Attachment J-3 CDRLs.pdf

SECTION J

ATTACHMENT J-3

Contract Data Requirement List (CDRL)

DD FORM 1423-1, FEB 2001 PREVIOUS EDITION MAY BE USED. Page 1 of 2 Pages

CONTRACT DATA REQUIREMENTS LIST

(1 Data Item)

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP TM OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO.

A010

2. TITLE OF DATA ITEM

Third Party Recoveries for Fiscal Year Report

3. SUBTITLE

Initial

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE

TOM C10 S4

6. REQUIRING OFFICE

OGC

7. DD 250 REQ 9. DIST STATEMENT

REQUIRED

B

10. FREQUENCY

See Block 16

12. DATE OF FIRST SUBMISSION

See Block 16

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

8. APP CODE 11. AS OF DATE

See Block 16

13. DATE OF SUBSEQUENT

SUBMISSION

See Block 16 Draft

Final

Reg Repro

16. REMARKS

FIRST SUBMISSION:

Frequency: Annual (Fiscal Year)

Reporting Period Start Date: Start of service delivery Due Date: November 1

SUBSEQUENT SUBMISSION: CONTINUE FROM FIRST SUBMISSION

PHI/PII: No FILE FORMAT: No specific file format required

CONTENT DETAILS:

The report shall include the following elements:

- Reporting Period (covering the 12 months of the previous Fiscal Year)

- The Contractor’s Name and Region Name (if applicable)

- The Uniformed Service that the report figures are associated with (i.e., Army, Air Force, Navy & Marine Corps, Coast Guard, United States Public Health Service (USPHS) and National Oceanic and Atmospheric Administration

(NOAA)).

The contractor shall create a breakdown for each of the Uniformed Services listed above which includes the following categories:

- Number of cases investigated for potential Third Party Liability (TPL).

- Total dollar amount actually paid on all claims investigated.

- Number of cases referred to the Uniformed Services for further investigation and collection.

- Actual dollar amount paid on all claims referred to the Uniformed Services for further investigation and collection.

For potential TPL claims that were investigated and/or referred, the contractor shall list the Uniformed Services Claim Office (USCO) where the potential TPL case was referred. The contractor shall then report the appropriate figures for the categories listed immediately above, by the appropriate state(s) and/or countries.

Template is attached with updates provided by the government as required.

Submit through the

DHA e-Commerce Extranet.

(Per TOM C14)

15. TOTAL 0 0 0

G. PREPARED BY

Bridget N Ewings

H. DATE

06/22/2026

I. APPROVED BY

Bridget N Ewings

J. DATE

06/22/2026

DRAFT

THIRD PARTY RECOVERIES FOR FISCAL YEAR REPORT

(CONTRACTOR NAME)

REPORTING PERIOD:

Branch

State Where

Accident

Occurred USCO Claims Office Name Contract

(Claims) Number of Cases

Involving TRICARE

Payments Investigated for

Potential Third Party

Liability

(Claims) Dollar Amount of

Cases Involving TRICARE

Payments Investigated for

Potential Third Party

Liability

(Inform) Number of Cases

Involving TRICARE

Payments Referred to

Uniformed Services

(Inform) Dollar Amount of

Cases Involving TRICARE

Payments Referred to

Uniformed Services

Air Force

Air Force Total

Army

Army Total

Marine

Marine Total

Navy

Navy Total

Coast Guard

Coast Guard Total

DHSS

DHSS Total

NOAA

NOAA Total

TOTAL

DD FORM 1423-1, FEB 2001 PREVIOUS EDITION MAY BE USED. Page 1 of 1 Pages

(1 Data Item)

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP TM OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO.

A020

2. TITLE OF DATA ITEM

Service Organization Control Report (SOC1) - Statement on Standards for Attestation Engagements, SSAE No. 18 (Service Organization Report)

3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

CRM

7. DD 250 REQ 9. DIST STATEMENT

REQUIRED

B

10. FREQUENCY

See Block 16

12. DATE OF FIRST SUBMISSION

See Block 16

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

8. APP CODE 11. AS OF DATE

See Block 16

13. DATE OF SUBSEQUENT

SUBMISSION

See Block 16 Draft

Final

Reg Repro

16. REMARKS

FIRST SUBMISSION:

Frequency: One Time (Start of service delivery – June 30) Reporting Period Start Date: Start of service delivery Due Date: 45 calendar days after end of reporting period

SUBSEQUENT SUBMISSION:

Frequency: Annual (1 July – 30 June) Period Start Date: July 1, 20xx Due Date: 45 calendar days after end of reporting period Note: CDRL required during transition-out

PHI/PII: No FILE FORMAT: No specific file format required

CONTENT DETAILS:

The contractor must engage an independent external auditing firm to conduct a System and Organizational Controls (SOC) for Service Organizations examination and produce a Report on Controls at a Service Organization Relevant to User Entities Internal Control over Financial Reporting, SOC 1 Type 2 Report, in accordance with the American Institute of Certified Public Accountants (AICPA) Statement on Standards for Attestation Engagements, No. 18, Attestation Standards: Clarification and Recodification (SSAE 18).

