A19-J.5-PWS TECHNICAL EXHIBIT 1- PERFORMANCE REQUIREMENTS SUMMARY.docx
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- Attached to
- PHARMACY BENEFITS MANAGEMENT SERVICES (PBM) Federal contract opportunity
- Solicitation number
- 1605C3-24-R-00011
About this file
This document is a Performance Work Statement (PWS) that summarizes the technical requirements for a Pharmacy Benefits Management (PBM) services contract on behalf of the U.S. Department of Labor's (DOL) Office of Workers' Compensation Programs (OWCP).
The key objectives include: maintaining a sufficient pharmacy network, processing claims for payment, implementing a drug formulary system, conducting drug utilization reviews, providing durable medical equipment and diagnostic services, and successfully testing and implementing all required systems. Performance thresholds and methods of surveillance are provided for each requirement. The PBM contractor must meet specific deadlines for implementation activities, reporting, security controls, and other deliverables. The PBM services contract is a single award fixed-price contract with a performance period of up to 5 years. The solicitation number is 1605C3-24-R-00011, and the due date for proposals will be provided in a future amendment.
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Performance Requirements Summary
TECHNICAL EXHIBIT 1
Performance Requirements Summary The contractor service requirements are summarized into performance objectives that relate directly to mission essential items. The performance threshold briefly describes the minimum acceptable levels of service required for each requirement. These thresholds are critical to mission success. As necessary, DOL reserves the right to modify the method of surveillance based on the agency’s needs and the contractor’s performance.
| Performance Objective |
| Standard/Deliverable |
| Performance Threshold (This is the maximum error rate. It could be “zero deviation from standard.”) |
| Method of surveillance (and who performs) (e.g. 100% inspection by COR) |
1.6.1 Enhanced Quality
Control
| Develop and implement internal quality control procedures that produce timely, accurate, complete and relevant data, which meet the full requirements of this performance work statement. |
| Final within 120 days from contract start date. |
| 100% inspection: |
OWCP COR
OWCP PM or designee
| 1.6.5 Hours of Operation |
| The contractor system and web-portal must be available 24 hours, 7 days per week, except for 2 hours of maintenance per week. |
Maintenance must occur at off-peak times and be approved in advanced by OWCP.
Contractor must display a message when the system and web-portal are temporarily unavailable.
Performance delays are to be reported immediately to the COR and government project management team verbally and, within 24 hours of occurrence, in writing.
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
1.6.5.3 Continuity of Operations
| Submit a Continuity of Operations (COOP) Plan |
| Within 30 days after contract start date. |
| 100% inspection: OWCP COR OWCP PM or Designee |
| 1.6.8.1 Returning GFE |
| The contractor must return PIV cards and government furnished equipment issued to contractor personnel who leave the project for 60 days or more. |
| PIV cards and GFE shipped upon departure from the project |
| 100% inspection: COR, PM, or designee |
1.6.8.2 Memorandum of Understanding (MOU) and Interconnection Security Agreement (MOU/ISA)
| Submit a Memorandum of Understanding and Interconnection Security Agreement |
| Within 30 days after contract start. |
| 100% inspection: OWCP COR, OWCP ISSO or Designee |
| 1.6.8.3 Security Requirements |
| Submit completed System Security Plan. |
| First review when 1/3 of the document is completed and then every 2 weeks until completed. Submission of completed draft document within 60 days after contract start. Final no less than 30 days prior to the implementation date. |
| Government Information Security |
Officer
| 1.6.8.4 Security Training |
| Each contractor employee must complete mandatory DOL security training prior to the first day of work on the project. |
| Prior to the employee's first day of work under the contract |
| 100% inspection: COR, PM, or designee |
1.6.8.5 Security Incidents, Disclosure, Breach or Disaster
| The contractor must provide, at its own expense, one year of credit monitoring services for the affected claimant(s), in the event of a confirmed PII breach. |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
1.6.8.5 Security Incidents, Disclosure, Breach or Disaster
