CCN Next Gen Dental_PWS_v7.2_RFI Draft.pdf

PRE-DECISIONAL DRAFT

Do Not Disclose – Source Selection Sensitive Information See FAR 2.101 and FAR 3.104

PRE-DECISIONAL - For VA Internal Planning Purposes Only

DEPARTMENT OF VETERANS AFFAIRS

VHA Office of Integrated Veteran Care

Integrated External Networks

Community Care Network Next Generation Dental Network

Performance Work Statement

Version 7.2 March 21, 2025

PRE-DECISIONAL - For VA Internal Planning Purposes Only

PRE-DECISIONAL - For VA Internal Planning Purposes Only

Table of Contents

1 GENERAL INFORMATION

1.1 Introduction

1.2 Scope of Services

1.3 Applicable Documents

2 PROJECT MANAGEMENT

2.1 Post Award and Contract Kickoff Meetings

2.2 Integrated Master Schedule

2.3 Deployment and Implementation

2.4 Risk Management

2.5 Contract Performance Management

2.5.1 Quality Assurance Surveillance Plan

2.5.2 Quality Assurance Program and Plan

2.5.3 Quality Improvement Plan

2.6 Progress Reporting

2.7 Service Organization Control Reporting

2.7.1 SOC 1 and SOC 2 Reporting Specifications and Deliverables

2.8 Contractor Maintained Records

2.9 Cooperation

2.10 Transition Out

3 DENTAL NETWORK DEVELOPMENT AND MAINTENANCE

3.1 Dental Network Establishment and Maintenance

3.1.1 Dental Network Adequacy Plan

3.2 Dental Provider Network

3.3 Network Adequacy Management

3.3.1 Dental Network Deviation Requests

PRE-DECISIONAL - For VA Internal Planning Purposes Only

3.4 Credentialing

3.5 Dental Network Provider Data for VA’s Provider Directory

3.6 Operations Support

4 ELIGIBILITY DATA MANAGEMENT

4.1 Member Information

4.2 Eligibility File Transmission Frequency

4.3 Member Query

4.4 Member Address Information

4.5 Veteran Community Care Eligibility Codes

5 CUSTOMER SERVICE

5.1 Contractor Contact Center

5.1.1 Contractor Contact Center Support to VA Staff

5.1.2 Contractor Contact Center Supporting Network Providers

5.1.3 After-Call Surveys

5.1.4 Contractor Contact Center Training Materials and Response Scripts

5.1.5 Contractor Contact Center Testing and Full Operating Capability

5.2 Contractor Self-Service Capabilities

5.2.1 Contractor IVR with Self-Service Capabilities

5.2.2 Contractor Self-Service Portal

5.2.3 Dental Network Provider Attestation

5.2.4 Contractor Self-Service Portal and VA-Provided Referral and Authorization System

5.2.5 Contractor Self-Service Portal Testing and Full Operating Capability

5.3 Contractor Use of VA-Provided Ticketing Tool

5.4 Information Technology Support

5.5 Dental Network Provider Satisfaction Surveys

5.6 Contractor Customer Service Quality Assurance

5.7 Customer Service Performance Requirements and Reporting

5.7.1 Contractor Contact Center Performance Requirements

5.7.2 Contractor Self-Service Portal Performance Requirements

5.7.3 Dental Network Customer Service Report

PRE-DECISIONAL - For VA Internal Planning Purposes Only

6 REFERRALS

6.1 Request For Services

7 PHARMACY

8 MEDICAL DOCUMENTATION

8.1 Medical Documentation Central Submission System

8.2 Medical Documentation Data Elements for Inclusion

8.3 Medical Documentation Submission Timeframes

8.4 Medical Documentation Compliance

8.5 Critical Findings

8.6 Medical Documentation and Audit

9 CLAIMS PROCESSING AND ADJUDICATION FOR DENTAL NETWORK

SERVICES RENDERED

9.1 Claims Submission and Processing Timeframes

9.2 Claims Processing and Adjudication

9.3 Claim Reprocessing and Adjustment

9.4 Test Claim Tracers

9.5 Claims Reporting

10 REIMBURSEMENT SUBMISSION TO VA

10.1 Resubmission of Rejected and Denied 837D COB to VA

10.2 Dental Network Provider Claim Appeals

10.3 Invoicing Accuracy

10.4 Accounting and Access to Records

11 COORDINATION OF BENEFITS

PRE-DECISIONAL - For VA Internal Planning Purposes Only

11.1 Debt Collection

11.2 Issuance of Explanation of Benefits

12 PROGRAM INTEGRITY

12.1 Program Integrity Responsibilities

12.2 Predictive Analytics

12.3 Anti-Fraud and Abuse Support

12.4 Fraud and Abuse Training and Education

12.5 Cost Avoidance and Recovery/Recoupments Reports

12.6 Termination of Network Agreement

12.7 Veteran and Network Provider Flags

12.8 Case Lifecyle

12.9 Dental Overutilization Review

12.10 Payment Integrity

12.11 Pre-Payment Review

12.12 Post-Payment Review

12.13 Recoupment Action

12.14 Annual Independent Payment Audit

12.15 Error Determination Rebuttals

12.16 Audit Review Action

12.17 Reduction of Improper Payment Performance Goals

12.18 Program and Payment Integrity Site Visits

13 CLINICAL QUALITY AND PATIENT SAFETY MONITORING

13.1 Clinical Quality Management and Safety Programs

13.1.1 Clinical Quality Management Program

13.1.2 Patient Safety Program

PRE-DECISIONAL - For VA Internal Planning Purposes Only

13.2 Clinical Quality and Patient Safety Issues Identification

13.2.1 Reporting

13.3 Peer Review of Identified Quality and Patient Safety Issues

13.4 VA Participation in Peer Review Committees

13.5 Patient Safety and Clinical Quality Plans

13.5.1 Patient Safety Plan

13.5.2 Clinical Quality Plan

13.6 Clinical Quality Steerage Model Data

13.7 Special Designation Stickers Data

14 TECHNOLOGY

14.1 Communication and Access to Contractor Systems

14.2 Configuration Management and Testing

14.2.1 Software Development (OPTIONAL TASK)

14.3 Continuity of Operations Plan

