36C10G20R0014-014.xlsx
XLSX spreadsheet Posted
- Solicitation number
- 36C10G20R0014
About this file
This pre-solicitation notice announces the Department of Veterans Affairs' intent to issue a solicitation for a Community Care Network contractor to provide medical, surgical, complementary and integrative services, durable medical equipment, pharmacy, and dental services to eligible Veterans in Alaska.
The contractor will be required to establish and maintain a network of licensed health providers to deliver these services, provide exemplary customer service, monitor and manage quality outcomes, use data and performance metrics to improve services, and process and pay claims. The government will award a single-source IDIQ contract for a 9-month base period and seven 1-year options to serve as a third-party administrator with responsibility for managed healthcare services. The anticipated solicitation posting date on beta.sam.gov is May 11, 2020, with offers due on June 1, 2020. Respondents must be registered in SAM under NAICS code 524292 for third-party administration of insurances and pension funds.
36C10G20R0014 CCN Region 5 Attachment U - Data Specification.xlsx
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Table of Contents
| Attachment U - Data Specifications - Version 010 |
| Region 5 |
| Table of Contents |
| Date Last Modified: | 2/3/20 |
| Date Approved: | 2/3/20 |
| NOTE: This attachment contains the view of the reports and their corresponding PWS reference. Where the report is to be transferred to VA via the VA DAS Portal, the word 'VA DAS (via ETL Feed)' is included in the Deliverable Delivery column on the Table of Contents and on the top row of the report along with the report PWS Reference. Electronic Transfer Load (ETL) feed is the method in which the data content is transferred. VA DAS is the how the data (ETL Feed) will come to VA. If an alternate method of transmission is required, then the words "Other Than VA DAS" are included in the top row of the report along with the report PWS Reference. The exact data specification for the fields in the report will be provided within 30 days of contract award. |
| Legend |
| Deliverables not slated for VA DAS are marked in RED to differentiate them and the tab labels are also in RED for easy detection. |
| System marked in PURPLE is to help differentiate from primary system listed |
| Below is the complete Table of Content for this attachment: |
| Tab Name | Item | PWS Task | ID | Deliverable Description | Deliverable Delivery | Cadence of Delivery | End System (where applicable) |
| 21 HPP Qual & Perf - Individ | 21 | 3.4 | B | High Performing Provider Quality and Performance Data | VA DAS (via ETL Feed) | Quarterly | EPRS |
| 21 HPP Qual & Perf - Group | 21 | 3.4 | B | High Performing Provider Quality and Performance Data | VA DAS (via ETL Feed) | Quarterly | EPRS |
| 21 HPP Qual & Perf - Institut | 21 | 3.4 | B | High Performing Provider Quality and Performance Data | VA DAS (via ETL Feed) | Quarterly | EPRS |
| 23 Net Adq Geo Access | 23 | 3.6 | B | Network Adequacy Performance Report | VA DAS (via ETL Feed) | Monthly | EPRS |
| 23 Net Adq Timeliness | 23 | 3.6 | B | Network Adequacy Performance Report | VA DAS (via ETL Feed) | Monthly | EPRS |
| 29 CCN Prov Satisf Srvy Reslts | 29 | 6.7 | A | CCN Provider Satisfaction Survey Results | VA DAS (via ETL Feed) | 60 days following conclusion of the survey quarter | EPRS |
| 30 CS Technology Report | 30 | 6.8 | A | Contractor Call Center Operations and Customer Service Technology Performance Report | VA DAS (via ETL Feed) | Monthly | EPRS |
| 30 CS Complaints Inquiries | 30 | 6.8 | A | Contractor Call Center Operations and Customer Service Technology Performance Report | VA DAS (via ETL Feed) | Monthly | EPRS |
| 30 CS Congressional Inq | 30 | 6.8 | A | Contractor Call Center Operations and Customer Service Technology Performance Report | VA DAS (via ETL Feed) | Monthly | EPRS |
| 35 Training Material | 35 | 10.2 | B | Review of Training Materials Report | Other than VA DAS | Annually | Secure Email |
| 54 Qtrly Cst Avd Ovpymts | 54 | 12.9 | A | Quarterly Cost Avoidance and Recovery/Recoupment Report | Other than VA DAS | Quarterly | Secure Email |
| 54 Qtrly Cst Avd Undpymts | 54 | 12.9 | A | Quarterly Cost Avoidance and Recovery/Recoupment Report | Other than VA DAS | Quarterly | Secure Email |
| 54 Qtrly Cst Avd Summary | 54 | 12.9 | A | Quarterly Cost Avoidance and Recovery/Recoupment Report | Other than VA DAS | Quarterly | Secure Email |
| 54 Qtrly Cst Avd Audit | 54 | 12.9 | A | Quarterly Cost Avoidance and Recovery/Recoupment Report | Other than VA DAS | Quarterly | Secure Email |
| 58 Wkly Claims Procssng | 58 | 12.12 | B | Weekly Claims Processing Report | VA DAS (via ETL Feed) | Weekly | EPRS |
| 59 Qtrly Claims Audit Report | 59 | 12.12 | C | Quarterly Claims Audit Report | VA DAS (via ETL Feed) | Quarterly | EPRS |
| 60 Qtrly Audit & RC IPERA 1 | 60 | 12.14.2 | A | Quarterly IPERA Audit & Root Cause (Recovery for IPERA 1) | VA DAS (via ETL Feed) | Quarterly | EPRS |
| 60 Qtrly RC Projections IPERA 1 | 60 | 12.14.2 | A | Quarterly IPERA Audit & Root Cause (IPERA 1) | VA DAS (via ETL Feed) | Quarterly | EPRS |
| 65 Overpymt Elec File IPERA 2 | 65 | 12.14.6 | F | Overpayments Electronic File (IPERA 2) | VA DAS (via ETL Feed) | 10 days after the stated audit cycle | EPRS |
| 65 OvUndpymt Elec File IPERA 1 | 65 | 12.14.6 | F | Overpayments/Underpayments Electronic File (IPERA 1) | VA DAS (via ETL Feed) | Quarterly | EPRS |
| 68 Clinical Quality | 68 | 14.2 | A | Quarterly Clinical Quality and Patient Safety Issues Report | VA DAS (via ETL Feed) | Quarterly | EPRS |
| 69 70 73 74 Pharmacy | 69 | 15.1 | A | Monthly Electronic Urgent/Emergent Prescription Report | VA DAS (via ETL Feed) | Monthly | EPRS |
| 69 70 73 74 Pharmacy | 70 | 15.1 | B | Monthly Electronic Prior Authorization Report (to include Continued Need Justifications) | VA DAS (via ETL Feed) | Monthly | EPRS |
| 69 70 73 74 Pharmacy | 73 | 15.2.1 | A | Monthly Urgent/Emergent Prescription Performance Metrics Report | VA DAS (via ETL Feed) | Monthly | EPRS |
| 69 70 73 74 Pharmacy | 74 | 15.4 | A | Electronic Disaster Response Prescription Report | VA DAS (via ETL Feed) | Monthly | EPRS |
| 76 COO Report | 76 | 18.2 | B | Continuity of Operations Report | VA DAS (via ETL Feed) | Monthly after SHCD | EPRS |
| 77 78 Network Provider File | 77 | 18.15.1 | A | Network Provider File | VA DAS (via ETL Feed) | At the kickoff meeting | PPMS |
| 77 78 Network Provider File | 78 | 18.15.1 | B | Network Provider Change File | VA DAS (via ETL Feed) | Weekly after the initial, full Network Provider File up until HCD; Post HCD every two (2) – four (4) weeks as directed by the Contracting Officer | PPMS |
