36C79118R0009-0002001.docx

1. In box 10 of SF 1449 the NAICS code listed is: 524292. On page 4 of the solicitation A.2.4 the NAICS code is: 524492. Can the Government please clarify the NAICS code?

The NAICS code assigned to this procurement is 524292. Section A.2 was corrected via Amendment 0001.

2. For purposes of meeting the Government’s requirement to be operational within 75 days of contract award and for purposes of planning staffing levels, can the Government provide historical call volumes from Community providers? If historical trends are not available, is the Government able to provide estimated call volume ranges?

Historical data is provided on separate sheets with this Q&A. This is provided for informational purposes only and may not be indicative of contractor’s experience in performance of the subsequent contract because it contains both Veteran and provider call data.

3. There is no separate CLIN for Provider Customer Service Center services. Prior practice in Government solicitations handles reimbursement for Customer Service Center services either in a separate administrative fee or as a separately billed item. Without a separate CLIN structure for customer service, costs for supporting provider and other customer calls will be embedded in claims processing costs. We believe it is the Government’s best interest to break the pricing for Customer Service out as a separate CLIN. The Government achieves better price transparency with Customer Service as a separate item. The Government can then better determine the price reasonableness of contractors’ Customer Service and claims processing bids independently. Will the Government reconsider breaking out Customer Service as a separate CLIN on a per call or similar rate?

No, the Government does not intend to reconsider breaking out Customer Service as a separate CLIN on a per call or similar rate. Offerors should determine the unit pricing appropriate for their proposal.

4. The Government identifies that it may implement a system modernization (e.g. migrating off FBCS and/or CP&E). However, price for such system conversion is not expressly called out as a separate CLIN. In commercial and Government procurements, systems conversions are typically called out as optional tasks. In this manner, if the Government does not, in fact, convert systems it does not incur the costs that contractors would otherwise have to embed in their claims processing price proposal. Additionally, the Government benefits from better price transparency for claims processing costs if the system conversion costs are accounted for in a separately priced CLIN. Will the Government reconsider breaking out system conversion as a separate CLIN?

The Government may consider a different CLIN structure, after contract award, if system modernization is implemented.

5. The Government identifies that the evaluation is based on the following factors, listed in descending order of importance: 1. Technical; 2. Past Performance; and 3. Price. And the Government states that Technical and Past Performance, when combined, are more important than Price. Will the Government disclose weights used for the evaluation factors?

The Government has disclosed its evaluation methodology in Section E.10 Evaluation Factors for Award.

6. The Government identifies Subfactor 1 (Management, Capabilities, and Technical Approach) and Subfactor 2 (Experience) for the Technical Evaluation Factor. Are each of the elements under each Subfactor of equal weight? If they are not of equal weight, will the Government disclose relative rankings or weights of the subfactor elements?

The Government has disclosed its evaluation methodology in Section E.10 Evaluation Factors for Award.

7. The Government identifies that the Contractor shall use its own ACD and IVR systems but shall use the Government’s CRM system. However, elsewhere in the PWS the Government requires that Contractors must train on the Government’s telephony (ACD, IVR) systems. Could the Government clarify which of the following scenarios is required from the Contractor: 1). Government Telephony System with Government CRM; 2). Contractor Telephony System with Contractor CRM; or 3). Contractor Telephony with Government CRM?

Contractor Telephony with Government CRM

8. Is the Contractor expected to record Provider calls? If so, how long is the Contractor required to store call recordings? Is screen capture required with recordings?

100% call recording, 20% screen recording, store for 6 years

9. In Section 4.1.2-subfactor 2 of the solicitation document there are three elements identified (a, b, c). Are these elements applicable to Subfactor 2 (Experience) or do they broadly apply to the overall proposal? Would the Government please clarify?

The three elements listed apply to Subfactor 2: Experience.

10. In the Past Performance Volume, is each past performance example supposed to provide Section 1, Section 2, Section 3 and Section 4 fully completed?

Yes.

11. In the Standard Form 1449 cover page, box 10 lists the procurement as 100% Small Business Set Aside. In Section A.2 on page 4, the RFP states "This RFP is a total set-aside for Veteran-Owned Small Businesses (VOSB)." Which information is correct?

See Amendment 0001 to the RFP. This RFP is now set-aside for Service-Disabled Veteran-Owned Small Businesses.

12. Our understanding from reading the RFP is that the VA would like to contract with a vendor to use vendor-staff who would receive claims directly from the various listed program providers and then use *VA* information systems (claims processing, etc.) to edit and process those claims from providers. Would the VA be open to innovative proposals that use a vendor's claims processing system (vs. the VA's claims processing system) to process the claims. By using such an approach, we believe we could meet VA’s implementation timeframe while establishing a new system to achieve substantial cost savings, increase claim submission and data accuracy, decrease payment time to providers, which will ultimately be good for both Veterans and the VA purchased care programs.

See Section E.7 Specific Instructions to Offerors Regarding Proposal Preparation, paragraph 2.1.4.

