Section_J_Attachment_J-1_TOM_Chap_20_4-2-13.doc

ATTACHMENT J-1

TRICARE Operations Manual 6010.56-M, February 1, 2008 Chapter 20

TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC) Section/Addendum Subject/Addendum Title

General

Jurisdiction

Claims Processing For Dual Eligibles

Other Contract Requirements

Transition

ATTACHMENT J-1

TRICARE Operations Manual 6010.56-M, February 1, 2008

TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC)

Chapter 20 Section 1

1.0 GENERAL

The TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC) encompasses the processing of all TRICARE claims for services rendered within the 50 United States and the District of Columbia, as well as Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern Mariana Islands, to individuals who have dual eligibility under both TRICARE and Medicare.

2.0 DUAL ELIGIBLE BENEFICIARIES

There are six general categories of beneficiaries who have dual eligibility under both TRICARE and Medicare and whose claims will be processed under TDEFIC.

2.1 TRICARE beneficiaries, who are 65 or older and who are entitled to premium-free Medicare Part A and who have Medicare Part B;

2.2 TRICARE beneficiaries who are 65 or older and who are not entitled to premium-free Medicare Part A on their own record or the record of their current, former, or deceased spouse; but have Medicare Part B;

2.3 Active Duty Family Members (ADFMs) who are 65 or older and who are entitled to premium- free Medicare Part A and not required to have Part B;

2.4 TRICARE beneficiaries who are entitled to premium-free Medicare Part A because of a disability or End Stage Renal Disease (ESRD) and who have Medicare Part B;

2.5 ADFMs who have a disability or ESRD and are entitled to premium-free Medicare Part A only (While those with Medicare based on disability get a special enrollment period and therefore are not subject to the Part B premium surcharge, the special enrollment period does not apply to those with ESRD. ESRD patients who do not keep Medicare Part B when first eligible may have to pay a surcharge of 10% for each 12 month period that they could have enrolled in Part B but did not.); and 2.6 TRICARE eligible individuals, who are under age 65 with an effective date of October 1, 2009 or later for Medicare Part B and entitled to premium-free Medicare Part A because of a disability, where Social Security Disability Insurance (SSDI) is awarded on appeal, resulting in a minimum 6 months gap between the Medicare Part A effective date and the Medicare Part B effective date remain TRICARE eligible for the period where only Part A was effective.

ATTACHMENT J-1

TRICARE Operations Manual 6010.56-M, February 1, 2008 Chapter 20, Section 1

If a beneficiary declines Part B coverage he/she will be ineligible for TRICARE from the original effective date of Part B until Part B coverage is reinstated.

3.0

APPLICABILITY OF TRICARE REQUIREMENTS

Unless specifically waived or superseded by the provisions of this chapter, all normal TRICARE requirements set for in the TRICARE Operations Manual (TOM), TRICARE Policy Manual (TPM), TRICARE Reimbursement Manual (TRM), and TRICARE Systems Manual (TSM) apply to claims processed under TDEFIC.

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ATTACHMENT J-1

TRICARE Operations Manual 6010.56-M, February 1, 2008

TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC)

Chapter 20 Section 2

Jurisdiction

1.0

REGIONAL BOUNDARIES

1.1 For claims processing jurisdiction purposes, TRICARE regional boundaries do not apply under the TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC). The TDEFIC contractor is responsible for processing all medical claims for services, except retail pharmaceuticals, rendered to TRICARE/Medicare dual eligible individuals within the 50 United States and the District of Columbia, as well as Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern Mariana Islands.

1.2 Medicare claims processing jurisdiction is based on place of service. The TDEFIC contractor shall contract with the Medicare Coordination of Benefits Contractor (COBC) to ensure that Medicare claims for all dual eligible beneficiaries receiving care within the respective carrier’s/FI’s state(s) are electronically forwarded to the TDEFIC contractor. The cross-over claims agreement shall include all dual-eligible beneficiaries regardless of the beneficiary’s status (Active Duty Dependent (ADD), retiree, survivor, etc.).

2.0

OUT OF JURISDICTION CLAIMS

2.1 The contractor shall forward all claims for treatment of beneficiaries who have eligibility for both Medicare and TRICARE, but there is evidence that the provider misdirected the claim to the TDEFIC contractor, the TDEFIC contractor shall forward the claim to the appropriate Medicare contractor within 72 hours of identifying it as being out of jurisdiction. Claims which the TDEFIC contractor knows would be denied by Medicare are exempt from this requirement.

2.2 Similarly, all other claims for which the TDEFIC contractor does not have immediate responsibility for adjudication shall be forwarded to the appropriate contractor (retail pharmacy contractor, TRICARE Overseas contractor, and MCS contractor) within 72 hours of identifying it as being out of jurisdiction. The TDEFIC shall not notify the provider claimant of the transfer. The TDEFIC contractor needs to notify the beneficiary claimant of the action taken and provide the address of the contractor to which the claim was forwarded.