| 83 Monthly Data Integrity | 83 | 19.5 | A | Monthly Data Integrity Report | VA DAS (via ETL Feed) | Monthly | EPRS |
R4_v1_Status IDA STAFF ONLY
| Version 010 Modification Status | |||||||||||||||
| 2/3/20 | |||||||||||||||
| Table 1: Table of Content | |||||||||||||||
| Tab Name | Item | PWS Task | ID | Deliverable Description | Deliverable Delivery | Cadence of Delivery | End System (where applicable) | BO Signed | CCCA Signed | End System Signed | System | IDA Signed | Modification Review Status | Next Step | Comment |
| 21 HPP Qual & Perf - Individ | 21 | 3.4 | B | High Performing Provider Quality and Performance Data | VA DAS (via ETL Feed) | Monthly | EPRS | 12/17/19 | 1/24/20 | 1/30/20 | EPRS | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 21 HPP Qual & Perf - Group | 21 | 3.4 | B | High Performing Provider Quality and Performance Data | VA DAS (via ETL Feed) | Monthly | EPRS | 12/17/19 | 1/24/20 | 1/30/20 | EPRS | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 21 HPP Qual & Perf - Institut | 21 | 3.4 | B | High Performing Provider Quality and Performance Data | VA DAS (via ETL Feed) | Monthly | EPRS | 12/17/19 | 1/24/20 | 1/30/20 | EPRS | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 23 Net Adq Geo Access | 23 | 3.6 | B | Network Adequacy Performance Report | VA DAS (via ETL Feed) | Monthly | EPRS | 1/10/20 | 1/24/20 | 1/30/20 | EPRS | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 23 Net Adq Timeliness | 23 | 3.6 | B | Network Adequacy Performance Report | VA DAS (via ETL Feed) | Monthly | EPRS | 1/10/20 | 1/24/20 | 1/30/20 | EPRS | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 29 CCN Prov Satisf Srvy Reslts | 29 | 6.7 | A | CCN Provider Satisfaction Survey Results | VA DAS (via ETL Feed) | 60 days follwing conclusion of the survey quarter | EPRS | 1/7/20 | 1/24/20 | 1/30/20 | EPRS | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 30 CS Technology Report | 30 | 6.8 | A | Contractor Call Center Operations and Customer Service Technology Performance Report | VA DAS (via ETL Feed) | Monthly | EPRS | 12/11/19 | 1/24/20 | 1/30/20 | EPRS | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 30 CS Complaints Inquiries | 30 | 6.8 | A | Contractor Call Center Operations and Customer Service Technology Performance Report | VA DAS (via ETL Feed) | Monthly | EPRS | 12/11/19 | 1/24/20 | 1/30/20 | EPRS | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 30 CS Congressional Inq | 30 | 6.8 | A | Contractor Call Center Operations and Customer Service Technology Performance Report | VA DAS (via ETL Feed) | Monthly | EPRS | 12/11/19 | 1/24/20 | 1/30/20 | EPRS | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 35 Training Material | 35 | 10.2 | B | Review of Training Materials Report | Other than VA DAS | Annually | Secure Email | 1/15/20 | 1/24/20 | 2/3/20 | COR | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 39 Appt Sch & Comp Care | 39 | 11.1.4 | C | Appointment Scheduling and Comprehensive Care Coordination Adequacy Performance Report | VA DAS (via ETL Feed) | Monthly | EPRS | Will be included on the Attachment version once officially approved via contract modification | CONTRACT MOD NEEDED: Per RFP this is to be reported on Attachment W not Attachment U, which would NOT go to EPRS. Report layout developed | ||||||
| 41 Daily Appts & Sch Comp Care | 41 | 11.1.4 | E | Daily Appointment and Scheduling Comprehensive Care Coordination Report | VA DAS (via ETL Feed) | Daily | EPRS | Will be included on the Attachment version once officially approved via contract modification | CONTRACT MOD NEEDED: Per RFP this is to be reported on Attachment W not Attachment U, which would NOT go to EPRS. Report layout developed | ||||||
| 43 Daily Care Coord FollowUp | 43 | 11.2 | B | Daily Care Coordination Follow-Up Report | VA DAS (via ETL Feed) | Daily | EPRS | Will be included on the Attachment version once officially approved via contract modification | CONTRACT MOD NEEDED: Per RFP this is to be reported on Attachment W not Attachment U, which would NOT go to EPRS. Report layout developed | ||||||
| 45 Comp Case Mgmt Prog | 45 | 11.3 | B | Comprehensive Case Management Progress Report | VA DAS (via ETL Feed) | Monthly | EPRS | Will be included on the Attachment version once officially approved via contract modification | No Report layout created | ||||||
| 47 Comp Disease Mgmt Prog | 47 | 11.4 | B | Comprehensive Disease Management Progress Report | VA DAS (via ETL Feed) | Monthly | EPRS | Will be included on the Attachment version once officially approved via contract modification | No Report layout created | ||||||
| 54 Qtrly Cst Avd Ovpymts | 54 | 12.9 | A | Quarterly Cost Avoidance and Recovery/Recoupment Report | Other than VA DAS | Quarterly | Secure Email | 1/29/20 | 1/30/20 | 2/3/20 | COR | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 54 Qtrly Cst Avd Undpymts | 54 | 12.9 | A | Quarterly Cost Avoidance and Recovery/Recoupment Report | Other than VA DAS | Quarterly | Secure Email | 1/29/20 | 1/30/20 | 2/3/20 | COR | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 54 Qtrly Cst Avd Summary | 54 | 12.9 | A | Quarterly Cost Avoidance and Recovery/Recoupment Report | Other than VA DAS | Quarterly | Secure Email | 1/29/20 | 1/30/20 | 2/3/20 | COR | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 54 Qtrly Cst Avd Audit | 54 | 12.9 | A | Quarterly Cost Avoidance and Recovery/Recoupment Report | Other than VA DAS | Quarterly | Secure Email | 1/29/20 | 1/30/20 | 2/3/20 | COR | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 58 Wkly Claims Procssng | 58 | 12.12 | B | Weekly Claims Processing Report | VA DAS (via ETL Feed) | Weekly | EPRS | 1/13/20 | 1/24/20 | 1/30/20 | EPRS | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 59 Qtrly Claims Audit Report | 59 | 12.12 | C | Quarterly Claims Audit Report | VA DAS (via ETL Feed) | Quarterly | EPRS | 1/13/20 | 1/24/20 | 1/30/20 | EPRS | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 60 Qtrly Audit & RC IPERA 1 | 60 | 12.14.2 | A | Quarterly IPERA Audit & Root Cause (Recovery for IPERA 1) | VA DAS (via ETL Feed) | Quarterly | EPRS | 12/27/19 | 1/24/20 | 1/30/20 | EPRS | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 60 Qtrly RC Projections IPERA 1 | 60 | 12.14.2 | A | Quarterly IPERA Audit & Root Cause (IPERA 1) | VA DAS (via ETL Feed) | Quarterly | EPRS | 12/27/19 | 1/24/20 | 1/30/20 | EPRS | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 65 Overpymt Elec File IPERA 2 | 65 | 12.14.6 | F | Overpayments Electronic File (IPERA 2) | VA DAS (via ETL Feed) | 10 days after the stated audit cycle | EPRS | 1/16/20 | 1/24/20 | 1/30/20 | EPRS | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 