Attachments_J21-J23c.pdf

Guaranty Agreement DCMA Form 1620 04-04 Page 1 of 2

GUARANTY AGREEMENT FOR CORPORATE GUARANTOR

(Applicable to One or More Government Contracts)

The undersigned (Insert Guarantor’s Name)

(Insert Guarantor's Address) for itself, its successors and assigns, hereinafter referred to as the Guarantor, requests the United States of America (Department of Defense) hereinafter called the Government, to award contract or contracts to a corporation (Insert Contractor's Name) organized under the laws of the State of having its principal place of business at (Street Address) in the City of in the State of , herein after called the Contractor. The undersigned Guarantor agrees to guarantee absolutely to the Government the full, complete and faithful performance of the Contractor of any and all contracts, hereinafter referred to as such contract, according to the terms and conditions thereof and at the time and in the manner provided therein.

In consideration of the award of any and all contracts to the Contractor, the undersigned Guarantor agrees as follows:

1. Guaranty. The Guarantor absolutely guarantees the full, complete and faithful performance by the Contractor of such contract, as such contract may be from time to time amended as authorized by its terms, according to the terms and conditions of such contract as so amended, and at the time and in the manner provided therein. The Guarantor agrees to provide the Contractor all necessary and required resources including financing, which are necessary to assure the full, complete and satisfactory performance of such contract.

2. Extension of Time of Performance. Any extension of the time of performance of such contract as so amended shall not release the undersigned Guarantor from liability hereon.

3. Assignment. This instrument shall bind the undersigned Guarantor, its successors and assigns. If any person, firm, corporation or entity other than the Contractor becomes obligated to perform the contract or any part thereof, whether by operation of law or otherwise, any and all rights of the Government against the Guarantor shall remain in full force.

4. Default. In the event of termination for default under the terms of such contract, or in the event of failure, insolvency, default, bankruptcy, arrangement, appointment of receiver of the Contractor or other liquidation of the Contractor, the Guaranty herein shall become absolute.

5. Waiver of Notice. The Guarantor waives notice of default on the part of the Contractor and agrees that its Guaranty shall become absolute without necessity for the giving of such notice.

6. Continuation of Guaranty. The Guaranty herein shall continue until full, complete and faithful performance of such contract as it may be from time to time amended as authorized by its terms.

7. Default Liability. In addition to all other guarantees contained in this Agreement, in the event that the Government terminates such contract for default and awards the uncompleted portion of such contract to another source at a fair and reasonable price, the Guarantor shall be liable for any excess costs incurred by the Government as a result of such reprocurement and for the repayment of any unrecouped payments (e.g., partial payments, Progress Payments, or Advance Payments) paid to the Contractor by the Government. In addition, the Guarantor shall be liable for all costs end expenses paid or incurred by the Government in enforcing this Guaranty. The Contracting Officer representing the Government in connection with such contract shall determine the total costs and expenses, if any, incurred by the Government.

8. Enforcement. This Guaranty Agreement shall inure to the benefit of and may be enforced by the Government.

9. Construction. Nothing in this Guaranty Agreement shall be construed to obligate the Government to award a contract to the Contractor.

Guaranty Agreement DCMA Form 1620 04-04 Page 2 of 2

10. Coverage, Termination, Waiver, and Expiration.

a. Except as otherwise provided herein, this Guaranty Agreement refers to and shall be effective with respect to any and all contracts for supplies or services entered into, on or after the date of this Agreement between the Government and the Contractor. Unless otherwise indicated by the context the singular of the word "contract" as used in this Agreement shall mean the plural term "contracts" whenever this Agreement shall become effective with respect to more than one contract between the Government and the Contractor. For the purpose of any additional procurement of supplies or services called for by any agreement supplemental to a contract between the Government and the Contractor, the term "contract" shall refer to such supplemental agreement.

Additionally, this Agreement will include the contracts already in existence between the Contractor and the Government before the Agreement date, as specified here:

b. The Guaranty Agreement is a continuing guaranty and shall remain in full force and effect until the later of (1) the performance in full of the guaranteed obligations, or under the guaranteed contracts. (2) the termination of all continuing obligations and commitments of the Contractor under the guaranteed contracts. In the case of termination of the continuing commitments of the Contractor on any guaranteed contract, the termination notices must be given in writing citing the affected contracts.

c. When the Government Contracting Officer determines that it is in the best interest of the Government to do so, the Contracting Officer may, by written notice addressed to the Guarantor at the Guarantor’s address shown herein, waive the effect of this Agreement with respect to any specifically identified individual contract between the Government and the Contractor entered into after the date of such written notice. A separate written notice shall be given with respect to each contract that the Contracting Officer determines shall not be subject to the effect of this Agreement.

d. In the event that all of the contracts covered by this Guaranty Agreement have been satisfactorily completed by the Contractor including all continuing commitment of the Contractor under the contracts, the Guarantor may request the cognizant Government Contracting Officer for this Guaranty Agreement to issue a written notice which states that this Guaranty Agreement is considered to have expired.

Executed the day of year of .

(Guarantor)

By (Title)

(Business Address)

Witness

Witness

I, , certify that I am the duly elected Secretary of the Corporation named as Guarantor herein; that who signed this

Agreement on behalf of the Guarantor, was then of said Corporation, that said Agreement was duly signed for and in behalf of said Corporation by authority of its governing body, and is within the scope of its corporate powers.

Corporate Seal:

(Secretary)

Receipt of a copy of the above Guaranty Agreement is acknowledged.