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ATTACHMENT J-1

TRICARE Operations Manual 6010.56-M, February 1, 2008

TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC)

Chapter 20 Section 3

Claims Processing For Dual Eligibles

GENERAL

Claims under the TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC) will be adjudicated under the rules set forth below. In general, TRICARE pays secondary to Medicare and any other coverage.

2.0

DETERMINING PAYMENTS DUE AFTER COORDINATION WITH MEDICARE

2.1 Special double coverage procedures are to be used for all claims for beneficiaries who are eligible for Medicare, including active duty dependents who are age 65 and over as well as those beneficiaries under age 65 who are eligible for Medicare for any reason. For specific instructions, refer to the TRICARE Reimbursement Manual (TRM), Chapter 4, Section 4.

2.2 Claims Auditing Software

The contractor is not required to have the claims auditing software described in the TRM, Chapter 1, Section 3.

3.0

EXCEPTIONS TO TIMELY CLAIMS FILING

3.1 Medicare

The contractor may grant exceptions to the claims filing deadline if Medicare accepted the claim as timely. If submitted by the beneficiary, the claim must be submitted within 90 calendar days from the date of Medicare’s adjudication to be considered for a waiver.

3.2 Other Health Insurance (OHI)

Reference Chapter 8, Section 3, paragraph 2.4.

4.0

CLAIMS DEVELOPMENT REQUIREMENTS

4.1 Medicare Providers

4.1.1 The contractor shall accept the Medicare certification of individual professional providers who have a like class of individual professional providers under TRICARE without further authorization. An

ATTACHMENT J-1

TRICARE Operations Manual 6010.56-M, February 1, 2008 Chapter 20, Section 3 Claims Processing for Dual Eligibles exception to this general rule occurs if there is information indicating Medicare, TRICARE or other federal health care program integrity violations by the physician or other health care practitioner. In such cases the TDEFIC contractor shall seek guidance from TRICARE Management Activity (TMA) Program Integrity (PI) prior to accepting the Medicare certification as valid for TRICARE purposes.

Individual professional providers without a like class (e.g., chiropractors) under TRICARE shall be denied.

4.1.2 TRICARE claims which TRICARE processes after Medicare do not need to be developed to the individual provider level for home health or group practice claims.

4.1.3 Electronic “cross over” claims received from Medicare after Medicare completes its claims processing do not need a beneficiary or provider signature. For paper claims, when TRICARE is second pay to Medicare and a Medicare EOB is attached, the contractor does not need to develop for provider or beneficiary signature. Signature on file requirements of Chapter 8, Section 4 apply.

4.2 Civilian Services Rendered to Military Treatment Facility (MTF) Inpatients

Civilian claims for TRICARE dual eligible beneficiaries shall be processed by Medicare first without consideration of the Supplemental Health Care Program (SHCP).

4.3 Preauthorization Requirements

Special authorization/preauthorization services outlined in Chapter 7, Section 2 and in TRICARE Policy Manual (TPM), Chapter 1, Section 7.1require preauthorization, and if necessary, review of waivers of the day limits for dual eligible beneficiaries when TRICARE is the primary payer. As secondary payer, TRICARE will rely on and not replicate Medicare’s determination of medical necessity and appropriateness in all circumstances where Medicare is primary payer (see the TRM, Chapter 4, Section 4). In the event that TRICARE is primary payer for these services and preauthorization was not obtained, the contractor shall obtain the necessary information and perform a retrospective review. SNF preauthorizations should be tracked separately from the required preauthorizations noted in Chapter 7, Section 2.

4.4

UTILIZATION MANAGEMENT

Any utilization management provisions applied under the TRICARE Managed Care Support Services (MCSS) contracts, except for those specifically required by the TPM, TRM, or TRICARE Operations Manual (TOM), shall not apply under TDEFIC. Region-specific requirements shall not apply.

ATTACHMENT J-1

TRICARE Operations Manual 6010.56-M, February 1, 2008

4.5 Resource Sharing or Clinical Support

The contractor shall not process a claim from any civilian provider practicing in a Military Treatment Facility (MTF) under the Resource Sharing or Clinical Support Agreement programs.

5.0

END OF PROCESSING

5.1.

Beneficiary Cost-Shares

End of processing. Beneficiary cost-shares shall be based on the following when TRICARE is the primary payer. If the services were received by a TRICARE Prime enrollee (as indicated on DEERS), the contractor shall apply the Prime copayments. For a TRICARE Standard beneficiary, if a provider is known to be a network provider the Extra cost-shares shall be applied. In all other cases, the TRICARE Standard cost-shares shall be applied.

5.2 Application of Catastrophic Cap

Only the actual beneficiary out-of-pocket liability remaining after TRICARE payments will be counted for purposes of the annual catastrophic loss protection.

5.3 Appeals and Grievances

5.3.1 Initial Determinations

Services and supplies denied payment by Medicare will not be considered for coverage by TRICARE if the Medicare denial of payment is appealable under the Medicare appeal process. If, however, a Medicare appeal results in some payment by Medicare, the services and supplies covered by Medicare will be considered for coverage by TRICARE. Services and supplies denied payment by Medicare will be considered for coverage by TRICARE, if the Medicare denial of payment is not appealable under the Medicare appeal process. The appeal procedures set forth in Chapter 12 are applicable to initial denial determinations by TRICARE under TDEFIC.

