Attachment C Performance Requirement Summary_Medical East_IDF.xlsx

PRS - EAST

PWS Attachment C - CCN Performance Requirement Summary (PRS ) - MEDICAL EAST

*VAMC Catchment Area drive time acceptability determined by station pass/fail rate. Stations are determined to have passed if veteran travel times by car meets drive time standards reflected in the PWS at least 90% of the time for at least 2 of 3 months for the quarter assessed.

**AQL for drive time standard for each station, each month, is assessed together (Primary Care Urban, Primary Care Rural/Highly Rural, Mental Health Care Urban, and Mental Health Care Rural/Highly Rural). Each VAMC Catchment Area pass rate:

*Example Catchment Area 13 pass rate: 7/8 of stations within that Catchment Area passed (met or exceeded 90%) = 87.5% = Met 85% AQL **See PRS Appendix A Station Names and Numbers ***Performance standard, AQL/ratings, and penalties apply to each Catchment Area, and is NOT applied to the total average performance of all Catchment Areas Random Sampling *Statistically significant

Veteran Drive times based on Veteran Address in VA Eligibility File/Referral and Provider address in the Provider Directory using Contractor's Azure API mapping tool

For each Catchment Area, sample from Primary Care and Mental Health Care claims for EACH Station within the period assessed (as determined by the EDI 837 Provider Claim Adjudication Date).

Drive time calculated regardless of travel modality.

Quarterly, or more/less as determined by VA. ST0-Data Preparation: The first step is EDI parsing and combining claims with referrals data to create a reporting dataset through these steps: Gather claims, extract referral number from claim, check referrals against previously evaluated referral numbers- only include claim with the earliest date of service that matches a not-yet-measured referral for this performance objective, sort all remaining claims in reporting data set by referral ID and claim submitted date, Identify first claim with the first date of service (DOS), match claims to referrals data to capture additional fields such as (but not limited to) Rurality, Veteran Preference, Veteran Address, etc. Note that each referral will be linked to a single unique referral ID, which will appear on all claims related to that referral. Each unique referral ID is assigned a single designation and/or category of care designation. Claims without referral IDs are excluded. All referral and claim level data must be reported at the Veteran, VAMC, and Catchment area level. This reporting data set will be used for subsequent analysis.

ST1- Capture all claims for Primary Care and Mental Health Care within the network regardless of catchment area ST2 - Gather claims for EACH Station (grouped by Catchment Area) from all the claims submitted (EDI 837) within the period assessed (as determined by the EDI 837 Claim Adjudication Date) ST3 - The reporting month will align with provider Claim Adjudication Date. The first date of the reporting month is the first day of the month through the last day of the month. E.g. For April 2025 reporting month include all claims with a Adjudication Date of 4/1/2025 through 4/30/2025. Do not exclude either 4/1 or 4/30.

ST4 - Apply Patient Rurality from associated referral - Urban, Rural and Highly Rural.

ST5 - Extract Patient Residential Address from Eligibility File/Referral.

ST6- Extract Provider Address from Provider Directory.

ST7 - Remove exclusions to this PO. See PRS Appendix B - Network Adequacy Performance Objective Exclusions List for exclusion(s) to this PO.

ST8 - Calculate drive time between Patient address and Provider address using Contractor's Azure API mapping tool. Patient files with address data element errors that restrict geocoding or without rurality indicated on the referral will be omitted.

ST9 - Identify as Success for every Primary Care instance where Drive Time ≤ the drive time indicated in the PWS for each rurality ST10 - Identify as Success for every Mental Health Care instance where Drive Time ≤ the drive time indicated in the PWS for each rurality ST11-Add all claims referenced for geographic accessibility for Primary Care = Potential Opportunities for Primary Care ST12- Add all claims referenced for geographic accessibility for Mental health Care= Potential Opportunities for Mental Health Care

*VAMC Catchment Area drive time acceptability determined by station pass/fail rate. Stations are determined to have passed if veteran travel times by car meets drive time standards reflected in the PWS at least 90% of the time for at least 2 of 3 months for the quarter assessed.

