Attachment 1 Draft Performance Work Statement Code Sets.pdf

PERFORMANCE WORK STATEMENT (PWS)

DEPARTMENT OF VETERANS AFFAIRS

Office of Veterans Community Care

Community Care Referral Guidelines (CCRG) VA Code-Set Development and Maintenance

Date: September 03rd, 2026 Draft for Market Research – Not a Solicitation

PWS Version Number: 0.9

Contents

1. BACKGROUND AND PURPOSE

1.1 Background

1.2 Purpose

2. SCOPE

3. APPLICABLE DOCUMENTS AND STANDARDS

4. TASKS AND DELIVERABLES

4.1 Task 1 – Project Kickoff and Transition

4.2 Task 2 – VA Code Set Development

4.3 Task 3 – Routine Maintenance and Update Deliverables

4.4 Task 4 – Quality Assurance and Validation Support

4.5 Task 5 – Reporting and Governance

5. GOVERNMENT-FURNISHED INFORMATION (GFI)

6. CONTRACTOR PERSONNEL REQUIREMENTS

6.1 Staffing

6.2 Key Personnel

6.3 Continuity of Operations

7. PLACE OF PERFORMANCE

8. DATA HANDLING AND SECURITY

8.1 Data Classification

8.2 Data Rights

8.3 Security Requirements

9. PERIOD OF PERFORMANCE

10. DELIVERABLE SUMMARY TABLE

11. CONTRACTOR PERFORMANCE ASSESSMENT

12. APPLICABLE CLAUSES AND REGULATIONS

APPENDIX A - DEFINITIONS

1. BACKGROUND AND PURPOSE

1.1 Background

The Department of Veterans Affairs (VA) is implementing Community Care Referral Guidelines (CCRGs) under next‑generation community care agreements. CCRGs are standardized clinical instructions included in referral and authorization packages transmitted to Third‑Party Administrators (TPAs), VA adjudication systems, and community providers. Each CCRG defines the authorized clinical scope of the referral and, when clinically applicable, specifies evaluations, imaging, laboratory services, procedures, and quantity or frequency limits by specialty.

To support accurate adjudication, payment, and reimbursement, VA will associate each CCRG service category with a versioned VA Code Set of allowable billing codes and, when applicable, linked adjudication‑rule metadata. A VA Code Set may include CPT, HCPCS Level II, ICD‑10‑CM/PCS, and other claim attributes designated by VA. Payment groupers/classifications (e.g., MS‑DRGs, APCs) and claim edits (e.g., NCCI, MUEs) will be captured as linked metadata and not treated as procedure code systems.

CCRGs apply to both network and non‑network community care. Services outside the authorized CCRG and VA Code Set scope require submission of a Request for Services (RFS) to VA for separate clinical review and authorization.

1.2 Purpose

The purpose of this effort is to obtain professional services to develop, refine, validate, maintain, and deliver VA‑approved, CCRG‑aligned VA Code Sets and associated supporting data. The requirement is for professional services and data deliverables; a contractor‑hosted software platform, terminology service, direct production‑system integration, or ongoing transaction‑processing service is not required. The contractor will perform technical mapping from CCRG clinical guidance to billable codes, maintain the VA Code Sets in response to national coding changes and VA direction, and deliver structured, adjudication‑ready files to VA on a defined recurring schedule.

2. SCOPE

The contractor shall provide all personnel, management, tools, industry data licenses, quality assurance, and subject matter expertise necessary to perform the following:

1. Review each VA-assigned CCRG, existing VA Code Sets, historical code lists, and related materials; identify gaps, overlaps, inconsistencies, and obsolete content;

and develop, validate, or revise the corresponding VA Code Set for the CCRGs, categories of care, and specialties identified by VA.

2. Maintain and update VA Code Sets and associated rule metadata to reflect applicable changes in official code systems and classifications, VA-created codes, VA-authored CCRGs, VA Payment Guidelines, VA Clinical Determination and Indications (CDIs), and other VA-approved coding, authorization, adjudication, or payment requirements and written VA direction.

3. Deliver structured, version-controlled, adjudication-ready code set files to VA on a VA-approved recurring schedule (see Section 4.3).

4. Support VA validation and acceptance of each deliverable prior to VA transmission to TPAs.

5. Manage discrepancies and errors identified during VA review, TPA testing/implementation, or production use.

6. Provide supporting evidence for code-set recommendations in the applicable deliverable. Provide standalone benchmark data and analytic services only when expressly ordered under Deliverable D2C or another authorized instrument.

When benchmark information is used to substantiate a recommendation, include sufficient supporting evidence in the applicable VA Code Set deliverable: source, methodology, relevant population, measurement period, findings, limitations, and how the evidence supports the recommendation. This supporting evidence is included within the scope and price of the applicable deliverable.

Standalone benchmark datasets, custom analyses, utilization studies, payment comparisons, anomaly‑detection analyses, specialty trend analyses, or other analytic products are required only when expressly ordered under Deliverable D2C or another applicable instrument.

Benchmark data, analyses, findings, and contractor recommendations are advisory. They do not independently establish or modify VA coverage, authorization, quantity or frequency limits, medical‑necessity policy, utilization direction, reimbursement methodology, or payment requirements.

