Dental Treatment PWS 2026.pdf

PERFORMANCE WORK STATEMENT (PWS)

FOR

Extensive Dental Treatment Services

1.0 General:

1.1 Scope: The contractor shall provide extensive dental treatment services as needed for soldiers in the Indiana Army National Guard (INARNG), as defined in this PWS.

1.2 Background: INARNG has a requirement to ensure medical readiness for 10,500 Service Members by providing services directly promoting comprehensive medical readiness, ensuring global deployability. Dental Readiness directly impacts deployability of soldiers.

Soldiers coded as Dental Readiness Code (DRC) 3 are non-deployable due to having oral conditions that will most likely result in a dental emergency within 12 months if not treated.

Utilizing a contracted dental office for extensive treatment services would greatly improve the INARNG’s ability to deploy soldiers and prevent oral conditions from worsening.

1.3 Period of Performance (PoP): The period of performance shall be one base year of 12 months or once the INARNG has utilized all funds provided to the contractor for extensive dental treatment services.

1.4 General Information:

1.4.1 Place and Performance of Services: The contractor shall provide services from their own dental office. The contractor shall be able to provide services during their dental office’s normal business hours. The contractor may be asked to provide services outside their normal business hours but can decline the request if they choose.

1.4.2 Quality Control (QC): The Contractor shall develop and maintain an effective QC Plan (QCP) to ensure services are performed in accordance with this PWS. The contractor shall develop and implement procedures to identify, prevent, and ensure non-recurrence of defective services. The contractor’s QCP is the means by which it assures itself that its work complies with the requirements of the contract. As a minimum, the contractor shall develop QC procedures that address the areas identified in Technical Exhibit 1, Performance Requirements Summary (PRS). After acceptance of the QCP, the contractor shall obtain the Contracting Officer’s (KO’s) acceptance in writing of any proposed changes to its QCP. As a minimum, the contractor shall develop QC procedures that address the areas identified in Technical Exhibit 1, Performance Requirements Summary (PRS).

1.4.3 Quality Assurance (QA): The Government will evaluate the contractor’s performance under this contract in accordance with the Quality Assurance Surveillance Plan (QASP). This plan is primarily focused on what the Government will do to ensure that the contractor has performed in accordance with the performance standards. It defines how the performance standards will be applied, the frequency of surveillance, and acceptable quality level(s) or defect rate(s).

2.0 Definitions and Acronyms:

2.1 Definitions:

2.1.1 Contractor. A supplier or vendor awarded a contract to provide specific supplies or service to the government. The term used in this contract refers to the prime.

2.1.2 Contracting Officer (KO). A person with authority to enter into, administer, and or terminate contracts, and make related determinations and findings on behalf of the government. Note: The only individual who can legally bind the government.

2.1.3 Contracting Officer’s Representative (COR). An employee of the U.S. Government designated by the KO to monitor contractor performance. Such appointment shall be in writing and shall state the scope of authority and limitations. This individual has authority to provide technical direction to the Contractor as long as the direction is within the scope of the contract, does not constitute a change, and has no funding implications. This individual does NOT have authority to change the terms and conditions of the contract.

2.1.4 Defective Service. A service output which does not meet the standard of performance associated with the Performance Work Statement.

2.1.5 Deliverable. A deliverable is anything that can be physically delivered and includes non-manufactured things such as meeting minutes or reports.

2.1.6 Key Personnel. N/A

2.1.7 Dental Readiness Code (DRC). The DRC is used to determine if a soldier has dental issues that will prevent them from being medically ready/deployable.

2.1.8 Physical Security. N/A

2.1.9 Quality Assurance. The government procedures to verify services being performed by the Contractor are performed according to acceptable standards.

2.1.10 Quality Assurance Surveillance Plan (QASP). An organized written document specifying the surveillance methodology to be used for surveillance of contractor performance.

