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Question # Source Document Section # Section Title Page # or Line # West Cross Reference Question from Industry VA Response
| 1 | PWS/Manual | 4.6.7 | | | Q29 | Our understanding of the Mission Act is that eyeglasses products and specialty lenses are not included in the CCN contracts. The PWS section 4.6.7 mentions "The Contractor shall provide medically necessary specialty lenses and associated fittings." The Contractor Manual mentions "Eyeglasses/Corrective Lenses: Eyeglasses and subsequent eyeglass fittings are not authorized as CCN does not cover the cost of eyeglasses and/or contacts. Eyeglass prescriptions, if indicated, will be provided to the Veteran to bring to their local VA facility in person for obtaining the eyeglasses (and related fittings) or provided per local VA facility policy." Please confirm if the intention is to include or exclude eyeglasses and specialty lenses in this contract? | VA will clarify the requirement in the RFP. |
| 2 | RFI | 6.0 | Questions | | N/A | Can VA clarify if it is expecting all responses to the RFI to use the Attachment 6 Vendor Response Template only or will VA also accept supplemental attachments to expand upon questions or recommendations, for information that may be cumbersome (such as a large amount of text) to insert into an excel file cell/field? | The Offeror should provide its responses to the questions in Section 6.0 on the Excel template. All other feedback may be submitted in either Word or PDF in accordance with Sections 4.2 and 5.0. |
| 3 | RFI | 7.0 | Attachments | | N/A | Can VA clarify that the Attachment 6 is the correct template for this RFI or is there another template that will be made available for the Medical Network(s)? | Attachment 6 is the correct template. The tab title has been updated. |
| 4 | Solicitation File | 5.0 | Submission Instructions: Formatting Guidelines | 7 | N/A | With respect to the Formatting Guidelines in both Presolicitation Notice documents outlined on page 7 of the RFI, will VA please clarify if our RFI response should be submitted within Attachment 6 - Vendor Responses Template, or if we may submit as a Word document converted to PDF? We assume a Word Document or PDF is the preferred method. | The Offeror should provide its responses to the questions in Section 6.0 on the Excel template. All other feedback may be submitted in either Word or PDF in accordance with Sections 4.2 and 5.0. |
| 5 | Solicitation File | 5.0 | Submission Instructions: Formatting Guidelines | 7 | N/A | With respect to the Formatting Guidelines in the Presolicitation Notice file, it states: Bullet #7 Header/Footer: Include company name and RFI number (36C10G25Q0090 or 1) in footer. | |
Question: Will VA allow the submitting company name to be placed in the page header only and not in the footer?
| Reason: Industry standard dictates having the submitting company name in the header only. Placing it in the footer as well creates a very crowded footer format. | Bullet #7 Header/Footer: Include company name and RFI number in footer. | | | | | | | |
| 6 | Solicitation File | N/A | N/A | N/A | N/A | Will VA clarify the Veteran and Member internal identifiers (are they ICN or PCN); will they be in the eligibility file and on all of the referrals? | This clarification is currently provided in the Medical Manual. |
| 7 | Solicitation File | N/A | N/A | N/A | N/A | Is the only integration pattern available via 278/275 for submission and clinical attachments? | DAS/EDI Gateway is the approved gateway for sharing data between external and VA entities. VA System Integration Requirements are described in Section 15.4.1. |
| 8 | Solicitation File | N/A | N/A | N/A | N/A | Prior to the release of the final solicitation, does VA intend to publish a Draft RFQ/RFP? If so, what is the expected release date? | VA is considering a dRFP; no decision is available at this time. |
| 9 | N/A | | N/A | N/A | N/A | Does VA intend to release updated utilization data prior to RFP release? The last data received was from FY22, and offerors would be better prepared to bid with updated utlization data. | VA will provide this information with the RFP. |
| 10 | Program Concepts | 2.1 | Waivers of Payment Rates | 17 | N/A | Do the following services qualify as scarce resources: CAR T, Transplant, and Gene Therapy? | It is expected that Contractors build their networks to include all medical services. Waivers will be determined on a case by case basis. |
| 11 | Program Concepts | 2.1 | Waivers of Payment Rates | 17 | N/A | Will VA clarify the approval or waver process for negotiated rates; specifically, how it applies when establishing a single case agreement for transplant services? | Refer to the Medical Manual. |
| 12 | Program Concepts | 2.1 | Waivers of Payment Rates | 17 | N/A | Can you clarify the expected turn around time for reviewing and approving waivers, specifically in the case when the waiver is required to support a single case agreement. Additionally, how should contractors account for this waiver timeline when adhering to the requirements to respond to SCA's within 30 days. | Although timelines are not defined, refer to the CCN Medical Manual for the steps to follow for a SCA. The rate waiver review/approval process would remain consistant. |
| 13 | PWS | 2.5.3 | Quality Improvement Plan | 16 | N/A | "The Contractor shall develop and implement a Quality Improvement Plan (QIP) when performance fails to meet VA standards." | |
| What thresholds or trends trigger the requirement for a Quality Improvement Plan (QIP)? | Triggers for QIPs may include, but are not limited to, failure to meet or downward trending AQLs or inadequate performance of other PWS requirements (e.g., timely delivery of deliverables, excessive errors in deliverables, correct application of claims adjudication requirements, etc.). | | | | | | |
| 14 | PWS | 2.1 | Transition Out | 21 | N/A | "The Contractor shall develop and execute a Transition-Out Plan that ensures continuity of care and transfer of all operational systems and data." |
Will VA clarify expectations for transition-out requirements at contract conclusion?
Will there be penalties for data or system transfer delays?
Will there be incentives for expediting? The PWS language currently outlines the requirements for transition out activities and includes the following statement "The CO may discuss additional items or considerations related to phasing out services prior to Transition Out." VA will provide further details with the RFP.
