Attachment C - Performance Requirement Summary_Dental_02_24_26 v3.pdf
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- Attached to
- Q503--CCN Next Gen - Dental Network
- Solicitation number
- 36C10G26R0004
About this file
This is a Performance Requirement Summary (PRS) document for dental services under a federal Veterans Affairs contract. The document establishes performance objectives, acceptable quality levels (AQLs), surveillance methods, and calculation methodologies for contractor compliance across multiple operational and service delivery categories.
The contract encompasses 18 catchment areas spanning all VA Medical Center (VAMC) stations nationwide, with performance standards varying by catchment area. Network Adequacy objectives (PO1.1 and PO1.2) require the contractor to ensure veteran drive times to dental providers meet established standards, with AQLs ranging from 80% to 88% depending on catchment area, assessed quarterly through claims data analysis. Appointment Timeliness (PO1.2) must achieve a 90% AQL, measured monthly from provider allocation date to first date of service. Customer Service objectives include Contact Center Operations (PO2.1-PO2.3) requiring 95% blockage/abandonment rates and 80% average speed of answer within 30 seconds, plus VA-provided ticketing tool performance (PO2.4-PO2.6) with resolution standards ranging from 5 business days (Tier 1) to 180 calendar days (Tier 4), achieving 95-98% AQLs. Claims and Medical Documentation objectives (PO3.1-PO4.2) mandate 98% claims processing within 30 calendar days, 98% accuracy in matching billed to approved services, and 90% medical documentation submission timeliness. All performance standards exclude specified claim types including out-of-network claims, telehealth services, mobile health services, and referrals with veterans preference indicators, as detailed in Appendix B.
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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**
PO1.1 Access:
Drive Time
3.1 Dental Network
Establishment and Maintenance
Contractor ensures Veteran travel time by car meets drive time standards 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 standards for each station, each month, is assessed together (Urban and Rural/Highly Rural).
Each VAMC Catchment Area pass rate:
| Catchment Area 1 (Stations 402, 405, 518, 523, 608, 631, 650, 689) - | 87% |
| Catchment Area 2 (Stations 526, 528, 528A5, 528A6, 528A7, 528A8, 561, 620, 630, 632) - | 80% |
| Catchment Area 3 (Stations 460, 503, 529, 542, 562, 595, 642, 646, 693) - | 88% |
| Catchment Area 4 (Stations 512, 517, 540, 581, 613, 688) - | 83% |
| Catchment Area 5 (Stations 558, 565, 590, 637, 652, 658, 659) - | 85% |
| Catchment Area 6 (Stations 508, 509, 521, 534, 544, 557, 619, 679) - | 87% |
| Catchment Area 7 (Stations 516, 546, 548, 573, 672, 673, 675) - | 85% |
| Catchment Area 8 (Stations 596, 603, 614, 621, 626) - | 80% |
| Catchment Area 9 (Stations 506, 515, 538, 539, 541, 552, 553, 583, 610, 655, 757) - | 81% |
| Catchment Area 10 (Stations 537, 550, 556, 578, 585, 607, 657A5, 676, 695) - | 88% |
| Catchment Area 11 (Stations 636, 589,589A4, 589A5, 589A7, 657, 657A4) - | 85% |
| Catchment Area 12 (Stations 502, 520, 564, 586, 598, 629, 667) - | 85% |
| Catchment Area 13 (Stations 437, 438, 568, 618, 636A6, 636A8, 656) - | 85% |
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 13 pass rate: 7/8 of stations within that Catchment Area passed (met or exceeded 90%) = 87.5% = Met 85% 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 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 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 instance where Drive Time ≤ the drive time indicated in the PWS for each rurality ST10- Add all claims referenced for geographic accessibility = Potential Opportunities ST11- % Success = Sum of Success divided by Potential Opportunities.
PO1.2 Access:
Appointment Timeliness (Appointment Availability)
3.1 Dental Network
Establishment and Maintenance
For each station, Contractor ensures Veteran appointment timeliness meets standards reflected in the PWS.
*AQL for appointment timeliness standards Urban and Rural/Highly Rural is assessed together.
≥ 90% Random Sampling *Statistically significant
EDI 835 and 837 claims and referral data
Sample from all 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 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 instance where Appointment Timeliness≤ the appointment timeliness indicated in the PWS ST8- Add all claims referenced for appointment timeliness = Potential Opportunities ST9- % Success = Sum of Success divided by Potential Opportunities.PO2.1 Contractor Contact Center
Operations - Blockage Rate
5.7.1 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.
PO2.2 Contractor Contact Center Operations - Call Abandonment Rate
5.7.1 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.
PO2.3 Contractor Contact Center Operations - Average Speed of Answer
5.7.1 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.
PO2.4 VA-Provided Ticketing Tool - Timeliness of Resolution
5.3 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.
PWS Attachment C - CCN Performance Requirement Summary (PRS ) - DENTAL
Customer Service
Network Adequacy
PO2.5 VA-Provided Ticketing Tool - Ticket First Submission Resolution
5.3 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.
