R499--Veteran and Family Member Programs (VFMP) Claims Processing, Customer Service (CS) & Centralized Authorizations for Emergency Care (CAEC) Contract (VC3) Request for Information (RFI)

RFI 36C10G23Q0084 VC3 Requirement Veteran and Family Member Programs (VFMP) Claims Processing, Customer Service (CS) & Centralized Authorizations for Emergency Care (CAEC) Contract (VC3) Request for Information Department of Veterans Affairs Veterans Health Administration Integrated Veteran Care Date: April 25, 2023 Contents 1.0 INTRODUCTION 5 2.0 BACKGROUND 5 3.0 SUBMISSION INSTRUCTIONS 6 4.0 PURPOSE 6 5.0 INFORMATION SOUGHT 7 5.1 Vendor Information 7 5.2 Vendor Responses to Questions 8 6.0 LIST OF QUESTIONS 8 REQUEST FOR INFORMATION INTRODUCTION THIS IS NOT A SOLICITATION. The Department of Veterans Affairs (VA) Veterans Health Administration (VHA) is issuing this Sources Sought Notice / Request for Information (RFI) as Market Research used for the potential procurement of services for a vendor to provide solutions for the following: Veteran and Family Member Programs (VFMP) claims processing system; Tier 0 (defined as, customer service in the form of self service, auto-chat bot, FAQs) and Tier 1 (defined as, a general inquiry answered by a live agent that does not require any type of follow up activities) VFMP Customer Service (CS) capabilities; Customer service 24/7/365 contact center capabilities to support Centralized Authorized Emergency Care (CAEC) documentation, reporting, and provider and stakeholder inquiries associated with Veterans receiving emergency care treatment in the community. The VFMP claims processing, CS, and CAEC Contract (VC3) aims to increase timely and accurate claims processing, enhance the overall customer experience, and increase operational effectiveness using industry state of the art best practices. This RFI is issued solely for information and planning purposes. There is no obligation for the Government to acquire any products or services described in this RFI. In accordance with the Federal Acquisition Regulations (FAR) Subpart 15.201(e), responses to this notice are not offers and cannot be accepted by the Government to form a binding contract. No funds have been authorized, appropriated, or received for this effort. The information provided may be used by VA in developing its acquisition strategy and informing, refining, and finalizing a Performance Work Statement (PWS). Interested parties are responsible for adequately marking proprietary, confidential, restricted, or competition sensitive information contained in their response. Only electronic responses to this RFI will be accepted. The Government will not pay for any time expended or information submitted in response to this RFI. Eligibility in participating in a future acquisition does not depend upon a response to this RFI. 2.0 BACKGROUND A Veteran or service member s spouse or dependent child may qualify for certain community healthcare benefits included in the scope of this acquisition. These programs can include, but are not limited to: Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) CHAMPVA Beneficiary Pharmacy Retail Claims Spina Bifida (SB) Children and Women of Vietnam Veterans (CWVV) Camp Lejeune (CL) Foreign Medical Program (FMP) The Contractor shall provide a claims processing system and associated customer service in support of adjudicating claims for the programs listed above. Additionally, the contractor shall provide customer service and associated administrative support for the CAEC process. 3.0 SUBMISSION INSTRUCTIONS Points of Contact Contracting Officer: Terri Duenas, VA Office of Acquisitions and Logistics (OAL), Email: contact@example.gov Contract Specialist: Justin Sink, VA Office of Acquisitions and Logistics (OAL), Email: contact@example.gov Responses It is requested that comments and questions in response to the RFI be provided no later than May 09, 2023 by 3PM Eastern. Responses are to be emailed to contact@example.gov and contact@example.gov. All email correspondence for this project must reference the RFI Number, Project Title and Company Name in the subject line of the email as follows: RFI 36C10G23Q0084_VC3 _Company Name Respondents are responsible for marking responses as Proprietary Information if the information included is considered to be business sensitive and/or includes trade secrets. Interested vendors are directed to respond to this RFI with documents in PDF format. VA requests total page count (exclusive of the title/cover page, vendor information, and table of contents) not to exceed 20 pages. All documents are to measure 8.5 x 11-inches (charts may be landscaped but must be 8.5 x 11-inches) in Times New Roman, font size (12), with 1 margins. All pages of the response are to be appropriately numbered, and identified with the RFI number (i.e., 36C10G23Q0084). Any documents not in conformance with these requirements may not be reviewed. Disclaimer This notice is for the purpose of posting a Request for Information (RFI) and is issued for information and planning purposes only. This does not constitute a solicitation, nor does it bind the government to produce a solicitation or restrict as to the ultimate acquisition approach should a solicitation result from this RFI. In accordance with FAR 15.201(e), responses to this notice are not offers and cannot be accepted by the Government to form a binding contract. 4.0 PURPOSE VA is soliciting an RFI to understand industry s capabilities to support the scope of a new contract. VA seeks industry s input regarding potential paths forward and recommendations as to where VA should focus its efforts in developing a solicitation for proposals. The intent is to gain information from industry relative to North American Industry Classification Codes (NAICS) 524292, Third Party Administration of Insurance and Pension Funds, with the applicable small business size standard of $45.5M. The purpose of the information provided in response to this RFI is to: Communicate a vision of the scope of services that VHA would ideally like to implement; to convey context regarding VHA s needs. Review approaches that VA might pursue to accomplish its priorities. Collect information about market capabilities and state of the art practices. Understand how industry best practices and emerging trends can be applied to the needs of this RFI. VA s goal in this exercise is to gather input on how industry would address these challenges and opportunities. To that end, the more specific your answers are, the more useful your response will be to VA. 5.0 INFORMATION SOUGHT The VA is seeking the following information to be provided by the vendors when responding to the RFI: Vendor Information Vendor Responses to Questions 5.1 Vendor Information Vendors shall provide the following information: Vendor Name Vendor Address Vendor Website Vendor Point of Contact name, telephone number, and email address Unique Entity Identifier (EUID), number under which the vendor is registered in SAM.gov Vendor Socioeconomic Status; Business Size and Status [e.g., Large Business, Service-Disabled Veteran-Owned Small Business (SDVOSB), Veteran-Owned Small Business (VOSB), Small Business (SB), etc.] GSA or similar Governmentwide contract vehicle to include contract number, schedule, and SIN category(s), if applicable. The number of years in business operating under NAICS 524292, if applicable. 