Attachment C - Performance Requirement Summary_Medical West_04_10_26_v4.pdf

Pillar PO # Performance

Objective (PO)

Performance Work

Statement

(PWS)

Reference

Performance Standard Acceptable Quality

Level (AQL) Surveillance Method / Frequency

Calculation Methodology **Assessed percentages shall not be rounded up or down**

Incentives / Disincentives

PO1.1 Access:

Drive Time - Primary Care and Mental Health Care

3.1 Medical

Network Establishment and Maintenance

Contractor ensures Veteran travel time by car meets drive time standards for Primary Care and Mental Health Care reflected in the PWS in each VAMC Catchment Area.

*VAMC Catchment Area drive time acceptability determined by station pass/fail rate. Stations are determined to have passed if veteran travel times by car meets drive time standards reflected in the PWS at least 90% of the time for at least 2 of 3 months for the quarter assessed.

**AQL for drive time standard for each station, each month, is assessed together (Primary Care Urban, Primary Care Rural/Highly Rural, Mental Health Care Urban, and Mental Health Care Rural/Highly Rural).

Each VAMC Catchment Area pass rate:

Catchment Area 14 (Stations 504, 519, 549, 580, 671, 674, 740, 756) - 87% Catchment Area 15 (Stations 442, 554, 575, 623, 635, 660, 666) - 85% Catchment Area 16 (Stations 436, 463, 531, 648, 653, 663, 668, 687, 692) - 88% Catchment Area 17 (Stations 459, 570, 593, 612, 640, 654, 662) - 85% Catchment Area 18 (Stations 501, 600, 605, 644, 649, 664, 678, 691) - 87%

*Example Catchment Area 14 pass rate: 7/8 of stations within that Catchment Area passed (met or exceeded 90%) = 87.5% = Met 87% AQL **See PRS Appendix A Station Names and Numbers ***Performance standard, AQL/ratings, and penalties apply to each Catchment Area, and is NOT applied to the total average performance of all Catchment Areas

Random Sampling *Statistically significant

Veteran Drive times based on Veteran Address in VA Eligibility File/Referral and the address where services were rendered on the claim calculated using Azure API mapping tool. The address where services were rendered on the claim must match the rendering provider address in the Provider Directory.

For each Catchment Area, sample from

Primary Care and Mental Health Care claims for EACH Station within the period assessed (as determined by the EDI 837

Provider Claim Adjudication Date).

Drive time calculated regardless of travel modality.

Quarterly, or more/less as determined by

VA.

ST0-Data Preparation: The first step is EDI parsing and combining claims with referrals data to create a reporting dataset through these steps: Gather claims, extract referral number from claim, check referrals against previously evaluated referral numbers- only include claim with the earliest date of service that matches a not-yet-measured referral for this performance objective, sort all remaining claims in reporting data set by referral ID and claim submitted date, Identify first claim with the first date of service (DOS), match claims to referrals data to capture additional fields such as (but not limited to) Rurality, Veteran Preference, Veteran Address, etc. Note that each referral will be linked to a single unique referral ID, which will appear on all claims related to that referral. Each unique referral ID is assigned a single designation and/or category of care designation. Claims without valid referral IDs are excluded. Claims must be submitted using the same Veteran Name that appears on the associated referrals. All referral and claim level data must be reported at the Veteran, VAMC, and Catchment area level. This reporting data set will be used for subsequent analysis.

ST1- Capture all claims for Primary Care and Mental Health Care within the network regardless of catchment area ST2 - Gather claims for EACH Station (grouped by Catchment Area) from all the claims submitted (EDI 835) within the period assessed (as determined by the EDI 837 Claim Adjudication Date) ST3 - The reporting month will align with provider Claim Adjudication Date. The first date of the reporting month is the first day of the month through the last day of the month. E.g. For April 2025 reporting month include all claims with a Adjudication Date of 4/1/2025 through 4/30/2025. Do not exclude either 4/1 or 4/30.

ST4 - Apply Patient Rurality from associated referral - Urban, Rural and Highly Rural. Rurality based on VA's referral system at the time of referral.

ST5 - Extract Patient Permanent Address from Eligibility File/Referral. Use Residential address as a secondary field when permanent address is not available.

ST6- Extract address where services were rendered from the claim and confirm that the rendering provider's address on the claim corresponds to an address on file for that rendering provider in the Provider Directory.

ST7 - Remove exclusions to this PO. See PRS Appendix B - Network Adequacy Performance Objective Exclusions List for exclusion(s) to this PO.

ST8 - Calculate drive time between Patient address and the address where services were rendered using Contractor's Azure API mapping tool. Patient files with address data element errors that restrict geocoding or without rurality indicated on the referral will be omitted.

ST9 - Identify as Success for every Primary Care instance where Drive Time ≤ the drive time indicated in the PWS for each rurality ST10 - Identify as Success for every Mental Health Care instance where Drive Time ≤ the drive time indicated in the PWS for each rurality ST11-Add all claims referenced for geographic accessibility for Primary Care = Potential Opportunities for Primary Care ST12- Add all claims referenced for geographic accessibility for Mental health Care= Potential Opportunities for Mental Health Care ST13- % Success = Sum of Success divided by Potential Opportunities.

None

PO1.2 Access:

Drive Time - Specialty Care

3.1 Medical

Network Establishment and Maintenance

Contractor ensures Veteran travel time by car meets drive time standards for Specialty Care reflected in the PWS in each VAMC Catchment Area.