2.1.11 Quality Control. All necessary measures taken by the Contractor to assure the quality of an end product or service meets contract requirements.

2.1.12 Subcontractor. One that enters into a contract with a prime contractor. The Government does not have privy of contract with the subcontractor.

2.2 Acronyms:

AFARS Army Federal Acquisition Regulation Supplement AMEDD Army Medical Department AR Army Regulation ARNG Army National Guard AUP Acceptable Use Policy AT/OPSEC Antiterrorism/Operational Security BBP Best Business Practices BI Background Investigation CFR Code of Federal Regulations CM Contract Manager COMSEC Communications Security CONUS Continental United States (excludes Alaska and Hawaii) COR Contracting Officer Representative COTS Commercial-Off-the-Shelf CMRA Contractor Manpower Reporting Application DA Department of the Army DD250 Department of Defense Form 250 (Receiving Report) DD254 Department of Defense Contract Security Requirement List DENCLASS Dental Classification Module D&F Determination and Findings DFARS Defense Federal Acquisition Regulation Supplement DHA Defense Health Agency DOD Department of Defense DODD Department of Defense Directive DODAAC Department of Defense Activity Address Code DODM Department of Defense Manual DSS Deputy State Surgeon eCASE Electronic Case Management FAR Federal Acquisition Regulation FBI Federal Bureau of Investigation FOUO For Official Use Only FPCON Force Protection Condition FSO Corporate Facility Security Officer FY Fiscal Year GFP/M/E/S Government Furnished Property/Material/Equipment/Services HIPAA Health Insurance Portability and Accountability Act of 1996 HQDA Headquarters Department of Army HRR Health Readiness Record HSS Health Services Specialist IA Information Assurance IAW In Accordance With IMR Individual Medical Readiness INARNG Indiana Army National Guard INCAP Incapacitation IS Information System(s) IT Information Technology

JTR Joint Travel Regulation KO Contracting Officer LAN Local Access Network LPN Licensed Practical Nurse LPVN Licensed Practical Vocational Nurse LOD Line of Duty MAR2 MOS Administrative Review Board MEB Military Evaluation Board MEDCHART Medical Electronic Data Care History and Readiness Tracking MEDCOM Medical Command MEDPROS Medical Protections System MHA Medical Health Assessment MHS Genesis Military Health Systems Genesis MMSO Military Medical Support Office MODS Medical Operational Data Systems MMPS Medical Management Processing System MND Medically Non-deployable MRC3 Medical Readiness Class 3 Non-Deployable MRDP Medical Readiness Decision Point MRE Medical Readiness Event MRP2 Medical Retention Processing MOS Military Occupational Specialty MTF Military Treatment Facility MTU Medical Transition Unit NACI National Agency Check with Inquiries NCO Non-Commissioned Officer NDR Non-Duty Related NDR-PEB Non-Duty Related Physical Evaluation Board NARSUM Narrative Summary NGB National Guard Bureau NTV Non-Tactical Vehicle OCI Organizational Conflict of Interest ODC Other Direct Costs OPM Office of Personnel Management OPSEC Operations Security OTSG Office of the Surgeon General OY Option Year PEB Physical Evaluation Board PEBLOS Physical Evaluation Board Liaison Officers PEC Physical Exam Center PCM Primary Care Manager PHA Periodic Health Assessment PII Personally Identifiable Information PIPO Phase In/Phase Out PIV Personal Identity Verification POC Point of Contact

PROFIS Professional Filler System PRS Performance Requirements Summary PSIP Personnel Security Investigation Portal PWS Performance Work Statement QA Quality Assurance QAP Quality Assurance Program QASP Quality Assurance Surveillance Plan QC Quality Control QCP Quality Control Program RAPIDS Real-Time Automated Personnel ID System RN Registered Nurse ROI Release of Information SM Service Member SOP Standard Operating Procedures SRP Soldier Readiness Processing SSN Social Security Number STR Soldier Treatment Records TA Trusted Agent TARP Threat Awareness Reporting Program TASS Trusted Associate Sponsorship System TEM Traumatic Event Management TE Technical Exhibit UIC Unit Identification Code USDI Under Secretary of Defense Intelligence

