VHA RFI: Community Care Network Integrated Veteran Care Utilization Management

Notice ID:  36C10G24Q0131

VA is researching utilization management (UM) (e.g., Prospective, Concurrent and Retrospective) and other medical management activities to support Veterans receiving care in the community.

In all models VA is exploring, there are specific VA requirements including, but not limited to: VA providing the parameters for the medical policies applied to UM, VA providing the authorization for care, and VA determining the medical necessity for any care requested. These and other VA functions cannot be delegated to non-VA entities. Given these parameters, VA is interested in receiving industry feedback on the use of UM with the Community Care Network contracts.

VA is seeking feedback on the following:

• Contracting approach (e.g., embedded in the CCN Next Gen solicitation or a standalone solicitation)
• Integrating UM people, process, tools/technology with the CCN referral management and claims payment processes Interoperability of UM tools/data/technology with VA and any other third-party administrator (e.g., inclusion of VA UM guidelines,
• Clinical Determinations Indications,
• shared decision-making, claims processing traceability)
• Bi-directional communication during the referral lifecycle and UM determination process (e.g., additional service requests from community providers, right of first refusal for care at VA, medical documentation, publishing necessary guidelines for community providers, etc.)
• What is your ability and experience in applying pre-defined UM business rules and policies to your UM ecosystem?

Please provide additional feedback on the following:

• Have you adopted Utilization Review Accreditation Commission (URAC) or National Committee for Quality Assurance (NCQA) UM standards?
• How well have you worked with other organizations to ensure a seamless patient and provider experience during the UM process and meeting Utilization Review (UR) timeliness metrics?
• What is your experience / capability to configure your UM platforms to support a tailored model for both inpatient and outpatient encounters?
• Are these applications/platforms web-based or cloud-based/FedRAMP certified?
• Are these applications/platforms able to leverage EDI transactions?
• What information, tools, resources, or support are most needed to address barriers and challenges to UM, Utilization Reviews and UM determinations between multiple parties?
• To ensure VA is delivering quality and cost-effective care, what other managed care strategies would your organization recommend VA consider implementing?
• What current UM tools or dashboards are considered industry standard in the provider networks you coordinate with? Can UM determinations be communicated/displayed to VA providers while the Veteran is seeking care in the community? …

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