SW Virginia PWS Dental Services - Final - 17APR2026.pdf

PERFORMANCE WORK STATEMENT (PWS)

FOR

Dental Services Virginia Army National Guard

1.0 General:

1.1 Scope: The contractor shall provide all personnel, equipment, tools, materials, supervision, and quality control necessary to perform Dental Services for referred Class 3 dental Soldiers of the Virginia Army National Guard, with services concentrated in the South-West region of Virginia, centered around Bristol.

1.2 Background: Readiness is the #1 Priority, and Medical and Dental Readiness is 80% of a Soldiers Readiness Posture. Military operations and deployments within the Virginia Army National Guard (VAARNG) have increased and has placed additional strain and requirements on our Soldiers and their families. Increased deployments and missions locally and around the globe have required Soldiers to be deployed more frequently, for longer periods in high physical and mental stress operations. All service members are expected to be deployable and not become a dental casualty within the 12 months of deployment.

1.2.1 Dental Services

1.3 Period of Performance (PoP). The ordering period shall be for five (5) years after the effective date of the agreement.

1.4 General Information:

1.4.1 Place and Performance of Services. Hours of Operation: The contractor shall have the capability of providing dental treatment services at their professional office during normal business hours, except on recognized US holidays.

1.4.2 Recognized Holidays: The following are recognized United States (US) holidays.

The contractor is not required perform services on these days:

1.4.3.1 New Year’s Day: January 1st

1.4.3.2 Martin Luther King, Jr.’s Birthday

1.4.3.3 President’s Day

1.4.3.4 Memorial Day

1.4.3.4 Juneteenth: June 19th

1.4.3.6 Independence Day: July 4th

1.4.3.7 Labor Day

1.4.3.8 Columbus Day

1.4.3.9 Veteran’s Day: November 11th

1.4.3.10 Thanksgiving Day

1.4.3.11 Christmas Day: December 25th

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

1.4.4 Maintain all records and transfer within HIPAA compliance.

1.4.5 Special Qualifications. Contractors must ensure that all personnel performing under this contract are fully trained, licensed, certified and qualified to provide services. The Government does not provide training to contractors. Contractor shall comply with: HIPAA, Privacy Act and OSHA certifications. (NOTE: The Government does not provide training to contractors. Contractors must ensure that any personnel performing under a contract are fully trained, licensed, certified and qualified to provide services.)

1.4.6 Post Award Conference/Periodic Progress Meetings: The contractor may be requested to attend any post award conference convened by the KO in accordance with FAR 42.5. The KO, COR and other Government personnel, as appropriate, may meet periodically with the contractor to discuss current issues, performance, and Government/Contractor concerns. Contractor attendance at these meetings shall be at no additional cost to the Government.

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

1.4.8 Data Rights: The Government has unlimited rights to all documents/materials produced under this contract. All documents and materials, to include the source codes of any software, produced under this contract shall be Government owned and are the property of the Government with all rights and privileges of ownership/copyright belonging exclusively to the Government. These documents and materials may not be used or sold by the contractor without written permission from the KO. All materials supplied to the Government shall be the sole property of the Government and may not be used for any other purpose. This right does not abrogate any other Government rights.

1.4.9 Organizational Conflicts of Interest (OCI): The contractor and subcontractor personnel performing services under this contract may receive, have access to or participate in the development of proprietary or source selection information (e.g., cost or pricing information, budget information or analyses, specifications or work statements, etc.) or perform evaluation services which may create a current or subsequent OCIs, as defined in FAR Subpart 9.5. The contractor shall notify the KO immediately whenever it becomes aware that such access or participation may result in any actual or potential OCI and shall promptly submit a plan to the KO to avoid or mitigate any such OCI. The contractor’s mitigation plan will be determined to be acceptable solely at the discretion of the KO. In the event the KO unilaterally determines that any such OCI cannot be satisfactorily avoided or mitigated, the KO may impose other remedies as he or she deems necessary, including prohibiting the contractor from participation in subsequent contracted requirements which may be affected by the OCI.

2.0 Definitions and Acronyms:

2.1 Definitions:

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

2.1.2 Defective Service: A service output that does not meet the standard of performance associated with the PWS.

2.1.3 Deliverable: Anything that can be physically delivered and includes non-manufactured things such as meeting minutes or reports.

2.1.4 Key Personnel: Contractor personnel that are evaluated in a source selection process and that may be required to be used in the performance of a contract by the PWS. When key personnel are used as an evaluation factor in best value procurement, an offer can be rejected if it does not have a firm commitment from the persons that are listed in the proposal.

