DRAFT PWS for Bridge 3rd Party Billing V.02-2026.docx

Consolidated Patient Account Center (CPAC) Third Party Billing Consolidated Patient Account Center (CPAC) Revenue Operations (RO) Performance Work Statement (PWS)

1. SCOPE

The Contractor shall provide all labor and equipment required for generation of Veteran Affairs (VA) claims to third party healthcare insurance carriers for CPAC sites nationwide.

2. BACKGROUND

The Department of Veterans Affairs (VA) has historically relied on contract services to improve collections through timely and accurate billing of third-party claims. VA’s CPACs are responsible for billing and collecting from insurance companies for medical treatment provided to veterans for NSC conditions.

2.1. There are 7 regional CPACs located as follows:

Station 730, Asheville, NC- Mid-Atlantic CPAC (MACPAC) Station 731, Smyrna, TN- Mid-South CPAC (MSCPAC) Station 732, Middleton, WI- North Central CPAC (NCCPAC) Station 733, Orlando, FL- Florida Caribbean CPAC (FCCPAC) Station 734, Lebanon, PA- Northeast CPAC (NECPAC) Station 735, Leavenworth, KS- Central Plains CPAC (CPCPAC) Station 736, Las Vegas, NV- West CPAC (WCPAC)

2.2. Public Law 99-272 grants VA authority to seek reimbursement from third party health insurers for the cost of medical care furnished to an insured non-service connected (NSC) veteran. Public Law 101-508 expanded VA's recovery program by providing authorities to seek reimbursement from third party payers for the cost of medical care provided to ensure service-connected veterans treated for their NSC conditions.

3. OBJECTIVES

The primary objective of this Performance Work Statement (PWS) is to outline the medical billing services for VA Care to generate accurate and timely third-party claims for CPAC sites nationwide.

4. TASKS and DELIVERABLES- Medical Billing Services-VA Care Contractors shall provide services to establish and authorize outpatient medical claims to third party insurance carriers in the VA Veterans Health Information Systems and Technology Architecture (VistA) information system or the most current system in accordance with VA established guidelines. Please be aware, VISTA is a Disk Operating System (DOS) based system, minimum expectation is to manually process 16-25 claims per hour per biller. Our legacy VA systems do not interface with modern Graphical User Interface billing software. Medical billing is to be performed within industry standards and in accordance with VA Guidebooks and policies. The estimated timeframe to complete one claim is approximately 3 minutes. Timely completion: Medical claims are generated within 2 business days of receipt of information from CPAC.

4.1. Billing Accuracy: Medical claims are authorized and released in accordance with CPAC guidebooks and VA policy and directives

4.2. Work claim rejections: Rejected claims will have an initial review within 5 business days, with follow up every 15 days. See VA Guidebook for guidance.

4.3. Accurate canceling claims and assigning correct reason not billable: Claims are appropriately canceled in VistA or most current system and correct RNB is assigned in Claims Tracking

4.4. Resolving billing related questions and concerns: Open lines of communication are always maintained between Contractor and CPAC

4.5. Conference call participation: Contractor participates in conference calls, as needed, to improve billing performance

4.6. Maintain VistA access (or current system): Contractor shall log onto the VistA system for each CPAC Medical Center at least once every 30 days to maintain this access. If an individual worker does not log on to our systems for a length of 30 days or more, their access must be reset. Resetting access is a time consuming process on our end. For this reason, the company must ensure that all workers log in at least once every 14 days.

4.7. Confidentiality: Contractor shall ensure all claims are released in compliance with VA specific requirements

4.8. Monthly Itemized Statement

4.8.1. The Contractor shall provide an itemized statement monthly outlining the claims processed and any access problems/issues encountered in the performance of this task.

Monthly reports (by the fifth business day of each month) on the billing activity shall include, but are not limited to:

4.8.1.1. Summary of quantity of claims processed per facility per reporting period, and cumulative for entire contract to date.

4.8.1.2. Number of claims authorized per biller

4.8.1.3. Unit price and total cost of claims authorized

4.8.1.4. Number of claims canceled

4.8.1.5. Unit price and total cost of claims canceled (for deduction)

4.8.1.6. Number of claims per CPAC broken down per biller and per VAMC

5. DELIVERABLES- Monthly Staffing Report The Contractor shall develop and submit a Monthly Staffing Report (due by the fifth day of each month). The report should include the name of staff hired for performance under this contract. The report should also include staff no longer working under this contract. The report shall include an anticipated start date or termination date and assigned primary CPAC facility.

