Attachment 1 - CCN Next Gen - Medical West TOPR PWS.pdf

B.7 Performance Work Statement

1 GENERAL INFORMATION

1.1 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 Contractor shall provide a network of licensed health care providers and practitioners for medical, surgical, complementary and integrative, durable medical equipment (DME), and pharmacy services.

This Performance Work Statement (PWS) is for CCN Next Generation Medical Network

– West (see PWS Section 3.4, “CCN Next Generation Medical Network” for region composition).

1.2 Scope of Services

The Contractor shall establish, maintain, and administer a network of health care providers and practitioners (“network providers”) for medical services, hospital care, and extended care services, per the requirements defined in this PWS, and in accordance with PWS Section 19, “SCHEDULE OF DELIVERABLES.”

The Contractor shall deliver required services using tools and practices that drive quality, efficiencies, cost savings, and a positive Veteran experience.

All references to days in this contract shall be construed as calendar days, unless otherwise specified.

1.3 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. Additionally, the Contractor shall comply with Attachment 1, “CCN Next Generation Medical Network Contractor Manual,” herein referred to as the Medical Manual.

The Medical Manual provides the Contractor with additional explanatory information, processes, and guidance associated with the requirements set forth in this PWS. The Medical Manual does not create new requirements. This PWS takes precedence over the information within the Medical Manual, and to the extent there is a discrepancy between the Medical Manual and the PWS, the PWS controls. Semi-annual updates to the Medical Manual will be provided to the Contractor by the Contracting Officer (CO).

These updates will fall into three (3) categories: minor, moderate, and substantive updates.

VA defines minor or moderate updates as administrative or configuration changes that do not impact cost, scope of contract, or any requirements with the difference between minor and moderate being the length of time to implement. The Contractor shall implement minor updates within 30 days of receipt at no additional cost to the Government. The Contractor shall implement moderate updates within 60 days of receipt at no additional cost to the Government. Examples of minor or moderate updates include:

1. Correcting typographical errors or grammatical mistakes in the Medical Manual

2. Updating or clarifying instructions without altering the underlying process

3. Adjusting table values to reflect minor changes in data

4. Modifying electronic data interchange (EDI) formats or field descriptions that do not impact the overall data processing functionality

5. Simple configuration changes within existing software parameters that do not require reprogramming or resource allocation VA defines substantive updates as updates that involve significant changes that could affect the requirements or result in additional costs. In these cases, the Contractor shall review the updates and submit a cost proposal to the CO within 15 days. This proposal shall outline any additional costs required to implement the updates. The CO will review and may negotiate the cost proposal. Agreement will be reflected in a contract modification. Once the contract modification is signed by both parties, the Contractor shall implement the updates within 30 days. Examples of substantive updates include:

1. Introducing new claims processing logic that changes how claims are evaluated and processed, potentially requiring reprogramming or system changes

2. Implementing changes to the data architecture, such as new database structures or modifications to data flow

3. Overhauling EDI transaction sets, including adding new data fields or changing the usage of existing fields in a way that affects system integration or data exchange processes

4. Significant updates to compliance requirements or regulatory standards, requiring adjustments to ensure adherence

To the extent practicable, the Medical Manual Table of Contents mirrors this PWS to easily identify when there is Medical Manual content for a PWS section. If there is no Medical Manual content for a corresponding PWS section, then the section is marked “RESERVED” in the Medical Manual.

2 PROJECT MANAGEMENT

The Contractor shall effectively manage the project by overseeing all aspects of planning, execution, and monitoring to ensure the successful delivery of the contract requirements. This includes developing detailed project plans, mobilizing appropriate resources, ensuring compliance with all contractual obligations, and achieving project milestones and deliverables on schedule.

2.1 Post Award and Contract Kickoff Meetings

Within five (5) days of the contract award, the Contractor shall participate in a virtual Post Award Meeting to be led by the CO. The date of this meeting will be determined by VA. The Contractor shall identify key project personnel, including the project manager, transition team lead, and any other relevant stakeholders 48 hours prior to the meeting so that VA can begin initial clearance processing. The Contractor shall ensure the attendance of these key project personnel. The action items established during the meeting shall be specific, measurable, and include assigned responsibilities and deadlines. The purpose of the Post Award Meeting is to accomplish the following:

1. Initiate the communication process between VA and the Contractor including:

a. Introduction of Contractor and VA personnel performing work related to this project

b. Identification of Contractor and VA stakeholders’ roles and responsibilities

2. Provide a comprehensive overview of the project’s administration processes and reporting protocols, including the frequency of reports, key performance indicators, and specific administrative responsibilities

3. Establish action items/next steps, confirm dates, locations, expectations, and agenda for the Kickoff Meeting

4. Identify and assign action items to be resolved prior to the Kickoff Meeting

The Contractor shall participate in a Kickoff Meeting within 30 business days after contract award, with the specific date and location to be determined jointly by the Contractor and the CO. The Kickoff Meeting presentation shall be delivered 15 days prior to the Kickoff Meeting.

