ABACUS Draft PWS 01172025.pdf

DHA PWS Template V13

November 16, 2021

Department of Defense

Defense Health Agency (DHA)

On Behalf Of

Program Executive Office

Defense Healthcare Management Systems (PEO DHMS)

Performance Work Statement

November 16, 2021

PART 1

1.0 GENERAL INFORMATION

1.1 This is a non-personal services contract: To provide maintenance and support for the

Armed Services Billing and Collection Utilization Solution (ABACUS), the legacy Software-as-a-Service (SaaS) cloud service offering for Medical Treatment Facility (MTF) billing and collections, to bridge the gap between the end of the existing ABACUS contract and deployment of Outpatient Pharmacy Billing (OPPB) with MHS GENESIS, for PEO DHMS in support of the

Defense Health Agency (DHA) Uniformed Business Office.

1.2 Description of services/introduction: The contractor shall provide all personnel, equipment, supplies, facilities, transportation, tools, materials, supervision, and other items and non-personal services necessary to operate, maintain and support all aspects of ABACUS as a cloud-based Software-as-a-Service offering to the Government as defined in this Performance

Work Statement (PWS) except for those items specified as government furnished property and services. The contractor shall perform to the standards in this PWS.

1.3 Background:

The ABACUS is a DoD Mission-Essential Acquisition Category III (ACAT III) Mission

Assurance Category (MAC) III Program acquired to provide DHA Uniform Business Offices

(DHA UBOs) with an industry standard, best practice means for billing, collection and reporting of medical services provided by DoD MTFs Worldwide.

ABACUS was procured under a Task Order of the Army Private Cloud 2 (APC2) Indefinite

Delivery/Indefinite Quantity (IDIQ) contract vehicle with a contract award date of January 31, 2014. After award, the ABACUS PMO transitioned to DHA Medical Health Services (MHS) and assigned the program to the Solutions Delivery Division on April 6, 2014.

ABACUS was acquired to provide the (UBOs) a common solution for Billing and Collection and the single source of information for revenue associated with medical services provided by

(MTFs) worldwide. Initially the source system for billing data used in ABACUS was Composite

Health Care System (CHCS). As DHA Electronic Health Record (EHR) Modernization progressed, source data, ABACUS began receiving source data from both CHCS and MHS

GENESIS. All MTFs have transitioned from CHCS to MHS GENESIS which is now the single source of patient encounter data used in ABACUS.

The aim of the new requirements in this PWS is to ensure users a smooth transition from

ABACUS to MHS GENESIS/RevX with Outpatient Pharmacy Billing (OPPB) while avoiding disruptions in service. All functions that currently exist, except those rendered obsolete due to migration to MHS GENESIS (e.g., query of patient appointment lists, etc.,), shall remain unchanged unless otherwise directed within this PWS or by the Government.

Significant requirements covered in Section 5.10 of the PWS include:

November 16, 2021

• Billing and Collections for:

o Retail pharmacy encounters until Outpatient Pharmacy Billing (OPPB) capability is implemented and deployed with MHS GENESIS/RevX o Miscellaneous and non-medical charges including Dining Hall, MAC, Elective

Cosmetic Surgery and Copy Charges

• Storage and retrieval of Unassociated Paper Explanations of Benefit (EOBs), Explanations of Payments (EOPs) and other paper documents

• Phase Out and Decommission activities:

o Post OPPB 379-Day continued operations o Support for legacy billing data migration o Decommission of ABACUS

All U.S Codes, Code of Federal Regulations (CFRs) and DoD directives described as follows in this paragraph remain in effect for the duration of this contract. Various portions of U.S. Code

(USC), the Code of Federal Regulations (CFR) and Department of Defense (DoD) directives require the Services to bill certain payers for the cost of healthcare delivered to persons who are seen in MTFs. Specifics of the statutory/regulation/instructional requirements can be found in 10

USC 1079b (requires designated non-DoD beneficiaries be billed for healthcare delivered in

MTFs – referred to as Medical Services Account (MSA), 10 USC 1095 (requires DoD MTFs to bill third party payers for the costs of healthcare delivered to non-Active Duty DoD beneficiaries with other health insurance (OHI) – referred to as Third Party Collections (TPC), 42 USC 2651-

2653 (requires DoD MTFs to bill insurance companies, individuals, auto policies, home owners’ policies, etc., as tort-feasors, for costs of medical and dental services provided to DoD

Beneficiaries as a result of illness or injury incurred due to negligence or civil wrong doing – referred to as Medical Affirmative Claims (MAC), and the DoD 6010.15-M (MTF UBO

Manual).

The Contractor shall maintain all necessary components of underlying software, infrastructure, and processes to meet the requirements set forth in the PWS including implementation, data conversion, help desk services, and ongoing solution maintenance. This PWS outlines the requirements for elements assigned to, reporting to, or serviced by the MTFs under the auspices of the Defense Health Agency Uniform Business Office (DHA UBO). DHA provides health care services to more than nine million beneficiaries utilizing 136 Medical Treatment Facilities

(MTF) worldwide. The DHA Uniform Business Offices (DHA UBOs) are responsible for Billing and Collection under three major patient billing components: TPC and MAC.

1.4 Objectives: The primary objectives set forth for this contract include the following:

• The Contractor shall provide continued support and maintenance for the existing ABACUS

Software-as-a-Service solution for Billing and Collection, and Enterprise Reporting as an

November 16, 2021 enterprise solution operated and maintained in a FedRamp certified, safe, and secure cloud-based environment compliant with DoD Cyber Security policies and guidelines.

