TDEFIC Draft Section H Contract Requirements.doc

SECTION H, SPECIAL CONTRACT REQUIREMENTS

H.1. Integrated Process Teams

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

H.2. Positive Incentives

H.2.1. There are monetary positive incentives available to the contractor under this contract. The contractor may qualify for positive incentives by exceeding specified levels of performance during the below defined periods. Positive incentives will be calculated quarterly, in arrears.

H.2.2. Positive Incentive Standards.

H.2.2.1. Electronic claims versus paper claims. Beginning with Option Period 2, based on the percentage of electronic claims received in Option Period 1, if the contractor achieves an increase in electronic claim receipts over Option Period 1, the contractor will be awarded 40% of the difference between the paper and electronic rates for the claims above the Option Period 1 electronic claim rate. For each follow on Option Period, the contractor must achieve an increase in the electronic claim rate over the preceding Option Period. The award amount will be calculated and paid within no later than 60 days after the end of the Option Period.

H.2.2.1.1. An incentive will be applied as follows based on the TEDs that have passed TMA edits for the preceding Option Period Assume the prior Option Period had an electronic claim rate of 80%, paper claim rate is $3.70 and the electronic claim rate is $1.30. For the current Option Period 82% of all claims received in the Option Period are electronic. Based on the volume of electronic claims, 2% differential equates to 600,000 claims. The difference between $3.70 and $1.30 is $2.40 and 40% of the difference = $0.96. The incentive award is 600,000 x $0.96 = $576,000.

H.2.2.2. Beneficiary Satisfaction. Beginning 6 months after the start of Option Period 1, if the contractor achieves a beneficiary satisfaction rate of 95% or higher based on a TMA administered survey, the contractor is awarded the below percentages from the applicable SubCLIN:

H.2.2.21. This positive incentive is based on the TMA survey (Section J, Attachment 15) and will be administered quarterly during each contract option period beginning with beneficiaries who had services in the 3rd quarter of Option Period 1. If more than 95% of the beneficiaries are “somewhat satisfied”, “very satisfied” and “completely satisfied” combined, the contractor shall be awarded an incentive of:

If 95%, but less than 97% 50% of the available funding

If 97%, but less than 99% 75% of the available funding

If 99% or more 100% of the available funding

H.2.2.3.1.

H.3. Negative Incentives

H.3.1. The negative incentive described in this clause is the contractor’s guarantee that the contractor’s performance will not be less than the performance standards described below. The rights of the Government and remedies described in the negative incentive sections are in accordance with, and in addition to all other rights and remedies of the Government. Specifically, the Government reserves its rights and remedies set forth in the Inspection of Services clause (FAR 52.246-4) and the Default clause (FAR 52.249-8).

H.3.2. The contractor guarantees that performance will meet or exceed the standards in this clause. For each occurrence the contractor fails to meet each guaranteed standard, the Government will reduce the amount payable for each SubCLIN listed in the schedule below. Negative incentive reductions will continue until the guarantee amount for the respective option period, for each SubCLIN, is depleted or the contractor’s performance improves to meet or exceed the standard. Performance will be measured as specified below. For all negative incentives the contractor will be notified and reductions will be made on a quarterly basis. For the purposes of this clause, the term “performance standard” is defined as the contract standards that are restated in this clause.

H.3.3. Telephone Service (Busy Signals)

H.3.3.1. Standard: Blockage rates shall never exceed 5%; not less than 95% of all calls shall be received without the caller encountering a busy signal.

H.3.3.2. A negative incentive shall be applied as follows:

H.3.3.2.1. Based on the contractor’s monthly report, the Government will reduce the amount shown on the applicable SubCLIN at the rate of $0.50 per blocked call below the standard (not less than 95% of all calls shall be received without the caller encountering a busy signal). For example, if 100,000 calls are received and the blockage rate is 8% then 3,000 calls are subject to the negative incentive (8% less 5% = 3% which is the difference between actual blockage rate and the allowed blockage rate. 100,000 calls received times the 3% = the 3,000 calls subject to the guarantee) making the negative incentive amount $1,500 (3,000 times $0.50). The blockage rate shall be determined no less frequently than once per hour.