Within the Kickoff Meeting presentation, the Contractor shall describe and explain in detail the following:

1. Names and roles of the Contractor’s transition team lead and members to facilitate clear communication and accountability throughout the contract implementation phase

2. Resolution of assigned action items from Post Award Meeting and identification of issues that require immediate response and coordination with VA

3. Approach to all deliverables in accordance with the expectations defined in PWS Section 19, “SCHEDULE OF DELIVERABLES”

4. Overview of all Deliverables submitted to VA by the Contractor as of the date of the kickoff meeting, to include all Deliverables that the Contractor is submitting at the kickoff meeting, as required under PWS Section 19, “SCHEDULE OF

DELIVERABLES”

5. Approach to communications required to manage the overall CCN Next Generation Medical Network- West to include:

a. Key messages that shall be articulated to the VA stakeholders to include the timing associated with the delivery of those messages

b. Communication method, type, style, and channels the Contractor will use to reach VA stakeholders and Veterans, as well as the desired outcomes for the communication. VA stakeholders, by role and hierarchy, that shall be included in communications are identified in Attachment A, “Community Care Network Stakeholders List.”

6. Explanation of the Implementation Strategy including all key elements in PWS Section 2.3, “Deployment and Implementation” in detail such that it can be presented to and reviewed by VA subject matter experts allowing them to provide real-time, meaningful feedback prior to execution of the Implementation Strategy

7. Explanation of the System Access and Controls Manual for access to the Contractor’s systems, as described in PWS Section 15.1, “Communication and Access to Contractor Systems”

8. Explanation of the training approach which is addressed in the Training Plan described in PWS Section 16.1, “Training Plan”

9. Detailed explanation of Contractor self-assessment calculation methodology for each performance objective (PO) (PO1.9, PO2.1 - PO2.6, PO3.1- PO3.4, and PO4.1 - PO4.6) in accordance with the Performance Requirement Summary (PRS), addressed in PWS Section 2.5.1, “Performance Surveillance and Assessment”

The Contractor shall record detailed meeting minutes of the Kickoff Meeting, which shall be submitted to the CO within five (5) days post-meeting. These minutes shall comprehensively document all discussions, including any major issues and agreed-upon actions with specific timelines for resolving any actions and/or disputes.

At the kick-off meeting, the VA reserves the right to discuss and require modifications to any component of the plan with the Contractor. The VA will implement the finalized plan, and a correction action plan for the purpose of measuring and maintaining oversight of contractor performance in accordance with the plan’s terms and applicable benchmarks

Deliverables: (See PWS Section 19, “SCHEDULE OF DELIVERABLES” for details.)

1. Kickoff Meeting Presentation

2. Kickoff Meeting Minutes and Action Items

2.2 Integrated Master Schedule

The Contractor shall create and maintain a fully resource-loaded and baselined Integrated Master Schedule (IMS) that depicts the implementation and deployment of the CCN Next Generation Medical Network – West pursuant to this contract and includes dependencies on VA. The Contractor shall use the IMS to manage and report on all elements of the CCN Next Generation Medical Network – West.

The Contractor shall include the following in the IMS:

1. Work Breakdown Structure (WBS) to a minimum of three (3) levels to define the activities, tasks, and outcomes

2. Tasks and milestones necessary to complete the project, including identifying and documenting the definition of the relationship between and among these tasks and milestones, and determining the expected duration of each event and resources required for each

3. Critical path depiction showing tasks that, if delayed in completion, will impact the overall timeline; the Contractor shall notify the CO within one (1) business day when data is provided/entered that creates overall critical path slippage

4. Planned (baselined IMS) versus actual program/project performance

5. Milestones to measure progress toward completion of individual WBS elements

The Contractor shall not implement any deviation to a critical path or any other change to the IMS that may affect cost, schedule, or performance without prior written approval from the CO. The Contractor shall submit all proposed changes, including a comprehensive impact analysis to the CO for review and approval no less than five (5) business days prior to the proposed implementation date. Approval shall be received in writing prior to the incorporation of such changes into the IMS.

The IMS shall be submitted to the CO 15 days prior to the Kickoff Meeting and updated quarterly as part of the Project Management Review (PMR) and as requested by the

CO.

Deliverable: (See PWS Section 19, “SCHEDULE OF DELIVERABLES” for details.)

1. Integrated Master Schedule

2.3 Deployment and Implementation

The Contractor shall develop a Deployment and Implementation Plan to detail the Contractor’s approach to implementing the CCN Next Generation Medical Network - West, as referenced in PWS Section 3.4, “CCN Next Generation Medical Network Regions.” The Deployment and Implementation Plan shall be submitted no later than five (5) days prior to the kick-off meeting. VA reserves the right to discuss and require modifications to any component of the plan with the Contractor. VA will incorporate the finalized, approved plan into the contract upon VA approval. The Contractor shall then implement the VA approved Deployment and Implementation Plan.

The Deployment and Implementation Plan shall detail all events and milestones for each functional area, described in this PWS, required to enable and achieve full health care delivery (HCD) throughout the region.

