Attachment D PWS .pdf

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?.## ATTACHMENT D PWS

Office of Community Care

Performance Work Statement (PWS)

1. Purpose. Healthcare Clearinghouse (HCCH) to Support Health Care Electronic Data Interchange (EDI) & paper-based Health claims and associated medical documentation.

2. Background. As a Payer, the Department of Veterans Affairs (VA), Veterans Health Administration (VHA), Office of Community Care (OCC) uses a HCCH(s) to provide connectivity for incoming and outgoing EDI transactions for services to support the payment for services provided by community providers to Veterans and Veteran Families. The Payer EDI program provides interfaces to both external and internal systems to facilitate the reimbursement processes. As a Payer, OCC accepts both paper and electronic submissions for health claims and for supporting documentation (i.e. attachments). Current programs are as follows:

Veteran:

Non-VA Medical Care Program (NNPO-legacy name VA Fee Basis) Non-VA Medical Care Dialysis National Contracts (DNC) Patient-Centered Community Care (PCCC) Indian Health Service and Tribal Health Program (IHS/THP) Community Care Network (CCN)

CHOICE

VA Maintaining Systems and Strengthening Integrated Outside Networks Act (MISSION)

Veteran Families:

Camp Lejeune Family Member Program (CLFMP) Civilian Health and Medical Program VA (CHAMPVA) Spina Bifida Health Care Program (SB) Children of Women Vietnam Veterans (CWVV)

As a Payer, VHA/OCC has initiated multiple projects to increase the volume and overall percentage of electronic transactions versus paper or other manual transactions to comply with legislation and to facilitate administrative simplification. VHA/OCC also employs a clearinghouse to transmit incoming and outgoing EDI transactions to the over one million medical and dental providers throughout the United States, Puerto Rico, and US Territories.

The EDI transactions consist of batch and real-time transfers of HIPAA ASC X12N 5010 transactions. VHA OCC 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) 2019:

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Transaction Type Hosted Direct Edits

FY19

Weekly Volume

FY20

Estimated Weekly Volume

837 Batch X x 456,215 487,015

837COB Batch X x 85,569 91,734

835 Batch X 291,484 305,977

270/271 Batch/ Real-Time x X x 329,848 442,486

276/277/277CA Batch x X 86,320 115,385

278*

Real-Time x X x n/a 4,615

277RFAI* Batch X n/a 1,300

275* Batch X 24,588 80,769

Paper to Electronic n/a n/a 534,016

Rejections n/a n/a 17,841

*Under development – will be implemented during this contract period of performance.

3. Objectives. VHA OCC will maintain EDI transaction capability throughout the term of this contract giving community health care providers access to HIPAA-compliant data and processes and contract support for the receipt of paper claims and their conversion to EDI transactions. Finally, the overall effectiveness and quality of these activities will be monitored using standard, regular reports.

4. Scope. VHA OCC currently exchanges EDI transactions between health care entities. OCC is seeking a Health Care Clearinghouse (HCCH) contractor, referenced as “the Contractor”, to support all its current EDI transactions across the United States and territories and to assist in continuing its mission to implement EDI transactions and utilization of a single national location that will receive paper-based submissions and convert these submissions to electronic formats and transmit these submissions via EDI to the VA. The Contractor will support three major EDI activities over the course of this contract: Implementation, Operations and Maintenance, and Reporting. Implementation shall cover all activities required to establish initial operational capabilities for Payer EDI. The initial implementation should limit the need for programmatic changes on VHA OCC Information Technology (IT) systems and shall not be priced separately.

Implementation shall include full trading partner transaction capabilities with provider communities in all 50 United States, Puerto Rico and Territories. Additional Implementations shall be proposed as optional tasks at various levels of effort (LOE) (i.e. small, medium, or large). Operations and Maintenance shall cover all activities required to sustain Payer EDI transactions over this contract’s period of performance. Finally, reports shall be required to monitor quality and volumetric data over the course of the contract. The Contractor shall provide all services related to receiving paper claims and/or paper medical documentation from community health care providers and Veteran Family Member Program (VFMP) providers via postal mail, in a single location, converting these documents to the appropriate HIPAA-compliant EDI transactions and sending as EDI transactions.