| In the event more than 3 breaches occur in a calendar month, the contractor must investigate to identify root cause(s) and take steps to mitigate the issues resulting in the breaches. |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
1.6.8.5 Security Incidents, Disclosure, Breach or Disaster
| Submit Security Incident Report |
| Within one hour of becoming aware of the incident, whether suspected or confirmed, and updated as additional information becomes available |
| Government Information Security |
Officer
1.6.8.6 System Security
| Submit third-party Security Monitoring Checklist |
| No less than 30 days prior to the implementation date and annually thereafter. |
| Government Information Security |
Officer
| 1.6.8.6 Security Audits |
| The contractor must successfully pass security audits that may be conducted by Government third-party contractors on the facilities, personnel, hardware, and software used to process OWCP claims. |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
| 1.6.8.6 NOC Monitoring |
| The contractor must record end-to-end response times to and from network devices, services, and applications, to aid in pinpointing areas of excessive network latency or identifying service outages. |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
| 1.6.8.7 Background Investigations |
| The background investigation should be thorough enough to establish the trustworthiness of the individual to handle federally owned, Unclassified Information. |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
1.6.10 Post Award Conference / Periodic Progress Meetings
| Coordinate and facilitate the kickoff meeting, provide meeting agenda and work plan that identifies all tasks, resources utilized (i.e., number, labor category, and description), deliverables to be completed, and the corresponding timetable/delivery dates. |
| Within 10 business days after contract start. |
| 100% inspection: COR, PM, or designee |
1.6.10 Post Award Conference / Periodic Progress Meetings
| Discuss the progress of the PBM with the DOL COR, Branch of Medical Standards and Operations (BMSO) PM and program management officials. |
| No less than quarterly, and as needed by the Government |
| 100% inspection: |
OWCP COR
OWCP PM or designee
1.6.12 Personnel
| Appoint and electronically notify the COR of the names and contact information of its authorized Contractor Program Manager (PM), who shall be the primary interface with the DOL COR on current PBM contract performance, and an alternate PM to serve in the primary PM role when the primary is unavailable. Appoint and electronically notify the COR of the names and contact information of clinical staff supporting the contract, including a Lead Clinical Pharmacist (Pharm.D.), a Lead FWA Expert, and a Technical Manager. |
| Within 5 business days after contract start. |
| 100% inspection: COR, PM, or designee |
1.6.12 Personnel
| Chart/matrix showing ALL proposed personnel (including outside consultants or Subject Matter Experts) by task and by hours. The contractor should clearly specify the role and responsibilities of each proposed staff and discuss the qualifications of the individuals proposed for specific tasks. Personnel includes; Pharmacists, FWA Experts, call support, information technology support, data analytic support, Pharmacy and Therapeutics Committee, Medical Director, and other staff. |
| Within 30 days after contract start. |
| 100% inspection: COR, PM, or designee |
1.6.13 Key Personnel
| Notify the Government of vacancies in key positions |
| Within 3 business days of occurrence |
| 100% inspection: OWCP COR OWCP PM or Designee |
| 1.6.14.2 Registered Nurses |
| Registered nurses (RN) that perform clinical services must have a bachelor’s or higher degree from an accredited professional nursing educational program. This education must have been accredited by the Commission on Collegiate Nursing Education, Council on Accreditation of Nurse Anesthesia Educational Programs, Accreditation Commission for Midwifery Education, or an accrediting body recognized by the Department of Education at the time the degree was granted. Nurses must also be currently licensed to practice nursing in a state, the District of Columbia, the Commonwealth of Puerto Rico, or other territory of the United States. |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
1.6.17 Transition-In/Transition-Out Period
| Submit a transition in/work plan/project plan and milestones for implementing elements of the PWS. |
| Final due within 45 days of contract start date. |
| 100% inspection: |
OWCP COR
OWCP PM or designee
1.6.17 Transition-In/Transition-Out Period
| Submit a transition out plan/project schedule/risk assessment. |
| Due within 15 business days of request by COR |
| 100% inspection: OWCP COR OWCP PM or Designee |