• The Contractor shall provide flexible, responsive, measurable, and supportive services as directed by PEO Defense Healthcare Management Systems Modernization (DHMSM) in support of the DHA Uniform Business Office (DHA UBO) user community for the duration of this contract.

• The Contractor shall provide support for incident management and problem resolution Monday through Friday 0800 through 2400 Eastern Time; and online support via the ABACUS

Knowledge base shall be available 24 hours a day x 7 days per week x 365 days per year.

▪ The Contractor shall ensure no disruption of service occurs during the transition of ABACUS from the previous contract to the contract that results from this PWS.

▪ The Contractor shall maintain Enterprise and Billing and Collection Reporting functionality to ensure that ABACUS can produce auditable financial reports that will be used by the

Services to produce monthly, quarterly, and annual financial statements in accordance with the Chief Financial Officer Act of 1990, the Affordable Care Act, DoD Financial

Management Regulation Volume 1, Chapter 3, and Generally Accepted Accounting

Principles (GAAP). The Contractor shall integrate DoD and Service-specific clinical data, patient demographics, billing data, cost allocation data, and accounting data to generate bills, generate metrics, and produce financial reports. The Contractor shall ensure that ABACUS remains capable of establishing and maintaining system internal controls that provide for (1) complete disclosure of the financial results, (2) adequate financial information for managerial purposes, (3) effective control over and accountability for the MTF assets, and (4) reliable accounting and financial reporting.

The Contractor shall ensure that ABACUS provides complete and accurate data for the UBOs to report medical billing and Collection. The Contractor shall maintain the ABACUS data export/output functions in user specified format that will be manually re-entered into external accounting systems. The Contractor shall ensure, to be audit compliant, that ABACUS does not duplicate transactions in reports used to prepare financial statements.

1.5 Scope: This contract is for continued operations, maintenance and support of the existing

ABACUS , cloud-hosted solution for MTF billing and collection; continued support and maintenance of the MHS GENESIS to ABACUS Interface; phase out and transition to the

ABACUS replacement; and ABACUS decommissioning and sunset. The Contractor shall maintain all existing ABACUS functionality to include all incidental support for the Services’ medical billing, collection, reporting and utilization for TPC, MSA and MAC services at multiple locations including MTFs worldwide, DHA UBO Program Office Falls church, VA, legal offices, and current/future central billing UBO central billing locations until decommissioning.

The Contractor shall ensure that ABACUS provides throughput at no less than the baseline capability of 155.52 mbps for dynamic, non-streaming WEB content. The Contractor shall

November 16, 2021 ensure bandwidth throughout the period of performance sufficient to support the prescribed business performances metrics for an average of 25,000 patient encounters per day by 1100 concurrent users with the potential for bandwidth increase of 15 percent in each contract year.

The Contractor shall provide labor, maintenance, supervision, and software administration associated with certifying, securing, operating, upgrading, and maintaining the ABACUS software and any associated hardware in accordance with this PWS. The Contractor shall provide

CAC-enabled public internet access to ABACUS and continue receipt of bulk data transfer from

MHS GENESIS. This requirement includes all modernization efforts and software improvements as required by changes in governing directives, policies and any system change requests submitted by the Services. The Contractor shall host a dedicated, logically separate, environment for cloud-based ABACUS access at a commercial facility within the United States.

The Contractor shall maintain the interface between ABACUS and MHS GENESIS, to obtain the data required for billing and collection. The Contractor shall support and maintain functionality in ABACUS to produce bills, claims, and/or invoices for medical, pharmacy, and dental services provided to patients receiving direct healthcare in the Services’ MTFs. The

Contractor shall also maintain the ABACUS reporting functionality that allows users to produce detailed reports for each of the UBO medical billing sub-programs. The Contractor shall maintain ABACUS as a healthcare industry standard accounts receivable management tool that allows the Government to assign, track, and report status, to include disputed claims for further review and processing. The Contractor shall support and maintain ABACUS interfaces to electronic clearinghouse services to transmit claims to insurance companies and receive Health

Insurance Portability and Accountability Act (HIPAA) standard responses. The Contractor shall utilize its own resources to discover valid OHI information for patients existing in the database without insurance; and the Contractor shall ensure continuation of OHI Discovery for retail pharmacy for MTFs until retail pharmacy billing is implemented. The Contractor shall maintain daily data back-up and archival of data on closed claims older than 3 fiscal years. The

Contractor shall ensure continued support of ABACUS functionality that provides for automated and manual posting to accounts and allows the Government to implement and assign roles, responsibilities, and business rules. The Contractor shall maintain the computer-based training

(CBT) environment in the ABACUS Production Portal and a test environment for testing of business rules, changes, Information Assurance Vulnerability Alerts (IAVAs) and other processes. In addition, the Contractor shall provide help desk support and maintenance services in accordance with this PWS. The Contractor shall coordinate all downtime with the

Government in advance of any outage. The Contractor shall not remove any features without prior notification to and approval by the Government.

ABACUS, its business rules (current and future), and methodologies constitutes a government solution containing subsidiary records. As such, the Contractor shall ensure that ABACUS is available for pre-approved and periodic review by Government auditors and examiners.

The Contractor shall fulfil all requirements for certification and accreditation in accordance with the DoD Information Risk Management Framework (RMF) certification process as specified in

Part 6 (Information Technology and Security) of this PWS.

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The Contractor shall provide the UBO functional community and users with access to an

ABACUS knowledge base of frequently asked questions, claim templates, best practices, and other supporting information that is Government-approved for distribution to ABACUS users.