5.1. Delivery

Electronic copies shall be delivered using Microsoft 365 Office suite of tools, unless otherwise specified by the COR. Electronic submission shall be made via email, unless otherwise agreed to by the COR.

6. FORMAL ACCEPTANCE or REJECTION of DELIVERABLES All written deliverables shall be phrased in layperson language. Statistical and other technical terminology shall not be used without providing a glossary of terms. The Contracting Officer Representative (COR) will have the right to reject or require correction of any deficiencies found in the deliverables. In the event of a rejected deliverable, the Contractor shall be notified in writing by the COR of the specific reasons for rejection. The Contractor shall have five (5) workdays to correct the rejected deliverable and return it per delivery instructions. If for any reason any deliverable cannot be delivered within the scheduled timeframe, the Contractor is required to explain why in writing to the COR by the delivery due date, including a firm commitment of when work shall be completed.

This notice to the COR shall cite the reasons for the delay, and the impact on the overall project. The COR will forward the notice and reasons for the delay to the CO with comments. The CO will then review the facts and issue a response, in accordance with applicable regulations.

The Contracting Officer’s Representative (COR) for the Contract is a government official who has been delegated specific technical, functional and oversight responsibilities for this contract. The COR is designated in the COR appointment letter, issued by the Contracting Officer, and is responsible for inspection and acceptance of all services and documents.

6.1. Acceptance Criteria

Certification by the Government of satisfactory services provided is contingent upon the Contractor performing in accordance with the performance standards contained in the Performance Requirements Summary Matrix (Section 16) and all terms and conditions of this contract including all modifications.

6.2. Government Acceptance Period

The COR will have ten (10) business days to review draft deliverables and make comments. The Contractor shall have five (5) business days to make corrections. Upon receipt of the final deliverables, the COR will have two (2) business days for final review prior to acceptance or providing documented reasons for non-acceptance. Should the Government fail to complete the review within the review period the Deliverable will become acceptable by default, unless prior to the expiration of the ten (10) business days the Government notifies the Contractor in writing to the contrary. The final submission should be deemed approved if the Government has not rejected it in thirty (30) calendar days.

7. Quality Performance Standards

7.1. Coordination

Direct communication regarding billing issues should be addressed to the Billing Manager or Supervisor. Names and contact information will be provided after the award.

8. PERFORMANCE DETAILS

8.1. Indefinite Delivery Indefinite Quantity (IDIQ) Period of Performance: Sixty (60) month ordering period.

8.2. Period of Performance and quantities will be established for each Task Order

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

Under current definitions, five are set by date:

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:

8.4. PLACE OF PERFORMANCE

The physical location of performance of work activity will be the responsibility of the Contractor. No space will be provided by the CPAC. Contractors shall provide a remote and secure business setting for healthcare billing. Patient confidentiality and database security must be always maintained.

8.5. Hours of Operation

The normal operating hours for the Federal Government are Monday – Friday, 8:00am – 4:30pm local area time. VA and CPAC employees must be able to communicate with the Contractor’s key personnel from 8:30 am to 5:00 pm ET during all federal workdays.

9. OTHER TERMS, CONDITIONS, AND PROVISIONS

9.1. Non-billable

If an outpatient medical care encounter is determined to be not billable the Contractor shall cancel the claim and/or enter a reason not billable (RNB) in the Veteran Health Information Systems and Technology (VistA), Web VistA Integration Reporting and Revenue (Web VIRR), or most current system Integrated Billing Software Package at no charge to the VA. VA estimates 10% of daily workload will be determined not billable

9.2. Non-Disclosure/Non-Use Agreement

The Contractor shall ensure that a Non-Disclosure Statement is signed before performing any work. The Non-Disclosure / Non-Use statement shall be cosigned by a corporate official (Contractor Task Manager or higher).

10. INFORMATION ASSURANCE

10.1. General Security Requirements

The Contractor shall establish appropriate administrative, technical, and physical safeguards to protect any and all Government data, to ensure the confidentiality, integrity, and availability of government data. As a minimum, this shall include provisions for personnel security, electronic security, and physical security as listed in the sections that follow.

10.2. Health Insurance Portability and Accountability Act (HIPAA) The Contractor shall comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (P.L. 104-191) requirements, specifically the administrative simplification provisions of the law and the associated rules and regulations published by the Secretary, Health and Human Services (HHS). This includes the Standards for Electronic Transactions, the Standards for Privacy of Individually Identifiable Health Information and the Security Standards. It is expected that the contractor shall comply with all HIPAA-related rules and regulations as they are published (including identifiers for providers, employers, health plans, and individuals, and standards for claims attachment transactions).