*VAMC Catchment Area drive time acceptability determined by station pass/fail rate. Stations are determined to have passed if veteran travel times by car meets drive time standards reflected in the PWS at least 90% of the time for at least 2 of 3 months for the quarter assessed.

**AQL for drive time standard for each station, each month, is assessed together (Specialty Care Urban and Specialty Care Rural/Highly Rural).

Each VAMC Catchment Area pass rate:

Catchment Area 14 (Stations 504, 519, 549, 580, 671, 674, 740, 756) - 87% Catchment Area 15 (Stations 442, 554, 575, 623, 635, 660, 666) - 85% Catchment Area 16 (Stations 436, 463, 531, 648, 653, 663, 668, 687, 692) - 88% Catchment Area 17 (Stations 459, 570, 593, 612, 640, 654, 662) - 85% Catchment Area 18 (Stations 501, 600, 605, 644, 649, 664, 678, 691) - 87%

*Example Catchment Area 14 pass rate: 7/8 of stations within that Catchment Area passed (met or exceeded 90%) = 87.5% = Met 87% AQL **See PRS Appendix A Station Names and Numbers ***Performance standard, AQL/ratings, and penalties apply to each Catchment Area, and is NOT applied to the total average performance of all Catchment Areas

Random Sampling *Statistically significant

Veteran Drive times based on Veteran Address in VA Eligibility File/Referral and the address where services were rendered on the claim calculated using Azure API mapping tool. The address where services were rendered on the claim must match

Specialty Care and Mental Health Specialty Care claims for EACH Station within the period assessed (as determined by the EDI 837 Provider Claim Adjudication Date).

Drive time calculated regardless of travel modality.

Quarterly, or more/less as determined by

VA.

ST0-Data Preparation: The first step is EDI parsing and combining claims with referrals data to create a reporting dataset through these steps: Gather claims, extract referral number from claim, check referrals against previously evaluated referral numbers- only include claim with the earliest date of service that matches a not-yet-measured referral for this performance objective, sort all remaining claims in reporting data set by referral ID and claim submitted date, Identify first claim with the first date of service (DOS), match claims to referrals data to capture additional fields such as (but not limited to) Rurality, Veteran Preference, Veteran Address, etc. Note that each referral will be linked to a single unique referral ID, which will appear on all claims related to that referral. Each unique referral ID is assigned a single designation and/or category of care designation. Claims without valid authorizations are excluded. Claims must be submitted using the same Veteran Name that appears on the associated referrals. All referral and claim level data must be reported at the Veteran, VAMC, and Catchment area level. This reporting data set will be used for subsequent analysis.

ST1- Capture claims for Specialty care within the network regardless of catchment area ST2 - Gather claims for EACH Station (grouped by Catchment Area) from all the claims submitted (EDI 835) within the period assessed (as determined by the EDI 837 Provider Claim Adjudication Date) ST3 - The reporting month will align with provider claim Adjudication Date. The first date of the reporting month is the first day of the month through the last day of the month. E.g. For April 2025 reporting month include all claims with a Adjudication Date of 4/1/2025 through 4/30/2025. Do not exclude either 4/1 or 4/30.

ST4 - Apply Patient Rurality from associated referral - Urban, Rural and Highly Rural. Rurality based on VA's referral system at the time of referral.

ST5 - Extract Patient Residential Address from Eligibility File/Referral. Use Residential address as a secondary field when permanent address is not available.

ST6 - Extract address where services were rendered from the claim and confirm that the rendering provider's address on the claim corresponds to an address on file for that rendering provider in the Provider Directory.

ST7 - Remove exclusions to this PO. See PRS Appendix B - Network Adequacy Performance Objective Exclusions List for exclusion(s) to this PO.

ST8 - Calculate drive time between Patient address and the address where services were rendered using Contractor's Azure API mapping tool. Patient files with address data element errors that restrict geocoding or without rurality indicated on the referral will be omitted.

ST9 - Identify as Success for every Specialty Care instance where Drive Time ≤ the drive time indicated in the PWS for each rurality category ST10-Overall Specialty Care Success = Total Specialty Care Urban Success + Total Specialty Care Rural/Highly Rural Success ST11- Add all claims referenced for geographic accessibility for Specialty Care= Potential Opportunities for Specialty Care ST12- % Success = Sum of Success divided by Potential Opportunities.

None

PO1.3 Access:

Drive Time - Emergency Room Care

3.1 Medical

Network Establishment and Maintenance

Contractor ensures Veteran travel time by car meets drive time standards for Emergency Room Care reflected in the PWS in each VAMC Catchment Area.

*VAMC Catchment Area drive time acceptability determined by station pass/fail rate. Stations are determined to have passed if veteran travel times by car meets drive time standards reflected in the PWS at least 90% of the time for Urban AND 70% of the time for Rural/Highly Rural for at least 2 of 3 months for the quarter assessed.

**Urban and Rural/Highly Rural are assessed separately.

***Urban and Rural/Highly Rural do not have to pass in the same month(s); however, Urban must pass 2 of 3 months and Rural/Highly Rural must pass 2 of 3 months for the quarter assessed for the station to pass for the quarter.