1.6 Period of Performance (PoP): One year with optional months/years (determined at time of award)

1.6.1 Transition: Transition-in/transition-out period

1.6.1.1 Transition-in period: Full performance start date is, 1 Aug 2025. Transition-in performance is defined as continuing operations without causing disruption of any services that remain the responsibility of ABACUS (i.e., billing and collection, reporting or any other aspect of ABACUS functionality) for ABACUS users. All activity associated with incoming transition shall be transparent to users. During the transition-in period, the contractor shall prepare to meet all contract requirements and ensure incoming personnel are functionally trained and qualified on the full performance start date except cybersecurity requirements, which must be fully adhered during transition and full performance periods. Within 60 days, the Contractor shall provide the

Government with a Sustainment Plan outlining the strategy the Contractor will use to manage and maintain ABACUS as related to the requirements herein. The Sustainment Plan shall identify underlying Commercial Software Offerings, list interface specifics, provide the data conversion strategies (if any), identify dependencies, milestones, and risks and mitigation strategies. (ABACUS Sustainment Plan – Deliverable 1).

1.6.1.1.1 The contractor shall comply with transition-in requirements of the DHA, as listed in paragraph 1.11.1, for contractors needing to be issued Common Access Card (CAC) identification, including Department of Defense (DoD) and DHA-directed training and forms submission, prior to network access.

1.6.1.2 Transition-out period: The transition-out plan shall facilitate the accomplishment of a seamless transition from the incumbent to an incoming contractor/Government personnel at the expiration of the contract.

The incumbent shall provide Phase Out documentation and services in accordance with Section

5.10 of this document. The transition may be to a government entity, another Contractor or to the incumbent Contractor under a new contract/order. The Contractor shall assist the Government in planning and implementing a complete transition or Phase Out of this contract to the follow-on provider. This work shall include formal coordination with DHA UBO Program Office, successor staff, ABACUS Project Manager and DHMS management. The transition may include, but is not limited to:

• Coordination with Service representatives

• Review, evaluation, and transition of current software support services

• Transfer of all necessary business and/or technical documentation

• Ability to access all open and previously processed claims to continue posting remits, write-offs, transfers, reporting, etc. for 379 days following deployment of

MHS GENESIS/RevX with Outpatient Pharmacy billing to all MTFs.

• Prepare/extract current and historic data for migration to new solution

The Contractor shall maintain the ABACUS environment until all MTFs are fully transitioned to

MHS GENESIS/RevX complete with Outpatient Pharmacy Billing (OPPB).

1.6.1.2.1 The contractor shall comply with transition-out requirements of the DHA for contractors who have been issued a CAC or who generate “records”, as defined by DoD (records manual), including DoD-directed disposition of records, and others displayed on the In/Out (I/O)

Processing Portal.

1.7 Administrative specifications

1.7.1 Place of performance: The work shall be performed at a Contractor-determined and

Government approved location. The system shall remain available for use by the UBOs, legal offices, TPC contract hub/home offices, and MTF personnel at facilities worldwide via a cloud-based interface. From time to time for various contract activities, the Contractor may be required to appear at individual MTFs or other Government locations, both CONUS and OCONUS. If

Contractor performance is required at OCONUS sites, the Contractor shall contact the

Contracting Office for guidance on OCONUS locations that will be travelled to.

1.7.2 Recognized Federal holidays: The Contractor is not required to perform services on recognized Federal holidays as listed below:

New Year’s Day Labor Day

Martin Luther King Jr.’s Birthday Columbus Day

President’s Day Veteran’s Day

Memorial Day Thanksgiving Day

Juneteenth Day Christmas Day

Independence Day

1.7.3 Hours of operation: The contractor is responsible for conducting business Monday thru

Friday except Federal holidays or when the Government facility is closed due to local or national emergencies, administrative closings, or similar Government directed facility closings. The contractor must at all times maintain an adequate workforce for the uninterrupted performance of all tasks defined within this PWS when the Government facility is not closed for the above reasons.

1.7.4 Emergency Services: On occasion, services may be required to support an activation or exercise of contingency plans outside the normal duty hours.

1.8 Contractor travel: Performance under this PWS may require the Contractor to travel, Continental United States (CONUS) and within the National Capitol Region (NCR) to attend meetings, conferences, and training. Contractor shall be authorized travel expenses consistent with the cost principles and procedures in Federal Acquisition Regulation (FAR) Part 31.2, Travel Costs and the limitations of funds specified in this contract. All travel requires

Government approval/authorization and notification to the Contracting Officer Representative

(COR).

1.9 Other Direct Costs (ODC): Reimbursement for Government approved Contractor travel will be covered under Other Direct Costs. All travel costs will be on a firm fixed price basis.

1.10 Quality

1.10.1 Quality Control (QC): The contractor shall develop and maintain an effective QC program to ensure services are performed in accordance with this PWS. The contractor shall develop and implement procedures to identify, prevent, and ensure nonrecurrence of defective services. The contractor’s QC program is the means by which the work complies with stated requirements. The Contractor shall provide a comprehensive, written Quality Control Plan (QCP) within 60 days of contract award. If changes are made thereafter, the Contractor shall deliver an updated QCP within 5 working days. The QCP shall be provided as a section within the ABACUS Sustainment Management Plan as Deliverable 1] After acceptance of the Quality Control Plan (QCP) the contractor shall receive the Contracting Officer’s (CO’s) acceptance in writing of any proposed change to his QC system.