3.0 Government Furnished Property, Material, Equipment and Services (GFP/M/E/S): The Government will provide the property, material, equipment, and/or services listed below solely for the purpose of performance under this contract: N/A

3.1 Property: N/A

3.2 Materials: N/A.

3.3 Equipment: N/A

3.4 Utilities: N/A

4.0 Contractor Furnished Property, Materials, and Equipment (CFP/M/E):

4.1 General: Except for those items specifically stated to be Government-Furnished in Paragraph 3.0, the contractor shall furnish everything required to perform these services as required by the contract.

4.2 Secret Facility Clearance: N/A.

5.0 Requirements:

5.1 The contracted dental office, at a minimum, must be able to provide the following dental treatments: Root Canal Therapy, Crowns, surgical extractions of teeth with exposed roots/impacted teeth/erupted teeth, and Core Build-Up.

5.1.2 The contracted dental office must be able to see a soldier for a dental exam or treatment within 14 calendar days of the dental treatment request being submitted to the dental office.

5.1.3 The Standard Form (SF) 603 will be submitted to the contracted dental office by the INARNG’s J1 Medical Branch representative to request dental treatment for a soldier. The SF 603 will be sent via DODSafe.

5.1.3.1 The SF 603 is filled out by INARNG dentists and lists the DRC3 dental treatment that is required convert a soldier to DRC2. The SF 603 will be used by the dental office to provide an estimate of the cost of treatment for each soldier.

5.1.3.2 The Indiana Army National Guard will not pay for any dental treatment that is not listed on the SF 603 provided. If additional treatment is required, a dentist from the Indiana Army National Guard must revise the treatment plan provided by the dental office and approve it before treatment can be performed.

5.1.3.3 The contracted dental office must provide an updated treatment plan and any imaging taken when requesting to do additional treatment on a soldier.

5.1.3.4 The contracted dental office must submit an invoice on the last business day of each month that shows the cost of all treatments that were provided that month. They must also provide invoices as requested by the Indiana Army National Guard.

5.1.3.5 The contracted dental office must utilize soldier’s insurance prior to using the funds provided by the Indiana Army National Guard.

5.1.3.6 The contracted dental office must provide a signed DD Form 2813 to the Indiana Army National Guard once any treatment has been performed on a soldier and include the soldiers DRC code.

5.1.4 Contract Manager (CM): The contactor shall designate a CM who shall ensure performance under this contract. The name of this person, and an alternate who shall act for the contractor when the CM is absent, shall be designated in writing to the KO. The CM or alternate shall have full authority to act for the contractor on all contract matters relating to daily operation of this contract. The CM shall work through the Contracting Officer’s Representative (COR) to resolve issues, receive technical instructions, and ensure adequate performance of services.

5.1.5 Combating Trafficking in Persons: The United States Government has adopted a zero-tolerance policy regarding trafficking in persons. Contractors and contractor employees shall not engage in severe forms of trafficking in persons during the period of performance of the contract; procure commercial sex acts during the period of performance of the contract; or use forced labor in the performance of the contract. The Contractor shall notify its employees of the United States Government’s zero tolerance policy, the actions that will be taken against employees for violations of this policy. The contractor shall take appropriate action, up to and including termination, against employees or subcontractors that violate the US Government policy as described at FAR 22.17.

5.1.6 Data Rights: N/A

5.1.7 Organizational Conflicts of Interest (OCI): The contractor and subcontractor personnel performing services under this contract will not disclose information regarding number of service members they are treating.

5.1.8 Phase In/Phase Out Periods. Reserved.

5.9 Contractor Manpower Reporting Application (CMRA): N/A

5.9.1 The contractor shall report ALL contractor labor hours (including subcontractor labor hours) required for performance of services provided under this contract for the National Guard Bureau via a secure data collection site.