65 OvUndpymt Elec File IPERA 1 | 65 | 12.14.6 | F | Overpayments/Underpayments Electronic File (IPERA 1) | VA DAS (via ETL Feed) | Quarterly | EPRS | 1/16/20 | 1/24/20 | 1/30/20 | EPRS | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 68 Clinical Quality | 68 | 14.2 | A | Quarterly Clinical Quality and Patient Safety Issues Report | VA DAS (via ETL Feed) | Quarterly | EPRS | 12/17/19 | 1/24/20 | 1/30/20 | EPRS | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 69 70 73 74 Pharmacy | 69 | 15.1 | A | Monthly Electronic Urgent/Emergent Prescription Report | VA DAS (via ETL Feed) | Monthly | EPRS | 1/15/20 | 1/24/20 | 1/30/20 | EPRS | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 69 70 73 74 Pharmacy | 70 | 15.1 | B | Monthly Electronic Prior Authorization Report (to include Continued Need Justifications) | VA DAS (via ETL Feed) | Monthly | EPRS | 1/15/20 | 1/24/20 | 1/30/20 | EPRS | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 69 70 73 74 Pharmacy | 73 | 15.2.1 | A | Monthly Urgent/Emergent Prescription Performance Metrics Report | VA DAS (via ETL Feed) | Monthly | EPRS | 1/15/20 | 1/24/20 | 1/30/20 | EPRS | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 69 70 73 74 Pharmacy | 74 | 15.4 | A | Electronic Disaster Response Prescription Report | VA DAS (via ETL Feed) | Monthly | EPRS | 1/15/20 | 1/24/20 | 1/30/20 | EPRS | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 71 Opioid Prescriptions Summary | 71 | Discussion that this may not be apart of Attachment U. Layout developed but not reviewed | |||||||||||||
| 76 COO Report | 76 | 18.2 | B | Continuity of Operations Report | VA DAS (via ETL Feed) | 30 days after SHCD then monthly | EPRS | 12/17/19 | 1/24/20 | 1/30/20 | EPRS | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 77 78 Network Provider File | 77 | 18.15.1 | A | Network Provider File | VA DAS (via ETL Feed) | Daily | PPMS | 1/21/20 | 1/24/20 | 2/3/20 | PPMS | 2/3/20 | Complete | No further action | Approved 2/3/2020; Trying to Remove from Attachment U, contract modification needed |
| 77 78 Network Provider File | 78 | 18.15.1 | B | Network Provider Change File | VA DAS (via ETL Feed) | Daily | PPMS | 1/21/20 | 1/24/20 | 2/3/20 | PPMS | 2/3/20 | Complete | No further action | Approved 2/3/2020; Trying to Remove from Attachment U, contract modification needed |
| 83 Monthly Data Integrity | 83 | 19.5 | A | Monthly Data Integrity Report | VA DAS (via ETL Feed) | Monthly | EPRS | 12/23/19 | 1/24/20 | 1/30/20 | EPRS | 2/3/20 | Complete | No further action | Approved 2/3/2020 |
| 86 Annual PMPM Recon Report | 86 | G.15 | 1.4 | Annual PMPM Reconciliation Report | VA DAS (via ETL Feed) | Annually | EPRS and CCRS | Will be included on the Attachment version once layout created and approved | No Report layout created |
Change Mgmt IDA STAFF ONLY Change Management for Attachment U - Region 4
| NOTE: This tab may only be changed by a VA IDA staff only |
| Last modified date: 2/3/2020 |
Version v010
| Change Request | 1 |
| Date Changed | 11/5/19 |
| Tab Name | All tabs |
| Type of Modification | Retitle tabs |
| Modification Description | Retitled all tabs to meet Region 4 deliverable numbers |
| Change Request | 2 |
| Date Changed | 11/5/19 |
| Tab Name | Remove Medical Documentation tab |
| Type of Modification | Removal of tab |
| Modification Description | Removed all data elements and the complete tab that referenced a medical documentation report. Per the CORs this is not a requirement under Region 4 |
| Change Request | 3 |
| Date Changed | 11/5/19 |
| Tab Name | Remove OHI Report tab |
| Type of Modification | Removal of tab |
| Modification Description | Removed all data elements and the complete tab that referenced a OHI report. Report layout will be refernced under the Enrollment System Core (ESC) Interface Control Document (ICN) which is managed by the ES PM and staff |
| Change Request | 4 |
| Date Changed | 11/5/19 |
| Tab Name | Table of Content |
| Type of Modification | Rename and Removal |
| Modification Description | Renamed and removed appropriate deliverables to ensure they meet the RFP for Region 4 |
| Change Request | 5 |
| Date Changed | 1/30/20 |
| Tab Name | All tabs |
| Type of Modification | Complete Layout |
| Modification Description | All necessary modifications made to finalize layout. Layout has been signed off by BO, CCCA and most Systems. Still pending finalization. |
| Change Request | 6 |
| Date Changed | 1/30/20 |
| Tab Name | N/A |
| Type of Modification | File Version format |
| Modification Description | Approved to have a 3 digit version number. Therefore file was renamed from v1 to v010 to be in compliance wth format |
| Date Version 010 Sent to CCCA: 2/3/2020 |
21 HPP Qual & Perf - Individ
| Item | PWS Task | ID | Deliverable Description | Deliverable Delivery | Date Report Approved: | 2/3/20 |
| 21 | 3.4 | B | High Performing Provider Quality and Performance Data | VA DAS (via ETL Feed) | Date Report Last Modified: | 2/3/20 |
REGION 5 - Version 010
| Section 3.4 High Performing Provider Quality & Performance Data Report (Individual Provider) | |||||||||
| Column Header Title | Name | Address | City | State | Zip | Individual Provider NPI | Threshold | Overall Score | HPP Designation |
| Data Description | Provider full name Format: Last Name, First Name Middle Initial | Individual Provider Address | Individual Provider City | Individual Provider State | Individual Provider Zip | Provide the NPI of the rendering provider | Provide the individual provider's total threshold z-score for HPP measures listed in Attachment G | Provide the individual provider's overall z-score for HPP measures listed in Attachment G | Provide the assigned HPP designation: Y, N or U |
21 HPP Qual & Perf - Group
| Item | PWS Task | ID | Deliverable Description | Deliverable Delivery | Date Report Approved: | 2/3/20 |
| 21 | 3.4 | B | High Performing Provider Quality and Performance Data | VA DAS (via ETL Feed) | Date Report Last Modified: | 2/3/20 |
REGION 5 - Version 010
| Section 3.4 High Performing Provider Quality & Performance Data Report (Group Provider) | |||||||||
| Column Header Title | Name | Address | City | State | Zip | Group Provider NPI | Threshold | Overall Score | HPP Designation |
| Data Description | Provider Group Name | Group Provider Address | Group Provider City | Group Provider State | Group Provider Zip | NPI of the organization where the care was provided | Provide the group provider's total threshold z-score for HPP measures listed in Attachment G | Provide the group provider's overall z-score for HPP measures listed in Attachment G | Provide the assigned HPP designation: Y, N or U |
21 HPP Qual & Perf - Institut
