Attachment A Performance Work Statement EDIP2E .pdf

ATTACHMENT A PWS

Veterans Health Administration Office of Integrated Veteran Care (VHA IVC)

Electronic Data Interchange (EDI) and Paper to EDI (P2E)

Performance Work Statement (PWS)

1. Purpose. Contract with a Healthcare Clearinghouse (HCCH) to support healthcare Electronic Data Interchange (EDI) and Paper to EDI (P2E) transactions.

2. Background.

The Department of Veterans Affairs (VA), Veterans Health Administration (VHA), Office of Integrated Veteran Care (IVC), formerly Office of Community Care (OCC), utilizes a HCCH to provide connectivity with community providers to support the payment for services provided to Veterans and Veteran Families via incoming and outgoing EDI transaction services. VHA IVC accepts both paper and electronic submissions for healthcare claims and for supporting documentation (i.e., attachments). Current programs are as follows:

Veteran Programs:

• Non-VA Medical Care Program (NNPO-legacy name VA Fee Basis)

• Non-VA Medical Care Dialysis National Contracts (DNC)

• Non-contract Dialysis

• Authorized Emergency Care

• Non-Preauthorized Emergency Care

• Community Nursing Home

• Veteran Care Agreements

• Home Health and Home Maker Claim Types

• VA Care Referred to DOD Facilities

• Beneficiary Travel special Mode and Ambulance Claim Types

• Patient-Centered Community Care (PCCC)

• Indian Health Service and Tribal Health Program (IHS/THP)

• Community Care Network (CCN)

• Veterans Choice Program (VCP)

• VA Maintaining Systems and Strengthening Integrated Outside Networks Act

(MISSION)

• Any Future Veteran Programs

Veteran Family Member Program:

• Civilian Health and Medical Program VA (CHAMPVA), CHAMPVA In-house Treatment Initiative (CITI), and CHAMPVA Foreign Medical

• Spina Bifida Health Care Program (SB)

• Children of Women Vietnam Veterans (CWVV)

• Camp Lejeune Family Member Program (CLFMP)

• Any Future Veteran Family Programs

VHA IVC has initiated multiple projects to increase the volume and overall percentage of electronic transactions versus paper or other manual transactions to comply with legislation

PWS – EDI P2E Services

- 2 -and to facilitate administrative simplification. VHA IVC employs a HCCH to communicate incoming and outgoing EDI transactions to the over one million medical and dental providers throughout the United States and US Territories. EDI transactions consist of batch and real-time transfers of Health Insurance Portability and Accountability Act (HIPAA) ASC X12N 5010 transactions. VHA IVC also supports several hosted real-time EDI transactions. The following table reflects EDI transaction types and average volume for worked performed during fiscal year (FY) 2021:

Transaction Batch Hosted Direct Edits

FY 2021

Weekly Volume

FY 2022

Weekly

Volume (est.)

837 X X 803,304 957,000

837COB X X 86,607 92,137

835 X 238,622 243,465

270/271 (Veteran/Direct)

X 278,041 368,255

270/271 (VFMP/Hosted)

X X* 263,925 335,734

276/277 X X* 15,650 14,198

277CA X* n/a n/a

278 (Veteran) X* X X n/a 4,615

278 (VFMP) X* X X* X n/a 4,615

277RFAI X* n/a 1,300

275 X 47,010 48,246*

P2E Rejections 6,764 6,134

Paper to Electronic 632,488 555,908

Receipt & Upload 73,943 317,450

*NOTES:

270/271 (VFMP): These transactions will move from Hosted to Direct during the Period of Performance of this contract.

276/277: These transactions will move from Hosted to Direct during the Period of Performance of this contract.

277CA: These transactions will be implemented during the Period of

Performance of this contract.

278 (Veteran): VA will be implementing 278x216 Batch and 278x215 and 278x217

Direct during the Period of Performance of this contract.

278 (VFMP): These transactions will move from Hosted to Direct during the Period of Performance of this contract.

VA will be implementing 278x216 Batch and 278x215 and 278x217 Direct during the Period of Performance of this contract.

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277RFAI: VA will be implementing 277RFAI during the Period of Performance of this contract.

3. Objectives.

VHA IVC seeks a Health Care Clearinghouse (HCCH) contractor, referenced as “the Contractor”, to support a P2E/EDI capability throughout the term of this contract to provide community health care providers access to HIPAA-compliant data and processes in support of payments for care provided to Veterans and Veteran Families.

4. Scope.

The Contractor shall support:

• A single national location to receive paper-based submissions and convert these submissions to electronic formats and transmit these submissions via EDI to the

VHA IVC.

• The transmission and receipt of EDI transactions between VHA IVC and health care providers across the United States and territories.

The Contractor shall support three major P2E/EDI transaction activities over the course of this contract: Implementation, Operations and Maintenance, and Reporting.

• Implementation shall cover all activities required to establish the Initial Operational Capability (IOC) for P2E/EDI transactions. The initial implementation should limit the need for programmatic changes on VHA IVC Information Technology (IT) systems.

Implementation shall include full trading partner transaction capabilities with provider communities in all 50 United States and US Territories.

• Operations and Maintenance shall cover all activities required to sustain P2E/EDI transactions over this contract’s period of performance (POP). Modifications to transactions will be required at various levels of effort (LOE) (i.e., small, medium, or large) and shall not be priced separately.

• Reports shall cover all activities to provide information required to monitor quality and volumetric data over the course of the contract.