THE UNITED STATES OF AMERICA

By

(Contracting Officer) (Contracting Officer Address)

TRICARE Dental Readiness and Wellness

(TDRAW)

Quality Assurance Surveillance Plan (QASP)

October 30, 2017

Quality Assurance Surveillance Plan (QASP)

TRICARE Dental Readiness and Wellness (TDRAW) contract

1 Vision

To ensure the timely delivery of quality dental care services to eligible TRICARE beneficiaries in the most cost-effective way for the Government.

2 Mission The Department of Defense (DoD) through the Defense health Agency (DHA) has a mission to offer dental care services to eligible TRICARE beneficiaries. In order to fulfill DHAs mission, the contractor shall provide comprehensive dental care services worldwide to eligible TRICARE beneficiaries under the TDRAW contract.

3 Purpose This Quality Assurance Surveillance Plan (QASP) is a Government-developed document used to determine if the contractor's performance meets the performance standards contained in the contract. The QASP establishes procedures on how this assessment/inspection process will be conducted. It provides the detailed process for a continuous oversight process:

• What will be monitored

• How monitoring will take place

• Who will conduct the monitoring

• How monitoring efforts and results will be documented

The contractor is responsible for implementing and delivering performance that meets contract standards using its Quality Control Plan. The QASP provides the structure for the Government's surveillance of the contractor's performance to assure that it meets contract standards. It is the Government's responsibility to be objective, fair and consistent in evaluating contractor performance.

The QASP is not part of the contract nor is it intended to duplicate the contractor's quality control plan. This QASP is a living document. Flexibility in the QASP is required to allow for an increase or decrease in the level of surveillance necessary based on contractor performance.

The Government may provide a copy of the QASP to the contractor to facilitate open communication. In addition, the QASP should recognize that unforeseen or uncontrollable circumstances might occur that are outside the control of the contractor.

Bottom line, the QASP should ensure early identification and resolution of performance issues to minimize impact on mission performance.

4 Authority Authority for issuance of this QASP is provided under Part 46 of the Federal Acquisition Regulation, Inspection of Services clauses, which provide for inspection, acceptance and documentation of the service called for in the contract or order. This acceptance is to be executed by the contracting officer or a duly authorized representative.

5 Roles and Responsibilities The following personnel shall oversee and coordinate surveillance activities.

5.1 Program / Project Manager

The PM provides primary program oversight, nominates the COR, ensures the COR is trained before performing any COR duties and supports the COR's performance assessment activities. While the PM may serve as a direct conduit to provide Government guidance and feedback to the contractor on technical matters, they are not empowered to make any contractual commitments or any contract changes on the Government's behalf.

Assigned PM: COL Jim Honey Organization or Agency: Defense Health Agency Telephone: (703) 681-8862 Email: james.r.honey2.mil@mail.mil

5.2 Contracting Office (CO)

The CO shall ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and shall safeguard the interests of the United States in the contractual relationship. The CO shall also ensure that the contractor receives impartial, fair, and equitable treatment under this contract.

Determine and document the final assessment of the contractor's performance in the Government’s past performance tracking system.

Assigned CO: Ms. Margaret A. Zancanella Organization or Agency: Defense Health Agency Telephone: (303) 676-3451 Email: margaret.a.zancanella.civ@mail.mil

5.3 Contracting Officer's Representative (COR)

The COR is responsible for providing continuous technical oversight of the contractor's performance. The COR uses the QASP to conduct the oversight and surveillance processes.

COR: Gene Mays Telephone: (303)-676-3528 Email: gene.c.mays.civ@mail.mil

5.4 Contractor Representatives

The following employees of the contractor serve as the contractor's Program Manager and Task Manager for this contract. (Complete this section after the contract award)

Program Manager – Title:

Telephone:

Email:

Task Manager - Title:

Telephone:

Email:

6 Performance Requirements and Method of Surveillance The methods of evaluating contractor compliance may vary depending on the tasks specified by the contract. The COR is responsible for selection of the method(s) to be used and the specific detailing of the method(s). In determining the evaluation method, the COR should consider what the contract specifically calls for, how performance can be observed, and if the method of surveillance is adequate to assure the required level of performance has been achieved. In making this determination, the COR will also consider the contractor’s Quality Control Plan.

6.1 Contract Surveillance

This section describes the available methods to be used in verifying the contractor’s compliance with the contract requirements. Periodic (scheduled or non-scheduled) performance assessments will be accomplished utilizing a combination of assessment methods and metrics as identified in Appendix 1 that contains performance objectives, performance indicators, and frequencies and monitoring methods extracted from sections of the contract. Listed below are some methods to be used:

• Contractor Self Reporting. The Government will use the contractor’s reports as part of its surveillance process for monitoring the performance of the contract requirements. The Government has specified the content, format and/or frequency of reports to be generated by the contractor as stated in Section J, Exhibit C of the contract.

• Customer Input. The COR may receive customer (e.g., beneficiaries, internal Government staff) input about the quality of services performed under the contract. These inputs maximize the Government’s resource potential and are considered in regular assessments as they may identify contractor process improvement opportunities or required corrective actions. The COR will validate any input before corrective action is required by the contractor.

• Periodic Performance Reviews. Performance reviews are an effective tool for keeping performance on course, measuring performance levels, and making adjustments as necessary. More frequent opportunities than the required contract briefings with the contractor are essential in maintaining focus on critical program areas and may occur as deemed necessary.

