Section_C_Amd_3_5-14-13.doc

SECTION C, DESCRIPTION/SPECIFICATIONS/WORK STATEMENT

TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC)

Description/Specifications/Work Statement

1.0 General: This contract applies to Active Duty family members, retired members, qualifying reservists and retired reservist members, their spouses and children and their surviving family members subject to the provisions of Chapter 55, Title 10, United States Code (USC) of the Uniformed Services, who have Medicare/TRICARE dual eligibility. The Uniformed Services include the US Army, Navy, Air Force, Marine Corps, Coast Guard, the Commissioned Corps of the Public Health Service and the Commissioned Corps of the National Oceanic and Atmospheric Administration. Determination of a person's eligibility status is the responsibility of the Uniformed Services as reported on the Defense Enrollment Eligibility Reporting System (DEERS).

1.1. The purpose of the TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC) is to provide claims processing and associated customer support services for claims submitted by and on behalf of MHS beneficiaries who are eligible for both Medicare and TRICARE benefits, for services received in the United States, Puerto Rico, Guam, the US Virgin Islands, American Samoa and the Northern Mariana Islands. The contractor shall provide the expertise of health care claims processing and its support services by incorporating and operating the best practices of the private sector in support of TRICARE. The contractor shall fulfill the objectives of the contract while complying with the scope and structure of TRICARE (benefits and beneficiary liabilities) and requirements as identified herein. The contractor shall deliver all services in a manner that supports the TRICARE fully integrated health care delivery and financing system for all MHS beneficiaries.

1.2. The contractor shall establish customer service activities that support the claims processing function and other administrative services traditionally associated with claims processing. Of critical importance is the contractor’s success in collaborating with and reaching agreements with the Centers for Medicare and Medicaid Services (CMS) Coordination of Benefits Contractor (COBC) to transfer Medicare processed claims to the contractor (“cross-over claims”) for secondary processing (TOM, Chapter 20, Section 2).

1.3. The contractor will be solely liable for any liability arising out of the performance of this contract. Consequently, the Government will not reimburse the contractor for any lawsuits, claims, settlements, judgments or other legal or administrative actions or costs as a result of contract performance.

2.0. DOCUMENTS: The documents listed below, including the changes identified, hereby establish the requirements for this contract These documents are the integral requirements of this contract. Requirements incorporated into this contract by reference have the same force and effect as if set forth in full text. The manuals and 32 CFR Part 199 are located at: http://manuals.tricare.osd.mil/.

Title 10, USC, Chapter 55

32 Code of Federal Regulations (CFR), Part 199 TRICARE Policy Manual (TPM) 6010.57-M, February 1, 2008; through Change No. 87 TRICARE Reimbursement Manual (TRM) 6010.58-M, February 1, 2008; through Change No. 80 TRICARE Systems Manual (TSM) 7950.2-M, February 1, 2008; through Change No. 48 TRICARE Operations Manual (TOM) 6010.56-M, February 1, 2008; through Change No. 99 The TRICARE Manuals incorporate federal statutes and regulations and may not be interpreted in contradiction thereto. Among the manuals, the TPM takes precedence over the other three TRICARE manuals. The TRM takes precedence over the TSM and TOM. The TSM takes precedence over the TOM.

3.0 DEFINITIONS. See 32 CFR Part 199.2, the TOM Appendix B and Section J, Attachment J-2.

4.0 GOVERNMENT FURNISHED PROPERTY AND SERVICES

4.1. In support of TMA’s educational initiatives, TMA will furnish educational materials for use in informing any interested parties of the program (paragraph 7.4.6).

4.2. Using the Defense Manpower Data Center’s (DMDC) DEERS, the Government will furnish appropriate DEERS data for the contractor’s use to perform all eligibility checks. DEERS is the database of record for eligibility.

5.0 CONTRACTOR FURNISHED ITEMS. The contractor shall furnish all necessary items (e.g., facilities, labor, services, supplies, etc.) not provided by the Government (as specifically identified in paragraph 4.0 or elsewhere within the contract as Government furnished) for the satisfactory performance of this contract.

6.0 OBJECTIVES: The objectives below represent the performance outcomes for this contract and are supported by technical requirements. The acceptable performance standards are explained further in the TOM and the contract. Where specific performance standards are not stated, the contractor shall use private sector best practices.

