TDEFIC Draft Section G Contract Administration.doc

SECTION G, CONTRACT ADMINISTRATION DATA

G.1. CONTRACT ADMINISTRATION

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

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

Telephone: ___________________

FAX Phone: ___________________

G.1.1.2. GOVERNMENT:

Contracting Officer

Department of Defense

TRICARE Management Activity

Acquisition Management and Support Division

Contract Management Branch B ATTN: TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC)

16401 East Centretech Parkway

Aurora, CO 80011-9066

Telephone: 303-676-3649 FAX Phone: 303-676-3987 G.1.2. Contract administration will be performed by the Acquisition Management and Support Division, TRICARE Management Activity or as delegated to other Government agencies by the Contracting Officer. The Government points of contact during the performance of this contract will be:

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

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

G.2. 252.201-7000

CONTRACTING OFFICER'S REPRESENTATIVE (DEC 1991)

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

(b) Subsequent to award, the CO will designate an individual to act as COR. The COR does not have the authority to act on behalf of the Contracting Officer beyond his/her specific written delegation of authority. The COR does not have the authority to change contract requirements. The ultimate responsibility for overall administration of the contract rests with the Contracting Officer and the COR at the TRICARE Management Activity. The contractor will receive a copy of the delegation letter which will delineate the scope and authority of the COR. The contractor shall work directly with the COR on those matters delegated to them.

(End of clause)

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

When submitting a request for payment, the Contractor shall-

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

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

G.4. 252.232-7003 ELECTRONIC SUBMISSION OF PAYMENT REQUESTS AND RECEIVING REPORTS (MAR 2008) As prescribed in 232.7004, use the following clause:

(a) Definitions. As used in this clause—

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

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

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

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

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

(1) The Contracting Officer authorizes use of another electronic form. With such an authorization, the Contractor and the Contracting Officer shall agree to a plan, which shall include a timeline, specifying when the Contractor will transfer to WAWF;

(2) DoD is unable to receive a payment request or provide acceptance in electronic form;

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

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

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

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

(End of clause) Note: (c) The contracting officer has authorized the use of 1Supplier rather than WAWF for submission of invoices to TMA, CRM.

G.5. ORDERING ACTIVITY

G.5.1. The TMA-Aurora Procuring Contracting Officer (PCO) has the authority to issue delivery orders or task orders under the Requirements CLINs of this Contract.

G.5.2. The PCO will issue delivery orders or task orders on DD Form 1155, Order for Supplies or Services. Orders may be placed by facsimile transmission, mail, or courier.

G.6. INVOICE AND PAYMENT - NON-TEDS

G.6.1. General:

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

G.6.1.2. Invoice Submission: Non-TEDs invoices shall be submitted electronically in accordance with G.3. and G.4. above. The Contractor shall submit invoices through iSupplier. If there is a problem with iSupplier that prevents the use of iSupplier, the contractor may submit a DD250. When DD250s are used they shall be submitted through email to CRM, the contracting officer and the COR. .

G.6.1.3. A proper invoice must include the elements identified at FAR 32.905, G.6.1.4. All payments made by the Government will be made by electronic funds transfer (EFT) or similar electronic transfers.

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

G.6.2 Types of Payments to Contractor:

G.6.2.1. Transition-In. The Contractor shall submit monthly invoices against the total lot price in Section B, CLIN 0001.

G.6.2.2. Phase-In DIACAP and Physical and Personnel Security. The Contractor shall submit monthly invoices against the total lot price in Section B, CLIN 0002. There is no separate CLIN or SubCLIN for DIACAP and Physical and Personnel Security for the option periods. DIACAP and Physical and Personnel Security shall be invoiced under the Administration CLIN in the option periods 2 through 6, if exercised.

G.6.2.3. Administration Payments. The contractor shall submit invoices based on the monthly prices in Section B.

G.6.2.4. Positive Incentives. The Contractor shall submit an invoice in accordance with the Contracting Officer’s instructions, accomplished via modification, for the amount shown on the modification, for Incentive CLIN/SubCLINs. The Contractor’s invoice shall note the specific Incentive SubCLIN against which the invoice is submitted.

G.6.2.5. Transition-Out. The Contractor shall submit an invoice based on the price in Section B. In the event Contractor is not awarded a follow on contract, payments will be made no more frequently than monthly, calculated at one-twelfth of the total Transition Out SubCLIN 0X05AB amount per Section B contract period. In the event that the incumbent is awarded a follow-on contract, the amount payable will be the amount proposed and awarded under the Transition Out SubCLIN 0X05AA. Regardless of whether or not the incumbent receives a follow on contract award, the amount payable against either of the Transition Out SubCLINs shall not exceed the amount proposed and awarded.

G.6.2.6. Change Orders and other Payments on CLINs. These are payments due to the contractor on CLINS established subsequent to the contract award. The Contractor shall submit an invoice based on the price in Section B and based on instructions in the modification.

