36C10G26R0003 Medical TOPR East 0001 - 05.pdf

5. PROJECT NUMBER (if applicable)

CODE 7. ADMINISTERED BY

2. AMENDMENT/MODIFICATION NUMBER

CODE

6. ISSUED BY

8. NAME AND ADDRESS OF CONTRACTOR

4. REQUISITION/PURCHASE REQ. NUMBER 3. EFFECTIVE DATE

9A. AMENDMENT OF SOLICITATION NUMBER

9B. DATED

PAGE OF PAGES

10A. MODIFICATION OF CONTRACT/ORDER NUMBER

10B. DATED

BPA NO. 1. CONTRACT ID CODE

FACILITY CODE CODE

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers

E. IMPORTANT:

is extended,

(a) By completing Items 8 and 15, and returning __________ copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY is not extended.

12. ACCOUNTING AND APPROPRIATION DATA

(REV. 11/2016)

is required to sign this document and return ___________ copies to the issuing office. is not, A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER NO. IN ITEM 10A.

15C. DATE SIGNED

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER

Contractor

16C. DATE SIGNED

14. DESCRIPTION OF AMENDMENT/MODIFICATION

16B. UNITED STATES OF AMERICA

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME AND TITLE OF SIGNER 16A. NAME AND TITLE OF CONTRACTING OFFICER

15B. CONTRACTOR/OFFEROR

STANDARD FORM 30 PREVIOUS EDITION NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.243

(Type or print) (Type or print)

(Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

(Number, street, county, State and ZIP Code)

(If other than Item 6)

(Specify type of modification and authority)

(such as changes in paying office, appropriation date, etc.)

(If required)

(SEE ITEM 11)

(SEE ITEM 13)

(X)

CHECK

ONE

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

(Signature of person authorized to sign) (Signature of Contracting Officer)

1 33

Medical TOPR East 0001 05 02-27-2026

36C10G

U.S. Department of Veterans Affairs OPAL | Strategic Acquisition Center

10300 Spotsylvania Ave | STE 400 Fredericksburg VA 22408-2697

36C10G

U.S. Department of Veterans Affairs OPAL | Strategic Acquisition Center

10300 Spotsylvania Ave | STE 400 Fredericksburg VA 22408-2697

To all Offerors/Bidders

36C10G26R0003

12-15-2025

X

X X x

The purpose of this TOPR Amendment (Medical TOPR East 0001 05) is to make the following changes:

1. Extend the proposal due date from March 16, 2026 to April 3, 2026.

2. Update language throughout the RFP.

3. Update attachments.

See continuation page for further details.

All other Terms and Conditions remain the same.

Jessica Portillo Contracting Officer

CONTINUATION PAGE MEDICAL TOPR EAST 0001- 05

Note: The words in red font in the “To” sections of each change denote the new language to be added in each version.

Change 1:

The following language in block 20 of the SF 1449 is hereby changed as follows:

FROM:

All Proposals must be submitted by 2:00PM EST on 3/16/2026.

TO:

All Proposals must be submitted by 2:00PM EST on 4/3/2026.

CHANGE 2:

The following language in section B, 3.2 WAIVERS OF PAYMENT RATES is revised as follows:

FROM:

B 3.2 WAIVERS OF PAYMENT RATES

The Contractor may submit a waiver of payment rates request to VA when payment to its providers aligned to Medicare or the VA Fee Schedule is insufficient to build or retain the network in highly rural areas and/or for scarce resources. A highly rural area is defined as a county with fewer than seven individuals residing per square mile. Scarce resources are defined as situations where the Contractor is unable to meet network adequacy standards for specific medical services due to a lack of capable providers in a specific area, as determined through the justification provided by the Contractor in the “Waiver of Payment Rate Request Form” described below.

If a waiver of payment rates is established for a network provider for specific healthcare services, the approved rates will be used to set the maximum price that VA will pay the Contractor for authorized services. Approved rates shall be applied as a percentage of the Medicare or VA Fee Schedule rate. The Contractor shall evaluate the billed charges versus the awarded maximum waiver rate and price the claim at the lesser of the two; if the provider's billed charges are lower than the awarded maximum waiver rate specified in the contract, the Contractor shall pay the provider claimed based on billed charges and the Contractor shall invoice the VA in that amount.

The Contractor shall use the “Waiver of Payment Rates Request Form” provided in Attachment R, Network Adequacy Rate Waiver Form. A waiver request shall specify the localities for which the waiver is being requested, with consideration given for all localities associated with the Taxpayer Identification Number (TIN) and/or National Provider Identifier (NPI). The Contractor shall ensure that the Waiver of Payment Rates Request Form is accurate, complete, and includes all required information related to the justification for the request, to include, but not limited to, the reasoning for submission in terms of network adequacy, the codes to be used with the proposed rate, and whether the Contractor is at risk of not successfully recruiting or retaining the network provider.

Waivers of payment rates will only be applicable to active codes, and VA will not modify codes or services submitted in a waiver request.