5.3.2 Grievance System

The contractor shall develop and implement a grievance system, separate and apart from the appeal process. The grievance system shall allow full opportunity for aggrieved parties to seek and obtain an explanation for and/or correction of any perceived failure of contractor or subcontractor personnel to furnish the level or quality of service to which the beneficiary may believe he/she is entitled. Any TRICARE beneficiary, sponsor, parent, guardian, or other representative who is aggrieved by any failure or perceived failure of the contractor or subcontractor to meet the obligations for timely, quality service may file a grievance. All grievances must be submitted in writing. If the written complaint reveals a TRICARE appealable issue, the correspondence shall be forwarded to the contractor’s appeals unit for a reconsideration review. If the complaint reveals a Medicare appealable issue or regards care for which Medicare was the primary payer and the issue does not involve any actions by a TRICARE contractor, the complaint shall be forwarded to Medicare for resolution. The beneficiary shall be notified that the complaint was forwarded to Medicare and the address and phone number of where the complaint was forwarded.

6.0

TED SUBMISSION

For every claim processed to completion, the TDEFIC contractor shall submit a TRICARE Encounter Data (TED) record to TMA in accordance with the requirements of the TRICARE Systems Manual (TSM).

7.0

TRICARE PROCESSING STANDARDS

All TRICARE Processing Standards in Chapter 1, Section 3 apply except for Chapter 1, Section 3, paragraph 1.2, 1.3, 1.4, and 3.4.1.

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ATTACHMENT J-1

TRICARE Operations Manual 6010.56-M, February 1, 2008

TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC)

Chapter 20 Section 4

CUSTOMER SERVICE

1.1 Telephone Inquiries

The contractor must provide nationwide (to include Hawaii, Alaska, and Puerto Rico) around-the-clock toll-free telephone access to a customer service staff in order to enable providers and TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC) beneficiaries to determine claims status as well as general TDEFIC information. Access outside of normal business hours for a Continental United States (CONUS) caller’s time zone may be by automated means, such as provision for leaving messages and/or for obtaining information via an automated response mechanism. During normal CONUS business hours, callers must be offered the option of speaking live with a customer service representative.

1.1.1 Automated Response Unit

The contractor shall provide its Interactive Voice Recognition (IVR) messaging to the Government for review and approval at least 30 calendar days prior to implementing changes for future revisions.

1.2 Written Inquiries

The contractor must respond promptly and meaningfully to all written inquiries, including inquiries received via e-mail. Responses must be furnished in accordance with Chapter 1, Section 3.

1.3 Education Requirements

1.3.1 The education of TRICARE beneficiaries and providers will be accomplished through a collaborative effort with the TRICARE Management Activity (TMA) Beneficiary Education and Support (BE&S). This collaboration will ensure information and education about the TRICARE for Life (TFL) Program, policies, changes and/or addition to benefits are effectively provided. Educational activities include targeted beneficiary and provider education, related to specific issues. Issues may be identified by the Government or the contractor.

ATTACHMENT J-1

TRICARE Operations Manual 6010.56-M, February 1, 2008 Chapter 20, Section 4

1.3.2 The contractor shall submit an education plan that outlines howTRICARE beneficiaries and provider will be informed and educated on all aspects of the TFL Program. TMA and BE&S will review the plan, and provide appropriate feedback for recommended changes.

1.3.3 Required Education Materials – The Government will furnish all beneficiary educational materials which may include printed and electronic media. Materials developed by the Government and distributed in support of the TFL Program will be selected on the basis of recommendations by the contractor, the Program Manager, TMA leadership and others with interests and concerns about the information being provided to TRICARE/Medicare dual eligible beneficiaries and other stakeholders. BE&S and the TMA Program Office will review all recommendations and will prioritize products in accordance with funding availability. TMA BE&S will have final approval authority. The contractor will be responsible for the distribution of Government-furnished materials to TFL beneficiaries.

1.3.4 The contractor shall furnish claim forms, claim completion instructions, the TFL Handbook, DEERS information and other TFL educational materials upon request to beneficiaries, providers, and congressional offices. The contractor shall establish and maintain effective communications with all TRICARE/Medicare dual eligible beneficiaries.

2.0

REFERRALS

All Military Health Systems (MHS) beneficiaries are allowed under the Managed Care Support (MCS) contract requirements to contact the TRICARE Service Center (TSC) for referrals to network providers. This shall continue with TRICARE/Medicare dual eligible individuals under TDEFIC. The Managed Care Support Contractor (MCSC) shall provide the TDEFIC beneficiary with the name, telephone number, and address of network providers of the appropriate clinical specialty located within the beneficiary’s geographic area. The MCSC is not required to make appointments with network providers.

