36C24725Q0806.docx

PAGE 1 OF

1. REQUISITION NO.

2. CONTRACT NO.

3. AWARD/EFFECTIVE DATE

4. ORDER NO.

5. SOLICITATION NUMBER

6. SOLICITATION ISSUE DATE

a. NAME

b. TELEPHONE NO. (No Collect Calls)

8. OFFER DUE DATE/LOCAL

TIME

9. ISSUED BY

CODE

10. THIS ACQUISITION IS

UNRESTRICTED OR

SET ASIDE:

% FOR:

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

WOMEN-OWNED SMALL BUSINESS

(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

8(A)

NAICS:

SIZE STANDARD:

11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

12. DISCOUNT TERMS

13a. THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13b. RATING

14. METHOD OF SOLICITATION

RFQ

IFB

RFP

15. DELIVER TO

CODE

16. ADMINISTERED BY

CODE

17a. CONTRACTOR/OFFEROR

CODE

FACILITY CODE

18a. PAYMENT WILL BE MADE BY

CODE

TELEPHONE NO.

UEI:

EFT:

PHONE:

FAX:

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER 18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW IS CHECKED

SEE ADDENDUM

19.

20.

21.

22.

23.

24.

ITEM NO.

SCHEDULE OF SUPPLIES/SERVICES

QUANTITY

UNIT

UNIT PRICE

AMOUNT

(Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA

26. TOTAL AWARD AMOUNT (For Govt. Use Only) 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA

ARE

ARE NOT ATTACHED.

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA

ARE

ARE NOT ATTACHED

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN _______________

29. AWARD OF CONTRACT: REF. ___________________________________ OFFER

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND

DATED ________________________________. YOUR OFFER ON SOLICITATION

DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY

(BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE

ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED

SET FORTH HEREIN IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER) 30b. NAME AND TITLE OF SIGNER (TYPE OR PRINT) 30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (TYPE OR PRINT) 31c. DATE SIGNED

AUTHORIZED FOR LOCAL REPRODUCTION

(REV. NOV 2021)

PREVIOUS EDITION IS NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.212

7. FOR SOLICITATION

INFORMATION CALL:

STANDARD FORM 1449

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

1358 Funded 36C24725Q0806 Laurinda Millage 09-30-2026

4PM

EDT

Department of Veterans Affairs VISN 7 Network Contracting Activity 501 Greene Street Hatcher Building - Suite 2 Augusta GA 30901 X 623110 $34 Million N/A X 36C247 Department of Veterans Affairs Atlanta VA Medical Center 1670 Clairmont Road Atlanta GA 30033 36C247 Department of Veterans Affairs VISN 7 Network Contracting Activity 501 Greene Street Hatcher Building - Suite 2 Augusta GA 30901

Department of Veterans Affairs

FMS-VA-2 (101)

Financial Services Center P.O. Box 149971 Austin TX 78714-9971 As a result of this Request for Quotes (RFQ), the Government anticipates awarding multiple Indefinite Delivery Contracts (IDC) under authority 38 U. S. C. 1720 for Nursing Home Services for eligible Veterans of the Department of Veterans Affairs in various counties within a geographical area of the Atlanta VAMC. Award will be made to qualified Community Nursing Home Facility as the need arises in their respective county.

The resulting Contract will be issued for a five year ordering period.

See Addendum 52.212-1 for instructions on submitting proposals.

X X X X Laurinda Millage

VA-VHA-RPOE-2022-224946

Table of Contents

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

1. Contract Administration: All contract administration matters will be handled by the following individuals:

a. CONTRACTOR:

b. GOVERNMENT: Contracting Officer 36C247 Laurinda Millage Department of Veterans Affairs VISN 7 Network Contracting Activity 501 Greene Street Hatcher Building - Suite 2 Augusta GA 30901

2. CONTRACTOR REMITTANCE ADDRESS: All payments by the Government to the contractor will be made in accordance with:

3. INVOICES: Invoices shall be submitted in arrears:

4. GOVERNMENT INVOICE ADDRESS: All Invoices from the contractor shall be submitted electronically in accordance with VAAR Clause 852.232-72 Electronic Submission of Payment Requests.

Addendum to VAAR 852.232-72 ELECTRONIC SUBMISSION OF PAYMENT REQUESTS

(NOV 2018)

Payment will be made upon receipt of a properly prepared detailed invoice, prepared by the Contractor and submitted through Tungsten Network (formerly known as OB10) http://www.tungsten-network.com/us/en/. A properly prepared invoice shall contain:

· Invoice Number and Date

· Contractor’s Name and Address

· Accurate Purchase Order Number

· Supply or Service provided

· Period Supply or Service Provided

· Total Amount Due

b. Please begin submitting your electronic invoices through the Tungsten Network for payment processing, free of charge.

c. If you have questions about the e-invoicing program or Tungsten Network, contact information is as follows:

• Tungsten e-Invoice Setup Information: 1-877-489-6135

• Tungsten e-Invoice email: VA.Registration@Tungsten-Network.com

• FSC e-Invoice Contact Information: 1-877-353-9791

• FSC e-invoice email: vafsccshd@va.gov

d. Web Address: HTTP://WWW.FSC.VA.GOV/EINVOICE.ASP

36C24725Q0806

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A. Overview

1. Federal Acquisition Regulation (FAR) – Indefinite Delivery Indefinite Quantity Contract (IDIQ). In accordance with FAR 16.504, Indefinite-Quantity Contracts, this is an IDIQ with an ordering period of up to five years beginning from the date of award. This requirement is being solicited under the authority of 38 CFR 17.4000, 38 U.S.C. 1710 and 38 U.S.C. 1720.

