8_Section_H__clean_4-4-13.doc

SECTION H, SPECIAL CONTRACT REQUIREMENTS

H.1. Special Contract Requirements H.1.1. The Government may develop major contract and program changes through Integrated Process Teams (IPTs). This clause describes the contractor’s participation in this process. The contractor shall provide the appropriate personnel (as agreed to by the CO and the contractor) to serve on IPTs to develop and/or improve the technical, business, and implementation approach to any and all proposed TRICARE program contract changes within 14 calendar days after notification by the CO. The contractor will participate in the entire process with the Government team from concept development through incorporating the change into the contract. This process includes developing budgetary cost estimates, requirement determination, developing rough order of magnitude cost estimates, preparing specifications/statements of work, and establishing a mutually agreeable equitable adjustment to the contract price as a result of incorporating the change (including pricing, negotiations, etc.). IPTs will not be formed for all contract changes, but generally will be formed for complex, system-wide issues. The contractor shall participate in all required meetings as determined by the Government team leader, regardless of how they are held (in person, via teleconference, by video-teleconference, or through electronic conferences within the TMA web site). The frequency and scheduling will vary depending on the topic.

H.1.2. The Government, may periodically (estimated as twice per quarter or eight times per year) submit claims data to the contractor to review potential issues identified by TMA. The contractor shall review and research claim payments or processing actions of the identified services. If, during the contractor’s review, errors in payment are found, the contractor shall take the necessary administrative action as directed by the Government to correct processing/payment errors. These actions may include recoupment of overpayments or claim adjustments.

H.2. Performance Guarantees H.2.1. The performance guarantees described here-in are the contractor’s guarantee that the contractor’s performance will not be less than the contract performance standards. The rights of the Government and remedies described in the performance guarantee sections are in accordance with, and in addition to, all other rights and remedies of the Government Allowed under the contract (See Section G, Contract Administration, paragraph G.6.3.1. Performance Guarantees, for specific instructions when a performance guarantee applies).

H.2.2. The contractor guarantees that performance will meet or exceed the contract standards. For all performance guarantees the contractor will be notified and reductions will be made on a quarterly basis. For each occurrence the contractor fails to meet a guaranteed standard stated below, the Government will reduce the amount payable to the contractor on a future invoice after notification. Performance guarantee reductions will continue to be assessed for the respective option period, until the contractor’s performance improves to meet or exceed the standard. Performance will be measured as specified below.

H.2.3. Telephone Service (Blockage Rates)

H.2.3.1. Standard: Blockage rates shall never exceed 5%; not less than 95% of all calls shall be received without the caller encountering a busy signal.

H.2.3.2. A performance guarantee shall be applied as follows:

H.2.3.2.1. Based on the contractor’s monthly report, the Government will assess at the rate of $0.50 per blocked call below the standard (not less than 95% of all calls shall be received without the caller encountering a busy signal). For example, if 100,000 calls are received during a quarterly assessment period and the blockage rate is 8% then 3,000 calls are subject to the performance guarantee (8% less 5% = 3% which is the difference between actual blockage rate and the allowed blockage rate. 100,000 calls received times the 3% = the 3,000 calls subject to the guarantee) making the performance guarantee amount $1,500 (3,000 times $0.50).

H.3.2.2.2. “All calls” is defined as any call to any contractor operated TRICARE customer service telephone number. Customer service shall be interpreted in the broadest terms including telephone calls from beneficiaries, providers, Government representatives, and interested parties about general program information, network providers, eligibility, benefits, referrals, preauthorizations/authorizations, claims, complaints, processes and procedures.

H.2.4. Telephone Service (Total Hold Time) H.2.4.1. Standard: 95% of all calls shall not be on hold for a period of more than 30 seconds during the entire telephone call.

H.2.4.2. A performance guarantee shall be applied as follows:

H.2.4.2.1. If performance falls below the standard for each individual call that has a total hold time of more than 30 seconds based on the contractor’s monthly report, the Government will assess at the rate of $0.50. For example, 100,000 calls are received during a quarterly assessment period and 8% of the calls have a total hold time of more than 30 seconds, then 3,000 blocked calls are subject to the performance guarantee. (8% less 5% = 3% which is the difference between the calls exceeding the 30 second time limit and the allowed percentage of calls being on hold for more than 30 seconds. 100,000 calls received times 3% = 3,000 calls subject to the performance guarantee.) The performance guarantee would be 3,000 times $.50 = $1,500.

