7_Section_G_clean_4-4-13.doc

SECTION G, CONTRACT ADMINISTRATION DATA

G.1. CONTRACT ADMINISTRATION

G.1.1. All contract administration matters will be handled by the following individuals:

G.1.1.1. CONTRACTOR (Name(s) and Address):

Telephone: (____)_________________________

FAX Phone: (____)________________________

G.1.1.2. GOVERNMENT:

Contracting Officer

TRICARE Management Activity

Contract Operations Division--Aurora ATTN: Contracting Officer, TRICARE Dual-Eligible Fiscal Intermediary Contract

16401 East Centretech Parkway

Aurora CO 80011-9066

Telephone: 303-676-3649 FAX Phone: 303-676-3866 G.1.2. Contract administration will be performed by the TRICARE Management Activity (TMA) Acquisition Management and Support Division, Contract Operations Division-Aurora (COD-A),or as delegated to other Government agencies by the Contracting Officer. The Government points of contact during the performance of this contract will be:

G.1.2.1. Contracting Officer (CO): The CO is responsible for administration of this contract and is solely authorized to take action on behalf of the Government which may result in changes to the terms of this contract, including deviation from Section C.

G.1.2.2. The Contract Resource Management (CRM) Certifying Officer is responsible for making payments to the contractor, establishing banking relationships with the Federal Reserve and the Treasury and related issues.

G.1.2.3. Contracting Officer's Representative (COR): In accordance with DFARS 252.201-7000, Contracting Officer's Representative,

(a) Definition. “Contracting officer's representative” means an individual designated in accordance with subsection 201.602-2 of the Defense Federal Acquisition Regulation Supplement and authorized in writing by the Contracting Officer to perform specific technical or administrative functions.

(b) If the Contracting Officer designates a COR, the Contractor will receive a copy of the written designation. It will specify the extent of the COR's authority to act on behalf of the contracting officer. The COR is not authorized to make any commitments or changes that will affect price, quality, quantity, delivery, or any other term or condition of the contract.

(End of clause)

G.3. 252.204-7006 BILLING INSTRUCTIONS (OCT 2005)

When submitting a request for payment, the contractor shall

(a) Identify the contract line item(s) on the payment request that reasonably reflects contract work performance; and

(b) Separately identify a payment amount for each contract line item included in the payment request.

(End of Clause)

G.4. 252.232-7003 ELECTRONIC SUBMISSION OF PAYMENT REQUESTS AND RECEIVING REPORTS (JUN 2012)

(a) Definitions. As used in this clause—

(1) “Contract financing payment” and “invoice payment” have the meanings given in section 32.001 of the Federal Acquisition Regulation.

(2) “Electronic form” means any automated system that transmits information electronically from the initiating system to all affected systems. facsimile, e-mail, and scanned documents are not acceptable electronic forms for submission of payment requests. However, scanned documents are acceptable when they are part of a submission of a payment request made using Wide Area Work Flow (WAWF) or another electronic form authorized by the Contracting Officer.

(3) “Payment request” means any request for contract financing payment or invoice payment submitted by the contractor under this contract.

(4) “Receiving report” means the data required by the clause at 252.246-7000, Material Inspection and Receiving Report.

(b) Except as provided in paragraph (c) of this clause, the contractor shall submit payment requests and receiving reports using WAWF, in one of the following electronic formats that WAWF accepts: Electronic Data Interchange, Secure File Transfer Protocol, or World Wide Web input. Information regarding WAWF is available on the Internet at https://wawf.eb.mil/.

(c) The contractor may submit a payment request and receiving report using other than WAWF only when—

(1) The Contracting Officer administering the contract for payment has determined, in writing, that electronic submission would be unduly burdensome to the contractor. In such cases, the contractor shall include a copy of the Contracting Officer’s determination with each request for payment;

(2) DoD makes payment for commercial transportation services provided under a Government rate tender or a contract for transportation services using a DoD-approved electronic third party payment system or other exempted vendor payment/invoicing system (e.g., PowerTrack, Transportation Financial Management System, and Cargo and Billing System);

(3) DoD makes payment for rendered health care services using the TRICARE Encounter Data System (TEDS) as the electronic format; or

(4) When the Government wide commercial purchase card is used as the method of payment, only submission of the receiving report in electronic form is required.

(d) The contractor shall submit any non-electronic payment requests using the method or methods specified in Section G of the contract.