**AQL for drive time standard for each station, each month, is assessed together (Specialty Care Urban and Specialty Care Rural/Highly Rural). Each VAMC Catchment Area pass rate:

*Example Catchment Area 13 pass rate: 7/8 of stations within that Catchment Area passed (met or exceeded 90%) = 87.5% = Met 85% AQL **See PRS Appendix A Station Names and Numbers ***Performance standard, AQL/ratings, and penalties apply to each Catchment Area, and is NOT applied to the total average performance of all Catchment Areas Random Sampling *Statistically significant

Veteran Drive times based on Veteran Address in VA Eligibility File/Referral and Provider address in the Provider Directory using Contractor's Azure API mapping tool

For each Catchment Area, sample from Specialty Care and Mental Health Specialty Care claims for EACH Station within the period assessed (as determined by the EDI 837 Provider Claim Adjudication Date).

Drive time calculated regardless of travel modality.

Quarterly, or more/less as determined by VA. ST0-Data Preparation: The first step is EDI parsing and combining claims with referrals data to create a reporting dataset through these steps: Gather claims, extract referral number from claim, check referrals against previously evaluated referral numbers- only include claim with the earliest date of service that matches a not-yet-measured referral for this performance objective, sort all remaining claims in reporting data set by referral ID and claim submitted date, Identify first claim with the first date of service (DOS), match claims to referrals data to capture additional fields such as (but not limited to) Rurality, Veteran Preference, Veteran Address, etc. Note that each referral will be linked to a single unique referral ID, which will appear on all claims related to that referral. Each unique referral ID is assigned a single designation and/or category of care designation. Claims without valid authorizations are excluded.All referral and claim level data must be reported at the Veteran, VAMC, and Catchment area level. This reporting data set will be used for subsequent analysis.

ST1- Capture claims for Specialty care within the network regardless of catchment area ST2 - Gather claims for EACH Station (grouped by Catchment Area) from all the claims submitted (EDI 837) within the period assessed (as determined by the EDI 837 Provider Claim Adjudication Date) ST3 - The reporting month will align with provider claim Adjudication Date. The first date of the reporting month is the first day of the month through the last day of the month. E.g. For April 2025 reporting month include all claims with a Adjudication Date of 4/1/2025 through 4/30/2025. Do not exclude either 4/1 or 4/30.

ST4 - Apply Patient Rurality from associated referral - Urban, Rural and Highly Rural.

ST5 - Extract Patient Residential Address from Eligibility File/Referral.

ST6- Extract Provider Address from Provider Directory.

ST7 - Remove exclusions to this PO. See PRS Appendix B - Network Adequacy Performance Objective Exclusions List for exclusion(s) to this PO.

ST8 - Calculate drive time between Patient address and Provider address using Contractor's Azure API mapping tool. Patient files with address data element errors that restrict geocoding or without rurality indicated on the referral will be omitted.

ST9 - Identify as Success for every Specialty Care instance where Drive Time ≤ the drive time indicated in the PWS for each rurality category ST10-Overall Specialty Care Success = Total Specialty Care Urban Success + Total Specialty Care Rural/Highly Rural Success ST11- Add all claims referenced for geographic accessibility for Specialty Care= Potential Opportunities for Specialty Care

*VAMC Catchment Area drive time acceptability determined by station pass/fail rate. Stations are determined to have passed if veteran travel times by car meets drive time standards reflected in the PWS at least 90% of the time for Urban AND 70% of the time for Rural/Highly Rural for at least 2 of 3 months for the quarter assessed.

**Urban and Rural/Highly Rural are assessed separately.

***Urban and Rural/Highly Rural do not have to pass in the same month(s); however, Urban must pass 2 of 3 months and Rural/Highly Rural must pass 2 of 3 months for the quarter assessed for the station to pass for the quarter. Each VAMC Catchment Area pass rate:

*Example Catchment Area 13 pass rate: 7/8 of stations within that Catchment Area passed (met or exceeded 90%) = 87.5% = Met 85% AQL **See PRS Appendix A Station Names and Numbers ***Performance standard, AQL/ratings, and penalties apply to each Catchment Area, and is NOT applied to the total average performance of all Catchment Areas Random Sampling *Statistically significant

Veteran Drive times based on Veteran Address in VA Eligibility File/Referral and Provider address in the Provider Directory using Contractor's Azure API mapping tool

For each Catchment Area, sample from Emergency Room Care claims for EACH Station within the period assessed (as determined by the EDI 837 Provider Claim Adjudication Date).