Each VAMC Catchment Area pass rate:

Catchment Area 14 (Stations 504, 519, 549, 580, 671, 674, 740, 756) - 87% Catchment Area 15 (Stations 442, 554, 575, 623, 635, 660, 666) - 85% Catchment Area 16 (Stations 436, 463, 531, 648, 653, 663, 668, 687, 692) - 88% Catchment Area 17 (Stations 459, 570, 593, 612, 640, 654, 662) - 85% Catchment Area 18 (Stations 501, 600, 605, 644, 649, 664, 678, 691) - 87%

*Example Catchment Area 14 pass rate: 7/8 of stations within that Catchment Area passed (met or exceeded 90%) = 87.5% = Met 87% AQL **See PRS Appendix A Station Names and Numbers ***Performance standard, AQL/ratings, and penalties apply to each Catchment Area, and is NOT applied to the total average performance of all Catchment Areas

Random Sampling *Statistically significant

Veteran Drive times based on Veteran Address in VA Eligibility File/Referral and the address where services were rendered on the claim calculated using Azure API mapping tool. The address where services were rendered on the claim must match

Emergency Room Care claims for EACH Station within the period assessed (as determined by the EDI 837 Provider Claim Adjudication Date).

Drive time calculated regardless of travel modality.

Quarterly, or more/less as determined by

VA.

ST0-Data Preparation: The first step is EDI parsing and combining claims with referrals data to create a reporting dataset through these steps: Gather claims, extract referral number from claim, check referrals against previously evaluated referral numbers- only include claim with the earliest date of service that matches a not-yet-measured referral for this performance objective, sort all remaining claims in reporting data set by referral ID and claim submitted date, Identify first claim with the first date of service (DOS), match claims to referrals data to capture additional fields such as (but not limited to) Rurality, Veteran Preference, Veteran Address, etc. Note that each referral will be linked to a single unique referral ID, which will appear on all claims related to that referral. Each unique referral ID is assigned a single designation and/or category of care designation. Claims without valid authorizations are excluded. Claims must be submitted using the same Veteran Name that appears on the associated referrals. All referral and claim level data must be reported at the Veteran, VAMC, and Catchment area level. This reporting data set will be used for subsequent analysis.

ST1- Capture claims for Emergency care within the network regardless of catchment area ST2 - Gather claims for EACH Station (grouped by Catchment Area) from all the claims submitted (EDI 835) within the period assessed (as determined by the EDI 837 Claim Adjudication Date).

ST3 - The reporting month will align with provider claim Adjudication Date. The first date of the reporting month is the first day of the month through the last day of the month. E.g. For April 2025 reporting month include all claims with a Adjudication Date of 4/1/2025 through 4/30/2025. Do not exclude either 4/1 or 4/30.

ST4 - Apply Patient Rurality from associated referral - Urban, Rural and Highly Rural. Rurality based on VA's referral system at the time of referral.

ST5 - Extract Patient Residential Address from Eligibility File/Referral. Use Residential address as a secondary field when permanent address is not available.

ST6- Extract Provider Address for the closet in network facility* ST7 - Remove exclusions to this PO. See PRS Appendix B - Network Adequacy Performance Objective Exclusions List for exclusion(s) to this PO.

ST8 - Calculate drive time between Patient address and the nearest emergency treatment facility that was active in the Provider Directory on the date of service, using Contractor's Azure API mapping tool. Patient files with address data element errors that restrict geocoding or without rurality indicated on the referral will be omitted.

ST9 - Identify as Success for every Emergency Care instance where Drive Time ≤ the drive time indicated in the PWS for each rurality category ST10- Add all claims referenced for geographic accessibility for Emergency Care= Potential Opportunities for Emergency Care ST11- % Success = Sum of Success divided by Potential Opportunities.

*Steps for identifying closest facility:

- Isolate the relevant Pre-auth/Referral Records based on the starting claim.

- Starting claim is determined by the claim with the earliest EDI payment issue date.

- The payment issue date qualifier will be based on the initial remit date. After a referral is assigned measure outcomes, the referral will not qualify for re-measurement in the future.In scenarios in which multiple claims are adjudicated in a single month, the claim with the earliest date of service will be considered the 'starting claim' in the series.

-From the submitted claim with the earliest DOS in the series

- Using patient address from the referral ID populate longitude and latitude.

- Identify 5 closest facilites to the Veteran using Provider Directory data.

- Isolate all active providers (organizations) from Provider Directory that match the Referral type (Emergent care) and pull the associated care site using coordinates.The ER facilities are identified as available if the following taxonomies are listed AND the organization site is listed as active in Provider Directory: 261QE0002X, 282N00000X, 282NC0060X, 282NC2000X, 282NR1301X, 282NW0100X

- Using Lat and Lon, return top 5 closest within bounding box (bbox). If no providers within bbox, expand bbox size and repeat. must have 1-5 coordinates, no empty arrays.

- Use 5 closest using haversine distance in miles.

- Calculate the drive times for the 5 closest facilties to determine the closest location. Use the shortest drive time for the closest provider.

- Note that a claim can apply to UC and Pharmacy or ER and Pharmacy

None

PO1.4 Access:

Drive Time - Urgent Care

3.1 Medical

Network Establishment and Maintenance

Contractor ensures Veteran travel time by car meets drive time standards for Urgent Care reflected in the PWS in each VAMC Catchment Area.

*VAMC Catchment Area drive time acceptability determined by station pass/fail rate. Stations are determined to have passed if veteran travel times by car meets drive time standards reflected in the PWS at least 90% of the time for at least 2 of 3 months for the quarter assessed.

**AQL for drive time standard for each station, each month, is assessed together (Urgent Care Urban and Urgent Care Rural/Highly Rural).