| 3.2 Suspended, Debarred, and Excluded Entities |
| Upon award, the Government will provide the contractor with a list of suspended, debarred, and excluded entities to which payments must not be made. The OWCP relies primarily on the List of Excluded Individuals/Entities (LEIE) managed by the Department of Health and Human Services, which can be accessed at https://oig.hhs.gov/exclusions/exclusions_list.asp, but the compensation programs can also suspend or exclude providers in accordance with their regulations. The contractor must update their system within 24 hours of being provided updated information regarding suspensions, debarments, exclusions, or reinstatements. |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
| 4.4 List of Pharmaceutical Networks for the Areas to be Served |
| The contractor must maintain a sufficient pharmacy network to service OWCP claimants. |
| 90% of claimants are within two miles of a network pharmacy in urban areas, 90% of claimants are within five miles of a network pharmacy in suburban areas, and 70% of claimants are within 15 miles of a pharmacy in rural areas. |
| 100% inspection: COR, PM, or designee |
| 5.2.9.2 Pharmacy Benefits Management |
| Mail order delivery timeframe |
| The maximum standard delivery time must not exceed seven calendar days. |
| 100% inspection: COR, PM, or designee |
| 5.2.10 Pharmacy Benefits Management |
| Automatic prescription refills |
| The contractor must notify claimants no less than two times before sending automatic prescription refills |
| 100% inspection: COR, PM, or designee |
| 5.2.12 Provider Enrollment Database |
| List of all network retail and mail order pharmacies and access to a provider enrollment database. |
| Due within 90 days after contract start with no less than monthly thereafter. |
| 100% inspection: |
OWCP COR
OWCP PM or designee
5.3.1 Welcome
Packet
| Submit the welcome packet including a welcome letter, benefit card, information about the pharmacy and DME programs, diagnostic services, and frequently asked questions (FAQs). |
| Draft document within 30 days of contract start date and final document within 120 days of contract start date for DEEOIC and DCMWC. Draft document no less than 180 days prior to the implementation date and final document no less than 30 days prior to the implementation start date for DFELHWC. |
| 100% inspection: |
OWCP COR
OWCP PM or designee
5.3.1 Welcome
Packet
| Mail welcome packet including a welcome letter, benefit card, information about the pharmacy and DME programs to claimants, diagnostic services, and frequently asked questions (FAQs).. |
| Within 120 days after contract start and within 1 business day of eligibility file receipt as new claimants are |
eligible for DEEOIC and DCMWC. No less than 30 days prior to the implementation date and within 1 business day of eligibility file receipt as new claimants are eligible for DFELHWC.
100% inspection:
OWCP COR
OWCP PM or designee
| 5.3.3 Customer Support |
| Provide a call center with IVR and toll-free telephone number staffed with dedicated customer service representatives. |
| Phone number within 30 days after contract start. Upon implementation, call center available 24 hours per day, 7 days per week, and 365 days per year 99% of the time. |
| 100% inspection: |
OWCP COR
OWCP PM or designee
| 5.3.3 Call Center |
| Call center accessibility |
| It must be accessible via toll free telephone lines and virtual chat 24 hours per day, seven days per week, 365 days per year. Available for DEEOIC and DCMWC within 150 days of contract start date, and for DFELHWC on the implementation date, no less than 365 days after contract start. |
| 100% inspection: COR, PM, or designee |
| 5.3.3 Call Center |
| Call center location |
| The call Center must be in the continental United States and no more than 180 minutes travel time by automobile from the airport that would be used when flying from/to Washington, D.C. |
| 100% inspection: COR, PM, or designee |
| 5.3.3 Call Center |
| Provide audio recordings and written notes of customer support calls |
| Due within 5 days upon request |
| 100% inspection: COR, PM, or designee |
| 5.3.3 Call Center Scripts |
| Call center scripts |
| Within 120 days of contract start date (DEEOIC and DCMWC), no less than 40 days prior to the implementation date (DFELHWC) |
| 100% inspection: COR, PM, or designee |
| 5.3.5 Customer Support |
| Provide monthly customer support reports to include approved metrics such as number of calls, length of calls, types of services provided, hold times, and number of dropped calls. |
| Due the third Wednesday of the month for the previous month with zero deviation. |
| 100% inspection: |