TO:

The Contractor may submit a waiver of payment rates request to VA when payment to its providers aligned to Medicare or the VA Fee Schedule is insufficient to maintain the network in highly rural areas and/or for scarce resources. A highly rural area is defined as a county with fewer than seven individuals residing per square mile. Scarce resources are defined as situations where the Contractor is unable to meet network adequacy standards for specific medical services due to a lack of capable providers in a specific area, as determined through the justification provided by the Contractor in the “Waiver of Payment Rate Request Form” described below.

If a waiver of payment rates is established for a network provider for specific healthcare services, the approved rates will be used to set the maximum price that VA will pay the Contractor for authorized services. Approved rates shall be applied as a percentage of the Medicare or VA Fee Schedule rate. The Contractor shall evaluate the billed charges versus the awarded maximum waiver rate and price the claim at the lesser of the two; if the provider's billed charges are lower than the awarded maximum waiver rate specified in the contract, the Contractor shall pay the provider claim based on billed charges and the Contractor shall invoice the VA in that amount.

The Contractor shall use the “Waiver of Payment Rates Request Form” provided in Attachment R, Network Adequacy Rate Waiver Form. A waiver request shall specify the localities for which the waiver is being requested, with consideration given for all localities associated with the Taxpayer Identification Number (TIN) and/or National Provider Identifier (NPI). The Contractor shall ensure that the Waiver of Payment Rates Request Form is accurate, complete, and includes all required information related to the justification for the request, to include, but not limited to, the reasoning for submission in terms of network adequacy, the codes to be used with the proposed rate, and whether the Contractor is at risk of not successfully retaining the network provider. Waivers of payment rates will only be applicable to active codes, and VA will not modify codes or services submitted in a waiver request.

Change 3:

The following language in section E.2 ADDENDUM TO FAR 52.212-2 EVALUATION— COMMERICAL ITEMS, RELATIVE ORDER OF IMPORTANCE, is hereby changed as followed:

FROM:

Factor 1 (Technical Evaluation) consists of Oral Presentation and Written Submission, which are of equal importance. When combined, Factor 1 is slightly more important than Factor 2 (Past Performance). When considered together, all non-price factors (Factors 1, 2) are significantly more important than Factor 3 (Veteran Involvement/ Subcontracting). Factor 4 (Price) is the least important factor.

TO:

Factor 1 (Technical) consists of Oral Presentation and Written Submission, which are of equal importance. When combined, Factor 1 is slightly more important than Factor 2 (Past Performance). When considered together, all non-price factors (Factors 1, 2) are significantly more important than Factor 3 (Veteran Involvement/ Subcontracting).

Factor 4 (Price) is the least important factor.

CHANGE 4:

The following language in section E.1 ADDENDUM TO FAR 52.212-1 INSTRUCTIONS

TO OFFERORS—COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES, 3.

Instructions, Conditions, and Notice to Offerors, is hereby changed as followed:

FROM:

b. Page Limitations: Page limitations shall be treated as maximums. The cover letter, title page, Table of Contents, Table of Figures, List of Tables, organizational chart and glossary of abbreviations and acronyms do not count against page count limitations.

However, be advised that all information contained within any Table of Contents and/or glossary of abbreviations or acronyms submitted with an Offeror’s response will not be evaluated by the Government. Proposal contents that exceed the stated page limitations will be removed from the proposal by the CO, prior to turning the proposal over to the Government evaluation teams and will not be considered in the evaluations.

If the contractor submits annexes, documentation, attachments or the like, not specifically required by this solicitation, such will not count against the Offeror’s page limitations unless otherwise indicated in the specific Volume instructions below. Pages in violation of these instructions, either by exceeding the margin, font or spacing restrictions or by exceeding the total page limit for a Volume, will not be considered in the evaluations. Pages not evaluated due to violation of the margin, font or spacing restrictions will not count against the page limitations. The page count will be determined by counting the pages in the order they come up in the print layout view. A single sheet of paper printed on both sides constitutes two pages.

TO:

b. Page Limitations: Page limitations shall be treated as maximums. The cover letter, title page, Table of Contents, Table of Figures, List of Tables, organizational chart and glossary of abbreviations and acronyms do not count against page count limitations.

However, be advised that all information contained within any Table of Contents and/or glossary of abbreviations or acronyms submitted with an Offeror’s response will not be evaluated by the Government. Proposal contents that exceed the stated page limitations will be removed from the proposal by the CO, prior to turning the proposal over to the Government evaluation teams and will not be considered in the evaluations.

If the contractor submits annexes, documentation, attachments or the like, not specifically required by this solicitation, such will count against the Offeror’s page limitations unless otherwise indicated in the specific Volume instructions below. Pages in violation of these instructions, either by exceeding the margin, font or spacing restrictions or by exceeding the total page limit for a Volume, will not be considered in the evaluations. Pages not evaluated due to violation of the margin, font or spacing restrictions will not count against the page limitations. The page count will be determined by counting the pages in the order they come up in the print layout view. A single sheet of paper printed on both sides constitutes two pages.