H.2.5. Claims Processing Timeliness (Retained Claims and Adjustment Claims) H.2.5.1. Standard: Not less than 98% percent of retained claims and adjustment claims processed shall be completed within 30 calendar days from the date of receipt.

H.2.5.2. A performance guarantee shall be applied as follows:

H.2.5.2.1. If the contractor fails to meet the standard of 98%, the Government will assess at the rate of $1.00 per retained claim not meeting the standard. For example, if 9% of 100,000 retained claims during a quarterly assessment period are not processed within 30 calendar days, then 7,000 claims are subject to the performance guarantee. (9% less 2% = 7% which is the difference between the percentage of claims not processed within 30 days and the percentage of claims allowed to exceed the 30 day standard. 100,000 claims times 7% = 7,000 claims.) The performance guarantee would be 7,000 times $1.00 = $7,000. The number of claims failing to meet the standard will be determined monthly based on the TRICARE Encounter Data System (TEDS) database.

H.2.6. Claims Processing Timeliness

H.2.6.1. Standard: 100% of all claims (both retained and excluded, including adjustments) shall be processed to completion within 90 calendar days.

H.2.6.2. A performance guarantee shall be applied as follows:

H.2.6.2.1. If the contractor fails to meet the standard and falls below the standard of all claims processed to completion within 90 calendar days, the Government will assess at the rate of $1.00 per claim not meeting the standard. For example, if the total number of claims is 100,000 and 1% of the claims is not processed within 90 days, then 1,000 claims are subject to the performance guarantee. (1% is the difference between the percentage of claims processed within 90 days and the 100% standard. 100,000 claims times 1% = 1,000 claims.) The performance guarantee would be 1,000 times $1.00 = $1,000. The number of claims failing to meet the standard will be determined monthly based on the TEDS database.

H.2.7. TEDS Edit Accuracy

H.2.7.1. Standard:

Following the start of claims processing services, the contractor shall have the following percentages of TEDS records (initial submissions, resubmissions and adjustment/cancellation submissions) passing the TMA edit system at the following time lines:

One through three months - 80%

Four through six months - 85%

Seven through nine months - 90%

Ten through 11 months - 95%

Twelve through 23 months - 96%

Month 24 through contract close - 97% H.2.7.2. A performance guarantee shall be applied as follows:

H.2.7.2.1. If the contractor fails to meet the standard and falls below a performance guarantee amount of $3.00 for each TEDS record not meeting the standard is applicable. For example, if the total number of TEDS records is 100,000 and 8% of the TEDS records did not pass edits after six months, then 3,000 TEDS records are subject to the performance guarantee. (8% less 5% = 3% which is the difference between the percentage of TEDS records that failed edits after six months and the allowed percentage. 100,000 TEDS records times 3% = 3,000 TEDS records). The performance guarantee would be 3,000 times $3.00 = $9,000.00. The number of TEDS records failing to meet the standard will be determined monthly based on the TEDS database.

H.3. Claim Cycle Time H.3.1. Claim Processing Cycle Time Measurement H.3.1.1 The Government will calculate the contractor claims processing cycle time performance utilizing TEDS records. Included in the monthly measurement will be TEDS records in initial submission batch/vouchers (Batch/Voucher Resubmission Number equals zero), and TEDS records in adjustment/cancellation submission batch/vouchers received by TMA during the reporting period and that have passed the TMA batch/voucher header edit(s). TEDS records in initial submission batch/vouchers, or TEDS records in adjustment/cancellation submission batch/vouchers, which fail the TMA batch/voucher header edits or which are otherwise unable to be processed as submitted by the contractor, and TEDS records in resubmission batch/vouchers (Batch/Voucher Resubmission Number is greater than zero), will be excluded from the claims processing cycle time calculation.

H.3.1.2 The cycle time calculation is one plus the difference between the Julian date the claim processed to completion, and the claim receipt date. The cycle time calculation for TEDS adjustments is one plus the difference between the Julian date the TEDS record was identified as an adjustment (Data Adjustment Identified not zero), and the date the adjusted record processed to completion. Results from the monthly cycle time measurement will be used to assess Contractor Performance Guarantees as stipulated in Section H.3.5 and H.3.7.

