHI) Perform insurance Identification and Verification2.5 Provider Options2.5.1 In accordance with the Veterans Access, Choice, and Accountability Act of 2014, the TPA will assist the Veteran in selecting a provider based on the requirements stated in legislation 2.5.2 The TPA will advise the Veteran of the following options based on coverage under the Veterans Choice Act:VA Medical Facilityexisting contracts or agreementsProvider of Veterans Choice2.6 Claims Adjudication and Payment2.6.1 The claims adjudication system will support the VA’s Veterans Choice program. The system will support changes in patients’ residences and determine eligibility based on current active residence. The TPA is responsible for receipt and management of clinical documentation from the provider prior to claims payment. The TPA will ensure that medical documentation from the provider is submitted in an electronic format agreed upon by the VA.2.6.2 The TPA will reimburse the entity for such care and services at the rates negotiated in accordance with Veterans Access, Choice, and Accountability Act of 2014.2.6.3 The TPA will use a HIPAA compliant, industry standard adjudication system. 2.6.4 The claims adjudication system must be configurable to support business rules and VA Policy provisions as defined by the VA. The claims system and processes will ensure billing of other health insurances/coordination of benefits occur.2.7 Reconsideration and Appeals Management2.7.1 Claims Payment Appeals - The TPA will manage and respond based on VA procedure for reconsideration and appeals. The TPA will gather and research electronic and hard copy documents and provide written responses to take further action pertaining to administrative health care claim reconsiderations, notice of disagreements, and if warranted, schedule hearings. The TPA will develop formal appeals for advancement to the Board of Veterans Appeals (BVA) electronically and /or in hard copy by secured, protected, and VA approved environments.2.7.1.1 Appeal PaymentThe TPA may be responsible for the redevelopment of claims as a result of a BVA remand or overturned decisions. 2.7.2 Clinical Appeals – The TPA will furnish documentation to the VA for the processing of a clinical appeal.2.8 Quality Control and Internal Controls2.8.1 The TPA will develop and maintain a quality program to ensure adherence to the Veterans Choice Legislation and VA standards and business rules. 2.8.2 The TPA will employ industry best practices that monitor compliance and support internal controls to prevent fraud, waste and abuse, and improper payments. The TPA will ensure the organizations payments to third parties are for valid services rendered.2.8.3 The TPA will ensure clinical quality through adherence to VA policies and directives on Clinical Practice Guidelines. The TPA will ensure credentials and licensure of Non-Department Providers are maintained consistent with VA credentials and licensure requirements. 2.9 Reporting2.9.1. The TPA will provide reports on the following but not limited to:Call Center MetricsTracking of Missed AppointmentsWait time MetricsClaims Processing MetricsAppeals StatusReturn Authorizations, No Shows, cancellationsAudit Reports Provider Option Utilization2.10 Analysis and Testing Performance of all required analysis and tests to aid in the design and implementation/integration of the Veterans’ Choice and TPA program requirements and to document the end product satisfies performance requirement including potential integration with VHA’s existing technical architecture.2.11 Implementation/IntegrationImplementation is considered implementation of the Veterans’ Choice Program nationally. This includes all TPA program requirements listed previously. Integration could include direct interface with VA systems, electronic sharing of medical documentation, and access to/from Veterans specific data information. In all cases of proposed interface VA Privacy and Security guidelines must be adhered to and encryption protocols followed.2.11.1 Medical DocumentationFor each episode of care VA requires that medical/clinical documentation is returned to VA electronically.2.12 Configuration ManagementEstablishment of a product and program baseline to define the configuration and management of the Veteran’s Choice program by the TPA to include a demonstration of the capabilities that satisfy performance requirements. Establishment and maintenance of an Integrated Product Team, to include government personnel, for insight and collaboration into the TPA program design’s progress.2.13 LogisticsDevelopment and delivery of all Veterans Choice program requirements to include but not limited to verification of Veterans Choice Card creation and distribution, policies and procedures for determining NSC/SC/SA, patient and provider education and training materials and plans, claims adjudication logic that meet VA policies, verification of claims processing rules consistent with VA business rules, care coordination plans with VA and Non-VA providers, tracking and managing medical records, claims processing and customer service call center reports consistent with VA’s program requirement and the health care industry if applicable and provider network adequacy reports. 3.0 Management ObjectiveThe management objective is to allow the offeror the maximum flexibility to innovatively manage the program schedule, performance, risks, warranties, subcontracts, and data to support the administration of the Veterans Choice Program that satisfies performance requirements. Another objective is to maintain clear government visibility into the program schedule, performance, and risk.3.1 Communications3.1.1 The TPA will provide weekly or on demand reports to VA. 3.1.2 The TPA will create a repository of communications to the Veteran on behalf of the VA.3.1.3 The TPA will develop communication artifacts to include but not limited to:Fact SheetsFAQ’sProgram UpdatesChanges to LegislationAppointment remindersProvider letters4.0 Transition Plan4.1 The TPA will develop a transition plan prior to expiration of the contract.INDUSTRY DAY LOCATION, DATE AND TIME:The Industry day will be held in Denver, CO on September 