3.0 Audits, Inspections, And Reports

3.1 TRICARE Management Activity (TMA) requires the contractor to prepare and submit routine workload and management reports used to establish a uniform format for recording data on contractor operations and to provide historical data for continued evaluation of contractor performance. While the data contained in the reports are essential to TMA for purposes of program management, they are equally essential for a contractor’s management of the program. A contractor is accountable for assuring that reports contain accurate and complete data. Each contractor shall prepare written procedures describing the source of information as well as the specific steps followed in the collection and preparation of data for each report. In addition, the contractor shall establish a Quality Assurance (QA) program to assure a high degree of reporting accuracy. All reports must be supported with sufficient documentation and audit trails by the contractor for TMA on-site and desk

ATTACHMENT J-1

TRICARE Operations Manual 6010.56-M, February 1, 2008 Chapter 20, Section 4 audit inspections. All plans, reports, etc. shall be titled as listed here. For reports where there is no data to report, the contractor shall submit a report indicating no data.

3.2 All deliverables shall be submitted to TMA via the E-commerce Extranet (https://ecommerceprod.csd.disa.mil/home.cfm). This system permits the contractor to log on to a secure system and upload the required deliverables (contract plans, reports, etc.). The system is accessed via the Internet through a workstation browser. The application is “thin client” meaning that no software needs to be installed on the client workstation and that no software is downloaded into the browser. Javascript and cookies need to be enabled in the browser to utilize the application. The application is best viewed at a resolution of 1024 X 768 pixels in an Internet Explorer (IE) browser. The system must be accessed using the Secure Socket Layer (SSL) protocol (https://) and is protected by individually assigned username and password. Access to the Extranet must be requesting using the E-Commerce Extranet Access Form which will be provided by the Government. While files are being submitted over the Internet they are encrypted within the secure layer. When files are stored on the TRICARE server, they are renamed with a randomly generated name of varying length. Access to information is granted to users at the contract level. Information submitted by one contractor will not be accessible to any other contractor.

3.2.1 Certain deliverables as identified by the Government will require entry of specific metric data from the deliverable into a template prior to uploading the deliverable.

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ATTACHMENT J-1

TRICARE Operations Manual 6010.56-M, February 1, 2008

TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC)

Chapter 20 Section 5

CONTRACT TRANSITION-IN

1.1 Start-Up Plan

This comprehensive plan shall be submitted electronically, in Microsoft® (MS) Project files, to the Procuring Contracting Officer (PCO) and the Contracting Officer’s Representative (COR) No Later Than (NLT) 10 calendar days following contract award. The plans shall address all events and milestones that need to occur for each functional area described in the contract to enable the start of service performance under this contract. Within 15 calendar days following the interface meetings, the incoming contractor shall submit to the TRICARE Management Activity (TMA) a revised start-up plan for approval which incorporates the results of the Transition Specifications and Interface meetings. The final start-up plan will be incorporated into the contract at no cost to the Government.

1.2 Transitions Specifications Meetings

The incoming and outgoing contractors shall attend a two to four day meeting with TMA at the TMA office in Aurora, Colorado, within 15 calendar days following contract award. This meeting is for the purpose of developing a schedule for phase-in and phase-out activities. TMA will notify the contractor as to the exact date of the meeting. Contractor representatives attending this meeting shall have the experience, expertise, and authority to provide approvals and establish project commitments on behalf of their organization.

1.3 Interface Meetings

Within 30 calendar days from contract award, the contractor shall arrange meetings with Government and external agencies to establish all systems interfaces necessary to meet the requirements of this contract, including, but not limited to the Defense Eligibility Enrollment System (DEERS), and TMA Beneficiary Education and Support. TMA representatives shall be included in these meetings and all plans developed shall be submitted to the TMA PCO and the COR within 10 calendar days after the meeting.

TRICARE Operations Manual 6010.56-M, February 1, 2008 Chapter 20, Section 5

2.0

START-UP REQUIREMENTS

2.1 Systems Development

Approximately 60 calendar days prior to the initiation of services delivery under this contract, the non-claims processing systems and the telecommunications interconnections between these systems shall be reviewed by the TMA or its designees, to include a demonstration by the contractor of the system(s) capabilities, to determine whether the systems satisfy the requirements of TRICARE as otherwise provided in the contract. This includes the telecommunications links with TMA and DEERS. All systems and telecommunications necessary to perform benchmarking testing must be operational at the start of benchmark testing, as outlined in paragraph 3.0. The review will also confirm connection to the NIPERNET for TRICARE Duplicate Claims System (DCS). This review is in addition to Benchmark testing. The contractor shall effect any modifications required by TMA prior to the initiation of services delivery under this contract.

2.2 Medicare Crossover Claims

NLT 60 calendar days prior to the start of the service delivery, the contractor shall have an established contract with the COBC for receipt of TRICARE crossover claims for all dual eligible beneficiaries for implementation when the outgoing contractor terminates claims processing. NLT 60 days prior to the start of services delivery, the contractor shall demonstrate to TMA successful receipt and testing of electronic claims batches from the COBC for accurate processing of dual eligible claims, including claims for services covered by TRICARE but not covered by Medicare.