2. Veteran Placements. Placements may be issued by authorized VA medical center personnel to place Veterans in Nursing Homes. Contact for authorized VA medical center personnel information will be provided separately.

B. Introduction. The Community Nursing Home (CNH) program is a key component of the Veterans Health Administration (VHA) continuum of care. The Contractor agrees to provide in accordance with the terms and conditions stated herein to the U.S. Department of Veterans Affairs Atlanta Health Care System, 1670 Clairmont Rd, in Atlanta Georgia 30033 at the prices specified in the section titled Schedule of Items of this IDIQ. Nursing home facilities in the CNH program shall cooperate with VA staff in referral of appropriate Veterans for care and accept Veterans of which they have the capability/capacity to care. The term, “facilities,” shall include but not be limited to rooms, wards, sections, eating areas, drinking fountains, entrances, and other like areas.

C. Requirements

1. General. Nursing home facilities in the CNH program shall ensure that care meets the health needs and promotes the maximum well-being of VA patients. Nursing home care will be furnished to ensure the total medical, nursing, and psychosocial needs of VA beneficiaries. All nursing home facilities in VA’s CNH program must have current Center for Medicare and Medicaid Services (CMS) certification (Medicare and/or Medicaid) and a State nursing home license. VA often has a particular need for specialty care services in the CNH program. The VA requires CNHs to have bed capacity to ensure their ability to take referrals when requested. The CNH also must be able to accept VA referrals in a timely fashion (ideally within 24 hours of request). Provider visits will be available at a minimum of one (1) visit per month. Laboratory, x-ray, and other special services will be available to VA patients as needed. In addition, the care provided will include room, meals, nursing care, and other services or supplies commensurate with the VA-authorized level of care, without extra charge. Duly authorized VA staff will provide quality oversight visits to Veterans placed to assure continuity of care and to assist in the Veterans’ transition back into the community. These visits do not substitute nor relieve the CNH in any way of the responsibility for the daily care and medical treatment of the Veteran. CNHs shall provide primary medical care, provider visits as needed per month, and specialty consultations, drugs and routine supplies, laboratory, x-ray, and other special services preauthorized by VA. Full attention shall be given to motivating and educating patients to achieve and maintain independence in the activities of daily living. Every effort shall be made to keep patients ambulatory and to achieve an optimal level of self-care.

2. Termination of Services. VA reserves the right to remove any or all VA patients from the CNH at any time when it is determined to be in the best interest of VA or the patients without additional costs to the Government.

3. VA Authorizations. VA authorization for nursing home care will be on VA Form 10-7080, “Approved Referral for Medical Care.” Each authorization referral period will be noted on the VA Form 10-7080 with a beginning and end date.

4. Patient Driven Payment Model (PDPM). The VA CNH Fee Schedule follows the Prospective Payment System (PPS) billing requirements found in "Chapter 6–Skilled Nursing Facility (SNF) Inpatient Part A Billing and SNF Consolidated Billing," Medicare Claims Processing Manual, Chapter 6, (https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c06.pdf) with some exceptions. This includes VA paying the lesser of billed charges or the CNH Fee Schedule, the interrupted stay policy and enhanced payments for HIV/AIDS. VA exceptions are published and updated on https://www.va.gov/COMMUNITYCARE/revenue-ops/Fee-Schedule.asp. Contractors are responsible for monitoring changes to this website which will be applied to claims automatically starting on the published effective date. The exceptions provided below are for information only and are superseded by published exceptions posted on the VA website after the contract award date.

Exceptions:

1. VA will use the Patient Driven Payment Model-based (PDPM) pricing software using the following specifications:

a) CNH day 1-100: multiply physical therapy (PT), occupational therapy (OT), speech language pathology (SLP), nursing, and non-case-mix components by 0.93 in addition to any other adjustment factors.

b) CNH day 101+: remove PT, OT, and SLP components (or set adjustment factor to 0). Multiply nursing and non-case-mix components by 1.25.

c) The non-therapy ancillary component will follow PDPM (3.0 for the first three days, 1.0 for CNH day 1-100, and 1.25 for CNH day 101+).

2. No special service pricing exists outside of VA PDPM-based PPS for services such as bed hold, memory care, behavioral, HIV/AIDS, respite, ventilator, tracheostomy, and isolation/private room.