14.3.1 Data Integrity

14.3.2 Data Security

14.4 Information and Data Exchange Requirements

14.4.1 VA System Integration Requirements

14.4.2 Exchange of EDI Transactions

14.5 Technology Compliance Requirements

14.5.1 Social Security Number Reduction

14.5.2 Equivalent Facilitation for 508 Compliance

14.5.3 Compatibility with Assistive Technology

15 TRAINING

15.1 Training Plan

15.1.1 Provider and Contractor Personnel Outreach and Education Program

15.1.2 Provider Only Training

15.1.3 Contractor-Provided VA Training Program for Contractor Network Providers, Contractor Personnel, and VA Staff

15.1.4 Contractor Dental Network Staff Training Sessions

15.1.5 Contractor Training Materials

15.2 VA Provided Training

PRE-DECISIONAL - For VA Internal Planning Purposes Only

15.2.1 Training Requirements Under the MISSION Act, Section 133

15.3 Opioid Training Requirements

16 OPTIONAL TASK: DENTAL APPOINTMENT SCHEDULING

16.1 Dental Appointment Scheduling Process

16.2 Daily Dental Appointment Scheduling Reporting

17 SCHEDULE OF DELIVERABLES

18 DEFINITIONS

PRE-DECISIONAL - For VA Internal Planning Purposes Only

1 GENERAL INFORMATION 1

1.1 Introduction 2

The Department of Veterans Affairs (VA) Veterans Health Administration (VHA) Office 3 of Integrated Veteran Care (IVC) is a national program office that manages and 4 advocates for Veterans' and beneficiaries' access to health care in both VA and 5 community facilities. IVC administers Veteran and Family Member/Beneficiary 6 Programs such as the Community Care Network (CCN). CCN is a complex and diverse 7 system of healthcare services, delivering timely, accessible, and high-quality care to 8 Veterans. The complete network delivers medical, surgical, complementary, and 9 integrative health services, durable medical equipment, pharmacy, and dentistry 10 services. CCN services and healthcare resources are purchased under the authority of 11 38 United States Code (U.S.C.) § 1703, Veterans Community Care Program. Currently, 12 there are five (5) regional CCN contracts in place. VHA is interested in becoming the 13 trend-setter and standard-bearer for streamlined healthcare services and deploying 14 innovative medical and dental models throughout the nation via the Community Care 15 Network Next Generation (CCN Next Gen). CCN Next Generation services will be 16 delivered through a set of contracts structured around the following: 17

• CCN Next Generation - Medical Network: Regional medical and pharmacy 18 networks, and claims processing 19

• CCN Next Generation - Dental Network: National dental network and claims 20 processing 21

This draft Performance Work Statement (PWS) is for the CCN Next Gen - Dental 22 Network. 23

1.2 Scope of Services 24

The Contractor shall establish, maintain, and administer a network of licensed dental 25 providers per the requirements defined in this PWS and in accordance with Section 26

TBD, “SCHEDULE OF DELIVERABLES.” 27

The Contractor shall deliver dental services using tools and practices that drive quality, 28 efficiencies, cost savings, and a positive Veteran experience. 29

1.3 Applicable Documents 30

The Contractor shall comply with all relevant Federal, State, and local government 31 regulations, as well as specific regulations, publications, policies, and procedures 32 https://www.va.gov/COMMUNITYCARE/programs/veterans/CCN-Veterans.asp

PRE-DECISIONAL - For VA Internal Planning Purposes Only outlined in the contract. This includes the latest versions of documents available on the 33 CCN Next Generation Applicable Documents webpage. Updated documents will be 34 posted on the webpage immediately upon their issuance. The Contractor is responsible 35 for regularly checking the webpage, at least bi-weekly, to ensure compliance with the 36 most current versions of the applicable documents. 37

In addition to these applicable documents, the CCN Next Generation Dental Network 38 Contractor Manual, hereinafter referred to as the Dental Manual, provides the 39 Contractor with additional information, processes, and guidance associated with the 40 requirements set forth in this PWS. This PWS takes precedence over the information 41 within the Dental Manual. Semi-annual updates to the manual will be distributed to the 42 Contractor by the Government. Within five (5) business days of receiving an update, the 43 Contractor shall inform the Contracting Officer (CO) in writing if it is unable to implement 44 the changes and the reason(s) why. Urgent changes outside of the semi-annual update 45 schedule will be communicated in writing via the CO. To the extent practicable, the 46 Dental Manual Table of Contents mirrors the PWS to easily identify when there is 47 Dental Manual content for a PWS section. If there is no Dental Manual content for a 48 corresponding PWS section, then the section is marked “RESERVED.” 49

2 PROJECT MANAGEMENT 50

The Contractor is required to effectively manage the project by overseeing all aspects of 51 planning, execution, and monitoring to ensure the successful delivery of the contract’s 52 defined outcomes. This includes developing detailed project plans, mobilizing 53 appropriate resources, ensuring compliances with all contractual obligations, and 54 achieving project milestones and deliverables on schedule. 55