2.1.5 Quality Assurance: The Government procedures to verify that services being performed by the Contractor are performed according to acceptable standards.

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

2.1.7 Quality Control: All necessary measures taken by the Contractor to ensure that the quality of an end product or service shall meet contract requirements.

2.1.8 Subcontractor: One that enters into a contract with a prime contractor. The Government does not have privity of contract with the subcontractor.

2.1.9 Blanket Purchase Agreement (BPA): A simplified method of filling anticipated repetitive needs for supplies or services by establishing "charge accounts" with qualified sources of supply.

2.2 Acronyms:

AEI Army Enterprise Infostructure AR Army Regulation CM Contract Manager COR Contracting Officer Representative DA Department of the Army DFARS Defense Federal Acquisition Regulation Supplement DoD Department of Defense FAR Federal Acquisition Regulation IS Information System(s) KO Contracting Officer NGB National Guard Bureau OCI Organizational Conflict of Interest PII Personally Identifiable Information POC Point of Contact PRS Performance Requirements Summary PWS Performance Work Statement QA Quality Assurance QC Quality Control QCP Quality Control Program TE Technical Exhibit

3.0 Government Furnished Property. There is not expected to be any furnished property, materials, equipment, services or utilities by the Government for this BPA.

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

4.1 General: The contractor shall furnish everything required to perform these services as indicated in Paragraph 1.1.

5.0 Requirements:

5.1 Dental Services Requirements:

5.1.1 The contractor shall provide all management, labor, material, equipment, certifications, and supplies necessary to provide dental care services at their professional office, which must be located within the South-West region of Virginia, centered around Bristol, for the Virginia Army National Guard Soldiers. Services will be notified to the contractor by documented communication (i.e., email, fax, written correspondence) with proper authorization from the State Surgeon’s Office, VAARNG. Treatment provided to Soldiers will be only that which is authorized in Memos generated by the State Dental Office. The contractor shall provide an appointment within 60 days of notification. Once service has been requested, the contractor will provide the previously identified dental treatment and documentation for each Soldier as necessary to meet Department of the Army standards and ensure the mission capability of the Virginia Army National Guard.

The service will comply with medical/dental readiness by converting the Soldier from Dental Class 3 to Dental Class 1 or 2. The contractor will ensure that their agents are appropriately familiar with the military dental classification system. The contractor shall provide customized comprehensive dental readiness services to include:

5.1.2 Class 3 dental treatments for Soldiers (as identified by VAARNG). Dental treatment authorized is outlined in Army Techniques Publication (ATP) 4-02.19 and Appendix 5.1.10d. These services will be completed at the contractor's professional office within the specified service area unless otherwise specified in a separate written agreement. The contractor will assure that procedures are done in accordance with Federal/State Regulations.

5.1.3 Specified Dental Specialty Services to include:

5.1.3a Oral and Maxillofacial Surgery (to include pathology reports if indicated) 5.1.3b Endodontics 5.1.3c Periodontics 5.1.3d Prosthodontics 5.1.3e Prescriptions/pharmaceuticals that are not directly provided by the vendor or can’t be billed directly to the vendor shall be coordinated with the DSS office. Patient shall not be directed to pick up prescriptions without directly contacting the DSS for further guidance. (Most dental offices won’t likely have a system to directly provide prescriptions/pharmaceuticals, in these cases the service member or DSS will have to use alternate means to provide the prescriptions/pharmaceuticals)

5.1.4 Radiographs shall be taken only for clinical reasons according to FDA and DENCOM guidelines as determined by the patient’s dentist. Radiographs should be of diagnostic quality, properly identified and dated. A panoramic radiograph of adequate quality for diagnostic/identification purposes is required to be part of the dental record.

There is no time requirement on updating panoramic radiographs. However, the panoramic radiograph will adequately represent the current oral condition of the Soldier.

Bitewing (or “bitewing slice” at the discretion of the State Dental Officer) radiographs are also required to be part of the dental record. All radiographs provided under this contract will be digital (unless specified in a separate written agreement) and transferred to the Virginia Army National Guard State Surgeon’s Office within 10 business days.

5.1.5 Upon completion of services, the contractor will provide a listing of all DRC3 conditions rectified during the time of treatment. This shall be in accordance with the guidelines set within Appendix 5.1.1 and 5.1.2.

5.1.6 Any condition of significance that has been identified by the VAARNG dental team that is not readily apparent when viewing radiographs is required to be treated by the contractor.

