S02 - Attachment 01 - PWS - IV Buffer Support - 19AUG2026.pdf

Consolidated Patient Account Center [CPAC] Revenue Operations [RO]

Performance Work Statement [PWS]

Indefinite Delivery Indefinite Quantity [IDIQ]

Insurance Entry and Verification Buffer Support Services

1.0 SCOPE

The Contractor shall provide all labor, supervision, management, equipment, facilities, systems, security controls, and other resources necessary to perform insurance entry and verification buffer support services for VA patient insurance information in authorized VA healthcare systems.

Services include reverification actions, new-policy actions, including Medicare policy actions, and other Task Order-authorized insurance actions necessary to establish, update, verify, maintain, sequence, resequence, terminate, or coordinate third-party insurance information for CPAC sites nationwide.

Except for Government-furnished resources expressly identified in the contract or applicable Task Order, all costs of performance are included in the Contractor’s fixed unit prices for accepted completed actions.

2.0 BACKGROUND

The VA uses insurance entry and verification buffer support services to improve the accuracy, completeness, and timeliness of third-party insurance information. CPAC RO uses this information to support third-party reimbursement activities for eligible veterans.

Insurance actions may include identifying, establishing, updating, verifying, terminating, sequencing, resequencing, and coordinating benefits for medical and prescription insurance policies in authorized VA systems.

2.1 There are seven [7] regional CPACs located as follows:

Number Location Name Abbreviation 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

The CPAC locations and assignments shown above reflect the Government’s current organizational structure. The Government may issue Task Orders for one [1] or more CPACs, VAMCs, facilities, or facility groupings, and may phase performance based on operational need, subject to the terms of this contract and applicable Task Orders.

2.2 VA may undergo organizational, operational, or process changes during the ordering period. These changes may affect CPAC structure, facility alignment, workload sources, work processes, priorities, or the timing of Task Orders.

The Contractor shall remain capable of supporting authorized changes within the scope of this PWS and applicable Task Orders. Any change that affects contract scope, performance standards, price, delivery period, or other contract term shall be made only by written contract modification or Task Order modification executed by an authorized Contracting Officer [CO].

2.3 The VA is authorized by law to seek reimbursement from third-party health insurers for the cost of certain medical care furnished to eligible veterans. Accurate and current third-party insurance information is necessary to support VA’s revenue-operations and reimbursement activities.

2.4 Workload Volumes and Forecasts

Historical and projected insurance entry and verification volumes vary by CPAC, VA Medical Center [VAMC], transaction type, and time period. The Government will provide available historical and projected workload information in the solicitation and/or applicable Task Orders for quotation planning, pricing, and performance planning.

Information may include workload by CPAC and VAMC, transaction type, backlog, rejection and non-chargeable-exception rates, and seasonal or workload-pattern information.

Based on current workload data, the Government estimates an existing insurance-buffer backlog of approximately 804,000 actions. For planning purposes, the Government estimates that 80 percent of this backlog consists of reverification actions and 20 percent consists of new-policy actions. The Government also estimates approximately 1,640,000 new Medicare policy actions.

For quotation evaluation, the Government estimates the following ordering-period quantities:

Action Type Estimated Quantity Reverification actions 643,200 New policy actions, including Medicare policy actions 1,800,800 Total Estimated Actions 2,444,000

The Government will use the estimated quantities stated in the solicitation pricing schedule to evaluate quoted prices on a common basis. The estimates are for quotation planning and price evaluation only. They do not guarantee an order quantity, level of effort, payment, staffing level, or Task Order award.

For workload-planning purposes only, the Government estimates that reverification actions may be processed at approximately 35 actions per labor hour and new-policy actions may be processed at approximately 24 actions per labor hour. Using these planning assumptions, the existing backlog represents approximately 25,077 labor hours, and the estimated Medicare-policy workload represents approximately 68,333 labor hours, for a combined planning estimate of approximately 93,410 labor hours. These planning assumptions are not contractual productivity standards, staffing requirements, or delivery-period requirements. Contractor performance will be evaluated under the standards in Section 12.4 and the applicable Task Order.

3.0 OBJECTIVES

The objective of this PWS is to obtain accurate, timely, secure, and compliant insurance entry and verification buffer support services for CPAC sites nationwide. The required outcome is the establishment, update, reverification, and maintenance of third-party insurance information, including new-policy and Medicare policy actions, in authorized VA systems.

The Contractor shall produce accepted completed insurance actions in accordance with CPAC guidebooks, VA policy, this PWS, and applicable Task Orders. The Contractor is responsible for determining the staffing approach, supervision, internal processes, and resources necessary to achieve the required outcome.