3. VA does not participate in the sequestration, quality reporting, or in the value-based program.

4. VA covers some services under CNH authorizations that are not considered part of the nursing home PPS, listed below. Nursing homes are required to submit separate claims for these services.

a) Physician services: Providers delivering Federally mandated or separately authorized services shall bill fee-for-service. The services will be reimbursed at the lesser of billed charges or the Medicare Physician Fee Schedule. Nursing facilities are required to make claims on behalf of the physician, unless the physician has a Veterans Care Agreement with VA.

b) PT, OT and SLP: When PT, OT or SLP therapy is required during days 101+ of a Veteran’s stay, providers must get prior authorization from VA. When care is delivered on days 101+ of a Veteran’s stay, providers will bill fee-for-service using the following procedure codes: G0151, G0152, G0153, G0157, G0158, G0159, G0160, G0161. The services will be reimbursed at the lesser of billed charges or the VA Fee Schedule.

c) Escort services: When an escort to a medical appointment is indicated, providers must get prior authorization from VA. Providers will bill fee-for-service using the following procedure code: G0156. The services paid will be the lesser of billed charges or the VA Fee Schedule.

d) Interrupted Stays: VA follows Medicare’s Interrupted Stay Policy.

e) High-Cost Medication: When a high-cost medication is required during a Veteran’s stay, providers must get prior authorization from VA. High-cost medication will be reimbursed at the lesser of billed charges or the VA Fee Schedule. (Note: as of October 1, 2024, the published fee schedule does not address high-cost medication. Once added to the website, changes to the website information supersede this paragraph. Remove note.)

5. Primary Medical Coverage. The assigned CNH provider is the primary medical provider during the nursing home stay and is responsible for writing or approving admission and all other orders as soon as the Veteran arrives at the CNH. The CNH provider is responsible for general medical care, urgent evaluation and intervention. Provider visits will be according to the Center for Medicare and Medicaid Services (CMS) guidelines. The assigned nursing home provider will provide timely care following the most current CMS guidelines; arranging 24/7 access for patient care; arranging easy access to VA staff for consultation; providing timely response to calls and arranging for timely provider back-up according to OBRA guidelines (42 CFR 483.40, OBRA Guidelines).

6. Rehabilitation Criteria. Follow CMS Medicare chapter on Maintenance Therapy. Therapy requires pre-approval by VA.

7. Emergency Care; Financial Responsibility; Advanced Directives. Veterans may have coverage for emergency care when the CNH alerts the VA within 24 hours of the care. The CNH will qualify for VA reimbursement of emergency care and ancillary transportation, provided that the CNH or private hospital contacts the VA Health Care System (VAHCS) within 72-hours of admission or first business day following a weekend or holiday. This includes the cost of necessary transportation for such care. Use of a VA or VA network medical facility is preferred.

8. HIPAA Compliance. HIPAA compliance is required. The Contractor must adhere to the provisions of Public Law 104-191, Health Insurance Portability and Accountability Act (HIPAA) of 1996 and the national Standards to Protect the Privacy and Security of Protected Health Information (PHI). As required by HIPAA, the Department of Health and Human Services (HHS) has promulgated rules governing the security and use and disclosure of protected health information by covered entities, including the Department of Veterans Affairs (VA). In accordance with HIPAA, the Contractor may be required to enter into a Business Associate Agreement (BAA) with VA, but VACO has recognized CNH Facilities as an entity that does not require a BAA as long as they are conducting health care on VA’s behalf. The CNH care program qualifies as a medical service, so no BAA is required.

9. Quality Expectations for CNH’s:

a. To participate in VA’s CNH Program, NHs are expected to have either 1) a three-star overall rating, or 2) a two-star overall rating with a four star or greater quality measures score on the Centers for Medicare and Medicaid (CMS) Nursing Home Compare Web site (https://www.medicare.gov/nursinghomecompare/search.html).

b. NHs with lower scores may participate in the CNH program only when specifically approved by the Deputy Under Secretary for Health for Operations and Management or designee.

c. All NHs in the CNH Program must be certified by CMS under Title XVIII (Medicare) or Title XIX (Medicaid) or have received special approval from the Office of Geriatrics and Extended Care (GEC) Office. NHs are responsible to the state of jurisdiction and CMS for the care provided. VA does not regulate the care or inspect CNHs. VA acts as an informed purchaser of care in order to purchase quality services for Veterans and enhance the Veterans’ experience in the home.

d. The CNH must maintain a current and unrestricted state license to operate as a skilled nursing facility. Changes in the status of the licensure will be immediately reported to the Department of Veterans Affairs Atlanta Health Care System and Community Care Department at (404) 521-6260 Ext. 558421. VA will monitor the professional care and administrative management of services provided to VA beneficiaries under this IDIQ (reference 9.a.).

(QASP Indicator #1) The CNH shall cooperate fully with VA’s quality improvement or quality assurance program functions relating to this IDIQ. The VA Contracting Officer shall make all final determinations as to the Contractor’s reasonable cooperation with VA and compliance with these requirements.

10. Corrective Action Plan. (QASP Indicator #2). The CNH will cooperate with timely development of Corrective Action Plans (CAPs) related to identified deficiencies and related to State or Medicare surveys. The CNH will provide copies of CAPs to VA.

