20260526 Dental Treatment Performance Work Statement.docx

Performance Work Statement (PWS) Nevada Army National Guard (NVARNG) Dental Services

1.0 General:

1.1 Scope: The contractor shall provide all personnel, facilities, equipment, tools, materials, supervision, and quality control necessary to perform Dental Readiness Services as defined in this PWS.

1.1.1. Dental treatment services shall be limited to procedures necessary to correct dental conditions identified during Nevada Army National Guard (NVARNG) dental readiness examinations in order to achieve or maintain a Dental Readiness Classification (DRC) of 1 or 2 in accordance with Department of Defense (DoD) dental readiness standards.

1.1.2. All services shall be performed in accordance with applicable Army Regulations, professional dental standards, and the requirements defined in this Performance Work Statement.

1.2 Background:

1.2.1 Individual Medical Readiness (IMR) and Fully Medically Ready (FMR) are essential components of force readiness for the NVARNG. Dental readiness is a critical element of IRM and directly impacts Soldier deployability.

Service Members with untreated dental disease are at increased risk for dental emergencies that may affect mission readiness and operational capability. The NVARNG maintains approximately 3300 Soldiers requiring ongoing dental readiness monitoring and treatment.

This requirement supports the treatment of approximately 130 Soldiers identified as Dental Class 3 in order to restore deployable dental status and maintain overall force readiness.

Period of Performance (POP): The Period of Performance is estimated from July 15, 2026 to July 14, 2027.

1.4 General Information:

1.4.1 Place of Performance of Services:

Dental services shall be performed at contractor-operated dental clinics

The contractor shall maintain access to dental treatment facilities located within:

· Fifty (50) mile radius of Carson City, Nevada

· Fifty (50) mile radius of Las Vegas, Nevada

Facilities must be properly licensed and capable of providing the dental services described in this PWS.

1.4.2 Quality Control (QC):

The contractor shall develop and maintain an effective QC Plan (QCP) to ensure services are performed in accordance with this PWS.

The contractor shall develop and implement procedures to identify, prevent, and ensure non-recurrence of defective services. The contractor's QCP shall be submitted to the Contracting Officer Representative (COR) no later than 10 days after contract award.

1.4.3 Quality Assurance (QA):

The Government will evaluate the contractor's performance under this contract in accordance with the Quality Assurance Surveillance Plan (QASP). The QASP defines how performance standards will be applied, the frequency of surveillance, and acceptable quality levels.

1.4.4 Special Qualifications:

The contractor shall ensure all dental personnel posses valid and unrestricted licenses to practice dentistry in the State of Nevada.

All contractor personnel must comply with applicable requirements including:

· Health Insurance Portability and Accountability Act (HIPAA)

· Occupational Safety and Health Administration (OSHA)

· American Dental Association Standards (ADA)

· Nevada Dental Board Regulations

2.0 DEFINITIONS AND ACRONYMS

2.1 DEFINITIONS

Definitions and acronyms used within this PWS are consistent with standard Department of Defense and Army contracting terminology.

3.0 Government Furnished Property, Material, Equipment and Services: N/A

4.0 Contractor Furnished Property, Materials, and Equipment:

Except for those items specifically identified as Government furnished, the contractor shall provide all facilities, equipment, instruments, materials, and personnel necessary to perform services under this contract.

5.0 REQUIREMENTS

5.1 GOVERNMENT AUTHORIZATION

Dental treatment services shall be provided only for Soldiers authorized by the NVARNG office of the State Surgeon.

The Government will provide the contractor with a list of Soldiers approved for treatment along with the authorized dental procedures necessary to correct Dental Class 3 conditions.

5.2 DENTAL TREATMENT AUTHORIZATION

Contractor shall provide perform only those procedures authorized by the Government based on the Soldier’s dental readiness examination and approved treatment plan.

Dental procedures performed under this contract shall be prioritize treatment necessary to correct Dental Class 3 deficiencies using the most clinically appropriate and cost-effective method.

Higher cost procedures such as crowns, root canals, dentures, or surgical treatments or any dental treatment plans exceeding $500 must receive prior approval form the State Dental Officer or designated Government representative before being performed.

5.3 DEPLOYMENT PRIORITY

Dental treatment services under this contract support Individual Medical Readiness requirements for NVARNG Soldiers.

Soldiers assigned to units preparing for mobilization or deployment shall receive priority scheduling and treatment under this contract. The NVARNG Office of the State Surgeon will identify priority Soldiers and coordinate scheduling with the contractor.