5.1.7 The Contractor shall furnish the following documentation:

5.1.7.1 Upon completion of services, medical information will be documented in accordance with Department of the Army Policy and be updated in the approved Army National Guard automated system. The contractor shall also ensure the requirements of Occupational Safety and Health Administration (OSHA) and applicable Federal regulations are met. The contractor shall develop and maintain records that fully document services performed, examination results, and names of soldiers referred to dental specialists. These records will be made available to the VAARNG State Surgeon’s Office, NLT 10 days after initial request. Contractor will return records to the State Dental Office once treatment is finished with detail procedure and signature.

5.1.7.2 All Soldiers must have a complete military dental record. No dental record is considered complete unless the documentation is complete and in the proper order as outlined in 5.1.8.

5.1.8 A complete military dental record includes the following:

5.1.8.1 Automated Health History Form or DA Form 5570 (with notations to “yes” answers and signed by both the Soldier and reviewing Doctor), Health Questionnaire

5.1.8.2 DD Form 2005 (signed), Privacy Act Statement

5.1.8.3 SF 603/603A, Record of Dental Exam

5.1.8.4 Supporting radiographs (panoramic and diagnostic bitewing radiographs documenting existing conditions). All radiographs will be uploaded into the ARNG automated system by the Dental NCOIC. A diagnostic quality copy of all radiographs will be placed in the Dental Record by the Dental NCOIC.

5.1.9 The Contractor will conduct additional dental treatments as required. The Government may request additional treatment not listed but may be required. These requests will be discussed with KO and Contractor prior to any changes.

5.1.10 APPENDICES:

5.1.10a Estimated Workload Data 5.1.10b Oral Health and Readiness Classification System 5.1.10c DA Form 5570E and SF 603-A (Dental Classification Module Version) 5.1.10d Authorized Dental Treatment

6.0 Applicable Publications: Publications applicable to this PWS are listed below:

Publication (Chapter/Page)

Date of Publication

Mandatory or Advisory

Website

Federal Acquisition Regulation https://www.acquisition.gov/?q=browsefar Defense Federal Acquisition

Regulation Supplement http://www.acq.osd.mil/dpap/dars/dfarspgi/current/in dex.html or https://www.acquisition.gov/dfars https://www.acquisition.gov/?q=browsefar http://www.acq.osd.mil/dpap/dars/dfarspgi/current/index.html http://www.acq.osd.mil/dpap/dars/dfarspgi/current/index.html

DoD 5400.11-R Department of Defense Privacy

Program

05/14/2007 https://www.esd.whs.mil/Directives/issuances/dodm/

DoD 5220.22-M National Industrial Security Program

Operating Manual (NISPOM)

02/28/2006 (Change 2:

05/18/2016) https://www.esd.whs.mil/Directives/issuances/dodm/

Executive Order on Combating Race and Sex Stereotyping

09/22/2020 Mandatory https://www.whitehouse.gov/presidential-actions/executive-order-combating-race-sex-stereotyping/ DOD Instruction 6025.19 Individual

Medical Readiness (IMR) 9 June 2014 Mandatory http://adp.army.mil

Army Regulation 40-502 Medical Readiness

June 2019 Mandatory http://adp.army.mil

Army Techniques Publication 4- 02.19: Dental Services

14 August https://armypubs.army.mil/epubs/DR_pubs/DR_a/A RN30126-ATP_4-02.19-000-WEB-1.pdf

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

Form Date Website DA Form 5570 01 October https://armypubs.army.mil/ProductMaps/PubForm/Details.asp x?PUB_ID=61118 SF Form 603 Dental Exam October 1975 https://www.gsa.gov/reference/forms/medical-record-dental

DD Form 2005 June 2016 https://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/d d2005.pdf https://www/

TECHNICAL EXHIBIT 1

Performance Requirements Summary (PRS)

This PRS includes performance objectives the Government will use to determine contractor performance and will compare contractor performance to the Acceptable Quality Level (AQL).

PWS Paragraph

Task

Performance

Standard

Acceptable

Quality Levels

(AQL)

Surveillance Method

By Whom

5.1

Treatment provided to Soldiers will be authorized only by Memo’s generated by State Dental Office.

Dental Treatment Authorization.

As needed Periodic Inspection - COR

5.1.2

Contractor will assure that procedures are done as per Army dental classification.

Dental Treatment Procedure

As needed Periodic Inspection - COR

5.1.7a

The contractor shall develop and maintain records that fully document serviced performed, examination results, and names of Soldiers referred to dental specialists. (NLT 5 days after initial request)

List of Names and Services 100%

Periodic Inspection - COR will review monthly work order logs.