OWCP COR
OWCP PM or designee
5.3.5 Customer Support
| Call response time, average handling time, first contact resolution rate, call escalation rate, quality analysis scoring, and performance problem resolution. |
| The contractor must meet performance standards established at the time of award |
| 100% inspection: COR, PM, or designee |
5.3.6 Customer Support
| The contractor must be available to meet with the Government upon request, and include appropriate SME |
| No more than two exceptions per month |
| 100% inspection: COR, PM, or designee |
| 5.5.6 Processing Claims for Payment |
| The contractor’s payment file dollar total must match the bill history file dollar total when seeking payment. This includes paid transactions, in-cycle reversals, and out-of-cycle reversals. |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
| 5.5.9 Processing Claims for Payment |
| Fully functional mailroom. |
| On the implementation date, no less than 365 days after contract start |
| 100% inspection: |
OWCP COR
OWCP PM or designee
| 5.5.17 Processing Claims for Payment |
| The contractor must accurately apply updated Eligibility Files from the OWCP. |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
| 5.5.21 Processing Claims for Payment |
| Provide final specification document for generating and transmitting programs required data files, such as bill history file, pharmacy data file, and treasury payment file, to include specific file formats and transmission timeframes |
| No less than 215 days prior to the implementation date |
| 100% inspection: OWCP COR OWCP PM or Designee |
| 5.5.21 Processing Claims for Payment |
| Transmit data files including but not limited to Bill History File, Pharmacy Data File, Payment File, in a timely manner. |
| Weekly or as specified by the Government with zero deviation from the standard |
| 100% inspection: OWCP COR OWCP PM or Designee |
| 5.5.22 Processing Claims for Payment |
| Ingest eligibility files and begin processing claims for eligible claimants as a third party provider through OWCP’s current pharmacy system. |
| Within 150 days after contract start for DEEOIC and DCMWC. |
| 100% inspection: |
OWCP COR
OWCP PM or designee
5.5.22 Processing Claims for Payment
Perform a one-time load of the claimant eligibility file extract from the OWCP for DFELHWC program
No less than 100 days prior to the implementation date
100% inspection:
OWCP COR
OWCP PM or designee
| 5.5.24 Processing Claims for Payment |
| Provide a specification document detailing the business rules for eligibility for each OWCP program. |
| Due within 120 days of contract start date. |
| 100% inspection: |
OWCP COR
OWCP PM or designee
| 5.6.2 Fee Schedule |
| Maximum Allowable Cost (MAC) List for generic drug products will be updated every quarter after government review and approval |
| Initial submission is due 90 days after contract award. Subsequent updates are due quarterly. |
| 100% inspection: |
OWCP COR
5.6.6 Classification of Drugs as Generic or Brand Name
| Brand name/generic classification system. |
| The system must apply to all drugs provided to OWCP claimants and, at minimum, use Medi-Span multi-source code, brand name code, and the FDA application. |
| 100% inspection: COR, PM, or designee |
| 5.6.6.3 Classification of Drugs as Generic or Brand Name |
| Provide an OWCP approved method for defining brand and generic drugs. |
| Final due within 120 days after contract start date. |
| 100% inspection: |
OWCP COR
OWCP PM or designee
| 5.6.9 Fee Schedule | Comment by Franklin, Bianka - OWCP: same as above |
| Provide an OWCP approved definition or a list of specialty drugs. | |
| Within 120 days after contract start and quarterly after implementation. | |
| 100% inspection: |
OWCP COR
OWCP PM or designee
| 5.7 Fraud, Waste and Abuse Monitoring |
| Submit document detailing FWA detection and reporting program |
| Due within 120 days of contract start |
| 100% inspection: COR, PM, or designee |
| 5.7.3 Fraud, Waste and Abuse Monitoring |
| Fraud, Waste, Abuse Memo |
The memorandum must include no less than the following information:
• Name and tax ID numbers of the provider(s), or name and case number(s) of the claimant(s);
• Description of the potential FWA and how it compares to industry standard indicators and metrics for FWA;
• The approximate dollar amount of the FWA, if applicable;
• The source or surveillance method that identified the provider(s), claimant(s) and/or case(s);
• Copy of records supporting the suspicion of FWA;
• An indication of whether the provider or claimant has been previously recommended for investigation by the contractor; and
• Other data/information deemed pertinent by the contractor.