Treatment scheduling shall be coordinated with the NVARNG Office of the State Surgeon or designated Government representative.

5.4 DENTAL TREATMENT SERVICES

The contractor shall provide dental treatment services necessary to correct Dental Class 3 deficiencies. Services may include diagnostic, restorative, endodontic, periodontal, prosthodontic, and oral surgery procedures as authorized by the Government.

Dental services should be performed in a clinical setting and shall conform to accepted dental standards of care.

5.5 PRICING STRUCTURE

Dental treatment services shall be billed using American Dental Association (ADA) Current Dental Terminology (CDT) procedure codes.

The contractor shall bill only those CDT codes identified in the Dental Procedure Price Schedule (Appendix B) of this contract.

5.6 DOCUMENTATION REQUIREMENTS

The contractor shall provide the following documentation:

· DD Form 2813 for each Soldier treated

· Dental radiographs when clinically indicated

· Documentation required for entry into the DENCLASS system.

All documentation shall be submitted to the NVARNG Office of State Surgeon within three (3) business days of treatment completion.

5.6 REPORTING REQUIREMENTS

The contractor shall provide a bi-weekly report identifying:

· Soldier Name

· Unit

· DoD ID number or last four of SSN

· Procedures performed

· Medications prescribed

· Final dental readiness status

Reports shall be submitted electronically to the COR.

5.7 INVOICING

Invoices shall be submitted through Wide Area Workflow (WAWF).

The contractor shall submit invoices within ten (10) calendar days of services rendered.

Invoices shall include:

· Soldier Identifier

· Procedure codes performed

· Date of Service

· Itemized cost per procedure

6.0 APPLICABLE PUBLICATIONS

The contractor shall comply with all applicable federal regulations and professional standards including but not limited to:

Publication (Chapter/Page)

Occupational Safety and Health Standards.

Title 29, Code of Federal Regulations, Part l910

Occupational Safety and Health Standards, Medical and Dental Offices

OSHA 3187-09R

Health Standards, Bloodborne Pathogens Standard (29 CFR1910.1030) Ionizing Radiation (29 CFR1910.1096) Exit Routes (29 CFR Subpart E1910.35, 1910.36,1910.37, and 1910.38 and 1910.39)

Mandatory

Dental Board of Nevada- Regulations, (Chapter 631.271 Dentistry)

Mandatory https://www.leg.state.nv.us/nrs/nrs-631.html

https://armypubs.army.mil/ProductMaps/PubForm/AR.aspx

35_Final_Web_ARN641.pdf

Federal Acquisition Regulation https://www.acquisition.gov/?q=browsefar

Protection of Personally Identifiable Information (PII)

DFARS 224.103

Department of Defense Privacy Program DoD5400.11

Federal Information Processing Standards (FIPS) Publication 201-2 Personal Identity Verification (PIV) of Federal Employees and Contractors (paragraph 9) August 2013 http://nvlpubs.nist.gov/nistpubs/FIPS/NIST.FIPS.20 1-2.pdf

Defense Federal Acquisition Regulation Supplement http://www.acq.osd.mil/dpap/dars/dfarspgi/current/index.html or https://www.acquisition.gov/dfars

https://www.dhs.gov/homeland-securitypresidential-directive-12

https://www.esd.whs.mil/Directives/issuances/dodi/

https://www.esd.whs.mil/Directives/issuances/dodm/

https://www.esd.whs.mil/Directives/issuances/dodd/

DoD 8570.01-M Information Assurance Workforce Improvement Program 12/19/2005 (Change 4:

11/10/2015) https://www.esd.whs.mil/Directives/issuances/dodm/

DoD 5220.22-M National Industrial Security Program Operating Manual (NISPOM) 02/28/2006 (Change 2: 05/18/2016) https://www.esd.whs.mil/Directives/issuances/dodm/

http://armypubs.army.mil/ProductMaps/PubForm/AR.aspx

http://armypubs.army.mil/ProductMaps/PubForm/AR.aspx

https://armypubs.army.mil/epubs/DR_pubs/DR_a/pdf/web/AR%2040-35_Final_Web_ARN641.pdf

https://armypubs.army.mil/epubs/DR_pubs/DR_a /ARN37720-AR_40-501-002-WEB-4.pdf

https://armypubs.army.mil/ProductMaps/PubForm/Details.aspx?PUB_ID=66994

https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/602519p.pdf?

ver=R2OKfDXWHtMkQ9hrl8wdOw%3D%3D

6.1 Applicable Forms: Forms applicable to the PWS are listed below:

TECHNICAL EXHIBIT 1

Performance Requirements Summary (PRS)

This PRS includes performance objectives the Government will use to determine contractor performance and will compare contractor performance to the Acceptable Quality Level (AQL).