1.10.2 Quality assurance (QA): The government will evaluate the contractor’s performance under this contract in accordance with the Quality Assurance Surveillance Plan (QASP). This plan provides a systematic method for the Government to evaluate performance and to ensure that the contractor has performed in accordance with the performance standards. It defines how the performance standards will be applied, the frequency of surveillance, and the minimum acceptable defect rate(s).

1.11 Contractor personnel

1.11.1 CAC requirements: For all contractors who will work in Government facilities, the

Facilities Security Officer (FSO)/Company's Security point of contact (POC) will provide the

Government all the required information per the DHA CAC request process current version 2.1, January 2018, or more recent when updated. See process attached at Part 7 Section 7.1.1 of the

PWS. A CAC is the standard identification for eligible DoD contractor personnel.

1.11.1.1 The contractor shall return all CACs to the COR upon the departure of the contractor(s).

1.11.2 Contractor onboarding and training. The contractor shall complete all requirements, training, and forms as prescribed in the following requirements:

1.11.2.1 RESERVED

1.11.2.2 The DHA’s contractor training instructions embedded at Part 7 Section 7.1.2.

1.11.2.3 The contractor shall comply with onboarding requirements of the DHA for contractors needing to be issued CAC identification, including DoD- and DHA-directed training and forms submission, prior to network access.

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1.11.3 Physical Security: The contractor shall be responsible for safeguarding all government equipment, information and property provided for contractor use.

1.11.4 RESERVED

1.11.5 RESERVED

1.12 Key personnel:

Government:

ABACUS Program Manager

ABACUS COR

DHA UBO Program Manager

DHA UBO Deputy Program Manager

DHMSM Information Systems Security Manager (ISSM)

Contractor: The contractor shall provide a contract manager who shall be responsible for the performance of the work. The name of this person and an alternate who shall act for the contractor when the manager is absent shall be designated in writing to the CO. The contract manager or alternate shall have full authority to act for the contractor on all contract matters relating to daily operation of this contract. The contract manager or alternate shall be available between 8:30 a.m. to 5:00 p.m., Monday thru Friday except Federal holidays or when the government facility is closed for administrative reasons.

1.13 Data rights:

1.13.1. All data and associated materials deemed relevant to the Government, which have been generated by the Contractor in the performance of this contract, with the exception of software, shall remain the exclusive property of the Government. The software in use with ABACUS is owned by the current Contractor and/or its sub-Contractors.

1.13.2. All other tools (i.e., in Microsoft Word, Access, Excel, PowerPoint, or other software developed databases) acquired by the Government for use in ABACUS shall remain the property of the Government and shall have no affect or impact on monies owed to the Contractor by the

Government. All data remains the property of the Government and shall be surrendered upon demand.

1.14 Reporting

1.14.1 Contractor Manpower Reporting (CMR): RESERVED.

1.14.2 Non-Disclosure Agreement (NDA): All contractor personnel who will obtain access to proprietary, classified, or confidential information or any information release of which is protected or governed by law or regulation associated with DHA acquisitions shall be required to complete and sign a DHA contractor NDA (DHA Form 49) prior to beginning work on the subject contract. The contractor shall execute an NDA on behalf of the company and shall ensure that all staff assigned to, including all subcontractors and consultants, or other personnel

November 16, 2021 performing on contract/Task order execute an NDA protecting the procurement sensitive information of the Government and the proprietary information of other contractors. The NDA shall be executed not later than first day of employment and to be renewed upon exercising a contract option period. Assignment of staff who has not executed this statement or failure to adhere to this statement shall constitute default on the part of the contractor. The contractor shall maintain originally signed NDAs of individual employees and provide copy to the COR. (Non-

Disclosure Agreement (NDA) – Deliverable 10)

1.14.3 Government’s COR: The COR monitors all technical aspects of the contract and assists in contract administration. The COR is authorized to perform the following functions: assure that the contractor performs the technical requirements of the contract; perform inspections necessary in connection with contract performance; maintain written and oral communications with the contractor concerning technical aspects of the contract; issue written interpretations of technical requirements, including Government drawings, designs, specifications; monitor contractor's performance and notifies both the CO and contractor of any deficiencies; coordinate availability of government furnished property; and provide site entry of contractor personnel. A letter of designation issued to the COR, a copy of which is sent to the contractor, states the responsibilities and limitations of the COR, especially with regard to changes in cost or price, estimates or changes in delivery dates. The COR is not authorized to change any of the terms and conditions of the resulting contract.

1.14.4 Post award conference/periodic progress meetings: The contractor agrees to attend any post award conference convened by the contracting activity or contract administration office in accordance with FAR Subpart 42.5. The CO, COR, and other Government personnel, as appropriate, may meet periodically with the contractor to review the contractor's performance.

At these meetings the CO will apprise the contractor of how the government views the contractor's performance and the contractor will apprise the Government of problems, if any, being experienced. Appropriate action shall be taken to resolve outstanding issues. These meetings shall be at no additional cost to the government.

1.15 Contractor Identification

1.15.1 Contractor personnel performing services in a contractor capacity in a Government facility are required to possess and wear an identification badge that displays his or her name and the name of their company. All contractor personnel shall identify themselves as contractor support personnel in all forms of communication with all entities with whom the Assistant

Secretary of Defense for Acquisition and Sustainment (DAD A&S) has business dealings. The contractor shall: Answer all telephone calls and have a personalized voice message with an introductory statement that includes the fact that the person is contractor support personnel.

Ensure all those with whom the person interacts in any face-to-face dealings while supporting the

DAD A&S understands that the person is contractor support personnel. Include a title block in all emails that states the fact that the person is contractor support personnel. Ensure all those with whom the person interacts in any face-to-face dealings while supporting DAD A&S understands that the person is contractor support personnel.