5. Mandatory Tasks and Deliverables.

The contractor shall provide the specific deliverables described below. All written deliverables shall be phrased in layperson language. Statistical and other technical terminology shall not be used without providing a glossary of terms. If for any reason, any deliverable cannot be delivered on time according to the below schedule, the contractor shall provide a written explanation three days prior to the due date to the Contracting Officer Representative (COR).

This written transmittal shall include a firm commitment of when the work will be completed.

This transmittal to the COR shall cite reasons for the delay and the impact on the overall project.

The COR will review collaboratively with the program office and issue a response in accordance with the contract terms and conditions. Unless otherwise specified, an electronic copy shall be placed in a SharePoint site designated by the IVC team. Specifically, the contractor shall perform the following tasks:

5.1 Task One: Kick-Off Meeting

5.1.1 Kick-Off Meeting

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The Contractor and COR shall establish a bilaterally acceptable date (but not later than (NLT) 10 business days following award) for the kick-off meeting and shall provide a briefing in (MS Power Point format) to designated VA personnel two business days prior to Kickoff Meeting.

The Contractor shall attend the contract kick-off meeting. This meeting may be held remotely and attended virtually (i.e., Live Meeting, teleconference). At the kick-off, the Contractor shall present, for review and approval by the Government, the details of the intended approach, work plan, and project schedule to complete all tasks defined in this PWS.

Deliverable 5.1.1: Kick-Off Meeting

5.1.2 Kick-Off Meeting Agenda

The Contractor shall provide a meeting agenda at least two (2) business days prior to the meeting. The Contractor shall coordinate with the COR to invite the Contracting Officer, Contract Specialist, and any other necessary VA personnel.

Deliverable 5.1.2: Kick-Off Meeting Agenda

5.1.3 Kick-Off Meeting Minutes

Meeting minutes from the Kick-Off Meeting shall be provided to all attendees within three (3) business days after conclusion of the meeting.

Deliverable 5.1.3: Kick-Off Meeting Minutes

5.2 Task Two: Initial Implementation of EDI Capability

5.2.1 Specifications for Hosted Transactions (270/271, 276/277, 278)

The contractor shall develop an Interface Control Document (ICD) in conjunction with Payer EDI for clearinghouse hosted transactions that include detailed technical descriptions of the data element formats, content requirements, and transmission methods that can be used by business and technical resources to produce automated batched files containing all required and appropriate optional data to support Real Time standard transactions as defined in the Technical Report 3 (TR 3) for each of the transactions.

Deliverable 5.2.1. Specifications for Hosted Transactions (270/271, 276/277,278)

5.2.2 Specifications for Direct Transactions (270/271, 277CA, 278, 837, 837COB, 275, 835)

The contractor shall develop specifications in conjunction with Payer EDI for clearinghouse Direct transactions that include detailed technical descriptions of the data element formats, content requirements, and transmission methods that can be used by business and technical resources to produce automated real-time and batched files containing all required and appropriate optional data to support standard transactions as defined in the TR 3 for each of the transactions.

Deliverable 5.2.2 Specifications for Direct Transactions (270/271, 278, 277CA, 837, 837COB, 275, 835)

5.2.3 Business Rules for Payer Specific Edits (278, 837, 837COB)

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The contractor shall develop specifications in conjunction with Payer EDI for business rules for payer specific edits.

Deliverable 5.2.3 Business Rules for Payer Specific Edits (270/271, 278, 837, 837COB)

5.2.4 Specifications for Paper to EDI (P2E)

The Contractor shall provide all services related to receiving paper claims and/or paper medical documentation from community health care providers and Veteran VFMP providers via postal mail, in a single location, converting these documents to the appropriate HIPAA-compliant EDI transactions and sending as EDI transactions. The contractor shall develop specifications in conjunction with Payer EDI to receive, scan, store, and convert paper claims (CMS-1500, UB- 04, and American Dental Association (ADA) Dental Forms), and documentation supporting claims from VA community providers.

Deliverable 5.2.4 Specification for Paper to EDI (P2E)

5.2.4.1 The Contractor shall receive paper claims (CMS-1500, UB-04, and American Dental Association (ADA) Dental Forms), and documentation supporting claims from VA community providers and all VFMP claims at a single location.

5.2.4.2 The contractor shall store original paper documentation for six calendar weeks after receipt. After six calendar weeks the contractor shall submit a shred request approval to the COR. Once the COR has provided written approval, the contractor will permanently destroy the paper documentation in accordance with the VA Record Control Schedule (RCS) (see PWS Section 18).

5.2.4.3 The contractor shall receive paper claims and supporting documentation scan paper claims and supporting documentation and convert all scanned documentation into the industry standard EDI transactions format and shall charge the VA a per transaction rate.

5.2.4.4 The contractor shall convert ninety-eight percent (98%) of all clean paper-based claims and supporting documentation to HIPAA compliant EDI transactions within two (2) business day of receipt and one hundred percent (100%) of all paper-based forms within five (5) business days.

5.2.4.5 The Contractor shall return one hundred percent (100%) of deficient claims and/or supporting documentation to the provider with a clear explanation of deficiencies within ten (10) business days of original receipt.

5.2.4.6 The Contractor shall confirm the actual date of receipt is entered into the Internal Control Number (ICN) and all required claims aging, and inventory controls are applied for all claims.

The Contractor shall count the actual date of receipt as day one.

5.2.4.7 The Contractor shall provide within Claims Attachments transactions identifiers and means to match to the existing claim.

5.2.4.8 The contractor shall provide all services necessary to return to sender the “inappropriate paper” and paper forms that are illegible that may be received, i.e., claims that are not contained on designated claims forms or valid medical documentation.

