Attachment 1-CCN Next Gen Medical IDIQ PWS.docx

DEPARTMENT OF VETERANS AFFAIRS

VHA Office of Integrated Veteran Care Integrated External Networks

Community Care Network Next Generation Medical Multiple Award IDIQ Performance Work Statement

Version 1.00 December 08, 2025

Table of Contents

DRAFT

GENERAL INFORMATION

Introduction Community Care Network (CCN) services and health care resources are purchased under the authority of 38 United States Code (U.S.C.) § 8153, “Sharing of health-care resources.” The primary goal of this acquisition is to establish a suite of indefinite-delivery indefinite-quantity contracts that will enable Veterans Health Administration (VHA) to provide CCN services and health care resources through an established network of licensed health care providers and practitioners for medical, surgical, complementary and integrative, durable medical equipment (DME), and pharmacy services that drive quality, efficiencies, cost savings, and a positive Veteran experience. This acquisition and resulting multiple award contracts offer a broad range of services, and solutions to deliver and support the delivery of quality and timely CCN health care services and health care resources. This Performance Work Statement (PWS) identifies general task areas under which Task Orders (TO) may be executed. Specific requirements will be further identified and defined at the TO level.

Scope of Services The Contractor shall provide the full range of health care and health care-related / supporting services, technical and management expertise, and solution-related products in one or more task areas to meet the mission needs of VHA. As identified in individual TOs, health care services and capabilities, and supporting services and capabilities, shall be provided to VHA. While the PWS identifies general task areas, the suite of resulting contracts are intended to satisfy the full range of health care and health care-related / supporting requirements. It is intended that this suite of contracts will provide the full range of current and emerging health care services and capabilities and supporting services and capabilities throughout the life of the contract. The Contractor shall provide solutions for one or more of the general task areas below, furnishing the necessary personnel, materials, equipment, and facilities, with specific tasks to be defined at the TO level. The general scope of this contract includes the following general task areas:

1. Program / Project Management (PWS 2.1)

2. Contractor Maintained Records (PWS 2.2)

3. Medical Network Development and Maintenance (PWS 2.3)

4. Eligibility Data Management (PWS 2.4)

5. Customer Service (PWS 2.5)

6. Utilization Management (PWS 2.6)

7. Pharmacy Network Development and Maintenance (PWS 2.7)

8. Medical Documentation (PWS 2.8)

9. Claims Processing and Adjudication (PWS 2.9)

10. Reimbursement Submission (PWS 2.10)

11. Coordination of Benefits (PWS 2.11)

12. Program Integrity (PWS 2.12)

13. Clinical Quality and Patient Safety (PWS 2.13)

14. Technology (PWS 2.14)

15. Training (PWS 2.15)

16. Appointment Scheduling (PWS 2.16)

17. Care Coordination (PWS 2.17) Applicable Documents The Contractor shall comply with all relevant Federal, State, and local government regulations, as well as specific regulations, publications, policies, and procedures outlined in the contract and the individual TOs.

IDIQ Contract Performance Management VA will use a Quality Assurance Surveillance Plan (QASP) to monitor the quality of the Contractor’s performance of the requirements of the base contract. The oversight provided for in the QASP will help to ensure that service levels reach and maintain the required levels throughout the contract term. The QASP is a tool used by the Government; therefore, it remains a living document through the TO performance period.

The QASP itself is not part of the contract; however, a copy of the QASP will be provided to the Contractor for informational purposes only. The Contractor shall meet all performance requirements established by the contract PWS for each TO issued under the scope of the IDIQ contract and Performance Requirement Summary (PRS) (Table 1 below). The PRS in Table 1 below applies only to the base contract, a QASP and PRS for each TO will be developed at the TO level, when appropriate.

Table 1. PRS

Level (AQL) Surveillance Method / Frequency

Inspection of all Task Order responses.

Quarterly or more/less as determined by VA.

GENERAL TASK AREAS

Program / Project Management The Contractor shall provide program / project management services to effectively manage each TO by overseeing all aspects of planning, execution, and monitoring to ensure the successful delivery of the TO requirements. This includes developing detailed project plans, mobilizing appropriate resources, risk management, ensuring compliance with all contractual obligations, and achieving project milestones and deliverables on schedule.

