REQUEST FOR INFORMATION (RFI) Pharmacy Benefit Manager (Retail Pharmacy Claim Adjudications) 1.0 Description 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 PBM (Pharmacy Benefit Manager (PBM)) with an extensive network of retail pharmacies. This RFI is issued solely for information and planning purposes and does not constitute a solicitation. The responses will be used to determine the availability of potential businesses with capabilities to provide the services described in the Statement of Work (SOW). All responses will be used to determine the appropriate acquisition strategy for a potential future acquisition, including whether a set-aside is possible. The Government will identify potential and eligible firms, of all sizes, prior to determining the method of acquisition and issuance of a solicitation. All small business socioeconomic contracting programs, including SDVOSBs, (8(a)), and HUBZone, will be considered. The Government must ensure there is adequate competition among the potential pool of available contractors within each status utilizing the System for Award Management (www.beta.sam.qov). In accordance with FAR 15.202(e), responses to this notice are not offers and cannot be accepted as such by the Government. Respondents are solely responsible for all expenses associated with responding to this RFI. Respondents will not be notified of the result of the review. Not responding to this RFI does not preclude participation in any future RFP, if any is issued. If a solicitation is released, it will be posted on the System for Award Management (www.beta.sam.qov). It is the responsibility of the potential offerors to monitor these sites for additional information pertaining to this requirement. Small business respondents must be able to perform in accordance with FAR Part 52.219-14 Limitations on Subcontracting (Nov 2011) (https://www.acquisition.gov/far/52.219-14). This clause does not apply to the unrestricted portion of a partial set-aside. This requirement is assigned a NAICS code of 524292 Professional Program Management/Support. The size standard for this NAICS code is $35 million. The Government remains open to alternative ideas and considerations. This announcement is based upon the best information available and is subject to future modification. 2.0 Background CHAMPVA was 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 program covers prescriptions filled and/or submitted electronically from retail pharmacies, at mail order (VA Meds by Mail (MbM)), on paper by beneficiaries, and electronically from the CHAMPVA In-house Treatment Initiative (CITI) VA Medical Center pharmacies. Claims from VA MbM and paper claims for cash services from retail pharmacies submitted by beneficiaries will continue to be processed internally. VHA OCC currently utilizes an open formulary with some medication exclusions. Medicare eligible CHAMPVA beneficiaries may opt to purchase a Medicare Part D plan. In such case, CHAMPVA is a secondary payer to Medicare, which allows enrolled PBM network pharmacies to bill VHA OCC as a secondary payer (through PBM). Caregiver Program was established under the Caregivers and Veterans Omnibus Health Services Act of 2010. The Veteran must first meet eligibility criteria to have a Caregiver. Once determined, the Veteran may have a Primary Caregiver and a Secondary Caregiver. This program offers access to CHAMPVA health care for an in-home designated Veteran Caregiver who is not already entitled to care or services under another health care plan. The VA has historically relied on contracted services to process pharmacy transactions. In procuring these services, VA can adjudicate and determine final payment for all eligible pharmacy transactions. 3.0 Response Instructions Interested parties are requested to respond to this RFI in the following manner: 3.1 Responses should be submitted in Microsoft Word for Office 2010 compatible format and due NLT 23 December 2021, 1200 MST. Emailed submissions only should be transmitted to the following Government Points of Contract (POC): Thomas Brick, Contracting Officer Phone: (303) 273-6217 Email:
[email protected] Joanna Hudson-Lundquist, Contracting Specialist Phone: (303) 273-6225 Email:
[email protected] Janica Francis-Hunter, Contracting Specialist Phone: (303) 215 5246 Email:
[email protected] 3.2 Responses are limited to 10 pages (excluding transmittal page). Proprietary information, if any, should be kept to minimum and MUST BE CLEARLY MARKED. NO MARKETING MATERIALS ARE ALLOWED IN RESPONSE TO THIS RFI. 3.3. Responses should contain: 3.3.1 Company name, mailing address, overnight delivery address (if different from mailing address), phone number, fax number, and e-mail address of designated point of contact. 