Drive time calculated regardless of travel modality.

Quarterly, or more/less as determined by VA. ST0-Data Preparation: The first step is EDI parsing and combining claims with referrals data to create a reporting dataset through these steps: Gather claims, extract referral number from claim, check referrals against previously evaluated referral numbers- only include claim with the earliest date of service that matches a not-yet-measured referral for this performance objective, sort all remaining claims in reporting data set by referral ID and claim submitted date, Identify first claim with the first date of service (DOS), match claims to referrals data to capture additional fields such as (but not limited to) Rurality, Veteran Preference, Veteran Address, etc. Note that each referral will be linked to a single unique referral ID, which will appear on all claims related to that referral. Each unique referral ID is assigned a single designation and/or category of care designation. Claims without valid authorizations are excluded. All referral and claim level data must be reported at the Veteran, VAMC, and Catchment area level. This reporting data set will be used for subsequent analysis.

ST1- Capture claims for Emergency care within the network regardless of catchment area ST2 - Gather claims for EACH Station (grouped by Catchment Area) from all the claims submitted (EDI 837) within the period assessed (as determined by the EDI 837 Claim Adjudication Date).

ST3 - The reporting month will align with provider claim Adjudication Date. The first date of the reporting month is the first day of the month through the last day of the month. E.g. For April 2025 reporting month include all claims with a Adjudication Date of 4/1/2025 through 4/30/2025. Do not exclude either 4/1 or 4/30.

ST4 - Apply Patient Rurality from associated referral - Urban, Rural and Highly Rural.

ST5 - Extract Patient Residential Address from Eligibility File/Referral.

ST6- Extract Provider Address for the closet in network facility* ST7 - Remove exclusions to this PO. See PRS Appendix B - Network Adequacy Performance Objective Exclusions List for exclusion(s) to this PO.

ST8 - Calculate drive time between Patient address and the nearest emergency treatment facility that was active in the Provider Directory on the date of service, using Contractor's Azure API mapping tool. Patient files with address data element errors that restrict geocoding or without rurality indicated on the referral will be omitted.

ST9 - Identify as Success for every Emergency Care instance where Drive Time ≤ the drive time indicated in the PWS for each rurality category ST10- Add all claims referenced for geographic accessibility for Emergency Care= Potential Opportunities for Emergency Care ST11- % Success = Sum of Success divided by Potential Opportunities.

*Steps for calculating nearest emergency treatment facility -Isolate the relevant Pre-auth/Referral Records (Emergent Care) based on the claim with the earliest DOS -From the submitted claim with the earliest DOS in the series -Using the patient zip (from address) look to the source zip to zip distance mapping table and pull all zip-to-zip combinations <= 180 miles -Rank all qualifying zip to zip returns by distance descending -Next isolate all active Emergency care facilities in Provider Directory that match the Referral type ( Emergent Care ) and pull the associated care site Zip Code . The ER facilities are identified as available if the following taxonomies are listed AND the organization site is listed as active in Provider Directory: 261QE0002X, 282N00000X, 282NC0060X, 282NC2000X, 282NR1301X, 282NW0100X -Join the provider matched Zips to the Ranked Zip to Zip distance combinations to select the available providers from the 2 closest zips (shortest distance from the patient zip)

*VAMC Catchment Area drive time acceptability determined by station pass/fail rate. Stations are determined to have passed if veteran travel times by car meets drive time standards reflected in the PWS at least 90% of the time for at least 2 of 3 months for the quarter assessed.

**AQL for drive time standard for each station, each month, is assessed together (Urgent Care Urban and Urgent Care Rural/Highly Rural).

Each VAMC Catchment Area pass rate:

*Example Catchment Area 13 pass rate: 7/8 of stations within that Catchment Area passed (met or exceeded 90%) = 87.5% = Met 85% AQL **See PRS Appendix A Station Names and Numbers ***Performance standard, AQL/ratings, and penalties apply to each Catchment Area, and is NOT applied to the total average performance of all Catchment Areas Random Sampling *Statistically significant

Veteran Drive times based on Veteran Address in VA Eligibility File/Referral and Provider address in the Provider Directory using Contractor's Azure API mapping tool

For each Catchment Area, sample from Urgent Care claims for EACH Station within the period assessed (as determined by the EDI 837 Provider Claim Adjudication Date).