Formal incentives and disincentives/penalties are not included as part of this contract structure. However, failure to adequately meet contract requirements may be reflected in CPARS and/or other appropriate actions as determined by the CO.
15 PWS 2.10 Transition Out 22 N/A “Providing “shadowing” and other knowledge transfer meetings and opportunities to facilitate the transfer of information, processes, and data needed to continue the services being performed by the Contractor”
| What duration should be expected for shadowing support? | VA anticipates that the Transition-Out Plan developed by the Contractor will include an appropriate and reasonable duration of shadowing and knowledge transfer for each activity. | | | | | | | |
| 16 | PWS | 3.1 | Medical Network Establishment and Maintenance | 24 | N/A | Does the VA define PCP eligibility based solely on licensure and scope of practice (e.g., MD/DO, NP, PA), or is there an established list of recognized specialties (such as Family Medicine, Internal Medicine, General Practice, etc.) used to determine provider inclusion? | VA will provide this information with the RFP. |
| 17 | PWS | 3.2 | Medical Provider Network | 27 | N/A | When can a list of Legacy CCN providers that have current referrals from VA be available? PWS Line 772: VA reserves the right to request the Contractor to recruit specific providers and/or provider groups into the CCN Next Generation Medical Network. | This information will be provided after contract award. |
| 18 | PWS | 3.2.1 | Mobile Healthcare Services | 27 | N/A | Given that mobile health services traditionally incur higher operational costs than standard brick-and-mortar care and are often reimbursed at rates above CMS benchmarks across the industry, will VA confirm whether there are separate, pre-established reimbursement rates for mobile health service or will negotiated rates be allowed? | The Contractor shall be reimbursed in accordance with TBD, “Price/Cost Schedule” for claims paid in accordance with Section 10.2, “Claims Processing and Adjudication.” |
Claims within the constructs of the VA CCN contract will be paid based on the VA Payment Hierarchy, which dictates reimbursement at the lesser of locality-adjusted Medicare rates, VA Fee Schedule, Alaska Fee Schedule, or 50% of billed charges, with payments submitted according to the timelines specified in the contract, such as monthly Active Veteran utilization rates or specific CLIN milestones, and reimbursement invoices submitted to the VA within 30 business days of service delivery.
| 19 | PWS | 3.2.1 | Mobile Healthcare Services | 27 | N/A | Will VA clarify what types of mobile healthcare services are considered acceptable or prioritized for delivery (e.g., primary care, diagnostics, telehealth, imaging, specialty consults)? | VA requests that the Contractor provide recommendations and best practices for consideration in your Mobile Healthcare Services Delivery Plan. |
| 20 | PWS | 3.2.1 | Mobile Healthcare Services | 27 | N/A | Section 3.2.1 references “Section TBD, SCHEDULE OF DELIVERABLES.” Will VA provide clarification or update this section to specify exact timing, format, and recipient(s) for the Mobile Healthcare Services Delivery Plan submission? | VA will provide this information with the RFP. |
| 21 | PWS | 3.2.1 | Mobile Healthcare Services | 27 | N/A | Will VA clarify the rationale and intent behind the restriction of mobile services on VA property unless directed by the CO? Would leased CBOC's whom have adjacent space for mobile diagnostic imaging next to VA facilities also be restricted? | * 6/19 This needs SME input. The restriction of mobile services only being allowed on VA propoerty when directed by CO may be a policy issue. Second question answer: VA only requires the services on VA property be directed by CO. |
| 22 | PWS | 3.5 | Accreditation | 31-32 | N/A | Will VA clarify the intent of this requirement: Does the use of the term “accredited” imply that the contractor must obtain formal, network-level accreditation (such as URAC or NCQA), or is it sufficient for the network and related programs to simply operate in accordance with the standards of a recognized accrediting body? | Formal network-level accreditation is required. VA will include this clarification with the RFP. |
| 23 | PWS | 3.5 | Accreditation | 31-32 | N/A | Will VA confirm whether formal network-level accreditation is required, given that it was explicitly refenced in the 2022 version of this requirement, but appears to be absent in the 2025 RFI/PWS? | Formal network-level accreditation is required. VA will include this clarification with the RFP. |
| 24 | PWS | 3.5 | Accreditation | 31-32 | N/A | The 2022 PWS referenced specific accrediting bodies (e.g., URAC, NCQA), while the 2025 version does not. Does this reflect a change in requirements, a redefined expectation, or an intention move toward broader flexibility regarding acceptable accreditation standards? | Unless otherwise noted, the PWS represents the VA's intention to offer broader flexibility concerning accrediting bodies, rather than mandating specific ones. |
| 25 | PWS | 3.5 | Accreditation | 31-32 | N/A | Does this language imply that the contractor is required to obtain Utilization Management (UM) accreditation from a nationally recognized accrediting organization, or is it sufficient for the UM program to simply operate in accordance with the applicable accreditation standards, without being formally accredited? | The Contractor will be required to have UM accreditation from a nationally recognized accrediting organization and operate in accordance with accreditation standards. |
| 26 | PWS | 3.5 | Accreditation | 32 | N/A | Does VA require submission of the official accreditation certificate and decision letter from the accrediting body, or is there additional or alternative documentation expected to satisfy this requirement? | Minimumally required accreditation deliverables are described in Section 3.5 and the Schedule of Deliverables. VA will accept additional industry feedback for consideration. |
| 27 | PWS | 3.5 | Accreditation | 32 | N/A | The updated guidance now requires accreditation documentation to be submitted with the RFP response, which was not previously stated. Given that organizations like NCQA require 6 months of data to complete accreditation, will the VA allow exceptions or flexibility for new TPAs to have accreditation in process at the time of submission? | For the UM program, VA will clarify in the RFP. The timeline for this deliverable will follow the start of healthcare delivery. |
| 28 | PWS | 3.6 | Credentialing | 33 | N/A | Will VA clarify whether credentialing and associated administrative functions must be performed onshore, or if the use of offshore resources is permissible, provided all VA data security and compliance standards are met? | Contract functions must be performed on-shore. |
| 29 | PWS | 3.7 | Medical Network Provider Data for VA's Provider Directory | 37 | N/A | In reference to the High Performing Provider (HPP) designation within the VA CCN, we understand that TPA's evaluate community provider based on quality and cost-efficiency measures. To better align our provider network, will VA provide: | |
1) A detailed matrix or list of the specific metrics and thresholds used to evaluate and designate HPPs.