The Deployment and Implementation Plan shall also contain the Contractor’s Transition- In Plan that includes:

1. Planned transition meetings and schedule

2. Transition-in team identifying key positions and individuals responsible for each functional area

3. Participation in VA led transition meetings and shadowing exercises with transitioning out contractor

4. Development of VA approved scripts for stakeholders

5. Documentation in relation to transition

6. Transition plan risk register

7. Transition execution steps with associated milestones ensuring seamless continuation of HCD with minimal disruption to Veterans and VA

8. Identification of what the Contractor will need from VA to effectively transition Recruitment plan for bringing in current community providers into the network and how providers will be engaged

The Contractor’s transition team shall coordinate with VA and the incumbent contractor(s) to identify the documentation, access to personnel (both VA and incumbent contractor), and system access necessary to begin the process of reaching full HCD, based on the VA-approved plan incorporated into the contract. The Contractor shall provide a bi-weekly Deployment and Implementation Status Report on all activities related to implementation until HCD is achieved. The Deployment and Implementation Status Report shall be aligned to the Deployment and Implementation Plan and shall specify activities occurring at each Station and by Region, State, and Catchment Area during the reporting period. The Deployment and Implementation Status Report shall demonstrate the ability to provide timely and effective health care services prior to HCD at each Station and by Region, State, and Catchment Area. The CO will review and approve the Deployment and Implementation Status Report. Upon approval, the CO will notify the Contractor that they shall initiate HCD activities. HCD at each Station will be achieved upon CO acceptance.

The Contractor shall not provide HCD at any site sooner than 90 days from contract award but shall achieve full HCD in the CCN Next Generation Medical Network - West no later than 12 months from contract award. The Contractor shall ensure successful deployment in CCN Next Generation Medical Network - West includes the necessary people, processes, and technology are in place and able to perform the required functions outlined in this PWS including provider network adequacy (see PWS Section

3.1 Medical Network Establishment and Maintenance) and training (see PWS Section 16 Training). The Contractor shall:

1. Participate in on- and off-site readiness planning and deployment activities, at locations determined by VA post-award and incorporated into the Deployment and Implementation Plan, to ensure operational readiness and provider network adequacy (e.g., communication scripting, operations support staff participation in HCD activities, data reporting)

2. Conduct initial testing and develop an Integrated Test Plan in accordance with PWS Section 16.2, “Configuration Management and Testing” for VA acceptance, completed and accepted by the CO, 30 days prior to HCD

3. Per the VA approved implementation strategy timeline, provide the summary of testing and completed resolutions for the Contractor Interactive Voice Response (IVR) and Contractor Self-Service Portal for CO acceptance of fully operational IVR and Contractor Self-Service Portal

4. Complete Contractor and network provider training requirements in accordance with PWS Section 17, “Training”

5. Test and implement all technical solutions as described in PWS Section 16.2, “Configuration Management and Testing”

The Contractor shall establish and operate a dedicated Deployment Command Center that shall, in continuous coordination with VA, proactively identify and address emerging issues during contract implementation, exercise incident command authority, resolve real-time operational problems, and immediately respond to unforeseen events requiring urgent attention. The Contractor shall stand up the Deployment Command Center no sooner than five (5) days after contract award but no later than 30 days after contract award. The Deployment Command Center, at a minimum, shall include information technology (IT) support, customer service, medical claims, and network support. Contractor staff within the Deployment Command Center shall provide the CO with updates regarding network build issues, identified problems and plans for resolution, and the status of network provider identification and recruitment, as necessary within the Deployment and Implementation Status Reports.

Additionally, the Contractor shall designate a single point of contact for each VA Medical Center (VAMC) to provide dedicated liaison support prior to full HCD at each site. The Contractor staff shall be available to assist with day-to-day activities and real-time resolution of issues. Issues include fixing network provider data in Contractor’s systems that VA cannot access, updating network provider demographics, assisting with claims resolution, providing additional over the shoulder training, solving problems, relaying priority information to Contractor leadership, and facilitating resolution of issues.

Deliverables: (See PWS Section 19, “SCHEDULE OF DELIVERABLES” for details.)

1. Deployment and Implementation Plan

2. Deployment and Implementation Status Reports

2.4 Risk Management

The Contractor shall manage risks using the Project Risk Register in Attachment B, “Project Risk Register” which shall consist of risk and issue management processes and report by Region, State, and Catchment Area. For each risk identified by the Contractor and/or VA, the Contractor shall include severity of risk, volumes, associated impacts (e.g., systems, Veteran experience, provider experience, etc.), measures to either minimize or eliminate the potential impact, and timelines for mitigation to be completed.

The Contractor shall deliver the Project Risk Register quarterly and report on the risks during the PMRs. The Contractor shall submit updated risk responses and actions, to include mitigation strategies in the quarterly submission of the Project Risk Register.

Additionally, when the Contractor or VA identifies an extreme impact risk(s) (a risk that could cause significant harm or delay), the Contractor shall update its Project Risk Register and submit it to VA within 24 hours of identification of the extreme impact risk(s).