VHA shall mimic and replicate all relevant commercial practices to the maximum extent practicable. Major healthcare providers utilize clearinghouses to process and pay claims. The

- 3 -subject acquisition is for clearinghouse services. VHA is the single largest healthcare provider in the United States. Major healthcare providers utilize clearinghouse services which only have the aforementioned certifications and credentialing. This is done to ensure the highest level of services. Further, this ensures the service providers adhere to the myriad of Federal and State regulatory requirements. To this end, the VA shall likewise ensure the contractor possesses the above certifications and credentialing so that the highest level of services are provided and commercial practices are followed.

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 shall 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 OCC team.

Specifically, the contractor shall perform the following tasks:

5.1 Task One: Kick-Off Meeting

5.1.1 Kick-Off Meeting

The Contractor and COR shall establish a bilaterally acceptable date (but not later than (NLT) 10 business days of 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, 278, 276/277)

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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, 278, 276/277)

5.2.2 Specifications for Direct Transactions (270/271, 278, 277CA, 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 Technical Report 3 (TR3) 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 (270/271, 278, 837, 837COB)

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 Specification for Paper to EDI (P2E)

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 Family Member Program (FMP) claims at a single location

5.2.4.2 The contractor shall store scanned documentation for six calendar weeks after receipt.

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 HIPPA compliant EDI transactions within 2 business day of receipt and one hundred percent (100%) of all paper-based forms within 5 business days

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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.

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 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)

5.2.5 Implementation Work Breakdown Structure and Schedule with Durations, Predecessors, and Responsible Parties

The contractor shall deliver a WBS and schedule that meets Project Management Institute (PMI) and VHA/OCC guidelines.

Deliverable 5.2.5 Implementation Work Breakdown Structure and Schedule with Durations, Predecessors, and Responsible Parties

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 OCC and its trading partners. The contractor shall provide connectivity that is at least compliant to the appropriate CAQH Core “Connectivity Rule” as defined at http://www.caqh.org to all EDI capable providers/submitters of transactions used by VHA/OCC Programs. This capability shall include providers/submitters in the District of Columbia, each of the United States, and the following territories: American Samoa, Guam, Puerto Rico and the U.S. Virgin Islands. 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:

- 6 -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 which meets VHA/OCC guidelines. 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 which meets VHA/OCC guidelines. 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

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/OCC 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 Programs (CHAMPVA, Spina Bifida, Children of Women Vietnam Veterans) 84146 - Medical batch transactions 84147 - Dental batch transactions 80214 - Medicare batch transactions VAHAC - Hosted transactions

Note: There may additional Payer IDs implemented in the future.

Deliverable 5.2.10 Create and Manage 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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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 system for providers to communicate issues and discrepancies. See Section 2, paragraph 4.

Deliverable 5.2.11.2 Provider Communication System

5.2.11.3 Secure Email System

The contractor shall implement 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,

(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/OCC Trading Partners

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

Deliverable 5.3.1 EDI Enrollment Process

5.3.2 Transactions

The contractor shall provide 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

- 8 -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 Health Care Eligibility Benefit Inquiry and Response 270/271 (includes acknowledgements) Hosted Real-Time transactions

5.3.2.5 Health Care Eligibility Benefit Inquiry and Response 270/271 (includes acknowledgements) Direct Real-Time transactions

5.3.2.6 Health Care Claim Status Request and Response 276/277/277CA (includes acknowledgements) Hosted Transactions

5.3.2.7 Health Care Claim Status Request and Response 276/277/277CA (includes acknowledgements) Direct Real-Time transactions

5.3.2.8 Health Care Claim Status Request and Response 277RFAI

5.3.2.9 Health Care Services Review – Request for Review and Response 278 (includes acknowledgements) Hosted Real-Time transactions

5.3.2.10 Health Care Services Review – Request for Review and Response 278 (includes acknowledgements) Direct Real-Time transactions

5.3.2.11 Health Care Claim Attachment 275 (includes acknowledgements) Batch Transactions

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

5.3.2.13 Rejection Claim plus USPS First Class Postage

Deliverable 5.3.2 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.