| Item | PWS Task | ID | Deliverable Description | Deliverable Delivery | Date Report Approved: | 2/3/20 |
| 21 | 3.4 | B | High Performing Provider Quality and Performance Data | VA DAS (via ETL Feed) | Date Report Last Modified: | 2/3/20 |
REGION 5 - Version 010
| Section 3.4 High Performing Provider Quality & Performance Data Report (Institution) | |||||||||
| Column Header Title | Name | Address | City | State | Zip | Institution TIN | Threshold | Overall Score | CoE Designation |
| Data Description | Institution Name | Institution Provider Address | Institution City | Institution State | Institution Zip | TIN number of the institution | Provide the institution's total threshold z-score for CoE measures listed in Attachment G | Provide the institution's overall z-score for CoE measures listed in Attachment G | Provide the assigned CoE designation: Y, N or U |
23 Net Adq Geo Access
| Item | PWS Task | ID | Deliverable Description | Deliverable Delivery | Date Report Approved: | 2/3/20 |
| 23 | 3.6 | B | Network Adequacy Performance Report | VA DAS (via ETL Feed) | Date Report Last Modified: | 2/3/20 |
REGION 5 - Version 010
Section 3.6 Network Adequacy Performance Report
| Column Header Title | Period covered by report | Type of Service | Rurality | Facility Station Number and Name | Number of Claims | Avg Drive Time | Avg Miles | Approved deviations from adequacy standards | Percentage of claims that met adequacy standards |
| Data Description | Period of the report is the reporting month and year, which is based on the first claim associated with the referral (claim date) Date Format: YYYYMM | Type of service: QASP Categories are Healthcare Services (Primary Care, General Care), Complementary and Integrative Services, Dental (General, Specialty) and Pharmacy. Provide a summary level roll up by QASP category. | Provide the rurality based on Veteran's home/residence zip code. Rurality is defined as Urban, Rural or Highly Rural | Provide Station number and name associated with data | Number of claims per Service type, per Rurality | Provide the average drive time per service type, per rurality. NOTE: This data is not applicable to Pharmacy service type | Provide the average miles per service type, per rurality. NOTE: This data is only applicable to Pharmacy service type | Provide the number of approved deviations | Percentage of claims that met Geo Accessibility standards |
| EXAMPLE | 201810 | primary | urban | 554 | 10 | 25 | n/a | 0 | 0.99 |
| 201810 | general | highly | 554 | 5 | 15 | n/a | 2 | 0.75 | |
| 201810 | dental | rural | 554 | 17 | 36 | n/a | 1 | 0.83 |
23 Net Adq Timeliness
| Item | PWS Task | ID | Deliverable Description | Deliverable Delivery | Date Report Approved: | 2/3/20 |
| 23 | 3.6 | B | Network Adequacy Performance Report | VA DAS (via ETL Feed) | Date Report Last Modified: | 2/3/20 |
REGION 5 - Version 010
Section 3.6 Network Adequacy Performance Report
| Column Header Title | Period covered by report | Service Type | Facility Station Number and Name | Appointment Type | # Claims | Avg Timeliness | Approved deviations from adequacy standards | Percentage of claims that met adequacy standards |
| Data Description | Period of the report is the reporting month and year, which is based on the first claim associated with the referral (claim date) Date Format: YYYYMM | Type of service - QASP Categories are Primary Care, General Care, Complementary and Integrative Services, Dental and Pharmacy | Provide Station number and name associated with data | Appointment type: Select appropriate category - Routine, Urgent, Emergent | Number of claims per Service type, per Appointment type | Average appointment availability to evaluate wait times, calculated using the date the referral is sent to provider from VA and actual appointment date on the first claim associated with that referral; | Provide the number of approved deviations | Percentage of claims that met timeliness standards |
| EXAMPLE | 201810 | Primary Care | 554 | Emergent | 100 | 32 | 0 | 0.75 |
29 CCN Prov Satisf Srvy Reslts
| Item | PWS Task | ID | Deliverable Description | Deliverable Delivery | Date Report Approved: | 2/3/20 |
| 29 | 6.7 | A | CCN Provider Satisfaction Survey Results | VA DAS (via ETL Feed) | Date Report Last Modified: | 2/3/20 |
REGION 5 - Version 010
Section 6.7 Provider Satisfaction Survey
| Group Header Title | Customer Service | Clinical Documentation | Billing and Payments/ General | Billing and Payments/ Problems and Complaints | Experience when providing care to Veterans under contractual relations | Satisfaction with CCN Contractor | Training | Provider Details | ||||||||||||||||||||||||
| Column Header Title | Majority of Customer Service Questions | Courteousness of Customer Service | Customer Service was knowledgeable | Customer Service Accessibility | Satisfaction/dissatisfaction with telephone customer service | Satisfaction/dissatisfaction with website customer service | HealthShare Referral Manager used | Ease of Use of HealthShare Referral Manager | Ease of Use of HealthShare Referral Manager description | Billing Process to CCN Contractor | Timeliness of payment to Contractor | EOB explanation | EOB clarity | EOB Accounts Receivable reconciliation | CCN Contractor Problems or complaints | Timeliness of resolution of problems or complaint | Detail of timeliness | Effort to resolve Problem | Description | Service Provided | Ease of Service | Valuation of Customer | Commitment to Veterans | Contractor Satisfaction regarding CCN Program | Providing Care on behalf of VA using CCN program | Comments | Training Adequacy | Training Adequacy Details | Place of work | Occupation | Number of Veterans Provided Care | Geographic Area |
| Data Description | The majority of the interactions with customer service were questions around: |
Referral Payment Status
| Other | Interactions with the customer service department were courteous: | |||
| Customer service department had the knowledge to answer CCN Program related questions: | ||||
| Customer service department was adequately accessible for advice and assistance: | What is your level of satisfaction or dissatisfaction for responses to inquiries using telephone customer service? | What is your level of satisfaction or dissatisfactions for response to inquiries using website customer service? | Do you use the HealthShare Referral Manager (HSRM)? | |
| It was easy to use the HSRM: | ||||
| If HSRM ease of use was Rarely or Never, please describe issue(s) you had: | ||||
| I understand the billing process to submit claims to the CCN Contractor: | ||||
| Payments by the CCN Contractor for “clean claims” were issued within 30 days of receipt. | ||||
| The EOB I receive from the CCN Contractor fully explains the adjudication of the claim(s). | ||||