The Contractor shall collaborate with VA to establish the priority, scope, bounds, and resources for managing project risks and issues, and/or assess the courses of action related to them. The Contractor shall inform VA of relevant deliberations and recommendations to mitigate and resolve risks and issues as they are identified. VA has final approval of risk and issue mitigation.

Deliverable: (See PWS Section 19, “SCHEDULE OF DELIVERABLES” for details.)

1. Project Risk Register

2.5 Contract Performance Management

2.5.1 Performance Surveillance and Assessment

VA will use a Quality Assurance Surveillance Plan (QASP) to monitor the quality of the Contractor’s performance. 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 contract and/or task order performance period.

This contract is structured to include incentives and disincentives; as such, VA has prepared and will use an Incentive/Disincentive Plan (IDP) to outline its strategy for evaluating and applying incentives and disincentives for the Contractor’s performance of PO2.7 in accordance with the PRS. The IDP is a tool used by the Government;

therefore, it remains a living document through the contract and/or task order performance period.

The QASP and IDP are not part of the contract; however, Attachment C, “Performance Requirement Summary” is incorporated into the contract as an attachment to this PWS.

The QASP and IDP will be provided to the Contractor, for informational purposes only, upon contract award.

The CO may make unilateral changes to any methods of surveillance (used by VA), surveillance schedules, frequencies of surveillance, and other minor updates to the PRS at no additional cost to the Government. VA defines minor updates as administrative or configuration changes that do not impact cost, scope of contract, or the Contractor’s ability to meet performance standards (e.g., nomenclature updates, data feed source changes, and category of care classification). The Contractor shall implement such changes to the PRS immediately upon execution of the contract modification(s).

Changes to the POs, Acceptable Quality Levels (AQL) or standards, methods of surveillance (used by the Contractor), and other major updates to the PRS shall be executed via bilateral agreement between VA and the Contractor. The VA defines major updates as those involving significant changes that could affect the Contractor’s ability to meet performance standards. The Contractor shall implement such changes to the PRS within the timeframe specified in the contract modification(s).

The Contractor shall meet all performance requirements established by the PWS and

PRS.

The Contractor shall self-assess its performance of each PO in accordance with the PRS using the surveillance methods and at the frequencies specified in the PRS. For PO1.1 – PO1.8, PO2.7, and PO5.1 the Contractor shall self-assess its performance using the VA provided assessment/calculation methodologies stated in the PRS. For PO1.9, PO2.1 - PO2.6, PO3.1- PO3.4, and PO4.1 - PO4.6, the Contractor shall use the Contractor developed, VA-approved assessment/calculation methodologies. The Contractor shall obtain VA approval of its assessment/calculation methodologies for PO1.9, PO2.1 - PO2.6, PO3.1- PO3.4, and PO4.1 - PO4.6 at the Kick-off Meeting.

The Contractor shall self-report the results of its self-assessment on a monthly basis, by Region, State, and Catchment Area in five (5) separate deliverables each summarized by Region, State, and Catchment Area: Network Adequacy Contract Performance Report, Customer Service Contract Performance Report, Claims/Invoicing Contract Performance Report, Medical Documentation Contract Performance Report, and Value Based Care Contract Performance Report. The reports shall be organized by pillar and each report shall include, but is not limited to the following information for each PO included under its respective pillar:

1. Period assessed

2. Assessed overall performance percentages against required AQL

3. For PO1.1 – PO1.8, assessed performance percentages for each category of care (Primary, Mental Health, Specialty, Emergency Room, Urgent Care, Pharmacy, and Non-Institutional Extended Care Services) shall be broken down by rurality (Urban and Rural/Highly Rural)

4. Overview of VA approved/provided calculation methodology

5. Breakdown of what and how the assessment was conducted (e.g., total population of data assessed, sample size assessed, calculations used, all data supporting the assessment, etc.)

6. Identification of the data source(s) and any systems/technologies used for the assessment

7. Overview of items/data excluded from the assessment

VA intends to perform surveillance at the frequencies stated in the PRS through reviews of the Contractor’s self-assessment of performance for compliance with the PRS. VA, at its discretion and at any time or frequency, may audit/inspect or reassess the Contractor’s performance and compliance with the PRS. The results of VA’s audit, inspection, or reassessment supersede the Contractor’s self-assessment. VA will assess performance in accordance with the PRS.

At least once within one (1) year of achieving full HCD and semi-annually (twice each fiscal year) thereafter, VA will evaluate the Contractor’s performance, in accordance with the PRS, and make a determination on the Contractor’s eligibility for and the application of incentives/disincentives. Incentive/disincentive performance thresholds and their associated values are identified in the PRS. VA may use the Contractor’s self-assessment of its performance of the PO(s) as part of its evaluation for the application of incentives/disincentives; however, the results of VA’s audit, inspection, or assessment/reassessment supersede the Contractor’s self-assessment. VA makes the final determination of incentives awarded or disincentives applied.

At VA’s discretion and as determined by the CO, VA may discontinue the requirement above for Contactor self-assessment and reporting of all or some of the POs and rely solely on VA surveillance and assessment of those POs.

