Attachment 1 Medical Network West PWS.docx

DEPARTMENT OF VETERANS AFFAIRS

VHA Office of Integrated Veteran Care Integrated External Networks

Community Care Network Next Generation Medical Network - West Performance Work Statement

Version 1.1 May 29, 2025

Table of Contents

DRAFT

PRE-DECISIONAL DRAFT DRAFT

GENERAL INFORMATION

Introduction The Department of Veterans Affairs (VA) Veterans Health Administration (VHA) Office of Integrated Veteran Care (IVC) is a national program office that manages and advocates for Veterans' and beneficiaries' access to health care in both VA and community facilities. IVC administers Veteran and Family Member/Beneficiary Programs such as the Community Care Network (CCN). CCN is a complex and diverse system of healthcare services, delivering timely, accessible, and high-quality care to Veterans. The complete network delivers medical, surgical, complementary, and integrative health services, durable medical equipment, pharmacy, and dentistry services. CCN services and healthcare resources are purchased under the authority of 38 United States Code (U.S.C.) § 1703, Veterans Community Care Program. Currently, there are five (5) regional CCN contracts in place, and VA is now ready to solicit for the next phase called “CCN Next Generation.” CCN Next Generation services will be delivered through a suite of contracts, organized around the following domains:

CCN Next Generation Medical Network: East and West regional medical and pharmacy networks and claims processing CCN Next Generation Dental Network: national dental network and claims processing This Performance Work Statement (PWS) is for CCN Next Generation Medical Network - West.

See CCN Next Generation Contractor Medical Manual for additional information.

Scope of Services The Contractor shall establish, maintain, and administer a network of healthcare providers and practitioners (“network providers”) for medical services as defined in 38 U.S.C. § 1703, per the requirements defined in this PWS, and in accordance with Section TBD, “SCHEDULE OF DELIVERABLES.”

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

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. This includes the latest versions of documents available on the CCN Next Generation Applicable Documents webpage. Updated documents will be posted on the webpage immediately upon their issuance. The Contractor is responsible for regularly checking the webpage, to ensure compliance with the most current versions of the applicable documents.

In addition to these applicable documents, the CCN Next Generation Medical Network Contractor Manual, hereinafter referred to as the Medical Manual, provides the Contractor with additional information, processes, and guidance associated with the requirements set forth in this PWS. This PWS takes precedence over the information within the CCN Next Generation Contractor Medical Manual. Semi-annual updates to the manual will be distributed to the Contractor by the Contracting Officer. Urgent changes outside of the semi-annual update schedule will be communicated at the direction of the CO. To the extent practicable, the Medical Manual Table of Contents mirrors the 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.”

PROJECT MANAGEMENT

The Contractor is required to effectively manage the project by overseeing all aspects of planning, execution, and monitoring to ensure the successful delivery of the contract’s defined outcomes. This includes developing detailed project plans, mobilizing appropriate resources, ensuring compliances with all contractual obligations, and achieving project milestones and deliverables on schedule.

Post Award and Contract Kickoff Meetings Within five days of the contract award, the Contractor shall participate a Post Award Meeting to be led by the CO. The date and location for this meeting shall be determined through a collaborative process between the Contractor and the CO to ensure mutual availability. Prior to the meeting, the Contractor shall identify key project personnel, including the project manager, transition team lead, and any other relevant stakeholders 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:

Initiate the communication process between VA and Contractor including:

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

· Identification of Contractor and VA stakeholder’s roles and responsibilities 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 Establish action items/next steps, confirm dates, locations, expectations and agenda for the Kickoff Meeting 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 and Contracting Officer’s Representative (COR). The Contractor shall create and deliver a comprehensive presentation at the Kickoff Meeting that outlines the approach, methodologies, and timelines for all contract deliverables aligning with the specifications in Section TBD, 'SCHEDULE OF DELIVERABLES. The Kickoff Meeting presentation shall be delivered 15 days prior to the Kickoff Meeting. The Contractor shall provide the names and roles of its transition team lead and members to facilitate clear communication and accountability throughout the contract implementation phase.