H.3.3.2.2. All calls is defined as any call to any contractor operated TRICARE customer service telephone number. Customer service shall be interpreted in the broadest terms including telephone calls from beneficiaries, providers, Government representatives, and interested parties about general program information, network providers, eligibility, benefits, referrals, preauthorizations/authorizations, claims, complaints, processes and procedures.

H.3.4. Telephone Service (Total Hold Time)

H.3.4.1. Standard: 95% of all calls shall not be on hold for a period of more than 30 seconds during the entire telephone call.

H.3.4.2. A negative incentive shall be applied as follows:

H.3.4.2.1. If performance falls below the standard for each individual call that has a total hold time of more than 30 seconds based on the contractor’s monthly report, the Government will reduce the amount shown on the applicable SubCLIN at the rate of $0.50. For example, 100,000 calls are received and 8% of the calls have a total hold time of more than 30 seconds, then 3,000 blocked calls are subject to the negative incentive. (8% less 5% = 3% which is the difference between the calls exceeding the 30 second time limit and the allowed percentage of calls being on hold for more than 30 seconds. 100,000 calls received times 3% = 3,000 calls subject to the negative incentive.) The negative incentive would be 3,000 times $.50 = $1,500.

H.3.5. Claims Processing Timeliness (Retained Claims and Adjustment Claims)

H.3.5.1. Standard: Not less than 98% percent of retained claims and adjustment claims processed shall be completed within 30 calendar days from the date of receipt.

H.3.5.2. A negative incentive shall be applied as follows:

H.3.5.2.1. If the contractor fails to meet the standard of 98%, the Government will reduce the amount shown on the applicable SubCLIN at the rate of $1.00 per retained claim not meeting the standard. For example, if 9% of 100,000 retained claims are not processed within 30 calendar days, then 7,000 claims are subject to the negative incentive. (9% less 2% = 7% which is the difference between the percentage of claims not processed within 30 days and the percentage of claims allowed to exceed the 30 day standard. 100,000 claims times 7% = 7,000 claims.) The negative incentive would be 7,000 times $1.00 = $7,000. The number of claims failing to meet the standard will be determined monthly based on the TMA TED database.

H.3.6. Reserved

H.3.7. Claims Processing Timeliness

H.3.7.1. Standard: 100% of all claims (both retained and excluded, including adjustments) shall be processed to completion within 90 calendar days.

H.3.7.2. A negative incentive shall be applied as follows:

H.3.7.2.1. If the contractor fails to meet the standard and falls below the standard of all claims processed to completion within 90 calendar days, the Government will reduce the amount shown on the applicable SubCLIN at the rate of $1.00 per claim not meeting the standard. For example, if the total number of claims is 100,000 and 1% of the claims is not processed within 90 days, then 1,000 claims are subject to the negative incentive. (1% is the difference between the percentage of claims processed within 90 days and the 100% standard. 100,000 claims times 1% = 1,000 claims.) The negative incentive would be 1,000 times $1.00 = $1,000. The number of claims failing to meet the standard will be determined monthly based on the TMA TED database. The Government will assess a negative incentive amount monthly until the claim is processed to completion.

H.3.11. TED Edit Accuracy

H.3.11.1. Standard:

Following the start of health care delivery, the contractor shall have the following percentages of TEDs (initial submissions, resubmissions and adjustment/cancellation submissions) passing the TMA edit system at the following time lines:

· One through three months - 80%

· Four through six months - 85%

· Seven through nine months - 90%

· Ten through 11 months - 95%

· Twelve through 23 months - 96%

· Month 24 through contract close - 97% H.3.11.2. A negative incentive shall be applied as follows:

H.3.11.2.1. If the contractor fails to meet the standard and falls below, a negative incentive amount of $3.00 for each TED record not meeting the standard is applicable. For example, if the total number of TEDs is 100,000 and 8% of the TEDs did not pass edits after six months, then 3,000 TEDs are subject to the negative incentive. (8% less 5% = 3% which is the difference between the percentage of TEDs that failed edits after six months and the allowed percentage. 100,000 TEDs times 3% = 3,000 TEDs). The negative incentive would be 3,000 times $3.00 = $9,000.00. The number of TEDs failing to meet the standard will be determined monthly based on the TMA TED database.

