DA10--Payment Integrity Validation and Oversight Tool (PIVOT) (VA-26-00015670) RFI 3

Questions & Answers / Clarifications

This document contains responses to questions submitted by vendors regarding the Payment Integrity Validation and Oversight Tool (PIVOT) RFI 3 (Solicitation Number: 36C10B26Q0121).

• PIVOT Tool Functionality: Clarifies that the PIVOT tool is intended for internal VA use to validate and oversee payment integrity, not for external vendor use.
• Data Sources: Confirms that the PIVOT tool will integrate with various VA data sources, including but not limited to, the Financial Management Business Intelligence System (FMBIS), Defense Health Agency (DHA) data, and other relevant systems.
• Reporting Requirements: Details that the PIVOT tool will generate reports on identified payment integrity issues, trends, and recommendations for corrective actions. Specific reporting formats and frequencies will be defined in the final PWS.
• Security Requirements: States that all data handled by the PIVOT tool must comply with VA data security and privacy regulations, including HIPAA. Access will be role-based and require appropriate clearances.
• Integration with Existing Systems: Confirms that the PIVOT tool is expected to integrate with existing VA IT infrastructure and systems, minimizing disruption and leveraging current capabilities.

This RFI response document provides clarification on the intended use, data integration, reporting, and security aspects of the PIVOT tool. Bidders should consider these clarifications when preparing any future proposals or responses related to this opportunity. No changes to the solicitation number or response date are indicated by this document.

Questions & Answers / Clarifications

This document contains responses to vendor questions regarding the Request for Information (RFI) for the Payment Integrity Validation and Oversight Tool (PIVOT) for the Department of Veterans Affairs (VA).

• Solution Scope: The VA expects vendors to demonstrate the ability to deliver the PIVOT solution as described in the PWS, not limited to home-based care. Solutions should address all aspects of the community care network.
• Submission Deadlines: Intent to Participate is due January 23, 2026, 12 PM ET. The full technical submission, including company information, ROM, technical functionality description (2 pages), RFI narrative (2 pages), and PowerPoint presentation, is due February 6, 2026, 12 PM ET. Deadlines are firm.
• Document Submission: The technical functionality description (2 pages), RFI narrative (2 pages), and PowerPoint presentation must be submitted as separate files.
• ROM Pricing: The Rough Order of Magnitude (ROM) should include pricing for the full period of performance, with a breakout of labor category hours by deliverable. It should encompass all requirements within the PWS, including SaaS subscription and implementation/professional services.
• MVP Requirements: The Minimum Viable Product (MVP) is expected to be a production-ready solution demonstrating scalability and reliability, not a proof of concept. It must include a fully operational rules engine and usable dashboards.
• FedRAMP Compliance: While FedRAMP High authorization is required, the VA may consider solutions hosted on FedRAMP High authorized infrastructure that commit to achieving FedRAMP authorization during the performance period.
• Data & Integration: The VA will provide a list of integrated systems, documented APIs, and technical specifications at the time of award, not during the RFI stage. Vendors should use synthetic/de-identified data and mock integration points for demonstrations and MVP development.

These clarifications provide critical details on submission requirements, technical scope, and development expectations, which bidders should consider when preparing their responses and demonstrations. Deadlines are firm and extensions will not be granted unless a modification is issued.

Request for Information (RFI)

This RFI is for planning and market research purposes for the Payment Integrity Validation and Oversight Tool (PIVOT) for the Department of Veterans Affairs (VA). The VA requires a Software as a Service (SaaS) solution to proactively detect and prevent improper VA Community Care healthcare claims payments, including fraud, waste, and abuse (FWA). The current manual, retrospective processes are inefficient, and PIVOT aims to modernize these capabilities using advanced analytics and automation.

• Solution Type: SaaS-based, supporting a minimum of 100 concurrent users.

• Integration: Must integrate with existing VA systems and identity/access management infrastructure (including PIV authentication).

• Data Ingestion: Process various claims formats (837P, 837I, 837D, NCPDP) and remittance advice (835), aggregate, normalize data, and maintain audit trails.

• Rules Engine: Execute VA and CMS compliance rules at scale, with configuration, testing, version control, and rollback capabilities.

• Pattern Recognition Engine: Utilize AI/ML to detect anomalies and suspicious billing behaviors, provide risk/confidence scoring, and support explainable AI.

• Workload Module: Centralized interface for VA staff to review flagged claims and manage dispositions.

• Dashboards & Reporting: Real-time dashboards, customizable reports, and export capabilities.

• Security & Compliance: FedRAMP High baseline, HIPAA, FISMA compliance, role-based access control, and audit logging.

• Virtual Technical Demonstration (VTD): Vendors will provide a live demonstration via Microsoft Teams (max 90 minutes). Demonstrations should showcase technical functionality, effectiveness, scalability, and security. No dataset will be provided by the VA; vendors should use representative data.

• Technical Functionality Description: Limited to two (2) pages.

• PowerPoint Presentation: No slide limitation.

• Vendor Intent to Participate: Due January 23, 2026, 12 PM.

• Technical Documents & Presentations Due: February 6, 2026, 12 PM.

• Questions Due: January 16, 2026, 12 PM.

• Submission Method: Email to Felica Griffin at Felica.Griffin@va.gov with "36C10B26Q0121" in the subject line.

• Set-aside decisions may be made based on RFI responses.

• This RFI is for planning and market research only; it is not an Invitation for Bid or a Request for Proposal.

• No costs incurred in responding will be reimbursed.

• All costs associated with the VTD are borne by the vendor.

• The Performance Work Statement (PWS) 3.0 contains major revisions indicated in red font.