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

· Resolution of assigned action items from Post Award Meeting

· Approach to all deliverables in accordance with the expectations defined in Section TBD, “SCHEDULE OF DELIVERABLES”

· Approach to achieving go-live within the timelines specified in Section 2.3, “Deployment and Implementation”

· Approach to communications required to manage the overall CCN Next Generation Medical Network project to include:

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

· 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 TBD, “Community Care Network Stakeholders List” Action items and issues that require immediate response and coordination with VA

· Explanation of the Implementation Strategy including all key elements in 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

· System Access and Controls Manual for access to Contractor Systems, as described in Section 15.1, “Communication and Access to Contractor Systems”

· Explanation of the training approach which is addressed in the Training Plan described in Section 16.0, “Training” The Contractor shall record detailed meeting minutes of the Kickoff Meeting, which shall be submitted to the CO and the COR within five (5) business days post-meeting. These minutes shall comprehensively document all discussions, including any major issues, agreements, disagreements, and agreed-upon actions with specific timelines for resolving any actions and/or disputes.

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

Kickoff Meeting Presentation Kickoff Meeting Minutes and Action Items Integrated Master Schedule The Contractor shall create and maintain a fully resource-loaded and baselined Integrated Master Schedule (IMS) in a mutually agreed upon format that depicts the implementation and deployment of the CCN Next Generation Medical Network pursuant to this contract. The Contractor shall use the IMS to manage and report on all elements of the CCN Next Generation Medical Network.

The Contractor shall include the following in the IMS:

Work Breakdown Structure (WBS) to a minimum of three levels to define the activities, tasks, and outcomes 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 Critical path depiction showing tasks that, if delayed in completion, will impact the overall timeline; the Contractor shall notify the CO and the COR within one (1) business day when data is provided/entered that creates overall critical path slippage Planned (baselined IMS) versus actual program/project performance Milestones to measure progress toward completion of individual WBS elements The Contractor shall obtain written approval from the COR for all proposed changes to the IMS.

The IMS shall be submitted in MS Project to the CO and the COR five (5) business days prior to the Kickoff Meeting and updated quarterly as part of the Project Management Review (PMR) and as requested by the COR.

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

Integrated Master Schedule (IMS) 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 Section 3.4, “CCN Next Generation Regions.” The Deployment and Implementation Strategy shall be submitted with the Contractor’s proposal and shall incorporated into the contract at contract award.

The Deployment and Implementation Plan shall outline the implementation of all requirements in this PWS.

The Deployment and Implementation Plan shall also contain the Contractor’s Transition-in Plan that includes, but not limited to:

Planned transition meetings and schedule Transition execution steps with associated milestones ensuring seamless continuation of healthcare delivery Expected VA inputs to ensure effective transition Recruitment plan for bringing in current community providers into the network and how unilateral providers will be engaged The Contractor’s transition team shall be responsible for coordinating with VA and the outgoing Contractor(s) to identify the documentation, access to personnel (both VA and incumbent contractor), and system access necessary to begin the process of reaching operating capability to go-live. The Contractor shall provide a bi-weekly Deployment and Implementation Status Report on all activities related to implementation until go-live is achieved. The Status Report shall be aligned to the Deployment and Implementation Plan and shall specify activities occurring at each Station https://www.va.gov/directory/guide/ during the reporting period. The Deployment and Implementation Status Report shall demonstrate readiness prior to go-live at each Station. The CO and the COR will review and approve the Status Report. Upon approval, the CO will notify the Contractor that they shall initiate go-live activities. Go-live at each Station will be achieved upon CO and COR acceptance.

The Contractor shall achieve go-live in the CCN Next Generation Medical Network West Region no later than 18 months from contract award. Successful deployment in the CCN Region shall ensure operational readiness, provider network adequacy, and completed training. The Contractor shall:

Participate in on- and off-site readiness planning and deployment activities to ensure operational readiness and provider network adequacy (e.g., communication scripting, embedded staff participation in go-live activities, data reports) Conduct user acceptance testing in coordination with VA, completed and accepted by the CO and COR prior to go-live Provide the summary of testing and completed resolutions for the Contractor interactive voice response (IVR) and Contractor self-service portal for CO and COR acceptance of Fully Operational IVR and Contractor self-service portal Complete Contractor and network provider training requirements Stand-up and operate a Deployment Command Center which shall include information technology (IT) support, customer service, claims, and network support. Contractor staff within the Deployment Command Center shall provide the CO and COR with updates of network build issues, identified issues and plans for resolution, and status of network provider identification and recruitment as necessary.

Test and implement all technical solutions as described in Section 15.2, “Configuration Management and Testing” Deliverables: (See Section TBD, “SCHEDULE OF DELIVERABLES” for details.)

Deployment and Implementation Plan Deployment and Implementation Status Reports Risk Management The Contractor shall manage risks using the Project Risk Register in Attachment TBD, “Project Risk Register” which shall consist of risk and issue management processes. For each risk identified, the Contractor shall include severity of risk, volumes, associated impacts (system, 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. In addition, the Contractor shall report extreme impact risk(s) identified as causing significant harm or delay within 24 hours of their identification(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 Section TBD, “SCHEDULE OF DELIVERABLES” for details.)