| 2) Information on whether these criteria vary by specialty or region. | VA wants offerors to provide the designation of High Performing Providers from their network, using their current crieria. | | | | | | | |
| 30 | PWS | 4.2 | CCN Complementary and Integrative Healthcare Services | 39 | N/A | Defined Scope: Is there an official or comprehensive list of CIHS modalities that VA intends to include under this contract? | Reference "Complementary and Integrative Health Services" section of B.5.3.6 Pricing and Coverage Deviations in the Medical Manual. |
| 31 | PWS | 4.3 | Community Nursing Home Care | 40 | N/A | Does VA define the Community Nursing Home (CNH) requirement as care delivered in a Skilled Nursing Facility (SNF) setting (typically short-term, post-acute care), or in a Nursing Home setting with long-term custodial care)? | The CNH Program covers short and long stay placements and covers skilled and low care (custodial). |
| 32 | PWS | 4.3 | Community Nursing Home Care | 40 | N/A | Will a referral and SEOC exist for skilled nursing/pallative care? | Referrals will have different durations of coverage, but will cover all levels of care. |
| 33 | PWS | 4.5 | Transplant | 43 | N/A | Line 1245: Will kidney organs be excluded per the 21st Century CMS CURES Act? | VA will provide this information with the RFP. |
| 34 | PWS | 4.5 | Transplant | 43 | N/A | Line 1248: Does the organ acquisition cost include organ perfusion (hypothermic and normothermic)? FYI - CMS has a new program (IOTA – Increasing organ Transplant Access) where there are CMS-approved facilities that have a goal to increase kidney transplants and use organs that may not typically be viable, but through certain organ perfusion may be more viable. | Yes, perfusion costs are included in accordance with CFR § 413.402 (b)(5) organ acquisition costs. |
| 35 | PWS | 4.5 | Transplant | 43 | N/A | Starting at Line 1253: Is the member responsible for the cost of being added to a second waiting list? | |
| Is it just a fee for the 2nd listing or are they responsible for the evaluation at the second facility? | In accordance with OPTN policy, VA covers the costs associated with dual-listing for transplant services for approved, eligible Veterans, including evaluations, procedures, medications, and related travel and lodging expenses. | | | | | | | |
| 36 | PWS | 4.5.2 | Transplant Network Compliance | 44 | N/A | Lines 1275 - 1296: Will we be provided the VAs criteria? | Criteria is specified in PWS section 4.5.2.1 CTC Evaluation and Monitoring Program. |
| 37 | PWS | 4.5.2 | Transplant Network Compliance | 44-45 | N/A | What is the formal process for including a VA representative in the committee when requested? | VA has not specified a formal process. VA requests that the Contractor provide recommendations and best practices for consideration. |
| 38 | PWS | 4.5.2 | Transplant Network Compliance | 44-45 | N/A | Are there any specific requirements, roles, or access provisions the contractor must provide to facilitate VA participation? | VA has not specified a formal process. VA requests that the Contractor provide recommendations and best practices for consideration. |
| 39 | PWS | 4.5.2 | Transplant Network Compliance | 44-45 | N/A | Is there a defined trigger point or communication pathway that VA will use to initiate this request? | VA has not specified a formal process. VA requests that the Contractor provide recommendations and best practices for consideration. |
| 40 | PWS | 4.5.2 | Transplant Network Compliance | 44-45 | N/A | Should the contractor anticipate any ongoing obligations or reporting tied to the VA representative's involvement? | The Contractor must include VA representation in the Credentialing Committee as requested by VA. This committee is responsible for evaluating Certified Transplant Centers (CTCs) annually for compliance with OPTN requirements and other VA-specific criteria. The Contractor must ensure that VA representatives have access to all relevant documentation and data necessary for credentialing decisions. |
| 41 | PWS | 5.0 | Eligibility Data Management | 49 | N/A | “The Contractor will receive enrollment and eligibility information from VA in a daily eligibility file primarily through Data Access Services (DAS)/EDI Gateway.” | |
| What file format will be used for enrollment and eligibility exchange? | VA will provide this information with the RFP. | | | | |
| 42 | PWS | | | |
| 6.1 & 6.2 | Customer Service | 51 | N/A | What level of user authentication will VA expect to be in place for self-service IVR capabilities? | Data security requirements are described in Section 15.3.2. |
Additional information will be provided with the RFP.
| 43 | PWS | | | |
| 6.2 & 6.2.1 | Customer Service | 55 | N/A | Is it VA’s intent that no PHI be distributed via self-service capabilities where digital credentials are not used (e.g., IVR interactions)? | Data security requirements are described in Section 15.3.2. |
Additional information will be provided with the RFP.
