Florida Federal Dental Health Plans
Florida Federal Dental Health Plans document sample
Shared by: ogr17517
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.