11. Re-admission to the VA Hospital and Emergency Care; Notification of Death of Veterans; CNH Responsibility for Veteran’s Belongings or Personal Effects (QASP Indicator #3). VA beneficiaries who begin to require more than the level of care authorized by VA will be readmitted to an appropriate VA facility, as determined and authorized by VA.

a. When such an admission is not feasible because of the nature of the emergency, hospitalization in a non-Federal facility may be accomplished provided VA authorization is obtained. VA authorization must be obtained within 72 hours of admission of the patient to a non-Federal facility and notice of any Veteran death within 24 hours or immediately upon the first business day after a weekend or holiday. If hospitalization of a non-emergency nature is required, readmission to a VA Medical Center may be accomplished as soon as the patient’s condition is sufficiently stabilized to permit admission to a VA Medical Center.

b. In the event of a death of any Veteran, the Contractor agrees to notify VA immediately of the death. In the event a death of a VA beneficiary while receiving nursing home care under this IDIQ, the CNH will promptly notify the VA facility which authorized admission and immediately assemble, inventory, and safeguard the patient’s personal effects. The funds, deposits, and effects left by the VA patients upon the premises of the CNH shall be delivered by the CNH to the person(s) entitled thereto under the laws currently governing the CNH for making disposition of funds and effects left by patients, unless the beneficiary died without leaving a will, heirs or next of kin capable of inheriting.

c. When disposition has been made, the itemized inventory with annotation as to the disposition of the funds and effects will be immediately forwarded to the VA facility that authorized admission. Should a deceased patient leave no will, heirs, or next of kin, his/her personal property and funds wherever located vests in and becomes the property of the United States in trust. In these cases, the CNH will forward an inventory of any such property and funds in its possession to the VA facility authorizing admission and will hold them (except articles of clothing necessary for proper burial) under safeguard until instructions are received from VA concerning disposition. CMS regulations require retention of records for five (5) years when there is no requirement in State law.

12. Reportable Events (QASP Indicator #4). VA requires CNHs to report to the CNH Coordinator at VA any of the below events within 24-hours or immediately upon the first business day after a weekend or holiday. Reporting shall include date of occurrence and patient disposition and outcome.

a. Sentinel events;

b. When there is a change of ownership of the CNH;

c. When there is a change of nursing home administrator or Director of Nursing/Director of Nursing Service;

d. substantiated allegations of mistreatment, neglect, abuse or misappropriation of CNH Veterans or property;

e. Elopements of CNH Veterans pursuant to state regulations;

f. Infectious outbreaks;

g. Resident to resident or resident to staff altercations involving a CNH Veteran resulting in any injury that is other than minor;

h. Copies of annual surveys or substantiated complaint investigations conducted by a State oversight agency; and

i. Adverse events.

A sentinel event may include, but is not limited to the following:

1. A fall resulting in death or injury;

2. Elopement resulting in a missing patient;

3. Patient abuse confirmed or under suspicion;

4. A medication error resulting in patient illness or injury;

5. Death or patient injury related to restraint (including side rails) use; or

6. Death related to an unconfirmed or suspicious cause.

When an adverse event occurs involving a CNH Veteran which is not determined to be a Sentinel Event (but that the State requires that the occurrence be reported to the State), such event is also to be reported to VA’s CNH program office. Some adverse events, such as minor medication errors without catastrophic outcomes, are managed by the CNH in the context of their quality improvement programs. It is not necessary for nursing homes to report such incidents to the CNH program office.

13. VA Actions Regarding Serious Quality of Care Deficiencies. In cases of serious deficiencies affecting the health or safety of Veterans or in cases of continued uncorrected deficiencies, VA will take one or more of the following actions in accordance with the terms and clauses of the IDIQ and applicable procurement regulations:

a. Increase VA staffing monitoring until the State survey agency clears the deficiency;

b. Suspend placement of Veterans in the CNH;

c. Remove or transfer Veterans under the IDIQ from the subject CNH;

d. Not renew the IDIQ; and/or

e. Terminate the IDIQ.

14. VA Staff Access to CNH Records (QASP Indicator #5). All medical records concerning the Veteran’s care in the CNH shall be readily accessible to VA. Selected VA staff will be provided access to the CNH electronic health record for each Veteran. Upon discharge or the death of a patient, medical records will be retained by the CNH for a period of at least five (5) years following termination of care. Patient records will be maintained in conformance with the Privacy Act of 1974 (5 U.S.C. § 552a). A medical record shall be maintained for each patient in accordance with CMS standards in 42 CFR 483.

15. Non-VA Specialty Care Services. The CNH shall notify VA program staff of the need for specialty care services for Veterans (examples include dental care, podiatry, and ophthalmology). Payment is based on the method of care authorized by VA.

16. Contact Information for VA Appointments/Admissions/Specialty Care.

(a) For urgent same-day outpatient specialty care or for non-urgent scheduled clinic appointments/consultations, phone number 1-800-224-4087 between 9 a.m. and 3 p.m. Monday through Friday, excluding holidays. If a same-day appointment is anticipated; please call as early as possible.