| 44 | PWS | 6.3 | Contractor Use of VA-Provided Ticketing Tool | 60-63 | N/A | What is the specific ticketing tool, are their APIs available to integrate into other portals? | "Real-time" API is unavailable, however VA may provide further information on RFP. |
| 45 | PWS | 6.4 | Information Technology Support | 63 | N/A | Will VA specify which interoperability standards (e.g., USCDI, HL7, FHIR, DICOM for imaging, Direct messaging) are required or preferred for electronic document and image exchange between the Contractor, VA, and network providers? | All images must be submitted in DICOM format and be accompanied by written reports. Written reports must be submitted as HL7 messages (most preferred), or DICOM Structured Reports (SR). VA will provide this information with the RFP. |
| 46 | PWS | 6.4 | Information Technology Support | 63 | N/A | Will the Contractor’s central submission system be required to interface directly with VA systems such as Cerner Millennium, VistA, HSRM, or other? If so, will VA provide a list of integration points, technical integration specifications, and will VA advise if API access will be provided? | DAS/EDI Gateway is the approved gateway for sharing data between external and VA entities. VA System Integration Requirements are described in Section 15.4.1. |
| 47 | PWS | 6.4 | Information Technology Support | 63 | N/A | Will VA clarify the data types and types of medical documentation objects that must be supported (e.g., progress notes, lab results, radiology images, consults) and whether any standardized formats (e.g., CDA, PDF/A, structured reports) are required for submission? | All images must be submitted in DICOM format and be accompanied by written reports. Written reports must be submitted as HL7 messages (most preferred), or DICOM Structured Reports (SR). VA will provide this information with the RFP. |
| 48 | PWS | 6.4 | Information Technology Support | 63 | N/A | Are there any specific APIs outside of the VA network the system may need to access for data exchange, i.e., Blue Button 2.0, Data at the Point of Care, Redox, Ribbon health APIs? | The Contractor may choose to access APIs outside of the VA to support operations. |
| 49 | PWS | 6.4 | Information Technology Support | 63 | N/A | What specific expectations exist regarding image submission (e.g., resolution, modality compatibility, DICOM standards)? | |
| Will VA provide a preferred or existing image archive integration (e.g., VistA Imaging or VNA)? | All images must be submitted in DICOM format and be accompanied by written reports. Written reports must be submitted as HL7 messages (most preferred), or DICOM Structured Reports (SR). VA will provide this information with the RFP. | | | | | | | |
| 50 | PWS | 6.4 | Information Technology Support | 63 | N/A | Does the contractor need to adhere to specfic policies such as the Trusted Exchange Framework and Common Agreement in order to support a standardized exchange of data with external entities? | The Contractor is required to adhere to all state and federal policies, rules, and regulations. The Contractor shall use recognized health information interoperability standards in all relevant IT systems used to support the CCN Next Generation Medical Network. |
| 51 | PWS | 7.0 | Referrals | 67 | N/A | Will the 278 be the only conduit to receive referrals? What about DAS? | For the Contractor, the EDI 278 is the method VA will use to send the referral. |
| 52 | PWS | 7.0 | Referrals | 67 | N/A | What is the integration pattern to receive REFDOC type artifacts? | Referral documentation will be sent via EDI 275 as an attachment to the approved referral (EDI 278). |
| 53 | PWS | 7.0 | Referrals | 67 | N/A | Do the code-sets mentioned refer to the SEOC tables? | Code sets will be the HCPCS and CPT codes applicable to an approved referral. |
| 54 | PWS | 7.0 | Referrals | 68 | N/A | What is the notification API used for ED admissions to inpatient? The PWS only mentions the self-service portal. | Please refer to section 7.2.2 Inpatient Utilization Review. |
| 55 | PWS | 7.1 | RFS | 69 | N/A | Will VA have a corresponding unique identifier for referrals? Currently, it says the contractor will need to generate them. How do we keep them in sync with HSRM? | VA will provide the Contractor with a unique referral number on the VA Approved Referral. Contractor shall use the VA provided referral number. |
The Request for Services (RFS) from the provider will be received by Contractor first, necessitating the need for the Contractor to generate a unique identifier.
56 PWS 7.2 Utilization Management 70 N/A Will VA provide current or estimated monthly or annual RFS data (total number of expected RFS’ by category)? No, VA does not intend to provide RFS volume data at this time.
VA will provide approved referral volume data with the RFP.
| 57 | PWS | 7.2 | Utilization Management | 70 | N/A | Will VA provide more information about the required “clinical review tools? | VA will provide Clinical Determinations and Indications (CDI) and the Utilization Review List as well as access to an industry standard clinical review tool, for the Contractor's use, to ensure consistency with VHA across care settings. If not available/applicable, the RFS will be directed to VA. For new technology, procedures, etc. the Contractor will direct the RFS to VA for review. |
| 58 | PWS | 7.2 | Utilization Management | 70 | N/A | Will VA confirm the minimum RFS reviewer and licensure requirements? | The Contractor is required to establish, execute, and sustain an accredited UM program that complies with the accrediting organization’s standards and applicable Federal and State laws, including reviewer and licensure requirements. |
| 59 | PWS | 7.2 | Utilization Management | 70 | N/A | Will VA provide clarification for “VA licensed evidence-based guidelines”? | VA will provide access to an industry standard clinical review tool, for the Contractor's use, to ensure consistency with VHA across care settings. In addition, VA will provide Clinical Determinations and Indications (CDI) and the Utilization Review List. |
| 60 | PWS | 7.2 | Utilization Management | 70 | N/A | Does the Contractor propose the criteria for approval (InterQual, MCG, etc.) or does VA have established criteria? | |
What is the Contractor’s role in developing criteria when none exists (new DME or imaging that hits the market)?