Drive time calculated regardless of travel modality.

Quarterly, or more/less as determined by VA. ST0-Data Preparation: The first step is EDI parsing and combining claims with referrals data to create a reporting dataset through these steps: Gather claims, extract referral number from claim, check referrals against previously evaluated referral numbers- only include claim with the earliest date of service that matches a not-yet-measured referral for this performance objective, sort all remaining claims in reporting data set by referral ID and claim submitted date, Identify first claim with the first date of service (DOS), match claims to referrals data to capture additional fields such as (but not limited to) Rurality, Veteran Preference, Veteran Address, etc. Note that each referral will be linked to a single unique referral ID, which will appear on all claims related to that referral. Each unique referral ID is assigned a single designation and/or category of care designation.Claims without valid authorizations are excluded.All referral and claim level data must be reported at the Veteran, VAMC, and Catchment area level. This reporting data set will be used for subsequent analysis.

ST1- Capture claims for Urgent care based on authorizations within the network regardless of catchment area (Urgent care claims are identified based Pre-authorization number annotated on claim, all urgent care claims begins with UC) ST2 - Gather claims for EACH Station (grouped by Catchment Area) from all the claims submitted (EDI 837) within the period assessed (as determined by the EDI 837 Claim Adjudication Date).

ST3 -The reporting month will align with provider claim Adjudication Date. The first date of the reporting month is the first day of the month through the last day of the month. E.g. For April 2025 reporting month include all claims with a Adjudication Date of 4/1/2025 through 4/30/2025. Do not exclude either 4/1 or 4/30.

ST4 - Extract Patient Residential Address from Eligibility File/Referral.

ST5- Extract Provider Address for the closet in network facility* ST6-Remove exclusions to this PO. See PRS Appendix B - Network Adequacy Performance Objective Exclusions List for exclusion(s) to this PO.

ST7 - Calculate drive time between Patient address and the nearest* urgent care facility that was active in the Provider Directory on the date of service, using Contractor's Azure API mapping tool. Patient files with address data element errors that restrict geocoding or without rurality indicated on the referral will be omitted.

ST8 - Identify as Success for every Urgent Care instance where Drive Time ≤ the drive time indicated in the PWS for each rurality category ST9 Add all claims referenced for geographic accessibility for Urgent Care= Potential Opportunities for Urgent Care ST10- % Success = Sum of Success divided by Potential Opportunities.

*Steps for Identifying Closest Facility -Isolate the relevant Pre-auth/Referral Records (Urgent Care (UC-prefix)) based on the claim with the earliest DOS -From the submitted claim with the earliest DOS in the series -Using the patient zip (from address) look to the source zip to zip distance mapping table and pull all zip-to-zip combinations <= 180 miles -Rank all qualifying zip to zip returns by distance descending -Next isolate all active providers in the Provider Directory that match the Referral type (Urgent Care) and pull the associated care site Zip Code .Providers are determined to be available if they are active at the care site level and the care site has one of the two POS codes- POS 17: Walk-in Retail Health Clinic and POS 20: Urgent Care Facility -Join the provider matched Zips to the Ranked Zip to Zip distance combinations to select the available providers from the 2 closest zips (shortest distance from the patient zip)

*VAMC Catchment Area drive time acceptability determined by station pass/fail rate. Stations are determined to have passed if veteran travel times by car meets drive time standards reflected in the PWS at least 90% of the time for Urban AND 70% of the time for Rural/Highly Rural for at least 2 of 3 months for the quarter assessed.

**Urban and Rural/Highly Rural are assessed separately.

***Urban and Rural/Highly Rural do not have to pass in the same month(s); however, Urban must pass 2 of 3 months and Rural/Highly Rural must pass 2 of 3 months for the quarter assessed for the station to pass for the quarter.

Each VAMC Catchment Area pass rate:

*Example Catchment Area 13 pass rate: 7/8 of stations within that Catchment Area passed (met or exceeded 90%) = 87.5% = Met 85% AQL **See PRS Appendix A Station Names and Numbers ***Performance standard, AQL/ratings, and penalties apply to each Catchment Area, and is NOT applied to the total average performance of all Catchment Areas Random Sampling *Statistically significant

Veteran Drive times based on Veteran Address in VA Eligibility File/Referral and Provider address in the Provider Directory using Contractor's Azure API mapping tool

For each Catchment Area, sample from Pharmacy claims for EACH Station within the period assessed (as determined by the EDI 837 Provider Claim Adjudication Date).