2.1 Post Award and Contract Kickoff Meetings 56

Within two weeks of the contract award, the Contractor shall organize and lead a Post 57 Award Meeting. The date and location for this meeting shall be determined through a 58 collaborative process between the Contractor and the VA CO to ensure mutual 59 convenience and availability. The Contractor shall ensure the attendance of key project 60 personnel, including the project manager, transition team lead, and any other relevant 61 stakeholders. The action items established during the meeting should be specific, and 62 measurable, and include assigned responsibilities and deadlines. The purpose of the 63 Post Award Meeting is to do the following: 64

• Initiate the communication process between VA and the Contractor including: 65

PRE-DECISIONAL - For VA Internal Planning Purposes Only o Introduction of Contractor and VA personnel performing work related to 66 this project 67 o Identification of Contractor and VA stakeholder’s roles and responsibilities 68

• Provide a comprehensive overview of the project’s administration processes and 69 reporting protocols, including the frequency of reports, key performance 70 indicators, and specific administrative responsibilities 71

• Establish action items/next steps and confirm dates, locations, and expectations 72 and agenda for the Kickoff Meeting 73

• Identify and assign action items to be resolved by the Kickoff Meeting 74

The Contractor shall participate in a Kickoff Meeting within 30 business days after the 75 contract award, with the specific date and location to be determined jointly by the 76 designated representatives of the Contractor and the CO and Contracting Officer’s 77 Representative (COR). The Contractor shall create and deliver a comprehensive 78 presentation at the Kickoff Meeting that outlines the approach, methodologies, and 79 timelines for all contract deliverables and services, aligning with the specifications in 80 Section TBD, SCHEDULE OF DELIVERABLES. The Kickoff Meeting presentation shall 81 be delivered 15 days prior to the Kickoff Meeting. The Contractor shall provide the 82 names and roles of its transition team lead and members to facilitate clear 83 communication and accountability throughout the contract implementation phase. 84

Within the Kickoff Meeting presentation, the Contractor shall describe and explain in 85 detail the following: 86

• Resolution of assigned action items from Post Award Meeting 87

• Approach to all deliverables and services under this contract in accordance with 88 the expectations defined in Section TBD, “SCHEDULE OF DELIVERABLES” 89

• Approach to achieving go-live within the timelines specified in Section 2.3, 90 “Deployment and Implementation” 91

• Approach to communications required to manage the overall CCN Next 92 Generation Dental Network project to include: 93 o Key messages that shall be articulated to the VA stakeholders to include 94 the timing associated with the delivery of those messages 95

PRE-DECISIONAL - For VA Internal Planning Purposes Only o Communication method, type, style, and channels the Contractor will use 96 to reach VA stakeholders and Veterans, as well as the desired outcomes 97 for the communication. VA stakeholders, by role and hierarchy, that shall 98 be included in communications are identified in Attachment TBD, 99 “Community Care Network Stakeholders List” 100 o Action items and issues that require immediate response and coordination 101 with VA 102

• Explanation of the Implementation Strategy including all key elements in Section 103 2.3, “Deployment and Implementation” in detail such that it can be presented to 104 and reviewed by VA subject matter experts allowing them to provide real-time, 105 meaningful feedback prior to execution of the Implementation Strategy 106

• System Access and Controls Manual for access to Contractor Systems, as 107 described in Section 14.1, “Communication and Access to Contractor Systems” 108

• Explanation of the training approach which is addressed in the Training Plan 109 described in Section 15.0, “Training” 110

The Contractor shall record detailed meeting minutes of the Kickoff Meeting, which shall 111 be submitted to the CO and COR within five (5) business days post-meeting. These 112 minutes should comprehensively document all discussions, including any major issues, 113 agreements, disagreements, and agreed-upon actions with specific timelines for 114 resolving any actions and/or disputes. 115

Deliverables: (See Section TBD, “SCHEDULE OF DELIVERABLES” for details.) 116

• Kickoff Meeting Presentation 117

• Kickoff Meeting Minutes and Action Items 118

2.2 Integrated Master Schedule 119

The Contractor shall create and maintain a fully resource-loaded and baselined 120 Integrated Master Schedule (IMS) in a mutually agreed upon format that depicts the 121 implementation and deployment of the CCN Next Generation Dental Network pursuant 122 to this contract. The Contractor shall use the IMS to manage and report on all elements 123 of the CCN Next Generation Dental Network. 124

The Contractor shall include the following in the IMS: 125

PRE-DECISIONAL - For VA Internal Planning Purposes Only

• Work Breakdown Structure (WBS) to a minimum of three levels to define the 126 activities, tasks, and outcomes 127

• Discrete events necessary to complete the project, including identifying and 128 documenting the definition of the relationship between and among these events, 129 and determining the expected duration of each event and resources required for 130 each 131

• Critical path depiction showing tasks that, if delayed in completion, will impact the 132 overall timeline; the Contractor shall notify the CO and COR within one (1) 133 business day when data is provided/entered that creates overall critical path 134 slippage 135

• Planned (baselined IMS) versus actual program/project performance 136

• Milestones to measure progress toward completion of individual WBS elements 137

The Contractor shall obtain approval from the CO and COR for all proposed changes to 138 the IMS. 139

The IMS shall be submitted to the CO and COR five (5) business days prior to the 140 Kickoff Meeting and updated quarterly as part of the Project Management Review 141 (PMR) and as requested by the CO and COR. 142

Deliverable: (See Section TBD, “SCHEDULE OF DELIVERABLES” for details.) 143

• Integrated Master Schedule (IMS) 144

2.3 Deployment and Implementation 145

The Contractor shall develop a Deployment and Implementation Strategy to detail the 146 Contractor’s approach to implementing the CCN Next Generation Dental Network. The 147 Deployment and Implementation Strategy shall be submitted with the Contractor’s 148 proposal and will be incorporated into the contract at contract award. The Contractor 149 shall execute the Deployment and Implementation Strategy. 150

The Deployment and Implementation Strategy shall outline the implementation of all 151 requirements in this PWS. 152