Contractor performance will be evaluated using the measurable performance standards in Section 12.4, the Quality Assurance Surveillance Plan [QASP], and applicable Task Order requirements.

4.0 TASKS AND DELIVERABLES

The Contractor shall perform the services necessary to establish, update, and verify veterans’ third-party insurance information in authorized VA systems and associated software interfaces.

The services include reverification actions, new-policy actions, including Medicare policy actions, and other insurance actions authorized by an applicable Task Order.

The required outcome is the timely completion of accurate, compliant, and accepted insurance actions that support CPAC operations. Except where the contract or an applicable Task Order states a specific constraint, the Contractor is responsible for determining the staffing approach, supervision, internal processes, and resources necessary to achieve the required outcome.

Performance will be measured under Section 12.4, the QASP, and the applicable Task Order. Task Orders may establish phased start dates, delivery periods, estimated action quantities, and Government-furnished access or training dependencies for the assigned CPACs or facilities.

Estimated quantities are for planning and ordering purposes only and do not guarantee a quantity, level of effort, payment, or Task Order award.

Each Task Order shall identify the CPACs, VAMCs or facilities, period of performance, delivery periods, and estimated quantities of reverification actions and new-policy actions, including Medicare policy actions, as applicable. The Contractor shall perform all requirements necessary to complete accepted actions at the fixed unit prices stated in Section B and the applicable Task Order. Estimated quantities are for planning and ordering purposes only and do not guarantee a quantity, level of effort, or payment except as expressly stated in the contract.

4.1 Deliverable – Entry and Verification of Insurance Information

The Contractor shall perform insurance entry and verification buffer support services that produce accurate, timely, and compliant insurance actions. Insurance actions include reverification actions, new-policy actions, including Medicare policy actions, and other insurance actions authorized by the applicable Task Order.

The Contractor shall complete assigned and available insurance actions in accordance with CPAC guidebooks, VA policy, this PWS, and Task Order requirements. An action is available for Contractor processing when complete source information and required system access are available. Required performance levels for this deliverable are stated in Section 12.4.

4.1.1 TIMELY COMPLETION OF INSURANCE ENTRY AND VERIFICATIONS:

The Contractor shall complete assigned and available insurance actions within the delivery period established by the applicable Task Order and at the performance level stated in Section 12.4.

Timeliness begins when the action becomes available for Contractor processing, meaning complete source information and required system access are available.

Timeliness will be measured in accordance with Section 12.4 and the QASP.

4.1.2 DATA ENTRY ACCURACY:

The Contractor shall complete insurance actions accurately, completely, and in accordance with CPAC guidebooks, VA policy, this PWS, and applicable Task Order requirements.

For purposes of this requirement, insurance actions include reverification actions, new-policy actions, including Medicare policy actions, and other Task Order-authorized insurance actions. Performance will be measured at the level stated in Section 12.4.

4.1.3 RESOLUTION OF CONTRACTOR-CAUSED REJECTED ACTIONS:

The Contractor shall review, correct, and take all required action on Contractor-caused rejected actions within the timeframe stated in Section 12.4 and the applicable Task Order.

A Contractor-caused rejected action is an insurance action returned for rework because of an error or omission attributable to the Contractor. Contractor-caused rejected actions are not accepted completed actions and shall be corrected at no additional cost to the Government.

Payer, system, and source-data conditions outside the Contractor’s control are non-chargeable exceptions and shall be handled in accordance with Section 8.1 and applicable Task Order procedures.

4.1.4 RESOLUTION OF INSURANCE-ACTION QUESTIONS AND CONCERNS:

The Contractor shall provide clear, timely, and effective communication necessary to resolve questions, discrepancies, and concerns related to insurance actions and contract performance.

The Contractor shall cooperate with the Contracting Officer’s Representative [COR], CPAC Insurance Verification Manager, Supervisor, and other Government personnel identified in the applicable Task Order to support issue resolution.

Performance will be evaluated in accordance with Section 12.4.

4.1.5 PARTICIPATION IN REQUIRED MEETINGS:

The Contractor shall participate in Government-required conference calls, meetings, or other performance-management sessions necessary to support contract performance, workload coordination, and issue resolution, as identified by the COR or in the applicable Task Order.

The Contractor shall ensure that a key person or authorized representative with knowledge of the relevant performance issue participates when requested by the Government. Performance will be evaluated in accordance with Section 12.4.