Drive time calculated regardless of travel modality.

Quarterly, or more/less as determined by VA. ST0-Data Preparation: The first step is EDI parsing and combining claims with referrals data to create a reporting dataset through these steps: Gather claims, extract referral number from claim, check referrals against previously evaluated referral numbers- only include claim with the earliest date of service that matches a not-yet-measured referral for this performance objective, sort all remaining claims in reporting data set by referral ID and claim submitted date, Identify first claim with the first date of service (DOS), match claims to referrals data to capture additional fields such as (but not limited to) Rurality, Veteran Preference, Veteran Address, etc. Note that each referral will be linked to a single unique referral ID, which will appear on all claims related to that referral. Each unique referral ID is assigned a single designation and/or category of care designation. Claims without referral IDs are excluded. Vaccines are not included. All referral and claim level data must be reported at the Veteran, VAMC, and Catchment area level. This reporting data set will be used for subsequent analysis.

ST1- Capture claims for Pharmacy within the network regardless of catchment area based on authorizations (Pharmacy claims are identified using a taxonomy- 3336C0003X (Suppliers/Pharmacy, Community/Retail Pharmacy) ST2 - Gather claims for EACH Station (grouped by Catchment Area) from all the claims submitted (EDI 837) within the period assessed (as determined by the EDI 837 Claim Adjudication Date) ST3 -The reporting month will align with provider claim Adjudication Date. The first date of the reporting month is the first day of the month through the last day of the month. E.g. For April 2025 reporting month include all claims with a Adjudication Date of 4/1/2025 through 4/30/2025. Do not exclude either 4/1 or 4/30.

ST4 - Extract Patient Residential Address from Eligibility File/Referral.

ST5- Extract Provider Address for the closet in network facility* ST6- Remove exclusions to this PO. See PRS Appendix B - Network Adequacy Performance Objective Exclusions List for exclusion(s) to this PO.

ST7 - Calculate drive time between Patient address and the nearest* pharmacy that was active in the Provider Directory on the date of service, using Contractor's Azure API mapping tool. Measurement is of the distance between Veteran's residential address and nearest in network pharmacy, not where Veteran actually picked up the prescription ST8 - Identify as Success for every Pharmacy instance where Drive Time ≤ the drive time indicated in the PWS for each rurality category ST9- Add all claims referenced for geographic accessibility for Pharmacy= Potential Opportunities for Pharmacy ST10- % Success = Sum of Success divided by Potential Opportunities.

*Steps for Identifying Closest Facility -Isolate the relevant Pre-auth/Referral Records (Pharmacy) based on the claim with the earliest DOS -From the submitted claim with the earliest DOS in the series -Using the patient zip (from address) look to the source zip to zip distance mapping table and pull all zip-to-zip combinations <= 180 miles -Rank all qualifying zip to zip returns by distance descending -Next isolate all active Pharmacy (organizations) in the Provider Directory that match the Referral type ( Pharmacy) and pull the associated care site Zip Code. Pharmacy providers in the provider directory are identified using Taxonomy Name = “PHARMACY COMMUNITY/RETAIL PHARMACY” -Join the provider matched Zips to the Ranked Zip to Zip distance combinations to select the available providers from the 2 closest zips (shortest distance from the patient zip)

*AQL for appointment timeliness standard is assessed together (Primary Care Urban, Primary Care Rural/Highly Rural, Mental Health Care Urban, and Mental Health Care Rural/Highly Rural). ≥ 90% Random Sampling *Statistically significant

EDI 835 and 837 claims and referral data

Sample from all Primary Care and Mental Health Care claims submitted (for each station) within the period assessed (as determined by the EDI 837 Provider Claim Adjudication Date), appointment timeliness calculated from Provider Allocation Date to the First Date of Service on the first claim received from the provider listed on the Referral.