VA retains sole authority for CCRG clinical scope, coverage, medical‑necessity policy, utilization direction, reimbursement policy, prioritization, and final acceptance. The contractor shall map, analyze, validate, and document proposed code and rule content but shall not independently establish, interpret, or change VA coverage, authorization, utilization, or payment policy.

The contractor shall document and refer any ambiguity, inconsistency, or policy question to VA for written direction before incorporating the affected interpretation into a VA code set or related deliverable (see Section 4.5 Governance).

3. APPLICABLE DOCUMENTS AND STANDARDS

The contractor shall use the version of each applicable source that is effective for the date of service, code-set effective period, or release being developed or maintained.

The contractor shall apply the following order of precedence when sources address the same issue:

1. VA‑authored CCRGs and written VA artifacts designated by VA for this procurement (e.g., VHA directives, handbooks, procedure guides, payment guidelines, Clinical Determinations and Indications (CDIs), VA‑defined procedure codes, and other written VA policy materials) for determining VA clinical scope, coverage, authorization, utilization direction, and reimbursement policy;

2. Federal transaction and code-set requirements and official coding guidelines;

3. publications, instructions, and updates issued by the maintaining organization for each applicable code system;

4. Payment, edit, and grouper sources adopted or directed for use by VA; and

5. Specialty guidance, professional practice guidance, or benchmark evidence approved by VA.

This order of precedence does not permit VA policy to alter official code definitions, coding conventions, or federal transaction requirements, nor does it permit external sources or benchmarks to independently establish or modify VA coverage, authorization, utilization limits, medical‑necessity policy, or reimbursement policy.

The contractor shall document and refer any ambiguity, inconsistency, or conflict to VA for written direction before applying a conflicting interpretation in any approved code set or related deliverable (see Section 4.5 Governance).

Subject to the order of precedence, the contractor shall use additional sources when they materially affect code‑set content, authorization conditions, utilization controls, reimbursement logic, or deliverable acceptance, and only with VA’s written approval unless required by law or regulation. Any additional sources shall be identified in the mapping methodology and the applicable deliverable.

Applicable documents, standards, and authoritative sources include:

• 45 CFR Part 162, Subpart J—Code Sets, including 45 CFR §§ 162.1000, 162.1002, and 162.1011, as applicable to code-set deliverables intended to support transactions governed by 45 CFR Part 162.

• American Medical Association Current Procedural Terminology (CPT), including applicable code-set releases, errata, interim updates, CPT Assistant guidance, and other official AMA coding instructions.

• CMS Healthcare Common Procedure Coding System (HCPCS) Level II code set, including applicable quarterly updates, corrections, and official CMS instructions.

HCPCS Level II content may include durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS).

• CMS International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), including applicable updates and the Official ICD-10-CM Guidelines for Coding and Reporting.

• CMS International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS), including applicable updates and the Official ICD-10-PCS Coding Guidelines.

• CMS Medicare Severity Diagnosis-Related Group (MS-DRG) Grouper, Inpatient Prospective Payment System publications, and related annual or interim updates, when VA requires inpatient payment-grouping information.

• CMS Hospital Outpatient Prospective Payment System and Ambulatory Payment Classification publications, including applicable addenda, status indicators, payment indicators, and quarterly updates, when VA requires outpatient payment-classification information.

• American Dental Association Code on Dental Procedures and Nomenclature (CDT), including applicable annual updates and official ADA coding guidance, when dental services are within the scope of a CCRG.

• U.S. Food and Drug Administration National Drug Code (NDC) Directory and applicable official CMS drug-code crosswalks, reporting instructions, and related data files, when VA requires drug-product-level identification or NDC reporting.

o For drug identification and reporting, include HCPCS Level II J‑codes or NDCs only as directed by VA for the applicable claim context. When VA requires product‑level identification, use NDCs with the applicable official crosswalks and reporting instructions; when VA requires procedure‑level identification, use HCPCS J‑codes

• CMS Health Insurance Prospective Payment System (HIPPS) code set, master files, grouper documentation, and applicable technical specifications, when VA requires HIPPS information for an institutional claim or payment context.

• CMS Home Health Prospective Payment System regulations, manuals, grouper software, technical specifications, and official program instructions, when VA requires home-health claim-context or payment-grouping logic.

• National Uniform Billing Committee Official UB-04 Data Specifications Manual, including applicable type-of-bill, revenue, condition, occurrence, occurrence-span, value, patient-status, and related institutional claim codes.

• CMS Place of Service Code Set, when place-of-service information is required for professional claim processing or CCRG rule application.

o National Uniform Claim Committee Health Care Provider Taxonomy Code Set, when VA requires provider classification or specialty information to operationalize a CCRG. Modifiers, place‑of‑service, type‑of‑bill, revenue, condition, occurrence, occurrence‑span, value, patient‑status/discharge‑status, provider taxonomy, and similar claim attributes shall be represented as claim‑context metadata and linked rules when VA designates them as applicable; they are not part of the code‑set assignment.

• CMS National Correct Coding Initiative edits, including applicable practitioner and outpatient hospital procedure-to-procedure edits.

• Published CMS Medically Unlikely Edits.

• CMS Medicare Physician Fee Schedule publications and associated payment-guideline files, when adopted or directed for use by VA.

• CMS National Coverage Determinations and Local Coverage Determinations, when adopted or directed for use by VA.