Change 5:

The following language in section E.1 ADDENDUM to FAR 52.212-1 INSTRUCTIONS TO OFFERORS—COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES, Factor 2: Past Performance is revised as follows:

FROM:

FACTOR 2: PAST PERFORMANCE

All proposals must include a Past Performance Volume to be considered for award. The Offeror shall complete and submit the Past Performance References attachment in its entirety, listing a minimum of three (3) contracts/orders in which the Offeror was the Prime contractor for work performed in the past five (5) years or currently being performed for similar work to this requirement. For any subcontractor that the Offeror proposes to use for this requirement, the Offeror must also provide Past Performance references for subcontractors they have used to perform services on a minimum of three (3) contracts/orders performed in the past five (5) years or currently being performed for similar work to this requirement.

Contracts/orders listed may include those entered into with the Federal, State, and local government and private. The Government may consider an offeror’s joint venture partners (or partners’) or an offeror’s affiliate’s (or affiliates’)/parent organization’s (or parent organizations’) contracts in the past performance evaluation if the information provided shows that the workforce, management, facilities or other resources of the JV partner(s), affiliate(s)/parent organization(s) will bear on the likelihood of successful performance by the offeror. Past performance information will not be considered for predecessor companies, proposed subcontractors or key personnel. For the purposes of this solicitation, a major subcontract is defined as 20% of the total contract effort.

Data concerning the prime contractor shall be provided first, followed by each proposed major subcontractor, in alphabetical order.

TO:

All proposals must include a Past Performance Volume to be considered for award. The Offeror shall complete and submit the Past Performance References attachment in its entirety, listing a maximum of three (3) contracts/orders in which the Offeror was the Prime contractor for work performed in the past five (5) years or currently being performed for similar work to this requirement. For any major subcontractor that the Offeror proposes to use for this requirement, the Offeror must also provide Past Performance references for subcontractors they have used to perform services on a maximum of three (3) contracts/orders performed in the past five (5) years or currently being performed for similar work to this requirement.

Contracts/orders listed may include those entered into with the Federal, State, and local government and private. The Government may consider an offeror’s joint venture partners (or partners’) or an offeror’s affiliate’s (or affiliates’)/parent organization’s (or parent organizations’) contracts in the past performance evaluation if the information provided shows that the workforce, management, facilities or other resources of the JV partner(s), affiliate(s)/parent organization(s) will bear on the likelihood of successful performance by the offeror. For the purposes of this solicitation, a major subcontract is defined as 20% of the total contract effort. Data concerning the prime contractor shall be provided first, followed by each proposed major subcontractor, in alphabetical order.

Change 6:

The following language in Section E.4 ADDENDUM to FAR 52.212-2 EVALUATION— COMMERICAL ITEMS, FACTOR 3: Veteran Involvement & Subcontracting Plan is hereby changed as follows:

FROM:

Non-Veteran offerors proposing to use certified SDVOSBs or VOSBs as sub-Offeror will receive partial credit under this evaluation factor. The prime contractor must state in this volume the name(s) of SDVOSB(s) and/or VOSB(s) with whom it intends to subcontract. The Offeror shall provide a brief description and the approximate dollar values of the proposed subcontracts. Additionally, proposed SDVOSB/VOSB subcontractor must be certified by the Small Business Administration (SBA) database (https://veterans.certify.sba.gov) and must meet federal small business size standards for the NAICS code assigned to this solicitation at time of both proposal submission and time of award in order to receive some consideration under this Factor. Note that the Government requires the Offeror to honor the evaluation factor commitment to the SDVOSB/VOSB concern throughout the life of the contract. The Offeror shall agree, if awarded a contract, to use the SDVOSB or VOSBs proposed as subcontractor or to substitute one (1) or more SDVOSBs or VOSBs for subcontract work of the same or similar value.

TO:

Non-Veteran offerors proposing to use certified SDVOSBs or VOSBs as sub-Offeror will receive some consideration under this evaluation factor. The prime contractor must state in this volume the name(s) of SDVOSB(s) and/or VOSB(s) with whom it intends to subcontract. The Offeror shall provide a brief description and the approximate dollar values of the proposed subcontracts. Additionally, proposed SDVOSB/VOSB subcontractor must be certified by the Small Business Administration (SBA) database (https://veterans.certify.sba.gov) and must meet federal small business size standards for the NAICS code assigned to this solicitation at time of both proposal submission and time of award in order to receive some consideration under this Factor. Note that the Government requires the Offeror to honor the evaluation factor commitment to the SDVOSB/VOSB concern throughout the life of the contract. The Offeror shall agree, if awarded a contract, to use the SDVOSB or VOSBs proposed as subcontractor or to substitute one (1) or more SDVOSBs or VOSBs for subcontract work of the same or similar value.