Each VAMC Catchment Area pass rate:

Catchment Area 14 (Stations 504, 519, 549, 580, 671, 674, 740, 756) - 87% Catchment Area 15 (Stations 442, 554, 575, 623, 635, 660, 666) - 85% Catchment Area 16 (Stations 436, 463, 531, 648, 653, 663, 668, 687, 692) - 88% Catchment Area 17 (Stations 459, 570, 593, 612, 640, 654, 662) - 85% Catchment Area 18 (Stations 501, 600, 605, 644, 649, 664, 678, 691) - 87%

*Example Catchment Area 14 pass rate: 7/8 of stations within that Catchment Area passed (met or exceeded 90%) = 87.5% = Met 87% AQL **See PRS Appendix A Station Names and Numbers ***Performance standard, AQL/ratings, and penalties apply to each Catchment Area, and is NOT applied to the total average performance of all Catchment Areas

Random Sampling *Statistically significant

Veteran Drive times based on Veteran Address in VA Eligibility File/Referral and the address where services were rendered on the claim calculated using Azure API mapping tool. The address where services were rendered on the claim must match

Urgent Care claims for EACH Station within the period assessed (as determined by the

EDI 837 Provider Claim Adjudication Date).

Drive time calculated regardless of travel modality.

Quarterly, or more/less as determined by

VA.

ST0-Data Preparation: The first step is EDI parsing and combining claims with referrals data to create a reporting dataset through these steps: Gather claims, extract referral number from claim, check referrals against previously evaluated referral numbers- only include claim with the earliest date of service that matches a not-yet-measured referral for this performance objective, sort all remaining claims in reporting data set by referral ID and claim submitted date, Identify first claim with the first date of service (DOS), match claims to referrals data to capture additional fields such as (but not limited to) Rurality, Veteran Preference, Veteran Address, etc. Note that each referral will be linked to a single unique referral ID, which will appear on all claims related to that referral. Each unique referral ID is assigned a single designation and/or category of care designation.Claims without valid valid authorizations are excluded. Claims must be submitted using the same Veteran Name that appears on the associated referrals. All referral and claim level data must be reported at the Veteran, VAMC, and Catchment area level. This reporting data set will be used for subsequent analysis.

ST1- Capture claims for Urgent care based on authorizations within the network regardless of catchment area (Urgent care claims are identified based Pre-authorization number annotated on claim, all urgent care claims begins with UC) ST2 - Gather claims for EACH Station (grouped by Catchment Area) from all the claims submitted (EDI 835) within the period assessed (as determined by the EDI 837 Claim Adjudication Date).

ST3 -The reporting month will align with provider claim Adjudication Date. The first date of the reporting month is the first day of the month through the last day of the month. E.g. For April 2025 reporting month include all claims with a Adjudication Date of 4/1/2025 through 4/30/2025. Do not exclude either 4/1 or 4/30.

ST4 - Apply Patient Rurality from associated referral - Urban, Rural and Highly Rural. Rurality based on VA's referral system at the time of referral.

ST5 - Extract Patient Residential Address from Eligibility File/Referral. Use Residential address as a secondary field when permanent address is not available.

ST6- Extract Provider Address for the closet in network facility* ST7-Remove exclusions to this PO. See PRS Appendix B - Network Adequacy Performance Objective Exclusions List for exclusion(s) to this PO.

ST8 - Calculate drive time between Patient address and the nearest* urgent care facility that was active in the Provider Directory on the date of service, using Contractor's Azure API mapping tool. Patient files with address data element errors that restrict geocoding or without rurality indicated on the referral will be omitted.

ST9 - Identify as Success for every Urgent Care instance where Drive Time ≤ the drive time indicated in the PWS for each rurality category ST10 - Add all claims referenced for geographic accessibility for Urgent Care= Potential Opportunities for Urgent Care ST11- % Success = Sum of Success divided by Potential Opportunities.

*Steps for Identifying closest facility

- Isolate the relevant Pre-auth/Referral Records based on the starting claim.

- Starting claim is determined by the claim with the earliest EDI payment issue date.

-The payment issue date qualifier will be based on the initial remit date. After a referral is assigned measure outcomes, the referral will not qualify for re-measurement in the future. In scenarios in which multiple claims are adjudicated in a single month, the claim with the earliest date of service will be considered the 'starting claim' in the series.

-From the submitted claim with the earliest DOS in the series

- Using patient address from the referral ID or SPatient table populate longitude and latitude.

- Identify 5 closest facilites to a Veteran using Provider Directory data.

- Isolate all active providers (organizations) in Provider Directory that match the Referral type (Urgent Care) and pull the associated care site using coordinates.

-The care site field must be active. Providers are determined to be available if they are active at the care site level and the care site has one of the two POS codes- POS 17: Walk-in Retail Health Clinic and POS 20: Urgent Care Facility)

- Using Lat and Lon, return top 5 closest within bounding box (bbox). If no providers within bbox, expand bbox size and repeat. must have 1-5 coordinates, no empty arrays.

- Use 5 closest using haversine distance in miles.

- Calculate the drive times for the 5 closest facilties to determine the closest location. Use the shortest drive time for the closest provider.

- Note that a claim can apply to UC and Pharmacy or ER and Pharmacy

None

PWS Attachment C - CCN Performance Requirement Summary (PRS ) - MEDICAL WEST

Network Adequacy

PO1.5 Access:

Drive Time - Pharmacy

3.1 Medical

Network Establishment and Maintenance

Contractor ensures Veteran travel time by car meets drive time standards for Pharmacy reflected in the PWS in each VAMC Catchment Area.

*VAMC Catchment Area drive time acceptability determined by station pass/fail rate. Stations are determined to have passed if veteran travel times by car meets drive time standards reflected in the PWS at least 90% of the time for Urban AND 70% of the time for Rural/Highly Rural for at least 2 of 3 months for the quarter assessed.