The Deployment and Implementation Strategy shall also contain the Contractor’s 153 Transition-in Plan that includes, but not limited to: 154

• Planned transition meetings and schedule 155

PRE-DECISIONAL - For VA Internal Planning Purposes Only

• Transition execution steps with associated milestones ensuring seamless 156 continuation of dental care delivery 157

• Expected VA inputs to ensure effective transition 158

• Recruitment plan for bringing in current community providers into the network 159 and how unilateral providers will be engaged 160

The Contractor’s transition team shall be responsible for coordinating with VA and the 161 incumbent contractor(s) to identify the documentation, access to personnel (both VA 162 and incumbent contractor), and system access necessary to begin the process of 163 reaching operating capability to go-live. The Contractor shall provide a bi-weekly 164 Deployment and Implementation Status Report on all activities related to 165 implementation until go-live is achieved. The Status Report shall be aligned to the 166 Deployment and Implementation Strategy and shall specify activities occurring at each 167 Station during the reporting period. The Deployment and Implementation Status Report 168 shall demonstrate readiness prior to go-live at each Station. The CO and COR will 169 review and approve the Status Report. Upon approval, the CO will notify the Contractor 170 that they shall initiate go-live activities. Go-live at each Station will be achieved upon CO 171 and COR acceptance. 172

The Contractor shall achieve go-live no later than 18 months from contract award. 173 Successful deployment shall ensure operational readiness, provider network adequacy, 174 and completed training. The Contractor shall: 175

• Prepare for deployment of the CCN Next Generation Dental Network 176

• Participate in on- and off-site readiness planning and deployment activities to 177 ensure operational readiness and provider network adequacy (e.g., 178 communication scripting, embedded staff participation in go-live activities, data 179 reports) 180

• Conduct user acceptance testing in coordination with VA, completed and 181 accepted by the CO and COR prior to go-live 182

• Provide the summary of testing and completed resolutions for the Contractor 183 interactive voice response (IVR) and Contractor self-service portal for CO and 184 COR acceptance of Fully Operational IVR and Contractor self-service portal 185

• Complete Contractor and network provider training requirements 186

PRE-DECISIONAL - For VA Internal Planning Purposes Only

• Stand-up and operate a Deployment Command Center which shall include 187 information technology (IT) support, customer service, claims, and network 188 support. Contractor staff within the Deployment Command Center shall provide 189 CO and COR with an ongoing update of network build issues, identified issues 190 and plans for resolution, and status of network provider identification and 191 recruitment. 192

• Test and implement all technical solutions as described in Section 14.2, 193 “Configuration Management and Testing” 194

Deliverable: (See Section TBD, “SCHEDULE OF DELIVERABLES” for details.) 195

• Deployment and Implementation Strategy 196

• Deployment and Implementation Status Reports 197

2.4 Risk Management 198

The Contractor shall manage risks using the Project Risk Register in Attachment TBD, 199 “Project Risk Register” which shall consist of risk and issue management processes. 200 For each risk identified, the Contractor shall include severity of risk, volumes, 201 associated impacts (system, Veteran experience, provider experience, etc.), measures 202 to either minimize or eliminate the potential impact, and timelines for mitigation to be 203 completed. 204

The Contractor shall deliver the Project Risk Register quarterly and report on the risks 205 during the PMRs. 206

The Contractor shall submit updated risk responses and actions, to include mitigation 207 strategies in the quarterly submission of the Project Risk Register. In addition, the 208 Contractor shall report risk(s) identified as having an extreme impact within 24 hours of 209 their identification(s). 210

The Contractor shall collaborate with VA to establish the priority, scope, bounds, and 211 resources for managing project risks and issues, and/or assess the courses of action 212 related to them. The Contractor shall inform VA of relevant deliberations and 213 recommendations to mitigate and resolve risks and issues as they are identified. VA has 214 final approval of risk and issue mitigation. 215

Deliverable: (See Section TBD, “SCHEDULE OF DELIVERABLES” for details.) 216

• Project Risk Register 217

PRE-DECISIONAL - For VA Internal Planning Purposes Only

2.5 Contract Performance Management 218

2.5.1 Quality Assurance Surveillance Plan 219

VA will use a Quality Assurance Surveillance Plan (QASP) to monitor the quality of the 220 Contractor’s performance. The oversight provided for in the QASP will help to ensure 221 that service levels reach and maintain the required levels throughout the contract term. 222 The QASP is a tool used by the Government; therefore, it remains a living document 223 through the contract and/or task order performance period. 224

While the QASP itself is not part of the contract, Attachment 1 of the QASP 225 (“Performance Requirement Summary (PRS)”) is incorporated into the contract as an 226 attachment to this PWS (see Attachment TBD). The QASP will be finalized upon 227 contract award and a copy will be provided to the Contractor for informational purposes 228 only. The CO may make unilateral changes to the QASP, as well as to any methods of 229 surveillance, surveillance schedules, and frequencies of surveillance identified in the 230 PRS. Changes to the performance objectives, Acceptable Quality Levels (AQL) or 231 standards, and incentives/disincentives identified in the PRS shall be executed via 232 bilateral agreement between VA and the Contractor. 233

The Contractor shall meet all performance requirements established by the PWS and 234 PRS. VA will assess performance and apply incentives and disincentives in accordance 235 with the PRS and make equitable adjustments as determined by the CO. Further, the 236 Contractor, because of failure to meet contract requirements, is subject to any or all 237 punitive measures permitted by the Federal Acquisition Regulation (FAR) and VA 238 Acquisition Regulation, as determined by VA. 239