PO2.6 VA-Provided Ticketing Tool - Rejected Ticket Resolution
5.3 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.
PO3.1 Claims Processing Timeliness 9.1 Claims Submission and Processing Timeframes
Contractor processes / adjudicates all claims, including resubmissions, no later than 30 calendar days after the provider submits the claim to the Contractor.
≥ 98% Adjudicated in 30 days or less
Random Sampling *Statistically significant
EDI 837 and EDI 835 claims data
Sample from all claims adjudicated within the period assessed . Adjudication timeliness calculated from
Provider Claim Submission Date (EDI 837 - Loop 2300, DTP Segment with Qualifier Code 050) to TPA
Adjudication Date (EDI 835)
Sample claim adjudication time calculation:
Provider Claim Submission Date: 10/1/2999
TPA Adjudication Date: 10/30/2999 Claim adjudication time = 30 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.
PO3.2 Accuracy: Adherance to Dental Treatment Plan
6 Referrals and 9.2 Claims Processing and Adjudication
Contractor billed services on each invoice matches services approved on the associated VA Referral.
≥ 98% Random Sampling *Statistically significant
Post Payment Data EDI 837 COB. VA Referral
Sample from all claims submitted (EDI 837 - Provider Claim Submission Date) within the period assessed.
Each claim that contains billed service(s) that do NOT match the service(s) approved on the associated VA
Referral equals one (1) failure of that claim as matching a valid referral.
The Contractor shall use the Contractor developed, Government approved Calculation Methodology, see PWS Section 2.5.1 Performance Surveillance and Assessment.
PO4.1 Medical Documentation Return -
RFS
8.3 Medical
Documentation Submission Timeliness
Contractor ensures any medical documentation required as a result of an RFS shall be submitted to the VA with the RFS.
≥ 90% Random Sampling *Statistically significant
Contractor's Central Submission System
Sample from all RFS within the period assessed. Medical documentation submission timeliness calculated from the date of the RFS submission to the date of associated documentation submission. RFS submission and documentation submission should reflect same date.
Each sampled submission is pass/fail.
Sample time calculation:
Date of RFS: 10/1/2999
Provider Documentation Submission Date: 10/1/2999 Submission time = 0 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.
PO4.2 Medical Documentation Return - Urgent
8.3 Medical
Documentation Submission Timeliness
Contractor ensures any medical documentation requested by VA through the Central Submission System for appropriate urgent follow up is provided to VA within three (3) business days of the request.
≥ 90% Random Sampling *Statistically significant
Contractor's Central Submission System
Sample from all authorized first appointments within the period assessed. Medical documentation submission timeliness calculated from the date of urgent care episode to the date of provider documentation submission. Each sampled submission is pass/fail.
Sample time calculation:
Date of Urgent Care Episode: 10/1/2999
Provider Documentation Submission Date: 10/3/2999 Submission 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.
Medical Documentation
Customer Service
Claims / Invoicing
Station Number Station Name Station Number Station Name Station Number Station Name
402 Togus, ME HCS 546 Miami, FL HCS 586 Jackson, MS HCS
405 White River Junction, VT HCS 548 West Palm Beach, FL HCS 598 Little Rock, AR HCS
518 Bedford, MA HCS 573 Gainesville, FL HCS 629 New Orleans, LA HCS
523 Boston, MA HCS 672 San Juan, PR HCS 667 Shreveport, LA HCS
608 Manchester, NH HCS 673 Tampa, FL HCS 504 Amarillo, TX HCS
631 Central Western Massachusetts HCS 675 Orlando, FL HCS 519 Big Spring, TX HCS
650 Providence, RI HCS 596 Lexington, KY HCS 549 Dallas, TX HCS
689 Connecticut HCS 603 Louisville, KY HCS 671 San Antonio, TX HCS
526 Bronx, NY HCS 614 Memphis, TN HCS 674 Temple, TX HCS
561 New Jersey HCS 621 Mountain Home, TN HCS 740 Texas Valley Coastal Bend HCS
620 Hudson Valley, NY HCS 626 Middle Tennessee HCS 756 El Paso, TX HCS
630 New York Harbor HCS 506 Ann Arbor, MI HCS 436 Montana HCS
632 Northport, NY HCS 515 Battle Creek, MI HCS 442 Cheyenne, WY HCS
528 Buffalo, NY HCS 538 Chillicothe, OH HCS 554 Aurora, CO HCS
528A5 Canandaigua, NY HCS 539 Cincinnati, OH HCS 575 Grand Junction, CO HCS