5.9.2 The contractor shall completely fill in all required data fields using the following web address: http://www.ecmra.mil/. Reporting inputs shall be for the labor executed during the period of performance during each Government fiscal year (FY), which runs October 1 through September 30. While inputs may be reported any time during the FY, all data shall be reported no later than October 31 of each calendar year, beginning with 2016. Contractors may direct questions to the help desk at http://www.ecmra.mil

The Unit Identification Code (UIC) for the Requiring Activity: W8AVAA.

Issuing Office DoDAAC: W912L9.

6.0 Applicable Publications: Publications applicable to this PWS are listed within.

Publication (Chapter/Page)

Date of Publication

Mandatory or Advisory

Website

Fed Acquisition Regulation Mandatory https://www.acquisition.gov/ ?q=browsefar

Defense Fed Acquisition Regulation Supplement

Mandatory http://www.acq.osd.mil/dpap/ dars/dfarspgi/current/index.h tml DoDI 5400.11

Department of Defense Privacy and Civil Liberties Programs

01/29/2019 Mandatory https://www.esd.whs.mil/Dire ctives/issuances/dodi/

DoD 5400.11-R Dept of Defense Privacy Program

05/14/2007 Mandatory http://www.dtic.mil/whs/direc tives/corres/pub1.html

DoDM 1000.13-M-V1 DoD Identification (ID) Cards

01/23/2014 Mandatory http://www.dtic.mil/whs/direc tives/corres/pub1.html http://www.ecmra.mil/ http://www.ecmra.mil/ http://www.acq.osd.mil/dpap/dars/dfarspgi/current/index.html http://www.acq.osd.mil/dpap/dars/dfarspgi/current/index.html http://www.acq.osd.mil/dpap/dars/dfarspgi/current/index.html http://www.dtic.mil/whs/directives/corres/pub1.html http://www.dtic.mil/whs/directives/corres/pub1.html

(Encl 2, para 3.b) Federal Information Processing Standards (FIPS) Publication 201-2 Personal Identity

Verification (PIV) of Federal Employees and Contractors (paragraph 9)

August

Mandatory http://nvlpubs.nist.gov/nistpu bs/FIPS/NIST.FIPS.201-

2.pdf

HSPC (Homeland Security Presidential Directive) -12 Policy for a Common

Identification Standard for Fed Employees and Contractors

08/27/2004 Mandatory https://www.dhs.gov/homela nd-security-presidential-directive-12

DoDM 5200.2 Procedures for the DoD Personnel Security Program

(PSP)

01/01/1987 Mandatory http://www.dtic.mil/whs/direc tives/corres/pub1.html

DoDD 8140.01 Cyberspace Workforce Management

08/11/2015 Mandatory http://www.dtic.mil/whs/direc tives/corres/dir.html

DoD 8570.01-M Information Assurance Workforce

Improvement Program

12/19/2005 (Change 4:

11/10/2015)

Mandatory http://www.dtic.mil/whs/direc tives/corres/pub1.html

AR 25-2

Information Assurance

10/24/2007 Mandatory http://armypubs.army.mil/Se arch/ePubsSearch/ePubsSe archForm.aspx?x=AR

AR 530-1

Operations Security 09/26/2014 Mandatory http://armypubs.army.mil/Se arch/ePubsSearch/ePubsSe archForm.aspx?x=AR

AR 381-12

Threat Awareness and Reporting Program

(TARP) (Section II, Para 2-4.b)

06/01/2016 Mandatory http://armypubs.army.mil/Se arch/ePubsSearch/ePubsSe archForm.aspx?x=AR

AR 40-501

Standards of Medical Fitness 12/14/2016 Mandatory http://www.apd.army.mil/Sea rch/ePubsSearch/ePubsSea rchForm.aspx?x=AR

AR 40-66

Medical Record Administration and Health

Care Documentation

06/17/2008 Mandatory http://www.apd.army.mil/Sea rch/ePubsSearch/ePubsSea rchForm.aspx?x=AR.