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5.2.4.9 The EDI 275 transaction file shall include a unique Trace Number (TRN) segment that contains the Provider Attachment Control Number.

5.2.4.10 The EDI 837 transaction file shall include a Paperwork (PWK) segment that contains the Attachment Control Number to include the matching unique TRN.

5.2.4.11 When additional accompanying EDI Standard Transactions are adopted and mandated by CMS for use at a future date, the Contractor shall comply with those EDI Standard Transactions by the compliance dates as specified by the Department of Health and Human Services (HHS).

5.2.4.12 The Contractor shall meet a data quality performance metric of >99.5% for overall data quality inclusive of Optical Character Recognition (OCR) and keyed data (including handwritten forms).

5.2.4.13 The contractor shall provide one single location for all Veteran claims and one single location for all VFMP claims.

5.2.4.14 If the VA discovers a scanning error after submission from the contractor, the contractor will assist the VA with resolution of the error so the claim may be processed.

5.2.4.15 The contractor shall perform data validation for the transfer of paper through OCR to meet the established performance metric.

5.2.4.16 The contractor shall provide for electronic document retention of received paper claims or paper medical documentation for a minimum of six years from the date received. The stored electronic documents retained in the contractor system shall be accessible and viewable to VA employees per Section 508 of the Rehabilitation Act (29 U.S.C. § 794d) as outlined in PWS

Section 16. . The VA shall be able to establish the folder taxonomy within the contractor’s system. The stored electronic documents shall be searchable by the following meta data:

• DCN

• Patient Last Name

• Patient First Name

• Patient DOB

• Billing Fed Tax ID

• Billing Provider NPI

• Date of Service

• Reject Code

• Dental claim

• HCFA

• UB

• Delinked Coversheet

• Claims with Greater that 500-page Attachments

• Rejects

• Region

• VISN

• SSN

5.2.5 Implementation Schedule

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The contractor shall deliver a schedule that meets Project Management Institute (PMI) guidelines.

Deliverable 5.2.5 Implementation Schedule

5.2.6 Implementation Development

The contractor shall implement the capability to support Payer EDI transactions. The Contractor shall provide full and complete implementation within 180 days of award to ensure no disruption of EDI services between VHA IVC and its trading partners. The contractor shall provide connectivity that is compliant with the appropriate Council for Affordable and Quality Healthcare (CAQH) Core “Connectivity Rules” as defined at http://www.caqh.org to all EDI capable providers/submitters of transactions used by VHA IVC Programs. This capability shall include providers/submitters in the District of Columbia, each of the United States, and US Territories.

The contractor shall provide Medicare Crossover connectivity, eligibility file routing and claims receipt from the Centers for Medicare and Medicaid Services (CMS) Coordination of Benefits Contractor (COBC) that meets the requirements of the Coordination of Benefits Agreement located at the following link:

https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/COBA-Trading- Partners/Coordination-of-Benefits-Agreements/Coordination-of-Benefits-Agreement-page.html

Deliverable 5.2.6 Implementation Development and Reports

5.2.7 Implementation Testing

The contractor shall deliver a detailed document of testing activities, test results, resource needs (people and environments), test data, test procedures, test reports, defect resolution, and acceptance criteria. The contractor shall conduct testing activities.

Deliverable 5.2.7 Implementation Testing and Reports

5.2.8 Implementation Deployment

The contractor shall deliver a detailed document of deployment activities, implementation guide, resource needs, timeline and exit criteria. The contractor shall deploy the capability to support Payer EDI transactions.

Deliverable 5.2.8 Implementation Deployment and Reports

5.2.9 Implementation Meetings

The Contractor shall conduct weekly meetings and provide written status updates to report on topics such as: schedule review, risk review, tasks accomplished in the past week, explanation of tasks not accomplished as expected, any blockers preventing progress, and tasks to be accomplished in the upcoming week.

Deliverable 5.2.9 Weekly Implementation Meetings and Status Reports

5.2.10 Payer Identifiers

https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/COBA-Trading-Partners/Coordination-of-Benefits-Agreements/Coordination-of-Benefits-Agreement-page.html https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/COBA-Trading-Partners/Coordination-of-Benefits-Agreements/Coordination-of-Benefits-Agreement-page.html

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The contractor shall create and manage payer identifiers used in payer EDI transactions required at the initial implementation of this contract. At the time of this writing, VHA IVC utilizes the following Payer IDs:

Non-VA Medical Care Program (Fee Basis)

• 12115 - Medical batch transactions

• 12116 - Dental batch transactions

VAFEE - Hosted and direct transactions

• 12117 - (CCN Network)

Veteran Family Member Programs (VFMP) (CHAMPVA, Spina Bifida, Children of Women Vietnam Veterans)

• 84146 - Medical batch transactions

• 84147 - Dental batch transactions

• 80214 - Medicare batch transactions

• VAHAC - Hosted transactions

• TBD

Deliverable 5.2.10 Create and Manage Payer Identifiers

5.2.11 Communications

5.2.11.1 Communication Plan: The contractor shall develop in conjunction with Payer EDI a communication plan for communicating with government stakeholders and trading partners current status and expected date and time to return to normal operations from any service interruptions. The Contractor shall monitor batch and real-time transaction activities for service interruptions, and these shall be communicated per the communication plan. The Communications Plan is to be completed within 180 days of award and shall include Contractor and Government points of contact, agreed upon forms and content of emergent and sustained communications detailing system or transaction downtime or reduced capability.

Deliverable 5.2.11.1 Communication Plan

5.2.11.2 Provider Communication System

The contractor shall implement a secure HIPAA compliant communication system that meets Federal Information Security Management Act (FISMA) II requirements for providers to communicate issues and discrepancies. The system shall create a traceable ticket system with reporting capabilities.