November 16, 2021

1.15.2 Contractor personnel will be required to attend meetings or otherwise communicate with

Government and/or other contract representatives to meet the requirements of this order.

Contractor personnel shall make their contractor status known during introductions.

1.15.3 Contractor personnel, while performing in a contractor capacity, are prohibited from using their retired or reserve component military rank or title in any written or verbal communications associated with the contracts in which they provide services.

1.16 RESERVED

1.17 Personnel Security

1.17.1 The contractor shall comply with DoD 8570.01-M, “Information Assurance Workforce

Improvement Program, CH4” November 10, 2015 as amended; 8500.01, “Cybersecurity”, dated

March 14, 2014; DoD Manual (DoDM) 6025.18, “Implementation of the Health Insurance

Portability and Accountability Act (HIPAA) Privacy Rule Compliance in DoD Health Care

Programs” dated March 3, 2019, Department of Defense Instruction (DoDI) 6025.18 “HIPAA

Privacy Rule Compliance in DoD Health Care Programs”, dated March 13, 2019; and DoDM

5200.02 “Procedures for the DoD Personnel Security Program (PSP),” incorporation change 3, effective September 24, 2020. Contractor responsibilities for ensuring personnel security include, but are not limited to, meeting the following requirements:

1.17.1.1 Follow the DHA Personnel Security Office guidelines for submittal of security clearances. Contact the DHA Personnel Security Office for guidance on the appropriate background investigation required for personnel on the contract. The DHA Personnel Security

Office can be reached at (703) 275-6038.

1.17.1.2 Initiate, maintain, and document personnel security investigations appropriate to the individual’s responsibilities and required access to Controlled Unclassified Information (CUI).

1.17.1.3 DHA Personnel Security Office does not deny any access to any automated information system (AIS), network, or Controlled Unclassified Information (CUI). If a contractor receives an unfavorable background investigation, the request for access will be sent back to the FSO for further action. Any unfavorable adjudication will result in DHA Personnel Security Office not signing off on any access request.

November 16, 2021

PART 2

2.0 DEFINITIONS, ACRONYMS, AND APPLICABLE

PUBLICATIONS/INSTRUCTIONS

2.1 Definitions:

BALANCE BILL Certain categories of patients are required to be balance billed for services not paid by their primary payer. The invoice for the remaining balance of a medical service charge is described as a balance bill.

BILLABLE DATA Billable data, for the purposes of ABACUS Billing and

Collection, consists of TPC eligible encounter data, MSA encounter data, and potential MAC encounter data. TPC eligible data consists of encounter data attributable to patients in the

ABACUS Billing Categories 1 and 2, as well as 4 and 4a if OHI exists. MSA data consists of encounter data attributable to patients in the ABACUS Billing Categories 3, 3a, 5-31, and 4 and 4a if no OHI exists. MAC data consists of encounter data attributable to patients in the ABACUS Billing Categories 1, 2, 4, 4a, and 32 if treatment is related to an injury. Updates to the

Patient Category Table and the ABACUS Billing Category Table will be provided as required

CATEGORY D Information Technology and Telecommunications Services

(called D-Services)

CATEGORY R Support (Professional/Administrative/Managements) Services

(called R-Services)

CHAMPUS

MAXIMUM

ALLOWABLE

CHARGE

TRICARE Management Activity (TMA) UBO CHAMPUS

Maximum Allowable Charge (CMAC) rates are developed for reimbursement in the purchased care community, however not all services furnished in an MTF setting are included; therefore, TMA UBO develops rates for each outpatient encounter, service, procedure, or supply provided within an MTF. Rates are billed as a line-item charge. The majority of outpatient, itemized charges are based on the CMAC fee schedule and other government furnished rate tables. CMAC reimbursement rates, established under Title 32, Section 199.14(h) of the Code of

Federal Regulations, are used to determine the appropriate charge for the professional and technical components of services based on the Healthcare Common Procedure Coding System

(HCPCS) methodology, which includes the Current Procedural

Terminology (CPT) codes. CMAC rates pertain to professional services (e.g., office and clinic visits) and ancillary services (e.g., laboratory and radiology). UBO CMAC rates differ from standard TMA CMAC rates in that UBO CMAC rates are formatted for military billing systems and include rates for

November 16, 2021 additional services not reimbursed by TRICARE. UBO CMAC rates are calculated for 91 distinct “localities”. These localities recognize differences in local costs to provide health care services in the different geographic regions in which MTFs are located. The CMAC table is further categorized by provider class. The Component rate table specifies which rates to use for

CPT codes, which can be provided as distinct professional and technical components, or as a combined professional and technical service. A separate rate is provided for each component, further categorized by provider class.

CLAIMS

SCRUBBER

A claims scrubber analyzes the data that is on the claim and compares the data to its rules engine before the claim is submitted.

COMPONENT

RATE TABLE

The Component Rate Table specifies the technical (TC) and professional (PC) components and/or the combined technical and professional service for CPT codes.

COMPOSITE

HEALTH CARE

SYSTEM

CHCS is a Virtual Memory System (VMS)-based medical informatics system that is used by all DoD military health care centers. CHCS is module based: modules include RAD

(Radiology), LAB (Laboratory), PHR (Pharmacy), PAS (Patient

Appointing & Scheduling), MCP (Managed Care Program), PAD (Patient Administration), MRT (Medical Records

Tracking), MSA (Medical Service Accounting), WAM

(Workload Assignment Module), DTS (Dietetics), CLN

(Clinical: Nursing, Physician, and Allied Health), DAA

(Database Administration), ADM (Ambulatory Data Module), and TOOLS (FileMan). Furthermore, the capabilities of CHCS are enhanced by its ability to interface to over 40 different clinical and administrative systems.