**Urban and Rural/Highly Rural are assessed separately.

***Urban and Rural/Highly Rural do not have to pass in the same month(s); however, Urban must pass 2 of 3 months and Rural/Highly Rural must pass 2 of 3 months for the quarter assessed for the station to pass for the quarter.

Each VAMC Catchment Area pass rate:

Catchment Area 14 (Stations 504, 519, 549, 580, 671, 674, 740, 756) - 87% Catchment Area 15 (Stations 442, 554, 575, 623, 635, 660, 666) - 85% Catchment Area 16 (Stations 436, 463, 531, 648, 653, 663, 668, 687, 692) - 88% Catchment Area 17 (Stations 459, 570, 593, 612, 640, 654, 662) - 85% Catchment Area 18 (Stations 501, 600, 605, 644, 649, 664, 678, 691) - 87%

*Example Catchment Area 14 pass rate: 7/8 of stations within that Catchment Area passed (met or exceeded 90%) = 87.5% = Met 87% AQL **See PRS Appendix A Station Names and Numbers ***Performance standard, AQL/ratings, and penalties apply to each Catchment Area, and is NOT applied to the total average performance of all Catchment Areas

Random Sampling *Statistically significant

Veteran Drive times based on Veteran Address in VA Eligibility File/Referral and the address where services were rendered on the claim calculated using Azure API mapping tool. The address where services were rendered on the claim must match

Pharmacy claims for EACH Station within the period assessed (as determined by the

EDI 837 Provider Claim Adjudication Date).

Drive time calculated regardless of travel modality.

Quarterly, or more/less as determined by

VA.

ST0-Data Preparation: The first step is EDI parsing and combining claims with referrals data to create a reporting dataset through these steps: Gather claims, extract referral number from claim, check referrals against previously evaluated referral numbers- only include claim with the earliest date of service that matches a not-yet-measured referral for this performance objective, sort all remaining claims in reporting data set by referral ID and claim submitted date, Identify first claim with the first date of service (DOS), match claims to referrals data to capture additional fields such as (but not limited to) Rurality, Veteran Preference, Veteran Address, etc. Note that each referral will be linked to a single unique referral ID, which will appear on all claims related to that referral. Each unique referral ID is assigned a single designation and/or category of care designation. Claims without valid referral IDs are excluded. Vaccines are not included. Claims must be submitted using the same Veteran Name that appears on the associated referrals. All referral and claim level data must be reported at the Veteran, VAMC, and Catchment area level. This reporting data set will be used for subsequent analysis.

ST1- Capture claims for Pharmacy within the network regardless of catchment area based on authorizations (Pharmacy claims are identified using a taxonomy- 3336C0003X (Suppliers/Pharmacy, Community/Retail Pharmacy) ST2 - Gather claims for EACH Station (grouped by Catchment Area) from all the claims submitted (EDI 835) within the period assessed (as determined by the EDI 837 Claim Adjudication Date) ST3 -The reporting month will align with provider claim Adjudication Date. The first date of the reporting month is the first day of the month through the last day of the month. E.g. For April 2025 reporting month include all claims with a Adjudication Date of 4/1/2025 through 4/30/2025. Do not exclude either 4/1 or 4/30.

ST4 - Apply Patient Rurality from associated referral - Urban, Rural and Highly Rural. Rurality based on VA's referral system at the time of referral.

ST5 - Extract Patient Residential Address from Eligibility File/Referral. Use Residential address as a secondary field when permanent address is not available.

ST6- Extract Provider Address for the closet in network facility* ST7- Remove exclusions to this PO. See PRS Appendix B - Network Adequacy Performance Objective Exclusions List for exclusion(s) to this PO.

ST8 - Calculate drive time between Patient address and the nearest* pharmacy that was active in the Provider Directory on the date of service, using Contractor's Azure API mapping tool. Measurement is of the distance between Veteran's residential address and nearest in network pharmacy, not where Veteran actually picked up the prescription ST9 - Identify as Success for every Pharmacy instance where Drive Time ≤ the drive time indicated in the PWS for each rurality category ST10- Add all claims referenced for geographic accessibility for Pharmacy= Potential Opportunities for Pharmacy ST11- % Success = Sum of Success divided by Potential Opportunities.

*Steps for Identifying Closest Facility

- Isolate the relevant Pre-auth/Referral Records based on the starting claim.

- Starting claim is determined by the claim with the earliest EDI payment issue date.

- The payment issue date qualifier will be based on the initial remit date. After a referral is assigned measure outcomes, the referral will not qualify for re-measurement in the future. In scenarios in which multiple claims are adjudicated in a single month, the claim with the earliest date of service will be considered the 'starting claim' in the series.

-From the submitted claim with the earliest DOS in the series

- Using patient address from the referral ID or SPatient table populate longitude and latitude.

- Identify 5 closest facilites to a Veteran using Provider Directory data.

- Isolate all active PPMS providers (organizations) that match the Referral type ( Pharmacy) and pull the associated care site using coordinates.

- The care site field must be active. Pharmacy providers in the provider directory are identified using Taxonomy = 333600000X,3336C0002X,3336C0003X,3336I0012X AND the caresite is listed as active in Provider Directory

- Using Lat and Lon, return top 5 closest within bounding box (bbox). If no providers within bbox, expand bbox size and repeat. must have 1-5 coordinates, no empty arrays.

- Use 5 closest using haversine distance in miles.