The independent auditing firm must have prior experience in conducting SSAE audits.

Annually, the contractor shall provide a copy of the SOC 1 Type 2 examination report (the “Service Organization Report”).

Scope – Refer to the contract requirements located in Section G of the contract.

Deficiencies & Corrective Action Plans – Refer to contract requirements located in Section G of the contract.

Monitoring & Evaluation – Refer to contract requirements located in Section G of the contract.

Submit through the

DHA e-Commerce

Extranet.

(Per TOM C14)

15. TOTAL 0 0 0

G. PREPARED BY

Laura E White

H. DATE

08/03/2026

I. APPROVED BY

Laura E White

J. DATE

08/03/2026

Initial

CTR G.11.2

PREVIOUS EDITION MAY BE USED. Page 1 of 1 Pages

(1 Data Item)

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP TM OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO.

A030

2. TITLE OF DATA ITEM

Service Organization Control Report (SOC1) - Statement on Standards for Attestation Engagements, SSAE No. 18 (Subservice Organization)

3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

CRM

7. DD 250 REQ 9. DIST STATEMENT

REQUIRED

B

10. FREQUENCY

See Block 16

12. DATE OF FIRST SUBMISSION

See Block 16

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

8. APP CODE 11. AS OF DATE

See Block 16

13. DATE OF SUBSEQUENT

SUBMISSION

See Block 16 Draft

Final

Reg Repro

16. REMARKS

FIRST SUBMISSION:

Frequency: One Time (Start of service delivery-May 31) Reporting Period Start Date: Start of service delivery Due Date: 45 calendar days after end of reporting period

SUBSEQUENT SUBMISSION:

Frequency: Annual (1 June – 31 May) Reporting Period Start Date: June 1, 20XX Due Date: 45 calendar days after end of reporting period Note: CDRL required during transition-out

PHI/PII: No FILE FORMAT: No specific file format required

CONTENT DETAILS:

The contractor must engage in independent external auditing firm to conduct a System and Organization Controls (SOC) for Service Organizations examination and produce a Report on Controls at a Service Organization Relevant to User Entities Internal Control over Financial Reporting, SOC 1 Type 2 Report, in accordance with the American Institute of Certified Public Accountants (AICPA) Statement on Standards for Attestation Engagements, No. 18. Attestation Standards: Clarification and Recodification (SSAE 18). The independent auditing firm must have prior experience in conducting SSAE audits.

If applicable, for any material subcontractors (e.g., a claims processing contractor), the contractor shall provide a copy of the SOC 1 Type 2 report (Subservice Organization Report) on an annual basis.

Scope – Refer to contract requirements in Section G of the contract.

Deficiencies & Corrective Action Plans – Refer to contract requirements located in Section G of the contract.

Monitoring & Evaluation – Refer to contract requirements located in Section G of the contract.

Submit through the

DHA E-Commerce

Extranet.

(Per TOM C14)

15. TOTAL 0 0 0

G. PREPARED BY

DD FORM 1423-1, FEB 2001

H. DATE

08/03/2026

I. APPROVED BY

Laura E White

J. DATE

08/03/2026Laura E White

Initial

DD FORM 1423-1, FEB 2001 PREVIOUS EDITION MAY BE USED. Page 1 of 4 Pages

(1 Data Item)

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP TM OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO.

A040

2. TITLE OF DATA ITEM

Bridge Letter in Support of Service Organization Control Report (SOC1) - Statement on Standards for Attestation Engagements, SSAE No. 18 (Service Organization Bridge Letter)

3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

CRM

7. DD 250 REQ 9. DIST STATEMENT

REQUIRED

B

10. FREQUENCY

See Block 16

12. DATE OF FIRST SUBMISSION

See Block 16

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

8. APP CODE 11. AS OF DATE

See Block 16

13. DATE OF SUBSEQUENT

SUBMISSION

See Block 16 Draft

Final

Reg Repro

16. REMARKS

FIRST SUBMISSION:

Frequency: Annual (1 July - 30 September) Reporting Period Start and End Date (Bridge Letter): 1 July - 30 September Due Date: 5 business days after end of reporting period

SUBSEQUENT SUBMISSION: CONTINUE FROM FIRST SUBMISSION

Note: CDRL required during transition out

PHI/PII: No

FILE FORMAT: No specific file format required

CONTENT DETAILS:

The contractor must provide a Bridge Letter covering the period through September 30 not covered by the Service Organization Report. Bridge Letter template attached to be used for example purposes only, updated format and questions to be provided annually by the government.

Submit through the

DHA e-Commerce

Extranet.

(Per TOM C14)

15. TOTAL 0 0 0

G. PREPARED BY

Laura E White

H. DATE

08/03/2026

I. APPROVED BY

Laura E White

J. DATE

08/03/2026

Initial

September 30, 20XX (Insert Contractor Name) Responses to

SOC 1 Review Questionnaire

1. Any changes to the operating processes/internal control environment which were detailed and tested in the SOC 1 for the period ended September 30, 20XX. Do you expect any changes to occur prior to September 30, 20XX?

