Florida Federal Dental Health Plans

							                      STATEMENT OF WORK
                              FOR
FLORIDA ARMY NATIONAL GUARD (FLARNG) DENTAL TREATMENT SERVICES

1. Background. Members of the Florida Army National Guard (FLARNG) receive a
yearly dental examination to evaluate dental readiness in accordance with the
“Department of Defense Oral Health and Readiness Classification System”, (Appendix
B). It is the policy of the Army National Guard, in accordance with “Authorized Dental
Treatment”, Appendix E, to bring members from a Class 3 to a Class 2. Class 3
deficiencies have been annotated in each member’s file, and treatment plans have been
approved by the State Dental Officer in DENCLASS (available through the Army
Medical Operations Data System [MODS] at http://www.mods.army.mil/). This
Statement of Work provides health readiness support services to the Florida Army
National Guard, and provides for the necessary dental standards and requirements
essential in maintaining a deployable force. Required services include dental
treatments and records updating, including DENCLASS updating.

2. DESCRIPTION OF SERVICES. Non-personal Services. The contractor shall
provide, in a mobile setting, all management, labor, material, equipment, certifications
and supplies necessary to provide dental treatment and dental record updating at
designated locations throughout the State of Florida, for the Florida Army National
Guard. These services will provide approved dental treatments necessary to meet
Department of the Army standards to meet medical readiness and deployability
standards to ensure mission capability of the Florida Army National Guard. Dental
health is vital for force health protection and failure to achieve a standard of level or oral
health could preclude a soldier from deploying. The results of treatments shall be
annotated in the member’s dental file and updated in DENCLASS.

2.1. BASIC SERVICES. In accordance with “Estimated Workload Data” (Appendix A),
the contractor shall provide Class 3 dental treatment for alerted Soldiers. Dental
treatment authorized is outlined in Appendix E. These services will be completed by
using contractor provided mobile dental equipment. The contractor shall update records
in DENCLASS within five (5) days following the event. No facilities will be provided by
the FLARNG. Upon completion of services, medical information will be documented in
accordance with Department of the Army Policy. The contractor shall also ensure the
requirements of Occupational Safety and Health Administration (OSHA) and applicable
Federal regulations are met. The contractor shall maintain record files within the State
Medical Command that documents services performed, and names of soldiers referred
to dental specialists.

2.2. EXAMS AND TREATMENT PLANS. Exams have been previously accomplished
and the results posted to each member’s Military Dental Record, and entered into
DENCLASS. It is preferred the contractor has “live” access to DENCLASS prior to, and
at the event in order to retrieve the treatment plans of the soldiers. However, if
requested by the contractor, the Florida National Guard will provide a representative
that will access DENCLASS in order to retrieve treatment plans to be executed by the
contractor.

2.3. DOCUMENTATION. All members must have a complete military dental record. No
dental record is considered complete unless the documentation is complete and in the
proper order as outlined in TB MED 250. The contractor shall provide electronic
documentation in the ARNG approved system, and a paper copy as outlined below. A
complete record includes the following:

  a. Military dental record jacket, DA Form 8005 through 8005-9

  b. The automated Health History Form or DA Form 5570 (signed), Health
Questionnaire envelope

  c. DD Form 2005 (signed), Privacy Act Statement

  d. SF 603/603A, Record of Dental Exam

  e. Supporting radiographs (panograph and four bitewings reflecting existing)

      (1) All radiographs will be uploaded into the ARNG automated system.

      (2) A diagnostic quality copy of all radiographs must be placed in the Dental
Record.

    f. The entries on the SF 603/603A should include the following: date, location,
“periodic oral examination”, indication/date of x-rays taken, indication/date of x-rays
consulted, oral cancer screening, caries risk assessment (based upon caries incidence),
Periodontal Screening and Reporting (PSR), charting of current oral condition class 2
issues identified and a listing of class 3 treatment needs, printed name of examining
dental officer and dental officer’s signature/initials. These required dental
documentation elements will be made in the approved ARNG automated system and
printed and placed into the dental record.

3. GENERAL INFORMATION.

3.1. QUALITY CONTROL. The contractor shall adopt a quality assurance program that
monitors all service activities and ensures the highest quality customizable dental
services available. It is the responsibility of the State Dental Officer to review and
approve dental treatment plans before treatment is performed based on the guidelines
provided by NGB.