Deliverables: (See PWS Section 19, “SCHEDULE OF DELIVERABLES” for details.)

1. Network Adequacy Contract Performance Report

2. Customer Service Contract Performance Report

3. Claims/Invoicing Contract Performance Report

4. Medical Documentation Contract Performance Report

5. Value Based Care Contract Performance Report

2.5.2 Quality Assurance Program and Plan

The Contractor shall implement its own Quality Assurance (QA) program. The Contractor shall develop, maintain, and execute a Quality Assurance Plan (QAP). The QAP shall detail the Contractor’s QA program and how the Contractor shall implement QA to ensure that the Contractor executes the performance of the requirements in this PWS and meets and/or exceeds the AQLs identified in the PRS throughout the life of the contract. The Contractor’s QAP shall include, at a minimum, staffing, processes, procedures, and technologies used by the Contractor to ensure quality, timeliness, responsiveness, customer satisfaction, and other performance requirements.

At the kick-off meeting, VA reserves the right to discuss and require modifications to any component of the plan with the Contractor. The Contractor shall implement the finalized VA-approved plan. The Contractor shall update the QAP to include its VA-approved self-assessment calculation methodologies for each PO (PO1.9, PO2.1 - PO2.6, PO3.1- PO3.4, PO4.1 - PO4.6, and PO5.1) and submit it to VA for approval after the Kick-off Meeting. The Contractor is responsible for the quality of all work performed under this contract; thus, the Contractor shall make required changes in staffing, processes, procedures, and technologies, at no additional cost to the Government, to ensure performance is managed effectively. The Contractor shall submit all proposed changes to the QAP to the CO for approval. The Contractor shall not implement any changes prior to receiving CO approval of such changes.

Deliverable: (See PWS Section 19, “SCHEDULE OF DELIVERABLES” for details.)

1. Quality Assurance Plan

2.5.3 Corrective Action

The VA may require corrective actions, take contractual measures to enforce the Contractor’s obligations, or impose intermediate sanctions when the Contractor fails to provide the required services. The type of corrective action implemented will be based on the nature, severity, duration, and recurrence of the deficiency. Corrective actions may be applied in any order and may include, but are not limited to, the following:

1. Written warning

2. Formal Quality Improvement Plan (QIP)

3. Formal Corrective Action Plan (CAP)

4. Withholding Administrative Invoice payments

5. Contract termination or offboarding at no cost to VA

2.5.3.1 Corrective Action Plan

The Contractor shall submit a formal CAP for approval within ten (10) business days of VA’s request.

The CAP shall include, at a minimum:

1. A detailed explanation of the deficiency and the circumstances contributing to the cited deficiency

2. The Contractor’s assessment or diagnosis of the root cause

3. A specific proposal, including a defined timeline, to correct or resolve the deficiency.

4. An explanation of how to sustain compliance or improvement

5. Assigned Responsible Parties

6. Outcomes/Results

2.5.3.2 Quality Improvement Plan

As required by the CO, the Contractor shall develop a Quality Improvement Plan (QIP) to address any area of concern identified by VA. The Contractor shall implement each QIP upon CO review and approval. The QIP shall detail how and by what date the Contractor shall bring performance up to the required levels. If problems have not been completely resolved to the satisfaction of VA, the Contractor shall provide an explanation, including its plan and timeframe for fully resolving the issue or concern.

The Contractor shall report its status in the Monthly Progress Report (MPR), see PWS Section 2.6, “Progress Reporting.” The Contractor shall participate in related ad hoc meetings with VA to address performance issues at no additional cost to the Government.

Deliverable: (See PWS Section 19, “SCHEDULE OF DELIVERABLES” for details.)

1. Quality Improvement Plan

2.6 Progress Reporting

The Contractor shall develop and submit MPRs to the CO. The MPR provides a structured overview of the Contractor’s performance of contract requirements, facilitates communication, and identifies existing and/or anticipated issues. The Contractor shall utilize Attachment D, “MPR Template,” to populate and submit the MPR. The MPR shall include:

1. Work and Progress Summary by Region, State, and Catchment Area

a. Task Summary – summary of the work that is being performed

b. Schedule Summary – summary of schedule elements that correspond with the reporting period

c. Actual Activities for the Preceding Month – summary of activities completed during the preceding month

d. Planned Activities for Next Month – summary of activities to be completed during the next month

e. Corrective Actions and Improvements – categorized narrative listing of the operational corrective actions and improvements that were executed during the reporting period

The MPRs shall reflect the data as of the last day of the preceding month, identify the sources from which the data is pulled, and include notifications when updates to the data or data sources are made.

Additionally, the Contractor shall facilitate the quarterly PMRs with VA at VA approved locations. The Contractor shall coordinate with the CO no later than 60 days prior to the scheduled PMR date to determine a location, date, and time. The Contractor shall draft the PMR materials using Attachment E, “PMR Template.” The PMR presentation shall include information contained in the MPRs for the most recent quarter, including contract performance, project management, and major VHA initiatives and topics to be identified by VA. The Contractor shall provide the draft PMR materials at least 15 days prior to the PMR. VA reserves the right to request changes or updates to the PMR material through the CO up to one (1) day prior to the PMR.