5.1.7a

Contractor will return memorandum to the State Dental Office once treatment is finished with detail procedure and signature.

Memorandum of treatment authorization 100%

Periodic Inspection - COR will review monthly work order logs.

TECHNICAL EXHIBIT 2

Deliverables Schedule

PWS Reference

/ Deliverable Title

Frequency Number of Copies Medium/Format Submit To

DA Form 5570

Completed Prior to procedure, Delivered to Dental Care Manager after procedure

1 Digital/paper Dental Care Manager

SF Form 603 After procedure 1 Digital/paper Dental Care Manager

DD Form 2005

Completed Prior to procedure, Delivered to Dental Care Manager after procedure

1 Digital/paper Dental Care Manager

TECHNICAL EXHIBIT 3

APPENDIX 5.1.10a

ESTIMATED WORKLOAD DATA

Deputy State Surgeon: Mr. Alan Louis Dental Care Manager: Mr. Chad Rhodes

Name Last four

SSN

Date of Procedures

ADA

Codes

Procedures Description Price

Provider Signature: ____________________

Date: _________________________

Deputy State Surgeon/Dental NCOIC Signature: _________________________________

Date: _________________________

APPENDIX 5.1.10b

Department of Defense Oral Health and Readiness Classification System

The oral health status of uniformed personnel shall be classified as follows:

a. Class 1 (Oral Health): Patients with a current dental examination, who do not require dental treatment or reevaluation. Class 1 patients are worldwide deployable.

b. Class 2: Patients with a current dental examination, which require non-urgent dental treatment or reevaluation for oral conditions, which are unlikely to result in dental emergencies within 12 months. Class 2 patients are worldwide deployable. Patients in dental class 2 may exhibit the following:

(1) Treatment or follow-up indicated for dental caries or minor defective restorations that can be maintained by the patient.

(2) Interim restorations or prosthesis that can be maintained for a 12-month period.

This includes teeth that have been restored with permanent restorative materials for which protective cuspal-coverage is indicated.

(3) Edentulous areas requiring prostheses but not on an immediate basis.

(4) Periodontium that:

(a) requires oral prophylaxis

(b) requires maintenance therapy

(c) requires treatment for slight to moderate periodontitis and stable cases of more advanced periodontitis

(5) Unerupted partially erupted or malposed teeth that are without historical, clinical or radiographic signs or symptoms of pathosis, but which are recommended for prophylactic removal.

(6) Active orthodontic treatment. The provider should consider placing the patient in passive appliances for deployment up to six months. For longer periods of deployment, the provider should consider removing active appliances and placing the patient in passive retention.

(7) Temporomandibular disorder patients in remission. The provider anticipates the patient can perform duties while deployed without ongoing care and any medications or appliances required for maintenance will not interfere with duties.

c. Class 3: Patients who require urgent or emergent dental treatment. Class 3 patients normally are not considered to be worldwide deployable.

(1) Treatment or follow-up indicated for dental caries, symptomatic tooth fracture or defective restorations that cannot be maintained by the patient.

(2) Interim restorations or prostheses that cannot be maintained for a 12-month period.

(3) Patients requiring treatment for the following periodontal conditions that may result in dental emergencies within the next 12 months.

(a) Edentulous areas or teeth requiring immediate prosthodontic treatment for adequate mastication or communication or acceptable esthetics.

(b) Active progressive moderate or advanced periodontitis.

(c) Periodontal abscess

(d) Progressive mucogingival condition

(e) Periodontal manifestations of systemic disease or hormonal disturbances

(f) Heavy subgingival calculus

(4) Edentulous areas or teeth requiring immediate prosthodontic treatment for adequate mastication or communication or acceptable esthetics.

(5) Unerupted, partially erupted or malposed teeth with historical, clinical or radiographic signs or symptoms of pathosis that are recommended for removal.

(6) Chronic oral infections or other pathologic lesions including:

(a) Pulpal, periapical or resorptive pathology requiring treatment.

(b) Lesions requiring biopsy or awaiting biopsy report.

(7) Emergency situations requiring therapy to relieve pain, treat trauma, treat acute oral infections or provide timely follow-up care (e.g., drain or suture removal0 until resolved.

(8) Acute Temporomandibular disorders requiring active treatment that may interfere with duties.

d. Class 4. Patients who require periodic dental examinations or patients with unknown dental classifications. Class 4 patients normally are not considered to be worldwide deployable.