| What is the Contractor’s role in reviewing and making recommendations for new medications, DME, medical processes, etc., including the annual HCPC process? | VA will provide Clinical Determinations and Indications (CDI) and the Utilization Review List as well as access to an industry standard clinical review tool, for the Contractor's use, to ensure consistency with VHA across care settings. If not available/applicable, the RFS will be directed to VA. For new technology, procedures, etc. the Contractor will direct the RFS to VA for review. | | | | | | |
| 61 | PWS | 7.2 | Utilization Management | 70 | N/A | It appears that the Contractor performs the initial RFS review, but sends the recommended determination to VA; VA makes all final decisions. If so, what is the Contractor’s role in provider and member appeals for RFS denials? |
| Are there established turn-around times for VA response and is this included in the required turn-around times listed in Line 12? | Contractor and VA shall manage appeals through the Self-Service Portal. VA will clarify the appeals process in the RFP. | | | | | | |
| 62 | PWS | 7.2 | Utilization Management | 70 | N/A | The RFI states the Contractor “shall follow federal accreditation requirements.” |
Please confirm if this is NCQI (15 calendar day turn-around time) vs. new CMS rules
| (7 calendar days) vs. other possible accreditations. | The Contractor shall follow Federal rules, policy, guidelines, and requirements, including those issued by CMS. There are various timelines associated with Utilization Management. | | | | | | | |
| 63 | PWS | 7.2 | Utilization Management | 70-71 | N/A | Will VA provide the minimum PA reporting requirements and communication processes? | Reporting and communication requirements are provided in the PWS and Manual. |
| 64 | PWS | 7.2 | Utilization Management | 70-71 | N/A | Will VA provide medical policy guidelines for the UM review? | VA will provide Clinical Determinations and Indications (CDI) and the Utilization Review List as well as access to an industry standard clinical review tool, for the Contractor's use, to ensure consistency with VHA across care settings. If not available/applicable, the RFS will be directed to VA. For new technology, procedures, etc. the Contractor will direct the RFS to VA for review. |
| 65 | PWS | 7.2 | Utilization Management | 70-71 | N/A | Will the contractor need to establish a UR manual review of all RFS submissions? | The Contractor shall conduct a Utiliization Review on a subset of RFSs that are included on the Utilization Review (UR) List. |
| 66 | PWS | 7.2 | Utilization Management | 70-71 | N/A | "The UM program shall include processes for identifying, preventing, and reducing unnecessary care and over- or under-utilization." | |
| What is VA’s primary goal in implementing this UM model—cost control, quality assurance, or compliance oversight? | VA's goal is to partner with the Contractor and Community Care Network Providers to provide high quality, safe, timely, effective, efficient care for Veterans accessing care in their communities. | | | | | | |
| 67 | PWS | 7.2 | Utilization Management | 70-71 | N/A | "The Contractor shall describe its approach...and a framework for continuous improvement...The UM Program Approach shall be submitted in the Contractor’s proposal and will be incorporated into the contract." |
| How will VA evaluate the success of our UM program—through KPIs, audits, or outcome improvements? | KPIs, audits, and outcome improvements are all tools at VA's disposal to evaluate the success of the UM Program. Data transparency and reporting are also key tools necessary for the Contractor and VA to evaluate the operations of the UM Program. VA may provide further information with the RFP. | | | | | | |
| 68 | PWS | 7.2 | Utilization Management | 70-71 | N/A | "The UM program shall use VA provided clinical review tools." |
| Are there specific tools that VA requires (e.g., InterQual®, MCG®), or does the contractor propose tools subject to VA approval? | There are specific tools that VA uses and will require the Contractor to use in the UM program within the Community Care Network. VA will provide further information with the RFP. | | | | | | |
| 69 | PWS | 7.2 | Utilization Management | 70-71 | N/A | "The Contractor shall conduct and review UM review using (in order of precedence): 1. Medical policy and Clinical Determinations and Indications (CDI) from VA. 2. VA licensed evidence based clinical guidelines. 3. Send RFS to VA for clinical review..." |
| Are we expected to follow this full hierarchy for every RFS, and how frequently does VA anticipate the need for clinical escalation? | The Contractor is expected to follow this hierarchy for evaluating every RFS. However, VA does not anticipate all RFS submissions requiring the full hierarchy of review. | | | | | | |
| 70 | PWS | 7.2 | Utilization Management | 70-71 | N/A | "The Contractor shall conduct an initial UR within 24 hours of a Veteran’s admission and daily thereafter." |
| Are there any exceptions to the daily inpatient review requirement, and how are weekends/holidays handled? | VA is not providing exemptions for the daily inpatient review requirement at this time. | | | | | | |
| 71 | PWS | 7.2 | Utilization Management | 70-71 | N/A | "Each Utilization Review shall include a complete recommendation package via EDI 278/275..." |
| Is the contractor required to support EDI 278/275 transactions directly with VA systems, and if so, what middleware (if any) is permitted? | The Contractor is required to support EDI 278/275 transactions. The Contractor's solution should meet all VA system requirements as outlined in section 15 of the PWS. | | | | | | |
| 72 | PWS | 7.2 | Utilization Management | 70-71 | N/A | "The complete package shall include...all supporting medical documentation..." |
| Will VA provide access to complete medical records for all RFS, or must the contractor rely solely on documentation submitted with the referral? | The Contractor will utilize the supporting medical documentation, submitted by their community provider, to make an RFS recommendation. | | | | | | |
| 73 | PWS | 7.2 | Utilization Management | 70-71 | N/A | "The Contractor shall follow the role of the UM Reviewer as defined in VHA Directive 1036 Standards for Observation in VA Medical Facilities." |
| What are VA’s expectations for enforcing compliance with VHA Directive 1036, and will VA audit UM reviewer activity against it? | VA will clarify the requirement in the RFP. | | | | | | |