The PMR materials shall contain the following, each summarized by Region, State, and Catchment Area:

1. Contractor performance self-assessment high-level overview, by PO (see PWS Section 2.5.1, “Performance Surveillance and Assessment”)

2. IMS Status (see PWS Section 2.2, “Integrated Master Schedule”)

3. Risk status (see PWS Section 2.4, “Risk Management”)

4. Continuous Query (CQ) monitoring results (see PWS Section 3.6, “Credentialing”)

5. Provider satisfaction survey results (see PWS Section 6.5, “Medical Network Provider Satisfaction Surveys”)

6. Medical documentation return compliance information (see PWS Section 10.4, “Medical Documentation Return Compliance Reporting”)

7. Key metrics and fraud and abuse summary report (see PWS Section 14.5, “Predictive Analytics and Machine Learning to Identify and Combat FWA”)

8. Program and payment integrity site visit and virtual review findings (see PWS Section 14.11, “Program and Payment Integrity Site Visits and Virtual Reviews”)

9. Patient safety reports (see PWS Section 15.5, “Reporting”)

10. Interoperability performance (see PWS Section 16.4.3.3, “Metrics and Validation”)

11. Value-Based Care report (see PWS Section 15.9, “Value-Based Care Strategy”)

The Contractor shall support monthly network adequacy and medical documentation meetings per VA Medical Center facilitated by VA stakeholders through a consistent point of contact with authority to act on network adequacy and medical documentation issue resolution. Additionally, the Contractor shall support VA requested ad hoc meetings limited to no more than two (2) times per month. At VA’s request, the Contractor shall coordinate and facilitate the network adequacy and medical documentation meetings. The Contractor shall participate in virtual ad hoc contract related meetings, as requested by the CO.

Deliverables: (See PWS Section 19, “SCHEDULE OF DELIVERABLES” for details.)

1. Monthly Progress Report

2. Project Management Review Materials

2.7 Service Organization Control Reporting

The Contractor shall engage an unaffiliated external auditing firm to conduct a Service Organization Control (SOC) 1 Type 2 Report, Report on Controls at a Service Organization Relevant to User Entities Internal Control over Financial Reporting, in accordance with Statement on Standards for Attestation Engagements (SSAE) No. 21 or in accordance with the current guidance issued by the American Institute of Certified Public Accountants (AICPA) Auditing Standards Board and shall provide the CO with a written copy of the SOC 1 Type 2 examination report (hereby known as the “Prime Report”). The Contractor shall ensure the independent auditing firm has prior experience in conducting SSAE audits. In addition, the Contractor shall provide a written copy of the SOC 1 Type 2 report, completed in accordance with SSAE 21, for any subservice organization (hereby known as the “Subcontractor Report”).

The Prime and Subcontractor Reports shall address the specific services provided by the Contractor to VA under the contract. The current guidance for SSAE 21 was issued in April 2016, c | SOC – Previously SSAE-16. This guidance may be updated during the performance of the contract. The Contractor shall comply with updates to SSAE 21 and provide new reports as required by any changes to the SSAE guidance. The Contractor shall check regularly for published updates to and/or new SSAE guidance to ensure that it is always complying with the most current version.

The Contractor shall engage an unaffiliated external auditing firm to conduct a SOC 2, Report on Controls at a Service Organization Relevant to Security, Availability, Processing Integrity, Confidentiality and Privacy, “Prime Report” in accordance with SSAE 21 and Trust Service Principles Criteria. The unaffiliated external auditing firm may be the same firm that provides the SOC 1 Type 2 report. The report shall cover all trust principles to include Security, Availability, Processing Integrity, Confidentiality and Privacy, and ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA) under those principles.

2.7.1 SOC 1 and SOC 2 Reporting Specifications and Deliverables VA’s fiscal year begins October 1 and ends on September 30. The Contractor shall submit initial Prime and Subcontractor Reports (SOC 1- Type 2 and SOC 2 - Type 2) for current business and financial operations. The initial reports shall cover a minimum of 12 months from contract award. Any deviation to the 12-month minimum of the initial report shall be approved by the CO. Subsequent Prime and Subcontractor Reports shall cover a minimum of 12 months, with a SOC 1 and SOC 2 Bridge Letter covering the gap between the end date of the period covered by the Prime and Subcontractor Reports and the end of VA’s fiscal year. The Contractor shall address the Bridge Letters to the CO from the Contractor’s senior management and shall specify the coverage begin and end dates. The SOC 1 and SOC 2 Bridge Letter shall include the Contractor management’s signed attestation that the processes and internal controls in effect during the period covered by the applicable Prime and Subcontractor Reports remain in effect, and/or summarize any material changes in the control environment and the impact to VA. The Bridge Letter shall provide an acknowledgement that it is not a replacement for the actual Prime or Subcontractor Reports.

