B06 JA 22-0260B Approval Redacted.pdf

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FOR OFFICIAL USE ONLY - Source Selection Information – See FAR 2.101 and 3.104

Justification and Approval (J&A) for Federal Acquisition Regulation (FAR) Subpart 6.3

Other Than Full and Open Competition Title: TRICARE Claim Review Services

1. Identification of the agency and contracting activity:

Managed Care Contracting Division

2. Nature and/or Description of Action being Approved:

modification to an existing contract Individual

This Justification and Approval is for the authority to award a sole source extension to contract HT9402-17-D-0001 to Concept Plus, LLC. (hereinafter referred to as “Concept Plus") to provide health care claims review services for DHA. The requested contract extension is for a 10 month period, with the potential to extend for an additional 2 month period. The extension will be a fixed price, requirements contract, for the same effort defined in the performance work statement of the existing contract. The contract is set to expire on February 28, 2023, and the Government anticipates awarding this extension on or before March 1, 2023. This extension is necessary to continue services while DHA completes the competitive process of the next generation TCRS contract.

3. Description of Supplies/ Services:

The DHA acquires compliance review services to assess the potential and actual risk of improper payments made by TRICARE purchased care contractors. The contractor provides an independent, impartial review of healthcare claims reimbursement methodologies and TRICARE Encounter Data (TED) payment record coding and active duty dental record coding procedures utilized by the two Managed Care Support Contractors (MCSC), TRICARE Medicare Eligible Program (TMEP), TRICARE Pharmacy Program (TPharm), TRICARE Overseas Program (TOP), and Active Duty Dental Program (ADDP) contractors.

TCRS compliance reviews have three primary components: (1) to evaluate purchased care contractor's claims processing procedures, reimbursement determinations, and compliance with TRICARE policies and directives when processing healthcare claims; (2) to measure and report to DHA Leadership and TRICARE Program Office Managers, purchased care contractor's claims processing performance as stipulated in TRICARE Operations Manual (TOM), Chapter 1, Section 3, paragraph 1.6, Claims Processing Accuracy and Sections C and H of purchased care contracts; and (3) to comply with the Payment Integrity and Information Act of 2019 (PIIA, P.L. 116-117), by identifying and reporting improper payment in the Department of Defense (DoD) Agency Financial Report (AFR). The base period of performance (PoP) will be from March 01, 2023 – December 31, 2023, there are also two (2) options for a potential total PoP of March 01, 2023 - February 29, 2024.

TOTAL Contract Value

POP: From 3/1/2023 to 2/28/2024

BASE

POP: From 3/1/2023 to 12/31/2023

Type of Contract (Primary):

FAR 16.202 Firm-Fixed-Price

Options: Yes

Number of Options: 2

POP (All options): From 1/1/2024 to 2/29/2024

Funding Type:

Operations & Maintenance (O&M)

4. Statutory and Regulatory Authority Permitting Other Than Full and Open Competition (see FAR 6.302), or the Specification of the Statutory and Regulatory Provision Providing Exception to 8(a) Program Competitive Requirements (see FAR 19.805-1):

10 U.S.C. 2304(c)(1) 6.302-1 -- Only One Responsible Source and No Other Supplies or Services Will Satisfy Agency Requirements

5. Rationale Justifying Use of the Statutory Authority Cited:

The TCRS contractor provides specialized compliance review services. This contractor has the unique and extensive experience needed to meet the rigorous quarterly, semi-annual and annual compliance review timelines developed to meeting DHA and PIIA reporting requirements. In order to effectively evaluate TRICARE medical, dental and pharmacy claims and meet existing review timelines, a contractor must have extensive knowledge of the TRICARE health benefits program and a thorough understanding of purchased care contract and claims processing requirements. In addition, the contractor's audit environment and system(s) infrastructure must meet and be in compliance with DoD National Institute of Standards and Technology (NIST) standards and all employees requiring access to DoD systems and applications must have current DoD Common Access Card (CACs).