Deliverable 5.2.11.2 Provider Communication System

5.2.11.3 Secure Email System

The contractor shall enable a secure e-mail system to use for communication between the VA and contractor (See Section 14 Security – Privacy Requirements).

Deliverable 5.2.11.3 Secure Email System

5.2.11.4 Emergency Call Back Service

The contractor shall respond to emergency call back service within two hours or less, and responses will be provided to requests by telephone or email from the (1) Contracting Officer,

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(2) COR, or (3) their designees in case of a malfunction or if emergency trouble should develop between regularly scheduled maintenance. This call back service shall be rendered at any hour of any day of the week as requested at no extra charge to the Government. There shall be no more than nine (9) callbacks per month when averaged over a six-month period, which is the acceptable rate of callbacks. Failure to maintain an acceptable rate of callbacks will be grounds to initiate termination for cause.

Deliverable 5.2.11.4 Emergency Call Back Service

5.3 Task Three: Operations and Maintenance

5.3.1 EDI Enrollment for VHA IVC Trading Partners

The contractor shall provide a user-friendly process for VHA IVC providers to enroll for EDI transactions.

Deliverable 5.3.1 EDI Enrollment Process

5.3.2 Transactions

The contractor shall support the following transactions and shall utilize EDI transaction formats that are compliant with the mandated HIPAA-Compliant X12 EDI standards. Otherwise, a mutually agreeable format can be used, but must support HIPAA-compliant responses to the trading partner. The contractor shall support multiple batch file transactions per day based on an agreed upon schedule:

5.3.2.1 Health Care Claim (includes Institutional, Professional, and Dental) 837 Batch Transactions (includes acknowledgements)

5.3.2.2 Health Care Claim (includes Institutional and Professional) 837 Medicare Crossover Batch Transactions (includes acknowledgements)

5.3.2.3 Health Care Claim Payment/Advice 835 (includes acknowledgements) for both Medicare Crossover and non-Medicare Crossover Batch Transactions

5.3.2.4 Eligibility, Coverage or Benefit Inquiry/Information 270/271 (includes acknowledgements) Hosted Transactions

5.3.2.5 Eligibility, Coverage or Benefit Inquiry/Information 270/271 (includes acknowledgements) Direct Transactions

5.3.2.6 Health Care Claim Status Request/Information Status Notification 276/277 (includes acknowledgements) Hosted Transactions

5.3.2.7 Health Care Claim Status Request/Information Status Notification 276/277 (includes acknowledgements) Direct Transactions

5.3.2.8 Health Care Claim Acknowledgement 277CA Batch Transactions

5.3.2.9 Health Care Claim Request for Additional Information 277RFAI

5.3.2.10 Health Care Services Review Information 278 (includes acknowledgements) Hosted Transactions

5.3.2.11 Health Care Services Review Information 278 (includes acknowledgements) Direct Transactions

5.3.2.12 Patient Information 275 (includes acknowledgements) Batch Transactions

5.3.2.13 Paper to Electronic (P2E) Conversion (See Appendix D)

5.3.2.14 Rejection Claim plus USPS First Class Postage

5.3.2.15 Receipt and Image capture of unmatched (orphan) documentation to Database

Deliverable 5.3.2 Transactions

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5.3.3 Modifications to Transactions

The Contractor shall provide support necessary to implement modifications to transactions as required by VHA IVC. The number and type of modifications for this acquisition may not exceed the following: 20 small implementations, 10 medium implements, and five (5) large implementations.

As EDI services change or business expectations change within healthcare it is necessary for VHA IVC to be able to implement changes as necessary. The HCCH shall support EDI modifications including, but not limited to, a single transaction transition to another VHA IVC system, single transaction transition to a different kind of connection, deployment of a transaction set not already in use as part of the initial implementation, deployment of a payer identifier and health plan identifier not already in use as part of the initial implementation, consolidation of payer identifiers and health plan identifiers in use at the initial implementation of the contract or added as part of the transition to future state, application of new edits to transactions while in the custody of the contractor.

Vendor shall perform modifications as required by VHA IVC. Modifications shall not be separately priced and will vary in the amount of support required as shown below:

• A small implementation modification is anticipated to include 3-6 full-time employee equivalents (FTEEs) working 4- 8hrs/day over a 30-60-day period.

• A medium implementation modification is anticipated to include 6-8 FTEEs working 6-8hrs/day over a 60-90-day period.

• A large implementation modification is anticipated to include 8-12 FTEEs working 6- 8hrs/day over a 60-120-day period.

For proposal purposes, the following modifications were executed over the previous five (5) years with the exception of transition to Payer ID which was implemented three times:

• Transition Payer ID to another VA adjudication system (Large) (3x)

• Implement 275 Attachments (Medium)

• Implement a New Payer ID (Small)

• Implementation of Eligibility (Small)

NOTE: The Government expects that the Department of Health and Human Services will mandate updated X12 and NCPDP Transaction standards during the POP of this contract. Any costs associated with these updated mandates shall be included in the proposed cost for this contract

Deliverable 5.3.3: Implement Modifications to Transactions

5.4 Task Four: Reporting and Accountability

The Contractor shall create and distribute routine reports that document transaction volume by transaction type in mutually agreed upon formats.