All Prime and Subcontractor Reports shall clearly indicate the services, systems, and locations covered by the review, as well as the nature and type of control testing performed. The Contractor shall also account for controls over subservice organization (Subcontractor) services and performance. The Prime and Subcontractor Reports shall cover all processes and services performed by the Contractor that align to VA contractual requirements. The Contractor shall include a cover letter on all Prime and Subcontractor Reports clearly identifying the Contractor that is performing services within the scope of the contract. The cover letter shall be addressed to the CO and summarize the results of the audit and the audit tests performed. The letter shall highlight unusual items, deficiencies, qualifications, and any inconsistencies with professional standards and provide an indication of actions being taken to address, remedy, or mitigate these or other weaknesses noted in the applicable report.

Deliverables: (See PWS Section 19, “SCHEDULE OF DELIVERABLES” for details.)

1. SOC 1, Type 2 – Prime Report

2. SOC 2, Type 2 – Prime Report

3. SOC 1, Type 2 – Subcontractor Report

4. SOC 2, Type 2 – Subcontractor Report

5. SOC 1 and SOC 2 Bridge Letters

2.8 Contractor Maintained Records

Upon written request from the CO, the Contractor shall provide VA conducting an audit, inspection, or investigation any and all records, information, and data in its possession, custody, or control in the requested format, including claims data; raw X12 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.

2.9 Administrative Invoices

The Contractor shall submit Administrative Services Invoices monthly in arrears for Administrative Services CLIN (CLIN X009) in accordance with the instructions provided in FAR 52.212-4(g).

The Contractor shall submit electronic copies of the monthly Administrative Services Invoices to the CO (in approved Microsoft Office format) and the Tungsten Network and in accordance with the instructions provided in FAR 52.212-4(g).

The Contractor shall submit Administrative Services Invoices following full HCD based on the number of Enrolled Veterans for the month covered under the invoice. The Contractor shall calculate the monthly simple average of enrolled Veterans within the Task Order’s geographic jurisdiction/region using the enrollment and eligibility information received from VA in a daily eligibility file. Invoicing for administrative services shall include a supplemental data file that includes the monthly average of enrolled Veterans calculation and source data.

The Contractor may resubmit rejected Administrative Services Invoices to VA, but no new Enrolled Veterans may be included on any rejected invoice.

If an invoice is rejected for a second time, the Contracting Officer's Representative (COR) will submit the results to the Contractor who will have seven (7) business days to provide its acceptance or non-concurrence to the Contracting Officer for final decision of the Administrative Services invoice.

See the Medical Manual for additional explanatory information.

2.9.1 Implementation Invoices

Invoices for services within CLIN X009 shall include the following information:

1. Contractor Tax ID

2. Description of implementation and administrative services

3. Date (s) of completed implementation and administrative services

4. Dollar amount invoiced

5. CLIN

6. VA provided obligation

2.9.2 Administrative Invoicing Fees

The Contractor shall submit invoices for administrative fees electronically through VA Financial Services Center (FSC) through the Tungsten Network. (http://www.tungsten-network.com/VeteransAffairs/ ).

2.9.3 Cooperation

The Contractor throughout the duration of the contract period of performance, shall cooperate with, collaborate and interact with, and generally maintain an effective working relationship with all other Contractor entities with VA IVC contracts.

Liability for the improper disclosure of any Contractor proprietary data by any contractor entity to another contractor entity rests with the contractors, not the Government.

To maintain effective working relationships with other Contractors with current and future IVC contracts, the Contractor may use either formal or informal methods, including agreements or other instruments, to establish roles and responsibilities among the Contractors supporting IVC. VA will not serve as an arbitrator or mediator in any dispute related to such agreements and instruments. Furthermore, liability for the improper disclosure of any Contractor proprietary data by any Contractor entity rests with the Contractors, and not the Government.

http://www.tungsten-network.com/VeteransAffairs/ http://www.tungsten-network.com/VeteransAffairs/

2.10 Transition Out

The Contractor shall perform the Transition Out and residual service tasks for this contract at the end of the task order period of performance when applicable. Transition Out activities require collaboration with a team comprised of VA and/or successor Contractor personnel. The term Transition Out is related to activities taking place during and after the last option period, in which the Contractor is transferring duties and responsibilities to a VA appointed designee, whether a Government entity, another Contractor or a mix of both.

The Contractor shall provide residual services during the Transition Out period, after the Contractor’s network no longer provides care, including continuing to process claims, appeals, grievances, and customer service support for health care that was previously delivered up to 12 months after the end of the Performance period. The Contractor shall ensure minimal disruption of services to Veterans receiving care and network providers delivering care during the Transition Out period.