(b) For non-emergency consultation or /evaluation for admission to the Department of Veterans Affairs Atlanta Health Care System (after initial evaluation or intervention by the nursing home physician) call phone number 404-728-7614 or 404-321-6111 ext. 207614.

(c) For urgent referrals or consultation after hours, weekends and holidays, call 404-728-7614 or 404-321- 207614.

(d) For transportation to and from the VA facility for appointments, evaluation, or hospitalization, call 404-321-6111 ext. 203245. Transportation will be arranged and paid by the VA for CNH patients when requested.

17. Soliciting Charitable Contributions. The CNH will not directly solicit contributions, donations, or gifts from Veteran patients or a Veteran’s family members. CNH-wide charitable fundraising activities such as United Way are allowed.

18. Prices/Rates

VA shall pay, and Provider shall accept, the following amounts as payment for Covered Services under this Contract: The lesser of billed charges or the VA Fee Schedule amount for the period in which the Covered Service was performed, as posted and contemporaneously available on VA.gov on the date of service. For purposes of this Contract, the “VA Fee Schedule amount” is a per diem rate determined by VA as set forth in the formula posted on VA.gov, https://www.va.gov/COMMUNITYCARE/revenue-ops/Fee-Schedule.asp

19. Claims Submission and Adjudication (QASP Indicator #6).

Provider shall always submit all claims within 180 days of the date of service. Claims must be submitted to the VA facility that issued the authorization. Electronic claims must be submitted by Electronic Data Interchange (EDI) using the following payer ID: 12115. Paper claims must be submitted in accordance with the instructions on the community care website on VA.gov, https://www.va.gov/COMMUNITYCARE/revenue-ops/Veteran-Care-Claims.asp.

Provider shall always submit clean claims. VA will only process and pay clean claims. A “clean claim” means a claim that contains all of the required data elements necessary for accurate adjudication, without obtaining additional information from the submitter, and which complies with all applicable VA requirements regarding information, documentation, and format, including the following specific requirements:

(a) Containing Provider’s name, address, and Taxpayer Identification Number (TIN).

(b) Containing the correct VA beneficiary identifiers, including Social Security Number.

(c) Containing the numbers of this Contract and the applicable VA authorization(s).

(d) Containing all information required by VA to determine the applicable VA Fee Schedule amount for the period in which the service was performed. Such information may include, but will not necessarily be limited to, HIPPS codes and/or minimum data sets or other data from or relating to resident assessments. VA will provide written notice of all required information prior to the applicable date(s) of service. Provider represents and warrants that any information submitted to VA accurately reflects the resident’s status and/or the Covered Services furnished, as applicable.

(e) Applying industry standard edits consistent with the current version of the CMS national Correct Coding Initiative (NCCI) Coding Policy Manual.

(f) For institutional paper claims, complying with all content requirements set forth in the current version of the national Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual.

(g) For professional paper claims, complying with all content requirements set forth in the current version of the national Uniform Claim Committee (NUCC) 1500 Claim Form Reference Instruction Manual.

(h) For electronic claims, complying with all content requirements set forth in the current version of the American national Standards Institute (ANSI) Accredited Standards Committee (ASC) X12 Health Care Claim (837) transaction Type 3 Technical Reports-TR3.

(i). If a claim is denied, VA will notify Provider in writing of the reason for denying the claim and what, if any, additional information is required to process the claim. VA will provide such notification within 45 calendar days of receipt of a paper claim and within 30 calendar days of receipt of an electronic claim. Provider must submit all additional information requested by VA within 30 calendar days of receipt of VA’s notice of denial. Such information must be submitted to the VA facility that issued the authorization, in accordance with the requirements of this section. VA will pay, deny, or otherwise adjudicate the claim within 30 calendar days of receipt of the requested information.

(j) Provider will also submit a copy of claim at the time of submission to authorized VA medical center personnel. This is for clinical review and will not delay payment through the automated system.

20. Payment

VA shall pay Provider, upon submission of clean claims, the amounts set forth in this Contract for Covered Services furnished and accepted. Payment will be made within 30 calendar days of receipt of a clean electronic claim and within 45 calendar days of receipt of clean paper claim.

Payment by Electronic Funds Transfer

Method of payment.

(a) All payments by VA under this Contract shall be made by electronic funds transfer (EFT), except as provided in paragraph (b)(1). As used in this clause, the term “EFT” refers to the funds transfer and may also include the payment information transfer.

(b) In the event VA is unable to release one or more payments by EFT, Provider agrees to either

(1) Accept payment by check or some other mutually agreeable method of payment; or

(2) Request VA to extend payment due dates until such time as VA makes payment by EFT.

Mandatory submission of Provider’s EFT information. Provider is required to provide the Government with the information required to make payment by EFT. Provider shall provide this information directly to the office designated in this contract to receive that information (the Designated Office') by no later than 10 business days prior to submission of the first claim. If not otherwise specified in this Contract, the payment office is the Designated Office for receipt of the Provider’s EFT information. If more than one Designated Office is named for the Contract, Provider shall provide a separate notice to each office. In the event that the EFT information changes, Provider shall be responsible for providing the updated information to the Designated Office(s).

