DEPARTMENT OF VETERANS AFFAIRS

VHA Office of Integrated Veteran Care

Integrated External Networks

Community Care Network Next Generation

Medical Multiple Award IDIQ Performance Work Statement

February 25, 2026

Table of Contents

1 GENERAL INFORMATION

1.1 Introduction

1.2 Scope of Services

1.3 Applicable Documents

1.4 IDIQ Contract Performance Management

2 GENERAL TASK AREAS

2.1 Program / Project Management

2.2 Contractor Maintained Records

2.3 Medical Network Development and Maintenance

2.4 Eligibility Data Management

2.5 Customer Service

2.6 Utilization Management (UM)

2.7 Pharmacy

2.8 Medical Documentation

2.9 Claims Processing and Adjudication

2.10 Reimbursement Submission

2.11 Coordination of Benefits

2.12 Program Integrity

2.13 Clinical Quality and Patient Safety

2.14 Technology

2.15 Training

2.16 Healthcare Appointment Scheduling

2.17 Care Coordination

1 GENERAL INFORMATION 1

1.1 Introduction 2

Community Care Network (CCN) services and health care resources are purchased 3 under the authority of 38 United States Code (U.S.C.) § 8153, “Sharing of health-care 4 resources.” The primary goal of this acquisition is to establish a suite of indefinite-5 delivery indefinite-quantity contracts that will enable Veterans Health Administration 6 (VHA) to provide CCN services and health care resources through an established 7 network of licensed health care providers and practitioners for medical, surgical, 8 complementary and integrative, durable medical equipment (DME), and pharmacy 9 services that drive quality, efficiencies, cost savings, and a positive Veteran experience. 10 This acquisition and resulting multiple award contracts offer a broad range of services, 11 and solutions to deliver and support the delivery of quality and timely CCN health care 12 services and health care resources. This Performance Work Statement (PWS) identifies 13 general task areas under which Task Orders (TO) may be executed. Specific 14 requirements will be further identified and defined at the TO level. 15

1.2 Scope of Services 16

The Contractor shall provide the full range of health care and health care-related / 17 supporting services, technical and management expertise, and solution-related 18 products in one or more task areas to meet the mission needs of VHA. As identified in 19 individual TOs, health care services and capabilities, and supporting services and 20 capabilities, shall be provided to VHA. While the PWS identifies general task areas, the 21 suite of resulting contracts are intended to satisfy the full range of health care and 22 health care-related / supporting requirements. It is intended that this suite of contracts 23 will provide the full range of current and emerging health care services and capabilities 24 and supporting services and capabilities throughout the life of the contract. The 25 Contractor shall provide solutions for one or more of the general task areas below, 26 furnishing the necessary personnel, materials, equipment, and facilities, with specific 27 tasks to be defined at the TO level. The general scope of this contract includes the 28 following general task areas: 29

1. Program / Project Management (PWS 2.1) 30

2. Contractor Maintained Records (PWS 2.2) 31

3. Medical Network Development and Maintenance (PWS 2.3) 32

4. Eligibility Data Management (PWS 2.4) 33

5. Customer Service (PWS 2.5) 34

6. Utilization Management (PWS 2.6) 35

7. Pharmacy Network Development and Maintenance (PWS 2.7) 36

8. Medical Documentation (PWS 2.8) 37

9. Claims Processing and Adjudication (PWS 2.9) 38

10. Reimbursement Submission (PWS 2.10) 39

11. Coordination of Benefits (PWS 2.11) 40

12. Program Integrity (PWS 2.12) 41

13. Clinical Quality and Patient Safety (PWS 2.13) 42

14. Technology (PWS 2.14) 43

15. Training (PWS 2.15) 44

16. Appointment Scheduling (PWS 2.16) 45

17. Care Coordination (PWS 2.17) 46

1.3 Applicable Documents 47

The Contractor shall comply with all relevant Federal, State, and local government 48 regulations, as well as specific regulations, publications, policies, and procedures 49 outlined in the contract and the individual TOs. 50