6.1. Provide timely and accurate delivery of claims processing and customer services.

6.2. Establish and maintain beneficiary and provider satisfaction at the highest level possible throughout the period of performance, through the delivery of a claims processing system as well as customer friendly program services.

6.3. Use an effective management approach to provide the necessary services, incorporating best business practices when practicable.

6.4. Ensure all services and systems are fully operational at the start of health care claims processing (beginning of Option Year 1), and disruption of services to beneficiaries is minimized.

7.0 TECHNICAL REQUIREMENTS. These technical requirements represent specific tasks, outcomes, and/or standards that, at a minimum, shall be achieved in support of the objectives (paragraph 6.0).

7.1 Claims Processing

7.1.1. The contractor shall establish, maintain, and monitor a single database Automated Information System (AIS) in accordance with the Department of Defense (DoD) Architecture Framework (DoDAF), Version 2.02, and/or any revision thereto (http://dodcio.defense.gov/dodaf20.aspx). The AIS will provide TMA highly reliable and timely access to the data through a data repository.

7.1.2. The contractor shall establish, maintain, and monitor the AIS to ensure claims are processed in an accurate and timely manner and meet the functional requirements of claims processing as set forth in the technical requirements, the TOM, and the TSM. The contractor shall provide, maintain and monitor the AIS for purposes of providing claims payment record information, and making available the data required by this contract.

7.1.3. The contractor shall establish, maintain, and monitor information management capability, or interoperate with or use Government-furnished AIS, to support aspects of the following TRICARE functions: claims processing, program administration, beneficiary services, finance, and other health insurance (OHI) and meet TRICARE objectives (paragraph 6.0). The AIS shall provide data to and/or interoperate with the contractor data repository and ensure required elements are communicated between the contractor’s AIS and DEERS.

7.1.4. The contractor shall accept and utilize the DEERS file indicating the Medicare eligibility and effective dates for TRICARE beneficiaries for coordinating with the Medicare COBC (TSM, Chapter 3, Section 1.4). DMDC sends the TDEFIC three record types (header and trailer records “single record types” and a detail record “multiple records”) on a monthly basis via Network Data Mover (NDM) or on a Compact Disk (CD). The file layouts are located at Section J, Attachment J-7.

7.1.5. All providers who receive reimbursement under this contract shall be TRICARE-authorized providers in accordance with the criteria set forth in 32 CFR Part 199.6. The contractor shall verify all providers' authorized status through the TRICARE Management Activity (TMA) centralized TRICARE Encounter Provider Records (TEPRV) (TSM, Chapter 2) or, if not listed, shall obtain and maintain documentary evidence to certify that the provider meets the criteria set forth in 32 CFR Part 199.6 and the TPM. EXCEPTIONS: The contractor is not required to verify the provider's authorized status if TRICARE is not the primary payer and Medicare has accepted the claim as from an authorized provider. The TRICARE Quality Monitoring Contractor (TQMC) will certify all Residential Treatment Centers (RTCs), Substance Use Disorder Rehabilitation Facilities (SUDRFs) and Psychiatric Partial Hospitalization Programs (PHPs). The contractor shall accept such certification as valid. The contractor shall submit information on all providers authorized by the contractor to the TMA centralized TEPRV system in accordance with the provisions of the TSM.

7.1.6. The contractor shall provide to each beneficiary and each participating provider an Explanation of Benefits (EOB) that describes the action taken on claims and meets the requirements of TOM, Chapter 8, Section 8. EOBs shall be suppressed when appropriate. EOBs shall be mailed in hardcopy, unless the beneficiary has provided written agreement to receive the EOB electronically. The contractor may issue monthly summary EOBs to beneficiaries in lieu of individual EOBs. EOBs must clearly describe the action taken on each claim and provide information regarding appeal rights to include the address for filing an appeal. The EOB must also provide information on the deductible and catastrophic cap status following processing as well as sufficient information to allow a beneficiary to file a claim with a supplemental insurance carrier. Within 5 calendar days of receiving a beneficiary’s request (written, verbal, electronic) for an EOB, the contractor shall send the requested EOB without charge to the beneficiary and regardless of the beneficiary’s status.