(e) In addition to the requirements of this clause, the contractor shall meet the requirements of the appropriate payment clauses in this contract when submitting payment requests.

(End of clause)

G.5. ORDERING ACTIVITY

G.5.1. The TMA COD-A CO has the authority to issue task orders under the CLINs of this contract on DD Forms 1155, Order for Supplies or Services. Orders may be placed by email, facsimile transmission, mail, or courier.

G.6. INVOICE AND PAYMENT--NON-TEDS

G.6.1. General:

G.6.1.1. The basis for payment to the contractor shall be the prices specified in Section B of this contract and as specified within delivery orders issued under this contract.

G.6.1.2. Invoice Submission: Non-TEDS invoices shall be submitted electronically in accordance with G.3. and G.4. above. The contractor shall submit invoices through WAWF.

G.6.1.3. A proper invoice must include the elements identified at FAR 32.905.

G.6.1.4. All payments made by the Government will be made by EFT.

G.6.1.5. Payments will be made in accordance with Prompt Payment Act.

G.6.2. Types of Payments to Contractor:

G.6.2.1. Transition-in/ Phase-in. The contractor shall submit a single invoice based on the price in Section B, CLIN 0001.

G.6.2.2. Administration Payments. The contractor shall submit invoices against CLIN 0X02 based on the monthly prices in Section B.

G.6.2.3. Transition-out. The contractor shall submit a single invoice based on the price in Transition-out CLIN 0X03 in Section B.

G.6.2.4. Change Orders and Other Payments on CLINs. These are payments due to the contractor for CLINs/SLINs established subsequent to the contract award. The contractor shall submit an invoice based on the modified price in Section B and instructions in the modification.

G.6.3. Payments Due from the Contractor to the Government G.6.3.1. Performance Guarantees. The Government will make collection by reducing the appropriate amount from the Administration CLIN/SLIN payments to the contractor upon determination of the amount of the performance guarantee and notification to the contractor by the CO. See Section H, Special Contract Requirements, paragraph H.2.

G.6.3.2. Other Payments from the Contractor to TMA. Contractor payments will be made electronically following the bank routing direction provided by CRM.

G.6.3.3. TMA reserves the right to collect overpayments made to the contractor from the payments due to the contractor (including any contract payments due the contractor from other contracts it may hold with TMA or other Federal Agencies).

G.7. INVOICE AND PAYMENT--CLAIMS PROCESSING CLINS (TEDS)

G.7.1. Invoice and payment procedures for claims processing fees are the same for paper and electronic claims. Submission of a TEDS record header to TMA is considered submittal of an invoice. No separate invoices are required for routine claims rate payments. However, invoices are required for non-automated payment requests. For purposes of determining the due date for payment under the Prompt Payment Clause, the “Transmission received end date/time stamp” (derived by TEDS at end of data transmission) will be used to determine the date of receipt. Transmission received after 10:00AM ET shall be considered as received the next calendar day.

G.7.2. Claim Quantity: The contractor is paid the unit price for each initial submission TEDS record (as defined under TSM 7950.2-M, February 2008, Chapter 2, Section 1.1) that passes all TEDS edits as specified in the TSM and validated by the TEDS record edit system. Additionally, the contractor is paid for the first adjustment TEDS record accepted under this contract that was initially submitted under a previous contract (even if the previous contract was held by the new contractor).

G.7.3. Unit Price and Performance Period: The contractor is paid the claims processing unit price identified in Section B for the contract period in which the contractor submits the initial TEDS record. The “Batch/Voucher Date” in the voucher header is used to determine the contract option period and applicable unit price and the “Claim Form Type” is used to determine electronic or paper CLIN.

G.7.3.1. In order for the contractor to receive payment of a claims processing fee, the TEDS record must pass all TEDS edits as specified in the TSM and validated by the TEDS record edit system no later than 210 calendar days following the end date for the contract.

G.7.4. Header Type: The contractor shall submit batch/vouchers under the correct “Header Type Indicator” as specified in the TSM Chapter 2, Section 2.3. to insure correct payment. Header Type Indicator indicates to the TEDS processing system if the contractor is requesting a claim rate payment, wants to retain a claim rate payment, does not want a claim rate payment or if the contractor is requesting the claim rate payment previously paid be retracted.