2.5.2 Quality Assurance Program and Plan 240

The Contractor shall implement its own Quality Assurance (QA) program. The 241 Contractor shall develop, maintain, and execute a QAP. The QAP shall detail the 242 Contractor’s QA program and how the Contractor shall implement QA to ensure that the 243 Contractor executes the performance of the requirements in this PWS and meets and/or 244 exceeds the AQLs identified in the PRS throughout the life of the contract. The 245 Contractor’s QAP shall include, at a minimum, staffing, processes, procedures, and 246 technologies used by the Contractor to ensure quality, timeliness, responsiveness, 247 customer satisfaction, and other performance requirements. 248

The Contractor’s QAP shall be submitted with its proposal and incorporated by 249 reference into the contract upon contract award. The Contractor is responsible for the 250 quality of all work performed under this contract; thus, the Contractor shall make 251

PRE-DECISIONAL - For VA Internal Planning Purposes Only required changes in staffing, processes, procedures, and technologies, at no additional 252 cost to the Government, to ensure performance is managed effectively. Any changes or 253 updates to the Contractor’s QAP shall be submitted to the CO and COR for approval 254 prior to implementing the changes or updates. 255

Deliverable: (See Section TBD, “SCHEDULE OF DELIVERABLES” for details.) 256

• Quality Assurance Plan 257

2.5.3 Quality Improvement Plan 258

As requested by the CO and COR, the Contractor shall develop a Quality Improvement 259 Plan (QIP) to address any area of concern identified by VA. The Contractor shall 260 implement each QIP upon CO and COR review and approval. The QIP shall detail how 261 and by what date the Contractor shall bring performance up to the required levels. If 262 problems have not been completely resolved, the Contractor shall provide an 263 explanation, including its plan and timeframe for fully resolving the issue or concern. 264 The Contractor shall report its status in the Monthly Progress Report (MPR), see 265 Section 2.6, “Progress Reporting.” The Contractor shall participate in related ad hoc 266 meetings with VA to address performance issues at no additional cost to the 267 Government. 268

Deliverable: (See Section TBD, “SCHEDULE OF DELIVERABLES” for details.) 269

• Quality Improvement Plan 270

2.6 Progress Reporting 271

The Contractor shall develop and submit MPRs to the CO and COR. The Contractor 272 shall utilize Attachment TBD, “MPR Template,” to populate and submit the MPR. The 273 MPR shall include: 274

• Work and Progress Summary 275

A. Task Summary – summarizes the work that is being performed 276

B. Schedule Summary – summary of schedule elements that correspond with the 277 reporting period 278

C. Actual Activities for the Preceding Month – summary of activities completed during 279 the month 280

PRE-DECISIONAL - For VA Internal Planning Purposes Only

D. Planned Activities for Next Month – summary of activities to be completed during the 281 next month 282

E. Self-identified Corrective Actions and Improvements – categorized narrative listing 283 of the operational corrective actions and improvements that were executed during 284 the reporting period 285

• Risks and issues for all CCN Next Generation Dental Network activities 286

• Operations support activities 287

• Network adequacy outcomes during the reporting period, including any identified 288 network inadequacies 289

• Customer service outcomes during the reporting period, including results of 290 customer service quality reviews and customer service availability statistics 291

• Claims processing outcomes during the reporting period 292

The MPRs shall reflect the data as of the last day of the preceding month, identify the 293 sources from which the data is pulled, and include notifications when updates to the 294 data or data sources are made. 295

Additionally, the Contractor shall facilitate the quarterly PMRs with VA at VA approved 296 locations. The Contractor shall draft the PMR materials using Attachment TBD, “PMR 297 Template.” The PMR presentation shall include information contained in the MPRs for 298 the most recent quarter, including but not limited to contract performance, project 299 management, and major VHA initiatives and topics to be identified by VA. The 300 Contractor shall provide the draft PMR materials at least 15 days prior to the PMR. 301

The PMR materials shall contain: 302

• Risk status (see Section 2.4, “Risk Management”) 303

• Continuous Query (CQ) monitoring results (see Section 3.4, “Credentialing”) 304

• Provider satisfaction survey results (see Section 5.5, “Dental Network Provider 305 Satisfaction Surveys”) 306

• Medical documentation return compliance information (see Section 8.4, “Medical 307 Documentation Compliance” 308

PRE-DECISIONAL - For VA Internal Planning Purposes Only

• Key metrics and fraud and abuse summary report (see Section 12.2, “Predictive 309 Analytics”) 310

• Program and payment integrity site visit finding (see Section 12.18, “Program 311 and Payment Site Visits”) 312

• Patient safety reports (see Section 13.2.1, “Reporting”) 313

The Contractor shall participate in ad hoc project related meetings as requested by VA. 314

Deliverables: (See Section TBD, “SCHEDULE OF DELIVERABLES” for details.) 315

• Monthly Progress Reports 316

• Project Management Review Materials 317

2.7 Service Organization Control Reporting 318

The Contractor shall engage an unaffiliated external auditing firm to conduct a Service 319 Organization Control (SOC) 1, Type 2 Report, Report on Controls at a Service 320 Organization Relevant to User Entities Internal Control over Financial Reporting, in 321 accordance with Statement on Standards for Attestation Engagements (SSAE) No. 21 322 or in accordance with the current guidance issued by the Auditing Standards Board and 323 will provide the CO and COR with a written copy of the SOC 1 Type 2 examination 324 report (hereby knows as the “Prime Report”). The independent auditing firm shall have 325 prior experience in conducting SSAE audits. In addition, the Contractor shall provide a 326 written copy of the SOC 1 Type 2 report, completed in accordance with SSAE 21, for 327 any subservice organization (hereby known as the “Subcontractor Report”). 328