H.4. Quarterly Claim Audit Sampling Methodology and Error Determinations H.4.1. Sampling Methodology. There will be three types of audit samples: one occurrence sample and two payment samples (one for non-denied claims and one for denied claims). Samples will be drawn from TEDS records that pass TMA validity edits. Records to be sampled will be “net” records (i.e. the sum of transaction records available at the time the sample was drawn related to the initial transaction record). TEDS records in vouchers which fail TRICARE edits or which otherwise are unprocessable as submitted by the contractor will be excluded from the sampling frame.

H.4.1.1 The occurrence samples will be drawn from TEDS records which pass TMA validity edits. The non-denied payment sample will be drawn from all records with government payments of $1.00 to a high dollar threshold to be determined by the Government. The Government will conduct a one-hundred percent (100%) audit of all records with Government payment amounts meeting or exceeding the high dollar threshold. The denied payment sample will be drawn from all records with billed amounts of $1.00 to a high dollar threshold determined by the Government. The Government will conduct a one-hundred percent (100%) audit of all records with billed amounts meeting or exceeding the high dollar threshold. The non-denied and denied payment samples will be stratified at multiple levels.

H.4.2. Required Contractor Documentation H.4.2.1. Upon receipt of the TEDS Internal Control Number (ICN) listing from TMA, the contractor shall retrieve and compile processing documentation for each selected claim. All documentation must be received at TMA or designated audit contractors within forty five (45) calendar days from the date of the TMA letter transmitting the ICN listing. The contractor shall submit one legible copy of each claim and the following required documents via registered mail, certified mail or similarly guaranteed delivery service.

H.4.2.1.1. Claim-related correspondence when attached to claim or related to the adjudication action, such as status inquiries, written and/or telephone, development records, other telephone conversation records.

H.4.2.1.2. Other claim-related documentation, such as medical reports and medical review records, coding sheets, all authorization and referral forms and their supporting documentation, referrals for civilian medical care (SF Forms 513 or 2161), other health insurance and third party liability documents, discounted rate agreements to include the following information: 1) provider name, 2) provider identification number, 3) effective and termination dates of agreements; and 4) negotiated rate(s), state prevailing fee(s) or fee schedule(s), DRG, OPPS, SNF pricing information and such other documents as are required to support the action taken on the claim.

H.4.2.1.3. A copy of the EOB (or EOB facsimile) for each claim selected.

H.4.2.1.4. The contractor shall send via electronic data input, the current family history (15 to 27 months) for each selected claim. This electronic data containing all required data fields must be received by TMA or designated audit contractor within forty five (45) calendar days from the date of the TMA letter transmitting the ICN listing.

H.4.2.2. Payment or occurrence errors will be assessed if a claim is selected for audit and the contractor cannot produce the claim, or the claim provided is not auditable. For TEDS records which do not represent a legitimate condition requiring submission of a record as defined in the TRICARE Systems Manual (TSM), a one-hundred percent (100%) payment error will be assessed. The payment error amount will be based upon the total Government Billed Amount. This condition is considered to be an unsupported TEDS. The contractor has the option of submitting the original document in those cases where the copy is not legible. TMA or designated audit contractors will return original documents upon completion of the audit process.

H.4.2.3. Additional Data to be Furnished by the Contractor H.4.2.3.1. Description of data elements by field position in family history file printout and field definitions for pricing, OHI, authorization and/or referral screens. Initial submission to TMA is due by the commencement of claims processing and revisions as they occur.

H.4.2.3.2. Claim adjudication guidelines used by processors; automated prepayment utilization review screens; automated duplicate screening criteria and manual resolution instructions shall be submitted to TMA by the commencement of claims processing.

H.4.2.3.3. Unique internal procedure codes with narrative and cross-reference to approved TRICARE codes and pricing manuals used in claims processing. Initial submission to TRICARE is due by the commencement of claims processing and revisions as they occur, but not later than the fifth (5th) work day of the month following the change.

H.4.2.3.4. Specifications for submission of the provider files are described in the TSM 7950.2-M, February 2008. Initial submission to TMA is due by the commencement of claims processing and updates to the files are to be submitted as specified in the TSM.

H.4.2.3.5. Documentation for any claim selected with adjustment transactions completed prior to the date of the sample must include the documentation to indicate both initial and adjustment processing actions to include claims EOBs and pricing documentation.