Contractor Maintained Records Upon written request from the Contracting Officer (CO), the Contractor shall provide to VA any and all records, information, and data in its possession, custody, or control in the requested format, including claims data; raw X12 electronic data interchange (EDI) data and metadata; claims images; medical records; network provider agreements; accreditation, credentialing and certification documentation; delegation of certification agreements; licensing files; competency measures; Federal exclusionary list matching; quality and safety issues submitted by VA facilities and all related reviews, data, and actions taken in response to quality and safety issue concerns; network provider education materials and related correspondence; network provider applications; network provider communications; and bank/payment records. The Contractor shall also ensure timely and reasonable access to its personnel upon written request from the CO, for the purpose of interview and discussion by VA and other Government officials conducting an audit, inspection, or investigation. The Contractor shall include VA’s right to access network provider records, information, and data as described in this paragraph in its provider agreements.

The Contractor shall provide access to the aforementioned artifacts within five (5) business days of request. Any issues identified during VA review will be sent to the Contractor. The Contractor shall correct the issues within the VA specified timeframe.

Medical Network Development and Maintenance The Contractor shall establish, maintain, and manage a CCN Next Generation Medical Network consisting of a comprehensive network of qualified health care providers, practitioners, and facilities. The Contractor shall provide a network of providers and practitioners capable of providing health care services described in 38 Code of Federal Regulations (C.F.R.) § 17.38(a). The Contractor shall also provide a network of practitioners capable of providing Complementary and Integrative Health Services (CIHS) and Community Nursing Home Care. The Contractor shall provide a network of providers and practitioners capable of providing Assisted Reproductive Technology (ART) and In Vitro Fertilization (IVF) services as described in 38 C.F.R. § 17.380. The Contractor shall provide a network of providers and practitioners capable of providing specific benefits associated with dialysis and transplants.

As medical care evolves, services may be added to the medical benefits package under appropriate statutory authority. The Contractor’s network shall have the capability to develop and expand its resources to provide those services.

Eligibility Data Management The Contractor shall receive enrollment and eligibility information from VA in a daily eligibility file through EDI Gateway/Data Access Services (DAS), which will serve as the primary method of data exchange until VA develops and implements real-time data-sharing capabilities. VA may also use secure messaging to transmit enrollment and eligibility information. The file will contain Veterans Community Care Eligibility (VCE) Code changes for eligible individuals. The Contractor shall meet all VA-connectivity requirements (e.g. Authority to Operate (ATO)) as specified at the TO level.

Customer Service The Contractor shall provide a broad scope of customer service capabilities in support of the CCN Next Generation Network. Customer Service support may include both virtual and on-site requirements.

Tasks under this section could include areas such as: Contact Center, Urgent Care Inquiries, After Call Surveys, Self Service Capabilities, Use of VA-Provided Ticketing Tool, Information Technology Support, Network Provider Satisfaction Surveys, Customer Service Quality Assurance, Self-Service Performance, and Customer Service Performance Requirements and Reporting.

Utilization Management (UM) The Contractor shall establish, execute, and sustain a UM program to assist VA in assessing the medical necessity, clinical appropriateness, and efficiency of health care services. The Contractor shall have the capacity to make UM recommendations to VA for care that furthers an existing VA Approved Referral based only on the appropriateness of care and service for each individual Veteran’s needs. A VA-Approved Referral supports a specific plan of care as it relates to a specified number of visits and/or services as long as the services are provided by a network provider. The Contractor shall conduct utilization reviews for inpatient and outpatient care. VA has the sole responsibility to make final decisions based on the Contractor’s UM recommendation.

The Contractor shall demonstrate ongoing UM accreditation from a nationally recognized UM accrediting organization. The Contractor shall notify VA of any changes in accreditation status as specified at the TO level.

Tasks under this section could include areas such as: Accreditation, Utilization Management Committees, Foundational Documents, Program Approach, Quality Improvement, Reporting Data, Trends and Risks, Data and Performance Requirements, UM Decisions, Review and Referrals, Medical Necessity Criteria, Interrater Reliability, Referrals, and Requests for Services, Emergency Care and Inpatient Admissions, Communication Services, Appeals Process and Pharmaceutical Management.