Change 7:

Section E.1 ADDENDUM to FAR 52.212-1 INSTRUCTIONS TO OFFERORS— COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES, Table 2 is hereby changed as follows:

FROM:

Table 2 – TOPR Proposal Volume Requirements

Factor Phase Content Delivery Method Volume Page Limit

N/A

Completed Task Order Offer

Written Proposal I

Executed Proposal, to include SF1449 and

N/A https://veterans.certify.sba.gov/

SF 30

Amendments Points of Contact

Factor 1

Technical Evaluation

I Use Case Approaches

Oral Presentation N/A N/A

Factor 1

Evaluation

II

1.1 Deployment and

Implementation Plan

1.2: Medical

Network Adequacy Plan

Written Proposal I 50 pages

Factor 2 II Past Performance Written Proposal II 3 PPQs; plus No more than a 3-page narrative for all PPQs

Factor 3 II Veteran Involvement/ Subcontracting

Written Proposal III 10

Factor 4 II Price Written Proposal IV 50 pages for the Price Narrative, including no more than 10-page BOE.

TO:

Table 2 – TOPR Proposal Volume Requirements

Factor Phase Content Delivery Method Volume Page Limit

Completed Task Order Offer

Written Proposal I

Executed Proposal, to include SF1449 and

SF 30

Amendments Points of Contact

Factor 1

Evaluation

I Use Case Approaches

Oral Presentation N/A N/A

Factor 1

Evaluation

II

1.2 Deployment and

Implementation Plan

1.2: Medical

Adequacy Plan

Written Proposal I 50 pages

Factor 2 II Past Performance Written Proposal II 3 PPQs per prime and each subcontractor plus No more than a 3-page narrative for all PPQs

Factor 3 II Veteran Involvement/ Subcontracting

Written Proposal III 10

Factor 4 II Price Written Proposal IV 50 pages for the Price Narrative, including no more than 10-page BOE.

Change 8:

E.2 ADDENDUM to FAR 52.212-2 EVALUATION— COMMERICAL ITEMS, Factor 2:

Past Performance paragraphs (c) and (d) are hereby changed as follows:

FROM:

c. The Government will consider up to three (3) recent (within the past five (5) years) and relevant contracts of similar scope, magnitude and complexity to the requirements in this solicitation in which the Offeror was the Prime Offeror. The Government may use information provided by the Offeror as well as information from other sources, including, but not limited to, CPARS, questionnaires, or interviews with previous customers.

d. The Government may also consider up to three (3) recent (within the past five (5) years) and relevant contracts from the past five (5) years to evaluate the past performance of the Offeror’s subcontractors (whom the Offeror proposes to use in this requirement) in providing services similar in scope, magnitude, and complexity to those required in this solicitation. Past performance relevancy will be evaluated using the following confidence ratings in Table 8.

TO:

c. The Government will consider three (3) recent (within the past five (5) years) and relevant contracts of similar scope, magnitude and complexity to the requirements in this solicitation in which the Offeror was the Prime Offeror. The Government may use information provided by the Offeror as well as information from other sources, including, but not limited to, CPARS, questionnaires, or interviews with previous customers.

d. The Government may also consider up to three (3) per subcontractors recent (within the past five (5) years) and relevant contracts from the past five (5) years to evaluate the past performance of the Offeror’s subcontractors (whom the Offeror proposes to use in this requirement) in providing services similar in scope, magnitude, and complexity to those required in this solicitation. Past performance relevancy will be evaluated using the following confidence ratings in Table 8.

Change 9:

The following language in section E.1 ADDENDUM to FAR 52.212-1 INSTRUCTIONS

TO OFFERORS—COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES,

Factor 2: Past Performance is revised as follows:

FACTOR 2: PAST PERFORMANCE

All proposals must include a Past Performance Volume to be considered for award. The Offeror shall complete and submit the Past Performance References attachment in its entirety, listing a minimum of three (3) contracts/orders in which the Offeror was the Prime contractor for work performed in the past five (5) years or currently being performed for similar work to this requirement. For any subcontractor that the Offeror proposes to use for this requirement, the Offeror must also provide Past Performance references for subcontractors they have used to perform services on a minimum of three (3) contracts/orders performed in the past five (5) years or currently being performed for similar work to this requirement.

Contracts/orders listed may include those entered into with the Federal, State, and local government and private. The Government may consider an offeror’s joint venture partners (or partners’) or an offeror’s affiliate’s (or affiliates’)/parent organization’s (or parent organizations’) contracts in the past performance evaluation if the information provided shows that the workforce, management, facilities or other resources of the JV partner(s), affiliate(s)/parent organization(s) will bear on the likelihood of successful performance by the offeror. Past performance information will not be considered for predecessor companies, proposed subcontractors or key personnel. For the purposes of this solicitation, a major subcontract is defined as 20% of the total contract effort.

Data concerning the prime contractor shall be provided first, followed by each proposed major subcontractor, in alphabetical order.

TO:

All proposals must include a Past Performance Volume to be considered for award. The Offeror shall complete and submit the Past Performance References attachment in its entirety, listing a maximum of three (3) contracts/orders in which the Offeror was the Prime contractor for work performed in the past five (5) years or currently being performed for similar work to this requirement. For any major subcontractor that the Offeror proposes to use for this requirement, the Offeror must also provide Past Performance references for subcontractors they have used to perform services on a maximum of three (3) contracts/orders performed in the past five (5) years or currently being performed for similar work to this requirement.