G.7.4.1. Eligible TEDS Records: If the TEDS record is eligible to receive or retain a previous payment under the claims processing CLIN, then the TEDS record (with the exception of Type of Submission “C” complete cancellation to TEDS record data, see G.7.4.3.) shall be submitted by the contractor to TMA using a Header Type Indicator of “6” or “9” (even if the TEDS record has already received payment under the claims processing CLIN).

G.7.4.2. Ineligible TEDS Records: If the TEDS record submitted is not eligible to receive payment or the contractor wants TMA to retract a previous claim rate payment under the claims processing CLIN, the contractor shall submit the TEDS record to TMA using a Header Type Indicator of “0” or “5”. No payment under the claims processing CLIN can occur on any TEDS record grouped in a Batch/Voucher with Header Type Indicator of “0” or “5.” Only no-pay and credits (where TMA retracts any previous claim rate) can be processed under these header types.

G.7.4.3. Cancelled TEDS Records: For a TEDS record submitted with a Type of Submission “C” by the contractor, the contractor shall determine if the TEDS record is still eligible to receive payment under the claims processing CLIN. The following criteria shall be used to determine if a TEDS record is still eligible for payment:

G.7.4.3.1. A TEDS record cancelled for any of the following reasons is eligible to retain the claims processing fee previously paid and shall be submitted with Header Type Indicator “6” or “9”:

· Cancellation was at Government direction.

· Government data error.

· Stale dated/voided checks.

· New initial TEDS record is required by the Government.

· Incorrect DEERS response.

· Check is returned in undeliverable mail.

· Beneficiary or provider requests stop payment due to non-receipt of check prior to stale date time period.

· Beneficiary or provider returns check because payment was received from other health insurance carrier whose responsibility was previously unknown to contractor.

· Provider returns check because beneficiary has erroneously paid the provider and believes that the TRICARE benefit check is a duplicate payment.

· Claim processed in good faith by the contractor but later identified as an error due to additional information received or learned.

· Claim processed by multiple contractors resulting in duplicate processing.

· TQMC case resolutions resulting in an error.

· Program Integrity cases that are recouped retrospectively after investigation.

· Provider requested claims to be reissued to a new provider Tax Identifier.

G.7.4.3.2. A TEDS record cancelled for any of the following reasons is not eligible to retain the claims processing fee previously paid and shall be submitted with Header Type Indicator “0” or “5”:

•Cancellation where a new initial TEDS record is required to correct a contractor error.

•Cancellation due to contractor error or an inability to adjust.

•Cancellation of a claim that was not TMA’s responsibility so it should not have been paid.

•Any other cancellations for a reason not identified in paragraph G.7.4.3.1 above.

If the contractor cannot determine the reason for the TEDS record cancellation, then the TEDS record submitted is not eligible to retain the claims processing fee previously paid. The cancellation of the cancelled TEDS record shall be submitted under Header Type Indicator “0” or “5.”

G.7.5. Procedure if TMA’s TEDS is Unavailable: Upon CO’s notification that the TEDS Record processing system is not operating normally, the contractor may submit invoices outside of the TEDS to the CO and CRM. The invoice shall list the number of claims processed by CLIN. This may be submitted daily or grouped by no more than 5 days of claims. These payments will be treated as an interim payment and will be a credit to the amount due as determined by the TEDS Record processing system when it is operating normally again. This process will not be used unless the payment will be paid past the Prompt Payment Act 30 day due date. If TEDS processing or CRM accounting system processes are delayed less than 30 days, the automated due dates on payments generated by TEDS will be adjusted for any delay in TEDS processing.

G.8. BENEFIT PAYMENTS–SET UP AND PROCESS FOR PAYMENT OF BENEFITS

G.8.1. The contractor acts as a Fiscal Intermediary (FI) for the Government to disburse Government funds for health care benefits (also know as “pass-through payments”). These are not costs to the contractor and are not reimbursed by the Government, so the contractor shall not collect or hold health care benefit funds before dissemination to the beneficiary or provider. The contractor shall immediately return any collections to the Government. No bank fees or other bank charges shall be paid from this account and no money should be drawn from the Federal Reserve Bank (FRB) for these charges.

G.8.1.1. All payments for claims processed by the contractor must be approved by the TMA/CRM Budget Office before the contractor may release payments to the beneficiary, provider or other authorized payee.

G.8.1.2. Funding for benefit payments made by the contractor on behalf of the Government will be facilitated by allowing the contractor (through the contractor's financial institution) to draw money from the designated FRB. These draws may only be done for benefit payments that have previously been submitted on TEDS or as a non-TEDS voucher, that were approved for release by TMA/CRM and that are clearing the contractor's financial institution on the day the draw is being accomplished. No advance payments are authorized.