H.4. Claim Cycle Time H.4.1. Claim Processing Cycle Time Measurement.

The Government will calculate the contractor claims processing cycle time performance utilizing TRICARE Encounter Data (TED) records. Included in the monthly measurement will be TED records in initial submission batch/vouchers (Batch/Voucher Resubmission Number equals zero), and TED records in adjustment/ cancellation submission batch/vouchers received by TMA during the reporting period and that have passed the TMA batch/voucher header edit(s). TED records in initial submission batch/vouchers, or TED records in adjustment/cancellation submission batch/vouchers, which fail the TMA batch/voucher header edits or which are otherwise unprocessable as submitted by the Contractor, and TEDs in resubmission batch/vouchers (Batch/Voucher Resubmission Number is greater than zero), will be excluded from the claims processing cycle time calculation.

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

H.5. Claim Audit Sampling and Error Determinations.

H.5.1. Sampling Methodology. Sample means will be used as point estimates of payment and occurrence errors. There will be two kinds of payment samples, one for non-denied claims and one for denied claims. The design of non-denied payment and the occurrence samples utilizes a ninety percent (90%) confidence level, while the denied payment sample design uses an eighty percent (80%) confidence level. Precision estimates are 1.0 percent (1%) for the non-denied payment sample, 2.0 percent (2%) for the denied payment sample, and 1.5 percent (1.5%) for the occurrence sample. The non-denied payment sample will be drawn from all records with government payments of $1.00 to $ 25,000. In addition, all records with a government payment of $25,000 and over will be audited. The denied payment sample will be drawn from all records with billed amounts of $ $1.00 to $500,000. In addition, all records with billed amounts of $500,000 and over will be audited. The non-denied payment sample will be stratified at multiple levels within the $1.00 to $25,000 range and the denied payment sample will be stratified at multiple levels within the $1.00 to $500,000 range. Samples will be drawn on a quarterly basis from TEDs that pass TMA edits. Records to be sampled will be “net” records (i.e. the sum of transaction records available at the time the sample was drawn related to the initial transaction record). TEDs in vouchers which fail TRICARE edits or which otherwise are unprocessable as submitted by the Contractor will be excluded from the sampling frame.

H.5.2. Required Contractor Documentation.

H.5.2.1. Upon receipt of the TEDs Internal Control Number (ICN) listing from TMA or designated audit contractor, the Contractor shall retrieve and compile processing documentation for each selected claim. The Contractor shall submit one legible copy of each claim and the following required documents via registered mail, certified mail or similarly guaranteed delivery service. All documentation must be received at TMA or designated audit contractors within thirty (30) calendar days from the date of the TMA or designated audit contractors letter transmitting the ICN listing:

H.5.2.1.1. Claim-related correspondence when attached to claim or related to the adjudication action, such as status inquiries, written and/or telephone, development records, other telephone conversation records.

H.5.2.1.2. Other claim-related documentation, such as medical reports and medical review records, coding sheets, all authorization and referral forms and their supporting documentation, referrals for civilian medical care (SF Forms 513 or 2161), other health insurance and third party liability documents, discounted rate agreements to include the following information: 1) provider name, 2) provider identification number, 3) effective and termination dates of agreements; and 4) negotiated rate or fee schedule and such other documents as are required to support the action taken on the claim.

H.5.2.1.3. A copy of the EOB (or EOB facsimile) for each claim selected.

H.5.2.1.4. The contractor shall send via electronic data input on a 3480 cartridge the current family history (15 to 27 months) for each selected claim. This electronic data containing all required data fields must be received by TMA or designated audit contractor within thirty (30) calendar days from the date of the TMA or designated audit contractor letter transmitting the ICN listing.

H.5.2.2. Payment errors or occurrence errors will be assessed if the Contractor does not provide the above claim-related documents or if the documents provided are not legible. The Contractor has the option of submitting the original document in those cases where the copy is not legible. TMA or designated audit contractors will return original documents upon completion of the audit process.

H.5.2.3. Additional Data to be Furnished by the Contractor.

H.5.2.3.1. Description of data elements by field position in family history file printout. Initial submission to TMA is due by the commencement of claims processing and revisions as they occur.