Sample time calculation:

Provider Allocation Date: 8/1/2999 First Date of Service: 8/24/2999 Appointment time = 23 days

Monthly, or more/less as determined by VA. ST0-Data Preparation: The first step is EDI parsing and combining claims with referrals data to create a reporting dataset through these steps: Gather claims, extract referral number from claim, check referrals against previously evaluated referral numbers- only include claim with the earliest date of service that matches a not-yet-measured referral for this performance objective, sort all remaining claims in reporting data set by referral ID and claim submitted date, Identify first claim with the first date of service (DOS), match claims to referrals data to capture additional fields such as (but not limited to) Veteran Preference, Veteran Address, etc. Note that each referral will be linked to a single unique referral ID, which will appear on all claims related to that referral. Each unique referral ID is assigned a single designation and/or category of care designation. Claims without referral IDs are excluded. All referral and claim level data must be reported at the Veteran, VAMC, and Catchment area level. This reporting data set will be used for subsequent analysis.

ST1- Capture claims for Primary care and Mental Health Care within the network regardless of catchment area ST2 - Gather claims for EACH Station (grouped by Catchment Area) from all the claims submitted within the period assessed (as determined by the EDI 837 Claim Adjudication Date).

ST3 -The reporting month will align with provider claim Adjudication Date. The first date of the reporting month is the first day of the month through the last day of the month. E.g. For April 2025 reporting month include all claims with a Adjudication Date of 4/1/2025 through 4/30/2025. Do not exclude either 4/1 or 4/30.

ST4 - Referral associated based on referral number annotated on claim ST5 - Remove exclusions to this PO. See PRS Appendix B - Network Adequacy Performance Objective Exclusions List for exclusion(s) to this PO.

ST6- Appointment timeliness calculation determined using the Provider Allocation Date to the First Date of Service on the first claim received from the provider listed on the Referral.

ST7 - Identify as Success for every Primary Care instance where Appointment Timeliness≤ the appointment timeliness indicated in the PWS ST8 - Identify as Success for every Mental Health Care instance where Appointment Timeliness≤ the appointment timeliness indicated in the PWS ST9-Add all claims referenced for appointment timeliness for Primary Care = Potential Opportunities for Primary Care ST10- Add all claims referenced for appointment timeliness for Mental health Care= Potential Opportunities for Mental Health Care

*AQL for appointment timeliness standard is assessed together (Specialty Care Urban and Specialty Care Rural/Highly Rural). ≥ 90% Random Sampling *Statistically significant

EDI 835 and 837 claims and referral data

Sample from all Specialty Care and Specialty Mental Health Care claims submitted (for each station) within the period assessed (as determined by the EDI 837 Provider Claim Adjudication Date), appointment timeliness calculated from Provider Allocation Date to the First Date of Service on the first claim received from the provider listed on the Referral.

Sample time calculation:

Provider Allocation Date: 8/1/2999 First Date of Service: 8/24/2999 Appointment time = 23 days

Monthly, or more/less as determined by VA. ST0-Data Preparation: The first step is EDI parsing and combining claims with referrals data to create a reporting dataset through these steps: Gather claims, extract referral number from claim, check referrals against previously evaluated referral numbers- only include claim with the earliest date of service that matches a not-yet-measured referral for this performance objective, sort all remaining claims in reporting data set by referral ID and claim submitted date, Identify first claim with the first date of service (DOS), match claims to referrals data to capture additional fields such as (but not limited to) Veteran Preference, Veteran Address, etc. Note that each referral will be linked to a single unique referral ID, which will appear on all claims related to that referral. Each unique referral ID is assigned a single designation and/or category of care designation. Claims without referral IDs are excluded. All referral and claim level data must be reported at the Veteran, VAMC, and Catchment area level. This reporting data set will be used for subsequent analysis.

ST1- Capture claims for Specialty care within the network regardless of catchment area ST2 - Gather claims for EACH Station (grouped by Catchment Area) from all the claims submitted within the period assessed (as determined by the EDI 837 Claim Adjudication Date) ST3 -The reporting month will align with provider Claim Adjudication Date. The first date of the reporting month is the first day of the month through the last day of the month. E.g. For April 2025 reporting month include all claims with a Adjudication Date of 4/1/2025 through 4/30/2025. Do not exclude either 4/1 or 4/30.

ST4 - Referral associated based on referral number annotated on claim ST5 - Remove exclusions to this PO. See PRS Appendix B - Network Adequacy Performance Objective Exclusions List for exclusion(s) to this PO.