- Calculate the drive distance for the 5 closest facilties to determine the closest location. Use the shortest drive distance for the closest provider.

- Note that a claim can apply to UC and Pharmacy or ER and Pharmacy

None

PO1.6 Access:

Appointment Timeliness (Appointment Availability) - Primary Care and Mental Health Care

3.1 Medical

Network Establishment and Maintenance

For each station, Contractor ensures Veteran appointment timeliness meets standards reflected in the PWS for Primary Care and Mental Health Care in each VAMC Catchment Area.

*AQL for appointment timeliness standard is assessed together (Primary Care Urban, Primary Care Rural/Highly Rural, Mental Health Care Urban, and Mental Health Care Rural/Highly Rural).

≥ 90% Random Sampling *Statistically significant

EDI 835 and 837 claims and referral data

Sample from all Primary Care and Mental Health Care claims submitted (for each station) within the period assessed (as determined by the EDI 837 Provider Claim Adjudication Date), appointment timeliness calculated from Provider Allocation Date to the First Date of Service on the first claim received from the provider listed on the Referral.

Sample time calculation:

Provider Allocation Date: 8/1/2999

First Date of Service: 8/24/2999 Appointment time = 23 days

Monthly, or more/less as determined by VA.

ST0-Data Preparation: The first step is EDI parsing and combining claims with referrals data to create a reporting dataset through these steps: Gather claims, extract referral number from claim, check referrals against previously evaluated referral numbers- only include claim with the earliest date of service that matches a not-yet-measured referral for this performance objective, sort all remaining claims in reporting data set by referral ID and claim submitted date, Identify first claim with the first date of service (DOS), match claims to referrals data to capture additional fields such as (but not limited to) Veteran Preference, Veteran Address, etc. Note that each referral will be linked to a single unique referral ID, which will appear on all claims related to that referral. Each unique referral ID is assigned a single designation and/or category of care designation. Claims without valid referral IDs are excluded. Claims must be submitted using the same Veteran Name that appears on the associated referrals. All referral and claim level data must be reported at the Veteran, VAMC, and Catchment area level. This reporting data set will be used for subsequent analysis.

ST1- Capture claims for Primary care and Mental Health Care within the network regardless of catchment area ST2 - Gather claims for EACH Station (grouped by Catchment Area) from all the claims submitted (EDI 835) within the period assessed (as determined by the EDI 837 Claim Adjudication Date).

ST3 -The reporting month will align with provider claim Adjudication Date. The first date of the reporting month is the first day of the month through the last day of the month. E.g. For April 2025 reporting month include all claims with a Adjudication Date of 4/1/2025 through 4/30/2025. Do not exclude either 4/1 or 4/30.

ST4 - Referral associated based on referral number annotated on claim ST5 - Remove exclusions to this PO. See PRS Appendix B - Network Adequacy Performance Objective Exclusions List for exclusion(s) to this PO.

ST6- Appointment timeliness calculation determined using the Provider Allocation Date from HSRM/CCRA to the First Date of Service on the first claim received from the provider listed on the Referral.

ST7 - Identify as Success for every Primary Care instance where Appointment Timeliness≤ the appointment timeliness indicated in the PWS ST8 - Identify as Success for every Mental Health Care instance where Appointment Timeliness≤ the appointment timeliness indicated in the PWS ST9-Add all claims referenced for appointment timeliness for Primary Care = Potential Opportunities for Primary Care ST10- Add all claims referenced for appointment timeliness for Mental health Care= Potential Opportunities for Mental Health Care ST11- % Success = Sum of Success divided by Potential Opportunities.

None

PO1.7 Access:

Appointment Timeliness (Appointment Availability) - Specialty Care

3.1 Medical

Network Establishment and Maintenance

For each station, Contractor ensures Veteran appointment timeliness meets standards reflected in the PWS for Specialty Care in each VAMC Catchment Area.

*AQL for appointment timeliness standard is assessed together (Specialty Care Urban and Specialty Care Rural/Highly Rural).

Sample from all Specialty Care and Specialty Mental Health Care claims submitted (for each station) within the period assessed (as determined by the EDI

837 Provider Claim Adjudication Date), appointment timeliness calculated from

Provider Allocation Date to the First Date of Service on the first claim received from the provider listed on the Referral.

Sample time calculation:

Provider Allocation Date: 8/1/2999

First Date of Service: 8/24/2999 Appointment time = 23 days

Monthly, or more/less as determined by VA.

ST0-Data Preparation: The first step is EDI parsing and combining claims with referrals data to create a reporting dataset through these steps: Gather claims, extract referral number from claim, check referrals against previously evaluated referral numbers- only include claim with the earliest date of service that matches a not-yet-measured referral for this performance objective, sort all remaining claims in reporting data set by referral ID and claim submitted date, Identify first claim with the first date of service (DOS), match claims to referrals data to capture additional fields such as (but not limited to) Veteran Preference, Veteran Address, etc. Note that each referral will be linked to a single unique referral ID, which will appear on all claims related to that referral. Each unique referral ID is assigned a single designation and/or category of care designation. Claims without valid referral IDs are excluded. Claims must be submitted using the same Veteran Name that appears on the associated referrals. All referral and claim level data must be reported at the Veteran, VAMC, and Catchment area level. This reporting data set will be used for subsequent analysis.