• The COR will identify the specific review items to the contractor in writing. The contractor will provide the COR with written documentation of their internal processes of the specified review items. The COR will review this documentation and perform an onsite review if deemed necessary. The COR may be accompanied on the site visit by other Government employees when warranted.

The COR will review contractor deliverables and other submittals (reports or plans) or any other information available and document evaluations in the Performance Assessment Tool (PAT) in accordance with DHA established policies. The PAT system has been developed to provide standardized assessment and documentation of contractor performance throughout the Military Health System. As the system of record for all TRICARE contracts, candid and fact based assessment of contractor performance will be documented in PAT throughout the year.

6.2 Surveillance Matrix

The Surveillance Matrix (Appendix 1) is the list of performance objectives and standards that must be performed by the contractor. This matrix details the method of surveillance the COR will use to validate and inspect these performance elements. Inspection of each element will be documented in the COR file.

Performance objectives define the desired outcomes. Performance Standards define the level of service required under the contract to successfully meet the performance objective. The inspection methodology defines how, when, and what will be assessed in measuring performance. The Government performs surveillance, using this QASP, to determine the quality of the contractor's performance as it relates to the performance element standards.

In evaluating the quality of contractor’s performance, the following performance ratings may be used.

Performance Rating

Criteria

Excellent / Outstanding

Performance meets contractual requirements and exceeds many to the government’s benefits. The contractual performance of the element or sub-element being assessed was accomplished with no problems and contractor actions were highly effective.

Very Good Performance meets contractual requirements and exceeds some to the government benefits. The contractual performance was accomplished with few minor problems for which corrective actions taken by the contractor were effective.

Good Performance meets contractual requirements. The contractual performance contains some minor problems for which corrective actions taken by the contractor were satisfactory.

Marginal Performance does not meet some contractual requirements.

The contractual performance reflects a serious problem for which the contractor has not yet identified corrective actions.

The contractor’s proposed actions appear marginally effective or were not fully implemented.

Unsatisfactory Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

Appendix 1 - Surveillance Matrix

Statements Standards/AQLs Inspections Ratings C.3.1. The contractor shall provide dental care services for ADSMs, Reservists and family members.

C.3.1.1. The contractor shall comply with the most current version of American Dental Association's (ADA) Current Dental Terminology (CDT) manual for covered services and update its systems.

a) Standard: Whenever the ADA issues an updated CDT manual, the contractor shall provide the DHA Dental Care Section with its recommended changes for Section J, Attachments J-2 a-c, Benefits, Exclusions and Limitations. The contractor shall identify CDT codes to be added, deleted and/or updated. The ADA updates CDT codes approximately once a year and the revisions are effective January 1 of the following year.

AQL: The contractor shall submit its CDT recommendation within 30 days of the release of the ADA’s updated CDT manual.

b) Standard: The contractor shall update its systems to reflect the DHA Dental Care Section’s approved CDT code changes no later than January 1 of the following year.

AQL: System updates shall be completed no later than January 1 100% of the time.

What: Annual CDT code updates.

How: Review contractor’s recommended annual CDT code updates. Approve updates as directed by the DHA Dental Program Manager Who: TDRAW COR and DHA Dental Program Manager Standards: a and b

C.3.1.2. The contractor shall process remote ADSMs’ enrollments.

Deliverables:

a) Standard: The contractor shall process remote ADSMs’ enrollment actions in accordance with TRICARE Systems Manual (TSM), Chapter 3; and

What: M010 Management Report M080 Enrollment and Fee Reconciliation Analysis Report

M010 Management Report M080 Enrollment and Fee Reconciliation Analysis Report Q030 Enrollment Activity Summary Report

Section J, Attachment J-3b, Program Operations for ADSMs.

AQL: 99% of remote ADSM enrollment actions shall be accurate and complete.

Q030 Enrollment Activity Summary Report How: Monthly and quarterly review of applicable reports.

Periodic review of source data.

Who: TDRAW COR Standard: a

C.3.1.3. The contractor shall offer Reservists and family members multiple avenues of access for continuous and portable open enrollment.

Minimum avenues of access will be telephone, paper, and on-line enrollment.

The definition for portable is members’ enrollment can transfer between active duty, Selected Reserve and IRR status (See Section J, Attachments J-3a-d, Program Operations; and Attachment J- 12, Reservist and Family Member Benefits Coverage Plans).

Deliverables:

M010 Management Report M080 Enrollment and Fee Reconciliation Analysis Report Q030 Enrollment Activity Summary Report

a) Standard: Enrollment actions shall be processed and monitored in accordance with the TSM Chapter 3.

AQL: 99% of entries for telephone and paper enrollments shall be accurate and complete.

b) Standard: If an enrollment application and premium payment are received before the 20th of the month, enrollment will begin on the first day of the next month. If receipt is after the 20th day of the month, enrollment will begin on the first day of the second month after the month in which the contractor received the application. If the contractor does not process an enrollment application on time, then the contractor shall retroactively enroll the beneficiary(ies).

AQL: 95% of applications shall be processed in accordance with the standard above.

c.) Standard: Reconcile enrollment and premium data discrepancies identified each month by Defense

What: M010 Management Report M080 Enrollment and Fee Reconciliation Analysis Report Q030 Enrollment Activity Summary Report How: Monthly and quarterly review of applicable reports.

Periodic review of source data.

Standards: a, b and c

Manpower Data Center (DMDC) in accordance with TSM, Chapter 3 and Section J, Attachment J-3c, Program Operations for Reservists and Family Members.

