Pharmacy Benefit Manager
FedBizOpps
Sources Sought Notice
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FedBizOpps Sources Sought Notice
Rev. March 2010
R
Pharmacy Benefit Manager
80111
36C25919Q0423
07-26-2019
60
N
14
518210
Department of Veterans Affairs
Network Contracting Office
NCO 19
6162 South Willow Drive, Suite 300
Greenwood Village CO 80111
Charlie Gritzmacher
charles.gritzmacher@va.gov
Department of Veterans Affairs
Veterans Health Administration Office
Office of Community Care (OCC)
3773 Cherry Creek Drive North, Suite 450
Denver, CO
80209
United States
charles.gritzmacher@va.gov
charles.gritzmacher@va.gov
VA HANDBOOK 6500.6 MARCH 12, 2010
APPENDIX C
C-12
A - 1
Page 1 of
Page 19 of 19
Page 1 of
Agency: Department of Veterans Affairs
Veteran Health Administration
Office: SAO West
Notice Type: Posted Date:
Sources Sought June 26, 2019
Response Date:
July 26, 2019 @ 4PM EST
Original Set Aside:
100% SDVOSB/VOSB
Classification Code:
R499 Professional Services
NAICS Code:
518210 Data Processing, Hosting, and Related Services
Size Standard:
$32.5 Million
SYNOPSIS
THIS IS NOT A SOLICITATION: This is a Sources Sought notice utilizing contracting by negotiation allowed by FAR Part 15 to conduct market research IAW FAR Part 10. This Sources Sought is issued solely for informational planning purposes only and does not constitute a Request for Quote (RFQ) or any promise to issue a RFQ or commit the Government to a contract for any supply or service. The Department of Veteran Health Administration (VHA) is not seeking proposals now and will not accept unsolicited costs incurred in response to this Sources Sought. All costs associated with responding to this Source Sought shall be at the interested vendor s expense. Not responding to this Sources Sought does not preclude participation in any future RFQ, if any is issued. Any information submitted by respondents to this Sources Sought is strictly voluntary. All submissions shall become the property of the VA and shall not be returned. This announcement is based upon the best information available and is subject to future modification.
This Sources Sought notice is for market research purposes only to determine the availability of potential businesses with capabilities to provide the services described in the Statement of Work Statement (SOW). All responses will be used to determine the appropriate acquisition strategy for a potential future acquisition in accordance with the SOW.
Contracting Office Address:
Network Contracting Office 19
Rocky Mountain Acquisition Center
6162 South Willow Drive, Suite 300
Greenwood Village, CO 80111
Point of Contact:
Charlie Gritzmacher / charles.gritzmacher@va.gov
OVERVIEW
The Veterans Health Administration Office of Community Care (VHA OCC) processes pharmacy transactions for a variety of health benefit programs administered by the Department of Veterans Affairs (VA). The programs covered include Civilian Heath and Medical Program of the Department of Veterans Affairs (CHAMPVA) 38 CFR, Section 17.270 to 17.278 to include the Caregiver Program, Spina Bifida Health Care (SB) and Children of Women Vietnam Veterans Healthcare (CWVV) programs 38 CFR, Section 17.900 to 17.905. The VHA OCC intends to adjudicate pharmacy transactions via Health Insurance Portability and Accountability Act (HIPAA) Compliant Electronic Data Interchange (EDI). The VHA OCC intends to utilize the expertise of a Contractor Pharmacy Benefit Manager (PBM) with an extensive network of retail pharmacies.
Please respond to this Sources Sought if your company can perform this requirement in accordance with FAR Part 52.219-14 Limitations on Subcontracting (Nov 2011).
As prescribed in 19.508(e) or 19.811-3(e), insert the following clause:
Limitations on Subcontracting (NovB 2011)
(a) This clause does not apply to the unrestricted portion of a partial set-aside.
(b) Applicability. This clause applies only to
(1) Contracts that have been set aside or reserved for small business concerns or 8(a) concerns;
(2) Part or parts of a multiple-award contract that have been set aside for small business concerns or 8(a) concerns; and
(3) Orders set aside for small business or 8(a) concerns under multiple-award contracts as described in 8.405-5 and 16.505(b)(2)(i)(F).
(c) By submission of an offer and execution of a contract, the Offeror/Contractor agrees that in performance of the contract in the case of a contract for
(1) Services (except construction). At least 50B percent of the cost of contract performance incurred for personnel shall be expended for employees of the concern.
(2) Supplies (other than procurement from a nonmanufacturer of such supplies). The concern shall perform work for at least 50B percent of the cost of manufacturing the supplies, not including the cost of materials.
(3) General construction. The concern will perform at least 15B percent of the cost of the contract, not including the cost of materials, with its own employees.
(4) Construction by special trade contractors. The concern will perform at least 25B percent of the cost of the contract, not including the cost of materials, with its own employees.
(End of clause)
SPECIFIC RESPONSE INSTRUCTIONS
Please submit your Sources Sought response in accordance with the following:
No more than 10 pages (excluding transmittal page). Include the name, email address and phone number of the appropriate representative of your company. Provide a brief capability statement with enough information to determine if the company can meet the requirement.
Capabilities will be evaluated solely for the purpose of determining set-aside status for the Small Business Community or to conduct as an Unrestricted Procurement. The Government must ensure there is adequate competition among the potential pool of available contractors utilizing the Government point of entry FedBizOpps (FBO) www.fbo.gov.
2) Submit your response via email to Charlie Gritzmacher / charles.gritzmacher@va.gov
3) Submit your response by 4:00 P.M. (EST) on July 28, 2019;
4) Mark your response as Proprietary Information if the information is considered business sensitive; and
5) NO MARKETING MATERIALS ARE ALLOWED AS PART OF THIS SOURCES SOUGHT. The Government will not review any other information or attachments included, that are more than the page limit.