• Applicable CMS regulations, manuals, transmittals, program instructions, coding guidance, payment-system publications, and other official CMS policy materials, when relevant to the code-set requirement and adopted or directed for use by VA.

• American Hospital Association Coding Clinic guidance, when applicable to the work and subject to applicable licensing and use restrictions.

• Applicable professional coding and practice guidance issued by recognized professional organizations, including AHIMA and AAPC, when relevant to the work and when such guidance does not conflict with applicable law or regulation, official CMS or other code-maintaining organization guidance, VA-authored CCRGs, or written VA direction.

• VA community care clinical guidance, VA payment-guidelines, directives, reimbursement rules, and coding instructions provided or identified by VA.

• VA-specific authorization conditions, bundling logic, utilization controls, reimbursement methodologies, and adjudication rules provided or approved in writing by VA.

• VA-approved benchmark data sources and supporting methodology documentation, when benchmark data or analytic support is expressly ordered under the contract.

CMS NCCI edits, published MUEs, LCDs, NCDs, payment-system files, grouper logic, claims-processing instructions, and other CMS payment or program policies shall be evaluated as reference sources and incorporated only to the extent applicable to the work and adopted or directed for use by VA. The contractor shall identify any confidential, unavailable, nonapplicable, obsolete, or conflicting source content and shall refer the matter to VA for written direction.

The existence of a code, edit, grouping, payment indicator, or other data element in a CMS or other external source shall not independently establish or modify VA coverage, authorization, quantity or frequency limits, medical-necessity policy, or reimbursement policy.

The contractor shall obtain and maintain licenses, subscriptions, and source‑access rights assigned under the contract. Document any use, reproduction, disclosure, or downstream‑distribution restriction that affects VA’s or a TPA’s ability to receive, store, use, reproduce, or implement a deliverable. Inclusion of a proprietary source in this section does not grant any license or intellectual‑property rights.

4. TASKS AND DELIVERABLES

This section defines the tasks and deliverables required to develop, validate, maintain, and release VA‑approved CCRG‑aligned VA Code Sets. Work will be planned and executed in collaboration between VA and the contractor—sequencing and prioritizing CCRGs and categories of care, aligning schedules to VA review capacity and authoritative source cycles, and making controlled adjustments through the governance process when VA requirements, sources, or operational needs change.

4.1 Task 1 – Project Kickoff and Transition

4.1.1 Kickoff Meeting

Within 10 business days of contract award, the contractor shall conduct a kickoff meeting with the VA Contracting Officer’s representative (COR) and designated VA program staff.

The kickoff shall address, at a minimum:

• Project governance structure, decision authority, escalation paths, and points of contact;

• Scope, workload assumptions, estimated CCRG volume, and applicable ordering structure;

• VA and contractor points of contact, roles and responsibilities;

• Required Government-Furnished Information (GFI) and applicable receipt dates;

• VA input requirements (see Section 5)

• Contractor and VA responsibilities for licenses, subscriptions, data rights, downstream payment/adjudication use, and any VA‑approved systems or repositories used to store, transmit, or ingest deliverables;

• The authoritative-source hierarchy and process for resolving source or policy conflicts;

• Proposed sequencing and prioritization of initial CCRG specialties;

• Collaborative prioritization criteria, including batching of updates, alignment to VA review capacity, and handling of urgent/off‑cycle changes.

• Code-set development sequencing and planned delivery schedule;

• Requirements for complete files, replacement files, and change-only or delta files;

• File-naming, version-numbering, effective-date, and release-management;

• Secure transmission methods and applicable security and privacy requirements;

• TPA implementation requirements and required advance-delivery periods;

• Mapping, clinical review, coding review, VA payment-guideline applicability review, quality-assurance, regression-testing, and acceptance workflows;

• Discrepancy severity definitions, correction timelines, root-cause analysis, and escalation procedures;

• Status-reporting, risk-management, issue-management, and decision-log requirements;

• Benchmark-data or analytic-support requirements, when needed to support code set creation; and

• Readiness criteria for the first production code-set delivery.

The contractor shall document kickoff decisions, open questions, action items, responsible parties, and required completion dates in the applicable project-management records/plan.

4.1.2 Transition-In and Readiness Plan

Within five business days after the kickoff meeting, the contractor shall submit a Transition-In and Readiness Plan.

The Transition-In and Readiness Plan shall identify, at a minimum:

• Required Government-Furnished Information and the date each item is required;

• The status, completeness, and usability of GFI received;

• Required licenses, subscriptions, and proprietary-source access;

• Proposed staffing and availability of key personnel and subject matter experts and proposed meeting cadence;

• Contractor tools, repositories, configuration-management processes, and version-control processes;

• Applicable security, privacy, system-access, and data-handling prerequisites;

• The proposed initial specialty VA Code Sets, CCRG, or pilot;

• Required data-schema and data-dictionary decisions;

• Required test data, test scenarios, and expected outcomes;

• Known assumptions, dependencies, constraints, and unresolved policy questions;

• Initial risks and proposed mitigation actions;

• Readiness criteria for beginning production delivery;

• The proposed schedule to the first VA-accepted production code-set deliverable;

and

• A GFI receipt and quality log.

Each milestone that depends on GFI, system access, licenses, VA decisions, or VA-furnished technical specifications shall identify the required receipt or decision date. The contractor shall notify the COR in writing within three business days after identifying a missing, late, incomplete, or unusable dependency and shall describe the affected work, anticipated impact, and proposed mitigation. The contractor shall continue unaffected work.