Project Risk Register Contract Performance Management Quality Assurance Surveillance Plan 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.

While the QASP itself is not part of the contract, Attachment 1 of the QASP “Performance Requirement Summary” (PRS) is incorporated into the contract as an attachment to this PWS (see Attachment TBD). The QASP will be finalized upon contract award and a copy will be provided to the Contractor for informational purposes only. The CO may make unilateral changes to the QASP, as well as to any methods of surveillance, surveillance schedules, and frequencies of surveillance identified in the Performance Requirement Summary (PRS). Changes to the performance objectives, Acceptable Quality Levels (AQL) or standards, and incentives/disincentives identified in the PRS shall be executed via bilateral agreement between VA and the Contractor.

The Contractor shall meet all performance requirements established by the PWS and PRS. VA will assess performance and apply incentives and disincentives in accordance with the PRS and make equitable adjustments as determined by the CO.

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.

The Contractor’s QAP shall be submitted with its proposal and incorporated by reference into the contract upon contract award. 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. Any changes or updates to the Contractor’s QAP shall be submitted to the CO and COR for approval prior to implementing the changes or updates.

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

Quality Assurance Plan Quality Improvement Plan As requested by the CO and COR, 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 and COR 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, 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 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 Section TBD, “SCHEDULE OF DELIVERABLES” for details.)

Quality Improvement Plan Progress Reporting The Contractor shall develop and submit MPRs to the CO and COR. The Contractor shall utilize Attachment TBD, “MPR Template,” to populate and submit the MPR. The MPR shall include:

Work and Progress Summary

· Task Summary – summarizes the work that is being performed

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

· Actual Activities for the Preceding Month – summary of activities completed during the month

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

· Self-identified Corrective Actions and Improvements – categorized narrative listing of the operational corrective actions and improvements that were executed during the reporting period Risks and issues for all CCN Next Generation Medical Network – West activities Operations support activities Network adequacy outcomes during the reporting period, including any identified network inadequacies Customer service outcomes during the reporting period, including results of customer service quality reviews and customer service availability statistics Claims processing outcomes 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 draft the PMR materials using Attachment TBD, “PMR Template.” The PMR presentation shall include information contained in the MPRs for the most recent quarter, including but not limited to 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.

The PMR materials shall contain:

· IMS Status (see Section 2.2, “Integrated Master Schedule”)

· Risk status (see Section 2.4, “Risk Management”)

· Continuous Query (CQ) monitoring results (see Section 3.6, “Credentialing”)

· Provider satisfaction survey results (see Section 6.5, “Medical Provider Satisfaction Surveys”)

· Medical documentation return compliance information (see Section 9.4, “Medical Documentation Compliance”)

· Key metrics and fraud and abuse summary report (see Section 13.2, “Predictive Analytics”)

· Program and payment integrity site visit findings (see Section 13.18, “Program and Payment Integrity Site Visits”)

· Patient safety reports (see Section 14.2.1, “Reporting”)

· Value-Based Care report (see Section 14.6.1, “Value-Based Care Model”) The Contractor shall participate in ad hoc project related meetings as requested by VA.

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

Monthly Progress Report Project Management Review Materials 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 Auditing Standards Board and will provide the CO and COR with a written copy of the SOC 1 Type 2 examination report (hereby known as the “Prime Report”). The independent auditing firm shall have 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 will address the specific services provided by the Contractor to VA under the contract. The current guidance for SSAE 21 was issued in April 2016, SSAE 21 Audits | 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 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.

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 nine (9) months from contact award. Any deviation to the 9 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 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 and COR from the Contractor’s senior management and shall specify the coverage begin and end dates. The Bridge Letter shall include Contractor management’s assertion 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 COR 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 Section TBD, “SCHEDULE OF DELIVERABLES” for details.)

SOC 1, Type 2 – Prime Report SOC 2, Type 2 – Prime Report SOC 1, Type 2 – Subcontractor Report SOC 2, Type 2 – Subcontractor Report SOC 1 and SOC 2 Bridge Letters Contractor Maintained Records Upon written request from the CO and COR, the Contractor shall provide any and all records, information, and data in its possession, custody, or control in the requested format, including, but not limited to, claims data, raw X12 electronic data interchange (EDI) data and metadata; claims images; medical records; network provider agreements; accreditation, credentialing and certification documentation; delegation of certification agreements; licensing files; competency measures; Federal exclusionary list matching; quality and safety issues submitted by VA facilities and all related reviews, data, and actions taken in response to quality and safety issue concerns; utilization management (UM) and review documentation; 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.