5.2 Vendor Responses to Questions The vendor shall provide answers to each question in the List of Questions in Paragraph 6.0 below of this RFI. The Vendor s response shall address the company s approach to satisfy the objectives, constraints, and requirements described in this notice and shall consider all additional information contained in this RFI. 6.0 LIST OF QUESTIONS When responding to the questions below, please provide examples from within the last five (5) years, if applicable. Claims Processing & Payment Describe your solution s scope, capability and your company experience supporting claims processing for federal healthcare and commercial healthcare programs to include development, implementation, and stabilization. Describe what innovative processes you have implemented to improve claims processing (time, quality, and cost) for your customers, and how you modernize, evaluate, and adjust processes over time based on industry trends. What are your mechanisms (processes and technology) to prevent, detect, and mitigate, fraud, waste, and abuse activities? Do you have the ability to manage multiple reimbursement methodologies in the same processing environment? Please explain your approach to the following capabilities: Ability to receive negotiated rates, Medicare rates, TRICARE rates, Medicaid rates, and local contracting rates from VA. Ability to interface with various payment hierarchies and business rules. Ability to mitigate any barriers or issues with leveraging different payment rules. Describe the capabilities and challenges of applying standard National Correct Coding Initiative (NCCI) Medically Unlikely Edits (MUEs) within a claims processing system. Do you have the ability to provide claims portal for provider review of reimbursement status? Please explain what functionalities the portal could support. Please explain your current Health Information Technology (HIT) standards (i.e., interoperability, content, data transfer). How would you develop, integrate, and synchronize with government systems to fulfill sharing of data such as mail, attachments, supporting documentations, pre-authorization determinations, eligibility and enrollment, customer service information (such as Interactive Voice Response (IVR) & Customer Relationship Manger (CRM)), rates and business rule updates? Please describe any problems you have encountered when implementing a claims processing system. What steps did you take to mitigate these challenges? What would you recommend as a timeline for implementation of a fully functioning claims processing system and why? Describe your quality assurance processes that you have implemented to ensure the quality, accuracy, consistency of claims processing and payments. How do you perform in regard to claims processing timeliness and accuracy? What is your mean and median claims processing time (from date claim received until processed to completion) for professional and hospital claims? Please provide accuracy metrics and results on metrics for professional and hospital claims. Customer Service How would your organization accommodate the development of industry best practices and state of the art technology associated with Tier 0 and Tier 1 Customer Service (including, but not limited to, calls, email, AI chat, AI interaction with customers on the front-end of initial communications, and web-based inquiries)? Describe your experience answering inquiries on claims, benefits, and eligibility from providers or beneficiaries. What is your mechanism for doing this? How would you coordinate with VA to fulfill the requirements? How would you measure timeliness and quality? Describe your approach to escalating Tier 0 and Tier 1 inquiries to VA for Tier 2 inquiry resolution (more detailed inquiries that require a VA employee respond, for example claim appeals). What is the best way for VA to have access to a tool to triage and document customer interactions? What type of information should be available to VA and how frequently should this data be available (e.g., live, daily, etc.)? Do you have the ability to create a self-service portal for VFMP beneficiaries and providers to submit claims, upload supporting documentation, and view and track status updates online? Do you have the ability to manage a 24/7 call line and supportive administrative functions associated with Veteran emergency care? Please describe your approach. Do you have call back capabilities from the contact center if wait time exceeds a standard time? Please describe your approach. Please describe your approach to tracking timeliness and accuracy for the 24/7 call center and the administrative tasks. Please describe your approach to adjusting staff allocations if necessary due to an unexpected outage or surge in volume. Describe your quality assurance capabilities for high-quality, accurate, and consistent information and staff performance for a customer service center. What would you recommend as a timeline for implementation of a fully functioning customer service contact center and why? Data Access, Integrity, and Reporting How would you provide VA with real time, read only, external access into your claims processing system so that VA can resolve customer service questions or issues that present? How would you provide VA access to the system to address claims related issues? How would access be granted and in what timeframe? What is your technical capability to provide customized summary reporting, including, but not limited to, timeliness, queues/stoppage, pre- and post-payment files, reject files, as well as detail level extracts to the VA? Describe ways that your organization manages data integrity and quality regarding data you administer. Include mitigation, incentives or solutions that may have been used to address pain points encountered in this area and any metrics used for monitoring. General As a Vendor, what questions would you have for VA to further define the capabilities needed to support this contract? What other questions would you suggest VA ask potential vendors in future RFIs?