1.4 IDIQ Contract Performance Management 51

VA will use a Quality Assurance Surveillance Plan (QASP) to monitor the quality of the 52 Contractor’s performance of the requirements of the base contract. The oversight 53 provided for in the QASP will help to ensure that service levels reach and maintain the 54 required levels throughout the contract term. The QASP is a tool used by the 55 Government; therefore, it remains a living document through the TO performance 56 period. 57

The QASP itself is not part of the contract; however, a copy of the QASP will be 58 provided to the Contractor for informational purposes only. The Contractor shall meet all 59 performance requirements established by the contract PWS for each TO issued under 60 the scope of the IDIQ contract and Performance Requirement Summary (PRS) (Table 1 61 below). The PRS in Table 1 below applies only to the base contract, a QASP and PRS 62 for each TO will be developed at the TO level, when appropriate. 63

Table 1. PRS 64

PO #

Performance

Objective

(PO)

Contract or

PWS

Reference

Performance Standard

Acceptable Quality Level

(AQL)

Surveillance Method /

Frequency

PO 1 Task Order Proposal Response Timeliness

B.2.1 Task Order Procedures

Contractor adheres to the response times specified in each Task Order Proposal Request

(TOPR).

100% 100% Inspection

Inspection of all Task Order responses.

Quarterly or more/less as determined by VA.

2 GENERAL TASK AREAS 65

2.1 Program / Project Management 66

The Contractor shall provide program / project management services to effectively 67 manage each TO by overseeing all aspects of planning, execution, and monitoring to 68 ensure the successful delivery of the TO requirements. This includes developing 69 detailed project plans, mobilizing appropriate resources, risk management, ensuring 70 compliance with all contractual obligations, and achieving project milestones and 71 deliverables on schedule. 72

2.2 Contractor Maintained Records 73

Upon written request from the Contracting Officer (CO), the Contractor shall provide to 74 VA any and all records, information, and data in its possession, custody, or control in 75 the requested format, including claims data; raw X12 electronic data interchange (EDI) 76 data and metadata; claims images; medical records; network provider agreements; 77 accreditation, credentialing and certification documentation; delegation of certification 78 agreements; licensing files; competency measures; Federal exclusionary list matching; 79 quality and safety issues submitted by VA facilities and all related reviews, data, and 80 actions taken in response to quality and safety issue concerns; network provider 81 education materials and related correspondence; network provider applications; 82 network provider communications; and bank/payment records. The Contractor shall 83 also ensure timely and reasonable access to its personnel upon written request from 84 the CO, for the purpose of interview and discussion by VA and other Government 85 officials conducting an audit, inspection, or investigation. The Contractor shall include 86 VA’s right to access network provider records, information, and data as described in this 87 paragraph in its provider agreements. 88

The Contractor shall provide access to the aforementioned artifacts within five (5) 89 business days of request. Any issues identified during VA review will be sent to the 90 Contractor. The Contractor shall correct the issues within the VA specified timeframe. 91

2.3 Medical Network Development and Maintenance 92

The Contractor shall establish, maintain, and manage a CCN Next Generation Medical 93 Network consisting of a comprehensive network of qualified health care providers, 94 practitioners, and facilities. The Contractor shall provide a network of providers and 95 practitioners capable of providing health care services described in 38 Code of Federal 96 Regulations (C.F.R.) § 17.38(a). The Contractor shall also provide a network of 97 practitioners capable of providing Complementary and Integrative Health Services 98 (CIHS) and Community Nursing Home Care. The Contractor shall provide a network of 99 providers and practitioners capable of providing Assisted Reproductive Technology 100 (ART) and In Vitro Fertilization (IVF) services as described in 38 C.F.R. § 17.380. The 101 Contractor shall provide a network of providers and practitioners capable of providing 102 specific benefits associated with dialysis and transplants. 103

As medical care evolves, services may be added to the medical benefits package under 104 appropriate statutory authority. The Contractor’s network shall have the capability to 105 develop and expand its resources to provide those services. 106