Transition Out activities shall include the following:

1. Delivering a Transition Out Plan inclusive of a timeline of major events, key positions responsible for each of the functional areas involved in the Transition Out, and processing of residual service inventories (e.g., claims, appeals, grievances), and staffing and other resources (e.g., transition project manager, transitions stakeholders) within 180 days of award of a new awardee

2. Providing retroactive processing of referrals and claims adjudication for authorized care up to 180 days following full HCD of the new contract

3. Processing of all open health care claims inventories (the outgoing contractor shall submit weekly status reports of claim inventories and phase-out activities by Region, State, and Catchment Area to the CO beginning the 20th day after notification from the CO to commence Transition Out activities)

4. Transitioning open referrals to an incoming contractor, as directed by the CO

5. Providing a current inventory of all Government-owned assets used by the Contractor over the life of the contract along with full support in the reconciliation of the inventory as needed

6. Providing “shadowing” and other knowledge transfer meetings and opportunities to facilitate the transfer of information, processes, and data needed to continue the services being performed by the Contractor

7. Removing and purging of all non-public or other Government-furnished information from any Contractor-owned system, and providing certification of execution to the CO

8. Updating Transition Out Plan seven (7) days after request is made from the CO to incorporate updates and the successor/incoming Contractor’s Transition In Plan (included as part of successor/incoming Contractor’s Implementation Strategy)

9. Developing customer service phone line transition message stating the line is no longer in service as of the end date of the contract and to contact a phone number directed by VA for assistance. This shall be maintained 120 days post period of performance end date. The Contractor shall transition the phone line to VA following the 120 days.

The list above is not exhaustive. The CO may discuss additional items or considerations related to phasing out services prior to Transition Out. The services required to Transition Out will only be required in the event of a need for an actual transition. The Transition Out Plan and Update (when requested by the CO) shall provide Region, State, and Catchment Area data. The Transition Out Plan and Update shall be delivered to the CO. After VA approval of the Transition Out Plan and Update, the Contractor shall execute the plan.

Deliverables: (See PWS Section 19, “SCHEDULE OF DELIVERABLES” for details.)

1. Transition Out Plan and Update

2. Weekly Status Report of Claims Inventories and Phase-Out Activities

3. Contractor’s Government-owned Asset Inventory List

3 MEDICAL NETWORK DEVELOPMENT AND MAINTENANCE

3.1 Medical Network Establishment and Maintenance

The Contractor shall establish, maintain, and manage a CCN Next Generation Medical Network – West consisting of a comprehensive network of qualified health care providers, practitioners, and facilities. The network shall include providers capable of delivering the services specified in PWS Section 4, “CCN Health Benefit Package,” and shall meet the minimum network adequacy standards specified in Table 1, including drive time and appointment availability.

VA reserves the right to direct the Contractor to remove any provider from the Contractor’s network, and the Contractor shall remove the provider immediately.

Drive time means the time required to drive between the Veterans’ official residence and the rendering network provider’s physical address (based on care site locations listed in the Contractor’s network provider data submitted to VA, as described in PWS Section 3.7, “Medical Network Provider Data for VA’s Provider Directory”). Drive times shall be determined using Microsoft Azure Maps for geo-mapping solutions. The Contractor shall provide VA with access to their Microsoft Azure geo-mapping solution for oversight.

CCN Next Generation Medical Network - West adequacy standards for appointment availability shall be measured based on the amount of time calculated in days; from the date the referral is approved by VA to the initial date of service captured on the first claim processed from the initial receiving network provider. Instances where a Veteran chooses an appointment outside the appointment timeliness standard as documented on the referral shall be excluded from measurement for appointment timeliness.

The Contractor may provide telehealth when medically appropriate as indicated by VA on the approved referral and if the Veteran chooses this modality of care. However, telehealth does not count towards meeting the network adequacy standards and is excluded from the calculation for network adequacy.

Table 1 - Network Adequacy Standards

Drive Times – Primary Care and Mental Health Care

Urban and Rural/Highly Rural* Within 30 Minutes

Drive Times – Specialty Care (excluding Transplant), Emergency Care, Urgent Care

Urban Within 45 Minutes

Rural/Highly Rural* Within 60 Minutes

Drive Times – Pharmacy (excluding Specialty Pharmacy)

Urban Within 15 Minutes

Rural Within 30 Minutes

Highly Rural Within 60 Minutes

Non-Institutional Extended Care Services Appointment Timeliness

Service Appointment Timeliness

Homemaker/Home Health Aide

In Home Respite

Community Adult Day Health Care

Veteran Directed Care

Within Seven (7) Days

Skilled Home Health Care

Hospice

Home Infusion and Ambulatory Fusion Suites

Bowel & Bladder – Agency

Community Nursing Home

Within Three (3) Days

Appointment Timeliness

Service Appointment Timeliness

Primary Care and Mental Health Care Within 20 days

Specialty Care (excluding Transplant) Within 28 days

3.1.1 Medical Network Adequacy Plan

The Contractor shall develop a CCN Next Generation Medical Network Adequacy Plan to document the Contractor’s approach for creating and maintaining an adequate network with details focusing on how all medical network adequacy requirements will be addressed for services outlined in PWS Section 3.1, “Medical Network Establishment and Maintenance” by Region, State, and Catchment Area.

As part of the CCN Next Generation Medical Network Adequacy Plan, the Contractor shall include the following elements:

1.