36C10G18R0208-1-0007002.pdf

Term Definition

Active Veteran A Veteran who has a Community Care claim paid by the Contractor during the billing month.

Affiliates

Associated business concerns or individuals if, directly or indirectly—

(1) Either one controls or can control the other; or

(2) A third-party controls or can control both

Ancillary Provider Providers who perform diagnostic or therapeutic services as an adjunct to basic medical or surgical services.

Approved Referral

Department of Veterans Affairs (VA)-Approved Referral constitutes an order under this contract. Approved Referrals from VA will support a specific plan of care as it relates to a specified number of visits and/or services related to a Standard Episode of Care as long as the services are provided by a Community Care Network (CCN) provider.

Assisted Reproductive Technology

Assisted Reproductive Technology services (ART), including in-vitro fertilization (IVF), for Veterans with a service-connected (SC) condition

Average Speed of Answer

The average time it took for a call to be answered by an agent from when the caller first selected the option to speak to an agent. Does NOT include abandoned calls.

Blockage Rates The percentage of callers that received a busy tone when they called.

Call Abandonment Rates

The percentage of contacts that spent time waiting to speak to an agent and then hung-up or otherwise exited the system before being offered to an agent. These calls are not resolved in the Interactive Voice Response (IVR).

Catchment Area The geographical area served by a Department of Veterans Affairs (VA) Facility.

Claim

An invoice for healthcare, dental or pharmacy services submitted to the Contractor from in-network or out-of-network providers. This term also includes a request for payment of healthcare, dental or pharmacy services from the Contractor to VA. As used in the Performance Work Statement (PWS), this term does not include the meaning of the term “claim” as defined in FAR 2.101.

Clean Claim A claim that contains all the required data elements necessary for adjudication without requesting supplemental information from the submitter.

CMS Place of Service code 17

A walk-in health clinic, other than: office, urgent care facility, pharmacy or independent clinic and not described by any other Place of Service code, that is located within a retail operation and provides, on an ambulatory basis, preventive and primary care services.

CMS Place of Service code 20

Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.

Collateral of Veteran A Collateral of Veteran is related to or associated with an eligible Veteran receiving care from the Department of Veterans Affairs (VA) for reasons relating to the Veteran's clinical care (e.g. ART).

Community Care Network (CCN)

Community Care Network (CCN) contracts to be awarded across specified regions to provide a network of licensed healthcare providers and practitioners for medical, surgical, complementary and integrative health services (CIHS), durable medical equipment (DME), pharmacy, and dental services. This acquisition is for one of those CCN regions. Once implemented contracts will be the preferred method of obtaining care from community providers

Complaint Any expression of an actual or perceived issue.

Community Care Contact Center (VA)

The Community Care Contact Center, established by VHA Office of Community Care, to address customer service issues.

Contractor team members

An arrangement in which—

(1) Two or more companies form a partnership or joint venture to act as a potential prime contractor; or

(2) A potential prime contractor agrees with one or more other companies to have them act as its subcontractors under a specified Government contract or acquisition program.

Critical Finding Those findings or results that require immediate evaluation by a healthcare provider such that failure to take immediate appropriate action might result in death, significant morbidity, or serious adverse consequences to the Veteran.

Data Access Service VA approved secure data transfer system

Days

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.

Durable Medical Equipment (DME)

Equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of an illness or injury, and is appropriate for use in the home.

Electronic Messaging Any one on one communications leveraging technology. Could include online/instant messaging, secure email, or similar capabilities.

Eligible Veteran Any Veteran who is eligible to receive care in the community.

Emergent Care

Medical care required within twenty-four hours or less essential to evaluate and stabilize conditions of an emergent need that if not provided may result in unacceptable morbidity/pain if there is significant delay in the evaluation or treatment. Emergent and emergency can be used interchangeably and has the same meaning throughout the PWS.