2.4 Eligibility Data Management 107

The Contractor shall receive enrollment and eligibility information from VA in a daily 108 eligibility file through EDI Gateway/Data Access Services (DAS), which will serve as the 109 primary method of data exchange until VA develops and implements real-time data-110 sharing capabilities. VA may also use secure messaging to transmit enrollment and 111 eligibility information. The file will contain Veterans Community Care Eligibility (VCE) 112 Code changes for eligible individuals. The Contractor shall meet all VA-connectivity 113 requirements (e.g. Authority to Operate (ATO)) as specified at the TO level. 114

2.5 Customer Service 115

The Contractor shall provide a broad scope of customer service capabilities in support 116 of the CCN Next Generation Network. Customer Service support may include both 117 virtual and on-site requirements. 118

Tasks under this section could include areas such as: Contact Center, Urgent Care 119 Inquiries, After Call Surveys, Self Service Capabilities, Use of VA-Provided Ticketing 120 Tool, Information Technology Support, Network Provider Satisfaction Surveys, 121 Customer Service Quality Assurance, Self-Service Performance, and Customer Service 122 Performance Requirements and Reporting. 123

2.6 Utilization Management (UM) 124

The Contractor shall establish, execute, and sustain a UM program to assist VA in 125 assessing the medical necessity, clinical appropriateness, and efficiency of health care 126 services. The Contractor shall have the capacity to make UM recommendations to VA 127 for care that furthers an existing VA Approved Referral based only on the 128 appropriateness of care and service for each individual Veteran’s needs. A VA-129 Approved Referral supports a specific plan of care as it relates to a specified number of 130 visits and/or services as long as the services are provided by a network provider. The 131 Contractor shall conduct utilization reviews for inpatient and outpatient care. VA has the 132 sole responsibility to make final decisions based on the Contractor’s UM 133 recommendation. 134

The Contractor shall demonstrate ongoing UM accreditation from a nationally 135 recognized UM accrediting organization. The Contractor shall notify VA of any changes 136 in accreditation status as specified at the TO level. 137

Tasks under this section could include areas such as: Accreditation, Utilization 138 Management Committees, Foundational Documents, Program Approach, Quality 139 Improvement, Reporting Data, Trends and Risks, Data and Performance Requirements, 140 UM Decisions, Review and Referrals, Medical Necessity Criteria, Interrater Reliability, 141 Referrals, and Requests for Services, Emergency Care and Inpatient Admissions, 142 Communication Services, Appeals Process and Pharmaceutical Management. 143

2.7 Pharmacy 144

The Contractor shall provide, as required, pharmacy benefits to Veterans through use 145 of a Pharmacy Benefit Manager (PBM) function that has a retail pharmacy network to 146 provide prescription fulfillment services for urgent/emergent prescriptions from 147

Community Care network providers and VA-approved providers. The Contractor shall 148 require all routine/maintenance prescriptions to be forwarded to VA pharmacy for 149 processing and fulfillment. The Contractor shall require all network providers be 150 registered with their own State’s prescription monitoring programs. 151

The Contractor’s administration of a pharmacy benefit shall accommodate eligibility 152 checks, urgent prescription access, and prior authorization rules as required by VA. 153

Tasks under this section could include areas such as: Retail Pharmacy, Pharmacy 154 Eligibility Data Management, Urgent/Emergent Prescriptions and Performance Metrics, 155 ART/IVF and Infertility Prescriptions, Contingency Plan for Disaster Response, 156 Vaccinations, Refunds and Reimbursements, Real Time Formulary, 157 Routine/Maintenance Prescriptions, and Specialty Pharmacy. 158

2.8 Medical Documentation 159

The Contractor shall provide a broad scope of medical documentation submission and 160 management capabilities in support of the CCN Next Generation Network. The 161 Contractor shall develop and maintain a Central Submission System for the 162 coordination of all medical documentation among the network provider, the Contractor, 163 and VA. The Central Submission System shall leverage connections and 164 interoperability standards in accordance with PWS Section 2.14 “Technology” to 165 facilitate bi-directional submission and receipt, requests, and acceptance of medical 166 documentation, to include images. The Central Submission System shall include, at a 167 minimum, an interoperable pathway for electronic document exchange among the 168 network provider, the Contractor, and VA as noted in that section. 169