5.4.1 Daily Claim (837) Transaction Counts by Payer ID, Claim Type and Provider – Required data elements:

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• Report Title

• Batch Date

• Claim Type (Institutional, Professional, Dental)

• Provider ID

• Count per Provider

• Batch Total Claim Transaction Count by Claim Type

Deliverable 5.4.1 Daily Claim (837) Transaction Counts

5.4.2 Monthly Summary Claim (837) Transaction Counts by Payer ID, Claim Type and Provider

– Required data elements:

• Report Title

• Month and Year report range

• Claim Type

• Provider ID

• Count per Provider

• Monthly Total Claim Transactions by Claim Type

Deliverable 5.4.2 Monthly Summary Claim (837) Transaction Counts by Payer ID, Claim Type and Provider

5.4.3 Daily 835 Health Care Payment/Advice Transactions Picked up by Provider – Required data elements:

• Batch Date

• Provider ID

• Total Daily Retrieval Count

Deliverable 5.4.3 Daily 835 Health Care Payment/Advice Transactions Picked up by Provider

5.4.4 Monthly Summary 835 Health Care Payment/Advice Transactions Picked Up by Provider

– Required data elements:

• Month and Year report range

• Provider ID

• Count per provider

• Total Monthly 835 Pickup

Deliverable 5.4.4 Monthly Summary 835 Health Care Payment/Advice Transactions Picked Up by Provider

5.4.5 Daily Real-Time Transaction Volume (270/271, 276/277/277CA, 277RFAI, 278) by Payer ID Including Error Types and Counts – Required Data Elements:

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• Date and day of reporting period

• Payer ID

• Transaction Type

• Provider ID

• Counts of successful transactions

• Counts of errored transactions by Error Reason

• Total successful transactions by Payer ID

• Total error transactions by Payer ID

• Total average connection time for successful real-time transactions by Payer ID

• Total average connection time for unsuccessful real-time transactions by Payer

ID

• List of any individual transactions not meeting the CAQH Connectivity Rule time requirements

Deliverable 5.4.5 Daily Real-Time Transaction Volume (270/271, 276/277/277CA, 278)

5.4.6 Monthly Summary of Real-Time Transaction Volume (270/271, 276/277/277CA, 277RFAI,

278) by Payer ID Including Error Types and Counts – Required Data Elements:

• Month and year of reporting period

• Payer ID

• Transaction Type

• Monthly Summary of Total successful transactions by Payer ID

• Monthly Summary of Total error transactions by Payer ID

• Monthly average connection time for successful real-time transactions by Payer

ID

• Monthly average connection time for unsuccessful real-time transactions by Payer ID

• List of any individual transactions not meeting the CAQH Connectivity Rule time requirements

Deliverable 5.4.6 Monthly Summary of Real-Time Transaction Volume (270/271, 276/277/277CA, 278)

5.4.7 Daily Attachments (275) Transaction Counts by Payer ID, Claim Type and Provider – Required Data Elements:

• Batch Date

• Claim Type (Institutional, Professional, Dental)

• Provider ID

• Batch Total Claim Transaction Count by Claim Type

Deliverable 5.4.7 Daily Attachments (277RFAI, 275) Transaction Counts

5.4.8 Monthly Summary Attachments (275) Transaction Counts by Payer ID, Claim Type and Provider – Required Data Elements:

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• Report Title

• Month and Year report range

• Claim Type

• Provider ID

• Count per Provider

• Monthly Total Claim Transactions by Claim Type

Deliverable 5.4.8 Monthly Summary Attachments (277RFAI, 275) Transaction Counts

5.4.9 Daily P2E Reports: The Contractor shall provide Daily Reports to VA that summarizes all P2E volumes. Required data elements to be organized by the age of the claim:

• Month and Year Report Range

• Total Number of Paper Received

• Total Number of Institutional

• Total Number of Dental

• Total Number Converted

• Total Number of Conversion Failures

• Total Number of Rejection Letters sent and Postage Costs

Deliverable 5.4.9 Daily P2E Reports

5.4.10 Monthly Summary P2E Reports: The Contractor shall provide Monthly Reports to VA that summarizes all P2E volumes. Required data elements to be organized by the age of the claim:

• Month and Year Report Range

• Total Number of Paper Received

• Total Number of Institutional

• Total Number of Dental

• Total Number Converted

• Total Number of Conversion Failures

• Total Number of Rejection Letters sent and Postage Costs

Deliverable 5.4.10 Monthly Summary P2E Reports

5.4.11 Ad Hoc Reports: The Contractor shall provide ad hoc reports (approximately 1 per month) analyzing open transactions, pending transactions, newly received transactions and transfers, transactions processed, adjustments processed, closing of pending transactions and closing of adjusted transactions within mutually agreed upon timelines, but no later than five (5) business days after requested by VA. The Contractor shall have search capabilities built into its systems. The contractor shall ensure data files are compressed using standard file compression technology (i.e., WINZIP) to reduce file size.

Deliverable 5.4.11 Ad Hoc Reports

5.4.12 Monthly Status Meetings

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The contractor shall conduct monthly conference call meetings with VA to discuss performance issues. Frequency of meeting can be adjusted by mutual agreement between the Government and contractor.

5.4.12.1 The Contractor shall be responsible for setting up the conference calls, preparing an agenda and preparing any other supporting materials as needed. Additional conference calls may be held to discuss individual items and/or issues. The agenda of the reviews shall include:

• Monthly performance assessment data and trend analysis

• Issues and concerns of both parties

• Projected outlook for upcoming months and progress against expected trends, including a corrective action plan analysis

• Recommendations for improved efficiency and/or effectiveness

• Issues arising from the performance monitoring processes

Deliverable 5.4.12.1 Monthly Status Meeting Agenda & Other Supporting Documentation

5.4.12.2 The Contract shall be responsible for documenting minutes. Minutes shall be provided to the COR no later than three business days following the meeting.