Deliverable D1A – Transition-In and Readiness Plan

ITEM DETAIL

DUE Within five business days after kickoff

FORMAT Machine‑readable deliverables shall use VA‑approved formats, anticipated to include CSV, XLSX, or JSON as applicable;

human‑readable review workbooks shall use XLSX; narrative reports shall use Microsoft Word or PDF. Other formats (e.g., XML) may be accepted with prior VA approval. At VA direction, a supplemental HL7 FHIR R4 representation (e.g., ValueSet for code‑set assignment;

ConceptMap for mappings) may be provided to support interoperability.

SUBMISSION Delivered via a VA‑approved secure repository or transmission method (e.g., SharePoint, SFTP, encrypted email).

APPROVAL VA will provide written acceptance or consolidated comments within 15 business days. Acceptance shall be provided by the CO or an authorized COR acting within the scope of the COR’s written delegation.

Government silence or expiration of the review period shall not constitute acceptance.

4.1.3 Project Management Plan

Within 30 business days of contract award, the contractor shall deliver a Project Management Plan (PMP) that documents the approach, schedule, staffing plan, quality assurance approach, update cadence plan, and governance structure for the life of the contract.

The Project Management Plan shall include, at a minimum:

• Project scope and management approach;

• Work breakdown structure;

• Milestone schedule and performance baseline;

• CCRG or specialty sequencing and delivery plan;

• Responsibility Assignment Matrix or RACI;

• Staffing plan, including named or proposed key personnel, functional roles, surge capacity, backup coverage, and continuity procedures;

• Source-specific monitoring and release calendar;

• Configuration-management and version-control plan;

• Code-set data-management and repository approach;

• Data dictionary and deliverable-schema development approach;

• Licensing, source-access, data-rights, and downstream-use plan;

• Mapping methodology;

• Clinical, coding, reimbursement, and payment-policy review approach;

• Quality-assurance and independent-review approach;

• Regression-testing and adjudication-scenario test plan;

• VA validation and acceptance workflow;

• Discrepancy severity, correction, root-cause, and escalation process;

• Risk, issue, assumption, dependency, and decision-management processes;

• GFI receipt and quality-management process;

• Security, privacy, and data-handling approach;

• Communication, meeting, and reporting plan;

• Monthly, quarterly, urgent, and annual update approach;

• Urgent or off-cycle release process;

• Benchmark-data and analytic-support plan;

• Transition-out, repository-transfer, and knowledge-transfer plan; and

• Procedures for maintaining the plan throughout contract performance.

The contractor shall update the Project Management Plan when a material change occurs in approved scope, methodology, schedule, staffing, governance, security, technical requirements, or deliverable requirements. Proposed changes affecting a contractual requirement shall not be implemented without written authorization from the CO.

Deliverable D1B – Project Management Plan (PMP)

ITEM DETAIL

DUE Within 30 Business Days after contract award.

FORMAT Machine‑readable deliverables shall use VA‑approved formats, anticipated to include CSV, XLSX, or JSON as applicable;

human‑readable review workbooks shall use XLSX; narrative reports shall use Microsoft Word or PDF. Other formats (e.g., XML) may be accepted with prior VA approval. At VA direction, a supplemental HL7 FHIR R4 representation (e.g., ValueSet for code‑set assignment;

ConceptMap for mappings) may be provided to support interoperability..

SUBMISSION Delivered via a VA‑approved secure repository or transmission method (e.g., SharePoint, SFTP, encrypted email).

APPROVAL VA will provide written acceptance or consolidated comments within 15 business days of submission. Acceptance shall be provided by the CO or an authorized COR acting within the scope of the COR’s written delegation. Government silence or expiration of the review period shall not constitute acceptance.

4.2 Task 2 – VA Code Set Development

4.2.1 Mapping Methodology

The contractor shall develop, document, implement, and maintain a structured, repeatable, and auditable methodology for mapping each VA-authored CCRG to the applicable code, classification, grouping, rule, and claim-data content required by VA.

The methodology shall preserve the distinction between VA clinical or policy decisions and contractor technical mapping activities. The contractor shall not revise CCRG language or independently establish, interpret, or modify VA coverage, authorization, utilization, medical-necessity, or reimbursement policy.

The methodology shall include, at a minimum, the following activities:

A. CCRG Intake and Requirements Validation

• Confirm the CCRG identifier, title, version, effective date, specialty, and applicable categories of care.

• Identify the authorized clinical scope, exclusions, authorization conditions, quantity or frequency limits, settings of care, and other VA-directed restrictions for each category of care.

• Identify missing, inconsistent, or ambiguous CCRG or policy information.

• Document assumptions and refer unresolved clinical or policy questions to VA for written direction before incorporating the affected interpretation into an approved production release.

B. Clinical Scope Decomposition

• Decompose CCRG language into discrete, traceable categories of care and rule concepts.

• Identify the relationship between each category of care and the authorized clinical purpose.

• Distinguish services expressly authorized by the CCRG from services that are conditional, excluded, out of scope, or subject to additional VA authorization.

C. Identification of Applicable Codes and Data-Elements

Identify applicable content from authoritative sources designated by VA and include only those elements that apply to the CCRG, category of care, claim type, setting, payment context, or adjudication requirement.