| The EOB I receive from the CCN Contractor is easy to understand. | ||||
| The EOB I receive from the CCN Contractor provides what I need to reconcile my Accounts Receivables. | ||||
| Have you experienced a problem with, or had a complaint about, the CCN Contractor? | ||||
| Problems or complaints with the CCN Contractor were resolved quickly. | ||||
| Problems or complaints were resolved within: | ||||
| Problems with the CCN Contractor were resolved with minimal effort on your part? | ||||
| Describe the problem(s) and how the problem(s) was resolved: | ||||
| I received the service I needed. | ||||
| It was easy to get the service I needed. | ||||
| I felt like a valued customer. | ||||
| I trust the CCN Contractor to fulfill our country’s commitment to Veterans. | ||||
| Overall, how satisfied are you with your interaction with CCN Contractor regarding the CCN Program? | ||||
| Will you continue to provide care to Veterans on behalf of VA using the CCN program? | ||||
| Is there anything you would like to share about your experience with the CCN Program or the CCN Contractor? | ||||
| I receive adequate training. | ||||
| If your answer is “Disagree” or “Strongly Disagree” what could be clarified: | ||||
| Where do you work? | ||||
| What is your occupation? |
| Within the last 3 months how many Veterans did you provide care for? |
| How would you describe the geographic area where you provide care? |
| Survey Result Options | Referral | Always | Always | Always | Very Satisfied | Very Satisfied | Yes | Always | Free Text | Always | Always | Always | Always | Always | Yes | Always | 0 to 3 days | Always | Free Text | Strongly Agree | Strongly Agree | Strongly Agree | Strongly Agree | Very Satisfied | Definitely Yes | Free Text | Strongly Agree | Payment Process | Independent Medical Office | Clinician | Fewer than 10 | Rural |
| Payment Status | Most of the time | Most of the time | Most of the time | Satisfied | Satisfied | No | Most of the Time | Most of the time | Most of the time | Most of the time | Most of the time | Most of the time | No | Most of the time | 4 to 7 days | Most of the time | Agree | Agree | Agree | Agree | Satisfied | Probably Yes | Agree | Referral/ Authorization Process | University Hospital | Office Manager or Office Staff | O - 39 | Urban | ||||
| Other | Sometimes | Sometimes | Sometimes | Somewhat Satisfied | Somewhat Satisfied | Unsure | Sometimes | Sometimes | Sometimes | Sometimes | Sometimes | Sometimes | Technical Note: If No, screen should skip user to the next sections, Overall Satisfaction) | Sometimes | 8 to 10 days | Sometimes | Neither Agree nor Disagree | Neither Agree nor Disagree | Neither Agree nor Disagree | Neither Agree nor Disagree | Somewhat Satisfied | Probably No | Neither Agree nor Disagree | Veteran Culture | Private Hospital | Billing and Accounts Receivable Personnel | 40-69 | Highly Rural | ||||
| Rarely | Rarely | Rarely | Somewhat Dissatisfied | Somewhat Dissatisfied | Technical Note: If No, screen should skip user to Billing and Payments | Rarely | Rarely | Rarely | Rarely | Rarely | Rarely | Rarely | 11 days or longer | Rarely | Disagree | Disagree | Disagree | Disagree | Somewhat Dissatisfied | Definitely No | Disagree | Other - If other please state what could be clarified: (Free text) | Other- Please Specify (free text) | Other- please specify (free text) | 70-99 | |||||||
| Never | Never | Never | Dissatisfied | Dissatisfied | Never | Never | Never | Never | Never | Never | Never | Never | Never | Strongly Disagree | Strongly Disagree | Strongly Disagree | Strongly Disagree | Dissatisfied | Not Sure | Strongly Disagree | 100 or more | |||||||||||
| Very Dissatisfied | Very Dissatisfied | Very Dissatisfied | Do not know |
30 CS Technology Report
| Item | PWS Task | ID | Deliverable Description | Deliverable Delivery | Date Report Approved: | 2/3/20 |
| 30 | 6.8 | A | Contractor Call Center Operations and Customer Service Technology Performance Report | VA DAS (via ETL Feed) | Date Report Last Modified: | 2/3/20 |
REGION 5 - Version 010
Section 6.8 - Contractor Call Center Operations and Customer Service Technology Performance Report
| Column Header Title | Blockage Rates | Call Abandon Rate | Average Speed of Answer | First Call Resolution | Congressional Inquiries Receipt and Response | Veteran Complaints and Grievances Receipt and Response | Customer Service Technology Availability Statistics | Reporting Period Start Date | Reporting Period End Date | |
| Data Description | The percentage of calls that attempt to access our IVR which are unsuccessful due to saturation of phone lines | The percentage of calls disconnected prior to reaching an agent once they have exited the IVR system | The total time it takes for a customer to speak to an agent after requesting one reported in min:sec | The percentage of calls whose issues are resolved the first time they are addressed by an agent | The number of Congressional inquiries received by the contractor and reported to VA | The number of issues that are escalated to Supervisors for resolution due to dissatisfaction from the customer | Percentage of time that agents are available to accept inbound calls AND web-based portal is available | Start Date | ||
| Date Format: MMDDYYYY | End Date |
Date Format: MMDDYYYY
EXAMPLE 0.01348 0.98652 00:25 0.98652 135 7 0.98652 04222018 04222018
30 CS Complaints Inquiries
| Item | PWS Task | ID | Deliverable Description | Deliverable Delivery | Date Report Approved: | 2/3/20 |
| 30 | 6.8 | A | Contractor Call Center Operations and Customer Service Technology Performance Report | VA DAS (via ETL Feed) | Date Report Last Modified: | 2/3/20 |
REGION 5 - Version 010
Section 6.8 - Contractor Call Center Operations and Customer Service Technology Performance Report
| Column Header Title | Referral Number | Facility Station Number and Name | Type of Complaint | Date Contractor receives Complaint or Grievance | Date Contractor submits Complaint or Grievance to VA | Date Contractor submits relevant background information to VA | Date VA requests supplemental information from the Contractor about a complaint or grievance | Date Contractor confirms receipt of a request from VA for supplemental information | Date VA receives a full written response to VA’s request for information about a complaint or grievance |
| Data Description | Referral number associated with complaint. Mandatory - if VA does not receive data will be rejected | Provide Station number and name associated with data | Select the type of complaint received from the Types of Complaints listed below: • Appointment Availability of Network Provider |
• Geoaccessibility of Network Provider
• Customer Service