RESPONSE:

2. Are there any scope changes since the last SOC 1 noted above?

RESPONSE:

3. Can you identify any event that may impact DHA’s internal controls over financial reporting during the current year?

RESPONSE:

4. Please indicate if there has been a significant, i.e. greater than 10% personnel turnover in any of the following areas as it relates to the Health Care contract (XXX,XXX, if any):

a. Claim Processing

b. Electronic Claim Entry

c. Manual Claim Entry

d. Claims Adjudication

e. Master File Maintenance

f. Claims Adjustments

g. Financial Administration

RESPONSE:

5. When was the last independent audit completed by the internal audit department which covered the XXXX claims processing for the TRICARE contracts? Have there been any deficiencies noted by the internal audit department in FY XX as it relates to the XXXX claims processing for the

TRICARE contracts?

RESPONSE:

6. Please discuss the progress of any corrective actions on any outstanding deficiencies noted in the SOC 1 referenced above as it relates to DHA.

RESPONSE:

Deficiency in FYE 9-30-XX TRICARE SOC 1 Current Status

1. Control Objective XX XXXXXX

2. Control Objective XX XXXXXX

3. Control Objective XX XXXXXX

4. Control Objective XX XXXXXX

7. Please indicate any system changes at XXXX or any changes XXXX needed to make due to requests from Defense Health Agency (DHA) as they relate to XXXX?

RESPONSE:

8. Please indicate any IT changes, as they relate to the XXXX Health Care contracts.

RESPONSE:

9. Please indicate any significant, i.e. greater than 10%, increases/decreases in the volume of claims processed for the XXXX Health Care contracts.

RESPONSE:

10. Please indicate any changes in the policies and procedures related to the claims processing and claims adjudication process, as they relate to the XXXX Health Care contracts.

RESPONSE:

11. Please indicate any changes in the policies and procedures related to the quality assurance department, as they relate to the XXXX Health Care contracts.

RESPONSE:

12. Please indicate any changes in the policies and procedures related to the duplicate claims reviews, as they related to the XXXX Health Care contracts.

13. If the Service Provider is using a Sub-Contractor, how is the Service Provider monitoring the Sub-

Contractor’ controls in compliance with SSAE No 18?

RESPONSE:

14. When is the Contractor’s new SOC 1, compliant with SSAE No 18, expected to be delivered to

DHA?

DD FORM 1423-1, FEB 2001 PREVIOUS EDITION MAY BE USED. Page 1 of 4 Pages

(1 Data Item)

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP TM OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO.

A050

2. TITLE OF DATA ITEM

Bridge Letter in Support of Service Organization Control Report (SOC1) - Statement on Standards for Attestation Engagements, SSAE No. 18 (Subservice Organization Bridge Letter)

3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

CRM

7. DD 250 REQ 9. DIST STATEMENT

REQUIRED

B

10. FREQUENCY

See Block 16

12. DATE OF FIRST SUBMISSION

See Block 16

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

8. APP CODE 11. AS OF DATE

See Block 16

13. DATE OF SUBSEQUENT

SUBMISSION

See Block 16 Draft

Final

Reg Repro

16. REMARKS

FIRST SUBMISSION:

Frequency: Annual (1 June - 30 September) Reporting Period Start and End Date: 1 June – 30 September Due Date: 5 business days after end of reporting period

SUBSEQUENT SUBMISSION: CONTINUE FROM FIRST SUBMISSION

Note: CDRL required during transition-out

PHI/PII: No

FILE FORMAT: No specific file format required

CONTENT DETAILS:

The contractor shall provide a Bridge Letter through September 30 not covered by the

Subservice Organization Report. Bridge Letter template attached to be used for example purposes only, updated format and questions to be provided annually for the government.

DHA e-Commerce Extranet.

(Per TOM C14)

15. TOTAL 0 0 0

G. PREPARED BY

Laura E White

H. DATE

08/03/2026

I. APPROVED BY

Laura E White

J. DATE

08/03/2026

Submit through the

Initial

September 30, 20XX (Insert Contractor Name) Responses to

SOC 1 Review Questionnaire

1. Any changes to the operating processes/internal control environment which were detailed and tested in the SOC 1 for the period ended September 30, 20XX. Do you expect any changes to occur prior to September 30, 20XX?

RESPONSE:

2. Are there any scope changes since the last SOC 1 noted above?

RESPONSE:

3. Can you identify any event that may impact DHA’s internal controls over financial reporting during the current year?

RESPONSE:

4. Please indicate if there has been a significant, i.e. greater than 10% personnel turnover in any of the following areas as it relates to the Health Care contract (XXX,XXX, if any):

a. Claim Processing

b. Electronic Claim Entry

c. Manual Claim Entry

d. Claims Adjudication

e. Master File Maintenance

f. Claims Adjustments

g. Financial Administration

RESPONSE:

5. When was the last independent audit completed by the internal audit department which covered the XXXX claims processing for the TRICARE contracts? Have there been any deficiencies noted by the internal audit department in FY XX as it relates to the XXXX claims processing for the

TRICARE contracts?