3.3.2 Concise capability statement containing sufficient information to determine if the respondent can meet the Government requirement and to determine appropriate set-aside or unrestricted procurement status. The capability statement should, at a minimum, contain the following information: (a) Business type of your company and all sub-contractors, teaming partners, joint ventures, and/or other partners (Partners). (large business, small business, small, disadvantaged business, 8(a)-certified small, disadvantaged business, HUBZone small business, woman-owned small business, very small business, veteran-owned small business, service-disabled veteran-owned small business). (Ref: FAR Part 2 and 19). Please indicate if all service disabled or veteran owned small businesses are registered in VA s VetBiz repository. (b) Overview of proposed solution(s) in terms of your capabilities/qualification/skills: (i) ability to meet the: - program objectives - general and specific program requirements - additional requirements - quality assurance - training - professional and industry participation - Phase-Out transition as outlined in the SOW (ii) ability of the company to make the required Phase-in capital expenditure to perform the requirements contained in the SOW and contract within 180 days after contract award (iii) systemic and/or other changes required to accomplish project goals, including applicable timelines (iv) description of the teaming Partners to be utilized in the performance of tasks outlined in the SOW (v) any other pertinent information (c) Answers to the following questions: (i) describe what services are included in administration fees (ii) do you have a 90-day retail maintenance network? (iii) what recommendations do you have for controlling pharmacy costs without a formulary? (iv) what other relevant services are available that are not listed in this RFI? (v) what periods of performance are customary for the same or similar commercial and/or government contracts; what are the best-known industry practices? 3.3.3 The Government is utilizing NAICS Code 524292 Professional Program Management/Support that has a size standard of $35 Million. Please identify any other NAICS codes your company believes would better represent the scope of work contained in the SOW. 3.3.4 A list of no more than three (3) same or similar projects performed by your company in a prime contractor or subcontractor capacity in the past three (3) years. Please include the following information: (a) name, address, and value of each project (b) name, address, and telephone contact of the project owner (c) prime contract type (e.g.: firm fixed price, cost reimbursement, time and material, etc.), (d) description of each project, project outcome (success/failure), and key challenges. Please include: (i) commercial price history and rough order of magnitude for the same or comparable services, (ii) identify any federal contract vehicles and GSA contract number(s) and dates, (iii) provide any other relevant information (e) description of services rendered for each project and in what capacity 4.0 Draft 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 PBM (Pharmacy Benefit Manager (PBM)) with an extensive network of retail pharmacies. The estimated prescription activity based upon fiscal year 2021 data for all programs is 5.2M prescriptions for approximately 260,000 active PBM enrollees. Each of the Administration Fee, Transaction Fee, and Drug utilization Fee shall be priced independently and billed accordingly. Dispensing Fee is not an Administrative Fee, therefore, not invoiced monthly by the PBM contractor but billed separately through the pharmaceutical claim process (currently CHAMPVA VistA system) by way of separate electronic submission by PBM for each dispensing fee claim. (Ref.: Part 3. Beneficiary Cost Share, below). Claims for Dispensing Fee are submitted via CHAMPVA VistA system and are paid at the contract rate. Background: CHAMPVA was 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 program covers prescriptions filled and/or submitted electronically from retail pharmacies, at mail order (VA Meds by Mail (MbM)), on paper by beneficiaries, and electronically from the CHAMPVA In-house Treatment Initiative (CITI) VA Medical Center pharmacies. Claims from VA MbM and paper claims (receipts) for cash services from retail pharmacies submitted by beneficiaries will continue to be processed internally. VHA OCC currently utilizes an open formulary with some medication exclusions. Medicare eligible CHAMPVA beneficiaries may opt to purchase a Medicare Part D plan. In such case, CHAMPVA is a secondary payer to Medicare, which allows enrolled PBM network pharmacies to bill VHA OCC as a secondary payer (through PBM). Caregiver Program was established under the Caregivers and Veterans Omnibus Health Services Act of 2010. The Veteran must first meet eligibility criteria to have a Caregiver. Once determined, the Veteran may have a Primary Caregiver and a Secondary Caregiver. This program offers access to CHAMPVA health care for an in-home designated Veteran Caregiver who is not already entitled to care or services under another health care plan. Enrollees and prescription volume data for this program is included in the CHAMPVA totals detailed above. The VA has historically relied on contract services for processing of pharmacy transactions. In procuring these services, VA can adjudicate and determine final payment for all eligible pharmacy transactions. PROGRAM OBJECTIVES: PBM responsibilities: Provide retail pharmacy services to the government in the most cost-efficient manner 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 NCPDP (National Council for Prescription Drug Programs) 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 communication between the VHA OCC, PBM, and other appropriate parties. GENERAL PROGRAM REQUIRMENTS: The VHA OCC requires a Pharmacy Benefit Manager (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 PBM 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 PBM must be URAC certified. PBM program requirements: Claims accepted at the point of sale by the PBM s network providers do