Tasks under this section could include areas such as: Data Elements to be Included, 170 Submission Timeframes, Compliance Reporting, Critical Findings, and Documentation 171 of Transplant Candidates. 172

2.9 Claims Processing and Adjudication 173

The Contractor shall receive, process, and adjudicate claims for services, when 174 provided by network providers or as an adjunct to services provided by the Contractor’s 175 network providers. The Contractor’s claims processing system shall include standard 176 business rules and edits in its Claims Processing Data Dictionary. The Contractor’s 177 claims processing system shall be capable of adding rules and edits based on 178 information from VA. When VA requests such updates to claims adjudication logic, the 179 Contractor shall implement and test the updates. The Contractor shall retain the claims, 180 claims processing information, and sufficient information on all claims, including 181 Electronic Visit Verification when appropriate, to allow processing to completion and to 182 permit audits pursuant to the record retention requirements contained in Health 183 Insurance Portability and Accountability Act (HIPAA) privacy regulations (45 C.F.R. § 184 160, 162 and 164). 185

Tasks under this section could include areas such as: Claims Submission and 186 Processing Timeframes, Processing and Adjudication, Electronic Visit Verification, 187 Claim Reprocessing and Adjustment, Medical Network Provider Claim Appeals, Test 188 Claim Tracers, Claims Reporting, Claims for Services Rendered to Veterans Assigned 189 to Other CCN Next Generation Region. 190

2.10 Reimbursement Submission 191

The Contractor shall submit claim invoices to VA for reimbursement within thirty (30) 192 calendar days of the Contractor’s complete adjudication of the claim submitted by the 193 network provider. 194

Tasks under this section could include areas such as: Resubmission of Claim Invoices 195 Processed by VA, Invoicing Accuracy, and Accounting and Access to Records. 196

2.11 Coordination of Benefits 197

The Contractor shall ensure that Veterans are not held responsible for payment and 198 that its network providers do not invoice Veterans for any services associated with a 199 VA-Approved Referral, even if the network provider’s claim is denied by the Contractor. 200 The Contractor shall ensure that by accepting a VA-Approved Referral and performing 201 services, the network provider agrees not to seek any payment from the Veteran for 202 services covered by the referral. 203

Tasks under this section could include areas such as: Debt Collection and Issuance of 204 Explanation of Benefits. 205

2.12 Program Integrity 206

The Contractor shall adhere to the principles of payment and program integrity that 207 support VA in achieving its mission without compromise. This will include ethical 208 conduct, accountability, and strict compliance with applicable laws, regulations, and 209 policies. The Contractor shall implement and maintain industry-standard tools for 210 program oversight, including robust internal controls and risk management strategies to 211 prevent improper payments. The Contractor shall have a Compliance Committee and 212 identified Compliance Officer and report to VA on its program/payment integrity 213 practices, on error rates and remediation plans, and other integrity efforts as specified 214 by VA in TOPRs. 215

Tasks under this section could include areas such as: Timelines for Fraud, Waste and 216 Abuse (FWA) Case Development and Referral to VA, Prohibited Actions, Prohibited 217 Affiliations with Contractor and Subcontractor Service Providers, Compliance with the 218 False Claims Act, Anti-Fraud, Waste, and Abuse Flags, Predictive Analytics and 219 Machine Learning to Identify and Combat FWA, Post Payment Review to Combat FWA, 220 Support for Investigative Agencies on FWA Cases, FWA Training and Education 221 Program for Network Providers, Recovery and Recoupment Actions Related to FWA 222 Cases, Payment Suspension and Termination from the Network Due to FWA, Provider 223 Termination, Payment Integrity, Cost Avoidance, Recovery, and Recoupment Reports, 224 Program and Payment Integrity Site Visits and Virtual Reviews. 225

2.13 Clinical Quality and Patient Safety 226

The Contractor shall align its quality and performance measurement process to the 227 VA’s quality goals and ensure they are relevant to Veterans. The Contractor shall 228 establish and maintain a structured framework for quality improvement interventions 229 and payment reform initiatives. The Contractor shall deploy a Quality Improvement Plan 230 (QIP) to address any area of concern identified by VA. The Contractor shall provide 231 reports about quality issues and improvement efforts. Where applicable, the Contractor 232 shall use or demonstrate quality performance through a standardized, accredited tool 233 (e.g., Utilization Review Accreditation Commission (URAC) or National Committee for 234 Quality Assurance (NCQA)). 235