17th located at:VA - Denver Acquisition & Logistics Center555 Corporate CircleGolden, CO 80401The schedule for the event is as follows:9:00 AM - 11:00 AM General Session - All Attendees11:00 AM - 5:00 PM One-on-One Sessions (30 minutes each for each vendor and VA)The General Session is an opportunity for all interested parties to hear about the Third Party Administrator program from The Department of Veterans Affairs. Time will be allowed in the General Session for questions and answers applicable to all attendees. The "One-on-One" session for the remainder of the day is an opportunity for vendors to meet one-on-one with representatives from VA to allow for direct questions and information sharing. Each "One-on-One" session will be limited to 30 minutes and attendance of no more than 5 from the vendor's organization. Vendors wishing to participate in the general session and/or a one-on-one session must register and request their one-on-one time by emailing: kyle.shaffer@ and julia.trautman@. Time will be assigned as requests are received. In the registration email, please include the following information (VA will send registration confirmation to the POC listed below):Company NameCompany AddressPOC and email addressNumber of AttendeesBrief synopsis of services the company offersOne-on-One sessions are restricted to one per vendor. Advance submission of questions and discussion topics for the One-on-One sessions is not required but is allowable. If questions and discussion topics are submitted in advance they will be kept confidential up to the time of the session. The session will not be restricted to those questions and discussion topics. Please submit any advance questions and discussion topics to julia.trautman@ and kyle.shaffer@.WRITTEN RESPONSES: Please prepare a written response to the following questions and submit those to Julia Trautman or Kyle Shaffer at Industry Day on Wednesday, September 17th. What do you see as a possible timeline to successfully deploy this program from this point through go live?What additional information would you need to know from VA to develop an approach for go live?Do you either possess the resources and capabilities or feel you can have these in place within our timeframe to successfully implement the program?Are there elements of our high level requirements that could be changed or omitted and still provide for successful implementation of the program under the P.L. 113-146 Veterans Choice Act, Title 1Section 101?How would payments to another entity (e.g., secondary insurance billing, provider, billing agent) be handled? How would you maintain an eligibility file and manage Veterans with multiple residences (e.g. summer/winter (“snow birds” residence)? The requirement is that the primary residence can alter within a calendar year.What are the key areas of VA support that you would need in order to successfully implement this program, such as IT support, clinical support? What elements of this program do you currently have experience in providing?What is your ability to transact administrative (e.g. address and insurance changes) and medical documentation in a computable format?What is your ability to create and distribute identification cards? What is your approach to incorporating changes in business rules (your standards of practice)? In other words, how would you incorporate changes that may occur over time and what is your typical timeframe to incorporate changes to your business rules?Does your organization currently track no-show appointments? Do you compensate providers for no show appointments?What is your process for pre-authorization / referral of health care services and authorization for necessary follow-on services?Do you require electronic health care claims submission or allow paper submission? If both, what percentage is each?What is your organization's process is for updating provider databases? How often does your provider list change and is it available or distributed to subscribers? How does your organization ensure continuity of care and appropriate utilization of services? Include referrals, handoffs and follow up processes; How would care be transitioned back to VA?Please describe your credentialing process, including how you obtain, track, maintain, and update records on licensure, board certification, and malpractice claims and where this information is stored. Is your organization able to provide provider-level information when requested? If your organization uses Credentialing Verification Organizations (CVOs), which one is used? How long does it typically take to credential a provider? How is loss of a license or certification managed? To which external organizations do you report credentialing data?What timelines do you require for providers and facilities to be re-credentialed or re-accredited? How often do you audit accreditation, credentialing, licensing, malpractice claim history, and board certification? If you do audit, it is 100% or statistical sampling? How do you manage the privileging process for your clinicians? How and how often do you track whether a clinician has lost/gained privileges at his/her institution? How do you notify your customers if there is a change in a clinician's privileges? Where are privileging records maintained? Are privileging records made available to customers for auditing purposes?How do you obtain and communicate the clinical documentation associated with the care delivered.What is your experience in receiving and transmitting electronic quality measures?Do you require the use of Office of the National Coordinator Certified electronic record usage for those providers with whom you engage?What is the business size, socioeconomic status, and NAICS of your organization?Questions concerning these vendor events may be submitted to kyle.shaffer@ and julia.trautman@. Please consult the list of document viewers if you cannot open a file.Attachments:1. HR 3230 Veterans Access Final2. Draft Veterans Choice FlowchartSee attached document: HR 3230 Veterans Access Final.See attached document: Draft Veterans Choice Flowchart. ................
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