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FedBizOpps Sources Sought Notice * * * * * * * CLASSIFICATION CODE SUBJECT CONTRACTING OFFICE'S ZIP-CODE SOLICITATION NUMBER RESPONSE DATE (MM-DD-YYYY) ARCHIVE DAYS AFTER THE RESPONSE DATE RECOVERY AC... FedBizOpps Sources Sought Notice * * * * * * * CLASSIFICATION CODE SUBJECT CONTRACTING OFFICE'S ZIP-CODE SOLICITATION NUMBER RESPONSE DATE (MM-DD-YYYY) ARCHIVE DAYS AFTER THE RESPONSE DATE RECOVERY ACT FUNDS SET-ASIDE NAICS CODE CONTRACTING OFFICE ADDRESS POINT OF CONTACT (POC Information Automatically Filled from User Profile Unless Entered) DESCRIPTION See Attachment AGENCY'S URL URL DESCRIPTION AGENCY CONTACT'S EMAIL ADDRESS EMAIL DESCRIPTION ADDRESS POSTAL CODE COUNTRY ADDITIONAL INFORMATION GENERAL INFORMATION PLACE OF PERFORMANCE * = Required Field 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 (Nov 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 50 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 50 percent of the cost of manufacturing the supplies, not including the cost of materials. (3) General construction. The concern will perform at least 15 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 25 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 dete...