4.1.6 MAINTAIN REQUIRED SYSTEM AND PROVIDER PORTAL ACCESS:

The Contractor shall maintain the access necessary to perform assigned insurance actions in authorized VA systems and assigned insurance-provider portals. The Contractor shall manage its personnel, training, credentialing actions, and internal processes to prevent Contractor-controlled access interruptions that adversely affect required performance.

The Contractor shall promptly document and report any Government-controlled access, credentialing, system, or provider-portal condition that affects performance, in accordance with Task Order procedures. The Contractor will not be held responsible for delays caused by documented Government-controlled conditions.

Performance will be evaluated in accordance with Section 12.4.

4.1.7 CONFIDENTIALITY AND INFORMATION SECURITY:

The Contractor shall perform all insurance actions in compliance with applicable privacy, confidentiality, information-security, and VA-information-protection requirements, including the requirements in Section 9, Section 10, and Section 13 of this PWS and all applicable solicitation and contract clauses.

The Contractor shall protect VA information, personally identifiable information [PII], and protected health information [PHI] from unauthorized access, use, disclosure, alteration, or loss. Performance will be evaluated in accordance with Section 12.4.

4.2 Deliverable – Monthly Itemized Statement – Not Separately Priced For reporting and pricing purposes, an accepted completed reverification action is an insurance reverification action that was assigned and available for Contractor processing;

completed in accordance with CPAC guidebooks, VA policy, this PWS, and Task Order instructions; and validated by the Government as accurate and properly documented, and accepted in accordance with the CO’s delegation of authority and the contract’s invoice and acceptance procedures.

An accepted completed new-policy action is a new insurance-policy addition, including a Medicare policy action, that was assigned and available for Contractor processing;

completed in accordance with CPAC guidebooks, VA policy, this PWS, and Task Order instructions; and validated by the Government as accurate and properly documented, and accepted in accordance with the CO’s delegation of authority and the contract’s invoice and acceptance procedures.

An action is available for Contractor processing when complete source information and required system access are available. A Contractor-caused rejected action is an action returned by CPAC or system validation for rework because of a Contractor error or omission. A non-chargeable exception is an action that cannot be loaded, linked, or otherwise processed because of a payer, system, or source-data condition outside the Contractor’s control.

Contractor-caused rejected actions must be corrected at no additional cost to the Government and are not accepted completed actions for payment purposes. Non-chargeable exceptions may require documentation and transfer under Task Order procedures, but are not accepted completed actions for payment purposes.

The Contractor shall submit the Monthly Itemized Statement to the COR and the CPAC Insurance Verification Manager, Supervisor, or other Government official identified in the applicable Task Order.

Monthly reports, due by the fifth day of each month unless otherwise specified in the Task Order, shall include, at a minimum:

4.2.1 Quantity of accepted completed reverification actions and accepted completed new-policy actions, including Medicare policy actions, completed during the reporting period, by CPAC and VAMC.

4.2.2 Cumulative quantity of accepted completed actions by action type, CPAC, and VAMC for the Task Order period of performance.

4.2.3 Applicable unit price and total extended amount for accepted completed reverification actions and accepted completed new-policy actions, if payment is based on the contract pricing schedule.

4.2.4 Number of Contractor-caused rejected actions, by action type, and confirmation that the actions were corrected at no additional cost to the Government.

4.2.5 Number of non-chargeable exceptions, by action type and exception category, and the disposition of each exception, such as transferred to CPAC, held pending source-data correction, or otherwise resolved.

4.2.6 Summary of access issues, system issues, or other conditions that affected performance during the reporting period.

4.2.7 Number of accepted completed actions per staff member, if required by the applicable Task Order.

The Contractor shall reconcile each invoice to the applicable Monthly Itemized Statement. For each billed line item, the invoice and Monthly Itemized Statement shall identify the applicable Task Order, CPAC or facility, reporting period, action type, accepted completed quantity, unit price, and extended amount. The Contractor shall separately identify Contractor-caused rejected actions and non-chargeable exceptions, which are not billable actions.

The Government may validate billed quantities and acceptance using CPAC records, Contractor reports, Government surveillance records, and other contract-performance documentation.

4.3 Deliverable – Monthly Staffing Report – Not Separately Priced The Contractor shall submit the Monthly Staffing Report to the COR and the CPAC Insurance Verification Manager, Supervisor, or other Government official identified in the applicable Task Order by the fifth day of each month, unless otherwise specified in the applicable Task Order.

