RFI Cover CCRA Demos- final.docx

Request for Information (RFI) Community Care Referral, Authorization, and Utilization Management and Care Coordination Systems TAC RFI Number: 36C10B26Q0120 Purpose:

The Department of Veterans Affairs (VA) is soliciting demonstrations for a new Referral, Authorization, and Utilization Management, and Care Coordination system to inform a future recompete of the existing Community Care Referral and Authorization (CCRA) product. We invite vendors to present their solutions' capabilities in the areas of referral management, utilization management, care coordination, clinical review, identity and access management, and interoperability. These solutions will ensure Veterans receive timely, clinically appropriate and high-quality care, while leveraging innovative industry technologies, including artificial intelligence (AI). Vendor responses and demos will be leveraged to educate and inform VA staff of industry capabilities, processes, practices, and standards; which will inform and help shape a future acquisition. Vendors shall provide responses to the rubric spreadsheet that will be scored based on the demo criteria outlined below, with the higher scores being prioritized for 1-hour demonstrations.

Strategic Vision:

VA provides care through its Veteran Affairs Medical Centers and through the Veterans Community Care Program to ensure comprehensive healthcare coverage across 50 states. This program includes care in the Community Care Network, which is managed through third-party administrators (TPAs), and non-network care through other agreements. VA annually issues over 8.5 million community care referrals and authorizations, and spending exceeds $35 billion.

VA envisions a next-generation Referral, Authorization, Utilization Management, and Care Coordination system that transforms how Veterans access and receive community care. This system will serve as a cornerstone for delivering timely, clinically appropriate, and high-quality care by leveraging modern technologies, interoperability standards, and data-driven decision-making. This system will serve as a bridge between VA and TPAs of the Community Care Network Next Generation (CCN NG) contract by establishing real-time collaboration empowered by automated workflows for clinical review, precertification, and care authorization, and utilization management. This system will interact with TPA portals (as described in SAM.gov notices 36C10G26R0003 and 36C10G26R0004) using standardized transactions.

VA will leverage innovative and agile industry solutions to ensure Veterans receive timely, quality, and safe care, while ensuring efficient use of VA resources. To achieve this vision, the solution will integrate seamlessly with VA’s electronic health record systems—including Computerized Patient Record System (CPRS) and Federal Electronic Health Record (Oracle Health)—as well as other technologies within the VA IT infrastructure. This approach will modernize VA’s community care capabilities, improve Veteran outcomes, and create a secure, interoperable, and adaptable platform for emerging technologies. The solution should not only meet current operational needs but also position VA for future innovations in healthcare delivery.

Background:

The mission of the VA Office of Information & Technology (OI&T), Product Delivery Service (PDS), is to provide benefits and services to U.S. Veterans. OI&T aims to deliver high-quality, effective, and efficient IT services to those providing care to Veterans at the point-of-care and throughout their healthcare journey. VA relies on Information Management/Information Technology (IM/IT) systems to achieve its mission goals.

The CCRA project currently uses HealthShare Referral Manager (HSRM), a Section 508 compliant Commercial Off-The-Shelf (COTS) product, to expedite Veterans’ access to community care. HSRM enables VA, TPAs, and community providers to manage community care referrals and authorizations more effectively. It reduces turnaround time for processing referrals, providing care, submitting claims, and receiving payments. HSRM integrates with various VA and non-VA healthcare systems and supports Emergency Care Reporting (ECR), the Veterans Affairs Precertification Portal (VAPP), and other essential functionalities to maintain continuity of care for Veterans.

However, a major pain point for community care providers is the need to create and maintain user accounts in HSRM. This process is time-consuming, technically challenging, and often a barrier to adoption. Additionally, the platform is not efficient for utilization management (UM) and care coordination. Future state, community providers will not have user-accounts, as their system interactions will be conducted in and through TPA portals, which will eliminate or reduce current-state adoption barriers. VA looks to move to an Electronic Data Interface (EDI)-based transaction system, which will reduce custom-coding needed for TPA portal integration.

Presented below is the latest high-level interface diagram of the CCRA, which includes both upstream and downstream dependencies:

Diagram 1: CCRA Interfaces

CCRA Usage/Metrics:

Currently, VA requires the CCRA solution to support up to approximately 7,500 concurrent VA users during peak hours, with the capability to scale and accommodate additional users as needed. VA provides care to Veterans through its own facilities (direct care) and through the Veterans Community Care program to ensure comprehensive healthcare coverage. The Community Care Network (CCN) is managed through third-party administrators across 50 states and annually issues over 8.5 million care referrals and authorizations. Capabilities for care coordination, clinical review tools, and utilization management may increase the concurrent user-base beyond current levels.