• Provider Issue
• Claims
• Eligibility
• Care Coordination
| • Request for Information | Date the Contractor received the Veteran's complaint or grievance | ||
| Date Format: MMDDYYYY | Date the Contractor submitted the complaint or grievance to VA | ||
| Date Format: MMDDYYYY | Date Contractor provides VA relevant background information Date Format: MMDDYYYY | Date VA requests supplemental information from the Contractor about a complaint or grievance. NOTE: Optional data - This date field is entered only when VA makes the request for supplemental data. Data point will be null if VA request is not received. Date Format: MMDDYYYY | Date Contractor confirms receipt of a request from VA for supplemental information. NOTE: Optional data - This date field is entered only when VA makes the request for supplemental data. Data point will be null if VA request is not received. |
| Date Format: MMDDYYYY | Date the Contractor submits the full written response to VA specific to Veteran's complaints and grievances. NOTE: Optional data - This date field is entered only when VA makes the request for supplemental data. Data point will be null if VA request is not received. |
Date Format: MMDDYYYY
| Contract Performance Measure | |||
| These 2 data elements measure the following requirement: 2 business days | |||
| These 2 data elements measure the following requirement: 3 business days | These 2 data elements measure the following requirement: 1 business day | ||
| These 2 data elements (Column H & Column J) measure the following requirement: 5 business days |
| EXAMPLE | Appointment Availability of Network Provider | 12152018 | 12182018 | 12222018 | 12282018 | 1022019 | 1052019 |
| Claims | 3222019 | 3242019 | 4012019 | 4032019 | 4082019 | 4132019 |
30 CS Congressional Inq
| Item | PWS Task | ID | Deliverable Description | Deliverable Delivery | Date Report Approved: | 2/3/20 |
| 30 | 6.8 | A | Contractor Call Center Operations and Customer Service Technology Performance Report | VA DAS (via ETL Feed) | Date Report Last Modified: | 2/3/20 |
REGION 5 - Version 010
Section 6.8 Contractor Call Center Operations and Customer Service Technology Performance Report
| Column Header Title | Referral Number | Facility Station Number and Name | Date Contractor Received Congressional Inquiry | Date Contractor Submits Congressional Inquiry and Copy of Full Written Response to VA Congressional Office | Date VA Requests Supplemental Information from the Contractor about a Congressional Inquiry | Date Contractor Confirms Receipt of a Request from VA about a Congressional Inquiry | Date Contractors Provides Full Written Response to VA's Request for Supplemental Information about a Congressional Inquiry | |
| Data Description | Referral number associated with Congressional inquiry. Mandatory - if VA does not receive data will be rejected | Provide Station number and name associated with data | The date the Contractor received the Congressional inquiry from the Congressional office | |||||
| Date Format: MMDDYYYY | The date the Contractor submits the Congressional inquiry and a copy of the Full Written Response to VA Congressional Office | |||||||
| Date Format: MMDDYYYY | The date VA requests supplemental information from the Contractor about a Congressional inquiry. NOTE: Optional data - This date field is entered only when VA makes the request for supplemental data. Data point will be null if VA request is not received. | |||||||
| Date Format: MMDDYYYY | The date the Contractor confirms receipt of a request from VA about a Congressional inquiry. NOTE: Optional data - This date field is entered only when VA makes the request for supplemental data. Data point will be null if VA request is not received. | |||||||
| Date Format: MMDDYYYY | The date VA receives a full written response to a request for supplemental information about a Congressional inquiry. NOTE: Optional data - This date field is entered only when VA makes the request for supplemental data. Data point will be null if VA request is not received. |
Date Format: MMDDYYYY
| Contract Performance Measure | ||
| These 2 data elements measure the following requirement: 5 business days | These 2 data elements measure the following requirement: 1 business day | |
| These 2 data elements (Column F & Column H) measure the following requirement: 5 business days |
| EXAMPLE | 12152018 | 12182018 | 12222018 | 12282018 | 1022019 |
| 3222019 | 3242019 | 4012019 | 4032019 | 4082019 |
35 Training Material
| Item | PWS Task | ID | Deliverable Description | Deliverable Delivery | Date Report Approved: | 2/3/20 |
| 35 | 10.2 | B | Review of Training Materials Report | Other than VA DAS (Secure Email) | Date Report Last Modified: | 2/3/20 |
REGION 5 - Version 010
Section 10.2 Review of Training Materials Report
| Column Header Title | Date Created | Updated Date | Status (Retired/Active) | Training Material | Type of Training Material | Description of Training Material | Recommended Updates to Overall Training Plan (Summary Item) |
| Data Description | Date Training Material Was Created |
Date Format:
MMDDYYYY Date Training Material Was Last Updated
| Date Format: MMDDYYYY | Status of the Training Material (Retired or Active) | Name of Training Material | Choose one of the following options: 1) Class handouts, 2) Manuals, 3) Student exercises, 4) User and Quick Reference Guides, 5) Job Aids, 6) Course Evaluation Surveys | Description of training materials objectives and content. | Description of recommended updates to overall training plan | |
| Example | 8222020 | 8222020 | Retired | Class handouts | ||
| 8222020 | 8222020 | Active | Manuals |
54 Qtrly Cst Avd Ovpymts
| Item | PWS Task | ID | Deliverable Description | Deliverable Delivery | Date Report Approved: | 2/3/20 |
| 54 | 12.9 | A | Quarterly Cost Avoidance and Recovery/Recoupment Report | Other than VA DAS (Secure Email) | Date Report Last Modified: | 2/3/20 |
| REGION 5 - Version 010 | |
| Reporting Period: 7/01/2019-9/30/2019 |
| Section 12.9 Quarterly Cost Avoidance and Recovery/Recoupment Report | |||||||||||||
| OVERPAYMENTS | |||||||||||||
| Column Header Title | Veteran Last Name | Veteran First Name | Veteran Middle Initial | Veteran Suffix | Internal Control Number (ICN) | Invoice Number | Claim Date | Billed Amount | Amount Payable | Amount Paid | Amount Recovered | Reason for Recovery | Date of Recovery |