Service Members COR inspection

management).

Missed no more than 1% of dental treatment of the scheduled 130 Service Members Random Monitoring and COR Review

from start to finish, unless mutual agreement is met, and alternate coverage is available.

100% of exams and treatments for the scheduled 130 service members Patient Feedback/COR

TECHNICAL EXHIBIT 2

Estimated Workload Data The following estimated workload is provided for planning purposes only and does not represent a guaranteed number of services to be performed under this contract. Actual workload may vary depending on Nevada Army National Guard dental readiness requirements.

APPENDIX A

Department of Defense

Oral Health and Readiness Classification System

The oral health status of uniformed personnel shall be classified as follows:

a. Class 1: (Oral Health): Patients with a current dental examination, who do not require dental treatment or reevaluation. Class 1 patients are worldwide deployable.

b. Class 2: Patients with a current dental examination, which require non-urgent dental treatment or reevaluation for oral conditions, which are unlikely to result in dental emergencies within 12 months. Class 2 patients are worldwide deployable. Patients in dental class 2 may exhibit the following:

(1) Treatment or follow-up indicated for dental caries or minor defective restorations that can be maintained by the patient.

(2) Interim restorations or prosthesis that can be maintained for a 12-month period. This includes teeth that have been restored with permanent restorative materials for which protective cuspal coverage is indicated.

(3) Edentulous areas requiring prostheses but not on an immediate basis.

(4) Periodontium that:

(a) requires oral prophylaxis

(b) requires maintenance therapy

(c) requires treatment for slight to moderate periodontitis and stable cases of more advanced periodontitis

(5) Unerupted partially erupted or malposed teeth that are without historical, clinical or radiographic signs or symptoms of pathosis, but which are recommended for prophylactic removal.

(6) Active orthodontic treatment. The provider should consider placing the patient in passive appliances for deployment for up to six months. For longer periods of deployment, the provider should consider removing active appliances and placing the patient in passive retention.

(7) Temporomandibular disorder patients in remission. The provider anticipates the patient can perform duties while deployed without ongoing care and any medications or appliances required for maintenance will not interfere with duties.

c. Class 3: Patients who require urgent or emergent dental treatment. Class 3 patients normally are not considered to be worldwide deployable.

(1) Treatment and/or follow-up indicated for dental caries, symptomatic tooth fracture or defective restorations that cannot be maintained by the patient.

(2) Interim restorations or prostheses that cannot be maintained for a 12-month period.

(3) Patients requiring treatment for the following periodontal conditions that may result in dental emergencies within the next 12 months.

(a) Edentulous areas or teeth requiring immediate prosthodontic treatment for adequate mastication or communication or acceptable esthetics.

(b) Active progressive moderate or advanced periodontitis.

(c) Periodontontal abscess

(d) Progressive mucogingival condition

(e) Periodontal manifestations of systemic disease or hormonal disturbances

(f) Heavy subgingival calculus

(4) Edentulous areas or teeth requiring immediate prosthodontic treatment for adequate mastication or communication or acceptable esthetics.

(5) Unerupted, partially erupted or malposed teeth with historical, clinical or radiographic signs or symptoms of pathosis that are recommended for removal.

(6) Chronic oral infections or other pathologic lesions including:

(a) Pulpal, periapical or resorptive pathology requiring treatment.

(b) Lesions requiring biopsy or awaiting biopsy report.

(7) Emergency situations requiring therapy to relieve pain, treat trauma, treat acute oral infections or provide timely follow-up care (e.g., drain or suture removal) until resolved.

(8) Acute Temporomandibular disorders requiring active treatment that may interfere with duties.

d. Class 4. Patients who require periodic dental examinations or patients with unknown dental classifications. Class 4 patients normally are not considered to be worldwide deployable

AUTHORIZED DENTAL TREATMENT

1. The following dental procedures are authorized:

(a) Diagnostic Services which are funded through NG6H 2065 Medical Readiness Funding:

D0140-Limited Oral Evaluation D0150-Comprehensive Oral Evaluation D0274-Bitewings- Four Radiographic Images D0330-Panoramic Radiographic Image D0364-Cone Beam CT

(b) Restorative Services which are funded through NG6H 2065 Medical Readiness Funding

D2140-Amalgam-One Surface D2150-Amalgam-Two Surfaces D2160-Amalgam-Three Surfaces D2330-Composite-One Surface D2331-Composite-Two Surfaces D2332-Composite-Three Surfaces

Posterior composites will be authorized only when a posterior composite is necessary to provide a quality restoration and no other alternative is available.