The Prime and Subcontractor Reports will address the specific services provided by the 329 Contractor to VA under the contract. The current guidance for SSAE 21 was issued in 330 April 2016, SSAE 21 Audits | SOC – Previously SSAE-16. This guidance may be 331 updated during the performance of the contract. The Contractor shall comply with 332 updates to SSAE 21 and provide new reports as required by any changes to the SSAE 333 guidance. 334

The Contractor shall engage an unaffiliated external auditing firm to conduct a SOC 2, 335 Report on Controls at a Service Organization Relevant to Security, Availability, 336 Processing Integrity, Confidentiality and Privacy, Type 2 Report, (the “Prime Report”) in 337 accordance with SSAE 21 and Trust Service Principles Criteria. The unaffiliated 338 external auditing firm may be the same firm that provides the SOC 1 Type 2 report. The 339 report shall cover all trust principles to include Security, Availability, Processing 340

PRE-DECISIONAL - For VA Internal Planning Purposes Only

Integrity, Confidentiality and Privacy, and ensure compliance with the Health Insurance 341 Portability and Accountability Act (HIPAA) under those principles. 342

2.7.1 SOC 1 and SOC 2 Reporting Specifications and Deliverables 343

VA’s fiscal year begins October 1 and ends on September 30. The Contractor shall 344 submit initial Prime and Subcontractor Reports (SOC 1, Type 2, and SOC 2 Type 2) for 345 current business and financial operations. The initial reports shall cover a minimum of 346 nine (9) months from contact award. Any deviation to the initial reports minimum shall 347 be approved by the CO. Subsequent Prime and Subcontractor Reports shall cover a 348 minimum of 12 months, with a Bridge Letter covering the gap between the end date of 349 the period covered by the Prime and Subcontractor Reports and the end of VA’s fiscal 350 year. The Contractor shall address the Bridge Letters to the CO and COR from 351 Contractor senior management and shall specify the coverage begin and end dates. 352 The Bridge Letter shall include Contractor management’s assertion that the processes 353 and internal controls in effect during the period covered by the applicable Prime and 354 Subcontractor Reports remain in effect, and/or summarize any material changes in the 355 control environment and the impact to VA. The Bridge Letter shall provide an 356 acknowledgement that it is not a replacement for the actual Prime or Subcontractor 357 Reports. 358

All Prime and Subcontractor Reports shall clearly indicate the services, systems, and 359 locations covered by the review, as well as the nature and type of control testing 360 performed. The Contractor shall also account for controls over subservice organization 361 (Subcontractor) services and performance. The Prime and Subcontractor Reports shall 362 cover all processes and services performed by the Contractor that align to VA 363 contractual requirements. The Contractor shall include a cover letter on all Prime and 364 Subcontractor Reports clearly identifying the Contractor that is performing services 365 within the scope of the contract. The cover letter shall be addressed to the CO and COR 366 and summarize the results of the audit and the audit tests performed. The letter shall 367 highlight unusual items, deficiencies, qualifications, and any inconsistencies with 368 professional standards and provide an indication of actions being taken to address, 369 remedy, or mitigate these or other weaknesses noted in the applicable report. 370

Deliverables: (See Section TBD, “SCHEDULE OF DELIVERABLES” for details.) 371

• SOC 1, Type 2 – Prime Report 372

• SOC 2, Type 2 – Prime Report 373

• SOC 1, Type 2 – Subcontractor Report 374

PRE-DECISIONAL - For VA Internal Planning Purposes Only

• SOC 2, Type 2 – Subcontractor Report 375

• SOC 1 and SOC 2 Bridge Letters 376

2.8 Contractor Maintained Records 377

Upon written request from the CO and COR, the Contractor shall provide any and all 378 records, information, and data in its possession, custody, or control in the requested 379 format, including, but not limited to, claims data; raw X12 electronic data interchange 380 (EDI) data and metadata; claims images; medical records; network provider 381 agreements; credentialing documentation; licensing files; competency measures; 382 Federal exclusionary list matching; potential quality issues submitted by VA facilities 383 and all related review, data, and actions taken in response to potential quality issue 384 concerns; network provider education materials and related correspondence; network 385 provider applications; network provider communications; and bank/payment records. 386 The Contractor shall also ensure timely and reasonable access to its personnel for the 387 purpose of interview and discussion by VA and other government officials conducting an 388 audit, inspection, or investigation. The Contractor shall include VA’s right to access 389 network provider records, information, and data as described in this paragraph in its 390 provider agreements. 391

The Contractor shall provide access to the aforementioned artifacts within five (5) 392 business days of request. Any issues identified during VA review will be sent to the 393 Contractor. The Contractor shall correct the issues within the VA specified timeframe. 394

2.9 Cooperation 395

The Contractor shall, on an ongoing basis and throughout the duration of the contract 396 period of performance, cooperate with, collaborate and interact with, and generally 397 maintain an effective working relationship with all other Contractor entities with current 398 VA IVC contracts. 399

Liability for the improper disclosure of any Contractor proprietary data by any Contractor 400 entity rests with the Contractors, and not the Government. 401

2.10 Transition Out 402

The Contractor shall perform the Transition Out and residual service tasks below for this 403 contract. Transition Out activities require collaboration with a team comprised of VA 404 and/or successor Contractor personnel. The term Transition Out is related to activities 405 taking place during and after the last option period, in which the Contractor is 406

PRE-DECISIONAL - For VA Internal Planning Purposes Only transferring duties and responsibilities to a VA appointed designee, whether a 407 government entity, another Contractor, or a mix of both. 408

The Contractor shall provide residual services during the transition out period, after the 409 Contractor’s network no longer provides care, including continuing to process claims, 410 appeals, grievances, and support customer service for dental care that was previously 411 delivered. All parties involved in Transition Out services shall ensure minimal disruption 412 of services to Veterans receiving care and network providers delivering care. 413