2.2.1 Sixty (60) calendar days prior to the start of services delivery, the contractor shall have executed a Memorandum of Understanding (MOU) with all TRICARE MCSCs. The MOU shall include, but not limited to provider file update coordination, beneficiary history transfers, customer service coordination and marketing/education coordination.

2.2.2 MOU with Beneficiary Education and Support (BE&S) . Within 60 calendar days of contract award, the contractor shall meet with and establish a MOU with the TMA BE&S. The MOU shall include, but not limited to, the review and approval process for education materials, the identification of desired education materials required by either TMA or the contractor, the process for requesting additional educational materials, and the ordering and bulk shipment of materials. The MOU shall be effective within 30 days of the meeting between TMA BE&S and the contractor. The content of the MOU will be coordinated with the Contracting Officer and the Contracting Officer’s Representative prior to uploading in PAT in accordance with the CDRL.

2.3 Claims Processing System and Operations

During the period between the date of award and the start of services delivery, contractor shall, pursuant to an implementation schedule approved by TMA, meet the following requirements:

ATTACHMENT J-1

TRICARE Operations Manual 6010.56-M, February 1, 2008

2.3.1 Contractor File Conversions and Testing

2.3.1.1 The contractor shall perform initial conversion and testing of all Automated Data Processing (ADP) files (e.g., provider files, pricing files, and beneficiary history and deductible files) No Later Than (NLT) 30 calendar days following receipt of the files from the outgoing contractor(s) . All ADP file conversions shall be fully tested and operational for the Benchmark (see paragraph 3.0). Integration testing will be conducted to validate the contractor’s internal interfaces to each of the TRICARE MHS Systems. This testing will verify the contractor’s system integration, functionality, and implementation process. The incoming contractor shall be responsible for the preparation and completion of Integration Testing prior to the start of Benchmark Testing.

2.3.1.2 TMA Test Managers will work with the contractor to plan, execute and evaluate the Integration Testing efforts. The contractor shall identify a primary and a back-up Testing Coordinator to work with the TMA Test Managers. The Testing Coordinator is responsible for contractor testing preparations, coordination of tests, identification of issues and their resolution, and verification of test results. A web application will be available for use by contractor Test Coordinators to report and track issues and problems identified during integration testing.

2.3.2 Receipt of Outgoing Contractor’s Weekly Shipment of History Updates and Dual Operations

2.3.2.1 Beginning with the 120th calendar day prior to the start of services delivery and continuing after the start of services delivery until all pertinent claims received by the outgoing contractor have been processed, the contractor shall convert the weekly shipments of the beneficiary history and deductible file updates from the outgoing contractor(s) within two work days following receipt. These files shall be validated by the incoming contractor before use. Tests for claims, update of catastrophic cap, and duplicate claims shall be performed within two workdays following conversion. Any issues identified by the incoming contractor shall be resolved with the outgoing contractor and the TMA COR shall be kept informed of all issues identified within two work days and the problem resolution. Following the start of services delivery, these files shall be loaded to history and used for claims processing on the first processing cycle following the check for duplicate claims.

2.3.2.2 During the period after the start of services delivery when the incoming contractor and the outgoing contractor are processing claims, both contractors shall maintain close interface on history update exchanges and provider file maintenance. During the first 60 calendar days of dual operations, the contractors shall exchange beneficiary history updates with each contractor’s claims processing cycle run. Thereafter, the exchange shall not be less than twice per week until the end of dual processing.

ATTACHMENT J-1

TRICARE Operations Manual 6010.56-M, February 1, 2008

2.3.3 Installation And Operation Of The DCS

The contractor shall NLT 60 days prior to the start of the services delivery establish connection to the NIPERNET for TRICARE Duplicate Claims System (DCS) in accordance with TSM Chapter 1. Approximately 30-45 days prior to services delivery, TMA will provide training for users of the DCS in accordance with Chapter 9. Following the start of services delivery, the DCS will begin displaying identified potential duplicate claim sets for which the contractor has responsibility. The contractor shall begin using the DCS to resolve potential duplicate claim sets in accordance with Chapter 9 and the transition plan requirements.

2.4 Contractor Weekly Status Reporting

The contractor shall submit a weekly status report of phase-in and operational activities and inventories to TMA beginning the 20th calendar day following “Notice of Award” by TMA through the 180th calendar day after the start of services delivery (or as directed by the PCO based on the status of the transition and other operational factors). The status report will address only those items identified as being key to the success of the transition as identified in the Transition Specifications Meeting or in the contractor’s start-up plan.

2.5 Public Notification Program – Provider and Congressional Mailing

The contractor shall prepare a mailing to all Congressional offices by the 45th calendar day prior to the start of services delivery according to the specifications of the official transition schedule. The proposed mailing shall be submitted to the PCO and the COR for review, and the TMA BE&S for approval NLT 90 calendar days prior to the start of services. The mailing shall discuss any unique processing requirements of the contractor and any other needed information dictated by the official transition schedule.

2.6 Automated Response Unit

The contractor shall provide its Interactive Voice Recognition (IVR) messaging to the Government for review and approval at least 90 calendar days prior to start work of services.