Pharmacy The Contractor shall provide, as required, pharmacy benefits to Veterans through use of a Pharmacy Benefit Manager (PBM) function that has a retail pharmacy network to provide prescription fulfillment services for urgent/emergent prescriptions from Community Care network providers and VA-approved providers. The Contractor shall require all routine/maintenance prescriptions to be forwarded to VA pharmacy for processing and fulfillment. The Contractor shall require all network providers be registered with their own State’s prescription monitoring programs.

The Contractor’s administration of a pharmacy benefit shall accommodate eligibility checks, urgent prescription access, and prior authorization rules as required by VA.

Tasks under this section could include areas such as: Retail Pharmacy, Pharmacy Eligibility Data Management, Urgent/Emergent Prescriptions and Performance Metrics, ART/IVF and Infertility Prescriptions, Contingency Plan for Disaster Response, Vaccinations, Refunds and Reimbursements, Real Time Formulary, Routine/Maintenance Prescriptions, and Specialty Pharmacy.

Medical Documentation The Contractor shall provide a broad scope of medical documentation submission and management capabilities in support of the CCN Next Generation Network. The Contractor shall develop and maintain a Central Submission System for the coordination of all medical documentation among the network provider, the Contractor, and VA. The Central Submission System shall leverage connections and interoperability standards in accordance with PWS Section 2.14 “Technology” to facilitate bi-directional submission and receipt, requests, and acceptance of medical documentation, to include images. The Central Submission System shall include, at a minimum, an interoperable pathway for electronic document exchange among the network provider, the Contractor, and VA as noted in that section.

Tasks under this section could include areas such as: Data Elements to be Included, Submission Timeframes, Compliance Reporting, Critical Findings, and Documentation of Transplant Candidates.

Claims Processing and Adjudication The Contractor shall receive, process, and adjudicate claims for services, when provided by network providers or as an adjunct to services provided by the Contractor’s network providers. The Contractor’s claims processing system shall include standard business rules and edits in its Claims Processing Data Dictionary. The Contractor’s claims processing system shall be capable of adding rules and edits based on information from VA. When VA requests such updates to claims adjudication logic, the Contractor shall implement and test the updates. The Contractor shall retain the claims, claims processing information, and sufficient information on all claims, including Electronic Visit Verification when appropriate, to allow processing to completion and to permit audits pursuant to the record retention requirements contained in Health Insurance Portability and Accountability Act (HIPAA) privacy regulations (45 C.F.R. § 160, 162 and 164).

Tasks under this section could include areas such as: Claims Submission and Processing Timeframes, Processing and Adjudication, Electronic Visit Verification, Claim Reprocessing and Adjustment, Medical Network Provider Claim Appeals, Test Claim Tracers, Claims Reporting, Claims for Services Rendered to Veterans Assigned to Other CCN Next Generation Region.

Reimbursement Submission The Contractor shall submit claim invoices to VA for reimbursement within thirty (30) calendar days of the Contractor’s complete adjudication of the claim submitted by the network provider.

Tasks under this section could include areas such as: Resubmission of Claim Invoices Processed by VA, Invoicing Accuracy, and Accounting and Access to Records.

Coordination of Benefits The Contractor shall ensure that Veterans are not held responsible for payment and that its network providers do not invoice Veterans for any services associated with a VA-Approved Referral, even if the network provider’s claim is denied by the Contractor. The Contractor shall ensure that by accepting a VA-Approved Referral and performing services, the network provider agrees not to seek any payment from the Veteran for services covered by the referral.

Tasks under this section could include areas such as: Debt Collection and Issuance of Explanation of Benefits.

Program Integrity The Contractor shall adhere to the principles of payment and program integrity that support VA in achieving its mission without compromise. This will include ethical conduct, accountability, and strict compliance with applicable laws, regulations, and policies. The Contractor shall implement and maintain industry-standard tools for program oversight, including robust internal controls and risk management strategies to prevent improper payments. The Contractor shall have a Compliance Committee and identified Compliance Officer and report to VA on its program/payment integrity practices, on error rates and remediation plans, and other integrity efforts as specified by VA in TOPRs.