Transition Out activities shall include the following: 414

• Delivery of a Transition Plan inclusive of a timeline of major events, key positions 415 responsible for each of the functional areas involved in the Transition Out and 416 processing of residual service inventories (e.g., claims, appeals, grievances), and 417 staffing and other resources (e.g., transition project manager, transitions 418 stakeholders) within 180 days of award 419

• Provide retroactive processing of referrals and claims adjudication for authorized 420 care up to 180 days following go-live of the new contract 421

• Processing of all open dental claims inventories (the outgoing Contractor shall 422 submit weekly status reports of claim inventories and phase-out activities to the 423 CO and COR beginning the 20th day after notification from the CO to commence 424 transition out activities) 425

• Transitioning open referrals to an incoming Contractor, as directed by the CO 426

• Providing a current inventory of all Government-owned assets used by the 427 Contractor over the life of the contract along with full support in the reconciliation 428 of the inventory as needed 429

• Providing “shadowing” and other knowledge transfer meetings and opportunities 430 to facilitate the transfer of information, processes, and data needed to continue 431 the services being performed by the Contractor 432

• Removal and purging of all non-public or other government-furnished information 433 from any Contractor-owned system, and providing certification of execution to the 434 CO and COR 435

• Update of the Transition Out Plan seven (7) days after request is made from the 436 CO to incorporate updates and the successor/incoming Contractor’s Transition-in 437

PRE-DECISIONAL - For VA Internal Planning Purposes Only

Plan (included as part of successor/incoming Contractor’s Implementation 438 Strategy) 439

• Develop a customer service phone line transition message stating the line is no 440 longer in service as of the end date of the contract and to contact a phone 441 number directed by VA for assistance. This shall be maintained 120 days post 442 Period of Performance end date. The Contractor shall transition the phone line to 443 VA following the 120 days. 444

The list above is not exhaustive. The CO may discuss additional items or considerations 445 related to phasing out services prior to Transition Out. The services required to 446 Transition Out will only be required in the event of a need for an actual transition. The 447 Transition Out Plan and Update when requested by the CO) shall be delivered to the 448 CO and COR. After VA approval of the Transition Out Plan and Update, the Contractor 449 shall execute the plan. 450

Deliverables: (See Section TBD, “SCHEDULE OF DELIVERABLES” for details.) 451

• Transition Out Plan and Update 452

• Weekly Status Report of Claims Inventories and Phase-Out Activities 453

• Government-owned Asset Inventory List 454

3 DENTAL NETWORK DEVELOPMENT AND MAINTENANCE 455

3.1 Dental Network Establishment and Maintenance 456

The Contractor shall establish, maintain, and manage a CCN Next Generation Dental 457 Network consisting of a comprehensive network of qualified dental providers. The 458 Contractor shall ensure that network providers have a signed and executed network 459 agreement. 460

The Contractor shall maintain a network of dental facilities and providers that extends 461 across the entirety of the nation and identified territories and is sufficient in size, scope, 462 and capacity to ensure that all services are accessible within the minimum network 463 adequacy standards found in Table 1 - Dental Network Adequacy Standards. 464

Measurement of Network Adequacy will be comprised of two elements: drive time and 465 appointment availability. The combination of these elements ensures the adequate build 466 and proper maintenance of the network. 467

PRE-DECISIONAL - For VA Internal Planning Purposes Only

Drive times are defined as the time required to drive between the Veterans’ official 468 residence (as determined in the eligibility and enrollment system) and the rendering 469 network provider’s physical address (based on care site locations listed in the 470 Contractor’s network provider data submitted to VA, as described in Section 3.5, “Dental 471 Network Provider Data for VA’s Provider Directory”). Drive times shall be determined 472 using the Contractor’s geo-mapping solution. 473

CCN Next Generation Dental Network adequacy standards for appointment availability 474 shall be measured based on the amount of time, calculated in calendar days, from the 475 date the referral is approved by VA to the initial date of service captured on the first 476 claim processed from the initial receiving network provider. Instances where a Veteran 477 chooses an appointment outside the appointment timeliness standard as documented 478 on the referral, shall be excluded from measurement for appointment timeliness. 479

The Contractor shall comply with network adequacy standards at individual VA Medical 480 Center (VAMC) catchment level and by specific categories of care. 481

Table 1 - Dental Network Adequacy Standards 482

Drive Times

Urban 45 minutes

Rural/Highly Rural* 60 minutes

Appointment Timeliness

28 days

*Note: Rurality is uniquely defined for each Veteran by VA. 483

3.1.1 Dental Network Adequacy Plan 484

The Contractor shall develop a CCN Next Generation Dental Network Adequacy Plan to 485 document the Contractor’s approach for creating and maintaining an adequate network 486 with details focusing on how all dental network adequacy requirements will be 487 addressed for services outlined in Section 3.1, “Dental Network Establishment and 488 Maintenance.” 489

PRE-DECISIONAL - For VA Internal Planning Purposes Only

As part of the CCN Next Generation Dental Network Adequacy Plan, the Contractor 490 shall include the following elements: 491

• Approach to building and maintaining a network with sizing and capacity specific 492 to each VAMC including details on the numbers and types of providers entering 493 the CCN Next Generation Dental Network (including those from other 494 contractors, Federally Qualified Healthcare Centers (FQHCs), and VA-identified 495 preferred providers) 496

• Recruitment and communication plan for transitioning currently contracted 497 providers into the CCN Next Generation Dental Network through unilateral and 498 bilateral agreements 499

• Geo-mapping drive time calculations solution and providing VA access to that 500 solution 501

• Identification of areas and services that may require a network adequacy 502 deviation 503

• Management of short notice network needs, including engagement with VAMCs 504 and consistent representation at monthly network adequacy meetings, as 505 described in Section 3.3, “Network Adequacy Management” 506