Contracts/orders listed may include those entered into with the Federal, State, and local government and private. The Government may consider an offeror’s joint venture partners (or partners’) or an offeror’s affiliate’s (or affiliates’)/parent organization’s (or parent organizations’) contracts in the past performance evaluation if the information provided shows that the workforce, management, facilities or other resources of the JV partner(s), affiliate(s)/parent organization(s) will bear on the likelihood of successful performance by the offeror. For the purposes of this solicitation, a major subcontract is defined as 20% of the total contract effort. Data concerning the prime contractor shall be provided first, followed by each proposed major subcontractor, in alphabetical order.

Change 10:

Use Case

Background

Use Case

1 Applying T- Shirt Sizing Methodology to Estimate a

The Department of Veterans Affairs (VA) is eager to modernize its healthcare data exchange systems by transitioning from the current Electronic Data Interchange (EDI) standards to the more advanced HL7/FHIR standards (the “Project Request”).

Use

Software Development Project for the

VA.

(PWS 16

Technology,

18.3 Optional

Task 3:

Software, Process, and Proof of Concept, Development

Recognizing the potential for improved interoperability and data management, the VA has submitted a detailed Software Development Project Request through the Configuration Control Board (CCB). In this Use Case, VA requires the Offeror to leverage a proposed T-Shirt sizing methodology as defined in Section 15.2.1 to estimate the scope, complexity, and effort required for the Project Request. This Use Case shall demonstrate your approach to assessing the feasibility of the Project Request through the T-Shirt sizing methodology.

1. Methodology and Processes o Provide an overview of your software development methodologies describing how they align with VA’s requirements.

o How would you ensure adherence to industry best practices and standards in your software development process?

2. Sprints and Planning o How would you estimate the size of the tasks for each sprint? Provide an example of a high-level Software Development Plan for a typical sprint?

o How would you manage dependencies and risks during the software development lifecycle?

o What criteria would you use to determine the most appropriate task size for completing the effort in accordance with the descriptions provided in Table 3?

3. Customization and Integration o How would you approach the customization and configuration of existing software solutions to meet VA’s specific needs?

o Describe how you would integrate the approved Referrals/Requests for Services (RFS), medical documentation, and claims submission system with the existing VA claims processing system?

4. Deliverables and Metrics o How would you ensure that all proposed sprints are testable and measurable?

o What metrics would you use to measure the progress and success of each sprint?

o Provide a detailed list of deliverables for a typical sprint, including planned releases, dependencies, risks, recommended task sizes, and milestones?

5. Security and Compliance o How would you ensure the security and confidentiality of PHI, PII, and VA sensitive data during the software development process?

o What measures would you take to comply with VA’s regulations and security standards?

2 Implementing a Central Submission System for Medical Documentation Management and Claims Processing System for Claims.

(PWS Section 10 Medical Documentation, PWS Section 11 Claims Processing and Adjudication for Medical Network Services Rendered, PWS Section 16 Technology)

You are required to provide a new medical documentation central submission system to streamline and automate the submission of medical records in support of bi-directional exchange of data from network providers to VA referring providers and vice versa. The system must also be configured with a new claims processing system to process and adjudicate claims including Approved Referral/RFS matching. The system must ensure timely, accurate, and error-free data exchange between the VA and network providers while adhering to compliance standards such as HIPAA and demonstrating protection from cyber and other security breaches.

Veteran Jane Doe is seen in the community for her primary care appointment. Describe how the Approved Referral/Request for Services (RFS), medical documentation, and claims are routed through a central submission portal and are integrated with the claims processing system. Describe how this integrated system will ensure accurate, timely, and secure data exchange, facilitating the efficient processing and adjudication of claims.

1. Key Challenges:

o What do you perceive as the key challenges in developing and maintaining the Medical Documentation Central Submission System for interoperability between VA, network providers, and your system?

2. System Capabilities o Interoperability: How will your Central Submission

System facilitate bi-directional submission, retrieval, requests, and acceptance of medical documentation between VA, network providers, and your system?

3. Medical Documentation Elements o Completeness and Accuracy: How will your system ensure that medical documentation is complete, verified, and authenticated before submission to VA?

4. Critical Findings and Documentation o Critical Findings: How will your system ensure that critical findings are communicated to both the Veteran and the referring VA provider within the stipulated timeframe?

5. Privacy and Security o Data Security: How will you ensure the confidentiality and security of all medical documentation and personal information handled by your system in compliance with applicable laws?

6. Medical Documentation Timeframes o Timely Submission: How will your system ensure that medical documentation is returned within the required timeframes for initial appointments, inpatient care, and urgent follow-ups?

7. System Capabilities o Automated Claims Processing System: How will your automated claims processing system be configured to meet the business rules, policies, guidelines, and medical documentation submission requirements as outlined in Attachment 2 CCN Next Gen Medical East Network Contractor Manual?

8. Additional Capabilities o Documentation for Opioid Pain Management: How will your system ensure that documentation regarding opioid pain management, including State’s Prescription Drug Monitoring Program checks, are included and up to date?