AQL: (1) 90% of enrollment and premium discrepancies shall be reconciled within 30 days after receipt of DMDC Electronic Information for Dental (EID).

AQL: (2) Remaining 10% shall be reconciled within 60 days after receipt of DMDC EID.

C.3.1.4. The contractor shall provide and maintain access to general and specialty network providers for beneficiaries.

The network provider’s practice shall be in a fixed structure in order to contribute to determining network compliance.

“Driving miles” do not include alternative means of transportation (e.g. ferries, trains, or planes) in order for the beneficiary to access the provider’s office.

• “Rural” is defined as less than 1,000 residents per square mile.

• “Suburban” is defined as 1,000 to 3,000 residents per square mile.

• “Urban” is defined as more than 3,000 residents per square mile

a) Standard: The contractor shall establish networks for general dental care in the United States, the District of Columbia, Puerto Rico, Guam, U.S.

Virgin Islands, American Samoa, and the Northern Mariana Islands.

AQL: (1) For Rural: 97% of ADSMs, Reservists and family members shall have access to two general dentists within 21 days of requesting a periodic or initial (non-emergency) appointment and within 35 driving miles of ADSM DTF referred care and place of residence for remote ADSMs, Reservists and family members.

AQL: (2) For Suburban: 97% of ADSMs, Reservists and family members shall have access to two general dentists within 21 days of requesting a periodic or initial (non-

What: M030 Provider Network Access Report How: Monthly review of applicable report.

Periodic review of source data.

(See Section H.4.1, Network Adequacy for Remote Active Duty Service Members [ADSMs], positive incentive, and H.5, Network Provider Access disincentive; and Section J, Attachments J-3a-d, Program Operations, for provider requirements).

Deliverables:

M030 Provider Network Access Report emergency) appointment and within 15 driving miles ADSM DTF referred care and place of residence for remote ADSMs, Reservists and family members

AQL: (3) For Urban: 97% of ADSMs, Reservists and family members shall have access to one general dentist within 21 days of requesting a periodic or initial (non-emergency) appointment and within 5 driving miles of ADSM DTF referred care and place of residence for remote ADSMs, Reservists and family members.

b) Standard: The contractor shall establish networks for specialty dental care in the United States, the District of Columbia, Puerto Rico, Guam, U.S.

Virgin Islands, American Samoa, and the Northern Mariana Islands.

AQL: (1) 90% of ADSMs, Reservists and family members shall have access to an orthodontist within 28 days of requesting an appointment and within 35 driving miles of ADSM DTF referred care and place of residence for remote ADSMs, Reservists and family members.

AQL: (2) 90% of ADSMs, Reservists and family members shall have access to an oral surgeon within 28 days of requesting an appointment and within

35 driving miles of ADSM DTF referred care and place of residence for remote ADSMs, Reservists and family

AQL (3) 90% of family members shall have access to a pediatric dentist within 28 days of requesting an appointment and within 35 driving miles of their place of residence.

AQL: (4) 85% of ADSMs, Reservists and family members shall have access to an endodontist within 28 days of requesting an appointment and within 35 driving miles of ADSM DTF referred care and place of residence for remote

AQL: (5) 85% of ADSMs, Reservists and family members shall have access to a periodontist within 28 days of requesting an appointment and within 35 driving miles of ADSM DTF referred care and place of residence for remote

AQL: (6) 80% of ADSMs, Reservists and family members shall have access to a prosthodontist within 28 days of requesting an appointment and within 35 driving miles of ADSM DTF referred care and place of residence for remote members.

c) Standard: The contractor shall maintain a network provider retention rate in accordance with Section J, Exhibit C, Contract Data Requirements List (CDRL) M030, Provider Network Access Report. For Option Period 1 the COR will validate the baseline 6 months after start of dental care delivery. The baseline will be reset at the beginning of each Option Period, and the COR will re-validate at the end of the Option Period.

AQL: 95% of network providers shall be retained annually.

C.3.1.5. The contractor shall develop, maintain and make available to beneficiaries, providers and Government representatives an up-to-date directory of network providers.

a) Standard: The contractor shall post the updated directory on the contractor’s website in accordance with Section J, Attachment J-3a, Program Operations for all TDRAW Beneficiaries.

AQL: 100% updated within 5 business days of receipt of the updated information.

What: Directory of network providers How: Periodic review of source data when contractor requests review of non-compliant areas so that the areas may be deemed compliant (i.e., network provider available)

C.3.1.6. The contractor shall develop agreements with TRICARE OCONUS Preferred Dentists (TOPDs).

Deliverables:

W010 Transition-In Status Report M010 Management Report

a) Standard: The contractor shall complete agreements with existing providers identified by the Government and for any new providers identified each option period in accordance with Section J, Attachments J-4a, OCONUS Program Operations; and J-17c, What: W010 Transition-In Status Report M010 Management Report How: Weekly and monthly review of applicable reports.

Periodic review of source data.

R070 MOU with TRICARE Overseas Program (TOP) Contractor

Transition-In TOP Remote ADSM Dental Services.

AQL: The contractor shall complete agreements with 95% of those existing providers identified by the DHA COR prior to Option Period 1 and any new providers identified each option period.

b) Standard: The contractor shall make available to beneficiaries, TOPDs and Government representatives an up-to-date list of TOPDs in accordance with Section J, Attachment J-4a, OCONUS Program Operations.

AQL: 100% updated within 5 business days of receipt of the updated information.