11. PROTECTION of INFORMATION

11.1. Dissemination of Information/Publishing

There shall be no dissemination or publication, except within and between the Contractor and any subcontractors. This includes VA Guidebooks, Standard Operating Procedures (SOPs), job aids, and other tools to support billing third-party payers, as well as insurance policy information or third-party payer agreements retained by VA. VA approval for publication will require provisions which protect the intellectual property and patent rights of both VA and the Contractor.

11.2. Personally Identifiable Information (PII) and Protected Health Information (PHI) Contractors collecting, storing, or disseminating personal identifiable information (PII) or protected health information (PHI) data must conform to all pertinent regulations, laws, and VA directives related to privacy. Contractors must provide access for VA privacy reviews and assessments and provide appropriate documentation as directed.

12. CONTRACTOR EMPLOYEES

12.1. Key Personnel

Skilled experience in managing insurance billing office with similar volumes and work projected in this PWS. These “Key personnel” are the individuals whose resumes were submitted and marked by the vendor as “Key Personnel”. The Contracting Officer (CO) may notify the Contractor and request immediate removal of any personnel assigned to the contract 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 the 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. Company must maintain adequate staffing numbers to meet the workload volume goal throughout the term of the contract, there may be increases or decreases in workload.

12.2. 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 sec19urity requirements, as defined in Section 11.1 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.

12.3. STAFF QUALIFICATIONS

12.3.1. General Experience: Contractor personnel assigned to this contract shall have expertise in performing outpatient medical billing.

12.3.2. Manager:

Comprehensive knowledge of the principles, practices, laws, rules, and regulations related to billing for healthcare services and the submission of healthcare claims. Provides management oversight, guidance, corrective measures, and direction for monitoring activities designed to ensure the integrity and accuracy of healthcare claims. The Incumbent serves as CPAC’s expert technical authority on matters relating to VHA’s Consolidated Billing departments and the interface with process drivers at the medical centers for which the individual CPAC supports. Exercises management responsibility for complex billing activities for all the facilities assigned to the CPAC. Implement and manage all aspects of billing activities for CPAC clients and a wide range of stakeholders. Manager must have minimum 5 years of third party medical billing experience supporting Outpatient, Durable Medical Equipment (DME) and Dental.

12.3.3. Supervisor:

Incumbent serves as Billing Supervisor responsible for the timely and accurate preparation and submission of claims for healthcare services, equipment, and/or medication. The Supervisor makes assignments based on the complexity of healthcare services, procedures, equipment, etc., provided, stabling deadlines and quality requirements. Comprehensive knowledge of framework of regulatory material regarding healthcare billing such as Medicare, TRICARE, and CHAMPVA guidelines, Sharing Agreements, Worker’s Compensation, appropriate Public Laws, HIPPA rules and regulations. Knowledge of coding of diseases and procedures using ICD-10, CPT, and HCPCS coding systems. Supervisor must have minimum 5 years of third party medical billing experience supporting Outpatient, Durable Medical Equipment (DME) and Dental.

13. MANAGEMENT and OVERSIGHT

13.1. The Contractor shall be responsible for managing and overseeing the activities of all Contractor and subcontractor personnel, 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 performance work statement.

14. DOMAIN KNOWLEDGE

The Contractors shall present domain knowledge of outpatient healthcare third party billing. Domain knowledge criteria are specified below:

Proposed personnel shall have an in-depth knowledge of health care revenue third party billing in the following areas:

Knowledge and experience in authorizing claims to third party carriers for outpatient services.

Knowledge of and ability to apply third party insurance and Medicare guidelines to claims.

Company must distribute training updates and new regulations to staff within 5 Business Days of being notified by CPAC.

Company must stay updated with the latest trends in Medicare, CMS, on a monthly basis, as updates are distributed to the public.

15. QUALITY ASSURANCE

The Government will review Monthly Itemized Statements and will attend regular task performance review meetings with the Contractor to survey the quality of products and services.

15.1. Quality Assurance Surveillance Plan (QASP)

The Government intends to utilize a Quality Assurance Surveillance Plan (QASP) to monitor the quality of the Contractor’s performance. The oversight provided for QASP will help to ensure that service levels reach and maintain the required levels throughout the contract term. Further, the QASP provides the COR with a proactive way to avoid unacceptable or deficient performance and provides verifiable input for the Contractor Performance Assessment Reporting system. The QASP will be finalized immediately following the award and a copy provided to the Contractor afterward. The QASP is a living document and may be updated by the Government as necessary.