not guarantee payment. The PBM transmits a minimum of six files of claims accepted from providers to the VHA OCC daily (as more particularly described in Claims Submission by the PBM section below). The VHA OCC performs the final adjudication and determines payment for all eligible claims. The PBM is not authorized or responsible for any adjudication of claims. All claims rejected by the VHA OCC will NOT be paid to the PBM. The VHA OCC rejects approximately 0.06% of claims upon receipt annually. The PBM has the right to seek compensation from the responsible party for all VHA OCC rejected claims. The PBM provides all labor, materials, equipment, transportation, and supervision necessary to complete the requirements of this Scope of Work in accordance with the highest level of quality standards and aligned with accepted industry best practices through URAC (Utilization Review Accreditation Commission) defined standards and accreditation. Under no circumstances and in no way will the PBM act as a representative of the VHA OCC. It is expressly agreed and understood that the pharmaceutical services rendered by pharmacies represented by the PBM 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 PBM will accept from the VHA OCC at minimum four daily files to include the Eligibility File, the Primary Status File, the Reversal Response File and the Claim Payment/Advice File (Secondary Status Report) (See Attachment 1-Eligibility and Reverse Response Formats). The daily Eligibility File contains eligible beneficiaries within each program and will be loaded into the PBM 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 PBM 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. Medicaid Subrogation 3.0 Claims and Medicaid Subrogation 3.0 Reversals may be requested at a later agreed upon date. Files will be submitted to VHA OCC by 8AM EST. The CHAMPVA beneficiary deductible is a combined medical and pharmacy deductible. The PBM will receive and process, along with beneficiary information, the deductible remaining information provided by the VHA OCC. (See Attachment 2-CHAMPVA Eligibility Sample Data. 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 PBM will provide a Pharmacy ID card to identified eligible beneficiaries for use within the pharmacy network. The PBM supplied Pharmacy ID card will comply with NCPDP standards. The PBM 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 PBM to Network Pharmacies or VHA OCC beneficiaries must be approved by the VHA OCC prior to distribution. The PBM 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 PBM 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 in order for the VHA OCC to process claims from the PBM. The PBM 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 PBM 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 PBM 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. The PBM will have the necessary personnel to authorize overrides to rejected claims from network pharmacies. The PBM 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 PBM 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 PBM 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 individual/family deductible ($50 individual/$100 family) has been met until such time as 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 PBM calculates the beneficiary cost share for coordination of benefit claims from Other Health Insurance Plans per instructions from the VHA OCC. There will be no beneficiary cost share, deductible, or cat cap for CITI eligible beneficiaries. The PBM 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 PBM 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 PBM 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 utilizing VHA OCC enrollees by zip code is available in Attachment 3- ZIP Code Listing. The PBM 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 PBM 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 PBM s criteria. This information must be made available to the VHA OCC upon request. The PBM must provide technical assistance to network pharmacies through the PBM s pharmacy help desk. The PBM must coordinate with the VHA OCC for those inquiries that require VHA OCC input. The PBM 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 PBM must ensure that network pharmacies collect beneficiary cost share amounts as returned on the paid claim s response. The PBM 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 PBM 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 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 PBM by Network Pharmacy Provider: The PBM will ensure, at its own expense, that electronic claims are submitted online, in real time, utilizing HIPAA designated standards. The PBM 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 PBM 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 PBM must ensure that reversals from network pharmacies are sent timely. VHA OCC expects reversals be completed within a 7 day cycle, All prescriptions not received by eligible members must be reversed within 45 days of processing. The PBM 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 PBM by the VHA OCC. The PBM 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 PBM and the VHA OCC will negotiate and agree in writing to reasonable time lines prior to each change. The PBM will submit six separate batch files daily 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. Medicaid Subrogation (3.0) Billing and Reversal may be requested at a later agreed upon date. Files will be submitted by 8AM EST. The PBM will be advised of all discrepancies by the VHA OCC via a primary proprietary response file. 