528A6 Bath, NY HCS 541 Cleveland, OH HCS 623 Muskogee, OK HCS
528A7 Syracuse, NY HCS 552 Dayton, OH HCS 635 Oklahoma City, OK HCS
528A8 Albany, NY HCS 553 Detroit, MI HCS 660 Salt Lake City, UT HCS
460 Wilmington, DE HCS 583 Indianapolis, IN HCS 666 Sheridan, WY HCS
503 Altoona, PA HCS 610 Northern Indiana HCS 463 Anchorage, AK HCS
529 Butler, PA HCS 655 Saginaw, MI HCS 531 Boise, ID HCS
542 Coatesville, PA HCS 757 Columbus, OH HCS 648 Portland, OR HCS
562 Erie, PA HCS 537 Chicago, IL HCS 653 Roseburg, OR HCS
595 Lebanon, PA HCS 550 Danville, IL HCS 663 Puget Sound, WA HCS
642 Philadelphia, PA HCS 556 North Chicago, IL HCS 668 Spokane, WA HCS
646 Pittsburgh, PA HCS 578 Hines, IL HCS 687 Walla Walla, WA HCS
693 Wilkes-Barre, PA HCS 585 Iron Mountain, MI HCS 692 White City, OR HCS
512 Baltimore, MD HCS 607 Madison, WI HCS 459 Honolulu, HI HCS
517 Beckley, WV HCS 676 Tomah, WI HCS 570 Fresno, CA HCS
540 Clarksburg, WV HCS 695 Milwaukee, WI HCS 593 Las Vegas, NV HCS
581 Huntington, WV HCS 589 Kansas City, MO HCS 612 N. California HCS
613 Martinsburg, WV HCS 657 St. Louis, MO HCS 640 Palo Alto, CA HCS
688 Washington, DC HCS 589A4 Columbia, MO HCS 654 Reno, NV HCS
558 Durham, NC HCS 589A5 Eastern Kansas HCS 662 San Francisco, CA HCS
565 Fayetteville, NC HCS 589A7 Wichita, KS HCS 501 New Mexico HCS
590 Hampton, VA HCS 657A4 Poplar Bluff, MO HCS 600 Long Beach, CA HCS
637 Asheville, NC HCS 657A5 Marion, IL HCS 605 Loma Linda, CA HCS
652 Richmond, VA HCS 437 Fargo, ND HCS 644 Phoenix, AZ HCS
658 Salem, VA HCS 438 Sioux Falls, SD HCS 649 Northern Arizona HCS
659 Salisbury, NC HCS 568 Black Hills, SD HCS 664 San Diego, CA HCS
508 Atlanta, GA HCS 618 Minneapolis, MN HCS 678 Southern Arizona HCS
509 Augusta, GA HCS 636 Nebraska HCS 691 Greater Los Angeles, CA HCS
521 Birmingham, AL HCS 656 St. Cloud, MN HCS
534 Charleston, SC HCS 636A6 Central and W Iowa HCS
544 Columbia, SC HCS 636A8 Iowa City, IA HCS
557 Dublin, GA HCS 502 Alexandria, LA HCS
619 Central Alabama HCS 520 Gulf Coast, MS HCS
679 Tuscaloosa, AL HCS 564 Fayetteville, AR HCS
516 Bay Pines, FL HCS 580 Houston, TX HCS
Appendix A - Station Names and Numbers
PO1.1
Remove validated approved network waivers, based on the Veteran county, and category of care and code sets.
Remove outpatient out of network claims-OON claims. OON claims identified via HCP15 equals = 1, 3,4 ; Outpatient is NOT = Place of Service Code: 13, 14, 21, 25, 31, 32, 33, 34, 51, 56, 61 - Facility codes NOT =11%, 12%, 21%, 22%, 41%, 81%, 82%, 83%, 84%, 85%, 86%. Note: These fields are on the claims data.
Remove referrals with a Veterans Preference indicator.
Remove any referral with a claim with a Place of Service (POS) 12.
Remove telehealth services indicated by POS 2 and POS10
Remove Mobile Health services indicated by POS 15.
Remove any referral date submitted prior to the activation of CCN NG for that facility.
Remove referrals for Destination Medical Centers.
Remove referrals with P.O. Box as Veteran Address
PO1.2
Remove validated approved network waivers, based on the Veteran county, and category of care and code sets.
Remove outpatient out of network claims-OON claims. OON claims identified via HCP15 equals = 1, 3,4 ; Outpatient is NOT = Place of Service Code: 13, 14, 21, 25, 31, 32, 33, 34, 51, 56, 61 - Facility codes NOT =11%, 12%, 21%, 22%, 41%, 81%, 82%, 83%, 84%, 85%, 86%. Note: These fields are on the claims data.
Remove referrals with a Veterans Preference indicator.
Remove any referral with a claim with a Place of Service (POS) 12.
Remove telehealth services indicated by POS 2 and POS10
Remove Mobile Health services indicated by POS 15.
Remove any referral date submitted prior to the activation of CCN NG for that facility.
Remove referrals for Destination Medical Centers.
Remove referrals with a Clinically Indicated Date that is greater than 90 days.
Remove referrals with an appointment no show or cancellation recorded in HSRM/CCRA that exceed the timeliness standard.
Remove any negative values where the appointment date (First DOS from claim) occurs prior to the referral date.
Appendix B - Network Adequacy Performance Objective Exclusions List
The following list of exclusions apply and shall not be included in the calculation of performance of the performance objectives (PO) as stated
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