Deliverable 5.4.12.2 Monthly Status Meeting Minutes

5.5 TRANSITION SUPPORT (OPTIONAL TASK)

If the Optional Task is exercised by VA, the Contractor shall provide a plan for outgoing transition support for transitioning work from the current effort to a follow-procurement or Government entity. This transition may be to a Government entity or to another Contractor or to the incumbent Contractor under a new procurement. In accordance with the Government-approved plan, the Contractor shall assist the Government in implementing a complete transition from this effort to a new support provider. This shall include formal coordination with Government staff and successor staff and management. It shall also include delivery of copies of all artifacts delivered under this effort, as well as existing policies and procedures, and delivery of baseline metrics and statistics.

This Transition Plan shall include but is not limited to:

• Coordination with Government representatives

• Review, evaluation and transition of current support services

• Transition of historic data to new Contractor and/or internal VA system

• Transition of all necessary business and/or technical documentation

• Orientation phase and program to introduce Government and Contractor personnel, programs, and users to the Contractor's team, tools, methodologies, and business processes

• Disposition of Contractor purchased Government owned assets

• Transfer of Government Furnished Equipment (GFE) and Government Furnished Information (GFI)

A finalized activity list shall be delivered as a Certificate of Transition Completion for all activities, which will be signed by the Development PM and the Receiving Organization to indicate acceptance.

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Deliverable 5.5: Transition Support

A. Transition Plan B. Certificate of Transition Completion

5.6 Schedule for Mandatory Deliverables.

5.6.1 Table of Base Period Mandatory Deliverables Due Dates

All “days” are calendar days unless otherwise specified.

Deliverable Frequency # of Copies Medium/Format Submit To

Documentation IAW

PWS 5.1.2

As requested, not to exceed once per quarter

1 copy, electronically

MS Word, MS Excel Spreadsheet or compatible format approved by IO

COR

Documentation IAW

PWS 5. 2.1.1 & 5.

2.1.2

As requested, not to exceed once per quarter

1 copy, electronically

MS Word, MS Excel Spreadsheet or compatible format approved by IO

COR

A task order for the services referenced in Tasks 5.1 – 5.4 will be issued upon award.

REFERENCE DELIVERABLE DUE DATE

5.1.1 Kick-Off Meeting Bilaterally acceptable date

(but not later than (NLT) 10 business days after award

5.1.2 Kick-Off Meeting Agenda NLT two (2) business

days prior to the Kick-Off Meeting

5.1.3 Kick-Off Meeting Minutes NLT three (3) business

days after conclusion of the Kick-Off Meeting

5.2.1 Specifications for Hosted

Transactions (270/271, 278, 276/277)

NLT 60 days after contract award

5.2.2

Specifications for Direct Transactions (270/271, 278, 277CA, 837, 837COB, 275, 835, 277 RFAI)

NLT 60 days after contract award

5.2.3 Business Rules for Payer

Specific Edits (270/271, 278, 837, 837COB)

NLT 60 days after contract award

5.2.4 Specification for Paper to EDI

(P2E)

NLT 60 days after contract award

5.2.5 Implementation Work

Breakdown Structure and Schedule with Durations, Predecessors, and Responsible Parties

NLT 30 days after contract award

- 16 -

5.2.6 Implementation Development NLT 180 days after

contract award

5.2.7 Implementation Testing and

Report

NLT 180 days after contract award

5.2.8 Implementation Deployment

and Report

NLT 180 days after contract award

5.2.9 Weekly Implementation

Meetings and Status Reports

NLT 180 days after contract award

5.2.10 Create and Manage Payer

Identifiers

NLT 180 days after contract award

5.2.11.1 Communication Plan NLT 180 days after

contract award

5.2.11.2 Provider Communication

System

NLT 180 days after contract award

5.2.11.3 Secure Email System NLT 180 days after

contract award

5.2.11.3 Emergency Call-Back Service NLT 180 days after

contract award

5.3.1 EDI Enrollment Process NLT 180 days after

contract award

5.3.2 Transactions NLT 180 days after

contract award

5.4.1 Daily Claim (837) Transaction

Counts Report

Daily

5.4.2 Monthly Summary Claim

(837) Transaction Counts by Payer ID, Claim Type and Provider Report

NLT the 4th business day of each month

5.4.3 Daily 835 Health Care

Payment/Advice Transactions Picked up by Provider Report

Daily

5.4.4 Monthly Summary 835 Health

Care Payment/Advice Transactions Picked Up by Provider Report

NLT the 4th business day of each month

5.4.5 Daily Real-Time Transaction

Volume (270/271, 276/277/277CA,277RFAI

278) Report

Daily

5.4.6 Monthly Summary of Real-

Time Transaction Volume (270/271, 276/277/277CA,277RFAI

278) Report

NLT the 4th business day of each month

5.4.7 Daily Attachments (275)

Transaction Counts Report

Daily

5.4.8 Monthly Summary

Attachments (275) Transaction Counts Report

NLT the 4th business day of each month

5.4.9 Daily P2E Reports Daily

- 17 -

5.4.10 Monthly Summary P2E

Reports

NLT the 4th business day of each month

5.4.11 Ad Hoc Reports NLT five (5) business

days after request

5.4.12 Monthly Status Meeting NLT than the seventh

(7th) day of each month

5.4.12.1 Monthly Status Meeting

Agenda & Other Supporting Documentation

NLT two (2) business days prior to the meeting

5.4.12.2 Monthly Status Meeting

Minutes

NLT three (3) business days after the meeting

5.6 Transition Support Optional

6.0 General Requirements:

6.1 Electronic Healthcare Network Accreditation Commission Accreditation: At the time of proposal submission, the proposal must validate the Contractor’s Healthcare Network Accreditation Program accreditation by the Electronic Healthcare Network Accreditation Commission (EHNAC). The proposal must demonstrate the ability to maintain these accreditations throughout the life of the contract by outlining the vendors process for maintaining accreditation. VHA IVC reserves the right to request proof of accreditation periodically throughout the life of the contract.