Statement of Work (SOW) / Performance Work Statement (PWS)

The Department of Veterans Affairs (VA) requires a Payment Integrity Validation and Oversight Tool (PIVOT) to proactively detect and prevent improper VA Community Care healthcare claims and invoice payments. This tool aims to replace current manual, retrospective processes with advanced analytics and automation to identify issues like fraud, waste, and abuse (FWA), thereby reducing financial waste and improving operational efficiency.

The contractor will provide a scalable and efficient PIVOT solution as a Software as a Service (SaaS). Key functionalities include:

• Data Ingest and Management: Ingesting and normalizing diverse data sources (claims, invoices, provider files, etc.) from various VA and external systems.
• Rules Engine: Validating claims against VA and CMS reimbursement policies, including edits, pricing logic, and compliance frameworks.
• Pattern Recognition Engine: Utilizing AI/ML to detect improper payments, FWA, and utilization anomalies.
• Workload Module: Centralizing analyst workflows for post-payment review and investigation.
• Dashboards and Reporting: Providing user-friendly interfaces with customizable dashboards and automated reports.
• System Architecture and Integration: Ensuring seamless integration with existing VA systems via secure APIs, supporting real-time data exchange.
• Minimum Viable Product (MVP): Delivering a functional MVP within 120 days, covering professional, institutional, and dental claims.

Key performance metrics include data quality resolution rate (≥98%), system uptime (≥99.9%), AI/ML accuracy (≥95%), recoupment realization rate (≥85%), and security compliance.

• Period of Performance: 12 months from award, with four 12-month option periods (totaling up to 60 months).

• Place of Performance: Contractor facilities.

• Security: Compliance with FedRAMP High baseline, VA Handbook 6500, VA Handbook 6517, and VA Directive 6513. Support for PIV authentication and role-based access controls.

• Data Ownership: All data processed, stored, or generated belongs to the VA.

• Compliance: Adherence to numerous VA policies, federal laws, regulations, and industry standards (e.g., HIPAA, FISMA, NIST, FAR, OMB Memoranda).

• Accessibility: Compliance with Section 508 standards.

• Personnel: Contractor personnel must undergo background investigations and complete required VA training.

Request for Information (RFI)

This RFI is for planning and market research purposes by the Department of Veterans Affairs (VA), Office of Information & Technology (OIT), for a Payment Integrity Validation and Oversight Tool (PIVOT). The VA seeks a SaaS-based solution to proactively detect and prevent improper VA Community Care healthcare claims payments, which may result from inaccurate coding, billing, unauthorized services, or non-compliance with VA or CMS reimbursement policies, including fraud, waste, and abuse (FWA). The current manual, retrospective processes are inefficient, and PIVOT aims to modernize these capabilities through advanced analytics, automation, and integration with VA systems.

• Solution Type: SaaS-based, supporting a minimum of 100 concurrent users.

• Integration: Must integrate with existing VA systems and VA’s identity and access management infrastructure (PIV authentication, role-based access controls).

• Data Ingestion: Process various claims (837P, 837I, 837D), remittance advice (835), and other healthcare data. Aggregate, normalize, and maintain audit trails.

• Analytics: Leverage advanced analytics, AI/ML for anomaly detection, pattern recognition, and explainable AI outputs.

• Functionality: Includes a rules engine (VA/CMS compliance), pattern recognition engine, workload module for claim review, and real-time dashboards/reporting.

• Security & Compliance: FedRAMP High baseline, HIPAA, FISMA compliance, role-based access control, and audit logging.

• Deployment: Secure, scalable, and elastic deployment models; accessible via VA-approved remote access methods.

• Virtual Technical Demonstration (VTD): Vendors must provide a live demonstration via Microsoft Teams, showcasing technical functionality (max 2 pages description). No dataset will be provided by the VA; vendors should use representative data.

• Demonstration Focus: Data ingestion, rules engine, pattern recognition, real-time analytics, reporting, system performance, and role-based access controls.

• VTD Schedule: Vendor intent to participate due by January 23, 2026. VTDs will be scheduled thereafter.

• Technical Document Submission: 2-page technical functionality description and PowerPoint presentation due by February 6, 2026.

• Questions: Due by January 23, 2026.

• Submission Method: All submissions via email to Felica.Griffin@va.gov with "36C10B26Q0121" in the subject line.

• NAICS code for this requirement is DA10.

• Set-aside decisions may be made based on RFI responses.

• This RFI is for planning and market research only; it is not a solicitation.

• No obligation to acquire products/services described.

• All costs for VTD are borne by the vendor.

• Draft PWS is available; vendors should review it for full scope and requirements.

• No marketing materials or generic capability statements are allowed.

Solicitation / RFP / RFQ

This document is a Request for Information (RFI) 3, related to the Payment Integrity Validation and Oversight Tool (PIVOT) for the Department of Veterans Affairs. It references attached documents: "RFI 3 Cover- PIVOT Final" and "RFI PWS- PIVOT Final Draft."

Specific requirements and deliverables are detailed in the attached "RFI PWS- PIVOT Final Draft."

Not specified in this RFI document.

• Response Date/Time/Zone: 02-06-2026 12:00PM EASTERN TIME, NEW YORK, USA

Not specified in this RFI document.

• Solicitation Number: 36C10B26Q0121
• NAICS Code: 541519
• Product Service Code: DA10
• Contracting Office: Department of Veterans Affairs, Technology Acquisition Center, Eatontown, NJ 07724.
• Points of Contact: Felica Griffin (Contract Specialist), Kimberly Geran (Contracting Officer).
• The RFI will be archived 30 days after the response date.