| Data Description | Provide Veteran's last name - Format: MVI Spec | Provide Veteran's first name - Format: MVI Spec | Provide Veteran's middle initial - Format: MVI Spec | Provide Veteran's suffix (if applicable) - Format: MVI Spec | This is the unique identifier for each Veteran from the Master Veteran Index (MVI) Format: 11vXXXXX (17 characters) | This is the Unique Invoice Number -number that is transmitted to VA on 837 COB | this is the date the Contractor submitted the claim to VA via VA Clearinghouse Date Format: MMDDYYYY | This is the total amount billed Format: XXXX.XX (no commas, no dollar sign; SQL Format 'MONEY') | This is the calculated amount payable Format: XXXX.XX (no commas, no dollar sign; SQL Format 'MONEY') | This is the actual amount paid Format: XXXX.XX (no commas, no dollar sign; SQL Format 'MONEY') | This is the amount recovered from overpayment Format: XXXX.XX (no commas, no dollar sign; SQL Format 'MONEY') | Remittance Advice Remark Codes (RARCs) are used to provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or to convey information about remittance processing. Please reference the industry standard listing using the link located in the 'Reference Files' swim lane below | This is the date funds were recovered Date Format: MMDDYYYY |
| Reference Files | http://www.wpc-edi.com/reference/ | ||||||||||||
| EXAMPLE | Champion | William | J | Jr. | 10163795070650500 | F241X0MX90000 | 9092019 | 354.00 | 94.75 | 75.93 | 18.82 | 13 The date of death precedes the date of service | 11232020 |
| Champion | William | J | N/A | 10163795070650500 | F241X0MX90000 | 9092019 | 354.00 | 94.75 | 75.93 | 18.82 | 14 The date of birth follows the date of service | 11232020 | |
| NOTE: When no data is available, return a report with blank rows |
http://www.wpc-edi.com/reference/ 54 Qtrly Cst Avd Undpymts
| Item | PWS Task | ID | Deliverable Description | Deliverable Delivery | Date Report Approved: | 2/3/20 |
| 54 | 12.9 | A | Quarterly Cost Avoidance and Recovery/Recoupment Report | Other than VA DAS (Secure Email) | Date Report Last Modified: | 2/3/20 |
| REGION 5 - Version 010 | |
| Reporting Period: 7/01/2019-9/30/2019 |
| Section 12.9 Quarterly Cost Avoidance and Recovery/Recoupment Report |
| UNDERPAYMENTS |
| Column Header Title | Veteran Last Name | Veteran First Name | Veteran Middle Initial | Veteran Suffix | Internal Control Number (ICN) | Invoice Number | Claim Date | Billed Amount | Amount Payable | Amount Paid | Amount Underpaid | Reason for Underpayment | Date of Underpayment |
| Data Description | Provide Veteran's last name - Format: MVI Spec | Provide Veteran's first name - Format: MVI Spec | Provide Veteran's middle initial - Format: MVI Spec | Provide Veteran's suffix (if applicable) - Format: MVI Spec | This is the unique identifier for each Veteran from the Master Veteran Index (MVI) Format: 11vXXXXX (17 characters) | This is the Unique Invoice Number -number that is transmitted to VA on 837 COB | This is the date the Contractor submitted the claim to VA via VA Clearinghouse Date Format: MMDDYYYY | This is the total amount billed Format: XXXX.XX (no commas, no dollar sign; SQL Format 'MONEY') | This is the calculated amount payable Format: XXXX.XX (no commas, no dollar sign; SQL Format 'MONEY') | This is the actual amount paid Format: XXXX.XX (no commas, no dollar sign; SQL Format 'MONEY') | This is the amount additionally paid due to underpayment Format: XXXX.XX (no commas, no dollar sign; SQL Format 'MONEY') | Remittance Advice Remark Codes (RARCs) are used to provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or to convey information about remittance processing. Please reference the industry standard listing using the link located in the 'Reference Files' swim lane below | This is the date funds were paid Date Format: MMDDYYYY |
| Reference Files | http://www.wpc-edi.com/reference/ | ||||||||||||
| EXAMPLE | Champion | William | J | Jr. | 10163795070650500 | F241X0MX90000 | 9092019 | 354.00 | 94.75 | 75.93 | 18.82 | 13 The date of death precedes the date of service | 11232020 |
| Champion | William | J | N/A | 10163795070650500 | F241X0MX90000 | 9092019 | 354.00 | 94.75 | 75.93 | 18.82 | 14 The date of birth follows the date of service | 11232020 | |
| NOTE: When no data is available, return a report with blank rows |
http://www.wpc-edi.com/reference/ 54 Qtrly Cst Avd Summary
| Item | PWS Task | ID | Deliverable Description | Deliverable Delivery | Date Report Approved: | 2/3/20 |
| 54 | 12.9 | A | Quarterly Cost Avoidance and Recovery/Recoupment Report | Other than VA DAS (Secure Email) | Date Report Last Modified: | 2/3/20 |
REGION 5 - Version 010
Section 12.9 Quarterly Cost Avoidance and Recovery/Recoupment Report
| A summary of errors by reason category to include number of cases and dollar value. | |||
| Column Header Title | Error Reason Category | Number of Cases | Dollar Value |
| Data Description | Overpayment / Underpayment Error Reason: Incorrect Veteran, Incorrect Vendor, Not an Eligible Veteran, Excluded or Non-Covered Benefit by Regulation, Lack of VACC Authorization, Service Excluded from Coverage by Authorization, Untimely Submission of Claim or Medical Records, Lack of Regulatory Authority to Pay (38 U.S.C. 1725, Veteran with OHI), Payments for Goods or Services Not Received, Claim Does Not Conform to Contract Requirements, Duplicate Caused by Change on Claim, Duplicate Caused by Data Entry Error, Exact Duplicate | The number of cases per error reason | The dollar amount (overpayment / underpayment) associated with each error reason |
| Example | Underpayment Error Reason: Lines were rejected in error for total visits having been exceeded. The error was identified and the claim corrected. | 1 | 18.82 |
| Overpayments Established - This report consist of 3 components: Number of Cases, Requested & Receive Dates, and Establish & Collection Phase Dates | |||||
| Column Header Title | Number of Cases | Requested Date | Received Date | Established Date | Collection Phase Date |
| Data Description | a) present the number of cases on which the Contractor has performed its initial assessment, | b) indicate if the Contractor has requested additional documentation from VA | b) indicate if the Contractor has received additional documentation from VA, If not date report, case is considered open | c) indicate the date the case was established | c) indicate the date the case was established and the date the Contractor is prepared to move on to the collection phase. |
| Contract Performance Measure | |||||
| The number of days between these days will calculate the timeframes associated with those documentation requests (4th bullet, component letter b) |
| Overpayments Collected – Collected amounts must only be included in this report if the amount has been successfully collected by the Contractor. Collected amounts must always be shown in a way that allows relation of the collected amount to a specific claim or invoice. | ||
| Column Header Title | Collected Amount | Invoice Number |