100% inspection: COR, PM, or designee
| 5.7.4 Fraud, Waste and Abuse Monitoring |
| The contractor must cooperate with the program to investigate and audit suspicious providers, place them under review, and perform claimant outreach to confirm receipt of products. The contractor must provide the full results and documents of the contractor’s audit in a timely manner. |
| No later than 120 days of the request from the Government. |
100% inspection: COR, PM, or designee
| 5.8.1 Key Performance Reports |
| 100% of all Performance Reports must be submitted within 5 business days after the end-of-month reporting period |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
| 5.8.2 Reporting and Data |
| Implement a secure, internet-based reporting tool for use by authorized OWCP program staff to generate management reports on an ad hoc basis. |
| Due within 330 days after contract start date. |
| 100% inspection: |
OWCP COR
OWCP PM or designee
| 5.8.2 Reporting and Data |
| Provide an internet-based reporting tool. |
| No less than 30 days prior to the implementation date . |
| 100% inspection: |
OWCP COR
OWCP PM or designee
| 5.8.3 Reporting and Data |
| Provide all formalized reports. |
• Pharmacy call center statistics
• POS edit statistics
• Diagnosis statistics
• Medi-Span updates
• Paid drugs that exceed a specific dollar threshold
• Number of brand-name drugs and dollar amounts paid
• Number of generic drugs and dollar amounts paid
• Total savings report on pharmacy medication spend
• Top 100 brand name drugs by units
• Top 100 generic drugs by units
• Top 100 brand name drugs by dollars
• Top100 generic drugs by dollars
• Monthly number of prospective and retrospective DUR edits completed
• Transaction line file depicting coverage decisions made by the contractor on PA or LMN
• Beers List medication report for ENERGY claimants over the age of 65 years
• Non-cancer opioid utilization report for the FECA program
• Non-cancer opioid spend report for the FECA program
• Benzodiazepine utilization report for the FECA program
• Concurrent opioid and benzodiazepine report for the FECA program
• Z-hypnotic utilization report for the FECA program
• Specialty drug report for the ENERGY program
• Oral steroid utilization report for the BLACK LUNG program
• Non-formulary transaction report
• PA report
• MUE and targeted MUE report
• Claimant adherence outreach report
• 90 MED program report
• Total number of items rented to include modifier by district office.
· Total number of items rented to include modifier by district office
· Total number of items purchased to include modifier by district office
· Total number of items purchased as used to include modifier by district office
· Total payment of rented items
· Total payment of purchased items
· Total payment of used items
· Total number of rented items converted to purchase
· Total savings on rented items converted to purchase
· Quarterly manufacturer rebate revenue report
· Transaction level file depicting which claims received a rebate
· Monthly and yearly congressional report detailing utilization, spend, and other elements of interest to congress.