ST1- Capture claims for Specialty care within the network regardless of catchment area ST2 - Gather claims for EACH Station (grouped by Catchment Area) from all the claims submitted (EDI 835) within the period assessed (as determined by the EDI 837 Claim Adjudication Date) ST3 -The reporting month will align with provider Claim Adjudication Date. The first date of the reporting month is the first day of the month through the last day of the month. E.g. For April 2025 reporting month include all claims with a Adjudication Date of 4/1/2025 through 4/30/2025. Do not exclude either 4/1 or 4/30.

ST4 - Referral associated based on referral number annotated on claim ST5 - Remove exclusions to this PO. See PRS Appendix B - Network Adequacy Performance Objective Exclusions List for exclusion(s) to this PO.

ST6- Appointment timeliness calculation determined using the Provider Allocation Date from HSRM/CCRA to the First Date of Service on the first claim received from the provider listed on the Referral.

ST7 - Identify as Success for every Specialty Care instance where Appointment Timeliness≤ the appointment timeliness indicated in the PWS ST8-Add all claims referenced for appointment timeliness for Specialty Care = Potential Opportunities for Specialty Care ST9- % Success = Sum of Success divided by Potential Opportunities.

None

PO1.8 Access:

Appointment Timeliness (Appointment Availability) - Non- Institutional Extended Care Services

3.1 Medical

Network Establishment and Maintenance

For each station, Contractor ensures Veteran appointment timeliness meets standards reflected in the PWS for Non-Institutional Extended Care Services in each VAMC Catchment Area.

*AQL for appointment timeliness standard is assessed together (Non- Institutional Extended Care Services Urban and Non-Instiitutional Extended Care Services Rural/Highly Rural).

Sample from all Non-Institutional Extended Care Service claims submitted (for each station) within the period assessed (as determined by the EDI 837 Provider Claim Adjudication Date), appointment timeliness calculated from Provider Allocation Date to the First Date of Service on the first claim received from the provider listed on the Referral.

Sample time calculation:

Provider Allocation Date: 8/1/2999

First Date of Service: 8/24/2999 Appointment time = 23 days

Monthly, or more/less as determined by VA.

ST0-Data Preparation: The first step is EDI parsing and combining claims with referrals data to create a reporting dataset through these steps: Gather claims, extract referral number from claim, check referrals against previously evaluated referral numbers- only include claim with the earliest date of service that matches a not-yet-measured referral for this performance objective, sort all remaining claims in reporting data set by referral ID and claim submitted date, Identify first claim with the first date of service (DOS), match claims to referrals data to capture additional fields such as (but not limited to) Veteran Preference, Veteran Address, etc. Note that each referral will be linked to a single unique referral ID, which will appear on all claims related to that referral. Each unique referral ID is assigned a single designation and/or category of care designation. Claims without valid referral IDs are excluded. Claims must be submitted using the same Veteran Name that appears on the associated referrals.All referral and claim level data must be reported at the Veteran, VAMC, and Catchment area level. This reporting data set will be used for subsequent analysis.

ST1- Capture claims for each category of Non-Institutional Extended Care Services within the network regardless of catchment area. The categories are listed in PWS (Homemaker/Home Health Aide, In Home Respite, Community Adult Day Health Care, Veteran Directed Care, Skilled Home Health Care, Hospice, Home Infusion and Ambulatory Fusion Suites, Bowel & Bladder- Agency, and Community Nursing Home) ST2 - Gather claims for EACH Station (grouped by Catchment Area) from all the claims submitted (EDI 835) within the period assessed (as determined by the EDI 837 Claim Adjudication Date) ST3 -The reporting month will align with provider Claim Adjudication Date. The first date of the reporting month is the first day of the month through the last day of the month. E.g. For April 2025 reporting month include all claims with a Adjudication Date of 4/1/2025 through 4/30/2025. Do not exclude either 4/1 or 4/30.

ST4 - Referral associated based on referral number annotated on claim ST5- Remove exclusions to this PO. See PRS Appendix B - Network Adequacy Performance Objective Exclusions List for exclusion(s) to this PO.

ST6- Appointment timeliness calculation determined using the Provider Allocation Date from HSRM/CCRA to the First Date of Service on the first claim received from the provider listed on the Referral.

ST7 - Identify as Success for every Non-Institutional Extended Care Services instance where Appointment Timeliness≤ the appointment timeliness indicated in the PWS for each category ST8-Add all claims referenced for appointment timeliness for Non-Institutional Extended Care Services instance= Potential Opportunities for Non-Institutional Extended Care Services ST9- % Success = Sum of Success divided by Potential Opportunities.

None

PO1.9 Provider Data Accuracy

3.7 Medical

Network Provider Data for VA's Provider Directory

Contractor ensures provider data displayed in each of the following required Provider Directory fields for Urgent Care providers is complete and accurate:

-NPI Number -CareSite Name -CareSite Address -CareSite Phone -CareSite Fax -CareSite Email

≥ 90% Random Sampling *Statistically significant

Active Urgent Care provider data fields (6 required) in VA Provider Directory validated against publicly available sources, as well as confirmation through direct contact with provider.

Sample from all active Urgent Care claims submitted within the period assessed

(determined by the EDI 837 Provider Claim Submission Date). Validation of the required data fields for each provider record sampled. The provider file as a whole does NOT pass/fail but each required field, six (6) per provider record, is assessed as an individual pass or fail.

Sample population (total fields sampled) = total claims sampled x 6

Monthly or more/less as determined by VA.

The Contractor shall use the Contractor developed, Government approved Calculation Methodology, see PWS Section 2.5.1 Performance Surveillance and Assessment. None

PO2.1 Contractor Contact Center Operations - Blockage Rate

6.7.1 Contractor

Contact Center Performance Requirements

Contractor ensures inbound calls reach the Contractor Contact Center.