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 PBM prior to transmission and processing at the VHA OCC. The PBM is required to provide VHA OCC 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 PBM. The VHA OCC will accept all valid claims which meet such edit requirements and return errant submissions for correction. The PBM will research and correct all discrepant claim submissions. Claims rejected for compliance prior to the VHA OCC s adjudication will be corrected by the PBM and resubmitted electronically as a new claim. (If the PBM receives the claim on a secondary status report, the claim has passed through the VHA OCC s adjudication system.) When the time frames for transmission of claims by the PBM cannot be met, the appropriate VHA OCC contact (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 PBM will receive CITI claims from participating VA facilities via an established network and make real-time coverage and eligibility determinations. The PBM 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 PBM 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 PBM, on behalf of pharmacy providers, will accept consolidated payments for all reimbursements to the same corporate tax identification number. A secondary response file with remittance information will be returned to the PBM. 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 PBM 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 such time as 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 PBM 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 PBM: Ninety-nine percent (99%) of electronic claims will be processed to completion within five seconds of receipt, measured on a monthly basis. By the 8th day of each month, the PBM 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 PBM 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 8th day of each month, the PBM will provide a report detailing actual outages. In the event that an unscheduled outage occurs, the PBM 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 PBM will use contact information provided by the VHA OCC to report status/progress. Claim Reversal Submission to the VHA OCC: The PBM 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 PBM will be advised of the amount due for all accepted network reversal transactions by the VHA OCC. Reversal files will be submitted daily. The PBM 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 the PBM determines a refund is due, the PBM will identify the refund situation to the VHA OCC prior to taking any action. The PBM 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 PBM, the VHA OCC will generate a recoupment action. The PBM 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 by provider. Recoupment payments will be paid within 30 days of the date on the Bill of Collection to avoid penalties, interest and fees. The PBM 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 PBM 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 PBM may pursue recoupment from the beneficiary. Under no circumstances will a beneficiary be billed a billing fee or additional charge which is in excess of the VHA OCC determined allowable amount. Attachment 4-Process Maps provides process maps detailing the adjudication and recoupment process. Rebates: The VHA OCC will allow the PBM 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 PBM 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 FY19 at the NDC (National Drug Code) 11 level is included in Attachment 5-NDC Listing. Beneficiary Help Desk: The PBM will maintain a toll-free telephone number at their own expense for use by the VHA OCC beneficiaries to assist with questions regarding the PBM 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 PBM 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 PBM 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 PBM will provide warm transfers in the event calls must be transferred 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 PBM 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 PBM will maintain a toll-free telephone number at their own expense for use by the network pharmacies to assist with questions regarding the PBM submitted claims or routine coverage questions. This toll-free number will be staffed, at a minimum, daily from 6:00 AM to midnight Eastern Standard Time (EST). The PBM may use an Automated Response Unit (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 PBM 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 PBM 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 PBM. 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 PBM 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 PBM, each participating pharmacy provider and the VHA OCC. The PBM, as a business associate of the VHA OCC will a) 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), b) report any and all incidents to the COR, CO, and Office of Community Care at