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.

Transition Out The Contractor shall perform the Transition Out and residual service tasks below for this contract. 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 support customer service for healthcare that was previously delivered. All parties involved in Transition Out services shall ensure minimal disruption of services to Veterans receiving care and network providers delivering care.

Transition Out activities shall include the following:

Delivery of a Transition 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 Provide retroactive processing of referrals and claims adjudication for authorized care up to 180 days following go-live of the new contract Processing of all open healthcare claims inventories (the outgoing Contractor shall submit weekly status reports of claim inventories and phase-out activities to the CO and COR beginning the 20th day after notification from the CO to commence transition out activities) Transitioning open referrals to an incoming Contractor, as directed by the CO 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 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 Removal and purging of all non-public or other Government-furnished information from any Contractor-owned system, and providing certification of execution to the CO and COR Update of the 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) Development of a 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 be delivered to the CO and COR. After VA approval of the Transition Out Plan and Update, the Contractor shall execute the plan.

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

Transition Out Plan and Update Weekly Status Report of Claims Inventories and Phase-Out Activities Government-owned Asset Inventory List

MEDICAL NETWORK DEVELOPMENT AND MAINTENANCE

Medical Network Establishment and Maintenance The Contractor shall establish, maintain, and manage a High Performing CCN Next Generation Medical Network consisting of a comprehensive network of qualified healthcare providers and practitioners. The Contractor shall ensure that network providers have a signed and executed network agreement.

The Contractor shall provide the services set forth in Section 4.0, “CCN Health Benefit Package.”

The Contractor shall maintain a network of facilities, providers, and practitioners that extends across the entirety of the CCN Next Generation Medical Network West Region and is sufficient in size, scope, and capacity to ensure that all services are accessible within the minimum network adequacy standards found in “Table 1. Network Adequacy Standards.”

Measurement of Network Adequacy will be comprised of two elements: drive time and appointment availability. The combination of these elements ensures the adequate build and proper maintenance of the network.

Drive times are defined as the time required to drive between the Veterans’ official residence (as determined in the eligibility and enrollment system) 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 Section 3.7, “Medical Network Provider Data for VA’s Provider Directory”). Drive times shall be determined using the Contractor’s geo-mapping solution.

CCN Next Generation Medical Network adequacy standards for appointment availability shall be measured based on the amount of time, calculated in calendar 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. Emergency room care and urgent care, as well as 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 shall comply with network adequacy standards at individual VA Medical Center (VAMC) catchment area level and by specific categories of care.

When medically appropriate and based on Veteran preference, network providers may provide Telehealth services to improve access and meet network adequacy standards.

Table 1- Network Adequacy Standards Drive Times – Primary Care Provider (PCP)/ Behavioral Health (BH)*

Drive Times – Specialty Care, Emergency Room, Urgent Care, Complimentary and Integrated Health Services (CIHS)

Geriatrics and Extended Care Services Appointment Timeliness

· Homemaker/Home Health Aide

· In Home Respite

· Community Adult Day Health Care

· Veteran Directed Care Seven (7) Days

· Community Nursing Home

· Brain Injury Residential Rehabilitation

· Skilled Home Health Care

· Hospice

· Home Infusion and Ambulatory Fusion Suites

· Bowel & Bladder - Agency Three (3) Days

PCP/BH & Specialty Care Appointment Timeliness

Maximum Drive Times to Network Pharmacy*

*Note: Rurality is uniquely defined for each Veteran by VA.

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 Section 3.1, “Medical Network Establishment and Maintenance.”

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

Approach to building and maintaining a network with sizing and capacity specific to each VAMC within the region including details on the numbers and types of providers entering the CCN Next Generation Medical Network – West (including those from other contractors, Federally Qualified Healthcare Centers (FQHCs), and VA-identified preferred providers) Recruitment and communication plan for transitioning currently contracted providers into the CCN Next Generation Medical Network – West through unilateral and bilateral agreements Geo-mapping drive time calculations solution and providing VA access to that solution Identification of areas and services that may require a network adequacy deviation Management of short notice network needs, including engagement with VAMCs and consistent representation at monthly network adequacy meetings, as described in Section 3.3, “Network Adequacy Management” Communication plan and approach to managing care for Veterans that reside outside of the region The Contractor shall submit the CCN Next Generation Medical Network Adequacy Plan with the proposal. The CCN Next Generation Medical Network Adequacy Plan shall be incorporated into the contract upon VA approval. The Contractor shall execute in accordance with the CCN Next Generation Medical Network Adequacy Plan.