CONTRACTING

OFFICER (CO)

A person with authority to enter into contract; administer or terminate contracts. Make related determinations and findings on behalf of the government. Note: The only individual who can legally bind the government.

CONTRACTING

OFFICER'S

REPRESENTATIVE

(COR)

An individual, including a contracting officer’s technical representative (COTR), designated and authorized in writing by the CO to perform specific technical or administrative functions.

This individual does NOT have authority to change the terms and conditions of the contract.

CONTRACTOR The term as used in this contract refers to the prime.

COORDINATED

UNIVERSAL TIME

UTC is the primary time standard by which the world regulates clocks and time. Computer servers, online services and other entities that rely on having a universally accepted time use UTC for that purpose. Time zones around the world are expressed as positive or negative offsets from UTC.

DEFENSE

MEDICAL

DMIS ID is a unique identification code assigned by TMA to facilities, catchment areas, and other entities.

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INFORMATION

SYSTEM

IDENTIFIER

DISPUTED

CLAIMS

TPC claims that have been unacknowledged or incorrectly paid and have failed to be resolved by UBO with the payer. The payer may be wrongfully withholding payment to the MTF.

Once the MTF UBO has exhausted its efforts, the incorrectly processed claims are referred to MEDCOM Office of the Staff

Judge Advocate which provides guidance and legal support to the TPCP by pursuing collection of claims inappropriately paid or denied by third-party payers.

DUNNING LETTER A Dunning Letter, also referred to as a delinquent and/or follow-up letter, is a notification sent to a debtor or insurer, stating that the debtor or insurer is overdue in paying an account receivable to the provider of services. Dunning Letters typically follow a progression from polite reminders to more strident demands for payment, if the customer continues to be non-responsive in paying. Generally, the UBO shall send demand letters at 30 days and 60 days after the payment due date. The due date for a receivable is normally 30 days from the date of the invoice or notice of indebtedness.

ELECTRONIC

CLEARING HOUSE

An Electronic Clearing House (ECH) accepts the electronic file from a medical provider, checks the claim for errors (scrubbing), alerts the user of required fixes, and then securely transmits the electronic file to the specified payer with which it has already established a secure connection that meets the strict standards as dictated by a HIPAA.

EXPLANATION OF

BENEFITS

An EOB is a statement sent by a health insurance company explaining what medical treatment and/or services were paid.

An EOB typically describes the service performed such as the date of the service, the provider of the service, and the name of the patient, the allowed amount, and the amount the patient is responsible for.

FAMILY MEMBER

PREFIX

A two-digit code used to identify a patient and his/her relationship to the sponsor. Examples include, 20-Sponsor, 30-

1st Spouse, 31-2nd Spouse, 01-1st Child, 02-2nd Child, 40-

Mother or Stepmother, 45-Father or Stepfather, 50-Mother-in-law, 55-Father-in-law, 98-Civilian Emergency. It is used in combination with the sponsor's Social Security Number; 20/123-

45-6789 indicates that the sponsor is the patient while 01/123-

45-6789 indicates that the 1st child of the sponsor is the patient.

FEDERAL RISK

AND

AUTHORIZATION

MANAGEMENT

PROGRAM

The FedRAMP is a government-wide program that provides a standardized approach to security assessment, authorization, and continuous monitoring for cloud products and services.

November 16, 2021

FISCAL YEAR A fiscal year, or financial year, is a period used for calculating annual financial statements in businesses and other organizations. The US Government fiscal year starts October 1 and ends September 30 of each year.

FULL

DEPLOYMENT

The functionality provided by ABACUS in accordance with the

Sustainment Plan such that the MSA and MAC modules are fully capable. ABACUS can be accepted by the Government as completely deployed.

GOVERNMENT

BILLING

CALCULATION

FACTORS

Government Billing Calculation Factors are discounts for

International Military Education & Training (IMET) and

Interagency/Other Federal Agency Sponsored Rate (IOR) calculated based on previous year expense and workload data from all DoD MTFs that offer outpatient and inpatient services.

IMET and IOR adjustments are calculated by removing from the

Full Reimbursable Outpatient Rate (FOR) those expenses which are excluded from consideration in IMET and Interagency billing. A government discount or billing calculation factor

(percentage discount) is applied to the FOR when billing for

IMET and IOR services.

GOVERNMENTAL

BILLING FORMS

Term used to encompass billings forms used by UBO to bill both

DoD and other Federal Agencies. These forms include the

Standard Form 1080, the DD Form 7, and the DD Form 7a.

INITIAL

DEPLOYMENT

The functionality provided by ABACUS in accordance with the

Sustainment Plan such that the TPC module is fully capable and deployed.

KNOWLEDGE

BASE

Knowledge Bases are databases designed to allow people to retrieve and use the knowledge they contain. They are commonly used to complement a help desk or for sharing information among employees within an organization. They might store troubleshooting information, articles, white papers, user manuals, or answers to frequently asked questions. Typically, a search engine is used to locate information in the system, or users may browse through a classification scheme.

LINES OF

BUSINESS

UBO Lines of Business are the Third-Party Collection, Medical

Services Account, and Medical Affirmative Claims Programs.

LOCALITY UBO CMAC rates are calculated for 91 distinct “localities”.