≥ 95% (less than 5% of inbound calls blocked) Random Sampling *Statistically significant

Contractor Contact Center data

Sample from all calls that entered the queue within the period assessed.

Monthly, or more/less as determined by VA.

The Contractor shall use the Contractor developed, Government approved Calculation Methodology, see PWS Section 2.5.1 Performance Surveillance and Assessment. None

Network Adequacy

Customer Service

PO2.2 Contractor Contact Center Operations - Call Abandonment Rate

6.7.1 Contractor

Contact Center Performance Requirements

Contractor ensures calls in Contractor Contact Center queue reach a live Contractor Call Center agent.

≥ 95% (less than 5% are abandoned) Random Sampling *Statistically significant

Contractor Contact Center data

Sample from all calls that entered the queue within the period assessed.

Monthly or more/less as determined by VA.

The Contractor shall use the Contractor developed, Government approved Calculation Methodology, see PWS Section 2.5.1 Performance Surveillance and Assessment. None

PO2.3 Contractor Contact Center Operations - Average Speed of Answer

6.7.1 Contractor

Contact Center Performance Requirements

Contractor ensures callers reach a live Contractor Contact Center agent in 30 seconds or less.

≥ 80% Random Sampling *Statistically significant

Contractor Contact Center data

Sample from all calls that entered the queue within the period assessed.

Monthly or more/less as determined by VA.

The Contractor shall use the Contractor developed, Government approved Calculation Methodology, see PWS Section 2.5.1 Performance Surveillance and Assessment. None

PO2.4 VA-Provided Ticketing Tool - Timeliness of Resolution

6.3 Contractor

Use of Va- Provided Ticketing Tool

Contractor fully resolves VA-provided ticketing tool tickets within:

Tier 1 - 5 business days Tier 2 - 15 business days Tier 3 - 30-180 calendar days Tier 4 - 180 calendar days

≥ 95% (for Each Tier) Random Sampling *Statistically significant

VA Ticketing Tool tickets

Sample from all tickets resolved, per tier, within the period assessed. Resolution timeliness calculated from Ticket Creation Date to Ticket Submission Date.

Sample time calculation:

Ticket Creation Date: 8/1/2999

Ticket Submission (Resolution) Date:

8/4/2999

Ticket resolution time = 3 days

Monthly or more/less as determined by VA.

The Contractor shall use the Contractor developed, Government approved Calculation Methodology, see PWS Section 2.5.1 Performance Surveillance and Assessment. None

PO2.5 VA-Provided Ticketing Tool - Ticket First Submission Resolution

6.3 Contractor

Use of VA- Provided Ticketing Tool

Contractor fully resolves VA-provided ticketing tool tickets on the first submission.

≥ 80% Random Sampling *Statistically significant

VA Ticketing Tool tickets

Sample from all tickets submitted within the period assessed. Tickets resolved on first submission = tickets “Approved” by VA without having been previously rejected*.

*Rejected tickets are those tickets that were resolved by the Contactor in the ticketing tool but upon review by VA, they were determined to NOT be fully resolved and were thus “rejected” and sent back to the Contractor for additional information or further resolution.

Monthly or more/less as determined by VA.

The Contractor shall use the Contractor developed, Government approved Calculation Methodology, see PWS Section 2.5.1 Performance Surveillance and Assessment. None

PO2.6 VA-Provided Ticketing Tool - Rejected Ticket Resolution

6.3 Contractor

Use of VA- Provided Ticketing Tool

Contractor fully resolves rejected VA-provided ticketing tool tickets as follows:

Tier 1 – no later than 3 business days of first ticket rejection Tier 2 – no later than 5 business days of first ticket rejection Tier 3 – no later than 30 calendar days of first ticket rejection Tier 4 – no later than 40 calendar days of first ticket rejection

≥ 98% (for Each Tier) Random Sampling *Statistically significant

VA Ticketing Tool tickets

Sample from all tickets, by tier, Approved by VA that were previously rejected* within the period assessed. Resolution timeliness calculated from First Ticket Rejection Date to Final Submission Date.

Sample time calculation:

First Ticket Rejection Date: 8/1/2999

Final Ticket Submission Date: 8/4/2999 Resolution time since first rejection = 3 days

Monthly or more/less as determined by VA.

The Contractor shall use the Contractor developed, Government approved Calculation Methodology, see PWS Section 2.5.1 Performance Surveillance and Assessment. None

PO2.7

IDF 1

VA-Provided Ticketing Tool - Adverse Credit Reporting (Tier 3) Ticket Volumes

6.3 Contractor

Use of VA- Provided Ticketing Tool

The Contractor shall minimize the monthly volume of Adverse Credit Reporting (ACR) tickets received by VA from Veterans related to erroneous collection, threat of collection, or credit-reporting activity traceable to authorized services provided under this Contract.

Minimum Threshold ACR Tickets ≤ 90

100% Inspection

VA Ticketing Tool tickets

Inspect all Tier 3 tickets resolved within the period assessed to determine number of

ACR tickets received and validated by VA to be traceable to authorized services provided under this Contract.

Minimum threshold assessed and reported Monthly or more/less as determined by VA

ST0- Data Preparation: Pull all Tier 3 tickets resolved within the period assessed (e.g., query conducted on September 15th for August 1st – August 30th).

ST1 - Determine the total number of Tier 3 Adverse Credit Reporting (ACR) Tickets resolved within the period assessed.

ST2- Review the ACR Tickets resolved and validate that they are traceable to authorized…