| Weekly or as specified by the Government |
| 100% inspection: |
OWCP COR
| 5.9.1 Information Management |
| Retain all pertinent records necessary to satisfy federal record retention requirements and the needs of other OWCP business functions |
| For a period specified by the Government that is no less than five years after final payment is made under the resulting contract. In the event any audit, litigation, or other action involving these records is started before the end of the five-year period, retain these records until all issues arising out of the action are resolved or until the end of the five-year period, whichever is later. |
| 100% inspection: COR, PM, or designee |
5.9.2 Automated
Process for Image Transfer
| Completed process, including completed testing, for automated image transfer into claimant case files. |
| No less than 40 days prior to the implementation date |
| 100% inspection: |
OWCP COR
OWCP PM or designee
| 5.9.4 Information Management |
| Sanitize or destroy all digital media prior to its disposal or release for reuse |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
| 5.10.1 Clamant Web Portal |
| Respond to all user questions received through the Claimant Portal |
| Within 24 hours, or if research is required, within 48 hours. |
| 100% inspection: COR, PM, or designee |
5.10.1 Clamant Web Portal qu
| Provide a specification document detailing the functionality of a Claimant Web Portal. |
| Final no less than 215 days prior to the implementation date. |
| 100% inspection: |
OWCP COR
OWCP PM or designee
5.10.1 Clamant Web Portal
| Provide a fully functional Claimant Web Portal. |
| On the implementation date, no less than 365 days after contract start. |
| 100% inspection: |
OWCP COR
OWCP PM or designee
5.10.2 Prescriber Web Portal
| Provide a specification document detailing the functionality of a Prescriber Web Portal. |
| Final no less than 215 days prior to the implementation date. |
| 100% inspection: |
OWCP COR
OWCP PM or designee
5.10.2 Prescriber Web Portal
| Provide a fully functional Prescriber Web Portal. |
| On the implementation date, no less than 365 days after contract start. |
| 100% inspection: |
OWCP COR
OWCP PM or designee
| 5.10.3 Staff Portal |
| Provide a specification document detailing the functionality of the Staff Portal. |
| Final due no less than 215 days prior to the implementation date |
| 100% inspection: |
OWCP COR
OWCP PM or designee
5.10.3
Staff Portal
| Provide a fully functional Staff Portal |
| On the implementation date, no less than 365 days after contract start. |
| 100% inspection: |
OWCP COR
OWCP PM or designee
| 5.10.4.4 |
| Allow authorized OWCP staff to modify individual claimant authorizations in exception to program policy in the staff portal |
| available to authorized OWCP staff 24 hours per day, seven days per week, and 365 days per year after implementation |
| 100% inspection: COR, PM, or designee |
| 5.11.1 Formulary Management |
| Provide names and degrees of members of the Pharmacy and Therapeutics Committee. Disclose any financial interests in drug manufacturing companies. |
| Within 30 days after contract start and updated as needed. |
| 100% inspection: |
OWCP COR
OWCP PM or designee
5.11.1Formulary Management
| Provide P&T progress report template and clinical recommendations and pharmacoeconomic analysis template. |
| Final due on the first business day after January 1 following contract award. |
| 100% inspection: |
OWCP COR
OWCP PM or designee
5.11.1 Formulary
Management
| Provide quarterly P&T progress reports at least 4 times a year. |
| On the first business day after January 1, April 1, July 1, and October 1 of each year. |
| 100% inspection: |
OWCP COR
OWCP PM or designee
5.11.2.1 Drug Formulary System.
Specification documents detailing formulary and DUR Point of Sale (POS) edits (e.g. drug-drug interactions and contraindications, therapeutic duplications, refill too soon edits, minimum/maximum dosage, DAW edits, quantity limits, step therapy edits) along with all drug information compendia utilized in formulating their POS edits for each program
| Final no less than 215 days prior to the implementation date |
| 100% inspection: |
OWCP COR
OWCP PM or designee
5.11.2.2 Drug Formulary System.
| All pended black lung drugs should be pended at the POS and reviewed by one of the contractor’s pharmacists. |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
5.11.2.2, 5.11.2.3, 5.11.2.4 Drug Formulary System.
| Provide a drug formulary. |
| Final no less than 160 days prior to the implementation date |
| 100% inspection: |
OWCP COR
OWCP PM or designee
5.11.2 Drug Formulary System.
| Complete an impact analysis identifying all claimants that have been recently dispensed non-formulary medications, medications outside of formulary limits, or medications for non-accepted conditions for each program and provide DOL with this analysis in the format DOL requests. |
| Final no less than 130 days prior to the implementation date |
| 100% inspection: |
OWCP COR
OWCP PM or
5.11.2 Drug Formulary System.
| Complete a major communication campaign notifying claimants and prescribers of non-formulary medications and transitioning them to formulary alternatives through a clinical letter campaign. |
| Complete the outreach campaign no less than 45 days prior to the implementation date |
| 100% inspection: |
OWCP COR
5.11.2 Drug Formulary System.
Complete 4 impact analysis identifying all claimants that have been recently dispensed non-formulary medications, medications outside of formulary limits, or medications for non-accepted conditions for each program and provide DOL with this analysis in the format DOL requests.