G.8.2. Establishment of Healthcare Claim Bank Accounts:

G.8.2.1. The Department of Treasury’s Automated Standard Application for Payment System (ASAP) and FEDWIRE provide a mechanism for disbursement of Government funds for health care services received by TRICARE beneficiaries. After authorization by TMA/CRM, these systems allow the contractor, through their bank, to draw cash directly from the FRB to cover payments as they clear the contractor’s bank account. ASAP is used by the Treasury, the FRB and TMA/CRM to verify the authorization to make draws and to track transactions made by the contractor’s bank. FEDWIRE is used by the contractor’s bank to actually draw funds from the FRB.

G.8.2.2. The contractor shall establish two (2) bank accounts for benefit-related transactions with a commercial bank that has FEDWIRE capability in accordance with current Treasury requirements. One bank account will be used for claims eligible for the Medicare Dual-Eligible Health Care Fund. The second account will be for claims that are not eligible for this fund (such as beneficiaries with an active duty sponsor). TEDS will be submitted separately for each account.

G.8.2.3. The contractor shall submit bank information to TMA/CRM not later than 60 calendar days prior to the beginning of processing claims on a new account. The information shall include:

· Name of Bank

· Overnight mail address

· American Banking Association (ABA) number/Routing Number (RTN)

· Contractor Taxpayer Identification Number (TIN)

· Data Universal Numbering System (DUNS) number for the contractor and the bank.

· Contractor’s bank account number (if separate checking and deposit account numbers are used, both shall be provided and identified)

· Individual point of contact at the bank and an alternate, including their phone numbers, and e-mail addresses

· Individual point of contact at the contractor and an alternate, including their phone numbers, and e-mail addresses

G.8.2.4. TMA/CRM will establish the bank accounts on ASAP with the Treasury Department. TMA/CRM will notify the bank and the contractor once the bank accounts have been established and provide codes or other information necessary for the bank to make draws against the FRB using FEDWIRE. Currently, ASAP has a requirement to identify a total dollar amount that may be drawn on the FRB. This total dollar limit only represents an administrative ceiling at the FRB, and does not constitute any authority to draw funds. Accounts will also have daily limits for the amount that can be drawn. The contractor will be notified of these limits by TMA/CRM. TMA/CRM is able to increase or decrease these limits as needed.

G.8.3. Fiscal Year Start-up of Bank Accounts: The contractor shall establish separate bank accounts for each new Government fiscal year following the procedures specified in G.8.2. “Establishment of Bank Accounts”. All payments issued for benefit payments and all refunds received shall be processed against the new account effective the first day of the new fiscal year. The contractor shall also transfer all recoupment installment payments to the new account from the previous year’s account.

G.8.4. Closing of Bank Accounts:

G.8.4.1. Bank accounts shall be closed no later than the end of February following the fiscal year end, or the end of the month after the month that the last payment on an account has cleared the account or been voided.

G.8.4.2. Cash drawdowns against the prior fiscal year’s bank account may continue, if required, until all payments from the prior year have either cleared or been canceled, but no longer than the end of February of the following year or five months after the last payments have been cut on an account (in the case of a contract closeout).

G.8.4.3. Any outstanding balance in the account shall be reimbursed to TMA no later than the required submission date of the final bank account reconciliation. This balance may be subject to interest and penalties if it includes overdrawn amounts that were required to be submitted at an earlier date.

G.8.4.4. The final bank account reconciliations shall be made by the end of the month following the month having the last authorized transactions. All transactions that were not previously approved by TMA/CRM shall be explained with supporting documentation on the final bank reconciliation report (Section F.5.1.3. CDRL M070). TMA/CRM reserves the right to not accept these transactions.

G.8.5. Draws on the Federal Reserve Bank

G.8.5.1. The total amount of a cash draw down on the FRB is based on the daily total of benefit payments presented to the bank for payment. Computation of the amount of the draw must also include available funds from deposits into the account. These deposits will reduce the amount of cash needed for the draw down on the day the deposit fund become available for transactions. If estimates are needed due to timing of reports from check clearinghouses or the FRB, the draws shall be adjusted the next business day.

G.8.5.2. The contractor shall ensure that cash draw downs do not exceed the payments that have been authorized by TMA. The contractor shall ensure that any excess draws are immediately returned to the FRB.