3.0

INSTRUCTIONS FOR BENCHMARK TESTING

3.1 General

3.1.1 Prior to the start of services delivery, the contractor shall demonstrate the ability of its staff and its automated eligibility checking, and claims processing systems to accurately process TRICARE claims in accordance with current requirements, including receipt and processing of Medicare cross-

ATTACHMENT J-1

TRICARE Operations Manual 6010.56-M, February 1, 2008 over claims. This will be accomplished through a comprehensive Benchmark Test. The Benchmark Test is performed by the contractor under the oversight of TMA and must be completed NLT 60 days prior to the start of services delivery under this contract.

3.1.2 The Benchmark Test may be conducted on the contractor’s production system or an identical copy of the production system (as applicable). Whichever system is used, it must meet all TRICARE requirements and contain all the system interconnections and features proposed for the production system in the contractor’s proposal. When the Benchmark Test is conducted on the contractor’s production system, the contractor shall prevent checks and EOBs from being mailed to the beneficiaries and providers, and prevent production TED from being generated and sent to TMA.

3.1.3 A Benchmark Test shall consist of up to 1,000 institutional claims and non-institutional, testing diverse claims conditions, including TRICARE covered and non-covered services, certified and non-certified providers, eligible and non-eligible beneficiaries. (The Benchmark Test may require a TMA presence at the contractor’s site). The Benchmark Test is comprised of multiple claim cycles or batches, which may be a combination of both electronic and paper claims. When more than one cycle is used, each cycle may be submitted on consecutive days. Each cycle after the initial one will include new test claims, as well as claims not completed during preceding cycles. Any aspect of claims processing may be tested, e.g., receiving and sending electronic transactions, provider file development and maintenance including interface with the National Provider System when implemented, screening, coding, data entry, editing, pricing, data management, data linking, record building, access control.

3.1.4 The contractor shall demonstrate its ability to conduct eligibility checking, and claims processing functions to include: claims control and development, accessing and updating DEERS for eligibility status, calculating cost-shares and deductibles, querying and updating internal and external family and patient deductible and cost-share files on the Catastrophic Cap and Deductible Database (CCDD), submitting and modifying provider and pricing records, applying allowable charge parameters, performing duplicate checking, applying prepayment utilization review criteria, adjusting previously processed claims, demonstrating recoupment and offset procedures and producing the required output for paper and electronic transactions [Explanations of Benefits (EOBs), summary vouchers, payment records, checks, and management reports]. Clinical editing functions will be evaluated including correct coding of diagnoses, medical and surgical procedures and accurately resolving edit exceptions. The Benchmark Test may include testing of any and all systems (internal and external) used by the contractor to process claims. Contractor compliance with applicable Health Insurance Portability and Accountability Act (HIPAA) of 1996 requirements and all applicable security requirements will be included in Benchmark Tests as appropriate.

3.1.5 Certain external test systems and files (e.g., DEERS) are an integral component of the Benchmark Test, and the contractor is expected to perform all necessary verifications, queries, etc., according to TRICARE procedures and policy. The contractor shall coordinate through TMA to ensure

ATTACHMENT J-1

TRICARE Operations Manual 6010.56-M, February 1, 2008 that direct interface with any required external test systems (i.e., DEERS) is established and operational prior to the Benchmark Test. A Benchmark Test of a contractor’s system may be administered at any time by TMA upon instructions by the PCO. All contractor costs incurred to comply with the performance of the Benchmark Test are the responsibility of the contractor.

3.2 Conducting The Benchmark

3.2.1 At the time of the scheduled benchmark test, TMA Benchmark Team members may arrive at the contractor’s work site to conduct the testing and evaluate the Benchmark Test results.

3.2.2 The amount of time a contractor shall have to process the Benchmark Test claims and provide all of the output (excluding TED) to the Benchmark Team members for evaluation will vary depending on the scope of the Benchmark Test and volume of claims being tested. As a guide, the following table is provided for contractor planning purposes.

The contractor will be provided details of benchmark testing at the pre-benchmark briefing (see paragraph 3.3.1) of the exact number of days to be allotted for processing the benchmark claims and the schedule for providing the output to the Benchmark Team for evaluation.

3.2.3 Administrative logistics of the location, equipment and documentation required by the Benchmark Team will be provided in detail approximately six weeks prior to the Benchmark Test. For instance, the Benchmark Team members will require a conference room that can be locked with table(s) large enough to accommodate the Benchmark Team. The conference room must be equipped with telephones with access to internal and outside telephone lines.

ATTACHMENT J-1

TRICARE Operations Manual 6010.56-M, February 1, 2008

3.3 Procedures

3.3.1 Within 90 calendar days following award to the contractor, representatives from TMA will provide the contractor’s staff with an overview and timeline of the Benchmark Test process.

Note: Provider and beneficiary data will be discussed at the pre-benchmark meeting to ensure that the contractor is able to adequately prepare all files prior to the Benchmark Test.