RESPONSE:

6. Please discuss the progress of any corrective actions on any outstanding deficiencies noted in the SOC 1 referenced above as it relates to DHA.

Deficiency in FYE 9-30-XX TRICARE SOC 1 Current Status

1. Control Objective XX XXXXXX

2. Control Objective XX XXXXXX

3. Control Objective XX XXXXXX

4. Control Objective XX XXXXXX

7. Please indicate any system changes at XXXX or any changes XXXX needed to make due to requests from Defense Health Agency (DHA) as they relate to XXXX?

RESPONSE:

8. Please indicate any IT changes, as they relate to the XXXX Health Care contracts.

RESPONSE:

9. Please indicate any significant, i.e. greater than 10%, increases/decreases in the volume of claims processed for the XXXX Health Care contracts.

RESPONSE:

10. Please indicate any changes in the policies and procedures related to the claims processing and claims adjudication process, as they relate to the XXXX Health Care contracts.

RESPONSE:

11. Please indicate any changes in the policies and procedures related to the quality assurance department, as they relate to the XXXX Health Care contracts.

RESPONSE:

12. Please indicate any changes in the policies and procedures related to the duplicate claims reviews, as they related to the XXXX Health Care contracts.

13. If the Service Provider is using a Sub-Contractor, how is the Service Provider monitoring the Sub-

Contractor’ controls in compliance with SSAE No 18?

RESPONSE:

14. When is the Contractor’s new SOC 1, compliant with SSAE No 18, expected to be delivered to

DHA?

(1 Data Item)

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP TM OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO.

A060

2. TITLE OF DATA ITEM

State Prevailing Annual Update Report

3. SUBTITLE

Initial

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE

TRM C5 S3

6. REQUIRING OFFICE

MB&RB/TMEP

7. DD 250 REQ 9. DIST STATEMENT

REQUIRED

B

10. FREQUENCY

See Block 16

12. DATE OF FIRST SUBMISSION

See Block 16

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

8. APP CODE 11. AS OF DATE

See Block 16

13. DATE OF SUBSEQUENT

SUBMISSION

See Block 16 Draft

Final

Reg Repro

16. REMARKS

FIRST SUBMISSION:

Frequency: Annual (Calendar Year) Reporting Period Start Date: Start of service delivery Due Date: 30 calendar days after CMAC file implementation

SUBSEQUENT SUBMISSION: CONTINUE FROM FIRST SUBMISSION

PHI/PII: No FILE FORMAT: Microsoft Excel

CONTENT DETAILS:

The contractor shall use the charges for claims for services that were provided on July 1 and ending on June 30. The updated amounts shall be implemented with the CMAC file, which normally occurs in February. For example, the annual update to state prevailings for 2025, shall be established using claims data from July 1, 2023, through June 30, 2024, and shall be implemented with the 2025 CMAC update, and continue with subsequent CMAC updates.

The report shall include, at a minimum, the HCPCS/CPT code, the applicable state, provider class, modifier, current pricing, the effective date for the current pricing, and previous pricing (if applicable) for the most recent two years, as well as the effective dates for the previous two years pricing.

Submit through the

DHA e-Commerce Extranet.

(Per TOM C14)

15. TOTAL 0 0 0

G. PREPARED BY

Elan P Green

H. DATE

06/22/2026

I. APPROVED BY

Elan P Green

J. DATE

(1 Data Item)

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP TM OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO.

A070

2. TITLE OF DATA ITEM

Risk Assessment Letter of Assurance

3. SUBTITLE

Initial

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE

TOM C19 S3

6. REQUIRING OFFICE

Privacy & Civil Liberties Office

7. DD 250 REQ 9. DIST STATEMENT

REQUIRED

B

10. FREQUENCY

See Block 16

12. DATE OF FIRST SUBMISSION

See Block 16

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

8. APP CODE 11. AS OF DATE

See Block 16

13. DATE OF SUBSEQUENT

SUBMISSION

See Block 16 Draft

Final

Reg Repro

16. REMARKS

FIRST SUBMISSION:

Frequency: Annual (Option Period) Reporting Period Start Date: Start of service delivery Due Date: No later than the anniversary date of previous report

SUBSEQUENT SUBMISSION: CONTINUE FROM FIRST SUBMISSION

PHI/PII: No FILE FORMAT: No specific file format required

CONTENT DETAILS:

The contractor shall submit letter of assurance representing that it has conducted its initial or annual HIPAA risk assessment and, if necessary, develop an action plan to address any deficiencies identified, in compliance with DoD HIPAA requirements applicable to the contractor.

Sample is attached.

Submit through the

DHA e-Commerce

Extranet.