D2335-Composite-Four or More Surfaces D2391-Composite-One Surface D2392-Composite-Two Surfaces D2393-Composite-Three Surfaces D2750-Crown -Porcelain Fused to High Noble Metal D2799-Provisional Crown - Full Cast (unspecified) D2931-Crown - Prefabricated Stainless Steel D2950-Core Buildup, including any pins D2952-Post and Core in Addition to Crown, Indirectly Fabricated D2954-Prefabricated Post and Core in Addition to Crown

(c) Endodontic Services which are funded through NG6H 2065 Medical Readiness Funding

D3310-Anterior Root Canal Therapy D3320-Bicuspid Root Canal Therapy D3330- Root Canal-Molar D3348-Molar Root Canal Retreatment

(d) Periodontal Services which are funded through the VFRE 2020 Dental Treatment Funding (provided only to Soldiers alerted to an OCONUS Mission):

D4341-Periodontal Scaling (4+teeth/quad) D4355-Full Mouth Debridement Periodontal scaling and root planning shall be only authorized when a periodontal abscess is present, or urgent readiness condition exists)

(e) Prosthodontic Services which are funded through NG6H 2065 Medical Readiness Funding

D5820-Interim Partial Denture D5821-Interim Partial Denture (Mandibular)

(f) Oral Surgery Services which are funded through NG6H 2065 Medical Readiness Funding

D7140-Extraction, Erupted Tooth or Exposed Root D7210-Surgical Removal of Erupted Tooth D7220-Removal of Impacted Tooth, Soft Tissue D7230-Removal of Impacted Tooth, Partial Bony D7240-Removal of Impacted Tooth, Completely Bony D7285-Biopsy of Oral Tissue (soft) D7953-Bone Graft

(g) Sedation/Anesthesia Services funded through NG6H 2065 Medical Readiness Funding

Sedation and anesthesia services associated with medically necessary oral surgery procedures intended to restore deployability and improve Dental Readiness Classification (DRC)

Authorized CDT Codes:

D9222-Deep Sedation/General Anesthesia – First 15 minutes D9223-Deep Sedation/General Anesthesia – Each Additional 15-minute increment D9230-Nitrous Oxide/Anxiolysis D9239-Intravenous Moderate (Conscious) Sedation – First 15 minutes D9243-Intravenous Moderate (Conscious) Sedation – Each Additional 15-minute increment D9610-Theapeutic Parenteral Drug, Single Administration

Restrictions:

1. Sedation services are authorized only when medically necessary and directly associated with approved readiness treatment.

2. Sedation for patient preference or convenience is not authorized.

3. Deep sedation/general anesthesia requires State Dental Officer approval prior to treatment.

4. Sedation services shall count toward total treatment plan cost.

5. Procedures exceeding $500 require prior approval.

2. Automatically Authorized – These procedures typically resolve the majority of Dental Class 3 deficiencies and may be performed without additional approval:

· Dental examinations

· Diagnostic radiographs

· Restorative procedures (Fillings)

· Simple extractions (D7140)

· Pulp Caps (D3110, D3120)

· Core buildup procedures

3. Requires State Dental Officer Approval. The following procedures require review and approval by the State Dental Officer or designated representative:

· Crowns (D2750, D2799, D2931)

· Molar root canals (D3330)

· Dentures (D5110, D5120, D5211, D5212, D5820, D5821)

· Surgical extractions (D7210-D7240)

· Bone grafts (D7953)

· Deep sedation/general anesthesia (D9222/D9223)

· Any treatment plan exceeding $500

4. Not authorized

· Bridges and/or implants

· Cosmetic restorations

· Removal of Asymptomatic third molars

· Routine Prophylaxes (cleanings)

· Restorations for aesthetics only

· Restorations for small (non-class 3) caries

· Extensive Root plane/scaling

· Osseous Surgery

· Diagnostic procedures not specifically identified within the PWS

Treatment under this contract is intended solely to correct conditions necessary to transition Soldiers from Dental Class 3 to Dental Class 2 status and improve deployability. Treatment selection shall prioritize the most clinically appropriate and cost-effective method to maximize readiness capability within available funding limitations.

(end PWS) PERFORMANCE WORK STATEMENT – MEDICAL and DENTAL READINESS – Oct 2009