Emergent Need Conditions of one’s health that may result in the loss of life, limb, vision, or result in unacceptable morbidity/pain when there is significant delay in evaluation or treatment.

Enrolled Veteran Any Veteran who is enrolled in VA’s patient enrollment system and is eligible to receive healthcare benefits.

Expired Approved Referral An Approved Referral that has passed the end date.

First Call Resolution The percentage of calls where the agent resolves the caller’s issue without escalating, transferring, or returning the call.

First Tier Subcontract

First-tier subcontractor is a company with a direct contractual relationship with the Offeror whose total contract price exceeds $200,000,000 for all option periods or a subcontractor who performs claims processing, operates a call center or has a direct responsibility for managing or directing the dental care services.

Full Healthcare Delivery (HCD)

Total healthcare delivery of all CCN services at all sites or locations within the awarded CCN Region.

Grievance A written Complaint on an actual or perceived issue

Highly Rural Care Area

Any Highly Rural Location, any Critical Access Hospital or any geographic location that necessitates a reimbursement greater than Medicare rates in order to maintain network adequacy.

Highly Rural Location Defined as a sparsely populated area located in a county that has fewer than seven individuals residing in that county per square mile.

Individual Entity An individual entity is a business type that is treated as a separate legal entity. This usually refers to corporations.

Joint Venture

Two or more businesses joining together under a contractual agreement to conduct a specific business enterprise with both parties sharing profits and losses. A joint venture is a separate legal entity, must have a separate DUNS number, and shall be separately registered in the SAM at time of proposal submission and time of award.

Julian Date The continuous count of days since the beginning of the calendar year; January 1st being “1” and December 31st being day “365”.

Medical Device

An instrument, apparatus, implement, machine, contrivance, or other similar or related article, including a component part or accessory, which is intended for use in the cure, mitigation, or treatment of disease or compensates for a person’s loss of mobility or other bodily functional abilities and function as a direct and active component of the person’s treatment and rehabilitation.

Non-service Connected Care

Medical care and services provided for a Veteran for an illness or injury that was not incurred in or aggravated by military service as determined by VA.

Ordering Officer

A VA employee, delegated in writing by the Contracting Officer (CO), to order services under the contract via issuance of Approved Referrals (in Section B.14, and PWS sections 4.0 and 7.0). There are two types of Ordering Officers under this contract: 1. Designated Ordering Officers with Routine referral authority and

2. Designated Ordering Officers with Elevated referral authority. Designated Ordering Officers with Routine referral authority may purchase all care under this contract, except for services identified in Section 7.4 of the PWS. Designated Ordering Officers with Elevated referral authority may purchase all care under this contract, to include those services specified in Section 7.4 of the PWS.

Parent Company

A parent company is a company that controls other, smaller businesses by owning an influential amount of voting stock or control. Parent companies are typically larger firms that exhibit control over one or more small subsidiaries in either the same industry or complimentary industries.

Per Member Per Month

This metric refers to the cost or price of care per month. Note that this request for proposal uses a slightly different definition when it asks for a per member per month price. For this procurement it is only for the price or average cost for those months where a veteran receives care, i.e., “active Veteran months.” In industry it is common to compute the PMPM by taking the total cost over a year and dividing by 12. Here the Contractor will only be reimbursed for active veteran months. It is projected that in FY19 there will be 1,488, 503 active Veterans month charged by 492, 661 enrolled Veterans, a ratio of 3.97, i.e., on average a Veteran has monthly billable invoice 4 times a year and the active Veteran PMPM may need to be (12/3=4) times higher than the industry PMPM for offeror to recoup their costs.

Primary Care Healthcare at a basic rather than a specialty level.

Prior Authorization

A required process through which VA reviews and approves certain medical services to ensure the medical necessity and appropriateness of care prior to services being rendered within a specified timeframe from a non-VA provider or additional resources in the community. This type of process requires Prior Authorization be obtained “prior to” the specified service.