6.2 Council for Affordable and Quality Healthcare Certification: At the time of proposal submission, the proposal must validate the Contractor’s certification by the Council for Affordable and Quality Healthcare (CAQH) as a Committee on Operating Rules for Information Exchange (CORE) Phase I, II, and III certified clearinghouse.

6.3 Administrative Simplification Provisions of HIPAA: The contractor shall acknowledge in their proposal they are a Covered Entity under the Administrative Simplification provisions of HIPAA and comply with all privacy, security, and disclosure requirements. VHA IVC reserves the right to request written confirmation of compliance periodically throughout the life of the contract.

6.4 Contractor Software Configuration Management Requirements: The Contractor shall utilize a solution to support the requirements herein that is configurable to allow for changes to be tested, accepted, and implemented. When VA requests a change, the Contractor shall implement the change by the mutually agreed upon date.

6.5 Performance Evaluation Meetings: The Contracting Officer may require the Contractor to meet with Government personnel as deemed necessary. The Contractor may request a meeting with the Contracting Officer or COR when the Contractor believes such a meeting is necessary.

At a minimum, the Contractor’s Account or Project Manager (and other Key Personnel), and the Contracting Officer or COR (or other Government personnel as deemed necessary) shall meet monthly to discuss the ongoing operation of the contract. The Contractor shall prepare written minutes of such meetings, which shall be recorded in the contract file. The Contractor’s Account or Project Manager and the COR shall sign the minutes indicating their approval or provide in writing their non-concurrence within five calendar days following receipt of the minutes.

6.6 Hours of Operation: Except as otherwise set forth in this contract or for scheduled maintenance, the Contractor shall conduct Real Time transaction operations 24 hours a day and

- 18 -

7 days a week. Batch transactions can be scheduled based upon the system and communication needs as agreed to by the COR and Contractor.

6.7 Execution of Agreements: Memoranda of Understanding (MOU), Business Associates Agreements (BAA), and other documentation required to perform the services described in this contract shall be returned to the Government within (ten) 10 business days of request for review and final signature by Contractor.

6.8 Transaction Formats: The Contractor shall utilize transaction formats that are compliant with the mandated HIPAA compliant X12 EDI in the 5010 standards. The Contractor shall be able to implement new standards as the industry moves to future mandates.

6.9 Period of Performance. The initial period of performance shall be from date of award for a period of 6 months, hereto referred to as the base. The contract also includes nine 12-month option periods which may be unilaterally exercised by the Government. All terms and conditions applicable to the base period shall extend to each option unless otherwise agreed upon.

There are ten (11) Federal holidays set by law (U.S.C. Title 5 Section 6103):

Under current definitions, five are set by date:

New Year’s Day January 1 Juneteenth June 19 Independence Day July 4 Veteran’s Day November 11 Christmas Day December 25

If any of the above falls on a Saturday, then Friday shall be observed as a holiday. Similarly, if one falls on a Sunday, then Monday shall be observed as a holiday.

The other six are set by a day of the week and month:

Martin Luther King Day Third Monday in January Washington’s Birthday Third Monday in February Memorial Day Last Monday in May Labor Day First Monday in September Columbus Day Second Monday in October Thanksgiving Fourth Thursday in November

6.10 Place of Performance. The Contractor shall support this effort at approved Contractor facilities.

7.0 Key Personnel. A skilled experienced professional and technical person is essential for accomplishing the work to be performed. This individual is defined as “Key Personnel” and is the person as detailed below. His/her resume shall be submitted and marked by the vendor as “Key Personnel”. Substitutions shall only be accepted if in compliance with “Substitution of Key Personnel” provision identified below. Additional Key Personnel may be proposed by the vendor. VA reserves the right to add Key Personnel as needed.

Title: Sr. Project Manager (PM) Qualifications: The Senior Project Manager (PM) is a technical expert with subject matter expertise in HIPAA compliant X12 EDI transactions and healthcare EDI software applications with a bachelor’s degree in Information Technology or a related field and with a minimum of 15 years’ experience in managing projects and/or programs related to healthcare EDI. He or she

- 19 -must be an expert in leading a team of diversified staff and have a proven record in managing programs related to healthcare EDI.

PM provides oversight to the daily operational management of the healthcare EDI claims processing and manages the resolution of technical and business defects and inefficiencies within EDI claims processing.

PM provides oversight to all design, development, testing and release work for healthcare EDI technical changes coordinating with customers, stakeholders, and internal technical support.

PM ensures completion of any healthcare EDI project, such as the implementation of new EDI standards and/or transactions including standard documentation, quality assurance and workflow management.

PM requires top level customer service skills and experience to coordination operational support and change management. PM will interface with internal Help Desk systems and staffs to document, track and resolve operational problems.

The Contracting Officer may notify the Contractor and request immediate removal of any personnel assigned to the task order by the Contractor that are deemed to have a conflict of interest with the government or if the performance is deemed to be unsatisfactory. The reason for removal will be documented and replacement personnel shall be identified within three business days of the notification. Employment and staffing difficulties shall not be justification for failure to meet established schedules.