H.5.2.3.2. Claim adjudication guidelines used by processors; automated prepayment utilization review screens; automated duplicate screening criteria and manual resolution instructions shall be submitted to TMA by the commencement of claims processing.

H.5.2.3.3. Unique internal procedure codes with narrative and cross-reference to approved TRICARE codes and pricing manuals used in claims processing. Initial submission to TRICARE is due by the commencement of claims processing and revisions as they occur, but not later than the fifth (5th) work day of the month following the change.

H.5.2.3.4. Specifications for submission of the provider and pricing files are described in the TEDs System Manual. Initial submission to TMA is due by the commencement of claims processing and updates to the files are to be submitted as specified in the TEDs System Manual.

H.5.3. Payment Error and Process Error Determinations.

H.5.3.1. There are two categories of payment errors: (1) a payment error, which cannot be removed by Contractor post payment processing actions, and (2) a payment error, which can removed by Contractor post payment processing actions (see below list of audit error codes defining payment error categories). Payment errors which can be removed by Contractor post payment actions will also be assessed a process error at audit. If Contractor post payment actions substantiate the initial processing decision, the payment error will be removed but the process error will remain. If the initial processing action is not substantiated, both the payment and the process error will remain. Claims containing process errors will not affect payment or occurrence error rates, but will be used as a performance indicator.

H.5.3.2. Payment errors are the amount of over/under payments on a claim, including but not limited to a payment in the correct amount but sent to the wrong payee, denial of a payable claim, misapplication of the deductible, payment of a noncovered service/supplies, or services/supplies for which a benefit determination cannot be based on the information available at the time of processing. Process errors result from: noncompliance with a required procedure or process, such as development required but not performed, medical emergency not substantiated, medical necessity review not evident and are cited in conjunction with a payment error. Process error determinations are based on the claim information available and those processing actions which have passed the TMA TED Validity edits up to the time the audit sample is pulled.

H.5.3.3. Payment errors which may not be removed by Contractor post payment actions (see below audit error categories) are based only on the claim information available and those processing actions which occur prior to the date the audit sample is pulled. Consideration will be given to subsequent processing actions that occur prior to the date the audit sample is pulled, including actions that have not passed the TMA TED edits, only if supporting documentation to indicate the action taken and the date the action was completed is submitted. Action determinations occurring subsequent to the date the audit sample is pulled or actions and determinations which occur after the date the audit sample is pulled will not be considered in the audit regardless of whether resolution of payment error exists. Adjustment transactions are not allowed on total claim denials. Therefore, subsequent reprocessing actions to a denied claim which occurs prior to the date the audit sample is pulled will be considered during the audit. .

H.5.3.4. All incorrectly coded financial fields on a TED are considered to be occurrence errors regardless of whether associated errors exist.

H.5.4. Computation of the “Total Amount Billed” for Denied Claims.

H.5.4.1. For treatment encounters for which no per diem, negotiated rate or DRG-based amount applies for consideration of payment, the “total amount billed” is the actual amount billed on the claims. This applies to treatment encounters involving services from DRG-exempt hospitals and hospital units, those involving DRG-exempt services and those which would otherwise be subject to the DRG-based payment methodology but for which a DRG allowed amount cannot be computed, regardless of whether or not these claim are paid;

H.5.4.2. For treatment encounters subject to the TRICARE per diem payments, negotiated rate, or the DRG-reimbursement methodology, the “total amount billed” is the correct per diem, negotiated rate, or DRG-based allowable amount including any applicable outlier amounts.

H.5.4.3. If a claim is selected for audit and the Contractor cannot produce the claim or the claim provided is not auditable, a 100 percent payment error based upon the total amount billed will be assessed. For health care services records which do not represent a legitimate condition requiring submission of a record as defined in the TRICARE Systems Manual, a 100 percent error will be assessed. The payment error amount will be based upon the total amount billed. This condition is considered to be an unsupported TED.

H.5.5. TED Occurrence Error Determination.

H.5.5.1. The TED occurrence error rate is defined as the total number of errors divided by the total number of data fields in the sample times 100.