15.2. Performance Requirements Summary Matrix

By monitoring the Contractor, the COR will determine whether the performance levels set forth in the order have been attained. Performance standards are specified in the following Performance Requirements Summary Matrix in the Standard and Acceptable Quality Level columns.

Timely completion of outpatient medical claims

Written confirmation from Contractor that billing has been completed within 10 business days or explanation for any delays

Billing accuracy

Bi-weekly quality reviews

Resolving claim rejections

CSA and MRW

Accurate canceling claims and assigning correct RNBs

Conference call participation.

100% of contractor billing leadership attend conference call.

Periodic Inspection Of list of training participants and when training was completed

16. INFORMATION SYSTEM SECURITY

The Contractor shall ensure adequate LAN/Internet, data, information, and system security in accordance with VA standard operating procedures and standard contract language, conditions laws, and regulations. The Contractor’s firewall and web server shall meet or exceed the government minimum requirements for security. All government data shall be protected behind an approved firewall. Any security violations or attempted violations shall be reported to the COR and the VHA Headquarters Information Security Officer as soon as possible. The Contractor shall follow all applicable VA policies and procedures governing information security, especially those that pertain to certification accreditation.

17. SECURITY CONTROLS COMPLIANCE TESTING

On a periodic basis, VA, including the Office of Inspector General, reserves the right to evaluate any or all the security controls and privacy practices implemented by the Contractor under the clauses contained within the contract. With 10 working days’ notice, at the request of the Government, the Contractor will fully cooperate and assist in a government-sponsored security controls assessment at each location wherein VA information is processed or stored, or information systems are developed, operated, maintained, or used on behalf of VA, including those initiated by the Office of Inspector General. The Government may conduct a security control assessment on shorter notice (to include unannounced assessments) determined by VA in the event of a security incident or at any other time.

18. SECURITY TRAINING

All Contractor employees and Sub-Contractor employees requiring access to VA sensitive information and/or VA information systems shall complete the following before being granted access to VA networks or sensitive information:

Sign and acknowledge understanding of and responsibilities for compliance with the Contractor Rules of Behavior relating to access to VA information and information systems.

Successfully complete Privacy and HIPAA Training and annual refresher training as required.

Successfully complete VA Privacy and Information Security Awareness and Rules of Behavior and annual refresher training as required; and successfully complete any additional cyber security or privacy training, as required for VA personnel with equivalent information system access [to be defined by the VA program official and provided to the contracting officer for inclusion in the solicitation document – e.g., any role-based information security training required in accordance with NIST Special Publication 800-16, Information Technology Security Training Requirements.

The Contractor shall provide to the COR and Contracting Officer a copy of the training certificates for each applicable employee within 1 week of the initiation of the contract and annually thereafter, as required. These online courses are located at the following web site: https://www.tms.va.gov/SecureAuth35/ Failure to complete this mandatory training within the timeframe required will be grounds for suspension or termination of all physical and/or electronic access privileges and removal from work on the contract until such time as the training is completed.

19. CONTRACTOR PERSONNEL SECURITY

All Contractor employees who require access to the Department of Veterans Affairs' computer systems shall be the subject of a background investigation and must receive a favorable adjudication from the VA Security and Investigations Center (07C). The contractor is responsible for the cost of all background investigations. The level of background security investigation shall be in accordance with VA Directive 0710 dated Sept. 08, 2025, and is available at:

19.1. Directive 0710

19.2. https://www.va.gov/vapubs/viewPublication.asp?Pub_ID=1631

19.3. Handbook 0710

19.4. https://www.va.gov/vapubs/viewPublication.asp?Pub_ID=1632 Appropriate Background Investigation (BI) forms shall be provided upon contract (or task order) award and are to be completed and returned to the VA Security and Investigations Center (07C) within 3 days for processing. Contractors shall be notified by 07C when the BI has been completed and adjudicated. These requirements are applicable to all Sub-Contractor personnel requiring the same access. If the security clearance investigation is not completed prior to the start date of the contract, the employee shall not work on the contract while the security clearance is being processed. Work will commence as soon as the Contractor and Contractor employee receives and email message that states the following: We show that background investigation request on the individual listed below has been completed and the case has been initiated by the Security Investigations Center. When the case is completed, all adjudicative paperwork will be returned to the requested office. You can provide this email to the Station ISO as proof the investigation has been initiated, and access can be granted. This notice does not ensure completion of VetPro or other required security training. Those individuals that require VetPro Credentialing or additional security training must receive those completion notifications from the proper authority prior to starting date.