The Contractor shall submit the CCN Next Generation Dental Network Adequacy Plan 507 with the proposal. The CCN Next Generation Dental Network Adequacy Plan shall be 508 incorporated into the contract upon VA approval. The Contractor shall execute in 509 accordance with the CCN Next Generation Dental Network Adequacy Plan. 510

Deliverables: (See Section TBD, “SCHEDULE OF DELIVERABLES” for details.) 511

• Dental Network Adequacy Plan 512

3.2 Dental Provider Network 513

The Contractor shall identify, contact, negotiate, and contract with dental providers. 514 Additionally, the Contractor shall ensure that the dental providers it contracts with 515 understand requirements of the CCN Next Generation Dental Network and their role as 516 a network provider. 517

The CCN Next Generation Dental Network shall include both general and specialized 518 dental care. Specialized dental services shall include recognized American Dental 519 Association (ADA) specialties. Recognized ADA Dental Specialties are Endodontics, 520

PRE-DECISIONAL - For VA Internal Planning Purposes Only

Oral and Maxillofacial Pathology, Oral and Maxillofacial Radiology, Oral and 521 Maxillofacial Surgery, Periodontics, Oral Medicine, Prosthodontics, Dental 522 Anesthesiology, Orthodontics, and Orofacial pain. Referrals to specialists shall be to a 523 dentist who has either completed a Commission on Dental Accreditation accredited 524 specialty training program or a board-certified specialist. A dentist who does not meet 525 the stated criteria shall not be substituted when a VA dentist has referred a Veteran to a 526 specialist. 527

The Contractor shall make every reasonable attempt to include academic teaching 528 facilities (academic affiliates), FQHCs, and Tribal Health Programs (THPs) as part of the 529 CCN Next Generation Dental Network. VA will provide a list of THPs to the Contractor 530 at award. The Contractor shall provide documentation to the CO and COR of the 531 reasons and rationale when academic affiliates, FQHCs, or THPs do not join the 532 network as part of the Network Build Report described below. The Contractor shall 533 annotate academic affiliates, FQHCs, and THPs within the data provided to VA for the 534 provider directory. 535

The Contractor shall make every attempt to enroll out-ot-network providers and 536 providers in the CCN Next Generation Dental Network that have current referrals from 537 VA, allowing Veterans to remain with their existing providers. The Contractor shall 538 ensure all providers will be considered for inclusion in the network and not be denied or 539 placed on a wait list due to network adequacy in that given area. Denials are 540 appropriate as detailed under Section 3.4, “Credentialing.” 541

The Contractor shall develop a Dental Network Build Report to provide VA with an 542 ongoing update of network status, build issues, plan for resolution, identification of 543 providers to recruit, and status of recruitment. The Dental Network Build Report shall be 544 submitted to the CO and COR weekly and contain, but is not limited to, the following: 545

• Summary of identified issues requiring action plans by VAMC catchment 546

• Overview of plan to address identified issues 547

• Full listing of health care providers in recruitment by VAMC catchment including 548 the following fields: 549

F. Provider name 550

G. Provider National Provider Identifier (NPI) 551

H. Dental specialty (if applicable) 552

PRE-DECISIONAL - For VA Internal Planning Purposes Only

I. Care site locations, including coverage area (if applicable) 553

J. Date of initial contact 554

K. Date of contracting completion or rationale for not contacting 555

L. Date the provider received the credentialing application 556

M. Date of credentialing completion 557

N. Date of required training completion 558

O. Date provider included in the provider data submitted for VA's provider directory 559

The Contractor shall supply additional or modified data at VA’s request. 560

VA reserves the right to request the Contractor to recruit specific providers and/or 561 provider groups into the CCN Next Generation Dental Network. 562

Deliverable: (See Section TBD, “SCHEDULE OF DELIVERABLES” for details) 563

• Dental Network Build Report 564

3.3 Network Adequacy Management 565

The Contractor shall monitor dental network adequacy, including any gaps or 566 deficiencies. 567

The Contractor shall notify VA of potential network inadequacies in the Dental Network 568 Build Report and in the MPR. 569

Through a consistent point of contact, with authority to act on network adequacy issue 570 resolution, the Contractor shall support monthly network adequacy meetings per Station 571 facilitated by VA stakeholders. Additionally, the Contractor shall support VA-requested 572 ad hoc meetings limited to no more than two times per month per Station. At VA’s 573 request, the Contractor shall coordinate and facilitate the network adequacy meetings. 574

3.3.1 Dental Network Deviation Requests 575

The Contractor may submit Dental Network Deviation Requests for a deviation to the 576 network drive time standards to the CO and COR if it is unable to meet CCN Next 577 Generation Dental Network adequacy due to a lack of providers in a specific area. VA 578 will consider the Contractor’s requests under specific and limited circumstances for 579 covered CCN Next Generation dental services. VA approved Dental Network Deviation 580

PRE-DECISIONAL - For VA Internal Planning Purposes Only

Requests will provide alternate and/or expanded drive time standards and will be 581 excluded from performance standards. 582

Each Dental Network Deviation Request shall be supported by information and 583 documentation as specified in the Attachment TBD, “Dental Network Adequacy 584 Deviation Request.” The Contractor shall submit all Dental Network Deviation Requests 585 to the CO and COR in writing, using the most current Dental Network Deviation Request 586 Form (Attachment TBD, “Dental Network Adequacy Deviation Request.”). If deviation 587 requests are needed for multiple specialists and counties, the Contractor shall include 588 the Multiple Specialty Deviation Addendum to Attachment TBD, “Dental Network 589 Adequacy Deviation Request.” 590

The Contractor shall ensure the availability of services with approved Dental Network 591 Deviation Requests, despite…