7.1 Substitution of Key Personnel. All Contractor requests for approval of substitutions hereunder shall be submitted in writing to the COR and the Contracting Officer at least thirty

(30) calendar days in advance of the effective date, whenever possible, and shall provide a detailed explanation of the circumstances necessitating the proposed substitution, a complete resume for the proposed substitute, and any other information requested by the Contracting Officer necessary to approve or disapprove the proposed substitution. New personnel shall not commence work until all necessary security requirements, as defined in Section 15.8, have been fulfilled and resumes provided and accepted. The COR and the Contracting Officer will evaluate such requests and promptly notify the Contractor of approval or disapproval in writing.

7.2 The Contractor shall be responsible for managing and overseeing the activities of all Contractor personnel, as well as subcontractor efforts used in performance of this effort. The Contractor’s management responsibilities shall include all activities necessary to ensure the Accomplishment of timely and effective support, performed in accordance with the Requirements contained in the statement of work.

8.0 Travel. There is no travel associated with this contract.

9.0 Type of Contract. The pursuant award shall be a Firm Fixed Price (FFP) Indefinite delivery Indefinite Quantity (IDIQ) Contract.

10. Changes to the PWS. Any changes to this PWS shall be authorized and approved only through written correspondence from the Contracting Officer. A copy of each change will be kept in a project folder along with all other products of the project. Costs incurred by the contractor through the actions of parties other than the Contracting Officer shall be borne by the contractor.

- 20 -

11. Government and Contractor Responsibilities.

11.1 VHA IVC shall provide the contractor with copies of documents that the VA is required to provide.

11.2 The contractor shall request other VA documentation deemed pertinent to the work accomplished directly from the COR. The contractor is expected to use common knowledge and resourcefulness in securing all other reference materials, standard industry publications, and related materials that are pertinent to the work.

11.3 The contractor shall maintain frequent communications with the Program Office and the COR to conduct work in progress reviews. Progress reports shall be delivered electronically to the COR, with an electronic courtesy copy to the Program Office.

12. Formal Acceptance or Rejection of Deliverables. The VA shall have seven (7) business days to review each document and provide feedback and comments. The contractor shall have five (5) business days to incorporate comments. A final review shall be conducted with the COR and the VHA IVC Program Manager. Delivery of the post-final review deliverables with incorporated comments from the final review meeting shall constitute acceptance by the VA with COR’s written approval.

13. Quality Standards for Deliverables - Performance Measures: As stated in the Quality Assurance Surveillance Plan (QASP), the Government shall evaluate the Contractor’s performance under this contract. For those tasks listed in the QASP, the COR or evaluators shall follow the methods of surveillance specified in the contract. The Government shall record all surveillance observations. When an observation indicates defective performance, the COR shall forward the observation to the Contractor manager or alternate(s), who shall initial the observation. The initialing of the observation does not necessarily constitute concurrence with the observation, only acknowledgement that he or she has been made aware of the defective performance. Government surveillance of tasks not listed in the QASP or by methods other than those listed in the QASP may occur during the performance period of this contract. Such surveillance shall be done according to standard inspection procedures or other contract provisions. Any action taken by the Contracting Officer as a result of surveillance shall be in accordance with the terms of this contract.

The COR will serve as the final authority on whether a task is performed accurately. The Government will return deliverables to the Contractor as needed for re-work; a task shall not be considered accurate until all applicable re-work has been performed.

14. SECURITY – PRIVACY REQUIREMENTS

General - All contractors and contractor personnel shall be subject to the same Federal laws, regulations, standards and VA policies as VA, and VA personnel, regarding information and information system security. Contractors must follow policies and procedures outlined in VA Directive 6500, Information Security Program and its handbooks to ensure appropriate security controls are in place.

14.1 Access to VA Information and VA Information Systems

14.1.1 A contractor shall request logical (technical) and/or physical access to VA information and VA information systems for employees, subcontractors, and affiliates only to the extent necessary: (1) to perform the services specified in the contract, (2) to perform necessary

- 21 -maintenance functions for electronic storage or transmission media necessary for performance of the contract, and (3) for individuals who first satisfy the same conditions, requirements and restrictions that comparable VA employees must meet in order to have access to the same type of VA information.

14.1.2 All contractors and subcontractors working with VA Sensitive Information are subject to the same investigative requirements as those of regular VA appointees or employees who have access to the same types of information. The level of background security investigation will be in accordance with VA Directive 0710, Handbook 0710, which are available at:

http://www1.va.gov/vapubs/ and VHA Directive 0710 and implementing Handbook 0710.01 which are available at: http://www1.va.gov/vhapublications/index.cfm Contractors are responsible for screening their employees. The following are VA’s approved policy exceptions for meeting VA’s background screenings/investigative requirements for certain types of contractors:

14.1.2.1 Contract personnel not accessing VA information resources such as personnel hired to maintain the medical facility grounds, construction contracts, utility system contractors, etc.,

14.1.2.2 Contract personnel with limited and intermittent access to equipment connected to facility networks on which no VA sensitive information is available, including contractors who install, maintain, and repair networked building equipment such as fire alarm; heating, ventilation, and air conditioning equipment; elevator control systems, etc. If equipment to be repaired is located within sensitive areas (e.g. computer room/communications closets) VA IT staff must escort contractors while on site.

14.1.2.3 Contract personnel with limited and intermittent access to equipment connected to facility networks on which limited VA sensitive information may reside, including medical equipment contractors who install, maintain, and repair networked medical equipment such as CT scanners, EKG systems, ICU monitoring, etc.