[email protected]. Records received by PBM on behalf of the VHA OCC in the performance of this contract shall be securely maintained and turned over to OCC at the termination/expiry of the contract. Network Certification and Administration: The PBM 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 NPI (National Provider Identifier) from NPPES (National Plan & Provider Enumeration System) Databases: The PBM will ensure that all PBM 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 PBM 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 PBM 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 PBM 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 PBM perform audits of certain network pharmacy providers when fraud, abuse or other aberrant activity is suspected. The PBM will notify the VHA OCC of any audits performed and any recoupment actions resulting from such audits by the PBM, which were performed as a result of the PBM s Quality Assurance Plan. Reporting: The PBM 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 8th day of the following month. The PBM 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 PBM 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 other designated representative. The PBM 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 PBM 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 Compliance 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. 99 % Daily Standard Business Reversal File No later than 6 am EST on the following day 99 % 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. 99 % Daily CITI Reversal File No later than 6 am EST on the following day 99 % Daily Medicaid Subrogation Billing File No later than 6 am EST on the following day 99 % Daily Medicaid Subrogation Reversal File No later than 6 am EST on the following day 99 % 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. 99 % Daily COB Reversal File No later than 6 am EST on the following day 99 % B: EDI Delivery Performance Guarantees The PBM will guarantee the EDI delivery standards listed above are met 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. The 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 Compliance 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 99 % 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 99 % 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 99 % 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 99 % D: EDI Receipt Performance Guarantees The PBM will guarantee the EDI delivery standards listed above are met 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. The 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 8 business days after the close of the reporting period Quarterly No later than 8 business days after the close of the reporting period B: Report Delivery Performance Guarantees The PBM 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 Percentage of Calls If received by an Automated Response Unit (ARU), calls shall be acknowledged within 10 seconds 98 % Each subsequent ARU menu selection shall be transferred within 10 seconds of the selection being made 98 % If not received by an ARU, calls shall be acknowledged within 20 seconds 98 % If the caller requests to speak to a customer service representative, they shall be connected within 10 seconds 98 % B: Beneficiary Help Desk Transfer Performance Guarantees The PBM will guarantee that each of these Beneficiary Help Desk Transfer standards listed above is met. C: Beneficiary Help Desk Response Standards Telephone Response Standard Percentage of Calls Blocked call rate 2 % Abandoned call rate 2 % Resolution rate during initial call 95 % Resolution rate within one working day of the initial call 100% D: Beneficiary Help Desk Response Performance Guarantees The PBM will guarantee that each of these Beneficiary Help Desk Response standards listed above is met. Pharmacy: A: Pharmacy Help Desk Transfer Standards Help Desk Transfer Standard Percentage of Calls If received by an Automated Response Unit (ARU), calls shall be acknowledged within 10 seconds 98 % Each subsequent ARU menu selection shall be transferred within 10 seconds of the selection being made 98 % If not received by an ARU, calls shall be acknowledged within 30 seconds 98 % If the caller requests to speak to a customer service representative, they shall be connected within 30 seconds 98 % B: Pharmacy Help Desk Transfer Performance Guarantees The PBM will guarantee that each of these Pharmacy Help Desk Transfer standards listed above is met. C: Pharmacy Help Desk Response Standards Telephone Response Standard Percentage of Calls Blocked call rate 2 % Abandoned call rate 4 % D: Pharmacy Help Desk Response Performance Guarantees The PBM will guarantee that each of these Pharmacy Help Desk Response standards listed above is met. Claims: A: Claims Processing Standards Claim Processing Standard Percentage of Claims Electronic claims shall be processed to completion within 5 seconds of receipt 99 % B: Claims Processing Performance Guarantees The PBM will guarantee that the Claims Processing standard listed above is met. C: Claims System Scheduled Downtime Standards Claims System Scheduled Downtime Standard Compliance Scheduled system downtime must not exceed 8 hours in any month 100 % D: Claims System Downtime Performance Guarantees The PBM will guarantee that the Claims System Scheduled Downtime standard listed above is met. 