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

CCN Next Generation Medical Network Adequacy Plan Medical Provider Network The Contractor shall identify, contact, negotiate, and contract with hospitals, physicians, and other healthcare professionals and practitioners within the CCN Next Generation Medical Network - West (see Section 3.4, “CCN Next Generation Regions”). Additionally, the Contractor shall ensure that the providers it contracts with understand the requirements of the CCN Next Generation Medical Network and their role as a network provider.

The Contractor shall ensure the CCN Next Generation Network is always composed of a comprehensive network of licensed and credentialed healthcare providers, unless licensure or accreditation is not applicable to such providers, to deliver the services identified in Section 4.0, “CCN Health Benefit Package,” and to meet the network adequacy standards in Section 3.1, “Medical Network Establishment and Maintenance.”

The Contractor shall make every reasonable attempt to include academic teaching facilities (academic affiliates), FQHCs, and Tribal Health Providers (THPs) as part of the CCN Next Generation Medical Network. VA will provide a list of THPs to the Contractor at award. The Contractor shall provide documentation to the CO and COR of the reasons and rationale when academic affiliates, FQHCs, or THPs do not join the network as part of the Medical Network Build Report described below. The Contractor shall annotate academic affiliates, FQHCs, and THPs within the data provided to VA for the provider directory.

The Contractor shall make every attempt to enroll out-of-network providers and providers in the legacy CCN that have current referrals from VA, allowing Veterans to remain with their existing providers. The Contractor shall ensure all providers will be considered for inclusion in the network and not be denied or placed on a wait list due to network adequacy in that given area. Denials are appropriate as detailed under Section 3.6, “Credentialing.”

The Contractor shall develop a Medical Network Build Report to provide VA with an ongoing update of network status, build issues, plan for resolution, identification of providers to recruit, and status of recruitment. The Medical Network Build Report shall be submitted to VA weekly and contain elements described in the Medical Network Build Report Contents (Attachment TBD).

The Contractor shall supply additional or modified data at VA’s request.

VA reserves the right to request the Contractor to recruit specific providers and/or provider groups into the CCN Next Generation Medical Network.

Deliverable: (See Section TBD, “SCHEDULE OF DELIVERABLES” for details) Medical Network Build Report Mobile Healthcare Services The Contractor may offer mobile services in accordance with state regulations to supplement the CCN Next Generation Medical Network and improve access specifically related to appointment timeliness. If the Contractor elects to utilize mobile services after go-live, then the Contractor shall submit a Mobile Healthcare Services Delivery Plan for the specific location(s) at the station level 30 business days prior to the intended implementation date of mobile healthcare services. The CO and COR must approve the Plan prior to the Contractor implementing mobile healthcare services.

Unless specifically directed by the CO, mobile healthcare services shall not be delivered on VA property.

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

Mobile Healthcare Services Delivery Plan Network Adequacy Management The Contractor shall monitor network adequacy, including any gaps or deficiencies.

The Contractor shall notify VA of potential network inadequacies in the Medical Network Build Report and in MPR.

Through a consistent point of contact, with authority to act on network adequacy issue resolution, the Contractor shall support monthly network adequacy meetings per Station facilitated by VA stakeholders https://www.va.gov/directory/guide/. Additionally, the Contractor shall support VA-requested ad hoc meetings limited to no more than two times per month per Station. At VA's request, the Contractor shall coordinate and facilitate the network adequacy meetings.

Medical Network Deviation Requests The Contractor may submit Medical Network Deviation Requests for a deviation to the network drive time standards to the CO and COR if it is unable to meet CCN Next Generation Medical Network adequacy due to a lack of providers in a specific area. VA will consider the Contractor’s requests under specific and limited circumstances for covered CCN Next Generation healthcare services. VA approved Medical Network Deviation Requests will provide alternate and/or expanded drive time standards and will be excluded from performance standards.

Each Medical Network Deviation Request shall be supported by information and documentation as specified in the Attachment TBD, “Medical Network Deviation Request.” The Contractor shall submit all Medical Network Deviation Requests to the CO and COR in writing, using the most current Medical Network Deviation Request Form (Attachment TBD, “Medical Network Deviation Request.”). If deviation requests are needed for multiple specialists and counties, the Contractor shall include the Multiple Specialty Deviation Addendum to Attachment TBD, “Medical Network Deviation Request.”

The Contractor shall ensure the availability of services with approved Deviation Requests, despite being excluded from drive time standards.