13. Will any of the claims processed under this procurement be as a result of the to-be-awarded VA Community Care Network (CCN) procurements? Alternatively, is the work under this contract only for the claims resulting from direct referrals from VA to community providers, without the involvement of the VA CCN contractors and networks?

Majority of the claims will be non-CCN claims, with exceptions.

14. Under the CHAMPVA claims processing tasks, will the contractor be responsible to handle the suspended claims work queues?

No.

15. Under the CHAMPVA claims processing tasks, will the contractor be responsible for performing Clinical/Mental Health Reviews? If yes, please provide the position qualifications.

No.

16. CLIN 0001, P.13 – The table shows the Minimum Timeliness Standard for Verification is 194 claims. In arriving at this number, what the . What is the percentage of claims that require “re-alignment and reprocessing” verses the percentage that can be validated without additional input?

In current state systems, approximately 20% require realignment, although the paper to electronic (P2E) conversion will reduce the volume of verification that is required because claims will come to VA as electronic transmissions.

17. PWS 3.3 – 3.6 P.13-P.14 The Office of Community Care tasks do not clearly outline processing performance standards as CHAMPVA does in PWS 3.7.2. Is there a separate table of performance standards specific to OCC processes?

Estimate for CAR claims is based on approx. 450,000 claims per month.

18. Para 3.4, P.13 – Historically, what percentage of claims received for distribution are considered “ 1) receipt of the electronic claim into the local FBCS system,” verses those considered “ 2) completion of data verification of paper claims. What is the average processing time for each i.e. 1) receipt of the electronic claim into the local FBCS system,” and those considered “ 2) completion of data verification of paper claims

Due to the impact of the Paper-to-EDI conversion project, FBCS EDI ratios have risen to 95% of all claim volume for Veteran programs. There are no differences in processing times associated with the method of receipt except that paper claims require verification. Distribution, processing and payment processes are the same.

19. Para 3.7.3, P.15 states, “The contractor’s train-the-trainer employees will be required to regularly provide “internal refresher training” to the contractor’s employees”. What is the estimated frequency and duration of regularly provided internal refresher training? Will this training be required for only those employees demonstrating a need for additional training or of all employees?

Offerors are responsible for determining frequency and duration. This training should be incorporated into the offeror’s quality assurance plan.

20. Para 3.8.1, P.16, Would the government please provide whatever call center historical data it has or estimates call volume, topics, duration for the Provider Customer Service Center to include: Total number of calls received per day, month, year? Number of calls per day, month, year by topic Duration of call per day/month/year by topic Other?

See the response to question 2.

21. Para 3.8.1, P.16 says “The Provider Customer Service Center shall additionally manage any calls received from VA Community Care Contact Center and its representatives. Would the government please provide whatever call center historical data it has or estimates to call volume, topics and duration of related to VA Community Care Contact Center. Also, please clarify if VA Community Care Contact Center calls are inclusive or exclusive of data provide Provider Customer Service Center as requested in the previous question.

Calls from the VA Community Care Contact Center are not expected to have a high volume and only intended to facilitate rapid communication between the contractor and VA for issues that require collaboration between VA and the contractor.

22. Para 3.8.1, P.16 - says, Would the government please provide whatever call center historical data it has or estimates call volume, topics, duration for the VA Community Care Contact Center to include: Total number of calls received per day, month, year? Number of calls per day, month, year by topic Duration of call per day/month/year by topic Number and of emails received and sent

See the response to question 2.

23. PWS 3.8.1 P.16 if available please provide Provider Customer Service Center historical call volumes on a weekly or monthly basis and a break out of call types, average handle time by call type, historical interval call arrival patterns. This data is critical to establish accurate staffing requirements for the Customer Service Center in addition to claims processing staff.

See the response to question 2.

24. 3.8.5, P.19 What is the estimated duration and location of the quarterly Program Management Review (PMR) meetings.

1-2 hours. These meetings can be held virtually/telephonically.

25. PWS 3.8.5 P.19 Please define Blockage Rate.

See Attachment 4 - PWS Appendices.

For further clarification, a blocked call is a call that cannot be connected immediately because no circuit is available at the time the call arrived.

26. PWS 3.8.6, P.20 – Is it correct to interpret part 3.8.6 as being for information only and the offeror should not price implementation of online chat capability as part of this solicitation?

Yes; however, the contractor may be asked to price this requirement after contract award if the VA expands to online chat capabilities and there is a price variance.

27. PWS 3.8.7 P.20 “the contractor shall conduct mail-out Provider Satisfaction Surveys” Is the government willing to enable the contractor to utilize electronic means of survey completion versus standard mail to improve efficiency of this process?

Not for the purposes of this RFP; however, the Government may consider this a later time if a contractor can sufficiently and satisfactorily demonstrate how it will reach a provider electronically. See Section E.7 Specific Instructions to Offerors Regarding Proposal Preparation, paragraph 2.1.4

28. PWS 3.8.7.P.20 – Is it the government’s expectation that the contractor will be responsible for all labor and cost associated with provider satisfaction surveys to include, survey instrument design, printing, mailing, postage, receiving, response data input, results analysis, and reporting?