C.3.1.7. The contractor shall process referrals, appointments and authorizations for ADSMs, remote ADSMs and Reservists.

a) Standard: The contractor shall schedule appointments as requested in accordance with Section J, Attachment J-3b, Program Operations for ADSMs;

and J-3d, Program Operations for Selected Reserve and IRR Mobilization- Asset.

AQL: 90% of appointments shall be scheduled within 5 days of the request.

b) Standard: The contractor shall complete authorization requests in accordance with Section J, Attachment J-3b, Program Operations for ADSMs;

and J-3d, Program Operations for Selected Reserve and IRR Mobilization- Asset.

What: M010 Management Report How: Monthly review of applicable reports.

Periodic review of source data.

Who: TDRAW COR and DHA Dental Program Manager

AQL: (1) 95% of authorization requests will be electronically sent to the Dental Service Point of Contact (DSPOC) within 5 days of receipt of a complete authorization request (to include required documentation).

AQL: (2) 100% of authorization requests will be electronically sent to the DSPOC within 7 days of receipt of a complete authorization request (to include required documentation).

AQL: (3) 95% of authorization requests will be completed within 5 days of receiving all required information from the DSPOC.

AQL: (4) 100% of authorization requests will be completed within 7 days of receiving all required information from the DSPOC.

C.3.1.8. The contractor shall process claims to completion for beneficiaries and providers.

“Process to completion” is defined in the TOM, Appendix A (See Section J, Attachment J-13, Reservist and Family Member Cost Shares, for a detailed list of cost share amounts).

Deliverables:

M010 Management Report

a) Standard: Process claims to completion.

AQL: (1) CONUS Claims 95% within 14 days of receipt.

98% within 30 days of receipt.

100% within 60 days of receipt.

AQL: (2) OCONUS Claims 95% within 21 days of receipt.

98% within 45 days of receipt.

100% within 60 days of receipt.

What: M010 Management Report M020 Market Basket Comparison/CDT Summary Report M040 OCONUS Payment Report M060 Worldwide Incurred/Paid Claims Report A010 Market Basket Comparison/CDT Summary Report How: Monthly and annual review of applicable reports. Annual onsite visit.

Periodic review of source data.

M020 Market Basket Comparison/CDT Summary Report M040 OCONUS Payment Report M060 Worldwide Incurred/Paid Claims Report A010 Market Basket Comparison/CDT Summary Report R190 MOU with Claims Audit Contractor

b) Standard: Claims shall be accurately paid in accordance with the covered benefit. CONUS and OCONUS claims shall be separately tracked.

AQL: 97% are accurately paid on initial submission of the claim.

c) Standard: Claim errors shall be corrected. CONUS and OCONUS claims shall be separately tracked.

AQL: 99% are corrected within 10 days after contractor identifies the error.

C.3.1.9. The contractor shall process all appeals to completion.

Deliverables:

M010 Management Report R130 Appeals Processing Guidelines, Desk Instructions and Reference Materials process provider, Reservist and family member appeals in accordance with 32 CFR 199.13(h) and the TOM, Chapter 12 (Use Section J, Attachment J-15, Appeals Summary Log, in place of TOM Chapter 12, Figure 12.A-2).

AQL: (1) 95 % of non-expedited medical necessity and factual reconsiderations processed to completion within 60 days of receipt.

AQL: (2) 100% of non-expedited medical necessity and factual reconsiderations processed to completion within 90 days of receipt.

AQL: (3) 100% of determinations that were reversed by appeals processed to completion with 21 days of receipt.

R130 Appeals Processing Guidelines, Desk Instructions and Reference Materials How: Monthly review of applicable reports.

b) Standard: The contractor shall process provider, ADSM and remote ADSM appeals in accordance with Section J, Attachment J-3b, Program Operations for ADSMs. Upon legislative approval, this standard shall also apply to Reservists covered under Section J, Attachment J-3d, Program Operations for Selected Reserve and IRR Mobilization-Asset.

AQL: (1) Forward complete appeal package to DSPOC within 7 days of receipt.

AQL: (2) Notify appealing party of the decision within 14 days after receipt.

C.3.1.10. The contractor shall process all grievances to completion.

process provider, Reservist and family member grievances to completion in accordance with the TOM, Chapter 11, Section 8.

AQL: 95% within 60 days of receipt.

99.9% within 90 days of receipt.

b) Standard: The contractor shall process provider, ADSM and remote ADSM grievances to completion in accordance with Section J, Attachment J-3b, Program Operations for ADSMs.

Upon legislative approval, this standard shall also apply to Reservists covered under Section J, Attachment J-3d, Program Operations for Selected Reserve and IRR.

What: M010 Management Report How: Monthly review of applicable reports.

AQL: 95% within 60 days of receipt.

99.9% within 90 days of receipt.

C.3.1.11. The contractor shall provide readily accessible comprehensive customer service for beneficiaries and providers.

Deliverables:

M010 Management Report A070 Network Provider Satisfaction Survey Results

a) Standard: The contractor shall provide customer service in accordance with Section J, Attachment J-3a, Program Operations for all TDRAW Beneficiaries.

AQL: (1) 98% of telephone calls answered by Automated Response Unit within 30 seconds.

AQL: (2) 80% of telephone calls answered by Customer Service Representative (CSR) - within 30 seconds of selection by caller.

AQL: (3) 5% or less telephone calls blocked at all times (measured at least hourly).

AQL: (4) 80% of telephone call – resolved during the initial call; 99.9% within 7 days.