(Per TOM C14)

15. TOTAL 0 0 0

G. PREPARED BY

Hector H Laureano

H. DATE

06/22/2026

I. APPROVED BY

Hector H Laureano

J. DATE

ANNUAL RISK ASSESSMENT LETTER OF ASSURANCE (SAMPLE)

Defense Health Agency (DHA)/Contract Management 16401 E Centretech Parkway Aurora, CO 80011 ATTN: Administrative Contracting Officer (ACO)

Dear :

An annual risk analysis of all systems, policies, procedures and practices of (name of contractor) in effect during the year ended (date) was performed in accordance with requirements outlined in the TRICARE Operations Manual (TOM), Chapter 19, Section 3, and the HHS HIPAA Privacy Rule.

The objectives of the risk analysis were to:

1. Consider both organizational and technical assessments that address all areas of privacy and security.

2. Assess the potential risks and vulnerabilities to the confidentiality, integrity and availability of all PHI (electronic, paper, and oral) created, received, stored or transmitted by the contractor.

3. Take into account all relevant losses that would be expected if privacy and security measures were not in place, including losses caused by unauthorized uses and disclosures, as well as losses of data integrity or accuracy.

4. Determine residual risk.

5. Identify and document an action plan from prioritized findings to mitigate risk to an acceptable level.

The results of the risk assessment, assurances given by appropriate (name of contractor) officials, and other information provided, indicate that the procedures and policies of (name of contractor) in effect during the year ended (Date), comply with the requirements in the TOM, Chapter 19, Section

3. The following action plans describe the risk identified during the annual assessment and the plan to correct deficiencies and achieve compliance. Please indicate “NONE” if the annual risk analysis did not identify weaknesses.

Attachment A to this statement contains (1) the (Name of Contractor) plans and schedules for correcting such weaknesses, and (2) the status of actions taken to correct weaknesses identified in prior years’ reports.

Sincerely, Name, Title and Office cc: Regional Director (RD) DHA Procuring Contracting Officer (PCO) HA/DHA Privacy Officer HA/DHA Contracting Officer’s Representative (COR)

Enclosure(s) (if any)

Note to Contractor

(1) If there are no material weaknesses, this sentence should be deleted, and there would be no list or Attachment A containing plans and schedules for correcting such weaknesses.

(2) If there were no actions taken during the past year to correct weaknesses, or no identified weaknesses for which corrective actions remain to be taken, this phrase would be deleted.

(1 Data Item)

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP TM OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO.

A080

2. TITLE OF DATA ITEM

Fraud Detection and Prevention Strategy and Internal Procedures

3. SUBTITLE

Initial

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE

TOM C13 S1

6. REQUIRING OFFICE

Program Integrity (PI)

7. DD 250 REQ 9. DIST STATEMENT

REQUIRED

B

10. FREQUENCY

See Block 16

12. DATE OF FIRST SUBMISSION

See Block 16

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

8. APP CODE 11. AS OF DATE

See Block 16

13. DATE OF SUBSEQUENT

SUBMISSION

See Block 16 Draft

Final

Reg Repro

16. REMARKS

FIRST SUBMISSION:

Frequency: Annual (Calendar Year) Reporting Period Start Date: Start of service delivery Due Date: 30 calendar days before start of reporting period with updates as changes occur

SUBSEQUENT SUBMISSION: CONTINUE FROM FIRST SUBMISSION

PHI/PII: No FILE FORMAT: No specific file format required

CONTENT DETAILS:

Internal procedures shall be in place for all offices to provide potential fraud and abuse cases to the contractor's program integrity function. The strategy and internal procedures shall be provided to the Program Integrity (PI) Office 30 calendar days prior to the start of health care delivery, with updates provided as changes occur.

Submit through the

DHA e-Commerce

Extranet.

(Per TOM C14)

15. TOTAL 0 0 0

G. PREPARED BY

Alison H Coleman

H. DATE

06/22/2026

I. APPROVED BY

Jennifer K Dietz

J. DATE

(1 Data Item)

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP TM OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO.

A090

2. TITLE OF DATA ITEM

Memorandum of Understanding with the TRICARE Claims Review Services (TCRS) Contractor

3. SUBTITLE

Initial

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE

TOM C20 S2 & CTR H.6

6. REQUIRING OFFICE

TMEP

7. DD 250 REQ 9. DIST STATEMENT

REQUIRED

B

10. FREQUENCY

See Block 16

12. DATE OF FIRST SUBMISSION

See Block 16

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

8. APP CODE 11. AS OF DATE

See Block 16

13. DATE OF SUBSEQUENT

SUBMISSION

See Block 16 Draft

Final

Reg Repro

16. REMARKS

FIRST SUBMISSION:

Frequency: One Time Reporting Period Start Date: Start of service delivery Due Date: 60 calendar days prior to start of service delivery

SUBSEQUENT SUBMISSION:

Frequency: Annual (Option Period) Reporting Period Start Date: Start of service delivery Due Date: 60 calendar days before start of reporting period

PHI/PII: No

FILE FORMAT: Microsoft Word (.doc / docx)

CONTENT DETAILS:

The Contractor shall execute a Memorandum of Understanding with the TCRS contractor for the safe, secure, and positive electronic transmittal of claims processing documentation/information. The contractor shall establish a process for accepting claims review documentation via a secure file transfer protocol (SFTP).