| Data Description | The amount of overpayment collected | Unique Invoice Number -number that is transmitted to VA on 837 COB |
| Overpayment Adjustments – During the course of the audit, there may be situations where the overpayment amount needs to be adjusted. This report will present any of those situations where adjustments have been required and the associated date of those adjustments | |||
| Column Header Title | Overpayment Amount | Corrected Invoice Number | Date of Adjustment |
| Data Description | The amount the claim was overpaid | Unique Corrected Invoice Number -number that is transmitted to VA on 837 COB | This is the date the adjustment (payment change) was made/resubmission |
| Underpayments Identified | ||
| Column Header Title | Number of Cases Underpaid | Estimated Value |
| Data Description | Indicate the number of cases that have been identified as having been underpaid | estimated value of the underpayments. |
| Example | 1 | 18.82 |
| Number of Reviews Completed | |
| Column Header Title | Sample Size |
| Data Description | The number of reviews completed during each month of the quarter. |
| Narrative Reports | |||
| Column Header Title | Narrative | ||
| Data Description | Free text narrative | ||
| • Trending of overpayments from inception and suggested corrective action. | |||
| • A detailed narrative with graphical and statistical information. | |||
| See EOY Summary Report | |||
| Section 12.9 Quarterly Cost Avoidance and Recovery Report - Variance analysis for any reporting category with a greater than 15% increase or decrease from the current quarterly report to the previous report, to include any unusual activity even if it does not exceed the percentage. | |||
| Column Header Title | Total Monthly Recovery | Variance from Previous Month (%) | Explanation of Variance (if greater than 15%) |
| Data Description | total recovered in reporting month Format Dollar Amount | Percent variance (+ or -) from previous reporting month | Free text narrative of explanation of the variance (why, and what was done to correct, if appropriate, etc.) |
54 Qtrly Cst Avd Audit
| Item | PWS Task | ID | Deliverable Description | Deliverable Delivery | Date Report Approved: | 2/3/20 |
| 54 | 12.9 | A | Quarterly Cost Avoidance and Recovery/Recoupment Report | Other than VA DAS (Secure Email) | Date Report Last Modified: | 2/3/20 |
| REGION 5 - Version 010 | |
| Reporting Period: 7/01/2019-9/30/2019 | |
| Date Uploaded to SharePoint for Addendum Submission: 11/26/2019 | |
| Section 12.9 Claims Auditing - Quarterly Cost Avoidance and Recoupments Report |
| Pre-Payment Audit | |||||||||||||||||||||||
| Column Header Title | Region and Care Type | Total $ Billed | Total # Claims Billed | Total $ Paid | Total # Claims Paid | Total # Claims audited | Total # Inpatient Claims Audited | Total # Outpatient Claims Audited | Total # Findings with Errors | Total $ affected | Type of Finding | # Claims with Prepayment Review | Total # Cases Open | Total # Cases Closed | Prepayment Review Denials - Total $ | Prepayment Review Denials - Total # Claims | Prepayment Duplicate Denials - Total $ Paid | Prepayment Duplicate Denials - Total # Claims | LEIE Provider Denials - Total $ Paid | LEIE Provider Denials - Total # Claim | LEIE Provider Name | LEIE Provider NPI | LEIE Provider Effective Date |
| Data Description | Provide totals of each data element based on: Region 1 Overall, Medical, Dental Pharmacy (see example below) | Total dollars billed for by region Format: MONEY $XXXXX.XX | Total claims billed for by region Format: Numerical Count | Total dollars paid for by region Format: MONEY $XXXXX.XX | Total claims paid for by region Format: Numerical Count | The number of inpatient and outpatient claims audited. Format: Numerical count | The number of inpatient claims audited. Format: Numerical count | The number of outpatient claims audited. Format: Numerical count | The number of findings with errors based on inpatient and outpatient claim audit. Format: Numerical count | Total dollar amount affected as result of finding Format: MONEY $XXXXX.XX | The type of finding (i.e. overpayment, underpayment, LEIE provider, etc.) FORMAT: Text | The total number of claims with prepayment review. Format: Numerical Count | The total number of cases open. Format: Numerical Count | The total number of cases closed. Format: Numerical Count | The total dollar amount denied as a result of prepayment review Format: MONEY $XXXXX.XX | The total claims count denied as a result of prepayment review Format: Numerical Count | The total dollar amount denied as a result of identified duplicates. NOTE: This data is a subset of total $ of Prepayment Review Denials reported in Column P. This dollar amount should be included in Column P's total. Format: MONEY $XXXXX.XX | The total claims count denied as a result of identified duplicates. NOTE: This data is a subset of total # of Prepayment Review Denials reported in Column Q. This total claims count should be included in Column Q's total. FORMAT: Numercial Count | Total dollars denied by LEIE Format: MONEY $XXXXX.XX | Total claims denied by LEIE Format: Numerical Count | If Column "T" has a positive entry, the name of the provider should be listed FORMAT: Text | If Column "T" has a positive entry, the NPI of the provider should be listed FORMAT: numeric, 10 digits (0000000000) | If Column "T" has a positive entry, the effective date of when the provider was placed on the LEIE should be listed |
| Example | Region 4 | 7,611 | $7,023,735.62 | 7,611 | $795.75 | 6 | $0 | 0 | N/A | N/A | N/A | ||||||||||||
| Medical | 0 | 0 | 0 | 0 | 0.00 | N/A | 408 | 0 | 0 | $1,742,383.37 | 408 | $795.75 | 6 | $0 | 0 | N/A | N/A | N/A | |||||
| Dental | 17 | $25,873.00 | 17 | 0 | 0 | $0 | 0 | N/A | N/A | N/A | |||||||||||||
| Pharmacy | 7,186 | $5,255,479.25 | 7,186 | 0 | 0 | $0 | 0 | N/A | N/A | N/A | |||||||||||||
| Post-Payment Review (Recoupment) | |||||||||||||||||||||||
| Column Header Title | Region and Care Type | Total $ Billed | Total # Claims Billed | Total $ Paid | Total # Claims Paid | Total # Claims audited | Total # Inpatient Claims Audited | Total # Outpatient Claims Audited | Total # Findings with Errors | Total $ affected | Type of Finding | # Claims with Post-payment Review | Total # Cases Open | Total # Cases Closed | Post Payment Review of Claims that Should have Denied- Total $ | Post Payment Review of Claims that Should have Denied - Total # Claims | Post Payment Duplicate Review - Total $ Paid | Post Payment Duplicate Review - Total # Claims | LEIE Provider Post Payment Review - Total $ Paid | LEIE Provider Post Payment Review - Total # Claim | LEIE Provider Name | LEIE Provider NPI | LEIE Provider Effective Date |
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