First analysis provided 60 days from the Option year 1 start date. Second analysis provided 150 days from the Option year 1 start date. Third analysis provided 240 days from the Option year 1 start date. Forth analysis provided 320 days from the Option year 1 start date.
100% inspection:
OWCP COR
5.11.2 Drug Formulary System.
| Complete 3 major communication campaigns notifying claimants and prescribers of non-formulary medications and transitioning them to formulary alternatives through a clinical letter campaign. |
| Complete the first outreach campaign at day 90 of the Option year 1. Complete the second outreach campaign at day 180 of the Option year 1. |
Complete the third outreach campaign at day 270 of the Option year 1.
100% inspection:
OWCP COR
5.11.2.2, 5.11.2.3, 5.11.2.4 Drug Formulary System.
| Fully implement the drug formulary for bill processing. |
| On the implementation date, no less than 365 days after contract start. |
| 100% inspection: |
OWCP COR
OWCP PM or designee
5.11.2.3, 5.11.2.4 Drug Formulary System.
| Pharmacist review of all GPI with reject 75 for Energy and FECA formularies |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
5.11.5 Drug Formulary System.
| Written notice to OWCP of any formulary change. |
| Within 90 days prior to implementation of any formulary change. |
| 100% inspection: |
OWCP COR
OWCP PM or designee
5.11.5.3 Drug Formulary System.
| Written notice to adversely impacted claimants, designated representatives, prescribing physicians, and participating pharmacies. |
| Within 45 days prior to implementation of any formulary change. |
| 100% inspection: |
OWCP COR
OWCP PM or designee
5.12.1 PBM Drug
Utilization Review
| Deploy point of sale editing. |
| On the implementation date, no less than 365 days after contract start. |
| 100% inspection: |
OWCP COR
OWCP PM or designee
| 5.12.1, 5.12.19, 5.12.20 PBM Drug Utilization Review |
| Provide a specification document detailing the processes of concurrent, retrospective and clinical drug utilization review. |
| Within 120 days of contract start date; Final no less than 215 days prior to the implementation date |
| 100% inspection: |
OWCP COR
OWCP PM or designee
| 5.12.20 |
| Track, trend, and report the outcomes of the PARF and PART reviews, 90 MED Program, MUE, targeted MUE, and Claimant Adherence Program |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
| 5.12.17 |
| 100% of clinical pharmacist adjudicated within 1 day, in accordance with compensation program policy. |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
| 5.12.20.1 |
| 100% of all prior authorization request forms (PARF) and prior authorization request templates (PART) must be adjudicated by the contractor |
| Review prior authorization requests within 24 hours of receipt (Monday – Friday, except federal holidays) |
| 100% inspection: COR, PM, or designee |
| 5.12.20.3 |
| Complete 1,000 MUE during each option year of the contract. |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
| 5.12.20.4 |
| Complete targeted MUE campaigns |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
| 5.12.20.5 |
| Assist at least 1,500 claimants during each option year of the contract to improve their adherence to their prescription medication regimen. |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
| 5.13.9 Durable Medical Equipment (DME) |
| Contractors seeking to obtain prior authorizations for DME or submit bills for reimbursement must first complete registration with the WCMBP contractor. |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
| 5.13.1 Durable Medical Equipment (DME) |
| Provide claimants with DME access. |
| Ninety-five percent (95%) of claimants within the Continental United States (CONUS), its permanently inhabited territories, and outside the Continental United States (OCONUS) can obtain prescribed DME within two calendar days and within a thirty-mile drive of their home |
| 100% inspection: COR, PM, or designee |
| 5.13.5 Durable Medical Equipment (DME) |
| DME suppliers must be accredited by the Centers for Medicare and Medicaid Services to furnish Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
| 5.13.7 Durable Medical Equipment (DME) |
| Provide accurate responses to DME inquiries/requests |
| Within one business day. |
| 100% inspection: COR, PM, or designee |
| 5.13.8 Durable Medical Equipment (DME) |
| Prior authorization for DME purchases equipment rentals, unlisted or not otherwise classified HCPCS codes, and items not listed on the fee schedule will be program specific. The contractor must have the capability to customize the dollar amount threshold for each program. |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
5.13.9 Durable Medical
Equipment (DME)
| All DME bills/invoices must be submitted timely and contain proper, accurate and complete information. |
| The minimum acceptable level is no less than 100%. |
| Medical Bill Processing System |
validation report(s).