The Government will provide the contractor with the Survey questions/design after contract award. All other costs associated with the survey will be the responsibility of the contractor.

29. PWS 3.8.7.P.20 To how many surveys recipients does the government estimate the contractor will send per year?

The Government estimates 2400 per year or 600 per quarter; however, this could be more or less depending on call volume. Surveys should be sent quarterly to providers who have called the contractor. The Government does not have historical data readily available at this time.

30. 3.9, P.20 states, “Each emergent episode that is not preauthorized has an entry edited or created in Clinical Tracking by the claims processor for claims that meet administrative eligibility for the Clinical Reviewers to apply medical eligibility determinations.” This seems to indicate need for clinical knowledge. Does the government expect some of the processing workforce to have medical qualification, i.e. registered nurse, physician etc? If so, please provide details on skills and level of effort.

Clinical reviews will be performed by VA staff.

31. PWS 5.0, P.22 states that an initial task order of 3.2 million authorized and unauthorized claims will be issued. How many of these claims are expected to be authorized vs. unauthorized? Production levels per hour are substantially different on these two activities so an estimate will help ensure proper staffing.

The Government’s current base year estimate is 75% authorized claims, 25% unauthorized claims gradually shifting to as much as 90 % unauthorized claims as current backlogs are processed and integration into community provider network. This is just an estimate and is subject to change during performance of the contract.

32. PWS 6.0, P.22 prescribed minimum timeliness standard in terms of numbers of claims processing actions per day for each of the five processing activities types. Are the number of activities per day provided based on historical data collected on workers’ performance performing these tasks? If not, what are these minimums based? If so, would the government provide offeror historic data to analyze and assist in more effective pricing?

These are standards the VA uses and are a result of time studies.

33. PWS 6.0 P.23 states there is an aged inventory of 1.1 million claims. Is this aged inventory included in the initial task order of 3.2 million claims? The paragraph states that the timeliness requirement for the initial portion is a completion time of six months from the date of issuance of the task order. What is the total number of claims that must be proceed in this six-month period? (I.E. PWS 5.0 on P.22 states initial task order for 3.2 million versus 1.1 million in PWS 6.0 P.23). Additionally, will the 1.1 million aged claim inventory need to be serviced concurrent with and in addition to normal monthly volume requirements?

Yes, the aged inventory will be included. The contractor has six months to demonstrate its ability to process 1 million plus claims per month.

34. IT Contract Security 2.b. “The level and process of background security investigations for contractors must be in accordance with VA Directive and Handbook 0710” Will the government provide access to a copy of the Directive and Handbook, or a detailed explanation of the background security investigation level and process?

VA publications can be found at www.va.gov/vapubs

35. Schedule of Services B.2 P.9 estimates don’t seem to correlate to PWS 6.0 P.23 claims processing requirements. Based on the annual claims estimates, there are 19,652,034 claims (1,637,670/month if divided evenly). How does this correlate to the ramp levels of 1M claims processed and 1.3 claims distributed? What accounts for the difference of 662,330?

The quantities in Section B.2 Schedule of Services and the ramp up in para. 6.0 are estimates and may differ from actuals as work progresses under the contract; however, the contractor must meet minimum timeliness standards in the table of para. 6.0 for all task orders after the initial order.

36. B.3 (PWS) Sections 3.3 (CLIN 0001) through Section 3.7.1 (CLIN 0005) all flow neatly and map to the CLINs listed on the B.2 Schedule Price Sheet (and are identified as such in each PWS section). Furthermore, for the Customer Service Center, the 5 Trainers and their time and travel is clearly identified (Section 9.0 an 10.0) and mapped and identified in the PWS to their corresponding CLIN numbers on the CLIN Sheet in areas of CLIN 0007 and CLIN 0008. However, there is no CLIN(s) for the Customer Service Center facility (and it’s staffing and systems) that the contractor is specified to provide in Sections 3.8.0 thru 3.8.6. Was the CLIN(s) for these major functional task accidentally (typographically) left off the CLIN Price Schedule? Or are contractors requested to amortize that bid cost across CLINs 0001 – 0006 (note: there is not specific pricing instruction or PWS instruction requesting we do this). Please let us know how the government wishes contractors to bid this portion (3.8.0 thru 3.8.6) of task/services requested.

No, it is not a typographical error. Offerors should determine the unit pricing appropriate for their proposal.

37. As we understand it, we would connect remotely to the VA systems, do we need FISMA, FIPS, NIST or other security certifications?

User accounts will require background screening Special Agreement Check (SAC), low-level investigation National Agency Check with Inquiries (NACI).

38. What is the average handle time for the calls (talk time +wrap-up)?

See the response to question 2.

39. What is the monthly call volume over the last year?

See the response to question 2.