Mechanisms for EFT payment. VA may make payment by EFT through either the Automated Clearing House (ACH) network, subject to the rules of the national Automated Clearing House Association, or the Fedwire Transfer System. The rules governing Federal payments through the ACH are contained in 31 CFR part 210.

Suspension of payment.

(1) VA is not required to make any payment under this Contract until after receipt, by the Designated Office, of the correct EFT payment information from Provider. Until receipt of the correct EFT information, any claim shall be deemed not to have been received by VA for purposes of determining payment due date.

(2) If the EFT information changes after submission of correct EFT information, VA shall begin using the changed EFT information no later than 30 calendar days after its receipt by the Designated Office to the extent payment is made by EFT. However, Provider may request that no further payments be made until the updated EFT information is implemented by the payment office.

Liability for uncompleted or erroneous transfers.

(1) If an uncompleted or erroneous transfer occurs because VA used the Contractor's EFT information incorrectly, VA remains responsible for:

(a) making a correct payment; and

(b) recovering any erroneously directed funds.

(2) If an uncompleted or erroneous transfer occurs because Provider’s EFT information was incorrect, or was revised within 30 days of VA release of the EFT payment transaction instruction to the Federal Reserve System, and

(a) If the funds are no longer under the control of the payment office, VA is deemed to have made payment, and Provider is responsible for recovery of any erroneously directed funds; or

(b) If the funds remain under the control of the payment office, VA shall not make payment, and the provisions of paragraph 20(b)(2) shall apply.

EFT and timing of payment. A payment shall be deemed to have been made in a timely manner in accordance with the terms of this Contract if, in the EFT payment transaction instruction released to the Federal Reserve System, the date specified for settlement of the payment is on or before the due date, provided the specified payment date is a valid date under the rules of the Federal Reserve System.

EFT and assignment of claims. If Provider assigns the proceeds of this Contract as provided for in the assignment of claims terms of this Contract, Provider shall require as a condition of any such assignment, that the assignee shall provide the EFT information to the Designated Office and shall be paid by EFT in accordance with the terms of this clause. In all respects, the requirements of this clause shall apply to the assignee as if it were Provider. EFT information that shows the ultimate recipient of the transfer to be other than Provider, in the absence of a proper assignment of claims acceptable to VA, is incorrect EFT information within the meaning of this paragraph.

Liability for change of EFT information by financial agent. VA is not liable for errors resulting from changes to EFT information provided by Provider’s financial agent.

Payment information. The payment or disbursing office shall forward to Provider available payment information that is suitable for transmission as of the date of release of the EFT instruction to the Federal Reserve System. VA may request Provider to designate a desired format and method(s) for delivery of payment information from a list of formats and methods the payment office can execute. However, VA does not guarantee that a particular format or method of delivery is available at any particular payment office and retains the latitude to use the format and delivery method most convenient to VA. If VA makes payment by check in accordance with this paragraph., VA shall mail the payment information to the remittance address in this Contract.

EFT information. Provider shall provide the following information to the Designated Office. Provider shall designate a single financial agent capable of receiving and processing the EFT information.

(1) The Contract number.

(2) Provider’s name and remittance address, as stated in the Contract.

(3) The signature (manual or electronic, as appropriate), title, and telephone number of the Provider official authorized to provide this information.

(4) The name, address, and 9-digit Routing Transit Number of Provider’s financial agent.

(5) Provider’s account number and the type of account (checking, saving, or lockbox).

(6) If applicable, the Fedwire Transfer System telegraphic abbreviation of Provider’s financial agent.

(7) If applicable, Provider shall also provide the name, address, telegraphic abbreviation, and 9-digit Routing Transit Number of the correspondent financial institution receiving the wire transfer payment if Provider’s financial agent is not directly on-line to the Fedwire Transfer System; and, therefore, not the receiver of the wire transfer payment.

Vendorization. Prior to submitting a claim, Provider must ensure the authorizing VA facility has received a completed FMS Vendor File Request form (VA Form 10091) and W-9, Request for Taxpayer Identification Number and Certification and all information contained therein is current and accurate.

Prompt Payment by VA.

(1) Interest penalty. The designated payment office will pay an interest penalty automatically, without request from Provider, if payment is not made by the due date and the conditions listed in paragraphs (a) and (b) are met. However, when the due date falls on a Saturday, Sunday, or legal holiday, the designated payment office may make payment on the following working day without incurring a late payment interest penalty.

(a) VA received a clean claim (see Claims Submission and Adjudication).

(b) VA processed a receiving report or other VA documentation authorizing payment, and there was no disagreement over payment amount, compliance of services furnished with any term or condition of this Contract, or Provider compliance with any other term or condition of this Contract.

(2) Computing penalty amount. The interest penalty shall be computed at the rate of interest established by the Secretary of the Treasury under section 3902 of title 31 U.S.C. and published in the Federal Register.

Overpayments.

(1) If Provider becomes aware of a duplicate VA payment or that VA has otherwise overpaid under the Contract, Provider shall:

(a) Remit the overpayment amount to the payment office cited in the Contract along with a description of the overpayment including the

(i) Circumstances of the overpayment (e.g., duplicate payment, erroneous payment, date(s) of overpayment)

(ii) Contract number, and number(s) of affected authorization(s) and claim(s); and

(iii) Provider point of contact.