H.4.3. Quarterly Payment Error and Process Error Determinations H.4.3.1. There are two categories of payment errors: (1) a payment error, which cannot be removed by contractor post payment processing actions, and (2) a payment error, which can be removed by contractor post payment processing actions (see below list of audit error codes defining payment error categories). Payment errors which can be removed by contractor post payment actions will also be assessed a process error at audit. If contractor post payment actions substantiate the initial processing decision, the payment error will be removed but the process error will remain. If the initial processing action is not substantiated, both the payment and the process error will remain. Claims containing process errors will not affect payment or occurrence error rates, but will be used as a performance indicator.

H.4.3.2. Payment errors are the amount of over/under payments on a claim, including but not limited to a payment in the correct amount but sent to the wrong payee, denial of a payable claim, misapplication of the deductible, payment of a non-covered service/supplies, or services/supplies for which a benefit determination cannot be based on the information available at the time of processing. Process errors result from: noncompliance with a required procedure or process, such as development required but not performed, medical emergency not substantiated, medical necessity review not evident and are cited in conjunction with a payment error. Process error determinations are based on the claim information available and those processing actions which have passed the TEDS Validity edits up to the time the audit sample is pulled.

H.4.3.3. Payment errors which may not be removed by contractor post payment actions (see below audit error categories) are based only on the claim information available and those processing actions which occur prior to the date the audit sample is pulled. Consideration will be given to subsequent processing actions that occur prior to the date the audit sample is pulled, including actions that have not passed the TEDS edits, only if supporting documentation to indicate the action taken and the date the action was completed is submitted with audit documentation. Action determinations occurring after the date the audit sample is pulled will not be considered in the audit regardless of whether resolution of payment error exists. Adjustment transactions are not allowed on total claim denials. Therefore, subsequent reprocessing actions to a denied claim which occur prior to the date the audit sample is pulled will be considered during the audit.

H.4.3.4. All incorrectly coded financial fields on a TEDS are considered to be occurrence errors regardless of whether associated errors exist.

H.4.4. Computation of the “Total Amount Billed” for Non-Denied Institutional Claims H.4.4.1. For treatment encounters for which no per diem, negotiated rate or DRG-based amount applies for consideration of payment, the “total amount billed” is the actual amount billed on the claims. This applies to treatment encounters involving services from DRG-exempt hospitals and hospital units, those involving DRG-exempt services and those which would otherwise be subject to the DRG-based payment methodology but for which a DRG allowed amount cannot be computed, regardless of whether or not these claim are paid.

H.4.4.2. For treatment encounters subject to the TRICARE per diem payments, negotiated rate, or the DRG-reimbursement methodology, the “total amount billed” is the correct per diem, negotiated rate, or DRG-based allowable amount including any applicable outlier amounts.

H.4.5. Quarterly TEDS Occurrence Error Determination H.4.5.1. The TEDS occurrence error rate is defined as the total number of errors divided by the total number of data fields in the sample times 100.

H.4.5.2. Occurrence errors determinations are based on only the claim information available and those processing actions taken at the time of adjudication. Actions and determinations occurring subsequent to the processed date of an audited claim, such as obtaining other health insurance documentation, adjusting a claim to correct financial or other data fields, or developing for required information not obtained prior to processing, are not a consideration of the audit regardless of whether a resolution of the incorrectly coded TEDS results.

H.4.5.3. Occurrence errors result from an incorrect entry in any data field of the TEDS. There are no exceptions. Any error, including errors in financial fields, shall be counted as occurrence errors.

H.4.5.4. Some TEDS error conditions are not attributable to any one specific data field but apply to the record as a whole or to certain parts of the record. In addition to erroneous data field coding, the following error conditions involving incorrect or unsupported records will result in occurrence errors being assessed as indicated.

H.4.5.5. The following are occurrence error categories and codes. All TEDS record occurrence errors, including errors in financial fields, are counted and the error rate is expressed as a percentage of the total number of data fields in the TEDS record.

* Not to exceed 21 errors for combination of these error conditions.

** Not to exceed 15 errors for combination of these error conditions.

H.4.6. The following are payment errors on which post payment actions are either not applicable or would not remove the payment errors assessed.