G.8.5.3. Unapproved draws or unauthorized payments by the contractor may be immediately collected and may subject the contractor to interest and penalties. Interest and a penalty will be charged beginning the day after the overdraw and interest will continue until the overdrawn amount is returned. Interest will accrue daily and is based on the Treasury Current Value of Funds Rate. The penalty is a one time payment and is based on the penalty rate in the CFR, Title 31, Chapter IX, paragraph 901.9. TMA/CRM may initiate immediate payment offset against any payments to the contractor involved for the interest, penalties and/or the overdrawn amount.

G.8.5.4. The contractor shall ensure transactions are properly accounted for to prevent the commingling of funds between bank accounts. Failure to properly associate transactions with the correct bank account could result in the over-execution of TMA/CRM budget authority. Transfers of funds between bank accounts are strictly prohibited except for correcting deposits that are in the wrong account. Any other transactions reported under one bank account and erroneously charged against a different bank account shall be reported immediately to TMA/CRM when identified. TMA/CRM will instruct the contractor as to what action to take depending on the situation.

G.8.6. Reporting: Monthly bank reconciliations are required for each account until the bank account is closed. Reports are to be submitted to CRM. See CDRL #M070 for the description of reporting requirements.

G.9. BENEFIT PAYMENTS—TEDS SUBMISSIONS

G.9.1. TEDS data submissions for benefit payments shall be grouped into TEDS Vouchers by the “Batch/Voucher CLIN/ASAP Account Number” field (defined in TSM, Chapter 2, Section 2.3).

G.9.2. Voucher Transmission Requirements: Batch/Vouchers shall be transmitted by 10 A.M. Eastern Time to be considered for that day’s business. Healthcare Batch/Vouchers received after 10:00 AM Eastern Time shall be considered received the next calendar day for payment and check release authorization purposes. Batch/Vouchers must pass all TEDS header edits as specified in the TSM. If all header edits are not passed, the Batch/Voucher will be rejected and returned to the contractor.

G.9.3. Voucher Integrity: Voucher header and detail amounts transmitted by the contractor become “fixed” data elements in the finance and accounting system for purposes of control and integrity. Corrections or adjustments to reported (payment) amounts must be accomplished on separate voucher transmissions.

G.9.4. Payment Suspension and TEDS Processing During Partial Funding Shortages:

G.9.4.1. Some of the funding TMA receives may be restricted in use to a specific federal agency, military department and/or to a particular health care program. Funding for these special purpose programs may run out before funding for other TMA programs. Therefore, the contractor shall have the ability to suspend claims payment and the associated submission of institutional TEDS records or non-institutional TEDS line item(s) to TMA based on values contained in the following TEDS record fields:

· Service Branch Classification Code (Sponsor), SBCC: As specified in the TSM, Chapter 2, Section 2.8.

· Enrollment/Health Plan Code (E/HPC): As specified in the TSM, Chapter 2, Section 2.5.

· Special Processing Code (SPC) - As specified in the TSM, Chapter 2, Section 2.8.

· Health Care Delivery Program Coverage Code: As specified in the TSM, Chapter 2, Addendum L.

G.9.4.2. The suspension of claims payment and TEDS records may be based on a single value (e.g., SBCC=A) or a combination of values (e.g., SBCC=A & E/HPC=SR). Suspension of TEDS records (institutional) or TEDS line items (non- institutional) containing specific values shall be implemented by the contractor within five workdays after receiving notification from the CO. On the sixth workday, TMA/CRM will implement immediate payment offset against contractor invoices of any amounts paid by the contractor from their bank account(s) for institutional TEDS records or non-institutional TEDS line items containing suspended value(s). The contractor shall not, without prior CO approval, initiate payment offset against any provider or beneficiary for payments made against suspended transactions and offset by TMA/CRM on contractor invoices.

G.9.4.3. For all suspended transactions, the contractor shall hold the claim information until receiving instructions from the CO to do otherwise. The contractor shall not reject the claims or return any information to the providers or beneficiaries unless instructed by the CO. Once the CO lifts the TEDS data submission restriction, the contractor may submit all withheld TEDS data on the next appropriate (batch/voucher) data submission. TMA/CRM will reimburse the contractor (without interest) for any invoice payment offsets done for TEDS suspended transaction that have not been recouped by the contractor.