| 74 | PWS | 7.2 | Utilization Management | 70-71 | N/A | "...include...summation of process steps taken to reach recommendation, to include any additional reviews or internal appeals, and the Contractor’s final recommendation." |
| What is the expected role of the Medical Director or clinical lead in UM determinations or appeals, and must these be documented in the final recommendation? | The Contractor must include clinical determinations and judgements in the recommendations to approve or deny RFS requests, including relevant rationale and justifications for the recommendations. | | | | | | | |
| 75 | PWS | 7.2.1 | Utilization Review | 71 | N/A | What is the approach to generating a list of “subset” RFSs that need review? Is this random or by some other criteria? | The subset of RFS requiring review are determined by the code or code sets provided in the UR list attachment. |
| 76 | PWS | 7.2.1 | Utilization Review | 71 | N/A | Is the list based on volumes or percentages of RFS? | The UR list was developed by VA staff for encounters/procedures where additional scrutiny was desired. |
| 77 | PWS | 7.2.1 | Utilization Review | 71 | N/A | Is the list specific to providers or a random sample by some region? | The UR list was developed by VA staff for encounters/procedures where additional scrutiny was desired. |
| 78 | PWS | 7.2.1 | Utilization Review | 71 | N/A | Will VA confirm there are three steps to a random UM review process…..CDI from the VA, then evidence based guidelines, and finally if a PEND, then send to VA for manaual review? | Three steps for utilization review are required only when the previous steps cannot be completed. If CDI from VA are available and applicable to the RFS, the Contractor shall make a recommendation. If CDI from VA are not available, the Contractor shall proceed to step 2 of the hierarchy of review. |
| 79 | PWS | 7.2.1 | Utilization Review | 71 | N/A | Will VA clarify the reporting requirements regarding the UR process (% reviewed, % denied, % accepted…)? | Clinical quality data and metrics, including conformance to RFS submission requirements and clinical guidelines, and RFS submission, approval, and denial rates as well as other metrics proposed by the Contractor will be included in the Clinical Quality Steerage Model data and associated deliverables. VA requests that the Contractor provide recommendations and best practices for consideration. |
| 80 | PWS | 7.2.2 | Inpatient Utilization Review | 71 | N/A | Please clarify who at VA will be the POC/recipient of the constant communication and by what means the communication is to occur, e.g., phone, portal, etc. | VA will provide further clarity during implementation. |
| 81 | PWS | 7.2.2 | Inpatient Utilization Review | 71 | N/A | Are only recommended denials sent back to VA, aside from the PENDs? | All recommendations are sent to VA for confirmation and final decision making. |
| 82 | PWS | 7.2.2 | Inpatient Utilization Review | 71 | N/A | Where is the VHA 1036 standards outlined? | Use of this VHA Directive will be clarified in the RFP |
| 83 | PWS | 7.2.2 | Inpatient Utilization Review | 71 | N/A | Are there any details on the “Central Submission System” for submitting UR of inpatient usage? | The reference to "Cental Submission System" is specific to providing medical documentation associated with the RFS, reference PWS Section 9.1 for additional information. |
| 84 | PWS | 7.2.2 | Inpatient Utilization Review | 72 | N/A | What is the update method for VA to send transfer recommendations back to the contractor and servicing provider? | The Self Service Portal is intended to serve as the communication and information hub for VA staff, the Contractor, Providers, and the Veteran. |
| 85 | PWS | 7.2.2 | Inpatient Utilization Review | 72 | N/A | What process does the Contractor need to have in place to ensure that CCN Next Generation Network provider facilities are able to notify VA? | |
| Does the notification need to be transmitted to VA via EDI 278—immediately and no later than 24 hours after a Veteran is admitted for approved inpatient care? | The Contractor is responsible for establishing communication pathways with its network Providers and ensuring communication with VA. The Self Service Portal is intended to be a communication and information hub for VA staff, the Contractor, Providers, and the Veteran. Notification requirements for approved referrals and RFS are listed in section 7. | | | | | | | |
| 86 | PWS | 7.2.2 | Inpatient Utilization Review | 72 | N/A | For IP UM, is the contractor to examine every RFS (or at a minimum all acute inpatients) and not a subset of these submissions as defined in the ambulatory RFS? | Inpatient utilization review should only occur for those RFS with encounters and procedures listed in the UR List attachment. |
| 87 | PWS | 7.2.2 | Inpatient Utilization Review | 72 | N/A | For the daily inpatient review, where should these status reports and transfer recommendations be submitted? | |
| Is there a DAS connector or interoperability API that we should leverage? | The Self Service Portal is intended to serve as the communication and information hub for VA staff, the Contractor, Providers, and the Veteran. Medical documentation should be submitted in the Medical Documentation Central Submission System. Additional guidance will be discussed between TPA and VA during implementation. | | | | | | | |
| 88 | PWS | 8.2 | Urgent/Emergent Prescriptions | 75-77 | N/A | Will VA confirm that the contractor is responsible for PA approvals related to non-formulary or off-label uses? | Yes. |
| 89 | PWS | 9.0 | Medical Documentation | 81 | N/A | Will this be standardized as a single system across TPAs to ensure programmatic efficiencies and streamlined provider interactions? | No, this will not be a single system across TPAs. Each TPA will be responsible for their own central submission system. |
| 90 | PWS | 9.1 | Medical Documentation and Central Submission System | 81 | N/A | Are there specific support SLAs that the contractor must meet for IT support response and resolution times based on priority? | See PWS section 15.3 Continuity of Operations Plan. |
| 91 | PWS | 9.2 | Medical Documentation Elements to be Included | 82 | N/A | In Section 9.2 it states: "All medical documentation submitted through the central submission system as described in Section 9.7, “Medical Documentation Central Submission System” shall be complete, verified, and authenticated by the submitting network provider or practitioner." However, the Medical Documentation Central Submission System is not described in Section 9.7. Will VA clarify? | Sections will be reconciled in RFP. |