(2) For purposes of this Contract, the term “overpayment” includes but is not limited to any amount that has been paid to Provider pursuant to this Contract that exceeds the correct VA Fee Schedule amount for the period in which the service was performed because information or data submitted to VA pursuant to this Contract (e.g., HIPPS codes, resident assessment data, medical documentation), upon which VA’s prior determination of payment amount relied, did not accurately reflect the resident’s status and/or the Covered Services provided.

(3) VA may deduct the amount of any overpayment from payments due Provider, in accordance with 38 U.S.C. § 1703D(e).

Interest from Provider.

(1) All amounts that become payable by Provider to VA under this Contract shall bear simple interest from the date due until paid unless paid within 30 calendar days of becoming due. The interest rate shall be the interest rate established by the Secretary of the Treasury as provided in 41 U.S.C. 7109, which is applicable to the period in which the amount becomes due, as provided in (c) of this clause, and then at the rate applicable for each six-month period at fixed by the Secretary until the amount is paid.

(2) VA may issue a demand for payment to the Contractor upon finding a debt is due under the Contract.

(3) Amounts shall be due on the date of the first written demand for payment.

(4) The interest charge shall be computed for the actual number of calendar days involved beginning on the due date and ending on:

(a) The date on which the designated office receives payment from Provider

(b) The date of issuance of a VA check to Provider from which an amount otherwise payable has been withheld as a credit against the contract debt; or

(c) The date on which an amount withheld and applied to the contract debt would otherwise have become payable to Provider.

The payment office for this Contract is: the applicable VA office, unless otherwise identified by VA.

20. Payment Responsibility

Provider agrees that payment by VA under this Contract shall, unless rejected and refunded by Provider within 30 calendar days of receipt, constitute payment in full and extinguish any liability on the part of the VA beneficiary for the treatment or care provided. No provision of any contract, agreement, or assignment to the contrary shall operate to modify, limit, or negate this requirement.

VA is solely responsible for payment for all Covered Services provided under this Contract. Provider shall not seek to recover or collect from any party, other than VA, any payment or fee arising from Covered Services authorized and provided under to this Contract, including any missed appointment fees or charges.

Provider shall not collect any cost share or copayment amount from any VA beneficiary for Covered Services provided under this Contract.

Provider agrees that it shall not seek to recover or collect from a health-plan contract or third party, as those terms are defined at 38 U.S.C § 1729, for any Covered Services provided under this Contract and paid for by VA.

B.2 PRICE SCHEDULE

The VA CNH Fee Schedule follows the Prospective Payment System (PPS) billing requirements found in "Chapter 6–Skilled Nursing Facility (SNF) Inpatient Part A Billing and SNF Consolidated Billing," Medicare Claims Processing Manual, Chapter 6, (https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c06.pdf) with some exceptions. This includes VA paying the lesser of billed charges or the CNH Fee Schedule, the interrupted stay policy and enhanced payments for HIV/AIDS. VA exceptions are published and updated on this VA website, https://www.va.gov/COMMUNITYCARE/revenue-ops/Fee-Schedule.asp. Contractors are responsible for monitoring changes to this website which will be applied to claims automatically starting on the published effective date. The exceptions provided below are for information only and are superseded by published exceptions posted on the VA website after the contract award date.

Exceptions:

1. VA will use the Patient Driven Payment Model-based (PDPM) pricing software using the following specifications:

1. CNH day 1-100: multiply physical therapy (PT), occupational therapy (OT), speech language pathology (SLP), nursing, and non-case-mix components by 0.93 in addition to any other adjustment factors.

2. CNH day 101+: remove PT, OT, and SLP components (or set adjustment factor to 0). Multiply nursing and non-case-mix components by 1.25.

3. The non-therapy ancillary component will follow PDPM (3.0 for the first three days, 1.0 for CNH day 1-100, and 1.25 for CNH day 101+).

2. No special service pricing exists outside of VA PDPM-based PPS for services such as bed hold, memory care, behavioral, HIV/AIDS, respite, ventilator, tracheostomy, and isolation/private room.

3. VA does not participate in the sequestration, quality reporting, or in the value-based program.

4. VA covers some services under CNH authorizations that are not considered part of the nursing home PPS, listed below. Nursing homes are required to submit separate claims for these services.

a. Physician services: Providers delivering federally mandated or separately authorized services shall bill fee-for-service. The services will be reimbursed at the lesser of billed charges or the Medicare Physician Fee Schedule. Nursing facilities are required to make claims on behalf of the physician, unless the physician has a Veterans Care Agreement with VA.

b. PT, OT and SLP: When PT, OT or SLP therapy is required during days 101+ of a Veteran’s stay, providers must get prior authorization from VA. When care is delivered on days 101+ of a Veteran’s stay, providers will bill fee-for-service using the following procedure codes: G0151, G0152, G0153, G0157, G0158, G0159, G0160, G0161. The services will be reimbursed at the lesser of billed charges or the VA Fee Schedule.

c. Escort services: When an escort to a medical appointment is indicated, providers must get prior authorization from VA. Providers will bill fee-for-service using the following procedure code: G0156. The services paid will be the lesser of billed charges or the VA Fee Schedule.

d. Interrupted Stays: VA follows Medicare’s Interrupted Stay Policy.