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 PBM will guarantee these network access standards listed above are met for each location type. Measurements shall be determined using GeoAccess reporting on a monthly basis, and these reports will be provided by the PBM to the VHA OCC no later than the 8th working day after the close of each month in the contract period. C: Network Size Standards Network Size Maximum Decrease in Size The PBM shall maintain the initial size of the retail pharmacy network within a permissible range 10% D: Network Size Performance Guarantees The PBM will guarantee the network size standard specified above is achieved. A report indicating the count of active contracted network pharmacies will be produced on a monthly basis, and this report will be provided by the PBM to the VHA OCC no later than the 8th 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 PBM 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 PBM 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 PBM 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 PBM will employ physical security safeguards for IS (Information Security)/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 PBM will be compliant with the Business Associate Agreement (BAA) requirements (Attachment 6-Business Associate Agreement) (to be executed by the PBM and sent to VA COR within 7 days after the award of the contract) and HIPAA. An executed copy of the BAA document will be required on file post award. The PBM 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 PBM will provide and document the necessary and appropriate security training of all workforce members (e.g. employees, volunteers, trainees, PBMs and other persons who conduct and perform work for the PBM) 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 ASSURANCE: Contractor shall: Develop and maintain an effective quality control program in accordance with their approved Management Oversight Plan (MOP) to ensure services are performed in accordance with the SOW. Demonstrate a quality control program to ensure that Contractor support complies with VA requirements. Develop and implement procedures to identify, prevent, and ensure non-recurrence of defective services. The Contractor s Quality Control Program (QCP) is the means to assure that the work complies with the requirement of the contract. As a minimum, the Contractor shall develop Quality Control Procedures (QCP) that address the areas identified in the Quality Assurance Surveillance Plan (QASP). The Government shall: Evaluate the Contractor s performance under this contract in accordance with the QASP in a separate document. This plan is primarily focused on what the Government shall do to ensure that the Contractor has performed in accordance with the performance standards. The QASP what shall be monitored, how monitoring shall take place, who shall conduct the monitoring, and how monitoring efforts and results shall be documented. The Contractor shall take corrective action when deficiencies are identified and return any corrective/additional information to VA within 14 business days. 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 PBM will provide orientation and instructions to their employees regarding VA programs, benefits, claims, and customer service. The PBM, 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 PBM staff will complete the annual privacy and security training provided online by the VHA. Completion certificates shall be provided to the Contracting Officer Representative (COR) upon request. The PBM 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 PBM 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 PBM 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 PBM 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 Scope of Work and contract within 180 days after contract award. The PBM 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. The PBM 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 PBM 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 PBM in executing daily operations. Policy/Coverage File (for initial set-up) Eligibility File (daily) Reversal Response File (daily) Claim Payment/Advise File (daily) Primary Proprietary Status Report (daily) 11. CHANGES TO SOW: Any changes to this SOW shall be authorized and approved only through written correspondence from the CO. A copy of each change shall be kept in a project folder along with any other products of the project. Costs incurred by the Contractor, through the actions of parties other than the CO, shall be borne by the Contractor alone. 12. CONTRACT ADMINISTRATION: All inquiries and correspondence relative to the administration of the Contract shall be addressed to: COR: Melissa Friese Telephone Number: (303) 398-5587 E-mail:
[email protected] CO: Thomas Brick Telephone Number: (303) 273-6217 E-mail:
[email protected] CS: Joanna Hudson-Lundquist Telephone Number: (303) 273 6225 E-mail:
[email protected] CS: Janica Francis-Hunter, Contracting Specialist Phone: (303) 215 5246 Email:
[email protected] [End of Draft SOW] 5.0 Meetings and Discussions The Government representatives may or may not choose to meet with potential RFI service provider. Such meetings and discussions would only be intended to get further clarification of potential capability. 6.0 Summary This RFI is only intended for the Government to identify sources that can provide Pharmacy Benefit Manager services. The information provided in this RFI is subject to change and is not binding to the Government. The Government has not made a commitment to procure any of the RFI requirements discussed, and release of this RFI should not be construed as such a commitment or as authorization to incur cost for which reimbursement would be required or sought. All submissions shall become the property of the Government and will not be returned.