G.6.3. Payments Due from the Contractor to the Government G.6.3.1. Negative Incentive. The Government will make collections by withholding the appropriate amount from the payments to the Contractor upon determination of the amount of the collection and notification to the contractor by the Contracting Officer. See clause H-2.

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

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

G.7. INVOICE AND PAYMENT - CLAIMS PROCESSING CLINS (TEDs) G.7.1. Invoice and payment procedures for claims processing fee are the same for paper and electronic claims. Submission of a TED record header to TMA is considered submittal of an invoice. No separate invoices are required for routine claims rate payments. However, invoices are required for non-automated payment requests. For purposes of determining the due date for payment under the Prompt Payment Clause, the header “end date/time” TRICARE Encounter Data (TED) submission is sent to TMA will be used to determine the date of receipt.

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

G.7.3. Unit Price and Performance Period: The Contractor is paid the claims processing unit price identified in Section B for the contract period in which the Contractor submits the initial TED record. The Batch/Voucher date in the voucher header is used to determine the contract period and applicable unit price.

G.7.3.1. Payments for claims the Contractor receives within 120 calendar days following the cessation of health care delivery (for services rendered during the health care delivery period) are made based on the claim processing fee unit price in effect during the health care delivery period immediately preceding transition-out.

G.7.3.2. In order for the Contractor to receive payment of a claims processing fee, the TED record must be accepted by TMA no later than 210 days following the end of health care delivery.

G.7.4. Header Type: The Contractor shall submit batch/vouchers under the correct “Header type Indicator” as specified in the TRICARE Systems Manual (TSM), Chapter 2, Section 2.3. to insure correct payment.

G.7.5. Retraction, or collection, of claim processing payments. These payments were previously paid to the Contractor and are collected if ‘Header Type Indicator’ of ‘5’ or ‘0’ is used. Proper use of ‘Header Type Indicator’ is defined below:

G.7.5.1. Eligible TED Records: If the TED record is eligible to receive payment under the claims processing CLIN, then the TED record (with the exception of Type of Submission ‘C’ - complete cancellation to TED record data) shall be submitted by the Contractor to TMA using a Header Type Indicator of ‘6’ or ‘9’ (even if the TED record has already received payment under the claims processing CLIN).

G.7.5.2. Ineligible TED Records: If the TED record submitted is not eligible to receive payment under the claims processing CLIN, the contractor shall submit the TED record to the TRICARE Management Activity (TMA) using a Header Type Indicator of ‘0’ or ‘5’. No payment under the claims processing CLIN can occur on any TED record grouped in a Batch/Voucher with Header Type Indicator of ‘0’ or ‘5’. Only no-pay and credits can be processed under these header types.

G.7.5.3. Cancelled TED Records: For a TED record submitted with a Type of Submission ‘C’ by the Contractor, the Contractor shall determine if the TED record is still eligible to receive payment under the claims processing CLIN. The following criteria shall be used to determine if a TED record is still eligible for payment:

G.7.5.3.1. A TED record cancelled for any of the following reasons is eligible to retain the claims processing fee previously paid and shall be submitted with Header Type Indicator ‘6’ or ‘9’:

• Cancellation was at Government direction.

• Government data error.

• Stale dated/voided checks.

• New initial TED record is required by the Government.

Incorrect DEERS response.

Check is returned in undeliverable mail.

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

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

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

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

Claim processed by multiple contractors resulting in duplicate processing.

TQMC case resolutions resulting in an error.

Program Integrity cases that are recouped retrospectively after investigation.

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

G.7.5.3.2. A TED record cancelled for any of the following reasons is not eligible to retain the claims processing fee previously paid and shall be submitted with Header Type Indicator ‘0’ or ‘5’:

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

Cancellation due to contractor error or an inability to adjust.

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

Any other cancellations for a reason not identified in paragraph G.7.5.3.1 above.

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

G.7.6. Procedure if TMA’s TED System is unavailable: Upon notification by the Contracting Officer that the TED Record processing system is not operating normally, the Contractor may submit invoices outside of the TED system to the Contracting Officer and CRM. The invoice shall list the number of claims processed by CLIN. This may be submitted daily or grouped by no more than 5 days of claims. These payments will be treated as an interim payment and will be a credit to the amount due as determined by the TED Record processing system when it is operating normally again. This process will not be used unless the payment will be paid past the Prompt Payment Act 30 day due date. If TEDs processing or CRM accounting system processes are delayed less than 30 days, the automated due dates on payments generated by TEDs will be adjusted for any delay in TEDs processing.

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

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

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

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

G.8.2. Establishment of Healthcare Claim Bank Accounts:

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

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

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

· Name of Bank

· Overnight mail address

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

· Contractor Taxpayer Identification Number (TIN)

· DUNS number for the contractor and the bank.

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

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

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

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

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

G.8.4. Closing of Bank Accounts:

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

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

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

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

G.8.5. Draws on the Federal Reserve Bank

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

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

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

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

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

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G.9. BENEFIT PAYMENTS - TED SUBMISSIONS

G.9.1. TED data submissions for benefit payments shall be grouped into TED Vouchers by the “Batch/Voucher CLIN/ASAP Account Number” field (defined in TSM, Chapter 2, Section 2.2).