3.2. QUALITY ASSURANCE. The government will evaluate the contractor’s
performance.
3.3. GOVERNMENT REMEDIES. The contracting officer shall follow the requirements
of FAR 52.212-4, Contract Terms and Conditions for Commercial Items (May 1997), for
contractor’s failure to correct nonconforming services.

3.4. HOURS OF OPERATION. The contractor shall have the capability of providing
dental services seven days a week. Also be able to work after normal working hours in
order to accomplish the mission.

3.5. SECURITY REQUIREMENTS. Security will be in accordance with DD Form 254
(Department of Defense Contract Security Classification Specification) if provided.

3.6. GENERAL INSURANCE, LICENSURE AND CERTIFICATIONS. The Contractor
shall ensure all providers maintain at least minimum amounts of malpractice/liability
insurance as required by state licensing requirements. The contractor is required to
ensure that its subcontracts for provisions of health care services, contain the
requirements of the clause at 52.237-7, including the maintenance of medical liability
insurance. The Contractor shall ensure that all providers, technicians and other HCPs
performing services under this agreement have current licenses, registrations, and/or
certifications according to industry standard and as required for the specific state,
commonwealth, district or territory in which they are providing contract services. The
Contractor shall ensure that all HCPs have a current certification in basic life support.

3.7. NON-PERSONAL SERVICES. This Statement of Work identifies services that are
strictly non-personal in nature as defined by FAR Section 37.101 “Definitions” and
described at FAR Subpart 37.4 “Non-personal Health Care Services.”

3.8. INHERENTLY GOVERNMENTAL FUNCTIONS. This requirement has been
reviewed and contains no services that are inherently governmental functions, as
defined in FAR Section 2.101“Definitions” and FAR Subpart 7.5 “Inherently
Governmental Functions.”

3.9. PRIVACY AND SECURITY. The Contractor shall ensure that all findings are
clearly recorded on Government or other approved forms, and are protected by Privacy
Act of 1974 and Health Insurance Portability and Accountability Act of 1996 (HIPAA)
mandated safeguards to ensure confidentiality of health information.

3.10. CONTRACTOR EVALUATION. The Government will evaluate the contractor’s
performance using the “Contractor Performance Assessment Reporting System
(CPARS)” (http://www.cpars.csd.disa.mil/). The Government may evaluate the quality
of professional and administrative services provided, but retains no control over the
medical, professional aspects of services rendered (e.g., professional judgments,
diagnosis for specific medical treatment).

3.11 INDEMNIFICATION. The contractor indemnifies the Government for any liability
producing act or omission by the contractor, its employees and agents occurring during
contract performance.
4.0 ARMY CONTRACTOR MANPOWER REPORTING REQUIREMENT

                  The Office of the Assistant Secretary of the Army (Manpower & Reserve
Affairs) operates and maintains a secure Army data collection site where the contractor
will report ALL contractor manpower (including subcontractor manpower) required for
performance of this contract. The contractor is required to completely fill in all the
information in the format using the following web address: https://cmra.army.mil/. The
required information includes: (1) Contracting Office, Contracting Officer, Contracting
Officer’s Technical Representative; (2) Contract number, including task and delivery
order number; (3) Beginning and ending dates covered by reporting period; (4)
contractor name, address, phone number, e-mail address, identity of contractor
employee entering data; (5) Estimated direct labor hours (including sub-contractors); (6)
Estimated direct labor dollars paid this reporting period (including sub -contractors); (7)
total payments (including sub-contractors); (8) Predominant Federal Service Code
(FSC) reflecting services provided by contractor (and separate predominant FSC for
each Sub-contractor if different); (9) Estimated data collection cost; (10) Organizational
title associated with the Unit Identification Code (UIC) for the Army Requiring Activity
(the Army Requiring Activity is responsible for providing the contractor with its UIC for
the purposes of reporting this information); (11) Locations where contractor and sub-
contractors perform the work (specified by zip code in the Untied States and nearest
city, country, when in an overseas location, using standardized nomenclature provided
on website); (12) Presence of deployment or contingency contract language; and (13)
Number of contractor and sub-contractor employees deployed in theater this reporting
period (by country). As part of its submission, the contractor will also provide the
estimated total cost (if any) incurred to comply with this reporting requirement.
Reporting period will be the period of performance not to exceed 12 months ending
September 30 of each government fiscal year and must be reported by 31 Oct of each
calendar year. Contractors may use a direct XML data transfer to the database server
or fill in the fields on the website. The XML direct transfer is a format for transferring files
from a contractor’s systems to the secure web site without the need for separate data
entries for each required data element at the web site. The specific formats for the XML
direct transfer may be downloaded from the web.