ST6- Appointment timeliness calculation determined using the Provider Allocation Date to the First Date of Service on the first claim received from the provider listed on the Referral.

ST7 - Identify as Success for every Specialty Care instance where Appointment Timeliness≤ the appointment timeliness indicated in the PWS ST8-Add all claims referenced for appointment timeliness for Specialty Care = Potential Opportunities for Specialty Care

*AQL for appointment timeliness standard is assessed together (Non-Institutional Extended Care Services Urban and Non-Instiitutional Extended Care Services Rural/Highly Rural).

≥ 90% Random Sampling *Statistically significant

EDI 835 and 837 claims and referral data

Sample from all Non-Institutional Extended Care Service claims submitted (for each station) within the period assessed (as determined by the EDI 837 Provider Claim Adjudication Date), appointment timeliness calculated from Provider Allocation Date to the First Date of Service on the first claim received from the provider listed on the Referral.

Sample time calculation:

Provider Allocation Date: 8/1/2999 First Date of Service: 8/24/2999 Appointment time = 23 days

Monthly, or more/less as determined by VA. ST0-Data Preparation: The first step is EDI parsing and combining claims with referrals data to create a reporting dataset through these steps: Gather claims, extract referral number from claim, check referrals against previously evaluated referral numbers- only include claim with the earliest date of service that matches a not-yet-measured referral for this performance objective, sort all remaining claims in reporting data set by referral ID and claim submitted date, Identify first claim with the first date of service (DOS), match claims to referrals data to capture additional fields such as (but not limited to) Veteran Preference, Veteran Address, etc. Note that each referral will be linked to a single unique referral ID, which will appear on all claims related to that referral. Each unique referral ID is assigned a single designation and/or category of care designation. Claims without referral IDs are excluded. All referral and claim level data must be reported at the Veteran, VAMC, and Catchment area level. This reporting data set will be used for subsequent analysis.

ST1- Capture claims for each category of Non-Institutional Extended Care Services within the network regardless of catchment area. The categories are listed in PWS (Homemaker/Home Health Aide, In Home Respite, Community Adult Day Health Care, Veteran Directed Care, Skilled Home Health Care, Hospice, Home Infusion and Ambulatory Fusion Suites, Bowel & Bladder- Agency, and Community Nursing Home) ST2 - Gather claims for EACH Station (grouped by Catchment Area) from all the claims submitted within the period assessed (as determined by the EDI 837 Claim Adjudication Date) ST3 -The reporting month will align with provider Claim Adjudication Date. The first date of the reporting month is the first day of the month through the last day of the month. E.g. For April 2025 reporting month include all claims with a Adjudication Date of 4/1/2025 through 4/30/2025. Do not exclude either 4/1 or 4/30.

ST4 - Referral associated based on referral number annotated on claim ST5- Remove exclusions to this PO. See PRS Appendix B - Network Adequacy Performance Objective Exclusions List for exclusion(s) to this PO.

ST6-Appointment timeliness calculation determined using the Provider Allocation Date to the First Date of Service on the first claim received from the provider listed on the Referral.

ST7 - Identify as Success for every Non-Institutional Extended Care Services instance where Appointment Timeliness≤ the appointment timeliness indicated in the PWS for each category ST8-Add all claims referenced for appointment timeliness for Non-Institutional Extended Care Services instance= Potential Opportunities for Non-Institutional Extended Care Services

-NPI Number -CareSite Name -CareSite Address -CareSite Phone -CareSite Fax -CareSite Email ≥ 90% Random Sampling *Statistically significant

Active Urgent Care provider data fields (6 required) in VA Provider Directory validated against publicly available sources, as well as confirmation through direct contact with provider.

Sample from all active Urgent Care claims submitted within the period assessed (determined by the EDI 837 Provider Claim Submission Date). Validation of the required data fields for each provider record sampled. The provider file as a whole does NOT pass/fail but each required field, six (6) per provider record, is assessed as an individual pass or fail.

Sample population (total fields sampled) = total claims sampled x 6

*Statistically significant

Contractor Contact Center data

Sample from all calls that entered the queue within the period assessed.

*Abandoned calls are those calls that voluntarily hung-up or ortherwise exited in the queue after entering the queue but before reaching an agent. It includes all calls that enter the queue. ≥ 95% (less than 5% are abandoned) Random Sampling *Statistically significant

Contractor Contact Center data

Sample from all calls that entered the queue within the period assessed.