9. Claims Adjudication o Business Rules, Adjudication Logic, and Claims

Validation: How will your system incorporate VA’s adjudication logic, business rules, validate the approved referral, and what is your process for implementing updates to these rules?

10. Testing and Validation o Test Claim Tracers: How will you support the submission of test claims tracers from VA in your testing environment? What processes will you use to validate these test claims?

11. Additional Capabilities o Support for Out-of-Network Claims: What processes will you implement to manage out-of-network claims and ensure they have a VA Approved Referral number? How will you ensure that invoices for in-network and out-of-network reimbursement requests are billed separately?

12. Recommended Roles: This use case should leverage the following recommended roles.

o Vendor System Administrator - Oversees the operation, maintenance, and security of the central submission system.

o Network Provider (e.g., Physician or Hospital) - Submits RFS, medical records and claims through the system.

o VA Claims Processor - Reviews and adjudicates claims based on submitted medical records and matching Approved Referral/RFS.

o VA Case Manager - Uses the system to coordinate care and verify medical documentation.

o Veteran Patient - Receives care and benefits based on the Approved Referral/RFS, processed claims and submitted medical records.

o Vendor Data Analyst - Monitors data accuracy and ensures error-free submissions.

o UM Vendor/Analyst – evaluates RFS for clinical necessity and appropriateness and makes recommendation to VA for approval/denial of care.

o Vendor Technical Support Team - Provides troubleshooting and support for providers and VA staff using the system.

3 Implementing a Secure, Role- Based Portal for VA Staff, Network Providers, and Veterans

(PWS Section 6.2.1 Contractor Self- Service Capabilities)

In effort to improve Veteran experience, you are required to develop a secure, role-based portal accessible via HTTPS is needed to streamline interactions between VA staff, network providers, and veterans. The portal shall include self-service capabilities tailored to each user group. This use case should demonstrate your approach to ensuring a Veteran, a Community Provider, and a VA Employee can each leverage the portal to manage healthcare and benefits independently, and ensure timely, accurate and error free data exchange between VA and Network Providers.

1. Security and Access:

o How will you ensure secure, HTTPS-based access to the role-based self-service portal for VA staff, network providers, and veterans?

o Describe your approach to integrating with AccessVA for secure login and federated identity management?

2. Portal Capabilities:

o What specific features will your portal offer to network providers in terms of viewing veteran benefits, eligibility information, claims status, and appeals processes?

o How will veterans use the portal to access their Explanation of Benefits (EOB), check eligibility and enrollment status, and view referrals and claims?

o How will your self-service portal provide specific functionalities for VA staff, such as access to all RFSs, notifications, claims status, and VA’s Provider Directory search?

3. User Experience:

o How does your portal ensure that veterans can opt to receive EOBs electronically and request paper summaries as needed?

o What mechanisms does your portal have in place for detecting and reporting suspected fraud and abuse, both anonymously and non-anonymously?

4. Real-Time Data Access:

o How will your portal provide VA personnel and network providers with real-time access to pharmacy dispensing data from your Pharmacy Benefits Manager (PBM)?

5. Compliance and Integration:

o How will your self-service portal comply with the

VA’s Opioid Safety Initiative and ensure network providers can self-attest their compliance?

o How do you plan to monitor and correct errors in network provider profiles within your portal?

6. Provider Management:

o How will your portal manage network providers' ability and willingness to accept VA Approved Referrals/Authorizations, including providing timelines when they cannot accept new referrals?

o What process will your portal provide for network providers to request removal from the network and communicate the impact on veterans to the VA?

7. Documentation and Reporting:

o How will you handle VA-requested changes to the portal content within the agreed timeframe during the contract period?

8. Education and Support:

o What will be your approach to educating network providers on accessing and using the VA-provided referral and authorization information system?

o How do you propose to support the exchange of data/documentation between VA and network providers through your portal?

9. Recommended Roles: This use case should leverage the following recommended roles.

o VA Staff (e.g., Case Manager) - Uses the portal to manage veteran care, review documentation, coordinate with network providers, and report clinical quality and patient safety issues within community care.

o Network Provider (e.g., Physician) - Uses the portal to submit and track RFS, submit medical documentation, access veteran medical histories report Veteran related clinical quality and patient safety issues, and communicate with VA staff.

o Veteran Patient - Uses the portal to access personal health records, schedule appointments, track RFS and claim statuses, and report clinical quality and patient safety issues.

o UM Vendor/Analyst – Uses the portal to receive and validate RFS, verify and review medical documentation, submit UM recommendations to VA, and provide UM guidance and resources to Veterans and Network Providers.

o Offeror’s System Administrator - Configures and maintains the portal, ensuring role-based access and security compliance.

o VA Security Officer - Ensures the portal complies with VA security policies and monitors for unauthorized access.