AQL: (5) Priority Written and E-mail Correspondence (final response) - 95% within 10 days of receipt; 99.9% within 30 days of receipt. (Priority correspondence is that which is received from Members of Congress, DoD leadership and DHA leadership.)

A070 Network Provider Satisfaction Survey Results How: Monthly and annual review of applicable reports, the DHA Quarterly Satisfaction Survey, and the contractor’s Network Provider Satisfaction Survey. Annual onsite visit.

AQL: (6) Routine Written and E-mail Correspondence (final response) - 85% within 14 days of receipt; 99.9% within 30 days of receipt.

b) Standard: The contractor shall maintain overall beneficiary satisfaction.

The measurement will be based on the annual average of the quarterly customer satisfaction phone surveys conducted by DHA, Defense Health Cost Assessment and Program Evaluation (DHCAPE). The results will be provided to the contractor within 30 days of completing each of the quarterly surveys.

AQL: At least 95% of customers surveyed will indicate that, overall, they are at a minimum “somewhat satisfied.”

c) Standard: The contractor shall maintain overall network provider satisfaction. The measurement will be based on the annual network provider survey conducted by the contractor.

Each option period the contractor shall coordinate development of the survey with the DHA Dental Care Section 60 days prior to the survey’s release in accordance with Section J, Exhibit C, CDRL A070, Network Provider Satisfaction Survey Results (See Section H.4.2, Network Provider Satisfaction, positive incentive).

AQL: At least 90% of network providers surveyed will indicate that, overall, they are at a minimum “somewhat satisfied.”

C.3.2 The contractor shall promote utilization of diagnostic and preventive services.

C.3.2.1. The contractor shall inform and educate beneficiaries and providers about the program benefits with emphasis to the beneficiaries about the benefit of utilizing diagnostic and preventive services.

Deliverables:

M010 Management Report M070 MDR Data Claims and Provider Files P010 Beneficiary and Provider Education Plan R120 MOU with DHA Communications

a) Standard: The contractor shall comply with its education plan in accordance with Section J, Attachment J-3a, Program Operations for all TDRAW Beneficiaries. The contractor shall allow 30 days for the DHA Dental Care Section to approve/deny any changes to the contractor’s education plan. Timing of the publication and/or implementation will be mutually agreed upon between the contractor and DHA Dental Care Section.

AQL: 99% of planned education activities shall be completed within the option period.

b) Standard: The contractor shall maintain or reduce the number of Reservists identified as DRC 3 and 4, as identified in Section J, Attachment J- 8b, Department of Defense Oral Health and Readiness Classification System, each option period. (See below for how the standard will be calculated.)

AQL: No more than 3% at DRC 4 level.

What: M010 Management Report M070 MDR Data Claims and Provider Files P010 Beneficiary and Provider Education Plan How: Review annual education plan.

Calculate DRC levels based on monthly MDR claims data.

Periodic review of education plan actions.

Standard(s): a, b, and c

No more than 2% at DRC 3 level.

c) Standard: The contractor shall maintain or increase the number of Reservists identified as DRC 1 or 2 each option period. (See below for how the standard will be calculated.)

AQL: No less than 65% shall be at DRC 1 or 2 level.

Standard Calculation for standards 3.2.1.b and c. The first full 12-month option period will establish the baseline.

All calculations will be based on contractor data submitted to the Military Health System (MHS) Data Repository (MDR) as of the last month of each option period (See C.4.9). The DHA Dental Care Section will perform the calculations for the DRC levels within 30 days after receipt of the data. DRC 4s will be determined by totaling the number of DRC codes 1, 2, and 3 based on the most recent claim submitted to the MDR for each unique user during the option period; then subtract this total number from total enrolled population of Reservists. The difference will be divided by the total enrolled population of Reservists to determine the percentage of DRC codes 4. DRC codes 3 will be determined by totaling the number of DRC codes 3 based on the most recent claim submitted to the MDR for each unique user during the option period;

then divided by the total enrolled population of Reservists. DRC codes 1 and 2 will be determined in the same manner that DRC codes 3 are calculated.

C.3.3. The contractor shall provide data systems to coordinate care between the Dental Care Section, Military Dental Treatment Facilities (DTF) ADSM referred care, remote ADSM and Reservist dental care authorizations, and the means in which to monitor dental health plan data and outcome measures for all dental care rendered.

C.3.3.1. The contractor shall provide training for the users on the data systems stated in Section J, Attachment J-3e, Program Operations for Data Interfaces.

a) Standard: The contractor shall train (initial and refresher) and provide secure means for the users to access the systems for viewing and/or utilization. The contractor may provide the training on-site or electronically.

AQL: (1) Initial system training conducted during the Transition-In period shall be completed no later than 30 days prior to Option Period 1.

AQL: (2) After start of Option Period 1, new users shall receive initial training no later than 30 days after identification is made to the contractor.

How: Monthly review of applicable reports.

AQL: (3) Refresher training shall be provided quarterly.

C.3.3.2. The contractor shall provide Government designated users with read-only access to the contractor’s full TDRAW data set.

a) Standard: The user shall have the ability to download any of the data elements for manipulation purposes in accordance with Section J, Attachment J-3e, Program Operations for Data Interfaces.

AQL: The system will be available 99% of the time 24 hours, 7 days a week (excluding downtime for scheduled maintenance).

reports.