VA conducts quality improvement initiatives relevant to Veterans. To support VA’s 236 Quality Improvement agenda, the Contractor shall maintain all of the quality 237 measurement functionalities, such as a quality review committee, standardized 238 measurement sets, and data integrity efforts to support quality improvement initiatives. 239 The Contractor shall report regularly on customer experience metrics, action plans, and 240 other customer experience improvement efforts in co-ordination with VAs Chief 241 Experience Office. 242

Tasks under this section could include areas such as: Clinical Quality and Patient 243 Safety Plan, Annual Work Plan, Annual Evaluation, Clinical Quality and Patient Safety 244 Issues Identification, Patient Safety Issue Reporting, Trending, and Forecasting, Peer 245 Review of Quality and Patient Safety Issues, Performance Reporting, Value-Based 246

Care, Clinical Quality Steerage Data Model, Predictive Analytics and Modeling, and 247 Nursing Home Quality Oversight. 248

2.14 Technology 249

The Contractor shall use recognized health information interoperability standards, such 250 as American National Standards Institute/American with Disabilities Act for 251 interoperability, in all information technology (IT) systems used to support the CCN Next 252 Generation Medical Network. 253

The Contractor’s systems shall have the capability for future enhancements that are 254 planned and developed, in accordance with VA direction, to keep systems in line with 255 evolving industry standards to include data transaction standards (such as Health Level 256 Seven (HL7), Fast Healthcare Interoperability Resources (FHIR)) and integration into 257 VA’s electronic health record (EHR)). VA also encourages implementation of Trusted 258 Exchange Framework and Common Agreement (TEFCA) or Substitute Medical 259 Applications and Reusable Technologies (SMART) on FHIR. 260

Tasks under this section could include areas such as: Communication and Access to 261 Contractor Systems, Configuration Management and Testing, Continuity of Operations 262 Plan, Data Integrity, Data Security, Information and Data Exchange Requirements, 263 Interoperability Standards Compliance Requirements, Software Development, and 264 Technology Compliance Requirements, and Data Analytics. 265

2.15 Training 266

The Contractor shall develop and deliver training for the CCN Next Generation Medical 267 Network users that results in: 268

1. Increased knowledge and understanding of the Contractor’s CCN Next 269 Generation Medical Network’s business processes and systems 270

2. Improved ability to use and operate the Contractor’s CCN Next Generation 271 Medical Network’s business processes and systems 272

3. Compliance with new VA or Congressional regulatory requirements 273

CCN Next Generation Medical Network users may include network providers, 274 Contractor personnel, and identified VA staff. 275

The Contractor shall develop and implement a training program for Contractor 276 personnel, network providers, and identified VA staff that ensures compliance with all 277 network-related training requirements which may include specific VA-provided training, 278 complete opioid safety and best practices training prior to the provision of care, an on-279 boarding and ongoing outreach and education program for network providers and 280 Contractor personnel and training on VA health care benefits, unique VA clinical 281 guidelines, and requirements under this contract for its staff and network providers. 282

Tasks under this section could include areas such as: Network Provider and Contractor 283 Personnel Outreach and Education, Network Provider Only Training 284

2.16 Healthcare Appointment Scheduling 285

The Contractor shall collaborate with VA to implement health care appointment 286 scheduling services and capabilities in support of CCN Next Generation. Tasks under 287 this section could include areas such as scheduling and booking of appointments, 288 confirming and communicating appointments, calendar management, managing 289 changes, and rescheduling of appointments. 290

2.17 Care Coordination 291

The Contractor shall collaborate with VA to implement a Comprehensive Care 292 Coordination process for Veterans who have been assigned by the VA Facility 293 Community Care staff as needing basic care coordination support. Comprehensive 294 Care Coordination involves the collaboration of health care providers, and 295 administrators, Veterans and other stakeholders. Comprehensive Care Coordination 296 and Care Coordination Follow-Up. 297