*Statistically significant

Contractor Contact Center data

Sample from all calls that entered the queue within the period assessed.

Contractor fully resolves VA-provided ticketing tool tickets within:

Tier 1 - 5 business days Tier 2 - 15 business days Tier 3 - 30-180 calendar days Tier 4 - 180 calendar days ≥ 95% (for Each Tier) Random Sampling *Statistically significant

VA Ticketing Tool tickets

Sample from all tickets resolved, per tier, within the period assessed. Resolution timeliness calculated from Ticket Creation Date to Ticket Submission Date.

Sample time calculation:

Ticket Creation Date: 8/1/2999 Ticket Submission (Resolution) Date: 8/4/2999 Ticket resolution time = 3 days

Contractor fully resolves VA-provided ticketing tool tickets on the first submission. ≥ 80% Random Sampling *Statistically significant

VA Ticketing Tool tickets

Sample from all tickets submitted within the period assessed. Tickets resolved on first submission = tickets “Approved” by VA without having been previously rejected*.

*Rejected tickets are those tickets that were resolved by the Contactor in the ticketing tool but upon review by VA, they were determined to NOT be fully resolved and were thus “rejected” and sent back to the Contractor for additional information or further resolution.

Contractor fully resolves rejected VA-provided ticketing tool tickets as follows:

Tier 1 – no later than 3 business days of first ticket rejection Tier 2 – no later than 5 business days of first ticket rejection Tier 3 – no later than 30 calendar days of first ticket rejection Tier 4 – no later than 40 calendar days of first ticket rejection ≥ 98% (for Each Tier) Random Sampling *Statistically significant

VA Ticketing Tool tickets

Sample from all tickets, by tier, Approved by VA that were previously rejected* within the period assessed. Resolution timeliness calculated from First Ticket Rejection Date to Final Submission Date.

Sample time calculation:

First Ticket Rejection Date: 8/1/2999 Final Ticket Submission Date: 8/4/2999 Resolution time since first rejection = 3 days

VA Ticketing Tool tickets

Inspect all Tier 3 tickets resolved within the period assessed to determine number of ACR tickets received and validated by VA to be traceable to authorized services provided under this Contract.

Minimum threshold assessed and reported Monthly or more/less as determined by VA ST0- Data Preparation: Pull all Tier 3 tickets resolved within the period assessed (e.g., query conducted on September 15th for August 1st – August 30th).

ST1 - Determine the total number of Tier 3 Adverse Credit Reporting (ACR) Tickets resolved within the period assessed.

ST2- Review the ACR Tickets resolved and validate that they are traceable to authorized services provided under this Contract. ACR tickets that are not traceable to authorized services provided under this Contract are excluded from the total count of ACR tickets under this measure.

ST3- Based on the total number of Tier 3 ACR Tickets that have been resolved (and are traceable to authorized services provided under this Contract) within the period assessed, determine if AQL has been met, exceeded, and qualifies for an incentive, or has NOT been met and qualifies for a disincentive for the month assessed.

*VA will make the final determination as to whether or not a ticket has been adequately resolved and if it is traceable to authorized services provided by authorized services under this contract. Incentives / Disincentives will be calculated / assessed monthly and cumulative incentives/disincentives will be reviewed and paid/applied at least once within one (1) year of achieving full HCD and semi-annually thereafter*

Targets Per Month

0 - 50 ACR Tickets = + 0.25 % of the Monthly Administrative Services (CLIN X008 AA and AB)

51 - 90 ACR Tickets = No Incentive / Disincentive

91- 100 ACR Tickets = - 0.25% of the Monthly Administrative Services (CLIN X008 AA and AB)

101- 110 ACR Tickets = - 0.50% of the Monthly Administrative Services (CLIN X008 AA and AB)

111- 120 ACR Tickets = - 0.75% of the Monthly Administrative Services (CLIN X008 AA and AB)

> 120 ACR Tickets = - 1% of the Monthly Administrative Services (CLIN X008 AA and AB)

*Semi-annually is defined as occurring twice a fiscal year (October 1st - September 30).

**The first month eligible for incentives/disincentives is the first month after Full HCD has been achieved.

***The Contractor is not eligible for an incentive…