• Identify content from multiple applicable authoritative sources designated by VA.

• Evaluate relevant code families, related code ranges, specialty overlaps, successor/predecessor codes, and applicable setting-specific variations.

• When furnished by VA, review existing VA code sets, prior versions, and known discrepancies.

• Include only elements VA designates as applicable for the CCRG, category of care, claim type (institutional/professional), setting, payment context, or adjudication requirement.

• Perform gap, overlap, mismatch, and duplicate analysis to reduce omissions and inappropriate inclusion.

Depending on the CCRG, claim context, and VA-defined operational requirement, applicable elements may include:

• CPT – Current Procedure Terminology (all levels)

• HCPCS – Health Care Common Procedure Coding System (all levels) o –HCPCS Level II (maintain by CMS)

• ICD-10 – International Classification of Diseases, 10th edition

• ICD-10-PCS – ICD-10 Procedure Coding System.

• NDC – National Drug Codes

• RUG-III and RUG-IV

• Health Insurance Prospective Payment System (HIPPS) codes

• VA – specific procedure codes;

• Other non-code set attributes identified by VA.

The contractor shall include a code, classification, payment grouping, or claim attribute only when VA identifies it as applicable to the CCRG, service category, claim type, setting, payment context, or adjudication requirement.

For each included element, the contractor shall document its claim context, rule purpose, source, applicable effective period, and relationship to the authorized clinical scope. The presence of an element in the list above does not make that element applicable to every CCRG or deliverable.

Claim attributes (e.g., modifiers, place of service, type of bill, revenue codes, condition, occurrence, occurrence span, value, patients tatus/discharge status, provider taxonomy) are represented as claim context metadata and linked rules when VA designates them as applicable; they are not part of the VA code-set assignment.

D. Structured Layer Separation

The contractor shall maintain separate but linked information categories:

1. Clinical scope and code‑set assignment (authorized codes by category of care);

2. Authorization conditions (exceptions, and additional-authorization requirements);

3. Utilization attributes/controls (units, quantity, and frequency) directed by VA;

4. Claim-context attributes/metadata (setting, claim type, provider type, modifier, and place of service, etc);

5. Payment, edit, and grouper metadata (e.g., NCCI, MUEs, MS‑DRG, APC) adopted or directed by VA;

6. Source evidence and VA decisions; and

7. Benchmark/analytic evidence (when used or separately ordered). Represent conditions through structured fields and linked rules, not free‑text notes.

A code or data element may have different statuses based on the category of care, date, setting, claim type, modifier, provider type, or other VA-approved condition. The contractor shall represent those conditions through structured fields and linked rules rather than through free-text notes alone.

E. Code and Rule Classification

The contractor shall apply VA-approved status and rule values to distinguish, as applicable:

• Allowed content;

• Conditionally allowed content;

• Excluded content;

• Bundled or separately non-payable content;

• Content requiring additional authorization;

• Informational or payment-grouping content; and

• Content awaiting a VA policy decision.

Status values, rule types, and their definitions shall be established in the VA-approved data dictionary. The contractor shall not use an undefined status or create a new status with policy implications without VA’s written approval.

F. Utilization and Authorization Controls

The contractor shall apply quantity, frequency, unit, place‑of‑service, and provider‑type controls only when specified in a VA‑authored CCRG or provided/approved in writing by VA.

The contractor may identify utilization or potential over-utilization patterns, benchmark findings, or coding concerns for VA review; such findings are advisory and shall not independently establish VA limits or policy.

G. CMS Edit, Coverage, and Payment References

The contractor shall evaluate applicable NCCI edits, published MUEs, LCDs, NCDs, payment-system files, grouper logic, and other CMS payment or program materials in accordance with Section 3.

The contractor shall apply only those CMS sources (and specific application rules) that VA has designated in writing as applicable to the CCRG, claim context, or payment function.

Separate VA direction is not required for each individual code or edit when the source and its application have already been approved. Request written VA direction when a source has not been designated, VA requirements differ from the source, or the source is ambiguous, confidential, unavailable, obsolete, non-applicable, or conflicts with another controlling requirement. The existence of a code, edit, grouping, or payment indicator in a CMS source shall not independently establish VA coverage, authorization, utilization limits, medical necessity, or reimbursement.

H. DMEPOS Requirements

HCPCS Level II content may include DMEPOS. The contractor shall include, exclude, or conditionally classify DMEPOS codes only in accordance with the applicable VA-approved CCRG scope and written VA policy distinguishing urgent, routine, and out-of-scope

DMEPOS.

A provider’s characterization of an item as urgent shall not, by itself, determine code-set inclusion or authorization.

The contractor shall document ambiguous DMEPOS items and refer them to VA for written direction before including the affected item or rule in an approved production release.

I. Review and Reconciliation

The contractor shall perform and document, as applicable:

• Multi-source reconciliation;

• Code-family and specialty-overlap review;

• Cross-taxonomy and cross-code-system reconciliation;

• Gap and omission analysis;

• Duplicate and conflicting-rule analysis;

• Retired, invalid, revised, and replacement-code analysis;

• Effective-date and termination-date validation;

• Historical-version reconciliation;

• Clinical subject matter expert review;

• Certified coding specialist review;

• Reimbursement and payment-policy specialist review; and

• Final quality-assurance review performed by personnel independent of the original mapping activity.