C.3.3.3. The contractor shall provide Government designated users with read-only access to a dental health plan data screen.

a) Standard: The data shall be provided in a consolidated manner in which the user shall have the ability to easily view dental health plan data and the outcome measurements without having to manipulate the data in order to retrieve the information in accordance with Section J, Attachment J-3e, Program Operations for Data Interfaces.

AQL: The system will be available 99% of the time 24 hours, 7 days a week reports and dental health plan data.

Periodic review of source data.

C.3.3.4. The contractor shall establish an electronic means to track and transmit ADSM referrals and ADSM and Reservist authorizations.

Deliverables:

a) Standard: The system will be Health Insurance Portability and Accountability Act (HIPAA) and Public Key Infrastructure (PKI) compliant, which will allow the user the ability to search, process, and transmit referrals and

What: M010 Management Report How: Monthly review of applicable reports.

Periodic review of source data.

authorizations in accordance with Section J, Attachment J-3e, Program Operations for Data Interfaces.

AQL: The system will be available 99% of the time 24 hours, 7 days a week

C.3.3.5. The contractor’s system shall interface with the Military Health Services (MHS) Genesis/Defense Health Medical Systems Modernization (DHMSM) Electronic Health Record System (EHRS).

DHA will implement when applicable (See Section J, Attachment J-3e, Program Operations for Data Interfaces).

Deliverables:

R180 MHS Genesis Interface Plan

a) Standard: The contractor’s interface shall include technical methodologies and capabilities to support referral management industry standards and dental record sharing in accordance with Section J, Attachment J-3e, Program Operations for Data Interfaces.

AQL: The system will be available 99% of the time 24 hours, 7 days a week

R180 MHS Genesis Interface Plan How: Monthly review of applicable report and the MHS Genesis Interface Plan actions.

Periodic review of source data.

C.3.3.6. The contractor shall correct any data submission mistakes identified by the Government or the contractor.

a) Standard: If the Government or the contractor identify data submission mistakes (e.g., the manner in which the data is submitted leads to incorrect data reporting), the contractor shall correct the mistakes.

AQL: 99% within 30 days of identification.

100% within 60 days of identification.

report.

Periodic review of source data.

Appendix 2 - Corrective Action Report (CAR)

CORRECTIVE ACTION REPORT (CAR)

(If more space is needed, use reverse and identify by number)

1. CONTRACTOR

2. CONTRACT NUMBER

3. TYPE OF SERVICES

4. FUNCTIONAL AREA

5. SUSPENSE DATE

6. CONTROL NUMBER

7. DEFICIENCY MAJOR MINOR

FINDING:

FINDING IMPACT:

Please respond with a written corrective action plan that details the corrective action of the cited deficiency, the cause of the deficiency, and actions taken to prevent recurrence by Suspense Date in Block 5. If date was not entered in Block 5, the contractor is not required to provide a response.

8. QUALITY ASSURANCE PERSONNEL (COR)

TYPED NAME AND GRADE

SIGNATURE AND DATE

9. ISSUING AUTHORITY

TYPED NAME AND GRADE

SIGNATURE AND DATE

10. COR RESPONSE TO CONTRACTOR CORRECTIVE ACTION AND ACTION TAKEN TO PREVENT RECURRENCE

11. COR DETERMINATION

ACCEPTED REJECTED

12. CLOSE DATE

Appendix 3 - Customer Complaint Record

CUSTOMER COMPLAINT RECORD

DATE/TIME OF COMPLAINT

SOURCE OF COMPLAINT

ORGANIZATION

BUILDING NUMBER

INDIVIDUAL

PHONE NUMBER

NATURE OF COMPLAINT

CONTRACT REFERENCE

VALIDATION

DATE/TIME CONTRACTOR INFORMED OF COMPLAINT

ACTION TAKEN BY CONTRACTOR

RECEIVED/VALIDATED BY

Appendix 4 - Performance Assessment Report (PAR)

PERFORMANCE ASSESSMENT REPORT (PAR)

(If more space is needed, use reverse and identify by number)

1. CONTRACT/TASK ORDER NUMBER 2. CONTRACTOR 3. TYPE OF SERVICES

4. QUALITY ASSURANCE PERSONNEL (COR) SIGNATURE AND DATE

5. COR PHONE 6. SUSPENSE DATE

I. PERFORMANCE

7. DEFICIENCY (CHECK ALL BOXES THAT APPLY)

NEW

REPEAT

NO DEFICIENCY NOTED

8. SERVICES SUMMARY or PWS PARAGRAPH ITEM REVIEWED

9. BRIEF DESCRIPTION OF DEFICIENCY (IF DEFICIENCY BOX WAS

CHECKED)

10. DETAILED PERFORMANCE ASSESSMENT

II. CONTRACTOR VALIDATION

11. CONTRACTOR REPRESENTATIVE CONCUR NON-

CONCUR

12. CORRECTIVE ACTION ESTIMATED COMPLETION DATE

13. CONTRACTOR REPRESENTATIVE CORRECTIVE ACTION AND PREVENTION OF RECURRENCE OR REASON FOR NON-

CONCURRENCE OF COR CITED DEFICIENCY

III. ACTION CORRECTED

14. CONCUR NON-CONCUR COR SIGNATURE AND DATE

15. COR REMARKS (REQUIRED)

6. CONTRACTOR REPRESENTATIVE REMARKS

Attachment J-23a Past Performance Questionnaire

TDRAW HT9402-17-R-0001 Attachment J-23a Page 1 of 7 SOURCE SELECTION INFORMATION See FAR 2.101 & 3.104

PAST PERFORMANCE QUESTIONNAIRE

SOURCE SELECTION INFORMATION

Please complete this questionnaire and return it directly to (Offeror’s Name and address).