3.3.2 On the first day of the Benchmark Test, a brief entrance conference will be held with contractor personnel to discuss the schedule of events, expectations and administrative instructions. The specific schedule for claims processing and the procedures for providing the output to the Benchmark Team will be discussed with the contractor at this time.

3.3.3 During the Benchmark Test the contractor shall process the claims and provide TMA with all output documentation, including hardcopy printouts of electronic crossover files, EOBs, summary vouchers, suspense reports, checks, claims histories, etc. Paper checks and EOBs may be printed on plain paper, with EOB and check overlays. Electronic output is required for electronic transactions. The contractor shall provide output for evaluation by TMA and contractor personnel as the claims are processed to completion.

3.3.4 During the Benchmark Test, team members will provide responses to all contractor’s written and telephonic development questions related to the test claims provided by TMA, and will evaluate the contractor’s output against the benchmark test conditions.

3.3.5 TMA personnel will compare the Benchmark Test claim output against the Benchmark Test conditions for each claim processed during the test and provide any findings to the contractor. All appropriate contractor and Benchmark Team personnel shall be present to answer any questions raised during the Benchmark Test claims review.

3.3.6 At the conclusion of the Benchmark Test, an exit conference will be held with the contractor staff to brief the contractor on any findings identified during the Benchmark Test. The Initial Benchmark Test Report will be forwarded to the contractor by TMA within 20 calendar days of the last day of the on-site test. The contractor’s response shall be submitted to the TMA CO within 20 calendar days after the Initial Benchmark Test Report is issued. This response must include details regarding any errors assessed with which the contractor disagrees, along with a written description of the disagreement and any specific references must be included. After receiving the contractor’s response, TMA shall provide the Final Benchmark Test Report to the contractor within 20 calendar days.

ATTACHMENT J-1

TRICARE Operations Manual 6010.56-M, February 1, 2008

Note: At TMA’s discretion, the Benchmark Test must be completed NLT 60 days prior to the start of health care delivery to allow time to make any needed system changes.

3.4 TRICARE Encounter Data (TED) Record Submission

3.4.1 During the Benchmark Test, generation and acceptance of TED records will be verified for every test claim. The contractor shall prepare and submit the initial TED records to the TMA, Purchased Care Systems Integration Branch (PCSIB) for evaluation during the Benchmark Test. A

TED record shall be prepared for each Benchmark Test claim processed to completion, whether allowed or denied, within two calendar days from the processed date. TED records will not be created for claims removed from the contractor’s processing system, i.e., out of jurisdiction transfers. The contractor will be notified of any TED records failing the TMA edits. The contractor shall make the necessary corrections and resubmit the TED records until 100% of the original Benchmark Test TED records have passed all edits and are accepted by TMA. TED record submission files related to the Benchmark Test must be identified by transmission file and batch/voucher numbers prior to submission to TMA.

3.4.2 The contractor has 45 calendar days from the date of the Initial Benchmark Test Report to submit all final corrected TED records to TMA. New TED records need not be generated to reflect changes created from claims processing corrections, however, all TED records originally submitted for the Benchmark Test claims which did not pass the TMA edits must continue to be corrected and resubmitted until all edit errors have been resolved and 100% of the TED records have been accepted by TMA, PCSIB.

4.0

CONTRACT TRANSITION OUT

4.1 Transition Specifications Meeting

The outgoing contractor shall attend a meeting with representatives of the incoming contractor and TMA at the TMA office in Aurora, Colorado, within 15 calendar days following contracting award. This meeting is for the purpose of developing a schedule of phase-out/phase-in activities. TMA will notify the contractor as to the exact date of the meeting. This outgoing contractor shall provide a proposed phase-out plan at the Transition Specifications Meeting.

4.2 Data

The outgoing contractor shall provide to TMA (or, at the option of TMA, to a successor contractor) such information as TMA shall require to facilitate transition from the contractor’s operations to operations under any successor contract. Such information may include, but is not limited to, the following:

· The data contained in the contractor’s claims processing systems.

· Information about the management of the contract that is not considered, under applicable Federal Law, to be proprietary to the contractor.

4.3 Phase-Out of the Contractor’s Claims Processing Operation

Upon notice of award to another contractor, and during the procurement process leading to a contract award, the contractor shall undertake the following phase-out activities regarding services as an outgoing contractor.

4.3.1 Provide Information

The contractor shall, upon receipt of written request from TMA, provide to potential offerors such items and data as required by TMA. This shall include non-proprietary information, such as record formats and specifications, field descriptions and data elements, claims and correspondence volumes, etc.

4.3.2 Transfer of Electronic File Specifications

The outgoing contractor shall transfer to the incoming contractor by express mail or similar overnight delivery service, NLT three calendar days following award announcement, electronic copies of the record layouts with specifications, formats, and definitions of fields, and data elements, access keys and sort orders, for the following:

· The TEPRV files

· The beneficiary history and deductible files (including eligibility files, if applicable)

· Mental Health Provider Files – The outgoing contractor must assure that the incoming contractor has been given accurate provider payment information on all mental health providers paid under the TRICARE inpatient mental health per diem payment system. This should include provider name; Tax Identification Number (TIN); address including

ATTACHMENT J-1

TRICARE Operations Manual 6010.56-M, February 1, 2008 zip code; high or low volume status; if high volume, provide the date the provider became high volume; and the current per diem payment system must be designated by Medicare or meet exemption criteria, as exempt from the inpatient mental health unit, the unit would be identified as the provider under the TRICARE inpatient mental health per diem payment system.