These localities recognize differences in local costs to provide health care services in the different geographic regions in which

MTFs are located. For each CMAC locality, the UBO creates two sub-tables of rates: CMAC and Component. The CMAC rate table specifies the rates to use as payment for professional services and procedures identified by CPT and HCPCS codes, which cannot be separately provided as component services.

MEDICAL

AFFIRMATIVE

CLAIMS

A sub-program of the UBO. MAC activities involve billing all areas of liability insurance, such as automobile, products, premises and general casualty, homeowner’s, renter’s, medical

November 16, 2021 malpractice (by civilian providers), and workers' compensation

(other than Federal employees).

MEDICAL

EXPENSE and

PERFORMANCE

REPORTING

SYSTEM

MEPRS is the standard cost accounting system for the Military

Health System (MHS), containing Tri-Service financial, personnel, and workload data from reporting medical and dental treatment facilities worldwide. From a UBO perspective, the

MEPRS code identifies the clinic/ancillary site in which services take place.

MEDICAL

SERVICES

ACCOUNT

A sub-program of the UBO. MSA activities involve the first-payer billing of individuals and other Government Agencies for services rendered in MTFs to include, but not limited to, the U.S.

Coast Guard, the National Oceanic and Atmospheric

Administration, and the U.S. Public Health Service.

NONPERSONAL

SERVICES

CONTRACT

A contract under which the personnel rendering the services are not subject, either by the contract’s terms or by the manner of its administration, to the supervision and control usually prevailing in relationships between the Government and its employees.

OTHER HEALTH

INSURANCE (OHI)

Third Party Insurance carried by DoD eligible beneficiaries, as well as non-DoD beneficiaries. OHI is any health insurance received through an employer or private insurance program. Any OHI held in addition to TRICARE or

MEDICARE coverage is the primary health policy.

PATIENT

CATEGORY

PATCAT codes are closely linked to entitlements under the

Uniformed Services Health Benefits Program (USHBP).

PATCATs allow identification and grouping of patients by

‘types’ of interest such as Sponsor Service, Beneficiary

Category, and Special Interest patient groups. PATCATs are directly linked to UBO Billing because they determine the rate to charge and method of billing.

PHYSICAL

SECURITY

Actions that prevent the loss or damage of government property.

PROVIDER CLASS The four provider classes are 1) Physicians, 2) Psychologists, 3)

Other Mental Health Providers, and 4) Other Medical Providers.

QUALITY

ASSURANCE

SURVEILLANCE

PLAN

An organized written document specifying the surveillance methodology to be used for surveillance of contractor performance. The Government may either prepare the QASP or require the offerors to submit a proposed quality assurance surveillance plan for the Government’s consideration in development of the Government’s plan.

QUALITY

ASSURANCE

The government procedures to verify that services being performed by the Contractor are performed according to acceptable standards.

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QUALITY

CONTROL

All necessary measures taken by the Contractor to assure that the quality of an end product or service shall meet contract requirements.

REMITTANCE

ADVICE

Health Care Claim Payment/Advice in the HIPAA 835 format.

As a remittance advice, the 835 provides detailed payment information relative to a health care claim(s) and, if applicable, describes why the total original charges have not been paid in full. This remittance information is provided as “justification” for the payment, as well as input to the payee’s patient accounting system/accounts receivable (A/R) and general ledger applications.

SOFTWARE AS A

SERVICE (SaaS)

Software that is developed and hosted by the SaaS vendor and which the end user customer accesses over the Internet. Unlike traditional packaged applications that users install on their computers or servers, the SaaS vendor owns the software and runs it on computers in its data center. The customer does not own the software but effectively rents it. SaaS is sometimes also known as hosted software or by its more marketing-friendly cousin, “on-demand.”

SUBCONTRACTOR One that enters into a subcontract and assumes some of the obligations of the primary Contractor.

SUBSISTENCE IN

KIND

Food furnished to enlisted personnel at government expense

(also known as meal card or Rations in Kind)

THIRD PARTY

COLLECTION

PROGRAM

A sub-program of the UBO. TPC activities involve billing third-party payers on behalf of non-active duty dependents for treatment provided in MTFs.

UNIFORM

BUSINESS OFFICE

TRICARE Management Activity (TMA) UBO Program Office is responsible for setting policy and providing program oversight for the Military Health System's (MHS’s) three health care cost recovery programs and providing overall revenue cycle direction. The Services establish and operate UBO offices at

MTFs throughout the world that administer TPC, MSA, and

MAC Programs. UBO offices focus on ensuring that billable services are identified; payer information is available; accurate and complete claims are generated; and appropriate collection are received.

VALID OHI Valid OHI is a policy that is defined as a UBO billable policy.

Valid billable policy submissions include the effective date, expiration date, plan type, coverage type (e.g., medical, dental, vision, etc.), policy ID, group ID, bin, other covered dependents, and patient level benefits. A valid billable policy cannot be older than two years from the expiration date at the time of submission. Plan types CANNOT be TRICARE, TRICARE

Supplement, Medicare Part A, Medicare Part B, Medicare Part

C, Medicare Part D, or Medicaid.

WORK WEEK Is defined as Monday through Friday.