INFORMATION REQUESTED FROM INDUSTRY
In response to the Sources Sought, interested contractors shall submit the following information:
1. Company Information/Socio-Economic Status
a. Provide your company size and POC information
b. The VA is utilizing NAICS Code 518210 Data Processing, Hosting, and Related Services that has a size standard of $32.5 Million. Please identify any other NAICS codes your company believes would better represent this scope of work that is included in the attached Performance Work Statement (PWS).
c. Indicate whether your company, Sub-Contractors, teaming partners, joint ventures have a Federal Socio-Economic Status, e.g., Small Business, Service-Disabled Veteran Owned Small Business, Veteran Owned Small business, Women-Owned Small Business, Disadvantaged Small business, and Hub Zone. If Service Disabled or Veteran Owned Small business, is your company and or partners registered in VA s VetBiz repository?
d. Provide the following information on a maximum of 3 similar projects dealing with the services listed in the PWS. All projects referenced must have been completed within the last 3 years for which the responder was a prime or subcontractor.
1. The name, address, and value of each project
2. The Prime Contract Type, Firm Fixed-Price, Cost Reimbursement or Time and Material
3. The name, telephone and address of the owner of each project
4. A description of each project, including difficulties and successes
5. Your company s role and services provided for each project.
e. Provide an overview of proposed solution(s); including, a description of the capabilities/qualification/skills your company possesses for each of the below statements:
1. Assessment of capabilities to perform requirements noted in the Sources Sought
2. Assessment of the types of changes required to accomplish the goals.
3. Approach to be utilized to develop necessary changes to the systems to meet the organizational goals
4. Draft schedule to complete necessary changes.
f. Provide a description of teaming partners, and/or joint ventures that your company would consider performing work.
1. Provide your commercial price history and rough order of magnitude for the same or comparable services
2. Provide any other relative information.
3. Identify the federal contract vehicles
4. Provide GSA contract number with dates of contract.
STATEMENT OF WORK
INTRODUCTION:
The Veterans Health Administration Office of Community Care (VHA OCC) processes pharmacy transactions for a variety of health benefit programs administered by the Department of Veterans Affairs (VA). The programs covered include Civilian Heath and Medical Program of the Department of Veterans Affairs (CHAMPVA) 38 CFR, Section 17.270 to 17.278 to include the Caregiver Program, Spina Bifida Health Care (SB) and Children of Women Vietnam Veterans Healthcare (CWVV) programs 38 CFR, Section 17.900 to 17.905. The VHA OCC intends to adjudicate pharmacy transactions via Health Insurance Portability and Accountability Act (HIPAA) Compliant Electronic Data Interchange (EDI). The VHA OCC intends to utilize the expertise of a Contractor Pharmacy Benefit Manager (PBM) with an extensive network of retail pharmacies.
Background:
The VHA OCC administers several health benefit programs. The CHAMPVA program is VA s health benefits program developed for dependents of permanently and totally disabled veterans, survivors of veterans who died from service-connected conditions, or who at the time of death, were rated permanently and totally disabled from a service connected disability. The VHA OCC also administers the Caregiver, Spina Bifida (SB) and Children of Women Vietnam Veterans (CWVV) programs. Estimated prescription activity based upon fiscal year 2018 data, for each program is:
CHAMPVA:
In Fiscal Year 18 (FY18) there were approximately 504,000 enrollees with an average age of 56 and utilizing approximately 8.65 million prescriptions annually.
4.49 million were filled at retail pharmacies (electronically submitted)
3.19 million were filled at the VA Meds by Mail (MbM) mail order pharmacy program
771 thousand were beneficiary submitted retail
200 thousand claims were submitted by the CHAMPVA In-house Treatment Initiative (CITI) VA Medical Center pharmacies
Claims from VA MbM will continue to be processed internally. Paper claims (receipts) for cash services from retail pharmacies that are submitted by beneficiaries will be entered in the VHA OCC adjudication system, which will continue to be processed internally. The VHA OCC currently utilizes an open formulary with some medication exclusions.
Many CHAMPVA beneficiaries are Medicare eligible and may opt to purchase a Medicare Part D plan. CHAMPVA is always a secondary payer to Medicare. Those beneficiaries, who choose to enroll in a Medicare Part D plan, may have their pharmacy bill VHA OCC as a secondary payer through the PBM if the pharmacy is enrolled in the PBM s network of pharmacies.
The Caregiver program is a separate program established under the Caregivers and Veterans Omnibus Health Services Act of 2010, the program provides a variety of services to include access to CHAMPVA health care insurance for an in-home designated Caregiver who is not already entitled to care of services under a health care plan. Enrollees and prescription volume data are included in the CHAMPVA totals detailed above.
Spina Bifida Program:
Approximately, 1,100 enrollees with 29,000 prescriptions annually
Children of Women Vietnam Veterans:
15 individuals enrolled (Program began in FY 2003) with 0 prescriptions annually
PROGRAM OBJECTIVES:
Contractor responsibilities:
Provide retail pharmacy services in the most cost-efficient method to the government by achieving cost savings, in accordance with the highest standards of retail pharmacy practice.
Receive pharmacy claims data in the HIPAA designated electronic format.
Provide a comprehensive retail pharmacy network to all the VHA OCC beneficiaries living in the fifty United States, the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, the Northern Marinara Islands, the American Samoa, and the Minor Outlying Islands.
Provide a conduit for on-line coordination of benefits from other primary payers, such as Medicare Part D, to the VHA OCC.
Achieve the highest level of beneficiary satisfaction possible through the provision of beneficiary friendly, quality, and professional retail pharmacy services.
Provide the VHA OCC with National Council for Prescription Drug Programs (NCPDP) compliant batch files containing electronically received claims that were submitted for processing on a regularly scheduled basis.
Provide detailed reports of pharmacy claims history to the VHA OCC.
Establish and maintain weekly, at a minimum, communication between the VHA OCC, Contractor, and other appropriate parties.