The report shall include, at a minimum:

4.3.1 Contractor personnel added to or removed from performance during the reporting period;

4.3.2 Anticipated personnel start dates and departures, when known;

4.3.3 Each individual’s assigned primary CPAC, facility, or group of facilities;

4.3.4 Staffing changes or other conditions that may materially affect the Contractor’s ability to meet Task Order delivery periods or PWS performance standards;

4.3.5 Training completed or material training updates provided during the reporting period, as applicable; and

4.3.6 Current contact information for the Contractor’s key personnel identified under Section 11.1.

The Contractor shall maintain sufficient qualified personnel to meet the requirements of this PWS and applicable Task Orders. The Contractor shall provide personnel with training and updates necessary to maintain performance in accordance with current applicable policies, procedures, and regulations.

The Contractor shall submit the report electronically in a format acceptable to the COR, unless otherwise specified in the applicable Task Order.

4.4 Deliverable – Weekly Pending Workload Report – Not Separately Priced The Contractor shall submit the Weekly Pending Workload Report to the COR and the CPAC Insurance Verification Manager, Supervisor, or other Government official identified in the applicable Task Order by Monday of each week, unless otherwise specified in the applicable Task Order.

The report shall identify pending insurance actions for VA Care and Community Care, as applicable, and shall include, at a minimum:

4.4.1 CPAC and VAMC or facility;

4.4.2 Action type: reverification action or new-policy action, including Medicare policy action;

4.4.3 Date the action became available for Contractor processing;

4.4.4 Number of actions pending at the beginning and end of the reporting week;

4.4.5 Number of actions completed during the reporting week;

4.4.6 Number of Contractor-caused rejected actions and non-chargeable exceptions identified during the reporting week; and

4.4.7 Any system, access, source-data, or other condition affecting timely completion of pending actions.

The Contractor shall submit the report electronically in a format acceptable to the COR, unless otherwise specified in the applicable Task Order.

4.5 Performance Measurement

Unless otherwise stated in the applicable Task Order, the Contractor’s performance under this section shall be assessed using the indicators, standards, acceptable quality levels [AQLs], and surveillance methods set forth in Section 12.4, Performance Requirements Summary Matrix [PRSM].

5.0 FORMAL ACCEPTANCE OR REJECTION OF DELIVERABLES

All written deliverables shall be clear, organized, and suitable for Government review and use.

The COR may reject or require correction of 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 in accordance with delivery instructions, unless otherwise directed by the COR or Task Order. If any deliverable cannot be provided within the scheduled timeframe, the Contractor shall notify the COR in writing by the delivery due date, explain the reason for the delay, describe the impact, and provide a firm commitment date for completion. The COR will forward the notice to the CO with comments, and the CO will respond in accordance with the contract and applicable regulations. Acceptance or rejection of recurring insurance actions will be determined through the performance standards, Government surveillance methods, and applicable payment provisions stated in Section 12.4, the QASP, Section B, and the applicable Task Order. Payment is limited to accepted completed actions as defined in Section 4.2 and validated in accordance with the contract’s invoicing procedures. Government receipt, review, or acceptance of a written report does not waive any Government right regarding deficient performance or invoice approval.

The COR is the Government official designated in writing by the CO to perform specific technical, functional, and oversight responsibilities for this contract, including inspection and acceptance of services and deliverables within the limits of that delegation.

5.1 Acceptance Criteria

Government acceptance of insurance actions and written deliverables is contingent upon the Contractor’s compliance with the applicable requirements of this PWS, the PRSM, the QASP, and the applicable Task Order.

An insurance action is eligible for payment only when it meets the definition of an accepted completed action in Section 4.2 and is validated by the Government as accurate and properly documented, and accepted in accordance with the CO’s delegation of authority and the contract’s invoice and acceptance procedures.

Government acceptance of a recurring report confirms receipt for review purposes and does not, by itself, establish acceptance of the underlying insurance actions, waive a performance deficiency, or authorize payment. Invoice approval remains subject to validation of billed quantities, applicable unit prices, and compliance with the contract and Task Order.

5.2 Government Acceptance Period

The COR will have ten [10] business days to review draft deliverables and provide comments, unless otherwise stated in the contract or Task Order. The Contractor shall have five [5] business days to make required corrections, unless otherwise directed. Upon receipt of final deliverables, the COR will have two [2] business days for final review prior to acceptance or providing documented reasons for non-acceptance. These review periods in this section apply to draft or nonrecurring written deliverables when an applicable Task Order requires draft submission. For recurring reports required under Section 4.2 through Section 4.4, the COR will assess timeliness, completeness, and accuracy under the PRSM and QASP. Receipt or review of a recurring report does not waive any Government right to address deficient performance or to withhold or adjust invoice approval consistent with the contract.