2.2 Acronyms:

ABACUS Armed Forces Billing and Collection Utilization Solution

ACAS Assurred Compliance Assessment Solution

ACOR Alternate Contracting Officer’s Representative

ADM Ambulatory Data Module

AF Air Force

AFB Air Force Base

AFMS Air Force Medical Service

AIS Automated Information System

AO Authorizing Official

AOR Area of Responsibility

API Application Programming Interface

APL Approved Products List APL

APV Ambulatory Procedure Visit

AQL Acceptable Quality Level

AR Army Regulations

ARRT Acquisition Requirements Roadmap Tool

A/R Accounts Receivable

ARRA American Recovery and Reinvestment Act of 2009

ASA Adjusted Standard Account

ASD (HA) Assistant Secretary of Defense (Health Affairs)

ATC Authority to Connect

ATCTS Army training and Certification Tracking System

ATO Authority to Operate

AUP Acceptable Use Policy

AWG Advisory Work Group

B2B Business-2-Business

BAA Business Associate Agreement

BER Billing Events Repository

BUMED Navy Bureau of Medicine and Surgery

CAC Common Access Card

CAO Contract Administration Office

CAP Cloud Access Point

CAPER Comprehensive Ambulatory/Professional Encounter Record

CBA Capability Based Assessment

CCE Coding Compliance Editor

CCEVS Common Criteria Cybersecurity Evaluation and Validation Scheme

CCV Cash Collection Voucher

CDI Covered Defense Information

CDM Charge Description Master

CDR Contract Discrepancy Report

CDT Current Dental Terminology

CE Computer Environment

CDRL Contract Data Requirement List

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CFO Chief Financial Officer

CFOIC Chief Financial Officer Integrating Council

CFR Code of Federal Regulations

CHAMPUS Civilian Health and Medical Program of the Uniformed Services

CHCS Composite Healthcare System

CIO Chief Information Officer

CITPO Clinical Information Technology Program Office

CJCSM Chairman of the Joint Chiefs of Staff Manual

CLN Clinical (Nursing, Physicial and Allied Health)

CMAC CHAMPUS Maximum Allowable Charge

CMBB Charge Master Based Billing

CMMC Cybersecurity Maturity Model Certification

CMR Contractor Manpower Reporting

CMS Centers for Medicare and Medicaid Services

CMS 1500 CMS 1500 Claim Form

CNC Currently Not Collectible

CNDSP Computer network Defense Service Provider

CNSS Committee on National Security Systems

CNSSI Committee on National Security Systems Instruction

CO Contracting Officer(s)

CONOPS Concept of Operations

CONUS Continental United States (excludes Alaska and Hawaii)

COR Contracting Officer Representative

COTR Contracting Officer's Technical Representative

COTS Commercial-Off-The-Shelf

CPA Cerner Patient Accounting

CPT Current Procedural Terminology

CS Contract Specialist

CSET Cosmetic Surgery Estimator Tool

CSP Cloud Service Provider

CSSP Cyber Security Service Provider

CST Central Standard Time

CVS Contractor Verification System

CUI Controlled Unclassified Information

DA Department of the Army

DAD-A Deputy Assistant Director for Acquisition

DAD-IO Deputy Assistand Director – Information Operations

DC3 DoD Cyber Crime Center

DCMO Debt and Claims Management Office

DD Form 254 Department of Defense Contract Security Requirement List (if applicable)

DB Design-Build

DBB Design-Bid-Build

DCQ Disputed Claims Queue

DEAMS Defense Enterprise Accounting and Management System

DEERS Defense Enrollment Eligibility Reporting System

DFARS Defense Federal Acquisition Regulation Supplement

November 16, 2021

DFAS Defense Finance and Accounting Services

DHA Defense Health Agency

DHP Defense Health Program

DHMSM DoD Healthcare Management Systems Modernization

DISA Defense Information System Agency

DISCO Defense Industrial Security Clearance Office

DMDC Defense Manpower Data Center

DME Durable Medical Equipment

DMIS Defense Medical Information System

DMIS ID Defense Medical Information System Identifier

DoD Department of Defense

DoDD Department of Defense Directive

DoDI Department of Defense Instruction

DSAs Data Sharing Agreements

DSAA Data Sharing Agreement Application

DMZ Demilitarized Zone

DoDM Department of Defense Manual

DPCLO DHA Privacy and Civil Liberties Office

DRG Diagnosis Related Group

DTS Defense Travel System

DUA Data Use Agreement

EAS IV Expense Assignment System Version 4

ECH Electronic Clearing House

ECS Elective Cosmetic Surgery

EFT Electronic Funds Transfer

E & M Evaluation and Management eMSM Enhanced Multi-Service Markets

EOB Explanation of Benefits

EOP Explanation of Payments

ERA Electronic Remittance Advice

ERP Enterprise Resource Advice

ESD Enterprise Service Desk

EULA End User License Agreement

EVM Earned Value Management

FAR Federal Acquisition Regulation

FCI Federal contract information

FE Facilities Enterprise

FedRAMP Federal Risk Authorization and Management Program

FIPS PUB Federal Information Processing Standards Publication

FISC Fleetand Industrial Supply Center

FISMA Federal Information Security Modernization Act

FLEX Flexible Rate

FLXO Flexible Outpatient Rate

FMP Family Member Prefix

FMR Family Member Rate

FMR Financial Management Regulation

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FOIA Freedom of Information Act

FOC Full Operational Capability

FOR Full Outpatient Rate

FRCS Facility Related Control Systems

FRR Full Reimbursable Rate

FSC Federal Service Code

FSO Facilities Security Officer

FY Fiscal Year

GAAP Generally Accepted Accounting Principles

GBF Governmental Billing Forms

GFEBS General Fund Enterprise Business System

GL General Ledger

HA Health Affairs

HB&FP Health Budgets and Financial Policy

HCPCS Healthcare Common Procedure Coding System

HHS Health and Human Services

HIPAA Health Insurance Portability and Accountability Act

HCA Head of the…