GENERAL PROGRAM REQUIRMENTS:
The VHA OCC requires a Contractor (PBM) representing pharmacies throughout the fifty United States, District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, the Northern Marinara Islands, the American Samoa, and the Minor Outlying Islands that provides services to CHAMPVA (38 CFR, Section 17.270 to 17.278) to include the Caregiver Program, SB, CWVV (38 CFR, Section 17.900 to 17.905) and any future VHA OCC program beneficiaries. The Contractor and its network pharmacy providers agree to abide by the rules, regulations, and procedures governing the various programs administered by the VHA OCC and in accordance with applicable Federal and State laws. Policies for each of these programs, as they relate to pharmacy coverage, are available for review at the VA website http://www.va.gov/communitycare. The Contractor must be Utilization Review Accreditation Commission (URAC) certified.
Contractor program requirements:
Claims accepted at the point of sale by the Contractor s network providers do not guarantee payment. The Contractor transmits a minimum of six files, as discussed in the Claims Submission by the Contractor section, of claims accepted from providers to the VHA OCC daily.
The VHA OCC performs final adjudication and determines payment for all eligible claims. The Contractor is not authorized or responsible for any adjudication of claims. All claims rejected by the VHA OCC will NOT be paid to the Contractor. The VHA OCC rejects approximately 0.009% of claims upon receipt annually. The Contractor has the right to seek compensation from the responsible party for all VHA OCC rejected claims. Table 1 provides VHA OCC Final Adjudication historical data.
Number of Claims Impacted
Percentage of Total Prescriptions
Process
Cost of Impacted Claims
Percentage of Total Cost
FY18
420
0.009%
4,452,337
$25034.24
0.009%
Table 1: Adjudication Data
The Contractor provides all labor, materials, equipment, transportation, and supervision necessary to complete the requirements of this Performance Work Statement in accordance with the highest level of quality standards and aligned with accepted industry best practices through URAC defined standards and accreditation. Under no circumstances and in no way, will the Contractor act as a representative of the VHA OCC.
It is expressly agreed and understood that the pharmaceutical services rendered by pharmacies represented by the Contractor are rendered in their capacity as autonomous pharmacies. The VHA OCC retains no control or supervision over the professional aspects of the pharmaceutical services of these pharmacies.
The Contractor will accept from the VHA OCC at minimum four daily files to include the Eligibility File, the Primary Status Report, the Reversal Response File and the Claim Payment/Advice File (Secondary Status Report) (See Attachment 1 for formats). The daily Eligibility File contains eligible beneficiaries within each program and will be loaded into the Contractor s beneficiary eligibility database no later than 6:00 AM Eastern Standard Time (EST) when available from the Government by 2:00 AM EST. This data is not a guarantee of coverage or payment. Final determination of eligibility, coverage, and payment are made at the time of claims adjudication by the VHA OCC.
The Contractor will submit six separate files daily, to include but not limited to the following: Coordination of Benefits (COB) Claims, COB Reversal, CITI Claims, CITI Reversals, Standard Retail Benefit Claims File, and Standard Retail Benefit Reversal File. Files will be submitted to VHA OCC by 8AM EST.
The CHAMPVA beneficiary deductible is a combined medical and pharmacy deductible. The Contractor will receive and process, along with beneficiary information, the deductible remaining information provided by the VHA OCC on the daily eligibility file. (See Attachment 2 for a sample of the data provided)
All VHA OCC programs have a unique identifier for each person on the eligibility file that is transmitted daily. VHA OCC beneficiaries have a unique program authorization card, with name and ID number (printed as Beneficiary SSN on the front) issued from the VHA OCC. The Contractor will provide a Pharmacy ID card to identified eligible beneficiaries for use within the pharmacy network. The Contractor supplied Pharmacy ID card will comply with NCPDP standards. The Contractor will provide all ID cards to beneficiaries within seven days of receipt of request (includes new cards, lost card, and eligibility status change).
The use of any VHA OCC logos and all marketing information provided by the Contractor to Network Pharmacies or VHA OCC beneficiaries must be approved by the VHA OCC prior to distribution.
The Contractor and/or the network provider will not assess any fees or charges to VHA OCC for testing; this includes all implementation and/or transmission of claims for testing purposes. All data transmission expenses associated with submitting and receiving test data under this agreement shall be borne by the Contractor and/or its pharmacy providers. The VHA OCC will cover any equipment or software costs that the VHA OCC may require for new initiatives requested by the VHA OCC or required by regulation for the VHA OCC to process claims from the Contractor.
The Contractor will ensure, by way of online real-time adjudication edits, that all claims submitted for CHAMPVA (to include Caregiver Program), SB, and CWVV Programs do not include any excluded prescription drugs, medical supplies or devices. The submission of an electronic claim by the Contractor is a claim for payment and intentional misrepresentation or falsification of any record or other information essential to that claim is subject to prosecution under federal criminal and civil laws and, upon conviction, may result in fines and/or imprisonment.
The Contractor and pharmacy provider will inquire of the beneficiary about Other Health Insurance (OHI) status and incorporate OHI information into their point of sale adjudication process in accordance with program requirements. Identifiers exist on the VHA OCC eligibility file that denote the beneficiary health plan (CHAMPVA, SB or CWVV) and OHI coverage. Until a future agreed upon state, the VHA OCC will reject claims where there are indications that the beneficiary has primary OHI other than Medicare Part D.
The Contractor will have the necessary personnel to authorize overrides of rejected claims from network pharmacies. The Contractor is given specific authority to override edits in certain instances for vacation supplies, lost medications, and other instances as determined by the VHA OCC and established at contract award.
Claims for medical supplies (non-drug items), which have National Drug Codes (NDC), may be submitted by the network pharmacies to the Contractor using NCPDP telecommunication standards as established by HIPAA rules. VHA OCC will provide an official list of covered and non-covered items upon contract award.