7.1.7. The contractor shall ensure that care provided is medically necessary, appropriate and within the scope of TRICARE benefits set forth in 32 CFR Parts 199.4 and 199.5 to achieve the efficient and effective provision of the right care, at the right time, and at the right level. The contractor shall use best business practices consistent with TRICARE law, regulation and policy in reviewing and approving care. The contractor shall be considered a multi-function Peer Review Organization (PRO) under this contract and shall follow the standards, rules, and procedures as defined in 32 CFR Part 199.15 as applicable to claims where TRICARE is primary payer.

NOTE: TMA is conducting an independent study to identify potential opportunities for implementation of case and care management programs applicable to the dual-eligible Medicare/TRICARE population to reduce costs to the TRICARE program. If the study indicates there are potential cost savings to TMA by implementing case management (CM) and utilization management (UM) services, those CM and UM services will be within the scope of this TDEFIC requirement, and the contract may be modified at a later date to add CM and UM services.

7.1.8. CMS implemented a Bundled Payments for Care Improvement (BPCI) Pilot Program which bundles payments for services across a single inpatient episode of care. The pilot program TED records for the institutional claims processed and reimbursed by Medicare under Model 4 of the BPCI Program must reflect the Special Processing Code “BP-CMS Bundled Care Payment Initiative” assigned to this pilot. Model 4 of the initiative requires professional providers paid by the hospital out of the bundled payment to submit “no-pay” claims to Medicare. For these “no-pay” Medicare crossover claims the contractor shall submit a complete denial initial TED record with a denial reason code of “97-The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.” In addition, the Special Processing Code “BP” must be denoted on the TED record.

7.2. Customer Service

7.2.1. The contractor shall furnish the DoD TRICARE Operations Center, each TRICARE Regional Office, and all Health Benefits Advisors (HBAs), Beneficiary Counseling and Assistance Coordinators (BCACs), and Debt Collections Assistance Officers (DCAOs) located in each region with “read only” access to claims data. EOBs shall be posted in a downloadable or print read-format. The contractor shall provide training, when requested, and ongoing customer support for this access.

7.2.2. The contractor shall operate a telephone automated voice response system that allows provider access to information on the status of claims filed by that provider, and patient access to information on the status of claims filed by or on behalf of that patient. This requirement is in addition to any Internet access offered by the contractor.

7.2.3. The contractor shall provide comprehensive, readily accessible customer services that include multiple, contemporary avenues of access (e.g., e-mail, worldwide web, telephone, facsimile) for the beneficiary and provider. Customer services shall be delivered in a manner that achieves the objectives of this contract without charge to beneficiaries or providers. All technology-based customer service (for instance Internet-based services) shall be provided using current and proven technology.

7.2.4. The contractor shall provide an approach for gathering feedback to measure whether their customer services are resulting in highly satisfied dual-eligible Medicare/TRICARE beneficiaries and providers. The contractor shall employ methods and procedures to mitigate any identified negative trends relating to the satisfaction findings and provide the results to TMA.

7.2.5. The contractor shall develop and implement an education plan for conducting targeted beneficiary and provider education. The contractor shall conduct targeted beneficiary and provider education related to specific issues that surface throughout the administration of this contract. TMA or the contractor may identify issues and will coordinate all education efforts and materials with BE&S in accordance with the Memorandum of Understanding (MOU).

7.2.6. The contractor will attend quarterly BE&S web partnership meetings to discuss best processes for joint endeavors.

7.3. Management

7.3.1. The contractor shall develop and operate a continuous Quality Management (QM) Program. The QM Program shall demonstrate how their organization’s goals and objectives, leadership, structure and operational components are designed to achieve the objectives of this contract. The QM Program shall cover every aspect of the contractor’s operations.