User Types:

Requirements for Demo:

If requested, the vendor shall provide a live demonstration inclusive of all proposed technical solutions for a fully deployable referral, authorization, and utilization management system. The demonstration must clearly show the system’s technical architecture, integration capabilities with multiple platforms, scalability features, and compliance with interoperability and security standards. The solution presented must be fully deployable at the time of proposal submission, not conceptual or in development. The vendor shall also provide documented examples of successful implementations in healthcare settings, including measurable outcomes, and outline an implementation roadmap. At a minimum, the demonstration shall cover the following key areas, which are prioritized in the order presented:

1. Referrals and Authorizations

· The vendor shall demonstrate the ability to coordinate, manage and track referrals and authorizations

· The vendor shall show the ability to accept prior authorization and emergency care transactions and communicate confirmation

2. Utilization Management:

· The vendor shall demonstrate enhanced support for prospective outpatient, inpatient and retrospective utilization management, including the ability to evaluate and audit services for medical necessity at both micro and macro levels, with advanced analytic capabilities.

· The vendor shall demonstrate the capability to implement VA-defined rules for episodes of care, incorporating utilization review of specific services based on CPT codes and applying clinical guidelines to support decision-making, including InterQual®, Milliman Care Guidelines, and VA-developed coverage policies.

3. Care Coordination:

· The vendor shall demonstrate the workflow management capabilities for case management of high-complexity patients, including the ability to track care status information.

· The vendor shall demonstrate incorporation of AI to optimize workflows related to the tracking and documentation of care coordination activities, supporting timely decision making and improved care delivery

· The vendor shall show the advanced analytics features that allow viewing claims data, medical documentation, care complexity, and risk factors.

· The vendor shall display how the system identifies completed and pending ancillary and supporting services.

· The vendor shall demonstrate the integration with direct care systems and other data capabilities/services to assist in transitioning care between direct and community settings.

4. Interoperability:

· The system must support seamless integration with VA and non-VA healthcare systems, ensuring efficient and secure bidirectional data exchange using industry standards such as HL7, FHIR, X12, and DICOM.

· The system must connect with regional and national Health Information Exchanges

· The system must collect and analyze meta data related to process and contents and ensure standardized data exchange

· The system must ensure AI decisions are transparent and auditable for compliance

· The system must allow for flexibility of system to work alongside other AI solutions.

5. Medical Documentation:

· The system must accept structured (HL7, FHIR) and unstructured (PDF, scanned documents) documents from TPAs and community care providers

· The system must connect with electronic health record systems such as a TPA platform

· The vendor shall show capabilities for automated data capture to utilize solutions that extract relevant information from submitted documents

· The system must utilize AI with machine learning to analyze medical records and flag cases for review.

6. Reporting and Data Analytics:

· The vendor shall show capabilities for standard and custom-built reports that allow for scheduled and on-demand analytics.

· The system shall support data warehouse integration with a central repository.

7. Member Tracking Capabilities:

· The vendor shall demonstrate capabilities to integrate with VA systems to allow for real-time status updates for referrals

· The system should provide notifications and alerts through VA systems to keep Veterans informed throughout the care coordination process.

To further elaborate on these requirements, the following refined requirements provide a detailed breakdown of the specific functionalities and capabilities that the VA seeks to evaluate during the vendor demonstrations. Submissions should show how the solution has been successfully implemented in a healthcare setting. While the VA is particularly interested in demonstrations that address these requirements, vendors are not obligated to cover every individual requirement listed below.

1. Utilization Management:

· Automated Utilization Review Demonstrate automated utilization review capabilities, including the ability to apply clinical guidelines and criteria to determine the medical necessity of services.

· Authorization Management Show how the system manages authorizations, including initial requests, renewals, and modifications.

· Reporting and Analytics Provide examples of reporting and analytics capabilities, including utilization trends, compliance with guidelines, and performance metrics.

2. Care Coordination:

· Receive Consults/Referrals from EHRs Demonstrate methods of interoperability with EHRs, especially HL7, including support for different versions of HL7.

· Send Status Updates to EHRs Showcase the ability to send status updates such as appointment scheduling, cancellations, and clinical notes.

· Receive and Associate Medical Records Display the process of receiving medical records from EHRs and associating them with the corresponding consult/referral.

· Disseminate Consults and Medical Records Show various communication methods for disseminating consults and associated records, including portals, electronic transfer, text, fax, letters, secure messaging, and email.

· Automated Workflows and Business Rules Focus on automated workflows and automation based on business rules. Provide both manual and automated solutions with service-oriented architecture, flexible components, APIs, and configurable workflows.

· Manage Worklists and Display Referral Status Demonstrate the management of worklists, task assignments, filtering, sorting, and display of referral status and history.

· Dental Plan Information Include an initial dental referral plan view: tooth, area of mouth, ADA codes, and related treatment plan guidelines.