The services are only available from the current source, Concept Plus, while DHA completes the competitive process of the next generation TCRS contract. The current contract expires February 28, 2023. The next generation TCRS contract is scheduled for award before August 2023. A 6 month transition-in process is scheduled to begin September 2023 followed by auditing services beginning March 2024. Therefore, without this extension, DHA would not have the compliance review services necessary to assist DHA Improper Payment Evaluation Branch (CRM-IPEB), Budget and Resource Management Division, Business Support Directorate, to identify, recover and report improper payment activities and claims processing performance in accordance with DHA Policy Directives and Public Laws (P.L) 116-117, as described in Section 3 above from March 2023 through February 2024.

The incumbent contractor has the unique qualifications and the capability to continue to provide the required services while the agency continues with the procurement of the next generation TCRS contract. Specifically, Concept Plus currently possesses the facilities, staff, security clearances, and IT systems to fulfill the services required by the TCRS contract.

Due to nature of the contract requirement to meet PIIA and DHA improper payment identification, recovery and reporting requirements, only the incumbent contractor could reasonably be expected to have the resources to continue to provide those services until the next generation contact can be awarded and all transition-in tasks are successfully completed. Accordingly, Concept Plus is the only firm capable of providing the services described in Section 3, above without the DHA experiencing unacceptable delays in fulfilling its requirements. If the current TCRS contract is not extended, DHA cannot meet its legal obligations to identify, recover, and report any improper payment activities within the TRICARE health benefits program.

6. Efforts to Obtain Competition:

The next generation TCRS contract is proceeding as a full and open competition. A request for proposals (RFP) was posted to SAM.gov in June of 2022.

7. Determination that Anticipated Cost to the Government will be Fair and Reasonable:

The procedures and criteria contained in FAR 15.404-1 will be followed to ensure the prices negotiated for this action are fair and reasonable. This determination will be based upon (1) historic cost information currently available under the current contract, (2) certified cost and pricing data provided by the contractor, (3) Technical Evaluations performed by the Program Office, and (4) any applicable Defense Contract Audit Agency (DCAA) audit reports and Defense Contract Management Agency (DCMA) recommendations. The Contracting Officer anticipates that the prices for these services will be fair and reasonable.

8. Market Research:

Market Research Conducted? Yes When was it conducted? 12/1/2022 to 12/12/2022 Description:

A Request for Information (RFI) was released on Sam.Gov on December 1, 2022. Four submissions were received in response to the RFI. Two of the contractors indicated they had healthcare claims and audit knowledge, but they did not provide evidence of specific TRICARE claims and compliance review experience relevant to the contract requirements. The other two contractors did not demonstrate experience with any medical claims processing. All of the contractors would require a substantial transition-in period as well as readiness testing, which would result in a significant gap in service. The incumbent contractor possesses the knowledge and skills required for successful performance during the bridge period without impacting service.

9. Other Facts:

None.

10. Interested Sources:

A Request for Information (RFI) was posted to beta.SAM.gov on December 1, 2022. The RFI announced the Government's intention to extend the TQMC contract for up to 1-year and invited industry responses.

11. Actions to overcome barriers:

This bridge action is an interim step to allow sufficient time to award the successor TCRS contract competitively using FAR Part 15 procedures. The source selection is currently in the proposal evaluation stage. Award of the new contract will be made as soon as practicable.

Coordination & Approval

12. Technical/Functional Representative:

I certify that the information provided in this justification is accurate and complete to the best of my knowledge and belief.

13. Requirements Certification:

I certify that the information provided in this justification is accurate and complete to the best of my knowledge and belief

14. Fair and Reasonable Cost Determination:

Estim ated cost is based on government estimated quantities for the period of performance priced at unit cost escalated 3% from the current pricing. Certified cost and pricing data will be required.

I have determined that the anticipated cost to the Government for this contract action is fair and reasonable.

Comments: