36C10G20R0014-037.xlsx
XLSX spreadsheet Posted
- Solicitation number
- 36C10G20R0014
About this file
This document contains a pricing template and mapping of clinical line items (CLINs) to requirements for the Community Care Network Region 5 contract in Alaska. The pricing template includes CLINs for various healthcare and administrative services with pricing terms to be provided by offerors. Services include medical, dental, home health, durable medical equipment, pharmacy, and telehealth. The contract will be a single-award indefinite-delivery indefinite-quantity agreement with a 9-month base period and seven 1-year options awarded on a firm-fixed price basis with an incentive plan. The Department of Veterans Affairs intends to issue a solicitation on May 11th with proposals due June 1st under solicitation number 36C10G20R0014 for a third-party administrator to establish a provider network and manage healthcare services for eligible veterans in Alaska.
36C10G20R0014 CCN Region 5 Attachment 8 - Pricing Template.xlsx
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Main Pricing Sheet
| Community Care Network - Region 5 |
| Prices Proposal for CLINs |
| Offeror Name: | ||||||||||||
| Prices per specific CLIN per year, where "Y" varies by the option year (OY), where the base year is 0. X represents the region, i.e., 5. | ||||||||||||
| Type | CLIN | Title | UNIT/Directions/Extended description | BASE | OY1 | OY2 | OY3 | OY4 | OY5 | OY6 | OY7 | Extend* |
| Informational | XY01 | Medicare (rates) for Health Services | Up to 100% Medicare | |||||||||
| Informational | XY03 | Urgent/Emergent Durable Medical Equipment (DME), Medical Devices, Orthotics, and Prosthetic items | Up to 100% Medicare | |||||||||
| XY04 | Home Health Care | Summary CLIN, not separately priced (NSP) | ||||||||||
| Informational | XY04AA | Skilled Home Health | Up to 100% Alaska VA Professional Fee Schedule | |||||||||
| Informational | XY04AB | Unskilled Home Health | Up to 100% Alaska VA Fee schedule | |||||||||
| Priced | XY05 | Seasonal Influenza Vaccination | Each, $_____ | |||||||||
| Informational | XY06 | General Health Services using Alaska VA fee schedules | Up to 100% Alaska VA Fee Schedules | |||||||||
| Informational | XY07 | Maximum Allowable Charges Schedule | Up to 100% Maximum Allowable Charge | |||||||||
| Informational | XY08 | Home Infusion Therapy | Up to 100% of the Alaska Fee Schedules | |||||||||
| XY09 | Urgent/Emergent Prescriptions | Summary CLIN, not separately priced (NSP) | ||||||||||
| Priced | XY09AA | Brand Name Medication | Percent of AWP | |||||||||
| Priced | XY09AB | Generic Medication | Percent of AWP | |||||||||
| Priced | XY09AC | Dispensing Fee | Each in $/prescription | |||||||||
| Informational | XY10 | Dental Services | Up to 100% Alaska VA Fee schedules | |||||||||
| XY11 | Administrative Services | Summary CLIN, NSP | ||||||||||
| Priced | XY11AA | Administrative Services for Healthcare Services | $ Price for Each Active Veteran per month | |||||||||
| Priced | XY11AB | Administrative Services for Dental | $ Price for Each Active Veteran per month | |||||||||
| Priced | XY11AC | Administrative Services for Pharmacy Benefit Management (PBM) | $ Price for Each Active Veteran per month | |||||||||
| Priced | XY11AD | Administrative Services for Assisted Reproductive Technology (ART) Services | $ Price for Each Collateral (donor/spouse) per month | |||||||||
| XY12 | Implementation and Transition Out | Summary CLIN, NSP | ||||||||||
| Priced | XY12AA | Implementation - Provider Network | Lump sum $ price based on target # of providers signed up | |||||||||
| Priced | XY12AB | Implementation - IT | Lump sum $ price based on IT system being ready for operation | |||||||||
| Priced | XY12AC | Implementation - Project Management | Lump sum $ price paid on staffing goals achieved | |||||||||
| Priced | XY12AD | Transition Out | Optional Lump sum $ price | |||||||||
| Informational | XY13 | Data | Contractual CLIN, no defined price. | |||||||||
| Priced | XY14 | Agreed Upon Procedures Audit | Total price | |||||||||
| Informational | XY20 | Assisted Reproductive Technology Services | Up to 100% Maximum Allowable Charge | |||||||||
| XY21 | Disaster Response Medication | Summary CLIN, NSP | ||||||||||
| Priced | XY21AA | Brand Name Medication (Disaster Response) | % of AWP, must be identical to XY09AA | |||||||||
| Priced | XY21AB | Generic Medication (Disaster Response) | % of AWP, must be identical to XY09AB | |||||||||
| Priced | XY21AC | Dispensing Fee (Disaster Response) | Must be identical to XY09AC | |||||||||
| XY22 | Tribal rates for Tribal providers only | Up to 100% Tribal fee schedule, Summary CLIN, NSP | ||||||||||
| Informational | XY22HI | Tribal Inpatient hospital services per diem (IHS rate) (excludes physician/practitioner services) | Up to 100% Per patient per IHS all inclusive inpatient hospital per diem rates | |||||||||
| Informational | XY22HO | Tribal Outpatient hospital services all inclusive per visit (IHS rate) | Up to 100% per encounter per the adjusted IHS all inclusive rate | |||||||||
| Informational | XY22AS | Tribal Ambulatory Surgical Services | Up to 100% Medicare rates for free standing surgical centers. | |||||||||
| Informational | XY22CO | Tribal Clinic Services, including certified community health aid services | Up to 100% per visit per the IHS all inclusive outpatient rate | |||||||||
| Informational | XY22MD | Physician and practitioner services at Tribal hospitals and non-Medicare services at free standing surgical centers | Up to 100% Alaska Professional VA fee schedule. | |||||||||
| Informational | XY23 | Transplant in-patient services | Up to 100% Maximum Allowable Charges | |||||||||
| Informational | XY24 | Telehealth Facility Support | Up to 100% per HCPCS Q3014 for telehealth originating sites facility fee per encounter | |||||||||
| Footnotes/instructions for schedule of services, aka, pricing template | ||||||||||||
| * "Extend" refers to the option to extend the contract for up to 6 months and shall be in accordance with 52.217-8 & 9. Such an extension shall be charged at the same price/rate as used in the last exercised option year. For evaluation purposes this period shall be assumed to be 6 months. | ||||||||||||
| ** All references to Medicare rates are to the locality adjusted Medicare Rates. | ||||||||||||
| Light gray is N/A, prices governed by existing rates. Nothing should be input into gray cells. | ||||||||||||
| The cells are locked to prevent input. While VA does not recommend unprotecting the sheets, the password to unprotect is a blank/null entry. Green cells with diagonals will auto-populate based on other green cells. | ||||||||||||
| CLINs XY02, XY15-XY19, and are reserved for consistency of numbering with other regions. XY13 is NSP. | ||||||||||||
| For ll CLINs with the “up to” language in this price table, the “up to” language reflects the scenario in which the Contractor is billing the VA something less than the full CLIN price (“the adjusted price”), per section B.5.2 in the RFP. The "up to" language does not alter the CLIN price. |
DRAFT
&KFF0000Do not disclose Source Selection Sensitive Information – See FAR 2.101 and FAR 3.104
PWS mapping The following is provided to facilitate the offerors quicker and deeper understanding of the mapping between the CLINs and the PWS. No warranty is made with regards to its completeness or correctness. Large X is 5 for Region 5. See also Section B of RFP package
| CLIN | Description | PWS Sections: |
| XY01 | Medicare for Health Services | Section B.5, 4.0 CCN Health Benefit Package (healthcare costs only), limited use expected due to the existence fo the Alaska Fee schedules. Use is at CO's discretion. |
| XY03 | Urgent/Emergent Durable Medical Equipment (DME), Medical Devices, Orthotics, and Prosthetic items | 16.0 Durable Medical Equipment, 7.0 Referrals and Prior Authorizations |
| XY04 | Home Health (skilled and unskilled) | 3.7.1 Credentialing |
| XY05 | Seasonal Influenza vaccination | 15.3 Routine/Maintenance Prescriptions: Time-Eligible and Distance-Eligible Veterans (cost of vaccine administration only) |
| XY06 | General Health Services using Alaska VA fee schedules | 4.0 CCN Health Benefit Package (healthcare costs only), |
15.3 Routine/Maintenance Prescriptions: Time-Eligible and Distance-Eligible Veterans
| XY07 | Non-Medicare, Non-VA Fee Schedule - Medical and Surgical Healthcare Services | 4.0 CCN Health Benefit Package (healthcare costs only) |
| XY08 | Home Infusion Therapy | 4.0 CCN Health Benefit Package (healthcare costs only) |
| XY09 | Urgent/Emergent Prescriptions | 15.0 Pharmacy (prescription costs and dispensing fees) |
| XY10 | Dental Services | 17.0 Dental (healthcare costs only) |
| XY11AA | Administrative Services for Healthcare Services | 2.0 Project Management, |
2.7 Accreditation,
3.3 Out of Network Providers,
3.4 Identification of High-Performing Network Providers,
3.5 CCN Regions,
3.6 Network Adequacy Management,
3.7 Credentialing,
4.0 CCN Health Benefit Package (administrative services costs only)
6.1 Contractor VA Support Call Center Function,
6.2 CCN Provider Call Center Function,
6.5 Veteran Complaints and Grievances and Customer Service Procedure,
6.6 Congressional and VA Inquiries,
6.7 CCN Provider Satisfaction Surveys,
6.8 Call Center Operations and Customer Service Technology Performance Requirements and Metrics,
7.0 Referrals and Prior Authorization,
8.0 Scheduling of Appointments,
9.0 Medical Documentation,
10.0 Training (delivery of training only),
12.0 Claims Processing and Adjudication for CCN Healthcare Services Rendered,
13.0 Veteran Claim Appeals and Provider Reconsiderations,
14.0 Clinical Quality and Patient Monitoring,
18.1 Contractor Software Configuration Management Requirements,
18.2 Continuity of Operations,
18.3 Contractor System Access,
18.4 VA System Integration Requirements (maintenance costs only),
18.5 Veteran Demographic and Administrative Data,
18.6 IT Customer Service (maintenance costs only),
18.7 VA Community Care Provider Portal (maintenance costs only),
18.8 Contractor Self-Service Website (maintenance costs only),
18.9 Contractor Reporting and Data Submission,
18.10 Email Communication,
18.11 Referrals and Prior Authorization,
18.12 Submission of EDI Transactions,
18.13 Submission of Medical Documentation,
18.14 Submission of OHI,
18.15 Provider Data Transfer,
18.16 Section 508 - Electronic and Information Technology (EIT) Standards,
19.1 Data Specification, Report Standardization, Dashboard, Repository and Data ETL (maintenance costs only),
19.2 Data Repository and Data Repository Relational Database Schema (maintenance costs only),
19.4 Nightly Data Extract,
19.5 Data Integrity.
| XY11AB | Administrative Services for Dental | 17.0 Dental (administrative costs only) |
| XY11AC | Administrative Fee for Pharmacy Benefits Management (PBM) | 15.0 Pharmacy (administrative costs only) |
| XY11AD | Administrative Fee for Assisted Reproductive Technology services (ART) | 4.4 CCN Assisted Reproductive Technology Services |
| XY12 | Implementation | 2.9.2 Transition Out |
3.1 Network Establishment and Maintenance,
3.2 Provider Networks,
18.4 VA System Integration Requirements (development costs only),
18.6 IT Customer Service (development costs only),
18.7 VA Community Care Provider Portal (development costs only),
18.8 Contractor Self-Service Website (development costs only),
19.1 Data Specification (development costs only),
19.2 Data Repository and Data Repository Database Schema (development costs only).
| XY13 | Data | 20.4 Schedule of Deliverables | |
| XY14 | Agreed Upon Procedures | 12.9 Claims Auditing | |
| XY20 | Assisted Reproductive Technology Services | 4.4 CCN Assisted Reproductive Technology Services | |
| XY21 | Disaster Response Medication | 15.0 Pharmacy (prescription costs, dispensing fees, and Contingency Plan for Disaster Response) | |
| XY22 | Tribal rates for Tribal providers only | 1.2 Background, and 3.2.1 CCN Healthcare Services Network | |
| XY22HI | Tribal Inpatient hospital services per diem (IHS rate) (excludes physician/practitioner services) | See Tribal Agreements | |
| XY22HO | Tribal Outpatient hospital services all inclusive per visit (IHS rate) (excludes physician/practitioner services) | See Tribal Agreements | |
| XY22AS | Tribal Ambulatory Surgical Services | See Tribal Agreements | |
| XY22CO | Tribal Clinic Services, including certified community health aid services | See Tribal Agreements | |
| XY22MD | Physician and Practitioner services at Tribal hospitals and non-Medicare services at free standing surgical centers | See Tribal Agreements | |
| XY23 | Transplant in-patient services | 9.7 9.7 | Identification and Documentation of Transplant Candidates |
| XY24 | Telehealth Facility Support | 3.1.6 Expanded Flexibility for Rural/Highly Rural Areas , 3.2.3 Telemedicine |
DRAFT
&KFF0000Do not disclose Source Selection Sensitive Information – See FAR 2.101 and FAR 3.104
PBM Schedule
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