6.0 COMMUNICATION REGARDING INSURANCE ACTIONS

The Contractor shall direct routine operational communications regarding insurance actions, workload status, discrepancies, access issues, and performance concerns to the CPAC Insurance Verification Manager or Supervisor identified by the Government after award, unless the COR or applicable Task Order provides different instructions.

Communications with the CO regarding contract administration, changes, funding, payment, or matters requiring contractual direction shall be made through the CO or as otherwise authorized in writing by the CO.

7.0 PERFORMANCE DETAILS

7.1 Indefinite Delivery Indefinite Quantity [IDIQ] Period of Performance: Thirty-six [36] month ordering period.

7.1.1 IDIQ Minimum and Maximum

The guaranteed minimum amount for this IDIQ contract is $500,000. The maximum amount that may be ordered under this IDIQ contract is $5,499,000.

Except for the guaranteed minimum, the Government is not obligated to order any minimum quantity or dollar value of services. The Government may issue Task Orders by CPAC, VAMC, region, or group of facilities, and may issue Task Orders in phases based on operational need, available funding, and the terms of this contract.

Section B of the contract governs the ordering, funding, and pricing terms.

Workload estimates and quotation-evaluation quantities are for planning and evaluation only; they do not establish a guaranteed order quantity or level of effort.

7.2 Periods of performance, CPACs, VAMCs, estimated quantities, and delivery periods shall be established in each Task Order. The Government may structure Task Orders by CPAC region, facility, or group of facilities and may issue Task Orders in phases based on operational need.

Each Task Order shall identify, as applicable:

7.2.1 The CPACs, VAMCs, or facilities covered;

7.2.2 The Task Order period of performance and applicable delivery periods;

7.2.3 The estimated quantities of reverification actions and new-policy actions, including Medicare policy actions;

7.2.4 Any phased start date, transition, ramp-up, or interim performance expectation;

7.2.5 The Government-furnished access, equipment, training, credentialing, or onboarding support, if any;

7.2.6 The reporting format, submission instructions, and Government points of contact;

and

7.2.7 Any facility-specific procedures, workload conditions, or other information necessary to perform the ordered services.

A Task Order may identify transition, mobilization, ramp-up, stabilization, baseline-measurement activities, Government-furnished access, training, credentialing, and interim performance expectations, as applicable. The Contractor shall perform these activities as necessary to begin and sustain performance.

Unless Section B or the applicable Task Order expressly provides otherwise, transition, mobilization, ramp-up, management, quality assurance, reporting, staffing, training, access administration, and other activities necessary to perform this PWS are included in the Contractor’s all-inclusive fixed unit prices for accepted completed actions. No separate payment will be made for these activities.

7.3 Eleven [11] Federal holidays set by law under U.S.C. Title 5 Section 6103 apply.

New Year’s Day January 1 Birthday of Martin Luther King Jr. Third Monday in January Washington’s Birthday Third Monday in February Memorial Day Last Monday in May Juneteenth National Independence Day June 19 Independence Day July 4 Labor Day First Monday in September Columbus Day Second Monday in October Veterans Day November 11 Thanksgiving Day Fourth Thursday in November Christmas Day December 25

7.3.1 If a Federal holiday falls on a Saturday, the holiday is observed on the preceding

Friday. If a Federal holiday falls on a Sunday, the holiday is observed on the following Monday.

7.4 Place of Performance

The Contractor shall perform services from a secure work environment suitable for healthcare insurance entry and verification operations. Government workspace will not be provided unless the contract or applicable Task Order expressly states otherwise.

The Contractor shall provide and maintain the personnel, supervision, facilities, equipment, connectivity, and other resources necessary to perform this PWS, except for Government-furnished resources expressly identified in the contract or applicable Task Order. The Contractor shall protect VA information and maintain patient confidentiality and data security at all times. Costs for Contractor-furnished resources are included in the Contractor’s fixed unit prices.

The Government will identify in the solicitation and/or applicable Task Order the authorized access method and any Government-furnished equipment, systems, training, credentialing, or onboarding support available for performance. The Contractor shall comply with VA technical, privacy, and information-security requirements applicable to the authorized access method.

Unless the contract or applicable Task Order expressly states that the Government will furnish an item or service, the Contractor shall provide the resources necessary to perform this PWS. The Contractor’s fixed unit prices include all costs necessary to provide those resources.

7.5 Hours of Operation

The normal operating hours for the Federal Government are Monday through Friday, 8:00am to 4:30pm local area time. The Contractor shall ensure that at least one [1] key person or authorized representative is available to communicate with VA and CPAC personnel from 8:30 am to 5:00 pm Eastern Time [ET] on federal workdays unless otherwise specified in the contract or applicable Task Order.