Specific Requirements:
Beneficiary Cost Share:
CHAMPVA Program (to include the Caregiver Program):
The Contractor calculates the beneficiary cost share at the time of service. The cost share is always twenty-five percent (25%) of the allowable amount, after the annual individual/family deductible ($50 individual/$100 family) has been met until the catastrophic cap of $3,000 has been met for that benefit year. The provider will collect the deductible when applicable. Once the catastrophic cap has been met for the benefit year, the VHA OCC reimburses at 100% of the allowable amount. The billed charge is the actual amount billed to the VHA OCC. The billed charge submitted to the VHA OCC will include any applicable dispensing fee. The beneficiary cost share is never to be calculated on an amount different than what is billed to the VHA OCC.
The Contractor calculates the beneficiary cost share for all coordination of benefit claims from other health insurance plans including but not limited to Medicare Part D per instructions from the VHA OCC.
There will be no beneficiary cost share, deductible, or cat cap for CITI eligible beneficiaries. The Contractor will not pay the CITI pharmacies as this will be done via funds transfer by VHA OCC.
Spina Bifida/CWVV Programs:
There is no deductible or cost-share for Spina Bifida or CWVV beneficiaries. The Contractor will ensure that the necessary programs are in place for the provider to collect no monies from Spina Bifida or CWVV beneficiaries.
Pharmacy Network Access:
The contractor will create and maintain a pharmacy network sufficient to meet the following minimum beneficiary access standards on an overall basis:
Urban: a pharmacy within two miles estimated driving distance of 90% of the beneficiaries;
Suburban: a pharmacy within five miles estimated driving distance of 90% of the beneficiaries;
Rural: a pharmacy within fifteen miles estimated driving distance of 90% of the beneficiaries.
An Excel spreadsheet showing the distribution of FY18 utilizing VHA OCC enrollees by zip code is available in Attachment 3.
The Contractor will ensure that the number of pharmacies included in its network does not decrease by more than 10% of the total number of pharmacies originally proposed for its network.
Pharmacy Network Services:
The Contractor will establish and maintain a pharmacy network throughout the fifty United States, the District of Columbia, Puerto Rico, Guam, the Northern Mariana Islands, the U.S. Virgin Islands, the American Samoa, and the Minor Outlying Islands.
All network pharmacies must be fully licensed and certified in accordance with applicable Federal and State laws and credentialed according to the Contractor s criteria. This information must be made available to the VHA OCC upon request.
The Contractor must provide technical assistance to network pharmacies through the Contractor s pharmacy help desk. The Contractor must coordinate with the VHA OCC for those inquiries that require VHA OCC input.
The Contractor must require network pharmacies to maintain a process to document the receipt of medication by a VHA OCC beneficiary or the beneficiary s authorized agent and meet HIPAA requirements.
The Contractor must ensure that network pharmacies collect beneficiary cost share amounts as returned on the paid claim s response. The Contractor will provide written instructions to each participating pharmacy provider that includes an explanation of each of the VHA OCC programs, a copy of the sample Pharmacy ID Card and specific guidelines regarding pharmacy benefits and the terms of this contract. The Contractor will review, update and disseminate these written instructions and/or provider agreement addendum any time there are substantive changes to VHA OCC program requirements or the contract. Any provider manual and all updates to the written instructions require approval by the VHA OCC prior to distribution.
The VHA OCC requires the PBM to support the current NCPDP telecommunication standard for transmission of electronic prescribing functionality throughout the network of retail pharmacies to improve the safety and accuracy of the prescribing process. The PBM must be able to adjudicate claims utilizing electronic prescribing capabilities in the allowable NCPDP SCRIPT standard for the secure, electronic transmission of prescriptions and prescription related information. These capabilities must allow an eligible prescriber to select medications, print prescriptions, transmit prescriptions electronically, and receive safety alerts. These alerts must include automated prompts that offer information on the drug being prescribed and warn the prescriber of possible undesirable or unsafe situations regarding current and profile medications, such as potential drug-drug interactions, duplicate therapies, and dosing warnings/cautions.
Claims Submission to the Contractor by Network Pharmacy Provider:
The Contractor will ensure, at its own expense, that electronic claims are submitted online, in real time, utilizing current NCPDP designated standards.
The Contractor will ensure that network pharmacies submit any claims for processing within one year of the date of service. Claims submitted after the one year filing deadline will be denied by the VHA OCC.
The Contractor must accept and process all electronic claims received from network pharmacies for pharmaceuticals and supplies furnished in the fifty United States, the District of Columbia, Puerto Rico, Guam, the Northern Mariana Islands, the U.S. Virgin Islands, the American Samoa, and the Minor Outlying Islands.
The Contractor must ensure that reversals from network pharmacies are sent timely. VHA OCC expects reversals be completed within a 7-day cycle.
The Contractor must ensure that each claim passes administrative and plan edits established by VHA OCC policy. The current policy manuals for VHA OCC programs are available online at http://www.va.gov/communitycare.
Modification to the claim edits or other electronic media claim procedures must be submitted in writing to the Contractor by the VHA OCC. The Contractor will be provided time to make any necessary system changes to accommodate such modifications; however, since the time required is dependent on the complexity of any change, the Contractor and the VHA OCC will negotiate and agree in writing to reasonable time lines prior to each change.
Daily, the Contractor will submit six separate batch files to include but not limited to the following: Standard Business Billing and Reversal, CITI Billing and Reversal, and Coordination of Benefit (COB) Billing and Reversal. Files will be submitted by 8AM EST. The Contractor will be advised of all discrepancies by the VHA OCC via a primary proprietary response file.
Paid claim (billing) files will be submitted daily, in batch, to the VHA OCC with a minimum 7-day lag to allow for a majority of claim reversals to be processed by the Contractor prior to transmission and processing at the VHA OCC.
The Contractor is required to provide medical documentation from the medical provider/prescriber for some medications prior to payment of the claim.