The contractor shall document the basis for each material inclusion and exclusion decision and maintain traceability from the CCRG service category to the applicable code, rule, source evidence, review action, and VA decision.

J. Minimum Record-Level Metadata

At a minimum, each code-set record or linked rule shall contain the following fields when applicable:

• VA code-set identifier;

• VA code-set name;

• CCRG identifier;

• CCRG version;

• CCRG effective date;

• CCRG category of care;

• Code system or classification;

• Authoritative code-system identifier, when required by the VA-approved schema;

• Code or classification value;

• Official display text or description, only when applicable licenses and delivery rights permit its inclusion;

• Code-system version or release;

• Inclusion status;

• Rule or condition type;

• Claim context;

• Setting of care;

• Applicable modifier;

• Place of service;

• Type of bill;

• Revenue code;

• Provider taxonomy;

• Unit, quantity, or frequency attribute;

• Effective date;

• Termination date;

• Source publication;

• Source citation or source-file reference;

• Inclusion or exclusion rationale;

• Predecessor or successor relationship;

• Known limitation or unresolved issue;

• Clinical review status;

• Coding review status;

• Payment-guideline review status

• CDI;

• Quality-assurance status;

• VA decision or acceptance status;

• Release version; and

• Last-modified date.

VA shall review and approve the data dictionary, permitted values, field definitions, cardinality rules, data relationships, and required fields before the contractor submits the first production code-set deliverable.

K. Use of Automation, Artificial Intelligence, or Machine Learning

Use of automation, artificial intelligence, machine learning, natural-language processing, or similar technology is optional unless expressly required by VA.

When used, such technology may support candidate identification, comparison, reconciliation, or anomaly detection but shall not replace accountable human clinical, coding, payment-policy, and quality-assurance review.

The contractor shall disclose:

• The tool and applicable use case;

• Whether the tool or model is contractor-owned, commercially provided, or developed specifically for the contract;

• The source data used;

• The validation methodology;

• Known limitations and error controls;

• Required human-review points;

• How generated results are distinguished from human-approved results; and

• Any VA data processed by the tool.

The contractor shall not use VA data to train, retrain, or improve a model or service outside performance of this contract without prior written authorization from the CO and satisfaction of all applicable VA security, privacy, data-rights, and records-management requirements.

4.2.2 Initial Code Set Development

VA will identify the initial pilot CCRG or specialty, the priority sequence for subsequent CCRGs, and the applicable workload inventory described in Section 4.2.3.

The contractor shall develop each code set using the VA-approved mapping methodology, data dictionary, deliverable schema, quality-assurance process, validation requirements, and source hierarchy established under this PWS.

Before beginning development of a code set, the contractor shall:

• Confirm receipt of the applicable finalized CCRG and required Government- Furnished Information;

• Confirm the CCRG identifier, version, effective date, specialty, service categories, clinical scope, and applicable VA policy direction;

• Identify the code systems, classifications, groupers, edits, claim attributes, and supporting sources applicable to the assignment;

• Identify any missing, incomplete, inconsistent, or ambiguous information;

• Document assumptions, dependencies, constraints, and open policy questions;

• Refer unresolved clinical, authorization, utilization, reimbursement, or policy questions to VA for written direction; and

• Confirm that the applicable VA-approved schema, secure delivery method, review workflow, and acceptance criteria are available.

The contractor shall not incorporate an unresolved contractor interpretation into an approved production code set when that interpretation could establish or modify VA clinical scope, coverage, authorization, utilization, medical-necessity policy, or reimbursement policy.

Pilot Development

The contractor shall first develop and submit a pilot code-set package for the CCRG or specialty identified by VA. The pilot shall use the complete proposed production methodology and deliverable package and shall not be limited to a demonstration, sample extract, or partial schema unless VA specifically directs otherwise in writing.

The pilot shall be used to validate, at a minimum:

• The mapping methodology;

• The decomposition of CCRG clinical scope into service categories;

• The proposed code and rule classifications;

• The data dictionary and machine-readable schema;

• The use of claim-context attributes;

• Source traceability;

• Inclusion and exclusion rationale;

• Quality-assurance procedures;

• Adjudication-scenario and regression testing;

• The VA review and acceptance workflow;

• File transmission and processing;

• Change-log and version-control conventions; and

• The contractor’s estimated production capacity and delivery schedule.

The contractor shall address VA comments, correct identified deficiencies, and update the methodology, schema, validation process, or Project Management Plan when required by

VA.

The contractor shall not begin full-scale code-set production of the remaining CCRGs until VA provides written acceptance of the pilot or written authorization to proceed concurrently. VA authorization to proceed concurrently shall not constitute acceptance of the pilot or waive correction of identified deficiencies.

Delivery Group Development

Following VA acceptance of the pilot or written direction to proceed, the contractor shall develop and submit the remaining assigned CCRGs in VA-approved delivery groups.

The Project Management Plan and associated delivery schedule shall identify, for each delivery group:

• Included CCRGs and specialties;

• Estimated number of service categories and code-set records;

• Applicable code systems and claim contexts;

• Known complexity factors;

• Required Government-Furnished Information;

• Contractor development and quality-assurance periods;

• VA review capacity and review period;

• Contractor correction and resubmission period;

• Dependencies on policy decisions, licenses, technical specifications, or other releases;

• Planned submission date;

• Planned acceptance date;

• Required TPA handoff date, when applicable; and

• Planned effective date.

