36C10G20R0014-025.docx
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- 36C10G20R0014
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This document contains four standardized episodes of care (SEOCs) for infertility services through the Veterans Health Administration Community Care Network. The SEOCs cover initial evaluations, diagnostic imaging and testing, procedures including ovarian stimulation and in vitro fertilization (IVF), and a maximum of six IVF cycles or six intrauterine insemination (IUI) cycles per patient. The related federal contract opportunity is a pre-solicitation notice for the Community Care Network region serving Alaska. The Department of Veterans Affairs intends to issue a request for proposal under full and open competition for a single-award fixed-price indefinite-delivery/indefinite-quantity contract with a nine-month base period and seven one-year options. The anticipated proposal due date is June 1, 2020. The contractor will be responsible for establishing a provider network and managing healthcare services for eligible Veterans in Alaska.
36C10G20R0014 CCN Region 5 Attachment AM ART IVF Standard Episodes of Care.docx
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VHA Office of Community Care – Standardized Episode of Care
Infertility Care
ART-IVF Female SEOC 1.0.1
Description: This authorization covers services associated with all medical care listed below as clinically indicated.
Duration: 365 days
Frequency: As clinically indicated
Procedural Overview
1. Initial outpatient evaluation and treatment for infertility
2. Six visits for diagnostic imaging relevant to the patient complaint/condition
3. Twelve visits for diagnostic studies, lab and pathology services relevant to the patient complaint/condition
4. Procedures to include: Ovarian stimulation medications (oral and/or injectable), oocyte harvesting, In-vitro insemination (IVF) including intra-Cytoplasmic Sperm Injection (ICSI), embryo culture, fresh or frozen embryo transfer, cryopreservation techniques and genetic testing as indicated. Ovarian stimulation will require multiple labs and ultrasounds
5. Maximum of six (6) attempts to achieve 3 complete IVF cycles in a lifetime of the eligible SC
Veteran. A cycle is defined as transfer of 1 or more embryos. Transfer of a frozen embryo would be considered a cycle.
**Additional consultations needed relevant to the patient complaint/condition require VA review and approval.
**DME, prosthetics and orthotics orders must be submitted to the local VA facility prosthetics department for provision.
**All routine medications must be faxed/sent to the VA to be dispensed by the VA.
Urgent/emergent prescriptions can be provided for a fourteen (14) day supply only.
The Veteran will be required to pay out of pocket for any urgent/emergent medications and can submit a reimbursement request to their local VA facility.
VHA Office of Community Care – Standardized Episode of Care
In-Vitro Fertilization Care
IVF Male SEOC 1.1.1
Description: This authorization covers services associated with all medical care listed below as clinically indicated. Services can only be provided through the Patient Centered Community Care (PC3) contract.
Duration: 365 days
Frequency: As clinically indicated
Procedural Overview
1. Initial outpatient evaluation and treatment for infertility
2. 10 visits for diagnostic imaging/studies, lab and pathology services relevant to the patient complaint/condition
3. Procedures to obtain viable sperm for reproductive efforts to include: surgical procedures, sperm extraction techniques
4. Cryopreservation techniques
5. Sperm genetic testing related to sperm function and viability
6. Please see attached consultation for number of cycles approved.
**Additional consultations needed relevant to the patient complaint/condition require VA review and approval.
**All routine medications must be faxed/sent to the VA to be dispensed by the VA.
Urgent/emergent prescriptions can be provided for a fourteen (14) day supply only.
The Veteran will be required to pay out of pocket for any urgent/emergent medications and can submit a reimbursement request to their local VA facility.
VHA Office of Community Care – Standardized Episode of Care
Infertility Care
IUI Female SEOC 1.2.1
Description: This authorization covers services associated with all medical care listed below as clinically indicated.
Duration: 365 days
Frequency: As clinically indicated
Procedural Overview
1. Initial outpatient evaluation and treatment for infertility
2. Six visits for diagnostic imaging relevant to the patient complaint/condition
3. Six visits for diagnostic studies, lab and pathology services relevant to the patient complaint/condition
4. Procedures to include: Ovarian stimulation medications (oral and/or injectable), Ovarian stimulation will require multiple ultrasounds (up to 6 per cycle) and laboratory tests (up to 6 per cycle) intrauterine insemination (IUI)
5. Maximum of six (6) cycles. Additional treatment cycles would require additional authorizations
**Additional consultations needed relevant to the patient complaint/condition require VA review and approval.
**DME, prosthetics and orthotics orders must be submitted to the local VA facility prosthetics department for provision.
**All routine medications must be faxed/sent to the VA to be dispensed by the VA.
Urgent/emergent prescriptions can be provided for a 14 day supply only.
The Veteran will be required to pay out of pocket for any urgent/emergent medications and can submit a reimbursement request to their local VA facility.
VHA Office of Community Care – Standardized Episode of Care
Infertility Care
IUI Male SEOC 1.3.1
Description: This authorization covers services associated with all medical care listed below as clinically indicated.
Duration: 365 days
Frequency: As clinically indicated
Procedural Overview
1. Initial outpatient evaluation and treatment for infertility
2. 10 visits for diagnostic imaging/studies, lab and pathology services relevant to the patient complaint/condition
3. Procedures to obtain viable sperm for reproductive efforts to include: surgical procedures, sperm extraction techniques
4. Cryopreservation techniques
5. Sperm genetic testing related to sperm function and viability
**Additional consultations needed relevant to the patient complaint/condition require VA review and approval.
**All routine medications must be faxed/sent to the VA to be dispensed by the VA.
Urgent/emergent prescriptions can be provided for a 14 day supply only.
The Veteran will be required to pay out of pocket for any urgent/emergent medications and can submit a reimbursement request to their local VA facility.
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