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

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.