5.13.9 Durable Medical
Equipment (DME)
| Enroll all DME contractors that submit bills for reimbursement. |
| The minimum acceptable level is no less than 100%. |
| Medical Bill Processing System |
validation report(s).
| 5.13.10 Durable Medical Equipment (DME) |
| Convert DME rental to ownership after trial period. |
| 100% of the DME rental costs applied to purchase during rental to ownership conversion. |
| 100% inspection: COR, PM, or designee |
| 5.13.11.2 |
| DME repairs must be performed by a factory-authorized technician. |
| Repair costs must not exceed 75% of the purchase price of the DME. |
| 100% inspection: COR, PM, or designee |
| 5.13.12.1 |
| DME valued at more than a dollar amount specified by OWCP, such as, one thousand dollars ($1,000), that has not been customized or permanently modified for a claimant must be retrieved when it is no longer needed by a claimant. |
| Retrieved and refurbished equipment must generate a credit to the Government, which is associated with the claimant and specific case for which the medical equipment was purchased. |
| 100% inspection: COR, PM, or designee |
| 5.14.1 |
| Provide claimants with diagnostic services and testing. |
| Ninety-five percent (95%) of claimants within the Continental United States (CONUS), its permanently inhabited territories, and outside the Continental United States (OCONUS) can obtain diagnostic services and testing within a thirty-mile drive of their home. |
| 100% inspection: COR, PM, or designee |
| 5.14.4 |
| Enroll all contractors that submit bills for reimbursement. |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
| 5.15.4 |
| Provide claimants with specialty pharmacy services |
| Accessible 24-hour per day, seven day per week, 365 day per year |
| 100% inspection: COR, PM, or designee |
5.16.2 System
Testing
| Provide a Requirements Traceability Matrix, testing plan and testing cases associated with all available systems. |
| no less than 180 days prior to the implementation date |
| 100% inspection: |
OWCP COR
OWCP PM or designee
| 5.16.5 |
| The contractor must successfully test all requirements from end-to-end, including SIT, volume and performance testing, and parallel testing—before releasing the system to the Government for GAT. |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
| 5.16.7 |
| The contractor’s GAT environment must exactly replicate its production environment and allow government users to perform comprehensive functional area process testing, system function testing, and user interface testing and validation. |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
| 5.16.10 |
| Successfully pass GAT prior to Government issuance of a certificate of operational readiness, and complete all other activities (e.g., load bill history files, load claimant authorizations from the prior contractor, provide user training) necessary to assume operations before full implementation of the contract. |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
| 5.17.1 |
| Allow document review and system access and assist government evaluator in performing the Controls |
Assessment for the necessary systems.
| By the 160th day after contract start. |
| Independent security |
assessor
| 5.17.2, 5.17.3, 5.17.5 |
| Provide a completed SOC 1 type II report, including all related deliverables, performed by an independent auditor according to current fiscal year DOL requirements, standards established by the American Institute of Certified Public Accountants, and the FISCAM or other audit standards specified by the DOL. |
| Initial report due August of each contract year after implementation, related deliverables, and final report due dates to be determined by OIG each year. |
| 100% inspection: OWCP COR OWCP PM or Designee |
| 5.17.7 |
| Implement corrective actions to resolve weaknesses identified during audits. |
| Zero deviation from the standard |
| 100% inspection: COR, PM, or designee |
| 508Testing (In accordance with Section I.10 DOL-2019-01 SECTION 508 REQUIREMENTS (January 2019)) |
| Successfully complete 508 compliance testing. |
| Successful testing no less than 100 days prior to the implementation date. |
| Government Information Security |
Officer
| Implementation (Go-Live) |
| Complete implementation of all elements of the PWS. |
| On the implementation date, no more than 365 days after contract start. |
| 100% inspection: |
OWCP COR
File details come from the government source that posted it. Updated .