4.3.3 Transfer of ADP Files (Electronic)

The outgoing contractor shall prepare in non-proprietary electronic format and transfer to the incoming contractor or TMA, by the 15th calendar day following the Transition Specifications meeting unless, otherwise negotiated by the incoming and outgoing contractors, all specified ADP files (e.g., provider and any pricing files, check copies, release of information documents, TPL files, etc.), in accordance with specifications in the official transition schedule and will continue to participate in preparation and testing of these files until they are fully readable by the incoming contractor or TMA.

4.3.4 Outgoing Contractor Weekly Shipment Of History Updates

The outgoing contractor shall transfer to the incoming contractor, in electronic format, all beneficiary history and deductible transactions (occurring from the date of preparation for shipment of the initial transfer of such history files and every week thereafter) beginning the 120th calendar day prior to the start of services delivery (until such a time that all processing is completed by the outgoing contractor) in accordance with the specifications in the official transition schedule. See dual operations in paragraph 2.3.2.

4.3.5 Transfer Of Non-ADP Files The outgoing contractor shall transfer to the incoming contractor all non-ADP files (e.g., Congressional and TMA completed correspondence files, appeals files, TRICARE medical utilization, and administration files) in accordance with the specifications in the official transition schedule and Chapter 2. The hard copies files are to be transferred to the incoming contractor or Federal Records Center (FRC) as required by Chapter 2. The contractor shall provide samples, formats and descriptions of these files to the incoming contractor at the Transition Specification Meeting.

4.3.6 EOB Record Data Retention And Transmittal If the contractor elects to retain the EOB data on a computer record, it must, in the event of a transition to another contractor, provide either a full set of electronic records covering the current and two prior years, or, at the CO’s discretion, provide the data and necessary programs to reproduce the EOB in acceptable form and transfer such data and programs to the successor contractor or to TMA.

ATTACHMENT J-1

TRICARE Operations Manual 6010.56-M, February 1, 2008

TMA shall be the final authority in determining the form and/or acceptability of the data and/or microcopies.

4.3.7 Outgoing Contractor Weekly Status Reporting

Until all inventories have been processed, the outgoing contractor shall submit a weekly status report of inventories and phase-out activities to TMA beginning the 20th calendar day following the Transitions Specifications Meeting until otherwise notified by the PCO to discontinue. This shall be done in accordance with specifications of the official transition schedule.

4.3.8 Prior Authorizations

The outgoing contractor shall provide all prior authorizations that cover care spanning the start of services delivery under the new contract or care that could potentially begin in the incoming contractor’s service delivery period. The outgoing and incoming contractor shall mutually agree to the date and schedule for transfer of this information.

4.3.9 Program Integrity Files

NLT 30 days prior to the start of services delivery under the new contract, the outgoing contractor shall provide the incoming contractor with all active Program Integrity case files that have been forwarded to TMA Program Integrity Office (PI). The outgoing contractor shall also provide weekly updates of Program Integrity case files, including new cases initiated through the end of the contract service delivery period.

4.4 Final Processing Of Outgoing Contractor

The outgoing contractor shall:

· Process to completion all claims, to include adjustments, received during its period of services delivery. Processing of these claims shall be completed within 180 calendar days following the start of the incoming contractor’s services delivery. All claims shall meet the same standards as outlined in the current outgoing contract. Any claims received after the start of the services delivery of the new contract shall be forwarded to the incoming contractor within 24 hours of receipt.

· Be liable, after the termination of services under this contract, for any payments to subcontractors of the contractor arising from events that took place during the period of this contract.

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TRICARE Operations Manual 6010.56-M, February 1, 2008

· Process all correspondence, allowable charge complaints, and incoming telephonic inquiries which pertain to claims or services processed or delivered under this contract within the time frames established for response by the standards of the contract.

· Complete all appeal/grievance cases that pertain to claims or services processed or delivered under this contract within the timeframes established for response by the standards of the contract.

4.4.1 Correction of Edit Rejects

The outgoing contractor shall retain sufficient resources to ensure correction (and reprocessing through TMA) of all TED record edit error NLT 210 calendar days following the start of the incoming contractor’s services delivery.

4.4.2 Phase-Out of the Automated TRICARE DCS

The outgoing contractor shall phase-out the use of the automated TRICARE DCS in accordance with Chapter 9 and transition plan requirements.

4.4.3 Cost Accounting If the outgoing contractor succeeds itself, costs related to each contract shall be kept separate for purposes of contract accountability.

4.4.4 Records Disposition The outgoing contractor shall comply with the provisions of Chapter 2, in final disposition of all files and documentation. The contractor shall include a records disposition plan as part of the phase-out plan submitted to TMA at the Transition Specifications Meeting.

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