Each submitted code set shall be complete for its VA-approved scope and shall be capable of being reviewed independently. The contractor shall not defer required content to a later delivery group unless VA approves the deferral in writing and the deliverable identifies the deferred content, reason, responsible party, and planned resolution date.

The contractor shall maintain cumulative schedule and production metrics sufficient to identify developing backlogs, review-capacity constraints, recurring mapping issues, and risks to future releases. The contractor shall report material schedule variance or projected delay in accordance with Section 4.5.

4.2.3 Specialties and Workload Inventory

As of the effective date of this PWS, VA anticipates approximately 373 active CCRGs. The detailed inventory will be provided as Government‑Furnished Information and maintained throughout performance.

4.2.4 Benchmark Data and Analytic Support

This section applies only when VA expressly orders a standalone benchmark dataset, custom benchmark analysis, utilization study, payment comparison, anomaly-detection analysis, specialty trend analysis, or other analytic product under Deliverable D2C.

This section does not apply to source citations, supporting research, or limited benchmark evidence used by the contractor to substantiate a recommendation contained in a code-set deliverable. Such supporting evidence shall be included in the applicable D2A, D2B, D3, or D5 deliverable and shall not be separately priced.

When separately ordered the contractor shall provide aggregated benchmark data or analyses to support one or more of the following:

• Code-set completeness assessment;

• Identification of potentially omitted or mismatched codes;

• Utilization review and comparisons;

• Payment-guideline or reimbursement comparisons;

• Coding, utilization, or payment anomaly analyses;

• Geographic, payer, provider, or specialty service comparisons;

• Trend analysis; or

• Other VA-defined analytic requirements.

Each ordered benchmark requirement shall identify, at a minimum:

• The intended use;

• Required deliverable or decision to be supported;

• Applicable VA Code Sets or CCRGs

• Data-source restrictions;

• Required Population;

• Payer composition;

• Geographic scope;

• Measurements and measurement period;

• Comparison groups

• Data-source restrictions;

• Required methodology;

• Refresh cadence;

• Required level of reproducibility;

• Delivery format;

• License and downstream-use requirements;

• Due date; and

• Acceptance criteria.

For each benchmark source or analysis, the contractor shall document, as applicable:

• Data source and data owner;

• Source license and use restrictions;

• Population and inclusion and exclusion criteria;

• Payer composition;

• Geographic scope;

• Provider or facility types;

• Applicable clinical or claim setting;

• Measurement period;

• Data lag;

• Refresh date and refresh cadence;

• Sample size;

• Unit of analysis;

• Measure definition;

• Statistical methodology;

• Normalization or risk-adjustment methodology;

• Handling of outliers, missing information, and suppressed values;

• Known source limitations;

• Material differences between the benchmark population and VA Community Care;

• Reproducibility information;

• Permitted and prohibited uses; and

• Applicable privacy, security, retention, and destruction requirements

The contractor shall distinguish observed benchmark results from contractor interpretations and recommendations. The contractor shall document the evidence supporting each conclusion and shall identify material uncertainty or data limitations/concerns.

Benchmark data, analyses, findings, and recommendations are advisory. They shall not independently establish or modify VA coverage, authorization, quantity or frequency limits, medical-necessity policy, utilization direction, or reimbursement methodology, or payment requirements.

Deliverable D2A – Pilot Code-Set Package

ITEM DETAIL

DUE Per agreed upon timeline set in the VA-Approved Project Management Plan and pilot schedule.

FORMAT Required package: The pilot package shall include, at a minimum:

1. A complete current code-set file in the VA-approved machine-readable schema;

2. A human-readable review workbook or other VA-approved review format;

3. A delta file from an existing VA baseline, when an applicable baseline exists;

4. The proposed data dictionary, schema, relationship rules, permitted values, and field-level validation requirements;

5. A release manifest identifying file names, file purposes, record counts, source versions, effective dates, file sizes, and checksums;

6. A complete change log, when applicable;

7. A CCRG and service-category-to-code, rule, and source-evidence traceability matrix;

8. A source and version inventory;

9. An inclusion and exclusion rationale;

10. A quality-assurance report;

11. Adjudication-scenario and regression-test cases and results;

12. An assumption, exception, and known-issue log;

13. An open VA policy-decision log;

14. An implementation-impact summary;

15. Implementation, supersession, and rollback instructions;

16. A list of applicable proprietary-source and downstream-use restrictions; and

17. A release and readiness certification signed by the Program Management and Quality Assurance personnel.

Machine‑readable deliverables shall use VA‑approved formats, anticipated to include CSV, XLSX, or JSON as applicable;

human‑readable review workbooks shall use XLSX; narrative reports shall use Microsoft Word or PDF. Other formats (e.g., XML) may be accepted with prior VA approval. At VA direction, a supplemental HL7 FHIR R4 representation (e.g., ValueSet for code‑set assignment;

ConceptMap for mappings) may be provided to support interoperability.

SUBMISSION Delivered via a VA‑approved secure repository or transmission method (e.g., SharePoint, SFTP, encrypted email).

APPROVAL VA will provide written acceptance or consolidated comments within 10 business days of submission. Acceptance shall be provided by the CO or an authorized COR acting within the scope of the COR’s written delegation. Government silence or expiration of the review period shall not constitute acceptance..