CNH Performance Work Statement for PDPM

e. High-Cost Medication: When a high-cost medication is required during a Veteran’s stay, providers must get prior authorization from VA. High-cost medication will be reimbursed at the lesser of billed charges or the VA Fee Schedule. (Note: as of October 1, 2024, the published fee schedule does not address high-cost medication. Once added to the website, changes to the website information supersede this paragraph.)

SECTION C - CONTRACT CLAUSES

C.1 52.212-4 CONTRACT TERMS AND CONDITIONS—COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES (NOV 2023)

(a) Inspection/Acceptance. The Contractor shall only tender for acceptance those items that conform to the requirements of this contract. The Government reserves the right to inspect or test any supplies or services that have been tendered for acceptance. The Government may require repair or replacement of nonconforming supplies or reperformance of nonconforming services at no increase in contract price. If repair/replacement or reperformance will not correct the defects or is not possible, the Government may seek an equitable price reduction or adequate consideration for acceptance of nonconforming supplies or services. The Government must exercise its post-acceptance rights—

(1) Within a reasonable time after the defect was discovered or should have been discovered; and

(2) Before any substantial change occurs in the condition of the item, unless the change is due to the defect in the item.

(b) Assignment. The Contractor or its assignee may assign its rights to receive payment due as a result of performance of this contract to a bank, trust company, or other financing institution, including any Federal lending agency in accordance with the Assignment of Claims Act (31 U.S.C. 3727). However, when a third party makes payment (e.g., use of the Governmentwide commercial purchase card), the Contractor may not assign its rights to receive payment under this contract.

(c) Changes. Changes in the terms and conditions of this contract may be made only by written agreement of the parties.

(d) Disputes. This contract is subject to 41 U.S.C. chapter 71, Contract Disputes. Failure of the parties to this contract to reach agreement on any request for equitable adjustment, claim, appeal or action arising under or relating to this contract shall be a dispute to be resolved in accordance with the clause at Federal Acquisition Regulation (FAR) 52.233-1, Disputes, which is incorporated herein by reference. The Contractor shall proceed diligently with performance of this contract, pending final resolution of any dispute arising under the contract.

(e) Definitions. The clause at FAR 52.202-1, Definitions, is incorporated herein by reference.

(f) Excusable delays. The Contractor shall be liable for default unless nonperformance is caused by an occurrence beyond the reasonable control of the Contractor and without its fault or negligence such as, acts of God or the public enemy, acts of the Government in either its sovereign or contractual capacity, fires, floods, epidemics, quarantine restrictions, strikes, unusually severe weather, and delays of common carriers. The Contractor shall notify the Contracting Officer in writing as soon as it is reasonably possible after the commencement of any excusable delay, setting forth the full particulars in connection therewith, shall remedy such occurrence with all reasonable dispatch, and shall promptly give written notice to the Contracting Officer of the cessation of such occurrence.

(g) Invoice.

(1) The Contractor shall submit an original invoice and three copies (or electronic invoice, if authorized) to the address designated in the contract to receive invoices. An invoice must include—

(i) Name and address of the Contractor;

(ii) Invoice date and number;

(iii) Contract number, line item number and, if applicable, the order number;

(iv) Description, quantity, unit of measure, unit price and extended price of the items delivered;

(v) Shipping number and date of shipment, including the bill of lading number and weight of shipment if shipped on Government bill of lading;

(vi) Terms of any discount for prompt payment offered;

(vii) Name and address of official to whom payment is to be sent;

(viii) Name, title, and phone number of person to notify in event of defective invoice; and

(ix) Taxpayer Identification Number (TIN). The Contractor shall include its TIN on the invoice only if required elsewhere in this contract.

(x) Electronic funds transfer (EFT) banking information.

(A) The Contractor shall include EFT banking information on the invoice only if required elsewhere in this contract.

(B) If EFT banking information is not required to be on the invoice, in order for the invoice to be a proper invoice, the Contractor shall have submitted correct EFT banking information in accordance with the applicable solicitation provision, contract clause (e.g., 52.232-33, Payment by Electronic Funds Transfer—System for Award Management, or 52.232-34, Payment by Electronic Funds Transfer—Other Than System for Award Management), or applicable agency procedures.

(C) EFT banking information is not required if the Government waived the requirement to pay by EFT.

(2) Invoices will be handled in accordance with the Prompt Payment Act (31 U.S.C. 3903) and Office of Management and Budget (OMB) prompt payment regulations at 5 CFR part 1315.

(h) Patent indemnity. The Contractor shall indemnify the Government and its officers, employees and agents against liability, including costs, for actual or alleged direct or contributory infringement of, or inducement to infringe, any United States or foreign patent, trademark or copyright, arising out of…