40. We would like to see what an average day looks like X calls at 7am-8am, etc. If that is not available, we would like to have a general understanding of any large ‘peaks’ or ‘valleys’ during the 7am-7pm window?

See the response to question 2.

41. Are there ‘peaks’ and ‘valleys’ during a normal week or first or last of the ‘month’, just before or after a holiday, etc.?

Call volume peaks on Monday or Tuesday and the day after a holiday.

42. Is there any seasonality to the call volume?

See the response to question 2.

43. What are the approximate percentages of English, Spanish speaking and hearing/vision impaired?

The Government estimates <1% of total call volume; but this may vary during contract performance.

44. What are the percentages of VA-Employee calls vs. Community providers calls

The expected volume of VA employees contacting the contractor is minimal and only for instances where coordination is necessary between both parties.

45. What is the anticipated start date (for pricing purposes)?

Date of award is TBD.

46. The number of claims appear to be based on a full calendar year. Although the base year will be less than a full calendar year. That said, should we still price to achieve the number of claims in this shortened period of performance or will the number of claims be adjusted?

Offerors should determine the unit pricing appropriate for their proposal.

47. Will there be a CLIN added for the phase-in period since the call center must be established and ready for testing in 30 days?

No. The capabilities must be ready for testing in 30 days, such as telephony, access to VA, etc. The handling of calls will not occur until 75 days.

48. Since the contractor will be responsible for processing “aged” (30+ days old) claims, does the 30-day requirement begin from the date of claim receipt?

Aged claims will be excluded from this metric

49. Will a CLIN be added for telephone support?

See the response to question 3. See Section B.2 Schedule of Services and Section B.3 Performance Work Statement for CLIN information.

50. Section 3.8 requires a customer service center staff but there is no CLIN for the work. Will a separate CLIN be added?

See the response to question 3. See Section B.2 Schedule of Services and Section B.3 Performance Work Statement for CLIN information.

51. PWS 1.0 Background Veterans Health Administration’s (VHA) Veterans Affairs (VA) Community Care program allows referral of eligible Veterans to community providers when the VA cannot provide the necessary services due to the capacity of the VA, the nature of the services required, the geographic availability of such services and the emergent need for services. When the VA refers an eligible Veteran to the community providers outside of national contracted networks, the non-VA providers and facilities bill the VA directly. Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) provides coverage for family members of 100% Service-related Disabled Veterans. These medical claims are submitted via Electronic Data Interchange (EDI) as a Health Insurance Portability and Accountability Act (HIPAA) compliant transaction or through the mail via paper invoice on a Center for Medicare Medicaid Services (CMS) 1450 or CMS 1500. When claims are received by the local VA medical center or consolidated payment center, they are scanned and uploaded into VA’s claims processing system and adjudicated for payment by administrative staff. The claims processing activity requires general knowledge of health care billing and VA payment methodologies, as well as Veteran eligibility rules for non-VA medical care. Office of Community Care (OCC) provides procedure guides and standard operating procedures (SOP) for processing claims.

a. Will the government provide bidders with the procedure guidelines and SOPs for processing these claims?

Processing guides and SOP will only be provided after award. See Section B.3 Performance Work Statement paragraph 15.0.

52. PWS 2.2 CHAMPVA The objective of this contract is the complete processing (review and determination of proposed payment of claims) of medical claims for CHAMPVA. This program is a comprehensive health care program in which the Claims processed may include current or aged claims as directed by OCC. Aged claims are defined as claims that have not been processed for payment 30 days after invoices are submitted.

a. VA Shares the cost of covered health care services and supplies - what portion of the CHAMPVA claims is paid for by the VA and whom are the cost sharing partners/agencies/insurance providers?

CHAMPVA pays the allowable amount as determined by policy. The cost sharing partners are other insurance (if the beneficiary has other insurance) and the providers who accept CHAMPVA allowed amounts.

53. PWS 3.0 TASKS For performance of this contract, the contractor shall possess knowledge of the CMS claims editing guidelines and submission requirements for Medicare and other on-line claims processing and query systems. VA adjudication and supporting information systems include the Fee Basis Claims System (FBCS), Computerized Patient Record System (CPRS), Joint Legacy Viewer, VistA, Claims Processing & Eligibility claims system (CP&E) and the EDI Web Viewer. The contractor shall access multiple FBCS systems remotely. Each system is unique to individual facilities and Consolidated Payment Centers. Site specific guidance will be provided to the contractor. VA has several system modernization efforts in process which may deploy during the base or option years. These modernization efforts will impact community care authorization, obligation data, and claim adjudication systems. Ensure pricing proposals accommodate transitioning claims processing staff, training, quality assurance and management support from one system to another. The CLINs which follow reference FBCS and other legacy systems but do not preclude the utilization of other systems for the described activities. CHAMPVA claims will also require knowledge of beneficiary eligibility for community care.

a. VA FSC has processed Choice Claims using FBCS prior to mid-2017; currently, the VA FSC processes Choice claims on the Plexis Claim Management System (PCM). PCM has much faster processing speed than FBCS and an auto adjudication feature that applies to approximately 50% of all claims.