The investigation history for Contractor personnel working under this contract must be maintained in the databases of either the Office of Personnel Management (OPM) or the Defense Industrial Security Clearance Organization (DISCO). Should the Contractor use a vendor other than OPM or Defense Security Service (DSS) to conduct investigations, the investigative company must be certified by OPM/DSS to conduct Contractor investigations.

20. BACKGROUND INVESTIGATION

The position sensitivity impact for this effort has been designated as low risk and the level of background investigation is Tier 1/Low Risk.

20.1. Contractor Responsibility

The Contractor must provide all equipment required for generation of VA and Non-VA outpatient claims to third party healthcare insurance carriers for CPAC sites nationwide.

The Contractor shall ensure staff are available to attend VA specific training on the dates and times specified by the CPAC.

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

The Contractor shall submit claims to payers electronically via a clearinghouse.

The Contractor shall provide automated secondary billing services provided the electronic (835) Medicare Remittance Advise (MRA) or Remittance Advise (RA) is supplied.

The Contractor shall ensure no paper claims are printed or mailed from any location other than a CPAC. Contractors will be provided with printing instructions after the award.

The Contractor shall make no decision(s) regarding whether a veteran’s treatment was service connected. The Contractor shall refer to all questions related to a veteran’s service-connected treatment, following the appropriate CPAC process The Contractor shall utilize client specific software currently in place to communicate with the different sections for additional information or clarification prior to cancelling a claim.

The Contractor shall use the Re-code/Reject function of the current coding compliance software to refer encounters back to the applicable medical center Heath Information Management Section (HIMS) for additional coding/medical records information.

The Contractor shall retrieve workload from a shared drive – this workload will be generated by the CPAC utilizing the Coding Compliance software daily.

The Contract staff shall fully utilize the Coding Compliance Claim Scrubber software as applicable. All edits will be reviewed and corrected as appropriate

20.2. Government Responsibilities

The COR will ensure all deliverables are reviewed and accepted/rejected within contract terms and conditions.

The CPAC Billing Manager or designee will monitor productivity (bills authorized, reasons not billable, and bill cancelations) on a weekly basis.

21. ELECTRONIC and INFORAMTION TECHNOLOGY STANDARDS Internet/Intranet The Contractor shall comply with Department of Veterans Affairs (VA) Directive 6102 and VA Handbook 6102 (Internet/Intranet Services).

VA Directive 6102 sets forth policies and responsibilities for the planning, design, maintenance support, and any other functions related to the administration of a VA Internet/Intranet Service Site or related service (hereinafter referred to as Internet). This directive applies to all organizational elements in the Department. This policy applies to all individuals designing and/or maintaining VA Internet Service Sites; including but not limited to full time and part time employees, Contractors, interns, and volunteers. This policy applies to all VA Internet/Intranet domains and servers that utilize VA resources. This includes but is not limited to va.gov and other extensions such as, “.com, .edu, .mil, .net, .org”, and personal Internet service pages managed from individual workstations.

VA Handbook 6102 establishes Department-wide procedures for managing, maintaining, establishing, and presenting VA Internet/Intranet Service Sites or related services (hereafter referred to as “Internet”). The handbook implements the policies contained in VA Directive 6102, Internet/Intranet Services. This includes, but is not limited to, File Transfer Protocol (FTP), Hypertext Markup Language (HTML), Simple Mail Transfer Protocol (SMTP), Web pages, Active Server Pages (ASP), e-mail forums, and list servers.

VA Directive 6102 and VA Handbook 6102 are available at:

Internet/Intranet Services Directive 6102 https://design.va.gov/content-style-guide/web-policies-and-directives In addition, any technologies that enable a Network Delivered Application (NDA) to access or modify resources of the local machine that are outside of the browser’s” sand box" are strictly prohibited. Specifically, this prohibition includes signed applets, or any ActiveX controls delivered through a browser's session. ActiveX is expressly forbidden within the VA while .NET is allowed only when granted a waiver by the VA CIO *PRIOR* to use.

JavaScript is the preferred language standard for developing relatively simple interactions (i.e., forms validation, interactive menus, etc.) and Applets (J2SE APIs and Java Language) for complex network delivered applications

22. COMPLIANCE DOCUMENTS

The following documents provide specifications, standards, or guidelines that must be complied with to meet the requirements of this order:

VA Directive 6102 and VA Handbook 6102 The Billing Guidebook will be provided by the CPAC The CPAC Billing Guidebook is available electronically via VA’s Knowledge Management (KM) portal and the link to the Guidebook will be shared with the Contractor after the award. This Guidebook outlines step-by-step processes for billing third-party payers on behalf of VA. The contractor is expected to follow the Guidebook in performance of billing functions.