The VHA OCC will apply validity and consistency edits to all submissions from the Contractor. The VHA OCC will accept all valid claims which meet such edit requirements and return errant submissions for correction. The Contractor will research and correct all discrepant claim submissions. Claims rejected for compliance prior to the VHA OCC s adjudication will be corrected by the Contractor and resubmitted electronically as a new claim. (If the Contractor receives the claim on a proprietary secondary status report, the claim has passed through the VHA OCC s adjudication system.)
When the time frames for transmission of claims by the Contractor cannot be met, the VHA OCC COR will be notified by phone and e-mail of the failure to meet the time frame, reason(s) why, and estimated time to resumption of transmissions.
Claims Submission by VA Facilities:
The Contractor will receive CITI claims from participating VA facilities via an established network and make real-time coverage and eligibility determinations.
The Contractor will return eligibility and coverage determinations on CITI claims to the requesting VA Facility through the established network.
Claim Reimbursements:
Claim reimbursements for network claims will be made to the Contractor via Electronic Funds Transfer (EFT) from the U.S. Treasury daily on claims that have been determined to meet all criteria for reimbursement by the VHA OCC. The Contractor, on behalf of pharmacy providers, will accept consolidated payments for all reimbursements to the same corporate tax identification number. A proprietary secondary response file with remittance information will be returned to the Contractor.
The allowable amounts for network claims submitted to the VHA OCC will be based on the pricing proposal and discounts submitted in the VHA OCC network in the Reimbursement Pricing Table. Due to policy restraints, the prescription dispensing fee shall not exceed $3.00.
Reimbursement to the Contractor for prescriptions and medical supplies for the CHAMPVA program, to include eligible Caregivers, will be seventy-five percent (75%) of the allowable amount after the individual/family deductible (currently $50 individual and $100 family) has been met, until the catastrophic cap of $3,000 has been met for that benefit year, at which time the VHA OCC reimburses at 100% of the allowable amount. Reimbursement for the Spina Bifida and CWVV programs will be 100% of the allowable amount.
The Contractor shall submit a daily file identifying CITI claims to be paid by the VHA OCC. The VHA OCC will pay the participating VA facilities directly.
Claims Processing Standards between the Pharmacy Provider and the Contractor:
Ninety-nine percent (99%) of electronic claims will be processed to completion within five seconds of receipt, measured monthly. By the 10th day of each month, the Contractor will provide reports to the VHA OCC detailing processing times for the previous month.
Scheduled downtime from processing of claims must not exceed eight hours during any month. The Contractor will provide a schedule of planned outages. Planned outages must be scheduled after Midnight EST and systems must be operational by 6 AM EST. By the 10th day of each month, the Contractor will provide a report detailing actual outages.
If an unscheduled outage occurs, the Contractor will notify the VHA OCC immediately and provide hourly updates of progress and estimated time for restoration of services by phone and e-mail. The Contractor will use contact information provided by the VHA OCC to report status/progress.
Claim Reversal Submission to the VHA OCC:
The Contractor will transmit one reversal batch (in NCPDP current Batch format) of an unlimited number of prescription claim records and assumes responsibility for ensuring that all reversals submitted to VHA OCC contain complete information.
The Contractor will be advised of the amount due for all accepted network reversal transactions by the VHA OCC on the reversal response file. Reversal files will be submitted daily.
The Contractor will submit to VHA OCC a paper check twice monthly with an Excel spreadsheet for reconciliation purposes.
Beneficiary Refunds:
If the VHA OCC determines a refund is due; the VHA OCC will initiate and ensure that the refund is properly made. If, however, the Contractor determines a refund is due, the Contractor will identify the refund situation to the VHA OCC prior to taking any action. The Contractor will send a written report to the VHA OCC of all identified refund situations on or before the 28th of every month. The VHA OCC has the right to audit files that are relevant to the refund situation.
Recoupments:
In the event the VHA OCC identifies a change in eligibility has occurred after a claim has been processed, and a claim was paid to the Contractor, the VHA OCC will generate a recoupment action.
The Contractor will provide all recoupment payments to the VHA OCC on behalf of its pharmacy providers. The VHA OCC s recoupment action will contain a detailed payment account on each claim. Recoupment payments will be paid within 30 days of the date on the Bill of Collection to avoid penalties, interest and fees.
The Contractor will make a reasonable effort to identify possible recoupment situations, and advise the VHA OCC of such situations. The VHA OCC has the right to audit files that are relevant to the recoupment situation. The VHA OCC will review each case and advise the Contractor of the results and will initiate a recoupment action when it is appropriate.
If it is determined the monies are due from the beneficiary, the Contractor may pursue recoupment from the beneficiary.
Under no circumstances will a beneficiary be billed a billing fee or additional charge which is more than the VHA OCC determined allowable amount.
Attachment 4 provides process maps detailing the adjudication and recoupment process. The following tables provide historical data for the past two fiscal years.
Number of Claims Impacted
Percentage of Total Prescriptions
Cost of Impacted Claims
Percentage of Total Cost
FY17
2271
0.05
131446.80
0.05
FY18
176
0.004
$10490
0.004%
Table 2: Recoupment Historical Data
Rebates:
The VHA OCC will allow the Contractor to obtain pharmaceutical rebates through the administration of this program while sharing the benefit of these rebates with the beneficiary at the point of sale. The Contractor shall propose the optimal rebate solution that provides a benefit from the rebates to the beneficiary at the point of sale. Summary information of all network retail claims dispensed for FY18 at the National Drug Code (NDC) 11 level is included in Attachment 5.
Beneficiary Help Desk:
The Contractor will maintain a toll-free telephone number at their own expense for use by the VHA OCC beneficiaries to assist with questions regarding the Contractor submitted claims, routine coverage questions, or to determine which providers are located near them. This toll-free number will be staffed, at a minimum, daily from 6:00 AM to midnight Eastern Standard Time (EST).