1) Does the Government have plans to upgrade to the use of PCM on this contract?

PCM will not be used in the performance of this contract.

2) In order to include transition, training and QASP cost in pricing, please identify the period of performance (BASE, Option Year). If the Government cannot identify the period of performance for this transition, would the Government include a CLIN for this additional cost?

The transition timeline is TBD. See the response to question 4.

3) What amount of training time does the Government anticipate for the transition of system modernization?

The Government estimates 1-2 weeks; however, this may be subject to change during contract performance.

4) Will the government provide access to bidders regarding the VA adjudication and supporting information systems to include FBCS, CPRS, Joint Legacy BViewer, VistA, CP&E and the EDI Web Viewer (page 12)"

Access may be granted to the awardee after contract award and after successful adjudication of background checks.

54. PWS 3.3 CLIN 0001: VERIFICATION OF OFFICE OF COMMUNITY CARE CLAIMS The contractor shall validate claim data to ensure scanned claim information is accurately entered into the claims system. The verify module relies on the user to visually validate claim data the system read during the scan and upload process against a displayed image of the claim. The system prompts input to be typed into fields that fail to meet certainty thresholds of the optical character recognition software. Some claims require more input than others depending on image quality and alignment of original document. Some claims may require re-alignment and reprocessing for the software to distinguish the text. The contractor shall meet or exceed VA internal control requirements. Verified claims pass into the Distribution module. Electronically submitted claims skip the verification module and pass directly into the Distribution module. As VA expands paper to electronic conversions, claims requiring verification will decrease.

a. What is the process for the Contractor to access the claims?

Fingerprints of employee and packet submitted to VHA Security Center, once successful adjudication is provided, system accounts will be requested/created, remote access granted and station level access will be requested/granted. See the response to question 34.

b. Are the claims dedicated to this contract in a queue created and maintained by the Government?

Contractor will be provided access to the verify claims and share claims with any other user accessing those claims.

c. Are the claims listed in an Excel format?

Claim reports could be in MS Excel.

d. The verification rate for this CLIN is 194 per processor per standard work day. The standard work day includes two (2) fifteen (15) minute breaks and time must be allowed for communication with Leads and Supervisors. It is normal and customary to use a seven (7) hour work day to calculate the per processor performance rates. Is the Government using a seven (7) hour work day to calculate the 194 Verifications per standard work day?

See the response to question 32. The VA used 6 hours of work in an 8-hour period.

e. Can the Government provide Verification performance data to demonstrate that 194 Verifications per processor per standard work day is currently performed using the existing software? If yes, please provide production data supporting this rate of production.

No.

f. Are the medical claims processors accessing the FBCS system at the local level? If yes, does that require them to have multiple passwords to maintain?

Yes, access to multiple systems must be maintained.

g. How many local systems are there?

In current state, there are 34 FBCS servers, 100+ Vista systems.

h. Are the local systems the equivalent of a VISN, or are there multiple FBCS platforms within the VISN?

It varies by region.

i. The contractor shall meet or exceed VA internal control requirements. Will the government provide details of these internal control requirements?

This will be provided to the contractor after award as part of instructions for proper processing.

j. Provide the number of Care Claims, on a monthly basis, that “require more input than other depending on image quality and alignment of original document.”

50% of the verified claims require more input than others.

k. What is the average number of pages per Care Claim that the contractor must scan?

Insufficient information is available to address this question. Scanning will be done prior to contractor receiving claims.

l. What is the process for the Contractor to access the unprocessed claims?

Most verify is in Web version of claim system, some remains in previous version that is accessed via VPN using user account information.

55. PWS 3.4 CLIN 0002: DISTRIBUTION OF OFFICE OF COMMUNITY CARE CLAIMS The contractor shall provide specialized and focused effort on the claim distribution process. This step in the overall claims process occurs immediately upon 1) receipt of the electronic claim into the local FBCS system, or 2) completion of data verification of paper claims. The majority of claims are expected to be electronic at the initial point of contract award or soon thereafter. Distribution is the process of reviewing the claim and other information systems, including Veteran eligibility data, to determine whether the claimed services were preauthorized by VA. When matching authorization data is located, the artifact is ‘attached’ to the claim which moves the claim into the Processing module as an Authorized program type. If no authorization exists, the claim will be assigned as an Unauthorized claim program type or Mill Bill claim program type which moves the claim into the Processing module.

a. What is the process for the Contractor to access these claims?

They are accessed via VPN using user account information.

b. Are the claims dedicated to this contract in a queue created and maintained by the Government?

The queues can be designated for contractor but may be co-maintained by government and contractor.

c. Is preauthorization and ""attaching"" that document to the claim the only function of Distribution?

The distribution step is the ‘determining’ and ‘assigning’ of the program that fits the claim.

d. Is the medical claims processor expected to correct missing or incorrect claims data or is that task completed within PWS 3.5 and PWS 3.6?