G.9.5. Federal Fiscal Year-end Processing:

G.9.5.1. All TEDS records must be received no later than 10:00 AM Eastern Daylight Time (EDT), (8:00 AM Mountain Daylight Time (MDT); 7:00 AM Pacific Daylight Time (PDT) on September 28. Any Batch/Voucher received after 10:00 AM EDT will be rejected by TMA and must be resubmitted by the contractor using next fiscal year Batch/Voucher CLIN/ASAP Account Numbers. The contractor should not submit batch/vouchers with dates of September 29 and September 30. Any payment processed after September 28 must use the next fiscal year Batch/Voucher CLIN/ASAP Account Numbers and must utilize the new fiscal year check stock, as applicable. The contractor shall not submit Batch/Vouchers to TMA between September 28, 10:00 AM EDT and October 1, 12:01 AM EDT. Transmission Files (TD Files) sent on September 28 cannot exceed 300,000 records.

G.9.5.2. Contractors will be able to test their new fiscal year’s transactions in benchmark starting September 1. Like production, benchmark data must be received at TMA by 10AM EDT on September 28. After 10:00 AM EDT on September 28 until October 1, 12:01 AM EDT no benchmark data can be transmitted to TMA.

G.9.6. Fiscal Year Start-up Processing. The October 1 TEDS and subsequent data submissions must cite the new fiscal year “Batch/Voucher CLIN/ASAP Account Number” assigned by TMA/CRM to report all new fiscal year TEDS data. Any previously unreported TEDS data citing the prior fiscal years “Batch/Voucher CLIN/ASAP Account Numbers” will not be accepted. If there is a need for an exception to this, contact CRM.

G.9.7. Uncorrected (Bad Master) TEDS. TEDS records that fail the edits specified in the TSM will be “flagged” by TMA/CRM as inadequate payment information. The contractor shall correct the claims identified to them, by TMA/CRM, within 90 calendar days. If not corrected in 90 days, TMA/CRM will send a demand letter requiring resolution or reimbursement for all claims identified through TEDS as edit failures. The contractor shall respond within 30 calendar days as to why the claim(s) in question cannot be corrected. If resolution cannot be reached between TMA/CRM and the contractor, the total amount of improper payments still in dispute will be collected by TMA/CRM. The contractor shall take no recourse against TRICARE beneficiaries or providers under the situations described in this paragraph without prior TMA approval.

G.9.8. Residual Benefit Claims. Claims for service provided prior to start of the contract will be paid as benefits under this contract as described in paragraph G.9 or, if necessary, under paragraph G.11.5. for non-routine payments.

G.10. BENEFIT PAYMENTS—AUTHORIZATION TO RELEASE TEDS-RELATED BENEFIT PAYMENTS:

G.10.1. Authorization: The contractor shall not release benefit payments without prior authorization from the TMA/CRM Budget Office. Authorization from TMA/CRM to release payments will be sent to the contractor via fax or e-mail no later than 5:00 PM Eastern Time the day of receipt. Authorization will specify contract number, ASAP Account ID#, initial transmission received date, and total dollar amount of funds that may be released based on information contained in the Batch/Voucher header. Approval for funds release will be given provided the following criteria are met:

· Voucher submissions must pass all header edits as specified in TSM, Chapter 2, Section 4.1.

· TMA/CRM Budget Officer has confirmed that funding is available to cover payments.

G.10.2. Payments Release: Benefit payments shall be released/mailed no later than two workdays after TMA/CRM has approved the release of payments.

G.10.3. TMA Acceptance: Authorization to release payments does not constitute TMA’s acceptance that all payments are valid and/or correct. Detailed records will be audited for financial compliance. All transactions in these bank accounts must be valid and justified. Any unreported/unauthorized disbursements identified by TMA will be subject to immediate payment offset against any payments being made to the contractor. All disputed amounts will remain in the possession of the Government until no longer in dispute.

