Attachment C- Performance Requirement Summary- Dental Network _V2.xlsx

PRS - DENTAL

PWS Attachment C - CCN Performance Requirement Summary (PRS ) - DENTAL

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

*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 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 Provider address in the Provider Directory using Contractor's Azure API mapping tool

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 referral IDs are excluded. 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 837) 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.

ST5 - Extract Patient Residential Address from Eligibility File/Referral.

ST6- Extract Provider Address from 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 Provider address 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.

*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 referral IDs are excluded. 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 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 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.

Customer Service 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.

*Statistically significant

Contractor Contact Center data

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

*Abandoned calls are those calls that voluntarily hung-up or ortherwise exited in the queue after entering the queue but before reaching an agent. It includes all calls that enter the queue. ≥ 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.

*Statistically significant

Contractor Contact Center data

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

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

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.

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

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

*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.

*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

*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.

PRS Appendix A Station Names Appendix A - Station Names and Numbers

PRS Appendix B Exclusions List 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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