Deliverable 5.4: Reports

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

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

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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:

Report Title 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:

Report Title 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:

Report Title 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:

Report Title Month and year of reporting period Payer ID Transaction Type Monthly Summary of Total successful transactions by Payer ID

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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:

Report Title 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:

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:

Report Title 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:

Report Title 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

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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 claims, pending claims, newly received claims and transfers, claims processed, adjustments processed, closing of pending claims and closing of adjusted claims within mutually agreed upon timelines, but no later than five (5) business days. 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

The contractor shall conduct monthly conference call meetings with VA to discuss performance issues. Frequency of meeting can be adjusted as necessary.

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 Task Five (Optional): Implement Modifications to Transactions

The Contractor shall provide support necessary to implement small, medium or large modifications to transactions as required by VHA/OCC. The Government may purchase any quantity any number of times but, may not exceed the following: 20 small implementations, 10 medium implementations, 5 large implementations.

Deliverable 5.5: Implement Modifications to Transactions Deliverable 5.5.1 Small Implementations: To include task in section 5.2 for example transaction edits or configuration changes.

Deliverable 5.5.2 Medium Implementations: To include tasks in section 5.2 for example if the vendor is a non-incumbent, they will have to perform task is section 5.2 for medium transition set such as 270s, 271s, and 276s.

Deliverable 5.5.3 Large Implementations: To include tasks in section 5.2 for example if the vendor is a non-incumbent, they will need to perform task in section 5.2 for large transactions sets such as 835, 837, 275s.

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Vendor shall be expected to cover all additional implementation costs in addition to cost provided in Implementation CLINs using transaction costs.

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

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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

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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

5.5 Implement Modifications to

Transactions (Optional)

Optional

5.5.1 Small Implementations

(Optional)

Optional

5.5.2 Medium Implementations

(Optional)

Optional

5.5.3 Large Implementations

(Optional)

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. OCC/VHA 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. OCC/VHA 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

- 15 -minutes of such meetings, which shall be recorded in the agreement 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 hour/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 period of performance shall be from date of award for a period of 12 months, hereto referred to as the base. The Requirements Contract also includes three 12-month option periods which may be unilaterally exercised by the Government. All terms and conditions applicable to the base year shall extend to each option unless otherwise agreed upon.

There are ten (10) Federal holidays set by law (U.S.C. Title 5 Section 6103):

Under current definitions, four are set by date:

New Year’s Day January 1 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 as directed by the COR and mutually agreed to by the Contractor.

7.0 Key Personnel. Certain skilled experienced professional and/or technical personnel are essential for accomplishing the work to be performed. These individuals are defined as “Key Personnel” and are those persons whose resumes were 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.

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Title: Sr. Project Manager 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 an Information Technology or a related field and with a minimum of 5 years’ experience in managing projects and/or programs related to healthcare EDI. He or she must be an expert in leading a team of diversified staff and have a proven record in managing programs related to healthcare EDI.

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) Requirements 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.

11. Government and Contractor Responsibilities.

11.1 VHA/OCC 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

- 17 -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/OCC 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 agreement. For those tasks listed in the QASP, the COR or evaluators shall follow the methods of surveillance specified in the agreement. 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 agreement. Such surveillance shall be done according to standard inspection procedures or other agreement provisions. Any action taken by the Contracting Officer as a result of surveillance shall be in accordance with the terms of this agreement.

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 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.

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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. In this case, Veterans Health Administration facilities must have a duly executed VA business associate agreement (BAA) in place with the vendor in accordance with VHA Handbook 1600.01, Business Associates, to assure compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) in addition to the contract. Contract personnel, if on site, should be escorted by VA IT staff.

14.1.3 Contract personnel who require access to national security programs must have a valid security clearance. National Industrial Security Program (NISP) was established by Executive Order 12829 to ensure that cleared U.S. defense industry safeguards the classified information in their possession while performing work on contracts, programs, bids, or research and development efforts. Defense Security Service (DSS) administers the NISP on behalf of the Department of Defense and 23 other federal agencies within the Executive Branch. VA will verify clearance through DSS.