4 Audit, Fraud, Waste & Abuse Scenario (recoupment actions, improper payments)

(PWS Section

The Department of Veteran Affairs (VA) has received multiple complaints from Veterans regarding ABC Medical Group, a provider in your Medical Network. Veterans have reported receiving bills for services they did not receive, and discrepancies have been noted between the services listed on their Explanation of Benefits (EOB) and the care they actually received. Additionally, VA data analytics flagged ABC Medical Group for a high volume of claims using a specific procedure code that is significantly above the regional average, raising

14 Program Integrity) concerns about potential overutilization and improper payments.

The VA has requested your organization to investigate ABC Medical Group for potential fraud, waste, and abuse (FWA) and improper payments. The VA has also asked for a detailed plan to address the issue pursuant to PWS 13.6. Your organization must demonstrate its ability to operationalize its FWA program, collaborate with the VA, and ensure compliance with Federal statutes and regulations.

You are tasked with demonstrating how your solution would address this scenario. Specifically:

1. Detection: How would your solution detect these FWA patterns in billings by network providers, pharmacies, entities, and beneficiaries?

2. Prepayment and Post-payment Operations: How does your solution operate on both a prepayment and post-payment basis to flag suspicious activity before payments are issued and identify improper payments after they are made?

3. Anti-Fraud and Abuse Controls: What anti-fraud and abuse controls does your solution utilize to prevent improper payments, and how does it ensure that fraudulent claims are corrected, and overpayments are recovered in a timely manner?

4. Deterrence: How would your solution deter future occurrences of FWA?

5. Transparency and Accountability: How does your solution share substantiated FWA information with program administrators, ensuring transparency and accountability?

Provide a detailed response, including specific features, methodologies, and success stories that demonstrate your ability to detect, prevent, correct, deter, and recover improper payments in scenarios like this. Highlight how your solution would empower the VA Community Care program to safeguard taxpayer dollars, maintain operational integrity, and ensure Veterans receive the care they deserve.

5 Assisting a Veteran with a

John, a 58-year-old veteran living in Wilmington, Illinois, has been experiencing frequent urination, pelvic pain, and blood in

Community Care Urology Appointment in Illinois

(PWS Section 3 Medical Network Development and Maintenance, PWS Section 7 Referrals, PWS Section 9 Pharmacy, PWS Section 10 Medical Documentation, PWS Section 8:

Utilization Management) his urine. He contacts the Edward Hines, Jr. VA Medical Center to schedule an appointment. Due to a 90 day wait time at the VA facility, John is referred to VA Community Care Program to see a Urologist in the community. Local providers in VA’s Community Care Network (CCN) are limited, and those available have wait times exceeding 60 days for new patients.

VA submits a referral to the TPA/Offeror responsible for coordinating Community Care in Northern Illinois. The referral includes John’s medical history, the reason for the referral, and authorization for community care services. Meanwhile, John’s condition worsens while waiting for care, leading to unnecessary emergency room visits and increased anxiety about his health and he also requires transportation assistance.

This use case scenario should demonstrate the Offeror’s approach to addressing this urgent need once the referral is received for a Urologist in Northern Illinois. Please note that there is not a Urologist currently in the network, this Veteran presents in Urgent Care and the ER which requires at least one admission, the Veteran requires transportation assistance, and the contact number for John is out of service.

Recommended Roles: This use case should leverage the following recommended roles.

o VA Staff (e.g., Case Manager) - Issues Approved Referral to Community Care, receives notice of ER encounter and admission, coordinates transfer to VA facility, responsible for coordinating Veteran transportation and for reporting any clinical quality and patient safety issues.

o Network Provider (e.g., Physician, ER) - Receives Approved Referral and provides care to Veteran;

additional care must be approved via RFS that is submitted to Offeror and may include UM. Can report clinical quality and patient safety issues via the self-service portal.

o Veteran Patient - Receives care via outpatient, ER, urgent care, and/or VA facility encounters. Can report clinical quality and patient safety issues via the self-service portal.

o UM Vendor/Analyst – Requires notice of ER visits resulting in admissions, conducts UM on inpatient care daily, and coordinates to transfer Veteran to VA facility if bed is available. Conducts UM for additional services requested via RFS from Network Providers

TO:

1 Applying T- Shirt Sizing Methodology to Estimate a Software Development Project for the

VA.

(PWS 16

Technology,

18.3 Optional

Task 3:

Software, Process, and Proof of Concept, Development

The Department of Veterans Affairs (VA) is eager to modernize its healthcare data exchange systems by transitioning from the current Electronic Data Interchange (EDI) standards to the more advanced HL7/FHIR standards (the “Project Request”).

Recognizing the potential for improved interoperability and data management, the VA has submitted a detailed Software Development Project Request through the Configuration Control Board (CCB). In this Use Case, VA requires the Offeror to leverage a proposed T-Shirt sizing methodology as defined in Section 18.3 to estimate the scope, complexity, and effort required for the Project Request. This Use Case shall demonstrate your approach to assessing the feasibility of the Project Request through the T-Shirt sizing methodology.

1. Methodology and Processes o Provide an overview of your software development methodologies describing how they align with VA’s requirements.

o How would you ensure adherence to industry best practices and standards in your software development process?