If a claims processor determines information is missing or incorrect, rejection or suspension of the claim, for the appropriate reason, are potential actions.

e. What are the ""other information systems"" referenced in PWS 3.4?

Other systems may include CPRS or Joint Legacy Viewer.

f. Will the Government provide recent production data report to support the 575 per processor per standard work day, if yes, please provide.

No.

g. Provide the number of non-electronic Care Claims “expected at the initial point of contract award.”

It varies by station, but the VA estimates 20-30% overall volumes are still paper. This is subject to change during contract performance.

h. What are the “VA internal control requirements” for Care Claims?

This will be provided to the contractor after award as part of instructions for proper processing.

i. What is the reason for the descrepancy? Are claims rejected at the Distribution level? If yes, what is the rate of rejected claims for CLIN 0002?

No, claims are not rejected in distribution.

j. Is the Contractor paid for rejected claims?

Yes, rejections are considered processed, but it is not done in distribution.

56. PWS 3.4 CLIN 0002: DISTRIBUTION OF OFFICE OF COMMUNITY CARE CLAIMS SOPs and other guidance documentation will be available to the contractor. Incorrect distribution decisions increase the risk of claim payment errors or delays, unnecessary suspensions and rework. The contractor shall document and manage an internal quality review process as well as actively participate in VA quality assurance efforts where those efforts overlap with these tasks. The contractor shall meet or exceed VA internal control requirements.

a. Will the Government provide recent production data to support 123 per processor per standard work day and if yes, please provide.

No data can be provided for this.

b. During the CAR batch certification, are claims audited for accuracy? If yes, is the batch suspended until the claim is corrected?

There is a quality check before releasing the batch, corrections will be required before continuing.

c. Are error suspended claims returned to the Contractor for correction?

This depends on the nature of the error, may require contractor to correct improper actions that caused error.

d. SOPs and other guidance documentation will be available to the contractor. Will the government provide details of these internal control requirements?

This will be provided to the contractor after award as part of instructions for proper processing.

57. PWS 3.5 CLIN 0003: AUTHORIZED OFFICE OF COMMUNITY CARE CLAIMS The contractor shall validate all data to ensure each claim is appropriately identified as Authorized program type or reassign program type if necessary, then process medical claims by reviewing documentation authorizing and obligating community-based medical services, ensure application of appropriate CMS claim edits or VA business rules, determine the correct amount due to recipient based on established procedures and process all necessary payment transactions for approval by VA representatives for each claim. The contractor shall send for payment, suspend and reroute, reject or deny claims when necessary, consistent with documented procedures. VA staff shall determine the appropriate action for suspended claims. Contractor shall batch claims using appropriate obligation, assign vendor, add remarks codes, add adjustment codes and close batch. The CAR facility or payment center staff or leadership shall be responsible for batch transmission, batch certification, and separation of duty requirements. The contractor shall meet or exceed VA internal control requirements. CAR field supervisors, analysts and/or managers will routinely analyze and audit claims, taking any necessary actions required for improper payments to include record and issue letters informing debtors of obligations, until all issues are resolved. SOPs and other process guidance will be available to the contractor. Incorrect processing decisions increase the risk of claim payment errors or delays, unnecessary suspensions and rework. The contractor shall document and manage an internal quality review process as well as actively participate in VA quality assurance efforts where those efforts overlap with these tasks.

a. Once the VA Mission Act is funded, will the Government provide update to training program for unauthorized services?

Yes.

b. Once sufficient medication documentation is found to support further review, what is the process for escalating the claim to VA Clinical reviewers?

Updating the clinical tracking record and rerouting claim to appropriate queue for processing.

c. Is this considered a completed process for the claim for that day?

Claims are not considered complete until the claim is paid, rejected or denied.

d. What is the process for the VA Clinical reviewers to return the claim to the Contractor for completion of the adjudication process?

Reviewer updates clinical tracking record with decision or comment and reroutes claims back to processing queue.

e. What is the current rate of duplicate claims that have been paid 100%?

Insufficient information is available at this time to address this question.

f. Are duplicate claims rejected and is the contractor paid for a rejected claim?

Yes, rejected claims are considered processed.

58. PWS 3.6 CLIN 0004: UNAUTHORIZED OFFICE OF COMMUNITY CARE CLAIMS The contractor shall validate all data to ensure each claim is appropriately identified as Unauthorized program type or reassign program type if necessary. The contractor shall review sources of Veteran eligibility data to determine applicability of available legislative authorities under which to consider unauthorized community-based emergency medical services and ensure there is sufficient medical documentation on file to support further review by VA Clinical reviewers, rejecting claim if insufficient documents exist. Once administrative eligibility is established, the contractor shall locate existing Clinical Tracking record or create a new Clinic Tracking record for episode of care using the prescribed template for VA clinical team to notate episode’s clinical determination. When claim is returned from Clinical review, contractor shall ensure application of appropriate CMS claim edits or VA business rules, determine the correct amount due to the recipient based on established procedures and process all necessary payment transactions for approval by VA representatives for each claim. The contractor shall send for payment, suspend and reroute, reject or deny claims when necessary, consistent with documented procedures. VA staff shall determine the appropriate action for suspended claims. Contractor shall batch claims using appropriate obligation, assign vendor, add remarks codes, add adjustment codes and close batch. The CAR facility or payment center staff or leadership shall be responsible for batch transmission, batch certification, and separation of duty requirements. The contractor shall meet internal control requirements. CAR field supervisors, analysts and/or managers will routinely analyze and audit claims, taking any necessary actions required for improper payments to include record and issue letters informing debtors of obligations, until all issues are resolved. SOPs and other process guidance will be available to the contractor. Incorrect processing decisions increase the risk of claim payment errors or delays, unnecessary suspensions and rework. The contractor shall document and manage an internal quality review process as well as actively participate in VA quality assurance efforts where those efforts overlap with these tasks.