AR 40-68

Clinical Quality Management 02/26/2004 Mandatory http://www.apd.army.mil/Sea rch/ePubsSearch/ePubsSea rchForm.aspx?x=AR.

AR 635-40

Physical Evaluation for Retention, Retirement, or Separation

02/08/2006 Mandatory http://armypubs.army.mil/Se arch/ePubsSearch/ePubsSe archForm.aspx?x=AR AR 58-1 Management, Acquisition , and Use of Motor Vehicles

04/03/2019 Mandatory https://armypubs.army.mil/Pr oductMaps/PubForm/Details .aspx?PUB_ID=1005116

6.1 Applicable Forms: Forms applicable to the PWS are listed below:

Form Date Website

DD 1172-2

Application for Identification

Card/DEERS Enrollment

Jan 2014 http://www.dtic.mil/whs/directives/forms/index.htm

I-9 Employment Eligibility

Verification

11/21/91 http://www.ilw.com/forms/i-9fillable.pdf http://www.dtic.mil/whs/directives/corres/pub1.html http://www.dtic.mil/whs/directives/corres/pub1.html http://www.dtic.mil/whs/directives/corres/dir.html http://www.dtic.mil/whs/directives/corres/dir.html http://www.dtic.mil/whs/directives/forms/forminfo/forminfopage2479.html http://www.dtic.mil/whs/directives/forms/forminfo/forminfopage2479.html

DD 441

Department of Defense

Security Agreement

May http://www.dtic.mil/whs/directives/forms/dd/ddforms0001- 0499.htm

DD 250

Material Inspection and

Receiving Report

Aug http://dtic.mil/whs/directives/forms/dd/ddforms0001- 0499.htm

DD 2766

Adult Preventive and Chronic

Care Flowsheet

Mar http://www.dtic.mil/whs/directives/forms/dd/ddforms2500- 2999.htm

DA Form 3822 Report of Mental Status Evaluation

Mar http://www.apd.army.mil/pub/eforms/DR_a/pdf/DA%20F ORM%203822.pdf

SF 600

Chronological Record of

Medical Care

May http://www.gsa.gov/portal/forms/type/SF#1-1000

DD254

Department of Defense

Contract Security Classification Specifica

APR

https://www.esd.whs.mil/Portals/54/Documents/DD/forms /dd/dd0254.pdf

DD2813

Active Duty/Reserve Forces Dental Examination

Mar 2017 http://www.esd.whs.mil/Directives/forms/dd2500_2999/

TECHNICAL EXHIBIT 1: PERFORMANCE REQUIREMENTS SUMMARY

PWS

Paragraph

Task Performance Standard Acceptable Quality Levels

(AQL)

Surveillance Method / By

Whom 5.1.3.4

Submit a tracker showing treatment provided and costs of treatment provided

Submit the tracker no later than the last business day of the month every month.

<2% of reports not completed within timeline

Acceptance of billing in WAWF will be acceptance of services rendered

5.1.2

Schedule soldier’s for treatment within 14 calendar days of a request being received

Ensure soldier’s receive an appointment within 14 calendar days of the dental office receiving the request

<2% of soldier’s not scheduled within timeline will be acceptance of services

5.1.3.6 Submit a DD Form

2813 for each soldier that receives any dental treatment

Submit the DD Form 2813 immediately following any treatment provided

<2% of forms not submitted will be acceptance of services

TECHNICAL EXHIBIT 3: Estimated Workload Data

(This information is provided for historical background only. It is not a guarantee of workload quantities.)

ITEM NAME ANNUAL ESTIMATED

QUANTITY

1 Dental Treatment 300 projected for FY27