2. Sprints and Planning o How would you estimate the size of the tasks for each sprint? Provide an example of a high-level Software Development Plan for a typical sprint?

o How would you manage dependencies and risks during the software development lifecycle?

o What criteria would you use to determine the most appropriate task size for completing the effort in accordance with the descriptions provided in Table 12?

3. Customization and Integration o How would you approach the customization and configuration of existing software solutions to meet VA’s specific needs?

o Describe how you would integrate the approved

Referrals/Requests for Services (RFS), medical documentation, and claims submission system with the existing VA claims processing system?

4. Deliverables and Metrics o How would you ensure that all proposed sprints are testable and measurable?

o What metrics would you use to measure the progress and success of each sprint?

o Provide a detailed list of deliverables for a typical sprint, including planned releases, dependencies, risks, recommended task sizes, and milestones?

5. Security and Compliance o How would you ensure the security and confidentiality of PHI, PII, and VA sensitive data during the software development process?

o What measures would you take to comply with VA’s regulations and security standards?

2 Implementing a Central Submission System for Medical Documentation Management and Claims Processing System for Claims.

(PWS Section 10 Medical Documentation, PWS Section 11 Claims Processing and Adjudication for Medical Network Services Rendered, PWS Section

You are required to provide a new medical documentation central submission system to streamline and automate the submission of medical records in support of bi-directional exchange of data from network providers to VA referring providers and vice versa. The system must also be configured with a new claims processing system to process and adjudicate claims including Approved Referral/RFS matching. The system must ensure timely, accurate, and error-free data exchange between the VA and network providers while adhering to compliance standards such as HIPAA and demonstrating protection from cyber and other security breaches.

Veteran Jane Doe is seen in the community for her primary care appointment. Describe how the Approved Referral/Request for Services (RFS), medical documentation, and claims are routed through a central submission portal and are integrated with the claims processing system. Describe how this integrated system will ensure accurate, timely, and secure data exchange, facilitating the efficient processing and adjudication of claims.

1. Key Challenges:

o What do you perceive as the key challenges in developing and maintaining the Medical Documentation Central Submission System for

16 Technology) interoperability between VA, network providers, and your system?

2. System Capabilities o Interoperability: How will your Central Submission

System facilitate bi-directional submission, retrieval, requests, and acceptance of medical documentation between VA, network providers, and your system?

3. Medical Documentation Elements o Completeness and Accuracy: How will your system ensure that medical documentation is complete, verified, and authenticated before submission to VA?

4. Critical Findings and Documentation o Critical Findings: How will your system ensure that critical findings are communicated to both the Veteran and the referring VA provider within the stipulated timeframe?

5. Privacy and Security o Data Security: How will you ensure the confidentiality and security of all medical documentation and personal information handled by your system in compliance with applicable laws?

6. Medical Documentation Timeframes o Timely Submission: How will your system ensure that medical documentation is returned within the required timeframes for initial appointments, inpatient care, and urgent follow-ups?

7. System Capabilities o Automated Claims Processing System: How will your automated claims processing system be configured to meet the business rules, policies, guidelines, and medical documentation submission requirements as outlined in Attachment 2 CCN Next Gen Medical Contractor Manual?

8. Additional Capabilities o Documentation for Opioid Pain Management: How will your system ensure that documentation regarding opioid pain management, including State’s Prescription Drug Monitoring Program checks, are included and up to date?

9. Claims Adjudication o Business Rules, Adjudication Logic, and Claims

Validation: How will your system incorporate VA’s adjudication logic, business rules, validate the approved referral, and what is your process for implementing updates to these rules?

10. Testing and Validation o Test Claim Tracers: How will you support the submission of test claims tracers from VA in your testing environment? What processes will you use to validate these test claims?

11. Additional Capabilities o Support for Out-of-Network Claims: What processes will you implement to manage out-of-network claims and ensure they have a VA Approved Referral number? How will you ensure that invoices for in-network and out-of-network reimbursement requests are billed separately?

12. Recommended Roles: This use case should leverage the following recommended roles.

o Vendor System Administrator - Oversees the operation, maintenance, and security of the central submission system.

o Network Provider (e.g., Physician or Hospital) - Submits RFS, medical records and claims through the system.

o VA Claims Processor - Reviews and adjudicates claims based on submitted medical records and matching Approved Referral/RFS.

o VA Case Manager - Uses the system to coordinate care and verify medical documentation.

o Veteran Patient - Receives care and benefits based on the Approved Referral/RFS, processed claims and submitted medical records.

o Vendor Data Analyst - Monitors data accuracy and ensures error-free submissions.

o UM Vendor/Analyst – evaluates RFS for clinical necessity and appropriateness and makes recommendation to VA for approval/denial of care.

o Vendor Technical Support Team - Provides troubleshooting and support for providers and VA staff using the system.

3 Implementing a Secure, Role- Based Portal for VA Staff,

1. Security and Access:

o How will you ensure secure, HTTPS-based access to the role-based self-service portal for VA staff, network providers, and veterans?

Providers, and Veterans

(PWS Section 6.2.1 Contractor IVR with Self- Service Capabilities) o Describe your approach to integrating with AccessVA for…