At a minimum the MOU shall address:

* Any necessary cooperation and exchange of information

* Identify contract points of contact (POCs)

* Appropriate system resources

* Node information (if appropriate)

* File organization and naming conventions

* Documentation- format (i.e., word, .pdf, etc.)

The MOU will specifically address the frequency of file transmissions, receipt confirmation procedures (i.e., file acceptance or rejection), file and document formatting and any additional information needed to ensure the successful acceptance and utilization of claims documentation.

Within one year of previous submission, the Contractor shall submit an updated MOU or notification to the government that the MOU has been reviewed and no updates were required.

Submit through the

DHA e-Commerce

Extranet.

(Per TOM C14)

15. TOTAL 0 0 0

G. PREPARED BY

Shane M Pham

H. DATE

08/03/2026

I. APPROVED BY

Vonda D Lawson

J. DATE

08/03/2026

(1 Data Item)

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP TM OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO.

A100

2. TITLE OF DATA ITEM

Freedom of Information Act (FOIA) Releasable Contract

3. SUBTITLE

Initial

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

TMEP

7. DD 250 REQ 9. DIST STATEMENT

REQUIRED

B

10. FREQUENCY

See Block 16

12. DATE OF FIRST SUBMISSION

See Block 16

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

8. APP CODE 11. AS OF DATE

See Block 16

13. DATE OF SUBSEQUENT

SUBMISSION

See Block 16 Draft

Final

Reg Repro

16. REMARKS

FIRST SUBMISSION:

Frequency: One Time Reporting Period Start Date: Contract Award Due Date: 60 calendar days after contract award

SUBSEQUENT SUBMISSION:

Frequency: Annual (Option Period) Reporting Period Start Date: Start of service delivery

Due Date: 30 calendar days after the end of reporting period

PHI/PII: No

FILE FORMAT: Microsoft Word or PDF

CONTENT DETAILS:

For the initial submission:

1. The contractor shall provide a bracketed copy of the original signed, executed contract with attachments and exhibits. Indicate with brackets, the information proposed as exempt from release, if any, and cite the applicable FOIA Exemption

(s) invoked within each bracketed area, pursuant to 5 USC § 552. The brackets may be made electronically or hand marked and the proposed FOIA Exemptions written in the margins.

2. To assist the Agency in its final determination of a releasable version of the contract, the contractor shall provide a letter addressing its justification and/or rationale for the proposed non-releasable portions of the contract.

For the subsequent submission:

1. The contractor shall provide a copy of the original signed, executed contract, attachments, and exhibits, with the modifications incorporated into the original contract as a conformed contract. The contractor shall identify the last modification (P00NNN and date) incorporated into the contract. Indicate with brackets, the information proposed as exempt from release, if any, and cite the applicable FOIA Exemption(s) invoked within each bracketed area, pursuant to 5 USC § 552. The brackets may be made electronically or hand marked with the proposed FOIA Exemptions written in the margins.

2. To assist the Agency in its final determination of a releasable version of the contract, the contractor shall provide a letter addressing its justification and/or rationale for the proposed non-releasable portions of the contract.

Submit through the

DHA e-Commerce

Extranet.

(Per TOM C14)

15. TOTAL 0 0 0

G. PREPARED BY

Shane M Pham

H. DATE

08/03/2026

I. APPROVED BY

Vonda D Lawson

J. DATE

08/03/2026

CTR H.3.1

(1 Data Item)

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP TM OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO.

A110

2. TITLE OF DATA ITEM

Disaster Recovery Test Results Report

3. SUBTITLE

Initial

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE

TSM C1 S1.1

6. REQUIRING OFFICE

HPOSD/TMEP

7. DD 250 REQ 9. DIST STATEMENT

REQUIRED

B

10. FREQUENCY

See Block 16

12. DATE OF FIRST SUBMISSION

See Block 16

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

8. APP CODE 11. AS OF DATE

See Block 16

13. DATE OF SUBSEQUENT

SUBMISSION

See Block 16 Draft

Final

Reg Repro

16. REMARKS

FIRST SUBMISSION:

Frequency: Annual (Option Period) Reporting Period Start Date: Start of service delivery Due Date: Within 10 business days of completion of test

SUBSEQUENT SUBMISSION: CONTINUE FROM FIRST SUBMISSION

PHI/PII: No FILE FORMAT: No specific file format required

CONTENT DETAILS:

In all cases, the results of the review and/or test results shall be reported to the DHA Contract Management Division within 10 days of the conclusion of the test.

The contractor's report shall include if any additional testing is required or if corrective actions are required as a result of the disaster recovery test. The notice of additional testing requirements or corrective actions to be taken should be submitted along with the proposed date for retesting and the completion date for any corrective actions required. Upon completion of the retest, a report of the results of the actions taken should be provided to the CO within 10 business days of completion.