8.0 ORDER TERMS, CONDITIONS, AND PROVISIONS

8.1 Rejections and Non-Chargeable Exceptions

If an insurance policy cannot be loaded into VistA, linked appropriately, or otherwise processed because of a payer, system, or source-data condition outside the Contractor’s control, the Contractor shall document the condition and transfer the matter to the appropriate CPAC contact for review and resolution in accordance with Task Order procedures. The Government estimates that non-chargeable exceptions may represent approximately 10 to 15 percent of daily workload; this estimate is for planning only and is not guaranteed.

A Contractor-caused rejected action is an insurance entry or verification action returned for rework because of an error or omission attributable to the Contractor. The Contractor shall identify, correct, and report Contractor-caused rejected actions in accordance with Section 4.1.3 and Section 4.2.

An accepted completed action is payable only when it has been completed in accordance with CPAC guidebooks, VA policy, this PWS, and Task Order instructions, and has been validated by the Government as accurate and properly documented, and accepted in accordance with the CO’s delegation of authority and the contract’s invoice and acceptance procedures.

Non-chargeable exceptions are not Contractor-caused rejected actions and are not billable actions. Contractor-caused rejected actions are not accepted completed actions, are not billable, and shall be corrected at no additional cost to the Government. The contract pricing schedule and applicable Task Order govern the unit price and invoicing procedures for accepted completed actions.

8.2 Non-Disclosure/Non-Use Agreement

Before performing work under this contract, each Contractor employee shall complete the required Non-Disclosure/Non-Use Statement. An authorized corporate official shall cosign the statement, and the Contractor shall provide the completed statement to the COR in accordance with contract or Task Order instructions.

The Contractor shall maintain completed statements for all personnel performing under the contract and shall provide them to the Government upon request.

9.0 INFORMATION ASSURANCE

9.1 General Security Requirements

The Contractor shall comply with the security, privacy, and information-system requirements in Section 13 and all applicable solicitation and contract clauses.

9.2 HIPAA

The Contractor shall comply with the applicable requirements of the Health Insurance Portability and Accountability Act of 1996 [HIPAA].

10.0 PROTECTION OF INFORMATION

10.1 Dissemination of Information/Publishing

The Contractor shall not disseminate or publish VA insurance information, policies, or tools except as authorized by this contract or by the CO.

10.2 Personally Identifiable Information [PII] and Protected Health Information [PHI] The Contractor shall protect PII and PHI in accordance with Section 13 and all applicable solicitation and contract clauses.

11.0 CONTRACTOR EXPERIENCE REQUIREMENTS

11.1 Key Personnel

Key personnel are individuals identified by the Contractor and accepted by the Government for performance of critical contract functions. Key personnel shall possess demonstrated experience managing or supervising insurance entry and verification operations, insurance-related data processing, or closely comparable healthcare administrative operations of similar scope, complexity, and volume.

The Contractor shall identify its proposed key personnel in its quotation and shall maintain qualified key personnel throughout contract performance. VA-specific system experience, including VistA experience, may be supplemented through VA-provided training, as applicable.

The CO may require removal of any Contractor-assigned individual whose performance is unsatisfactory or whose continued performance presents a conflict of interest or other concern to the Government. The Contractor shall identify replacement personnel within three [3] business days after notification, unless otherwise approved by the CO.

Employment or staffing difficulties do not excuse failure to meet contract requirements.

11.2 Substitution of Key Personnel

The Contractor shall submit requests to substitute key personnel in writing to the COR and CO at least 30 calendar days before the proposed substitution whenever practicable. The request shall explain the reason for the substitution and include a resume for the proposed replacement and any other information requested by the CO.

Replacement personnel shall possess qualifications and experience equal to or greater than those of the individual being replaced. A proposed replacement shall not begin performing in a key position until all applicable security, privacy, suitability, credentialing, training, and access requirements under Section 13 have been satisfied and the Government has accepted the replacement, if acceptance is required by the contract.

11.3 Management and Oversight

The Contractor shall manage and oversee all Contractor and subcontractor personnel performing under this contract. The Contractor is responsible for all actions necessary to ensure timely, accurate, secure, and effective performance in accordance with this PWS and applicable Task Orders.

The Contractor shall provide the supervision, workload management, quality control, internal communication, corrective action, and other management support necessary to meet contract requirements. These functions are included in the Contractor’s fixed unit prices and are not separately payable unless expressly stated otherwise in Section B or the applicable Task Order.