Responses will be treated as confidential and will be used only by source selection officials in evaluating the offeror’s submitted documents for the contract.

Contractor/Subcontractor Name:

Customer/Account Name:

Customer/Account Address:

Primary Point of Contact Name/Title:

Primary Point of Contact Phone/Fax Numbers:

Alternate Point of Contact Name/Title:

Alternate Point of Contact Phone/Fax Numbers:

Contract Summary (to include type of contract and scope of services provided):

Period of Performance (month/year): From _________________ to _________________

Annual Contract Value:

Number of Beneficiaries/Customers Served:

Annual Number of Claims Processed (if applicable):

TDRAW HT9402-17-R-0001 Attachment J-23a Page 2 of 7 SOURCE SELECTION INFORMATION See FAR 2.101 & 3.104

INSTRUCTIONS: Please provide your responses to the questions below. Questions 1-4 pertain to the contractor’s performance in relation to the stated terms of the contract (contract requirements, timeliness/processing standards, provider network access). Questions 5 – 8 pertain to the manner in which the work was performed (responsiveness, attitude, staff knowledge/skills/abilities, etc.), regardless of how the contractor performed in relation to the terms of the contract. Additional questions 9-11 follow. Please use the space following each question to provide additional detailed information. Detailed information is critical to the evaluation of the past performance.

If there are any questions regarding the responses provided, source selection officials will attempt to contact the Primary or Alternate Points of Contact identified on Page 1.

1. In regard to only the stated contract requirements (not the manner in which the work was performed), please mark an “X” next to the response that best describes the contractor’s performance and summarize some examples below.

(__) Met all of the contract requirements and exceeded some. Where requirements were exceeded, the result was a significant benefit to the customer. Contractual performance was accomplished with few, if any, minor problems. Any corrective actions taken by the contractor were prompt and effective.

(__) Met all of the contract requirements and exceeded some. Where requirements were exceeded, the result was nominally beneficial to the customer. Contractual performance was accomplished with few, if any, minor problems. Any corrective actions taken by the contractor were prompt and effective.

(__) Met all of the contract requirements. Contractual performance was accomplished with few, if any, minor problems. Any corrective actions taken by the contractor were prompt and effective.

(__) Met most of the contract requirements. Contractual performance reflects problem(s) for which the contractor did not perform (or has not yet performed) corrective actions, or corrective actions were only marginally effective, or not full implemented.

(__) Failed to meet most contract requirements. Contractual performance contains serious problems for which the contractor’s corrective actions, if any, were incorrect or ineffective.

(__) Not applicable (explain why)

Comments (e.g., summarize some examples of the performance indicated above; explain why/how exceeded requirements were beneficial to the customer; what were some of the problems and the corrective actions taken, etc.):

TDRAW HT9402-17-R-0001 Attachment J-23a Page 3 of 7 SOURCE SELECTION INFORMATION See FAR 2.101 & 3.104

2. Does or did the stated contract have timeliness/processing standards? If so, please mark an “X” next to the response that best describes the contractor’s performance and summarize some examples below.

(__) Met all of the timeliness/processing standards and exceeded some. Where the standards were exceeded, the result was a significant benefit to the customer. Contractual performance was accomplished with few, if any, minor problems. Any corrective actions taken by the contractor were prompt and effective.

(__) Met all of the timeliness/processing standards and exceeded some. Where the standards were exceeded, the result was nominally beneficial to the customer. Contractual performance was accomplished with few, if any, minor problems. Any corrective actions taken by the contractor were prompt and effective.

(__) Met all of the timeliness/processing standards. Contractual performance was accomplished with few, if any, minor problems. Any corrective actions taken by the contractor were prompt and effective.

(__) Met most of the timeliness/processing standards. Contractual performance reflects problem(s) for which the contractor did not perform (or has not yet performed) corrective actions, or corrective actions were only marginally effective, or not full implemented.

(__) Failed to meet most timeliness/processing standards. Contractual performance contains serious problems for which the contractor’s corrective actions, if any, were incorrect or ineffective.

(__) Not applicable (explain why)

Comments (e.g., summarize some examples of the performance indicated above; explain why/how exceeded timeliness/processing standards were beneficial to the customer; what were some of the problems and the corrective actions taken, etc.):

3. Does or did the stated contract have provider network access standards? If so, please mark an “X” next to the response that best describes the contractor’s performance and summarize some examples below.

(__) Met all of the provider network access standards and exceeded some. Where the standards were exceeded, the result was a significant benefit to the customer. Contractual performance

TDRAW HT9402-17-R-0001 Attachment J-23a Page 4 of 7 SOURCE SELECTION INFORMATION See FAR 2.101 & 3.104 was accomplished with few, if any, minor problems. Any corrective actions taken by the contractor were prompt and effective.

(__) Met all of the provider network access standards and exceeded some. Where the standards were exceeded, the result was nominally beneficial to the customer. Contractual performance was accomplished with few, if any, minor problems. Any corrective actions taken by the contractor were prompt and effective.

(__) Met all of the provider network access standards. Contractual performance was accomplished with few, if any, minor problems. Any corrective actions taken by the contractor were prompt and effective.

(__) Met most of the provider network access standards. Contractual performance reflects problem(s) for which the contractor did not perform (or has not yet performed) corrective actions, or corrective actions were…