G.10.4. Procedure if TMA’s TEDS is unavailable: Upon CO’s notification that the TEDS Record processing system is not operating normally, the contractor will send an email or fax with a listing of specific vouchers to TMA/CRM to request release of payments. This may be done daily. TMA/CRM will return to the contractor a signed release so the contractor can pay the providers and beneficiaries without delay. The contractor must not release payments until this approval is received. Upon notification by the CO that the TEDS Record processing system is operating again, this process can be discontinued. The contractor shall have 30 days to submit, on TEDS vouchers, all vouchers where payments have been released and to clear, at a minimum, all the TEDS header edits (as specified in the TSM, Chapter 2). Failure to clear all header edits for any vouchers where the contractor was authorized, under this contingency process, to release payments shall result in the Government collecting back the rejected voucher header totals via payment offset. When the vouchers clear the header edits, the monies collected via payment offset shall be refunded to the contractor (without interest or penalty). The contractor requests will include the following Header information for each voucher (See TSM, Chapter 2, Section 2.2):

ELN Element Name

0-001 Header Type Indicator

0-005 Contract Identifier

0-010 Contract Number

0-015 Batch/Voucher Identifier

0-020 Batch/Voucher Number

0-025 Batch/Voucher ASAP Account Number

0-030 Batch/Voucher Date YYYYDDD

0-035 Batch/Voucher Sequence Number

0-040 Batch/Voucher Resubmission Number

0-045 Total Number of Records

0-050 Total Amount Paid

G.11. OTHER BENEFIT AND RELATED PAYMENTS—NON-TEDS ROUTINE MANUAL VOUCHERS

G.11.1. General: These are TRICARE programs that are paid through the ASAP related bank accounts but can not be paid through TEDS processing.

G.11.2. Bonus Payments in Health Professional Shortage Areas (HPSA) and in Physician Scarcity Areas (PSA) (TRM, Chapter 1, Section 33):

G.11.2.1. Bonus payments are an addition to the amount normally paid under the allowable charge methodology in order to provide services in medically underserved areas (Health Professional Shortage Areas [HPSA] and Physician Scarcity Areas [PSA]). On a quarterly basis, the contractor shall submit the voucher electronically as a pass-through payment. Supporting documentation including lists of doctors, their addresses, and the calculation of the payment, shall also be sent electronically based on approved formats as specified in the TOM 6010.56-M, February 2008, Chapter 2. The contractor shall process and make payment within 2 business days after receipt of clearance from TMA/CRM.

G.11.2.2. Vouchers shall contain the following:

• Format for Vouchers

Period Covered (Quarter)

Physician Name

Physician Address

Physician Provider Number

Amount Paid/Collected for Bonus

Total Bonus Paid [5 and/or 10 percent of the above bullet]

Total of all Bonuses Being Paid

• Sort for Vouchers:

By Contract

By Automated Standard Application for Payment System (ASAP) ID (Fiscal Year) of Bank Account

By Type (e.g., standard or active duty) By Coverage (Prime, Extra, Standard)

By State By Physician By Physician Number By Specialty By Address & Zip

By Participating & Non-Participating

By Contracted (Network) and Not Contracted (Non-network)

By Modifier (“QB”, “QU” or “AR”)

G.11.2.3. Additionally, monthly vouchers shall be submitted for voids, stale dates and reissues that occur in months that do not have a quarterly payment voucher.

G.11.2.4. Federal Fiscal Year-end Processing for HPSA/PSA vouchers: September vouchers that are submitted in the month of October shall utilize the check stock for the new fiscal year that started in October.

G.11.3. Medicare Crossover Fees:

G.11.3.1. Medicare crossover fees are paid to Medicare contractors to cover the transmission of data on claims from the Medicare contractor to the TDEFIC contractor. Voucher will be sent monthly with a summary sheet showing the total being paid and supporting documentation showing the payee and amount of payment. Voucher and supporting documentation will be submitted electronically based on approved formats as specified in the TOM, Chapter 2.

G.11.3.2. Federal Fiscal Year-end Processing for Medicare Crossover Fees: September vouchers that are submitted in the month of October shall utilize the check stock for the new fiscal year that started in October.

G.11.4. Demonstrations and Other New Benefit Programs:

G.11.4.1 These are trial programs or new programs, and they may vary in many ways from TRICARE benefits. TEDS will be used if possible; but if the data associated with demonstrations is incompatible with TEDS data formats, the contractor shall submit a separate voucher with related supporting documents/calculations to TMA/CRM no more frequently than monthly to obtain approvals for payment prior to making non-underwritten bank account payments. Directions for these vouchers will be identified in the contract modification incorporating the demonstration.

G.11.4.2 If a separate voucher is used rather than the TEDS, the payments will be recorded as a separate item on the monthly bank reconciliation reports.

G.11.5. Other Payments:

G.11.5.1. Other payments are rare situations where a payment needs to be done manually or separately from TEDS records or other routine vouchers. For example, these payments may be the result of an old claim or direction from TMA.