Contracting Office: W911YN-USPFO for Florida
Contracting Officer: Brian Williams
Contracting Officer’s Technical Representative: TBD
Requiring Activity Unit Identification Code (UIC): TBD each event

5.0. Contractors will ensure compliance with the following requirements prior to
utilizing any x-ray producing device on Soldiers;

  a. Have established written policies and procedures to assure compliance with
applicable Federal, State, DOD, and Army radiation safety regulations and directives.
These documents include staff emergency reaction plans, as necessary, and
procedures for investigating and reporting radiation accidents or
incidents, possible radiation overexposures to Soldier patients or contractor staff, and
provisions to ensure the safe use of x-ray producing devices on humans.

   b. Upon request by the NGB Contracting Officer's Representative (COR), provide
documentation regarding the Contractor's employee radiation safety training
commensurate with potential radiation hazards with the x-ray producing devices
they are using.

   c. Upon request by the NGB Contracting Officer's Representative
(COR), provide copies of a Qualified Health Physics Expert's acceptance test and most
recent health physics survey of each diagnostic x-ray machine. The acceptance test
and the most recent survey include tests of electrical, mechanical, image quality and
radiation (output) dose tests or measurements. This also includes verification of the
adequacy of radiation protection shielding in and around the
x-ray machine and x-ray facility (e.g., mobile van).


Certain radiation emitting products require the submission of product reports to FDA
and the retention of records as included in 21 CFR Part 1002
All manufacturers of electronic products are subject to the reporting of accidental
radiation occurrences, as required by 21 CFR 1002.20.
http://www.fda.gov/cdrh/radhlth/xraystandard.html

Army
AR 11-9, The Army Radiation Safety Program, 28 May 1999.
http://www.army.mil/usapa/epubs/pdf/r11_9.pdf
AR 40-5, Preventive Medicine, 22 July 2005.
http://www.army.mil/usapa/epubs/pdf/r40_5.pdf
TB MED 52, Occupational and Environmental Health, Management and Control of
Diagnostic, Therapeutic, and Medical Research X-Ray Systems and Facilities, 26
February 2002.
http://www.army.mil/usapa/med/DR_pubs/dr_a/pdf/tbmed521.pdf

6. APPENDICES.

A. Estimated Workload Data

B. Dental Classification

C. SF 603A and DA Form 5570 (Dental Classification Module Version)

D. Government Furnished Property/Services/Equipment

E. Authorized Dental Treatment
                                  APPENDIX A

                         ESTIMATED WORKLOAD DATA

Date: 18-19 April 2009

Location:
Armed Forces Reserve Center
2801 Grand Avenue
Pinellas Park, FL 33782

Total Number of patients scheduled:
Pinellas Park (unit BSTB)—133 Class 3 (Est. 118 Class 3A, 15 Class 3B)

Location:
HHC 1/124 IN
700 NW 28th ST
Miami, FL 33127

Total Number of patients scheduled:
Miami (unit 1/124)—77 Class 3 (Est. 63 Class 3a, 15 Class 3B)

Date: 24-25 April 2009

Location:
Armed Forces Reserve Center
2801 Grand Avenue
Pinellas Park, FL 33782

Total Number of patients scheduled:
Pinellas Park (unit BSB)—244 Class 3 (Est. 226 Class 3A, 18 Class 3B)



The following data elements will be reported at the end of an event:

Date
Location
List of contract employees (providers, dental technicians and administrative staff)
Total number of patients scheduled
Total number of patients treated
Total number of Soldiers by dental classification: 1, 2, 3
A by name listing of all Soldiers treated and the dental classification of the
Soldier after treatment
A by name listing of all Soldiers requiring additional treatment
                                   APPENDIX B

                           Department of Defense
              Oral Health and Readiness Classification System


The oral health status of uniformed personnel shall be classified as fo llows:

   a. Class 1 (Oral Health): Patients with a current dental examination, who do
not require dental treatment or reevaluation. Class 1 patients are worldwide
deployable.

   b. Class 2: Patients with a current dental examination, which require non-
urgent dental treatment or reevaluation for oral conditions, which are unlikely to
result in dental emergencies within 12 months. Class 2 patients are worldwide
deployable. Patients in dental class 2 may exhibit the following:

       (1) Treatment or follow-up indicated for dental caries or minor defective
restorations that can be maintained by the patient.

       (2) Interim restorations or prosthesis that can be maintained for a 12
month period. This includes teeth that have been restored with permanent
restorative materials for which protective cuspal coverage is indicated.

       (3) Edentulous areas requiring prostheses but not on an immediate basis.

       (4) Periodotium that:

              (a) requires oral prophylaxis

              (b) requires maintenance therapy

             (c) requires treatment for slight to moderate periodontitis and stable
cases of more advanced periodontitis

        (5) Unerupted partially erupted or malposed teeth that are without
historical, clinical or radiographic signs or symptoms of pathosis, but which are
recommended for prophylactic removal.

       (6) Active orthodontic treatment. The provider should consider placing
the patient in passive appliances for deployment up to six months. For longer
periods of deployment, the provider should consider removing active appliances
and placing the patient in passive retention.
       (7) Temporomandibular disorder patients in remission. The provider
anticipates the patient can perform duties while deployed without ongoing care
and any medications or appliances required for maintenance will not interfere
with duties.

   c. Class 3: Patients who require urgent or emergent dental treatment. Class
3 patients normally are not considered to be worldwide deployable.

       (1) Treatment or follow-up indicated for dental caries, symptomatic tooth
fracture or defective restorations that cannot be maintained by the patient.

      (2) Interim restorations or prostheses that cannot be maintained for a 12
month period.

       (3) Patients requiring treatment for the following periodontal conditions
that may result in dental emergencies within the next 12 months.

              (a) Edentulous areas or teeth requiring immediate prosthodontic
treatment for adequate mastication or communication or acceptable esthetics.

               (b) Active progressive moderate or advanced periodontitis.

               (c) Periodontontal abscess

               (d) Progressive mucogingival condition

               (e) Periodontal manifestations of systemic disease or hormonal
disturbances

               (f) Heavy subgingival calculus

       (4) Edentulous areas or teeth requiring immediate prosthodontic treatment
for adequate mastication or communication or acceptable esthetics.

       (5) Unerupted, partially erupted or malposed teeth with historical, clinical
or radiographic signs or symptoms of pathosis that are recommended for
removal.

       (6) Chronic oral infections or other pathologic lesions including:

               (a) Pulpal, periapical or resorptive pathology requiring treatment.

               (b) Lesions requiring biopsy or awaiting biopsy report.
       (7) Emergency situations requiring therapy to relieve pain, trea t trauma,
treat acute oral infections or provide timely follow-up care (e.g., drain or suture
removal0 until resolved.

      (8) Acute Temporomandibular disorders requiring active treatment that
may interfere with duties.

   d. Class 4. Patients who require periodic dental examinations or patients with
unknown dental classifications. Class 4 patients normally are not considered to
be worldwide deployable.
APPENDIX C
                                 APPENDIX D

     GOVERNMENT FURNISHED PROPERTY/SERVICES/EQUIPMENT

1. General. The Government will provide the following resources:

2. Facilities, Supplies, and Services. The Government shall provide an area to
park mobile dental practice.

3. Information. The Government will provide the following information:

    a. Names and i nformation on members requiring treatment necessary to
retrieve treatment plans from DENCLASS.

   b. State Dental Officer (SDO) or representative to answer questions
concerning treatments and retrieve dental treatment plans from DENCLASS.

4. The FLARNG will provide initial familiarization/orientation. Standard
Operational Procedures will be available to the contractor at the place of
performance.
                                 APPENDIX E

                    AUTHORIZED DENTAL TREATMENT

1. The following dental procedures are authorized:

(a) Diagnostic Services which are funded through NG6H 2065 Medical
Readiness Funding:

D0120-Periodic Oral Evaluation
D0150-Comprehensive Oral Evaluation
D0330-Panoramic Film
D0272-Bitewings-Two Films
D0274-Bitewings-Four Films
D0220/D0230- Periapical (limited)

(b) Restorative Services which are funded through the VFRE 2020 Dental
Treatment Funding (provided only to soldiers alerted to an OCONUS Mission):

D2140-Amalgam-One Surface
D2150-Amalgam-Two Surfaces
D2160-Amalgam-Three Surfaces
D2161-Amalgam-Four or More Surfaces
D2330-Composite-One Surface
D2331-Composite-Two Surfaces
D2332-Composite-Three Surfaces

Posterior composites will be authorized only when a posterior composite is
necessary to provide a quality restoration and no other alternative is
available.

D2335-Composite-Four or More Surfaces
D2391-Composite-One Surface
D2392-Composite-Two Surfaces
D2393-Composite-Three Surfaces
D2394-Composite-Four or More Surfaces
D2799-Provisional Crown
D2931-Prefabricated Stainless Steel Crown
D2950-Core Buildup, including any pins
D2954-Prefabricated Post and Core

(c) Endodontic Services which are funded through the VFRE 2020 Dental
Treatment Funding (provided only to Soldiers alerted to an OCONUS Mission):

D3310-Anterior Root Canal Therapy
D3320-Bicuspid Root Canal Therapy
D3330-Molar Root Canal Therapy
D3346-Anterior Root Canal Retreatment
D3347-Bicuspid Root Canal Retreatment
D3348-Molar Root Canal Retreatment

(d) Periodontal Services which are funded through the VFRE 2020 Dental
Treatment Funding (provided only to Soldiers alerted to an OCONUS Mission):

D4355-Full Mouth Debridement
D4342-Periodontal Scaling and Root Planing, 1 to 3 teeth per quadrant

Periodontal scaling and root planing is authorized only when a periodontal
abscess is present)

(e) Prosthodontic Services which are funded through the VFRE 2020 Dental
Treatment Funding (provided only to Soldiers alerted to an OCONUS Mission):

D5110-Complete Denture-Maxillary
D5120-Complete Denture-Mandibular
D5211-Maxillary Partial Denture-Resin Base
D5212-Mandibular Partial Denture-Resin Base

(f) Oral Surgery Services which are funded through the VFRE 2020 Dental
Treatment Funding (provided only to Soldiers alerted to an OCONUS Mission):

D7140-Extraction, Erupted Tooth or Exposed Root
D7210-Surgical Removal of Erupted Tooth
D7220-Romoval of Impacted Tooth, Soft Tissue
D7230-Removal of Impacted Tooth, Partial Bony
D7240-Removal of Impacted Tooth, Completely Bony

(g) Orthodontic Services which are funded through the VFRE 2020 Dental
Treatment Funding (provided only to Soldiers alerted to an OCONUS Mission):

       D8680-Orthodontic Retention

 2. The following dental procedures are not authorized:

Bridges and/or implants
Removal of Asymptomatic third molars
Routine Prophylaxes (cleanings)
Restorations for aesthetics only
Restorations for small (non-class 3) caries
Extensive Root plane/scaling
Osseous Surgery
Other diagnostic services
The above listings are guides to assist the State Dental Officer or his/her
designee in determining treatment to be authorized. The treatment
provided by the ARNG is to get the Soldier from a dental class 3 to a dental
class 2 only. Comprehensive Treatment (to dental class I) is not
authorized.

3. If a Soldier needs all of his/her remaining teeth in an arch extracted and a
denture placed, the Soldier will not be available for deployment for at least 6
months and shall be disqualified from immediate deployment. However, if the
Soldier is otherwise deployable (passes all medical, personnel and training
requirements) and, after extraction and placement of prosthesis, would be
deployable, the dental treatment could be provided and the Soldier could be
considered as a replacement at a later date.

4. If a Soldier will have a number of teeth extracted to the extent mastication
and speech are adversely affected, then an acrylic removable partial denture will
be authorized if there is sufficient time for healing and construction of the partial
denture prior to departure to Mobilization Station.

 5. Soldiers requiring extensive periodontal treatment will be disqualified from
deployment and educated on the TRICARE Dental Program. If he/she obtains
the required therapy (from his/her private dental provider) and reaches a
maintenance level, then he/she would become deployable.

 6. The State Dental Officer (or designated representative) will review any dental
treatment plan for dental care which exceeds $800 to insure that the above
clinical guidelines are met. Exceptions can be made, but they must be
coordinated with the State Surgeon.