| 92 | PWS | 10.0 | Claims Processing | 86 | N/A | "The Contractor’s claims adjudication system shall validate the VA Approved Referral and any other data needed to properly adjudicate claims. VA will issue a VA Approved Referral and provide the Contractor with code sets for use in the Contractor's claims adjudication system." | |
| Will VA consider requiring the claims processor to attempt to obtain an authorization (pre-existing but missing on the claim or new auth for ancillary but otherwise should be authorized) prior to claim denial? | Please refer to Manual section 10.2.2 Claims Adjudication, Referral Matching, for exceptions to approved referral requirement. | | | | | | | |
| 93 | PWS | 10.2 | Claims Processing and Adjudication | 87 | N/A | Will the TPA be required to process Veterans Choice Agreement claims? | No, the Contractor will not be required to process any Veterans Choice claims or any other claims associated to any non CCN- contract. |
| 94 | PWS | 10.2 | Claims Processing and Adjudication | 87-89 | N/A | "The report...shall include clinical quality and cost performance metric results...down to the network provider/institution level." | |
| What specific KPIs will VA use to measure UM effectiveness at the contractor and provider level? | VA is not able to provide a response without further clarification on the question and referenced PWS section. Offeror should provide responses to applicable PWS content. | | | | | | | |
| 95 | PWS | 10.3 | Electronic Visit Verification | 89-90 | N/A | What is the Electronic Visit Verification (EVV) for personal and home care services? | Electronic Visit Verification (EVV) is a system that electronically verifies the occurrence of in-home or community-based service visits. It's a federal requirement, mandated by the 21st Century Cures Act, to ensure accurate billing and service delivery. |
| 96 | PWS | 10.7 | Claims for Services Rendered to Veterans Assigned to Other CCN Region | 92 | N/A | "The Contractor shall receive, process, and adjudicate claims for all services provided pursuant to the contract by network providers in the Contractor’s CCN Next Generation Medical Network region, regardless of whether the Veteran resides in a different CCN Next Generation Medical Network region." | |
| Will VA be stipulating a process for sending payment information to the appropriate provider network TPA for the payment to the provider, or is the intention for a TPA to cover payments for all providers nationwide regardless of network affiliation? | Payment is based on the VA approved referral issued for the care and the network affiliation on the referral. Veterans are not restricted to care within the CCN NextGen region of their permanent address. | | | | | | |
| 97 | PWS | 14.7 | Clinical Quality Steerage Model Data | 123 | N/A | Will VA specify the initial set of metrics it proposes to include in the Clinical Quality Steerage Model, particularly given that many of the referenced measures appear to be operational or administrative rather than strictly clinical in nature? |
| Additionally, considering the substantial volume of primary care that continues to be delivered within VA facilities, how does VA envision these metrics being used to meaningfully compare or evaluate community care performance relative to in-house VA care? | Based on PWS section 14.7, VA has outlined preliminary metrics for the Clinical Quality Steerage Model, including both clinical and operational/administrative measures. The Contractor is also required to recommend additional metrics with target thresholds and weighting, indicating that the initial metrics are not exhaustive and may evolve with Contractor input and VA feedback. | | | | | | |
| 98 | PWS | 15.1 | Communication and Access to Contractor Systems | 125 | N/A | Will VA clarify the type internal access needed to fulfill this requirement? |
Will VA require log-in access to backend systems such as the database, web servers, etc., or will the R/O access be restricted only to APIs?
| Is the access for an actual person or for automated agents, of both? | VA will provide this information with the RFP. | | | | | | |
| 99 | PWS | 15.2 | Configuration Management and Testing | 126 | N/A | "The Contractor shall support configuration management and testing of system interfaces with VA and ensure full operational capability." |
| Will VA provide a test environment for APIs and system connections during the transition-in phase? | VA will provide this information with the RFP. | | | | | | |
| 100 | PWS | 15.3 | Continuity of Operations | 129 | N/A | "The Contractor shall prepare a Contractor Security Control Assessment (CSCA) and submit documentation in accordance with VA cybersecurity requirements." |
| What is the timeline and format required for the Contractor Security Control Assessment (CSCA) and subsequent validation steps? | Contractor shall complete CSCA within 30 days of contract award and on a yearly basis thereafter. Reference Attachement 3, CCN Next Gen Medical East Program Concepts | | | | | | |
| 101 | PWS | 15.3.1 | Data Integrity | 131 | N/A | Will there be a requirement to migrate or pre-populate the system with legacy data? |
If so, what data types would need to be migrated?
| Do you have an estimate of the size of data? | VA may provide further clarity with the RFP and this information will be provided after contract award. | | | | | | |
| 102 | PWS | 15.4 | Information and Data Exchange Requirements | 133 | N/A | "The Contractor is required to integrate with VA’s DAS or EDI Gateway to provide a standard interface for data access and transmission of information to VA (including reports and files) required throughout this PWS." |
| Does this eliminate the use of TEFCA and Smart on FHIR as stipulated differently in the Program Concepts - Attachment 3? | The Contractor is required to adhere to all state and federal policies, rules, and regulations. The Contractor shall use recognized health information interoperability standards in all relevant IT systems used to support the CCN Next Generation Medical Network. As stated, VA also encourages implementation of Trusted Exchange Framework and Common Agreement (TEFCA) or SMART on FHIR. | | | | | | |
| 103 | PWS | 15.4.1 | VA System Integration Requirements | 133 | N/A | "The Contractor is required to integrate with VA’s DAS or EDI Gateway to provide a standard interface for data access and transmission." |
What are the requirements or definition of “standard interface”?
Will these be the only integration points?