a. Define internal control requirement

This will be provided to the contractor after award as part of instructions for proper processing.

b. What are the “VA internal control requirements” for Care Claims?

This will be provided to the contractor after award as part of instructions for proper processing.

c. 3.6 using the prescribed template for VA clinical team to notate episode’s clinical determination. Will the government provide a copy of this template?

Yes, after contract award.

d. What are the “VA internal control requirements” for Care Claims?

This will be provided to the contractor after award as part of instructions for proper processing.

e. What is the current rate of duplicate claims?

Insufficient information is available at this time to address this question.

f. Is the contractor paid for identifying and rejecting a duplicate claim?

Yes, rejected claims are considered processed.

59. PWS 3.7 CLIN 0005: CHAMPVA CLAIMS The contractor will examine invoices, claims and other payments for medical services for beneficiaries and family member programs. The contractor will ensure each claim is accurate, provides adequate documentation or citations, and complies with applicable laws and regulations. The contractor shall ensure justifications submitted are compliant with Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS) and the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) standards. The contractor shall be responsible for procedural processing of standardized vouchers for various types of medical expenses. The contractor must maintain an understanding of billing and regulations as related to the CHAMPVA program. CHAMPVA leadership shall ensure all desk procedures are followed, internal controls met, audits completed and reviewed; and that any follow-up corrective actions have been completed per the Quality Assurance Surveillance Plan (QASP).

a. The solicitation states "The contractor shall meet all internal control requirements. SOPs and other process guidance will be available to the contractor and must be used for all claims processed. Incorrect processing decisions increase the risk of claim payment errors or delays, unnecessary suspensions and rework.”

1) Will the government provide these requirements and SOPs prior to due date?

No, this information will be provided to the contractor after award. See Section B.3 Performance Work Statement, paragraph 15.0

60. PWS 3.7.2 CLIN 0005: CHAMPVA CLAIMS PROCESSING PERFORMANCE STANDARDS The contractor will be required to process a minimum of 143,000 claims per week (see summary below) with an accuracy rate of 96.5% of all claims processed. To meet performance standards, 90% of the processed claims must be input within 30 days of receipt

a. Will the government provide historical processing performance data to enable bidders to analyze weekly, monthly, annual volume and accuracy rates?

No, this information cannot be provided.

b. Will the USG provide historical claims processed on a monthly basis, by claim, over the life of this contract?

Yes, this information might be made available to the contractor after award.

c. What is the current accuracy rate, by month, for each claim type?

CHAMPVA only has one type of electronic claim. An accuracy rate of 98.56% was occurred in October 2018.

61. PWS 3.8 CUSTOMER SERVICE The contractor shall establish and maintain customer service capabilities as part of the claims processing. These capabilities, detailed in Sections 3.8.1-3.8.7, must include:

1. Establishing and maintaining metrics for contractor-maintained call center functionality for handling provider calls

2. Staffing and supporting call centers functionality in compliance with the standards established

3. Managing complaints and grievances based on established procedures

4. Providing monthly reporting to VA and maintaining communication between VA and the contractor on performance in all areas of customer service

5. Managing correspondence, including Congressional and VA inquiries

a. Where is this work being done now?

Denver, CO

b. Address?

No address is being provided.

c. Are USG employees conducting this work?

Yes.

d. Is the incumbent staff available for hire?

No.

e. How many FTEs are currently conducting this work, by position?

The Government does not currently handle provider calls exclusively so all staffing includes calls from providers, Veterans and beneficiaries and therefore the numbers are not applicable to provider calls exclusively. Insufficient information is available at this time to address this question further.

f. Provide the IT hardware used to conduct call center operations by make, model, year, quantity, user.

Computers with 8G RAM and soft phones.

g. Is the current customer service facility available to use by the contractor?

No.

h. Is the current facility available for contractor use upon award?

No.

i. How many Congressional and VA inquiries, respectively, are received on a monthly basis. Provide historical data.

The Government does not have data on the number of inquiries that are exclusive to providers. Insufficient information is available at this time to address this question further.

j. What is the current call volume?, What was the call volume in the preceding two years (calendar or Gov't fiscal year)?