· Clinical View Show the receipt and display of care coordination plans, documents, notes, and a comprehensive view of the patient's care.

3. Clinical Review Tool:

· Clinical Decision Support Demonstrate the integration of clinical decision support tools to assist in the review and authorization process.

· Peer Review Process Show how the system supports peer review processes, including case assignment, review workflows, and documentation.

4. Analytical AI Integration

· The system shall include and allow for Analytical AI capabilities, enabling data analytics and workflow automations while ensuring human intervention in clinical decision-making. The approach to generate AI should be progressive but controlled, maintaining human oversight in critical areas.

· The system must ensure AI decisions are transparent and auditable for compliance.

· The system must allow for flexibility of system to work alongside other AI solutions.

5. Interoperability:

· Standards-Based Integration Demonstrate the system's ability to integrate with other healthcare systems using standards such as HL7, FHIR, X12, and DICOM.

· Data Exchange Show how the system supports bidirectional data exchange with VA and non-VA systems, including the ability to handle various data formats and protocols.

6. Identity and Access Management:

· User Authentication and Authorization Demonstrate robust user authentication and authorization mechanisms, including support for single sign-on (SSO) and multi-factor authentication (MFA).

· Role-Based Access Control Show how the system implements role-based access control (RBAC) to ensure users have appropriate access based on their roles and responsibilities.

· Multi-channel Communication for Real Time Engagement Veteran engagement features that support multi-channel communication for real time engagement.

7. Compliance, Security, and Maintenance:

· Compliance with VA's Technical Reference Model (TRM) and Section 508 Standards Ensure the solution is compliant with VA's TRM and Section 508 standards.

· Security and Privacy Demonstrate the capability to securely handle PII and PHI.

· System Maintenance Provide details on software maintenance, configuration, development, testing, implementation, training, along with sustaining the cloud and network infrastructure.

· Data Security Demonstrate how the system ensures the security of sensitive data, including PII and PHI, through encryption, access controls, and audit logging.

· Regulatory Compliance Show how the system complies with relevant regulations and standards, including HIPAA, VA's Technical Reference Model (TRM), and Section 508.

8. Support:

· Customer Support Describe the customer support services offered, including helpdesk support, training, and user documentation.

Submittal Information:

This is a request for information (RFI) only. It is requested that all companies interested in participating in this effort note their interest and provide an indication of their respective capabilities to perform the effort described above. Marketing material will not be accepted as an indication of capability. The vendor must display that their solution is tested and has been successfully implemented in a healthcare setting. Only responses related to the Government’s requirements as listed above will be considered. Vendors shall provide responses to the rubric spreadsheet that will be scored based on the demo criteria outlined below, with the higher scores being prioritized for 1-hour demonstrations.

Provide the following information on the first page/slide of the submission:

· Name of Company

· Address

· Point(s) of Contact

· Phone Number(s)

· Fax Number

· Email addresses

· Company Business Size and Status

· NAICS code(s) – If applicable, identify your company’s Small Business size status based upon the applicable NAICS code of 541512. For more information refer to http://www.sba.gov/.

· Socioeconomic data

· Data Universal Numbering System (DUNS) Number

The vendor shall include the following information in supporting pages/slides, separate from the informational materials:

· Is your company currently providing similar solutions to the VA, another government agency, or other non-government customers? Please provide up to three (3) references.

· Indicate all scheduled contracts your company may have (e.g., General Services Administration (GSA) Schedules, Government Wide Acquisition Contracts (GWAC), etc.) with specific regard to this RFI and the requirements hereunder. Please include Contract Number, expiration date, etc.

· Provide any other pertinent information as deemed necessary to demonstrate your and any proposed team member’s capabilities and prior experience as it relates to the requirements.

The vendor shall submit their response no later than January 26, 2026 at 12 PM. Questions shall be submitted no later than January 16 at 12 PM. Responses and questions are to be sent via email to Felica Griffin at Felica.Griffin@va.gov. Please include "36C10B26Q0120 CCR&A " in the subject line of your response. Mark your response as "Proprietary Information" if the information is considered business sensitive. VA will review submissions and may request a one-hour demonstration within a 30-day time period after the submission deadline.

NO MARKETING MATERIALS ARE ALLOWED AS PART OF THIS RFI.

The Government will only review what is being requested under the “Submittal Information” section of this RFI. The Government will not review any other information or attachments included that exceed this limit.

DISCLAIMER

This RFI is issued solely for information and planning purposes only and does not constitute a solicitation. All information received in response to this RFI that is marked as proprietary will be handled accordingly. In accordance with FAR 15.201(e), responses to this notice are not offers and cannot be accepted by the Government to form a binding contract. Responders are solely responsible for all expenses associated with responding to this RFI.

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