Tasks under this section could include areas such as: Timelines for Fraud, Waste and Abuse (FWA) Case Development and Referral to VA, Prohibited Actions, Prohibited Affiliations with Contractor and Subcontractor Service Providers, Compliance with the False Claims Act, Anti-Fraud, Waste, and Abuse Flags, Predictive Analytics and Machine Learning to Identify and Combat FWA, Post Payment Review to Combat FWA, Support for Investigative Agencies on FWA Cases, FWA Training and Education Program for Network Providers, Recovery and Recoupment Actions Related to FWA Cases, Payment Suspension and Termination from the Network Due to FWA, Provider Termination, Payment Integrity, Cost Avoidance, Recovery, and Recoupment Reports, Program and Payment Integrity Site Visits and Virtual Reviews.

Clinical Quality and Patient Safety The Contractor shall align its quality and performance measurement process to the VA’s quality goals and ensure they are relevant to Veterans. The Contractor shall establish and maintain a structured framework for quality improvement interventions and payment reform initiatives. The Contractor shall deploy a Quality Improvement Plan (QIP) to address any area of concern identified by VA. The Contractor shall provide reports about quality issues and improvement efforts. Where applicable, the Contractor shall use or demonstrate quality performance through a standardized, accredited tool (e.g., Utilization Review Accreditation Commission (URAC) or National Committee for Quality Assurance (NCQA)).

VA conducts quality improvement initiatives relevant to Veterans. To support VA’s Quality Improvement agenda, the Contractor shall maintain all of the quality measurement functionalities, such as a quality review committee, standardized measurement sets, and data integrity efforts to support quality improvement initiatives.

Tasks under this section could include areas such as: Clinical Quality and Patient Safety Plan, Annual Work Plan, Annual Evaluation, Clinical Quality and Patient Safety Issues Identification, Patient Safety Issue Reporting, Trending, and Forecasting, Peer Review of Quality and Patient Safety Issues, Performance Reporting, Value-Based Care, Clinical Quality Steerage Data Model, Predictive Analytics and Modeling, and Nursing Home Quality Oversight.

Technology The Contractor shall use recognized health information interoperability standards, such as American National Standards Institute/American with Disabilities Act for interoperability, in all information technology (IT) systems used to support the CCN Next Generation Medical Network.

The Contractor’s systems shall have the capability for future enhancements that are planned and developed, in accordance with VA direction, to keep systems in line with evolving industry standards to include data transaction standards (such as Health Level Seven (HL7), Fast Healthcare Interoperability Resources (FHIR)) and integration into VA’s electronic health record (EHR)). VA also encourages implementation of Trusted Exchange Framework and Common Agreement (TEFCA) or Substitute Medical Applications and Reusable Technologies (SMART) on FHIR.

Tasks under this section could include areas such as: Communication and Access to Contractor Systems, Configuration Management and Testing, Continuity of Operations Plan, Data Integrity, Data Security, Information and Data Exchange Requirements, Interoperability Standards Compliance Requirements, Software Development, and Technology Compliance Requirements, and Data Analytics.

Training The Contractor shall develop and deliver training for the CCN Next Generation Medical Network users that results in:

1. Increased knowledge and understanding of the Contractor’s CCN Next Generation Medical Network’s business processes and systems

2. Improved ability to use and operate the Contractor’s CCN Next Generation Medical Network’s business processes and systems

3. Compliance with new VA or Congressional regulatory requirements CCN Next Generation Medical Network users may include network providers, Contractor personnel, and identified VA staff.

The Contractor shall develop and implement a training program for Contractor personnel, network providers, and identified VA staff that ensures compliance with all network-related training requirements which may include specific VA-provided training, complete opioid safety and best practices training prior to the provision of care, an on-boarding and ongoing outreach and education program for network providers and Contractor personnel and training on VA health care benefits, unique VA clinical guidelines, and requirements under this contract for its staff and network providers.

Tasks under this section could include areas such as: Network Provider and Contractor Personnel Outreach and Education, Network Provider Only Training Healthcare Appointment Scheduling The Contractor shall collaborate with VA to implement health care appointment scheduling services and capabilities in support of CCN Next Generation. Tasks under this section could include areas such as scheduling and booking of appointments, confirming and communicating appointments, calendar management, managing changes, and rescheduling of appointments.

Care Coordination The Contractor shall collaborate with VA to implement a Comprehensive Care Coordination process for Veterans who have been assigned by the VA Facility Community Care staff as needing basic care coordination support. Comprehensive Care Coordination involves the collaboration of health care providers, and administrators, Veterans and other stakeholders. Comprehensive Care Coordination and Care Coordination Follow-Up.

image1.png image2.png