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

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

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

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

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

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

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

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

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

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

G.9.5. Federal Fiscal Year-end Processing:

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

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

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

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

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

G.10 BENEFIT PAYMENTS - AUTHORIZATION TO RELEASE TED RELATED BENEFIT PAYMENTS:

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

· Voucher submissions must pass all header edits as specified in TSM, Chapter 2, Section 2.3.

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

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

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

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

ELN Element Name

0-001 Header Type Indicator

0-005 Contract Identifier

0-010 Contract Number

0-015 Batch/Voucher Identifier

0-020 Batch/Voucher Number

0-025 Batch/Voucher ASAP Account Number

0-030 Batch/Voucher Date YYYYDDD

0-035 Batch/Voucher Sequence Number

0-040 Batch/Voucher Resubmission Number

0-045 Total Number of Records

0-050 Total Amount Paid

G.11. OTHER BENEFIT AND RELATED PAYMENTS– NON-TED ROUTINE MANUAL VOUCHERS

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

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

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

G.11.2.2. Vouchers shall contain the following:

• Format for Vouchers

Period Covered (Quarter

Physician Name

Physician Address

Physician Provider Number

Amount Paid/Collected for Bonus

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

Total of all Bonuses being paid

• Sort for Vouchers:

By Contract

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

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

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

By Participating & Non-Participating

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

By Modifier (“QB”, “QU” or “AR”)

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

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

G.11.3. Medicare Crossover Fees (TOM Chapter 20, Section 4, paragraph 4.0):

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

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

G.11.4. Demonstrations:

G.11.4.1 These are trial programs and they may vary in many ways from TRICARE benefits. TEDs will be used if possible but if the data associated with demonstrations is incompatible with TED data formats, the Contractor shall submit a separate voucher, with related supporting documents/calculations, to TMA/CRM no more frequently than monthly to obtain approvals for payment. Directions for these vouchers will be identified in the mod creating the demonstration.

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

G.11.5. Other Payments:

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

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

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

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

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

G.12. BENEFIT PAYMENTS – ADJUSTMENTS

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

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

G.12.3. Voided or Stale-dated Payments:

G.12.3.1 For payments that are voided or stale-dated that are over $10, a credit voucher through TEDs must be processed in accordance with the standards detailed in TSM Chapter 1, Section 3. Or, if the check was issued as a manual voucher (i.e. HPSA, Medicare Crossover Fee or other payments) , the credit should be submitted as a similar manual voucher on a monthly basis.

G.12.3.2. For voided/stale-dated payments of $10.00 or less, the Contractor may elect either to create a credit voucher for the payment using a TED or manual voucher, or the contractor may do included the credit as a listing of under $10 credit transactions and submit it monthly in the Bank Account Reconciliation Report.

G.12.4. Replacement Payments:

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

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

G.12.4.3. If the claim history is not available to the Contractor, the Contractor shall submit a request for approval of check release to TMA/CRM within 10 workdays from the request by payee. Supporting documentation shall include the payee’s name and sponsor’s SSN plus the original check or statement as described in G.12.4.2.above and a copy of the EOB (if available) or other documentation showing the computation and payment of the original check.

G.12.4.4. The Contractor shall report the reissuance using the same procedure as was used to void/staledate the original.

G.12.4.4.1. If no credit voucher was made in voiding/stale-dating of the check, no credit voucher is required for the reissue (i.e. if the Contractor gets a returned check and immediately reissues from the same bank account, no TED or other voucher needs to be done). If the reissuance involves a check from a prior year, a TED or other voucher will need to be done to report the reissuance from the current year.

G.12.4.4.2. If the amount of the stale-dated check to be reissued is $10.00 or less, the Contractor shall use the same procedure in the reissuance as was used for the stale-dating. If no credit voucher was made in the stale-dating of the check, no credit voucher is required for the reissue. The Contractor shall reissue the payment and include the amount in the Bank Account Reconciliation Report.

G.12.4.5. Reissuance of Payments When Original Payee is Deceased: Payments issued by the Contractor shall be made payable to the legal representative of the estate of the person concerned with an additional line stating “For the estate of _____.” Payments shall not be payable to the “estate of” a decedent, nor to a deceased person. Payments shall be to the named payee or mailed to the payee’s address of record.

G.13. COLLECTIONS/RECEIVABLES

G.13.1 Collections - See the TOM chapter 3, Section 3. Procedures for non-underwritten refunds apply to the TDEFIC contract.

G.13.2. Receivables – Recoupments policies and procedures are detailed in the TOM Chapter 10, non-financially underwritten.

G.13.3. Reporting – Receivables held by the contractor will be reported monthly to CRM as detailed in CDRL# _____.

G.14. RESERVED.

TDEFIC Draft HT9402-12-R-0005