The Contractor may use an Automated Response Unit (ARU) to receive beneficiary calls. If calls are received by an ARU, 98% of all telephone calls will be acknowledged within 10 seconds. The first menu choice presented to the caller will allow the caller to be transferred to a Customer Service Representative. Each subsequent menu selection will be transferred and answered 98% of the time within 10 seconds of the menu selection being made. If the caller requests to speak with a customer service representative, they will be connected 98% of the time within 10 seconds of the request.
The Contractor will ensure the necessary number and type of personnel are available during all hours of operation of the Beneficiary Help Desk to answer beneficiary questions. The Contractor will provide the VHA OCC toll-free telephone number to the caller and then transfer the caller to VHA OCC.
Telephone Response Standards: When a caller requests to speak with a Customer Service Representative, the connection will be made within 10 seconds, 98% of the time. The abandonment rate will not exceed 2%. The blocked call rate will not exceed 2%. The Contractor will fully resolve (meaning the caller understands the resolution) all customer service calls 95% of the time during the initial call and 100% of the time resolution within two working days of receiving the initial call.
Pharmacy Help Desk:
The Contractor will maintain a toll-free telephone number at their own expense for use by the network pharmacies to assist with questions regarding the Contractor submitted claims or routine coverage questions. This toll-free number will be staffed, at a minimum, daily from 6:00 AM to midnight EST.
The Contractor may use an ARU to receive pharmacy calls. If calls are received by an ARU, 98% of all telephone calls shall be acknowledged within 10 seconds. The first menu choice presented to the caller shall allow the caller to be transferred to a Customer Service Representative. Each subsequent menu selection will be transferred and answered 98% of the time within 10 seconds of the menu selection being made. If the caller requests to speak with a customer service representative, they will be connected 98% of the time within 30 seconds of the request.
The Contractor will ensure the necessary number and type of personnel are available during all hours of operation of the Pharmacy Help Desk to answer questions.
Telephone Response Standards: When a caller requests to speak with a Customer Service Representative, the connection will be made within 30 seconds, 98% of the time. The abandonment rate will not exceed 4%. The blocked call rate will not exceed 2%.
Internet Website:
The Contractor will maintain an Internet website at its own expense. The website will have the ability to look up network locations by the zip code, print a temporary ID card, and provide VHA OCC beneficiaries with telephone or mailing contact information for the Contractor.
Access to Claim Data:
Parties to this contract will ensure only authorized access to this data to guarantee that the electronic data interchange (EDI) messages are authentic, properly authorized and traceable. The messages will also be protected from loss, modification, or unauthorized disclosure both during transmission and storage. Health claim submissions for treatment for sickle cell anemia, Human Immunodeficiency Virus (HIV), and substance and alcohol abuse are specifically protected by 38 U.S.C. S 7332. This statute includes a penalty provision for the unauthorized use or disclosure of information. To maintain confidentiality and to preclude the filing of fraudulent clams, access to all claims data will be restricted to:
The designated/authorized employees of the Contractor and each of their participating pharmacy providers.
The designated/authorized employees of the VHA OCC, and/or
Any third part as deemed necessary by the Contractor, each participating pharmacy provider and the VHA OCC.
The Contractor, as a business associate of the VHA OCC under the terms of the contract will comply with all requirements and provisions regarding Privacy, Protected health Information (PHI) and Security as required by the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (Public Law 104-191).
Network Certification and Administration:
The Contractor will maintain complete provider certification documents on all providers and make them available for review by the VHA OCC, upon request. Accompanying all new certification documents will be the following provider licensure information.
Drug Enforcement Agency (DEA) identification number by pharmacy
State pharmacy license number by pharmacy
NCPDP number ((formerly called (National Association of Boards of Pharmacy) NABP)) of each pharmacy
Internal pharmacy designated number (applies only to pharmacy chains or multi-locations i.e. Store Number)
Complete address of each pharmacy including telephone number
Federal tax identification number of each pharmacy/pharmacy chain
Provider s National Provider Identifier (NPI) from National Plan & Provider Enumeration System (NPPES)
Databases:
The Contractor will ensure that all Contractor reference database files are maintained and updated weekly to include the most recently published information. Those files include, but are not limited to, DEA provider files, MediSpan, First DataBank, Micromedex, NCPDP pharmacy provider file, HCIdea and the NPI.
VHA OCC utilizes MediSpan for identifying NDCs and drug pricing.
Audits:
The Contractor will retain the submitted electronic transactions and any other source documentation for a period of no less than 75 months from the date of service.
The VHA OCC, or any authorized representative, has the right to conduct an audit during normal business hours at the Contractor s site at no cost to the government, and confirm any source documents (such as the prescription form, the NCPDP prescription data captured on-line from the provider, or any documents used to bill the VHA OCC) that are relevant to claims submitted to the VHA OCC electronically. Incorrect payments, which are discovered because of such an audit, will be adjusted in accordance with VA guidelines and applicable program provisions. The VHA OCC may request ad hoc reports (regarding costs, time frames, etc.) on a case by case basis. The Contractor will provide adequate space and any source documents or reports needed by the VHA OCC to verify compliance at no charge to the VHA OCC.
The VHA OCC may request that the Contractor perform audits of certain network pharmacy providers when fraud, abuse or other aberrant activity is suspected.
The Contractor will notify the VHA OCC of any audits performed and any recoupment actions resulting from such audits by the Contractor, which were performed because of the Contractor s Quality Assurance Plan.
Reporting:
The Contractor will provide a list of available monthly/periodic reports summarizing claim data and identifying trends, averages, utilization rates and other such information needed to effectively track the VHA OCC expenditures and drug utilization.
The reports will include, at a minimum:
Total Number of Prescriptions
Total Number of Brand Name Prescriptions
Total Number of Generic Prescriptions
Total Cost of All Prescriptions
Total Cost of Brand Name Prescriptions
Total Cost of Generic Prescriptions
Annual Report on Program Costs
These reports, and any other agreed upon, will be prepared in a VHA OCC approved format. Crosswalks will be included in all pharmacy (NPI and NCPDP) and prescriber (NPI to DEA) reports. Reports will be electronically generated and transmitted by the 10th day of the following month.