11.4 Domain Knowledge

The Contractor shall demonstrate knowledge of outpatient healthcare insurance entry and verification operations relevant to the services required by this PWS. This knowledge shall include, as applicable, insurance reverification, new-policy entry, Medicare policy entry, policy updates and termination, sequencing, resequencing, coordination of benefits, exception handling, and quality control.

The Contractor shall ensure that personnel assigned to perform insurance actions have the knowledge and training necessary to perform assigned work accurately and in accordance with CPAC guidebooks, VA policy, this PWS, and applicable Task Order requirements.

11.5 Training

The VA will provide training on VA VistA and related applications necessary for insurance entry and verification to Contractor personnel, including key personnel, managers, supervisors, and other personnel assigned to perform the work, as applicable.

The Contractor remains responsible for ensuring its personnel possess the underlying insurance entry and verification knowledge required by Section 11.4 and Section 11.8.

The Contractor shall provide any additional training necessary for personnel to perform the services in accordance with this PWS, CPAC guidebooks, VA policy, and applicable Task Order requirements.

11.6 Standards of Conduct

The Contractor shall ensure that personnel comply with applicable Federal, VA, VHA, privacy, security, workplace-conduct, and conflict-of-interest requirements.

The CO may require the Contractor to remove an individual whose conduct, technical performance, security posture, or continued participation presents a Government concern. The Contractor shall promptly replace removed personnel with qualified personnel. Personnel changes do not relieve the Contractor of its obligation to meet contract requirements.

11.7 Utilization of Government Employees

The Contractor shall notify the CO whenever an employee of the United States Government is utilized by the Contractor in performance of the contract. The notification shall include sufficient information for the CO to review the matter in accordance with applicable Federal Acquisition Regulation [FAR] conflict of interest requirements.

11.8 Staff Qualifications

11.8.1 General Experience:

Contractor personnel assigned to perform insurance actions shall have experience or training relevant to insurance entry and verification services, healthcare insurance data processing, or closely comparable healthcare administrative operations. Personnel shall be qualified to perform their assigned work accurately and in accordance with CPAC guidebooks, VA policy, this PWS, and applicable Task Order requirements.

11.8.2 Supervisory Experience:

Contractor personnel responsible for supervising or managing performance shall have recent relevant experience leading insurance entry and verification operations, insurance-related data processing, or closely comparable healthcare administrative operations involving quality control, workload management, exception handling, and staff oversight. VA-specific system experience may be supplemented through Government-provided training, as applicable.

11.9 Limitations on Subcontracting

The Contractor shall comply with the limitations-on-subcontracting requirements in the applicable solicitation and contract clauses. This PWS does not alter or supersede those clauses. In the event of a conflict, the applicable clause controls.

12.0 QUALITY ASSURANCE

12.1 Contractor Quality Assurance

The Contractor shall establish and maintain internal quality-control procedures for insurance actions. The Contractor shall conduct reviews of completed actions sufficient to identify and correct errors, prevent recurrence, and support performance at or above the standards stated in this PWS, the PRSM, and applicable Task Orders.

The Contractor shall document and take corrective action for Contractor-caused errors identified through internal quality control, Government surveillance, CPAC review, or system validation. Contractor quality-control activities do not replace Government surveillance or alter the Government’s acceptance authority.

12.2 Government Quality Assurance

The Government, including external auditors when applicable, may conduct periodic independent reviews of the Contractor’s insurance actions, reports, and related performance records. The Government may use the results of these reviews to validate performance, identify deficiencies, require corrective action, and administer the contract in accordance with the PWS, PRSM, QASP, applicable Task Order, and Section B.

Government quality-assurance activities do not relieve the Contractor of responsibility for performing in accordance with contract requirements.

12.3 Quality Assurance Surveillance Plan [QASP]

The QASP is incorporated as a solicitation and contract attachment. The QASP describes the Government’s surveillance approach for evaluating Contractor performance, including rating periods, validation criteria for communication failures, sampling methodology for accuracy reviews, documentation requirements, and escalation procedures.

The QASP does not change the PWS, PRSM, Section B, or any other contract term. The Government may revise surveillance procedures by written notice from the CO when the revision does not change contractual performance requirements. Any change to performance standards, AQLs, payment, deductions, scope, price, or schedule requires a contract modification.

12.4 Performance Requirements Summary Matrix

By monitoring the Contractor, the COR will determine whether the Contractor has met the performance standards stated in this PWS and the applicable Task Order. The PRSM identifies the performance indicators, standards, AQLs, and Government surveillance methods.

For each indicator, the AQL is the minimum performance level the Government will accept during the applicable rating period, as stated in the QASP or Task Order. Timeliness is calculated as the number of insurance actions completed within the applicable delivery period divided by the total number of actions assigned and available for Contractor processing during the rating period. Accuracy is determined through Government surveillance of completed actions using the sampling methodology stated in the QASP.