See the response to question 2.

62. PWS 3.8.1 PROVIDER CUSTOMER SERVICE CENTER FUNCTIONS The contractor shall establish and maintain a Provider Customer Service Center that operates from 7AM to 7PM CT, Monday through Friday, excluding Federal holidays. The Provider Customer Service Center will address inquiries made by community (non-VA) providers regarding information such as, but not limited to, claim status requests and reports, claim issues, claim rejection/denial clarifications, appeals, Preliminary Fee Remittance Advice Report (PFRAR) print requests, billing instructions, benefits and eligibility inquiries, referral/authorization and/or prior authorization status, provider enrollment, medical equipment and pharmacy benefits, complaints and grievances, and Congressional and VA inquiries. The Provider Customer Service Center shall additionally manage any calls received from VA Community Care Contact Center and its representatives. The Provider Customer Service Center shall not limit the number of questions/inquiries providers and VA employees can make during each call.

a. On page 16 this section states "The contractor shall establish and maintain a Provider Customer Service Center that operates from 7AM to 7PM CT, Monday through Friday, excluding Federal holidays." QUESTION: How is this facility charged back to the government?

See the response to question 50.

63. PWS 3.8.1 PROVIDER CUSTOMER SERVICE CENTER FUNCTIONS The VA Community Care Contact Center manages inbound and outbound calls and emails, metrics, workforce optimization reporting, knowledge base scripting, and adverse credit reporting case management in support of the following programs: Community Care, CHAMPVA, Spina Bifida, Family Caregivers, Veteran Foreign Medical Program and Children of Women Vietnam Veterans. The VA Community Care Contact Center was established to ensure seamless use of these benefits by Veterans and Family Members. The VA Community Care Contact Center also handles calls from community providers and VA employees. After the award of this contract, the VA Community Care Contact Center will transition all provider calls to the contractor.

a. Where is this call center located currently?

See the response in question 61.

b. Are all the staff government employees?

See the response in question 61.

c. Can the incumbent contractor transition the call center staff to contractor's staff?

See the response in question 61.

d. Are there any restrictions on where the contractor locates this center?

Anywhere in the United States.

64. PWS 3.8.1 PROVIDER CUSTOMER SERVICE CENTER FUNCTIONS "The contractor shall provide, at a minimum, their own telephony system with toll-free telephone lines, warm transfer capabilities, automated phone call back, virtual hold and an Interactive Voice Response (IVR) that mirrors the existing VA IVR for provider calls. The contractor must offer support for English and Spanish speaking and hearing/vision impaired callers. Additionally, the phone system must allow for after-call surveys via the IVR, with reporting on the results correlated to the agent who handled the call. The IVR survey questions must mirror that of the VA, one for customer satisfaction (CSat) and one for first call resolution (FCR). Currently, the questions are:

• How satisfied are you overall with the service you received from the customer service representative? 1 – 5 Likert Scale. (CSat)

• Regarding your question or issue today; if it was your first call on this issue and the issue was resolved, press one. Otherwise, press two. (FCR)"

a. Please provide the system specifications for the current VA IVR phone system.

The VA is currently using Avaya soft phones with automated call back, virtual hold and post-call survey features. This answer does not change the requirements as stated in the RFP.

b. On page 16 of this section it states “The contractor shall establish and maintain a Provider Customer Service Center that operates from 7AM to 7PM CT, Monday through Friday, excluding Federal holidays.”

1) Q1 how is this facility charged back to the government?

See the response to question 50.

2) Q2: What is “existing VA IVR” protocols is the VA expecting the contractors to “mirror” for provider calls?

See the response to question 2.

65. PWS 3.8.1 PROVIDER CUSTOMER SERVICE CENTER FUNCTIONS Successful operation of Provider Customer Service Center must be complete and must be accepted by VA no later than 75 days after the date of contract award, including the appropriate training of all contractor customer service staff as outlined above. The contractor must always utilize technology, processes, training documents, response scripts and quality standards provided by and updated by the VA (see Appendix A, OCC CC Quality Evaluation Definitions Document and Appendix C, OCC CC Quality Protocols September 2018 Final).

a. Is this training part of the 2-weeks training outlined above?

Yes.

b. If not, then when will this training occur?

66. PWS 3.8.3 COMPLAINTS AND GRIEVANCES The contractor must always forward all complaints and grievances received to the VA within one business days of receipt. The contractor must always provide the VA relevant background information regarding the complaint or grievance within two business days of the notification to VA. The VA reserves the right to request supplemental information relating to complaints and grievances and customer service at any time. When the VA requests information from the contractor, the contractor must always confirm receipt of the request within one business day. Notification of receipt can be accomplished electronically via an agreed-upon mechanism with the VA. The contractor must always provide the full written response within three business days or within a timeframe as agreed to by the contractor and the VA. A full response must always consist of a description of the issue, actions taken to resolve the issue, and the final resolution to the issue. The written response must always include copies of any and all documentation on file with the contractor.

a. Please confirm that "forward all…