G.11.5.2. These must be submitted to TMA/CRM with supporting documentation explaining the issues that don’t allow a TEDS record, along with a copy of the claim, computation of the amount of the payment, and other applicable documents.

G.11.5.3. After release approval by TMA/CRM, the contractor shall make payment within 2 working days.

G.11.5.4. The contractor shall report these payments on the Bank Reconciliation Report under the section for TMA approved manual transactions.

G.11.5.5. No payments will be approved by CRM that are advance payments or otherwise represent claims that have not been completely processed.

G.12. BENEFIT PAYMENTS–ADJUSTMENTS

G.12.1. Underpayments: When the contractor makes an additional payment due to a prior underpayment, these payments shall be reported as an adjustment to the original TEDS record or manual voucher, but in the current fiscal year and current CLIN/ASAP ID regardless of the fiscal year or CLIN/ASAP ID of the original payment.

G.12.2. Overpayments: When reporting collections the contractor makes (whether cash or offset), the collection shall be accomplished as a separate credit transaction as an adjustment to the original TEDS record or manual voucher. Identified debts shall be reported on the Accounts Receivable Report in accordance with Section F.5.1.3.

G.12.3. Voided or Stale-dated Payments:

G.12.3.1. For voided or stale-dated payments over $10.00, a credit voucher through TEDS records must be processed in accordance with the standards detailed in TSM Chapter 1, Section 3. Or, if the check was issued as a manual voucher (i.e. HPSA, Medicare Crossover Fee or other payments), the credit should be submitted as a similar manual voucher on a monthly basis.

G.12.3.2. For voided/stale-dated payments of $10.00 or less, the contractor may elect either to create a credit voucher for the payment using a TEDS or manual voucher, or the contractor may include the credit as a listing of under $10.00 credit transactions and submit it monthly in the Bank Account Reconciliation Report.

G.12.4. Replacement Payments:

G.12.4.1. Reissuance of payments will be made against the current fiscal year bank account.

G.12.4.2. Replacement payments may be issued upon written request of the payee or authorized representative. If the payee does not return the check, the payee must provide a statement describing the loss or destruction of the check. Before issuing a replacement check, a stop payment order for the original check must be issued to and accepted by the bank.

G.12.4.2.1. If the claim history is not available to the contractor, the contractor shall submit a request for approval of check release to TMA/CRM within 10 workdays of the payee’s request. Supporting documentation shall include the payee’s name and sponsor’s SSN plus the original check or statement as described in G.12.4.2. above and a copy of the EOB (if available) or other documentation showing the computation and payment of the original check.

G.12.4.3. The contractor shall report the reissuance using the same procedure used to void/staledate the original.

G.12.4.3.1. If no credit voucher was made in voiding/staledating of the check, no credit voucher is required for the reissue (i.e. if the contractor gets a returned check and immediately reissues from the same bank account, no TEDS or other voucher needs to be done). If the reissuance involves a check from a prior year, a TEDS or other voucher must be done to report the reissuance from the current year.

G.12.4.3.2. If the amount of the stale-dated check to be reissued is $10.00 or less, the contractor shall use the same procedure in the reissuance as was used for the stale-dating. If no credit voucher was made in the stale-dating of the check, no credit voucher is required for the reissue. The contractor shall reissue the payment and include the amount in the Bank Account Reconciliation Report.

G.12.4.4. Re-issuance of Payments When Original Payee is Deceased: Payments issued by the contractor shall be made payable to the legal representative of the estate of the person concerned with an additional line stating “For the estate of _____.” Payments shall not be payable to the “estate of” a decedent, nor to a deceased person. Payments shall be to the named payee or mailed to the payee’s address of record.

G.13. COLLECTIONS/RECEIVABLES

G.13.1. Collections: Procedures for non-underwritten refunds apply to the TDEFIC contract. See TOM, Chapter 3, Financial Administration, Section 3, Claim Refund And Collection Procedures.

G.13.2. Receivables: Recoupments policies and procedures are detailed in the TOM, Chapter 10, Claims Adjustments and Recoupments, Section 4, Overpayments Recovery - Non-Financially Underwritten Funds.

G.13.3. Reporting: Receivables held by the contractor will be reported monthly to CRM as detailed in CDRL# M060, Accounts Receivable Summary Report including Supplemental Reports.

TDEFIC, HT9402-12-R-0005, Section G