The QASP will identify the applicable rating periods, sampling methodology, documentation requirements, and escalation procedures. The Contractor shall conduct its own quality-control activities as required by Section 12.1. The Government will not hold the Contractor responsible for delays or inaccuracies caused by Government-controlled conditions, including incomplete source data, unavailable required system access, background-investigation or credentialing delays, or VistA or provider-portal outages, when the Contractor documents and reports the condition in accordance with the contract and applicable Task Order.

PERFORMANCE REQUIREMENTS SUMMARY MATRIX – PRSM

TASK INDICATOR STANDARD ACCEPTABLE

QUALITY LEVEL [AQL]

METHOD OF

SURVEILLANCE

4.1.1 Timely

completion of insurance actions

Contractor completes assigned and available insurance entry and verification actions within the delivery period stated in the applicable Task Order

At least 93% of assigned and available actions are completed on time during the applicable rating period

Review of VA CPAC QA documents or periodic Government inspection

4.1.2 Data accuracy Contractor performs

insurance entry and verification actions accurately, completely, and in accordance with CPAC guidebooks, VA policy, and Task Order requirements

Individual data entry quality review does not fall below 95% during the applicable rating period

Review of VA CPAC QA documents or periodic Government inspection

QUALITY LEVEL [AQL]

METHOD OF

SURVEILLANCE

4.1.3 Resolution of

Contractor-caused rejected actions

Contractor reviews and takes required corrective action on Contractor-caused rejected actions within the required timeframe

100% of Contractor-caused rejected actions are reviewed and corrected within five [5] business days

Review of QA documents

4.1.4 Resolution of

insurance-action questions and concerns

Contractor provides clear, timely, and effective communication necessary to support resolution of insurance-action questions, discrepancies, and performance concerns

No more than three [3] validated communication failures per quarter

Validated user complaints

4.1.5 Participation

in required meetings

Contractor participates in Government-required calls, meetings, and performance-management sessions

No more than two [2] missed calls per rating period; 100% attendance by a key person or authorized representative when required

Validated attendance records

4.1.6 Maintain

required system and provider-portal access

Contractor maintains the access necessary to perform assigned insurance actions

No more than one [1] access reset per month attributable to Contractor failure to maintain access

Validated requests to regain access

4.1.7 Confidentiality

and information security

Contractor performs insurance actions in compliance with applicable VA privacy, confidentiality, and information-security requirements

No substantiated violations of VA privacy or security requirements

Revenue Operations Privacy Officer or other designated Government review

4.2 Monthly

Itemized Statement

Contractor submits a complete and accurate Monthly Itemized Statement by the required due date. The report identifies accepted completed reverification actions and new-policy actions, including Medicare policy actions, and separately identifies Contractor-caused rejected actions and non-chargeable exceptions, as required by Section 4.2

100% on time, complete, and accurate by the fifth day of each month, unless otherwise stated in the Task Order

COR review of submission and content

QUALITY LEVEL [AQL]

METHOD OF

SURVEILLANCE

4.3 Monthly

Staffing Report

Contractor submits a complete and accurate Monthly Staffing Report by the required due date

100% on time, complete, and accurate by the fifth day of each month, unless otherwise stated in the Task Order

COR review of submission and content

4.4 Weekly

Pending Workload Report

Contractor submits a complete and accurate Weekly Pending Workload Report by the required due date

100% on time, complete, and accurate by Monday of each week, unless otherwise stated in the Task Order

COR review of submission and content

13.0 SECURITY, PRIVACY, AND INFORMATION-SYSTEM REQUIREMENTS

The Contractor shall comply with all applicable Federal, VA, VHA, FAR, VAAR, and contract-clause requirements governing information security, privacy, protection of VA information, personnel vetting and credentialing, system and facility access, incident reporting, safeguarding of covered contractor information systems, and data handling.

The Contractor shall protect VA information, including personally identifiable information and protected health information, and shall use VA information only as authorized for performance of this contract and applicable Task Orders.

The Contractor shall ensure that personnel complete all required privacy, information-security, system-access, role-based, and other required training before performing work requiring that training.

The Contractor shall comply with the authorized access methods and any Government-furnished resource requirements identified in the contract or applicable Task Order. The Contractor shall promptly report conditions affecting access, system availability, security, privacy, or performance in accordance with the applicable contract clauses and Task Order instructions.

In the event of a conflict between this PWS and an applicable solicitation or contract clause, the clause controls.