Deliverable D2B – Initial and Scheduled Delivery of Code-Set Packages

ITEM DETAIL

DUE In accordance with the VA-approved delivery schedule established in the Project Management Plan.

FORMAT Each delivery shall contain the complete delivery package identified for Deliverable D2A, using the accepted data dictionary, schema, methodology, and quality-assurance process, as subsequently modified through approved change control.

When a delivery group or schedule changes or replaces previously delivered content, the package shall include both:

• A complete replacement file containing the full code-set content applicable to the release; and

• A delta file identifying changes from the immediately preceding VA-accepted release.

Machine‑readable deliverables shall use VA‑approved formats, anticipated to include CSV, XLSX, or JSON as applicable;

human‑readable review workbooks shall use XLSX; narrative reports shall use Microsoft Word or PDF. Other formats (e.g., XML) may be accepted with prior VA approval. At VA direction, a supplemental HL7 FHIR R4 representation (e.g., ValueSet for code‑set assignment;

ConceptMap for mappings) may be provided to support interoperability.

SUBMISSION Delivered via a VA‑approved secure repository or transmission method (e.g., SharePoint, SFTP, encrypted email).

APPROVAL VA will provide written acceptance or consolidated comments within 15 business days of submission, unless a different period is established in the approved release schedule. Acceptance shall be provided by the CO or an authorized COR acting within the scope of the COR’s written not constitute acceptance.

Deliverable D2C – Benchmark Data Package

Required only when VA expressly orders a standalone benchmark dataset, custom benchmark analysis, utilization study, payment comparison, anomaly-detection analysis, specialty trend analysis, or other analytic product. Contractor supporting evidence used to substantiate a code-set recommendation is not a D2C deliverable and shall be included in the applicable code-set package.

ITEM DETAIL

DUE Per agreed delivery schedule established in the PMP

FORMAT the package shall include, as applicable:

• Machine and human-readable benchmark data or analytic results;

• Data dictionary;

• Source and license inventory;

• Methodology report;

• Population and measure definitions;

• Quality-assurance results;

• Reproducibility materials;

• Limitations and comparability assessment;

• Executive summary;

• Contractor findings and recommendations, clearly distinguished from observed results; and

• Permitted-use and downstream-distribution restrictions.

human‑readable review workbooks shall use XLSX; narrative reports shall use Microsoft Word or PDF. Other formats (e.g., XML) may be accepted with prior VA approval. At VA direction, a supplemental HL7 FHIR R4 representation (e.g., ValueSet for code‑set assignment;

ConceptMap for mappings) may be provided to support interoperability.

SUBMISSION Delivered via a VA‑approved secure repository or transmission method (e.g., SharePoint, SFTP, encrypted email).

APPROVAL VA will provide written acceptance or consolidated comments within 15 business days of submission. Acceptance shall be provided by the CO or an authorized COR acting within the scope of the COR’s written not constitute acceptance.

4.3 Task 3 – Routine Maintenance and Update Deliverables

The contractor shall monitor, maintain, and update all active VA-accepted VA code sets throughout the period of performance.

Maintenance shall include applicable changes to code systems, classifications, payment groupers, edits, claim attributes, official coding guidance, VA-authored CCRGs, and written VA policy direction.

The contractor shall maintain traceability between each release and the applicable:

• CCRG version;

• Source publication;

• Code-system or classification version;

• Effective period;

• VA policy decision;

• Change record;

• Quality-assurance evidence;

• Test evidence; and

• Prior and subsequent releases.

The contractor shall not assume that all code systems, edit files, groupers, payment files, and policy sources share the same publication schedule or effective-date cycle.

4.3.1 Update Cadence and Release Management

A. Source-Specific Monitoring

The contractor shall maintain a source-specific release calendar for each authoritative source applicable to active VA code sets.

The release calendar shall identify, at a minimum:

• Source name;

• Responsible code-maintaining or issuing organization;

• Current version;

• Expected publication date;

• Actual publication date;

• Effective date;

• Known amendment or correction cycle;

• Applicable active VA code sets;

• Preliminary impact assessment;

• VA policy decision required, if any;

• Contractor analysis period;

• Planned VA submission date;

• VA review period;

• Contractor correction and resubmission period;

• Required TPA handoff date, when applicable;

• Planned production effective date; and

• Identified schedule risk.

The contractor shall monitor applicable authoritative sources on an ongoing basis and shall formally document the monitoring results at least monthly.

B. Standard Production Releases

Standard production releases shall follow a quarterly baseline schedule. VA may establish a different cadence for a particular VA Code Set, or release when necessary to align with source publication or effective dates, VA CCRG or policy changes, urgent operational requirements, or TPA implementation needs. Source-specific, annual, interim, correction, and urgent/off-cycle changes are managed in accordance with this section.

The contractor shall incorporate applicable annual, fiscal-year, quarterly, interim, as needed corrections or amendments, and other source changes based on:

• The source publication date;

• The source effective date;

• The applicable date-of-service requirement;

• VA’s implementation direction;

• The required VA review period;

• The required contractor correction period; and

• The required TPA implementation period.

A standard quarterly production release may include content from sources with different effective dates. The contractor shall preserve the effective and termination dates applicable to each code, rule, classification, or data element and shall not assign a common effective date when the underlying sources or VA direction require different dates.

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