7.3.2. The contractor shall implement and maintain information security in its project, enterprise and company-wide unclassified information technology system(s) in accordance with the requirements set forth in DoD Instruction (DoDI) 8582.01, Security of Unclassified DoD Information on Non-DoD Information Systems, June 6, 2012. The contractor shall comply with the specified National Institute of Standards and Technology (NIST) Special Publication (SP) 800–53 Security Controls, Privacy Act Program Requirements (DoD 5400.11-R), the Personnel Security Program (DoD 5200.2-R) and OMB M-06-16, Protection of Sensitive Agency Information. In addition, the contractor shall comply with DoD minimum security requirements as outlined in the TSM, Chapter 1, Section 1.1. Government validation of the Contractor’s Checklist and Certification Form (Section J, Attachment J-5, CDRL A050) is required prior to accessing DoD data or interconnectivity with the Government systems and testing. If a control is not implemented, the contractor shall prepare a written determination that explains why the required security control is not applicable and/or how an alternative control or protective measure is used to achieve equivalent protection (sample form at Section J, Attachment J-5, CDRL A050). At the Government’s discretion, the contractor will provide a NIST certification briefing of its certification efforts at a Government-designated location.

7.3.2.1. The NIST requirements apply to the contractor and subcontractors/business partners that perform functions such as program/business management, where the program/business management function requires access to DoD systems and/or the use of DoD/TRICARE data, beneficiary enrollment eligibility verification, claims processing, etc. The NIST requirements do not apply to providers who provide health care to CHAMPUS/TRICARE-eligible beneficiaries and who do not have access to DoD systems or use of DoD/TMA data.

7.3.3. The contractor shall implement processes and procedures that ensure full compliance with the most current version of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry's Consumer Bill of Rights and Responsibilities (http://www.hcqualitycommission.gov/) and DoD Instruction 6000.14, DoD Patient Bill of Rights and Responsibilities in the Military Health System (www.dtic.mil/whs/directives).

7.3.4. The contractor shall participate in quarterly round table meetings/summits with Government representatives, other contractors, and any other participants that the Government determines are necessary. Attendance at these meetings will be at no additional cost to the Government. The round table meetings/summits requires high level managerial participation from the contractor (CEOs, Operations) and participation, in person, by the contractor’s technical and cost experts as determined by the agenda. The round table meetings/summit participants are tasked with reviewing current policies and procedures to determine where proven best practices from the participants’ Government and private sector operations can be implemented in the administration of TRICARE to continue TRICARE’s leading role as a world-class health care delivery system.

7.3.5. Audits and contract performance evaluations by Government staff will be conducted periodically at the location(s) of the contractor's operations and/or subcontractor(s’) operations. These reviews will include all aspects of the contractor's performance under the terms of the contract. The contractor shall make available all personnel, facilities, and documentation required in the conduct of such reviews or investigations by TMA staff or other authorized Government agencies and staff. Upon the Contracting Officer’s (CO’s) request, the contractor shall provide a lockable office space equipped with desks, conference table and chairs, at a contractor-operated facility for any on-site auditors. The contractor shall also furnish local and long distance telephone capability. Results of these audits and/or evaluations may be furnished to the contractor in writing.

7.3.6. The contractor shall refer to TMA Program Integrity, cases that involve $75,000 or more in potential losses to the Government or any loss with patient harm following the procedures prescribed in the TOM, Chapter 13, Section, Paragraph 4.0.

7.3.7. CONTRACTOR MANPOWER REPORTING - Enterprise-wide Contractor Manpower Reporting Application (eCMRA). The contractor shall report ALL contractor labor hours (including subcontractor labor hours) required for performance of services provided under this contract for the TRICARE Management Activity via a secure data collection site. The contractor is required to completely fill in all required data fields using the following web address: http://www.ecmra.mil/. Reporting inputs will be for the labor executed during the period of performance during each Government fiscal year (FY), which runs October 1 through September 30. While inputs may be reported any time during the FY, all data shall be reported no later than October 31 of each calendar year, beginning with 2013. Contractors may direct questions to the help desk at help desk at: http://www.ecmra.mil.

7.4. Transition

7.4.1. The contractor shall provide ongoing collaboration with the Government to ensure that the appropriate Government personnel, as identified during transition planning, are kept informed of start-up and transition progress. The frequency, type, and nature of communication shall be based on the task and involvement of the Government. Any commonly utilized form of business communication (e.g. telephonic, email) is acceptable to the Government.

7.4.2. No later than 45 days prior to the start of services (Option Period 1), the contractor will mail an introductory letter to all beneficiary households who had claims activity in the previous 12 months.

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TDEFIC, HT9402-12-R-0005

, Amendment 0003, May 14, 2013 Section C