H.5.5.2. Occurrence errors determinations are based on only the claim information available and those processing actions taken at the time of adjudication. Actions and determinations occurring subsequent to the processed date of an audited claim, such as obtaining other health insurance documentation, adjusting a claim to correct financial or other data fields, or developing for required information not obtained prior to processing, are not a consideration of the audit regardless of whether a resolution of the incorrectly coded TED results.

H.5.5.3. Occurrence errors result from an incorrect entry in any data field of the TED. There are no exceptions.

Any error, including errors in financial fields, shall be counted as occurrence errors.

H.5.5.4. Some TED error conditions are not attributable to any one specific data field but apply to the record as a whole or to certain parts of the record. In addition to erroneous data field coding, the following error conditions involving incorrect or unsupported records will result in occurrence errors being assessed as indicated below:

H.5.5.5. Following are error conditions and the associated number of occurrence errors assessed with each condition; payment error codes that post payment actions do not apply; payment error codes that post-payment actions do apply, and process error codes.

Unlike Procedures/Providers Combined

(Noninstitutional Record) 7 errors for each additional utilization data set*

Unlike Revenue Codes Combined

(Institutional Record) 5 errors for each erroneous revenue code set**

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

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

H.5.6. The following are payment errors on which post payment actions are either not applicable or would not remove the payment errors assessed.

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

03K-Billed Amount Incorrect

04K-Cost-share I Deductible Error

07K- Duplicate Services Paid

08K- Eligibility Determination — Patient

09K- Eligibility Determination — Provider

12K- Non-Availability Statement Error

13K-OHI/TPL — Govt. Pay Miscalculated

16K- Payee Wrong- Provider

17K- Participating/Non-Participating Error

18K- Pricing Incorrect

19K-Procedure Code Incorrect

20K-Signature Error

22K- DRG Reimbursement Error

24K-Incorrect Benefit Determination

25K-Claim Not Provided

26K-Claim Not Auditable

27K-Incorrect MCS System

H.5.6.1. The following are payment errors on which post-payment actions may support original processing. On rebuttal, if documentation is provided that supports the processing actions, the payment errors could be removed but the process errors would remain.

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

02K-Unsupported Benefit Determination

05K-Development Claim Denied Prematurely

06K-Development Required

10K-Medical Emergency Not Substantiated

11K-Medical Necessity/Review Not Evident

21K-Timely—Filing Error

23K-Contract Jurisdiction Error

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

H.5.6.2. The following are process errors which will be assessed for noncompliance of a required procedure/process. These errors are neither occurrence errors or payment errors and are not used to calculate the occurrence error or payment error rate. A payment error will be assessed along with the process error. Upon rebuttal if the process is followed to conclusion and the actions support the original decision, the payment error will be removed but the process error will remain.

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

02P — Unsupported Benefit Determinations

05P — Development Claim Denied Prematurely

06P — Development Required l0P - Medical Emergency Not Substantiated l1P — Medical Necessity/Review Not Evident

21 P — Timely Filing Error

23P — Contract Jurisdiction Error

99P—Other

H.5.7. Error Determination Rebuttals:

H.5.7.1. Contractor rebuttals of audit error findings must be submitted to TMA or the designated quality audit within forty- five (45) calendar days of the date of the audit transmittal letters. Rebuttals not postmarked within forty- five (45) calendar days of the audit letter will be excluded from further consideration. Rebuttal responses are final and will not receive further consideration except when during the audit rebuttal process the Contractor submits a claim not previously submitted with the audit and an error is assessed, or when the Contractor’s explanation of the basis on which a claim was processed results in the assessment of a new error not previously reviewed by the Contractor. Contractor rebuttals to new errors assessed by TMA or the designated audit contractor during the initial rebuttal process must be postmarked within thirty (30) calendar days of the TRICARE or designated quality review contractor rebuttal response letter. Rebuttals to new errors not postmarked within thirty (30) calendar days from the date of the rebuttal letter will be excluded from further consideration. The due dates of rebuttals will be calculated by adding forty- five (45) to the Julian calendar date of the TMA or designated audit contractor audit letter or by adding thirty (30) to the Julian calendar date of the TMA or designated audit contractor rebuttal response letter.

TMA TDEFIC HT9402-12-R-0005