Submit through the

DHA e-Commerce

Extranet.

(Per TOM C14)

15. TOTAL 0 0 0

G. PREPARED BY

Steven F Alvarado

H. DATE

06/22/2026

I. APPROVED BY

Jose L Lozoya

J. DATE

(1 Data Item)

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP TM OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM

TRICARE Specific NTAP

3. SUBTITLE

Initial

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE

TRM C6 S11

6. REQUIRING OFFICE

MBRS

7. DD 250 REQ 9. DIST STATEMENT

REQUIRED

A

10. FREQUENCY

See Block 16

12. DATE OF FIRST SUBMISSION

See Block 16

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

8. APP CODE 11. AS OF DATE

See Block 16

13. DATE OF SUBSEQUENT

SUBMISSION

See Block 16 Draft

Final

Reg Repro

16. REMARKS

FIRST SUBMISSION:

Frequency: Annual (July 9 - July 8)

Reporting Period Start Date: Starting first year of service delivery in July Due Date: August 1 of every year

SUBSEQUENT SUBMISSION: CONTINUE FROM FIRST SUBMISSION

PHI/PII: No FILE FORMAT: Excel

CONTENT DETAILS:

The contractor shall receive and process TRICARE New Technology Add on Payment (NTAP) applications submitted by the technology manufacturer within 21 calendar days of receipt. The contractor shall ensure the annual cutoff date (July 8) is enforced. While the contractor must create their own application, a sample NTAP application can be found at:

https://www.health.mil/ntap

The Sample contains all necessary elements required for NTAP applications and should be used as a guide.

Based on TRM Chapter 6, Section 11, paragraph 4.6.1.3: The contractor shall forward the NTAP application to DHA through the DHA e-Commerce system for their contracting officer no later than August 1 of every year to be considered for TRICARE NTAP status for the next fiscal year, if the conditions stated in paragraph 4.5 are satisfied.

This CDRL will require the contractor to submit two lists to DHA every year of rejected and accepted NTAPs. If no applications are received during the submission period, it should be indicated on the submission. Submissions will contain:

a. The vendor and the reason for rejection/qualifiers for approval

b. The accompanying completed application

Submit through the

DHA E-Commerce

Extranet.

(Per TOM C14)

15. TOTAL 0 0 0

G. PREPARED BY

Sharon L Seelmeyer

H. DATE

06/22/2026

I. APPROVED BY

Elan P Green

J. DATE

06/22/2026

A120 https://www.health.mil/ntap

DD FORM 1423-1, FEB 2001 PREVIOUS EDITION MAY BE USED. Page 1 of 3 Pages

(1 Data Item)

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP TM OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO.

D010

2. TITLE OF DATA ITEM

Non-Financially Underwritten (NFUW) Contractor Payment/Check Issue Report

3. SUBTITLE

Initial

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

CRM/TMEP

7. DD 250 REQ 9. DIST STATEMENT

REQUIRED

B

10. FREQUENCY

See Block 16

12. DATE OF FIRST SUBMISSION

See Block 16

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

8. APP CODE 11. AS OF DATE

See Block 16

13. DATE OF SUBSEQUENT

SUBMISSION

See Block 16 Draft

Final

Reg Repro

16. REMARKS

FIRST SUBMISSION:

Frequency: Daily Reporting Period Start Date: Start of claims processing Due Date: Required with each cycle

SUBSEQUENT SUBMISSION: CONTINUE FROM FIRST SUBMISSION

PHI/PII: YES

FILE FORMAT: Data file (.dat)

CONTENT DETAILS:

The contractor shall provide a Contractor Payment/Check and EFT/ACH data files listing the payments issued for each cycle or each approved manual release. The occurrence of this data file is based on a daily TED cycle processed on a normal workday. Voided/Staledated payments must also be reported as negative amounts in this same format.

Standard File Name:

Dyymmdd_T000000_R#######_TMEP.dat

Since this is a data feed it should be submitted through the B2B Gateway rather than the Extranet.

Payment file layouts are attached with updates provided by the government as required.

Attachment A: Check Issued Layout Attachment B: EFT/ACH Issued Layout

Submit through the

B2B Gateway

15. TOTAL 0 0 0

G. PREPARED BY

Laura E White

H. DATE

08/03/2026

I. APPROVED BY

Laura E White

J. DATE

08/03/2026

CTR G.10.1

Attachment A:

Contractor “Check Issued” File Layout

OPTIONS (rows=1) ***CHECK Type Transactions***

LOAD DATA

INFILE '&1'

REPLACE

INTO TABLE TMA_PCR_CONTR_IMP_HEADERS

WHEN (1) = 'H'