14.1.4 This contract will require establishment of a Memorandum of Understanding and Interconnection Security Agreement (ISA) between VHA/OCC on behalf of VA Financial Services Center (FSC) and the Contractor regarding development, management, operation, and security of a connection between the VA-FSC VLTrader Secure Shell/File Transfer Protocol (SSH/FTP) Electronic Data Interface (EDI) Transfer System, owned by VA-FSC, and the Contractor’s server, owned by the Contractor. This agreement will govern the relationship between VHA/OCC-FSC and the Contractor, including designated managerial and technical staff. The authority for this interconnection is based on:

• Federal Information Security Management Act (FISMA)

• VA Directive 6500, Managing Information Security Risk: VA Information Security

Program, and Handbook 6500, Risk Management Framework for VA Information Systems: Tier 3 – VA Information Security Program http://www1.va.gov/vapubs/ http://www1.va.gov/vhapublications/index.cfm

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• Health Insurance Portability and Accountability Act (HIPAA) Security Rule, 45 C.F.R.

Part 160

• 38 United States Code (U.S.C.) §§ 5721-5728, Veteran’s Benefits, Information Security

• Office of Management and Budget (OMB) Circular A-130, Appendix III, Security of

Federal Automated Information Systems

• 18 U.S.C. 641 Criminal Code: Public Money, Property or Records

• 18 U.S.C. 1905 Criminal Code: Disclosure of Confidential Information

The authority for VHA/OCC-FSC to share data for the purpose outlined under this Agreement with the recipient is as follows:

• HIPAA Privacy Rule, 45 Code of Federal Regulations (C.F.R.) Part 164, Standards for Privacy of Individually Identifiable Health Information

• Privacy Act of 1974, 5 U.S.C. § 552a, as amended

• Confidential Nature of Claims, 38 U.S.C. § 5701

• Confidentiality of Healthcare Quality Assurance Review Records, 38 U.S.C. § 5705

• VA Claims Confidentiality Statute, 38 U.S.C § 5701

• Confidentiality of Certain Medical Records, 38 U.S.C. § 7332

• Freedom of Information Act, 5 U.S.CC. § 552

14.2 VA Information Custodial Requirements

14.2.1 Information made available to the contractor by VA for the performance or administration of this contract or information developed by the contractor in performance or administration of the contract shall be used only for those purposes and shall not be used in any other way without the prior written agreement of the contracting officer. This clause expressly limits the contractor's rights to use data as described in Rights in Data - General, FAR 52.227-14(d) (1).

14.2.2 Information generated by a Contractor as a part of the contractor’s normal business operations, such as medical records created while providing treatment, is subject to a review by the Office of General Counsel (OGC) to determine if the information is the property of VA and subject to VA policy. If the information is determined by OGC to not be the property of VA, the restrictions required for VA information will not apply.

14.2.3 VA information will not be co-mingled with any other data or the contractors and, or sub-contractors information systems/media storage systems in order to ensure VA requirements related to data protection and media sanitization can be met. If co-mingling must be allowed to meet the requirements of the business need, the contractor must ensure that VA's information is returned to the VA or destroyed in accordance with VA's sanitization requirements.VA also reserves the right to conduct IT resource inspections to ensure data separation and on-site inspection of information destruction/media sanitization procedures to ensure they are in compliance with VA policy requirements.

14.2.4 Prior to termination or completion of this contract, contractor will not destroy information received from VA or gathered or created by the contractor in the course of performing this contract without prior written approval by the VA contracting officer. Any data destruction done on behalf of VA by a contractor must be done in accordance with National Archives and Records Administration (NARA) requirements as outlined in VA Directive 6300, Records and Information Management and its Handbook 6300.1 applicable VA Records Control Schedules, and VA Handbook 6500.1, Electronic Media Sanitization. Self-certification by the contractor that the data destruction requirements above have been met must be sent to the VA Contracting Officer within 30 days of termination of the contract.

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14.2.5 The contractor will receive, gather, store, back up, maintain, use, disclose and dispose of VA information only in compliance with the terms of the contract and applicable Federal and VA information confidentiality and security laws,…