The Contractor will provide the VHA OCC with a list of available retrospective detailed Drug Utilization Reports (DUR) to identify over utilization or abuse of medications by the VHA OCC beneficiaries and to suggest more cost-efficient options.
The Contractor may be required to provide additional ad hoc utilization reports related to electronically filed claims. Examples may include: Top 100 drugs, Brand and Generic quantities prescribed, Brand and Generic costs or other such data as required by the VHA OCC. These will be on an as needed basis as determined by the VHA OCC Contracting Officer s Representative (COR) or another designated representative.
The Contractor will provide samples of all reports at the time of proposal submission. Award of the contract does not imply acceptance of any sample reports or formats. After award of the contract, the VHA OCC Contracting Officer or COR will approve specific reports on an individual basis.
Annually, the Contractor will provide a yearend review and briefing on site or by teleconference to the VHA OCC which will include summaries of the cumulative yearend reports.
PERFORMANCE REQUIREMENTS SUMMARY
EDI TRANSFER STANDARDS
A: EDI Delivery Standards
Standard EDI Transfer
EDI File Delivery Standard
Daily Standard Business Billing File
No later than 6 am EST on the following day, after a 7 day hold period to allow for in-cycle adjustments.
Daily Standard Business Reversal File
No later than 6 am EST on the following day
Daily CITI Billing File
No later than 6 am EST on the following day, after a 7 day hold period to allow for in-cycle adjustments.
Daily CITI Reversal File
No later than 6 am EST on the following day
Daily COB Billing File
No later than 6 am EST on the following day, after a 7 day hold period to allow for in-cycle adjustments.
Daily COB Reversal File
No later than 6 am EST on the following day
B: EDI Delivery Performance Guarantees
The contractor will meet the EDI delivery standards listed above for all required standard EDI file transfers, unless there is a technical problem that requires immediate resolution which causes a delay to the file being posted as stated. TheB reasons for the delay will be given to the COR via email and shall be documented.
C: EDI Receipt Standards
Standard EDI Transfer
EDI File Receipt Standard
Daily Eligibility File
No later than 6 am EST on the following day, when the file is made available by the Government by 2 am EST
Daily Reverse Response File
No later than 6 am EST on the following day, when the file is made available by the Government by 2 am EST
Daily Claim Payment/Advice File
No later than 6 am EST on the following day, when the file is made available by the Government by 2 am EST
Daily Claim Status Response File
No later than 6 am EST on the following day, when the file is made available by the Government by 2 am EST
D: EDI Receipt Performance Guarantees
The contractor will meet the EDI delivery standards listed above for all required standard EDI file transfers, unless there is a technical problem that requires immediate resolution which causes a delay to the file being posted as stated. TheB reasons for the delay will be given to the COR via email and shall be documented.
REPORTING STANDARDS
A: Report Delivery Standards
Standard Report Frequency
Delivery Standard
Monthly
No later than 10 business days after the close of the reporting period
Quarterly
No later than 10 business days after the close of the reporting period
B: Report Delivery Performance Guarantees
The Contractor will guarantee the standard report delivery standards listed above are met for all required standard reports in each reporting period.
SERVICE STANDARDS
Beneficiary:
A: Beneficiary Help Desk Transfer Standards
Help Desk Transfer Standard
If received by an Automated Response Unit (ARU), calls shall be acknowledged within 10 seconds
Each subsequent ARU menu selection shall be transferred within 10 seconds of the selection being made
If not received by an ARU, calls shall be acknowledged within 20 seconds
If the caller requests to speak to a customer service representative, they shall be connected within 10 seconds
B: Beneficiary Help Desk Transfer Performance Guarantees
The Contractor will meet each of these Beneficiary Help Desk Transfer standards listed above.
C: Beneficiary Help Desk Response Standards
Telephone Response Standard
Blocked call rate will not exceed 2%
Abandoned call rate will not exceed 2%
95% of the time, resolution rate will be during initial call
100% of the time, resolution rate will be within one working day of the initial call
D: Beneficiary Help Desk Response Performance Guarantees
The Contractor will meet each of these Beneficiary Help Desk Response standards listed above.
Pharmacy:
A: Pharmacy Help Desk Transfer Standards
Help Desk Transfer Standard
If received by an Automated Response Unit (ARU), calls shall be acknowledged within 10 seconds
Each subsequent ARU menu selection shall be transferred within 10 seconds of the selection being made
If not received by an ARU, calls shall be acknowledged within 30 seconds
If the caller requests to speak to a customer service representative, they shall be connected within 30 seconds
B: Pharmacy Help Desk Transfer Performance Guarantees
The Contractor will meet each of these Pharmacy Help Desk Transfer standards listed above.
C: Pharmacy Help Desk Response Standards
Telephone Response Standard
Blocked call rate will not exceed 2%
Abandoned call rate will not exceed 4%
D: Pharmacy Help Desk Response Performance Guarantees
The Contractor will meet each of these Pharmacy Help Desk Response standards listed above.
Claims:
A: Claims Processing Standards
Claim Processing Standard
Electronic claims shall be processed to completion within 5 seconds of receipt
B: Claims Processing Performance Guarantees
The Contractor will meet the Claims Processing standard listed above.
C: Claims System Scheduled Downtime Standards
Claims System Scheduled Downtime Standard
Scheduled system downtime must not exceed 8 hours in any month
D: Claims System Downtime Performance Guarantees
The Contractor will meet the Claims System Scheduled Downtime standard listed above.