APPENDIX 5.1.10c

APPENDIX 5.1.10c

Appendix 5.1.10c

APPENDIX 5.1.10d

AUTHORIZED DENTAL TREATMENT

1. The following dental procedures are authorized:

(a) Diagnostic Services which are funded through the NG6H 2065 Medical Readiness or VFRE 2065 Medical & Readiness Funding:

D0120-Periodic Oral Evaluation D0150-Comprehensive Oral Evaluation D0220- Periapical (First films) limited D0230- Periapical (limited) D0272-Bitewings-Two Films D0274-Bitewings-Four Films

D0330-Digital Panoramic Film

(b) Restorative Services which are funded through the NG6H 2065 Medical

Readiness (provided only to soldiers non-alerted or VFRE 2020 Dental Treatment Funding (provided only to soldiers alerted to an OCONUS Mission):

D2140-Amalgam-One Surface D2150-Amalgam-Two Surfaces D2160-Amalgam-Three Surfaces D2161-Amalgam-Four or More Surfaces D2330-Composite-One Surface D2331-Composite-Two Surfaces D2332-Composite-Three Surfaces

Posterior composites will be authorized only when a posterior composite is necessary to provide a quality restoration and no other alternative is available.

D2335-Composite-Four or More Surfaces

D2391-Composite-One Surface D2392-Composite-Two Surfaces D2393-Composite-Three Surfaces

D2394-Composite-Four or More Surfaces D2799-Provisional Crown D2931-Prefabricated Stainless-Steel Crown D2950-Core Buildup, including any pins D2954-Prefabricated Post and Core

(c) Endodontic Services which are funded through the NG6H 2065 Medical Readiness or VFRE 2020 Dental Treatment Funding (provided only to Soldiers alerted to an OCONUS Mission):

D3310-Anterior Root Canal Therapy D3320-Bicuspid Root Canal Therapy D3330-Molar Root Canal Therapy D3346-Anterior Root Canal Retreatment D3347-Bicuspid Root Canal Retreatment D3348-Molar Root Canal Retreatment

(d) Periodontal Services which are funded through the NG6H 2065 Medical

D4355-Full Mouth Debridement D4342-Periodontal Scaling and Root Planning, 1 to 3 teeth per quadrant

Periodontal scaling and root planning is authorized only when a periodontal abscess is present)

(e) Prosthodontic Services which are funded through the NG6H 2065 Medical

D5110-Complete Denture-Maxillary D5120-Complete Denture-Mandibular D5211-Maxillary Partial Denture-Resin Base D5212-Mandibular Partial Denture-Resin Base

(f) Oral Surgery Services which are funded through the NG6H 2065 Medical

D7140-Extraction, Erupted Tooth or Exposed Root D7210-Surgical Removal of Erupted Tooth D7220-Romoval of Impacted Tooth, Soft Tissue D7230-Removal of Impacted Tooth, Partial Bony D7240-Removal of Impacted Tooth, Completely Bony

(g) Orthodontic Services which are funded through the NG6H 2065 Medical

D8680-Orthodontic Retention

2. The following dental procedures are not authorized:

Crown (PFM) or (Gold) Bridges and/or implants Removal of Asymptomatic third molars Routine Prophylaxes (cleanings) Restorations for aesthetics only Restorations for small (non-class 3) caries Extensive Root plane/scaling Osseous Surgery Other diagnostic services

The above listings are guides to assist the State Dental Officer or his/her designee in determining treatment to be authorized. The treatment provided by the VAARNG is to get the Soldier from a dental class 3 to a dental class 2 only. Comprehensive Treatment (to dental class I) is not authorized.

3. If a Soldier needs all of his/her remaining teeth in an arch extracted and a denture placed, the Soldier will not be available for deployment for at least 6 months and shall be disqualified from immediate deployment. However, if the Soldier is otherwise deployable (passes all medical, personnel and training requirements) and, after extraction and placement of prosthesis, would be deployable, the dental treatment could be provided, and the Soldier could be considered as a replacement at a later date.

4. If a Soldier will have a number of teeth extracted to the extent mastication and speech are adversely affected, then an acrylic removable partial denture will be authorized if there is sufficient time for healing and construction of the partial denture prior to departure to Mobilization Station.

5. Soldiers requiring extensive periodontal treatment will be disqualified from deployment and educated on the TRICARE Dental Program. If he/she obtains the required therapy (from his/her private dental provider) and reaches a maintenance level, then he/she would become deployable.