Referral Request

A request and approval process that authorizes the Veteran to obtain specified care within a specified timeframe from additional resources in the community. Upon approval, a referral number is generated. The referral number must always be included on claims submitted by CCN providers for payment.

Residential Facility

A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board

Response Accuracy

The percentage of calls where the response provided by the Call Center is accurate and complete according to the terms of the contract. One mechanism for tracking this is the use of an automated survey at the end of the communication with the customer service representative session.

Root Cause Analysis A process or procedure that helps guide people to discover and understand the initiating causes of a problem, with the goal of determining missing or inadequately applied controls that will prevent recurrence.

Rural Areas not designed as Urban or Highly Rural Location.

Scarce Medical Services

A scarce medical resource is defined as any health care examination or treatment that has significantly reduced access due to geographic location, lack of providers to support patient demand, lack of equipment or technology to provide necessary services, or any other factors negatively impacting access regardless of geographic designation, i.e., urban, rural, or highly rural.

Service Availability Services and applications being available, whether it is during abnormal system operation or software upgrade regardless of hardware or software failure.

Service Connected Care

Medical care and services provided for a Veteran for a Service-Connected (SC) condition is an illness or injury adjudicated by the Veterans Benefits Administration (VBA) as having been incurred or aggravated in line of duty in the active military, naval, or air service.

Service Unavailability “Service Unavailability” consists of the number of hours that the systems were not available. Calculation of Service Unavailability must not include any time the service is unavailable due to scheduled maintenance.

Shall Must always

Site The entire Catchment Area of a specific VA Facility, as identified by VA.

Solution All components of the Contractor’s response and planned execution of the High Performing Network, claims processing, medical administrative management, customer service, and technology components.

Specialty Care All other care and services offered under VA Health Benefit Package other than Primary Care and complementary and integrative health services (CIHS).

Standardized Episode of Care

A set of clinically related healthcare services for a specific unique illness or medical condition (diagnosis and/or procedure) provided by an authorized provider during a defined authorized period of time not to exceed one year.

Start of Healthcare Delivery (SHCD)

The beginning of healthcare delivery at a site or location within the awarded CCN Region.

State One of the fifty (50) states of the United States, District of Columbia, U.S. Virgin Islands, Puerto Rico, Northern Mariana Islands, Guam, and American Samoa.

Subcontractor Any person, other than the prime contractor, who offers to furnish or furnishes any supplies, materials, equipment, or services of any kind under a prime contract or a subcontract entered into in connection with such prime contract.

Subsidiary

A subsidiary, subsidiary company or daughter company is a company that is owned or controlled by another company, which is called the parent company, parent, or holding company. The subsidiary can be a company, corporation, or limited liability company. In some cases it is a government or state-owned enterprise.

Tribal Health Services Tribal health programs are defined as services contracted by tribes, from the Indian Health Service, through the authority of Public Law 93-638 (the Indian Self Determination and Education Assistance Act).

Urban Census tracts with at least thirty (30) percent of the population residing in an urbanized area as defined by the Census Bureau.

Urgent Care Provision of immediate medical service offering outpatient care for the treatment of acute and chronic illness or injury.

Urgent Walk-In Care Provision of immediate medical service offering outpatient care for the treatment of episodic care, including therapeutic vaccines and flu shots and not longitudinal management of conditions or Preventive Health Services.

VHA Office of Community Care

(OCC)

VHA office designated to support CCN Region under this contract.

VA Facility A VA Facility is a VA Hospital or VA Medical Center.

VA Hospital A VA hospital is any VA-owned, staffed, and operated facility providing acute inpatient and/or rehabilitation services.

Warm Transfer When the agent who is currently speaking with the caller (and wishes to transfer them) speaks with the new agent before the call is transferred and introduces the caller to the new agent.

Work Breakdown Structure

A hierarchical decomposition that organizes work into manageable portions of the total scope of work to be carried out to accomplish the project objectives.