FIELDS OPTIONALLY ENCLOSED BY '"' TRAILING NULLCOLS

ASAP_ACCT_NUMBER POSITION(02:09) CHAR "rtrim(:asap_acct_number)", TMA_AUTH_NUMBER POSITION(10:17) CHAR NULLIF TMA_AUTH_NUMBER=BLANKS "rtrim(:tma_auth_number)", RECORD_COUNT POSITION(18:23) INTEGER EXTERNAL, TOTAL_AMOUNT POSITION(24:34) DECIMAL EXTERNAL ":total_amount/100"

INTO TABLE TMA_PCR_CONTR_IMP_DETAILS

WHEN (1) = 'D'

FIELDS OPTIONALLY ENCLOSED BY '"' TRAILING NULLCOLS

ASAP_ACCT_NUMBER POSITION(002:009) CHAR "rtrim(:asap_acct_number)", BANK_ACCT_NUMBER POSITION(010:019) CHAR NULLIF BANK_ACCT_NUMBER=BLANKS "rtrim(:bank_acct_number)", CHECK_NUMBER_PFX POSITION(020:020) CHAR "decode(:check_number_pfx,'

',NULL,'0',NULL,:check_number_pfx)", (NOTE: Should contain a C for Checks)

CHECK_NUMBER POSITION(021:030) CHAR,

CHECK_PAYMENT_DATE POSITION(031:038) DATE "YYYYMMDD"

"DECODE(:check_payment_date,'00000000',NULL,'99999999',NULL,:check_payment_date)", PAYEE_NAME POSITION(039:088) CHAR NULLIF PAYEE_NAME=BLANKS "rtrim(:payee_name)", PROVIDER_TIN POSITION(089:106) CHAR NULLIF PROVIDER_TIN=BLANKS "rtrim(:provider_tin)", INTEREST_PAID POSITION(107:117) DECIMAL EXTERNAL ":interest_paid/100", AMOUNT_PAID POSITION(118:128) DECIMAL EXTERNAL ":amount_paid/100"

* On detailed record paid amount should be right justified, left zero filled.

Attachment B:

Contractor “EFT/ACH” Payment Issued” File Layout

OPTIONS (rows=1) *** EFT/ACH Type Transactions***

LOAD DATA

INFILE '&1'

REPLACE

INTO TABLE TMA_PCR_CONTR_IMP_HEADERS

WHEN (1) = 'H'

FIELDS OPTIONALLY ENCLOSED BY '"' TRAILING NULLCOLS

ASAP_ACCT_NUMBER POSITION(02:09) CHAR "rtrim(:asap_acct_number)", TMA_AUTH_NUMBER POSITION(10:17) CHAR NULLIF TMA_AUTH_NUMBER=BLANKS "rtrim(:tma_auth_number)", RECORD_COUNT POSITION(18:23) INTEGER EXTERNAL, TOTAL_AMOUNT POSITION(24:34) DECIMAL EXTERNAL ":total_amount/100"

INTO TABLE TMA_PCR_CONTR_IMP_DETAILS

WHEN (1) = 'D'

FIELDS OPTIONALLY ENCLOSED BY '"' TRAILING NULLCOLS

ASAP_ACCT_NUMBER POSITION(002:009) CHAR "rtrim(:asap_acct_number)", BANK_ACCT_NUMBER POSITION(010:019) CHAR NULLIF BANK_ACCT_NUMBER=BLANKS "rtrim(:bank_acct_number)", CHECK_EFT_NUMBER_PFX POSITION(020:020) CHAR "decode(:check_number_pfx,'

',NULL,'0',NULL,:check_number_pfx)", (NOTE: Should contain an E for EFT/ACH)

EFT/ACH Unique Cust ID POSITION(021:030) CHAR, CHECK_PAYMENT_DATE POSITION(031:038) DATE "YYYYMMDD"

"DECODE(:check_payment_date,'00000000',NULL,'99999999',NULL,:check_payment_date)", PAYEE_NAME POSITION(039:088) CHAR NULLIF PAYEE_NAME=BLANKS "rtrim(:payee_name)", PROVIDER_TIN POSITION(089:106) CHAR NULLIF PROVIDER_TIN=BLANKS "rtrim(:provider_tin)", INTEREST_PAID POSITION(107:117) DECIMAL EXTERNAL ":interest_paid/100", AMOUNT_PAID POSITION(118:128) DECIMAL EXTERNAL ":amount_paid/100"

Contractor/Bank

Note1: The Contractor sends an electronic industrial standard NACHA (National Automated Clearing House

Association) EFT/ACH payment file to their banks containing a Unique Customer identifier number. This unique customer ID must be passed in the NACHA file in Record Type 6, Field 7, Position 40-54. The contractor shall require the bank to include this unique customer identifier number in the Industry Standard BAI (Bank

Administration Institute) format, Record Type 16 Field 8.

Note2: This Unique EFT/ACH Customer ID number is equivalent to a Check Number for a regular Check payment.

* On detailed record paid amount should be right justified, left zero filled.

DD FORM 1423-1, FEB 2001 PREVIOUS EDITION MAY BE USED. Page 1 of 13 Pages

(1 Data Item)

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is…