NETWORK STANDARDS
A: Network Access Standards
Location Type
Distance Traveled
Percentage of Beneficiaries
Urban
A pharmacy within 2 miles estimated driving distance
90 %
Suburban
A pharmacy within 5 miles estimated driving distance
90 %
Rural
A pharmacy within 15 miles estimated driving distance
90 %
B: Network Access Performance Guarantees
The Contractor will guarantee these network access standards listed above are met for each location type. Measurements shall be determined using GeoAccess reporting monthly, and these reports will be provided by the contractor to the VHA OCC no later than the 10th working day after the close of each month in the contract period.
C: Network Size Standards
Network Size
Maximum Decrease in Size
The contractor shall maintain the initial size of the retail pharmacy network within a permissible range
10%
D: Network Size Performance Guarantees
The Contractor will guarantee the network size standard specified above is achieved. A report indicating the count of active contracted network pharmacies will be produced monthly, and this report will be provided by the contractor to the VHA OCC no later than the 10th working day after the close of each month in the contract period. The count of active contracted network pharmacies will be compared to the initial count at the beginning of the initial contract period to determine compliance.
Network Size
Maximum Decrease in Size
Greater than 18.0% but less than or equal to 20.0%
2.0 %
Greater than 20.0%
3.0 %
ADDITIONAL REQUIREMENTS:
Disaster Recovery Plan - The Contractor will implement and provide a copy of a Disaster Recovery Plan to ensure that the VHA OCC services will not be disrupted for more than twenty-four (24) consecutive hours throughout the life of the contract. The plan will detail procedures to ensure sufficient staffing, processes, facilities, testing, redundancy, and back-up hardware. The plan will address continuity of beneficiary service in the event of a disaster at the Contractor s site. The plan will be approved, post award, by the VHA OCC Contracting Officer or COR. Award of the contract does not imply acceptance of the plan.
Fraud and Abuse Detection Plan - The Contractor will provide a copy of the Fraud and Abuse Detection Plan. The Fraud and Abuse Detection Plan will describe pharmacy audit procedures in place at the network pharmacies. The plan will be approved post award by the VHA OCC Contracting Officer, or COR. Award of the contract does not imply acceptance of the plan.
Security Plan - The Contractor will employ physical security safeguards for Information Security (IS)/Networks involved in the operation of the VHA OCC programs to prevent the unauthorized access, disclosure, modification, destruction, use, etc., of sensitive information and to otherwise protect the confidentiality and ensure the authorized use of sensitive information. The Contractor will be compliant with the Business Associate Agreement (BAA) requirements (Attachment 6) and HIPAA. An executed copy of the BAA document will be required on file post award. The Contractor will operate program systems of records strictly in accordance with controlling laws, regulations and the VA policy on confidentiality and privacy of individual identifiable information. The Contractor will provide and document the necessary and appropriate security training of all workforce members (e.g. employees, volunteers, trainees, Contractors and other persons who conduct and perform work for the Contractor) in the proper handling and safeguarding of this information.
All electronic communications containing Protected Health Information (PHI) with the VHA OCC will be conducted in a secure manor, utilizing FTP (File Transfer Protocol) and encryption in accordance with VA Directive 7610, VHA Directive 7610, etc.
QUALITY CONTROL
The Contractor will demonstrate a quality control program to ensure that PBM support complies with VA requirements. The Contractor will take corrective action when deficiencies are identified and return any corrective/additional information to VA within 14 business days.
The Contractor will submit and implement a Quality Control Plan that will identify areas for improvement, approaches to change implementation, and metrics to measure the successes or failures of the changes implemented.
The plan will be approved post award by the VHA OCC Contracting Officer or COR. Award of the contact does not imply acceptance of the plan.
TRAINING
The Contractor will provide orientation and instructions to their employees regarding VA programs, benefits, claims, and customer service. The Contractor, in consultation with VA, will prepare and implement a training program for all support staff personnel who will have routine contact with Veterans and beneficiaries, to provide a basic overview of VA programs, available sources of Veteran assistance and an understanding of the core claims process. Information concerning referral to VA's health care system will also be provided. All Contractor staff will complete the annual privacy and security training provided online by the VHA. Completion certificates shall be provided to the COR upon request. The Contractor will establish and implement a training plan to ensure that its staff and subcontractors are knowledgeable and trained regarding the requirements of the VHA OCC programs and its administration under this contract. The plan will be approved post award by the VHA OCC Contracting Officer or COR. Award of the Contract does not imply acceptance of the plan.
PROFESSIONAL AND INDSTRY PARTICIPATION:
The Contractor will provide a statement representing its or its employee s participation in Industry Standards Development Organizations (SDOs) and other pharmacy professional or technical organizations. The Contractor will indicate the organization name, and number of employees actively participating and the time participating in these SDOs (e.g. NCPDP, ANSI X12, WEDI, HL7, AMCP, NACDS, APHA, NCA, etc.). The Contractor will be URAC certified.
TRANSITION (PHASE-IN/PHASE-OUT)
Phase-in Performance consists of all the preparation activities, including but not limited to making capital expenditures, ensuring a qualified workforce in place, providing appropriate training, and implementing the information technology support necessary to fully perform the requirements contained in this performance work statement and contract within 180 days after contract award. The Contractor will begin performance of all requirements under this contract on date of contract award. The Base Period will be one year and begin on date of contract award. Any additional options years awarded, will be one-year long.
The Contractor will submit a transition plan to include but not be limited to a discussion of key milestones and timeline, resources required, risks, and mitigation strategies.
Upon conclusion of the contract, the Contractor will participate in a phase-out period not to exceed 180 days.
GOVERNMENT FURNISHED INFORMATION
VHA OCC will provide the following government furnished information for use by the Contractor in executing daily operations.
Policy/Coverage File (for initial set-up)
Eligibility File (daily)
Reversal Response File (daily)
Claim Payment/Advise File/Secondary Proprietary Status Report (daily)
Primary Proprietary Status Report (daily)
Charles Gritzmacher (CS)
Contract Specialist
303-712-5724
charles.gritzmacher@va.gov