01K-Authorization I Preauthorization Needed (all—except ECHO and Adjunctive Dental Authorizations)

03K-Billed Amount Incorrect

04K-Cost-share I Deductible Error

07K-Duplicate Services Paid

08K-Eligibility Determination—Patient

09K-Eligibility Determination—Provider

12K-Non-Availability Statement Error

13K-OHI/TPL—Govt Pay Miscalculated

16K-Payee Wrong-Provider

17K-Participating/Non-Participating Error

18K-Pricing Incorrect

19K-Procedure Code Incorrect

20K-Signature Error

22K-DRG Reimbursement Error

24K-Incorrect Benefit Determination

25K-Claim Not Provided

26K-Claim Not Auditable

27K-Incorrect MCS System

H.4.6.1. The following are payment errors on which post-payment actions may support original processing. On rebuttal, if documentation is provided that supports the processing actions, the payment errors could be removed but the process errors would remain.

01K-Authorization/Preauthorization Needed (ECHO and Adjunctive Dental Authorizations)

02K-Unsupported Benefit Determination

05K-Development Claim Denied Prematurely

06K-Development Required

10K-Medical Emergency Not Substantiated

11K-Medical Necessity/Review Not Evident

21K-Timely—Filing Error

23K-Contract Jurisdiction Error

99K-Other. This payment error is very general and claims would have to be reviewed on an individual basis with regard to post-payment actions.

H.4.6.2. The following are process errors which will be assessed for noncompliance of a required procedure/process. These errors are neither occurrence errors nor payment errors and are not used to calculate the occurrence or payment error rate. A payment error will be assessed along with the process error. Upon rebuttal if the process is followed to conclusion and the actions support the original decision, the payment error will be removed but the process error will remain.

01P-Authorization/Preauthorization needed (ECHO and Adjunctive Dental Authorizations)

02P-Unsupported Benefit Determinations

05P-Development Claim Denied Prematurely

06P-Development Required l0P-Medical Emergency Not Substantiated

11P-Medical Necessity/Review Not Evident

21P-Timely Filing Error

23P-Contract Jurisdiction Error

99P–Other H.4.6.3. The following are procedural/documentation errors which will be assessed to document the contractor’s procedural errors and documentation problems which impact the audit process or indicate a situation of contractual noncompliance which is identifiable during the audit and requires follow-up corrective action. These errors are neither occurrence errors nor payment errors and are not used to calculate the occurrence or payment error rates.

01L–Audit Documentation Incomplete

02L–Audit Documentation Illegible

03L–Documentation Submitted Late

04L–EOB Incorrect

05L–NAS Questionable

06L–Error in Claim History

08L–Erroneous Claim Split

09L–Erroneous TEDS Record Split

10L–Adjustment – No Authorizing Official

11L–Contract Jurisdiction Error H.4.7. Quarterly Payment and Occurrence Error Determination Rebuttals H.4.7.1. Contractor rebuttals of initial payment and occurrence error findings must be submitted to TMA or the designated claims review contractor within thirty (30) calendar days of the date of the TMA initial payment and occurrence error transmittal letters. Rebuttal comments not postmarked within thirty (30) calendar days of the transmittal letter will be excluded from further consideration. Rebuttal error determinations are considered final and will not receive further consideration except when during the rebuttal process the contractor submits a claim not previously submitted with the initial claims review process and an error is assessed on rebuttal, or when the contractor’s rebuttal explanation of the basis on which a claim was processed results in the assessment of a new error not previously reviewed by the contractor. Contractor rebuttal responses must be postmarked within thirty (30) calendar days of the TMA or designated claims review contractor’s initial payment and occurrence error transmittal letter. The due date of contractor rebuttals will be calculated by adding thirty (30) to the Julian calendar date of the TMA or designated contractor’s initial error transmittal letter.

H.4.7.2. Contractor rebuttals to new errors assessed by TMA or the designated claims review contractor during the rebuttal process must be postmarked within thirty (30) calendar days of the TMA or designated claims review contractor’s rebuttal transmittal letter. Rebuttals to new errors not postmarked within thirty (30) calendar days from the date of the rebuttal transmittal letter will be excluded from further consideration. The due date of rebuttal comments will be calculated by adding thirty (30) to the Julian calendar date of the TMA or designated claims review contractor’s rebuttal response letter.

TDEFIC, HT9402-12-R-0005

, Section H