| Will VA provide a list of integration points/systems? | VA will provide this information with the RFP. | | | | | | |
| 104 | PWS | 16.0 | Training | 135-136 | N/A | Is there an estimate to the number "Medical Network users" that will need to be trained? |
| Will VA be prescriptive on the type of media the training is delivered in, i.e., virtual live sessions, webinars, in-person, etc.? | Medical Network users may include network providers, Contractor personnel, and VA staff. Contractors may propose training media and delivery methods in the Training Plan described in Section 16.1. VA requests that the Contractor provide recommendations and best practices for consideration. | | | | | | | |
| 105 | PWS | N/A | General PWS Question | N/A | N/A | We don’t see any reference to other health insurance discovery. Will that be part of the PWS? | Other Health Insurance Discovery is not a requirement of this contract. |
| 108 | Program Concepts | 1.0 | General | 3 | N/A | "VA and its partners must exchange data using standardized formats such as HL7, EDI, and consider FHIR-based interoperability standards." | |
| Will VA provide additional information on data exchange expectations via HL7, FHIR, TEFCA, and whether all providers must support those standards? | VA System Integration Requirements are described in Section 15.4.1. The Contractor shall use recognized health information interoperability standards in all relevant IT systems used to support the CCN Next Generation Medical Network. DAS/EDI Gateway is the approved gateway for sharing data between external and VA entities. | | | | | | | |
| 109 | Program Concepts | 2.1 | Waiver of Payment Rates | 16-20 | N/A | Will VA confirm the Contractor has no ability to negotiate rates above the VA fee schedule without the VA’s written approval, or approval of a waiver, under Section 2.1—Waiver of Payment Rates? | VA will reimburse the TPA at the awarded rates per the Schedule of Services. |
| 110 | Program Concepts | 11.0 | System Security Governance | 15 | N/A | "The Contractor is required to achieve and maintain a FedRAMP rating as directed by VA and governed by the FedRamp.gov program. This rating must apply to any and all interfaces or data repositories maintaining or displaying health care PHI, PII, or financial information. " | |
| What impact level does the VA anticipate CCN falling under, Moderate or High, and will this pertain to all systems supporting CCN, or will each independent system potentially proposed by the individual TPAs be subject to separate impact rating determinations? | CCN NextGen will require a High Impact FedRAMP level due to the sensitive nature of Veteran health information. | | | | | | | |
| 111 | Contractor Manual | B.5.3.6 | Pricing and Coverage Deviations | 3 | N/A | Will VA confirm that Contractors can use SCAs for ART/IVF, Transplants and Abortions instead of developing a contracted network? | Yes, SCAs are allowed when appropriate. The contractor is still required to report information on drive-time and availability for any services excluded from Network Adequacy performance monitoring. Reference section 3.3.2 of PWS, section 3.3.1 of Manual, and QASP. |
| 112 | Contractor Manual | 3.3.1 | Medical Network Deviation Requests | 6 | N/A | Will VA confirm that, aside from ART/IVF, SCAs for all other services must be at the VA reimbursement level? | Yes, other services not indicated in Part 2: B.5.3.6 Pricing and Coverage Deviations, under SCA follow VA payment hierarchy. |
| 113 | Contractor Manual | 3.3.1 | Medical Network Deviation Requests | 6 | N/A | Will VA confirm that ART/IVF services are exempt from VA rates, and will be reimbursed at the lessor of billed changes or the rates Contractor is able to get using commercially reasonable efforts? | ART/IVF services are not exempt from VA rates; however, they do have "distinct coverage and payment policies" that must be adhered to as outlined in B.5.3.6 Pricing and Coverage Deviations. The Contractor will make commercially reasonable efforts to negotiate provider rates that are less than billed charges. |
| 114 | Contractor Manual | 5.0 | Data Management | 12 | N/A | Will eligibility be accessed by a real-time API call or will there be a nightly feed of theses files sent to the contractor? | Real-time API is unavailable, however VA may provide further information on RFP. |
| 115 | Contractor Manual | 5.2 | Transmission Frequency | 13 | N/A | If there are nightly files exchanged will they be complete refreshes or delta files? | Delta files, provided via the daily file exchange. |
| 116 | Contractor Manual | 5.1 | Member Information | 13 | N/A | Will VA clarify the required integration pattern; this section references DAS, while section 5.0 references x12 connectivity? | Data will be transmitted following X12 standards through Data Access Services (DAS)/EDI Gateway. |
| 117 | Contractor Manual | 5.3 | Member Query | 15 | N/A | Outlines an asynchronus query for Veterans and members that are not in the eligibility file. Please verify this query is connected to DAS and verify that there is not a real-time eligibility API that can be used instead. | Currently, the query is connected to DAS. Real-time API is unavailable, however VA may provide further information on RFP. |
| 118 | Contractor Manual | 5.6 | Eligibility Codes | 20 | N/A | Section 5.6, Table 8 List of VCE codes mentions the "U" designation for urgent care but not quantity. Will the contractor need to authorize UC visits or in any way track accumulators for UC? | The Contractor shall make UC eligibility information available to network providers via the Contractor self-service portal and shall ensure its UC network providers confirm Veteran’s eligibility prior to rendering care. The Contractor shall create an automated UC referral for the encounter at time of service as outlined in section 7.3 of the PWS. |
Section 7.3; Table 11 Referral Scenario (Urgent Care) in the Manual provides additional information.
| 119 | Contractor Manual | 7.1 | RFS | 27 | N/A | Section 7.1 Table 10, Please confirm that contractor is responsible for 100% of RFS evaluations before they are sent to the VA for approval? | Contractor shall administratively review for acceptance or rejection 100% of ALL RFSs. VA will provide further clarify in the RFP. |
| 120 | Contractor Manual | 7.2.2 | Inpatient UR | 29 | N/A | The workflow in this section is different from the PWS. The PWS has a requirement to notify the VA when the patient arrives for a planned inpatient visit. Will VA please clarify? | The Contractor shall notify VA when patient arrives for planned inpatient visits. The flow maps in the PWS and Manual will be aligned in the RFP. |
| 121 | Contractor Manual | 7.2.2 | Inpatient UR | 29 | N/A | Section 7.2.2 Figure 5, what systems should the contrator be connecting to for emergent IP notifications? | The Contractor is not required to connect to a VA system; but rather submit via EDI 278 or equivalent. |
| 122 | Contractor Manual | 7.2.3 | Outpatient UR | 30 | N/A | Will VA confirm that Outpatient UR applies to 100% of the RFS submisssions and not a sample? | The Contractor is expected to follow the hierarchy, outlined in PWS secftion 7.2.1, for evaluating every RFS. However, VA does not anticipate all RFS submissions requiring the full hierarchy of review. |
This is the start of the file's text. The full file is on GovTribe.
