DRAFT_ADDP_RFP_HT9402_13_R_0002.pdf

HT9402-13-R-0002

SOLICITATION, OFFER AND AWARD

4. TYPE OF SOLICITATION2. CONTRACT NUMBER 3. SOLICITATION NUMBER

7. ISSUED BY CODE 8. ADDRESS OFFER TO (If other than Item 7)

ORDER UNDER DPAS (15 CFR 700)

6. REQUISITION/PURCHASE NUMBER

NOTE: In sealed bid solicitations "offer" and "offeror" mean "bid" and "bidder".

NEGOTIATED (RFP)

SEALED BID (IFB)

5. DATE ISSUED

1. THIS CONTRACT IS A RATED RATING PAGE OF PAGES

DO-C9 1 84

C. E-MAIL ADDRESS

EXT.NUMBERAREA CODE

B. TELEPHONE (NO COLLECT CALLS)A. NAME

10. FOR

INFORMATION

CALL:

CAUTION: LATE Submissions, Modifications, and Withdrawals: See Section L, Provision No. 52.214-7 or 52.215-1. All offers are subject to all terms and conditions contained in this solicitation.

(Date)(Hour) local timeuntildepository located in copies for furnishing the supplies or services in the Schedule will be received at the place specified in Item 8, or if hand carried, in the

SOLICITATION

9. Sealed offers in original and

PART IV - REPRESENTATIONS AND INSTRUCTIONS

OTHER STATEMENTS OF OFFERORS

EVALUATION FACTORS FOR AWARD

INSTRS., CONDS., AND NOTICES TO OFFERORS

REPRESENTATIONS, CERTIFICATIONS AND

LIST OF ATTACHMENTS

CONTRACT CLAUSES

PART III - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACH.

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J

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L

M SPECIAL CONTRACT REQUIREMENTS

CONTRACT ADMINISTRATION DATA

DELIVERIES OR PERFORMANCE

INSPECTION AND ACCEPTANCE

PACKAGING AND MARKING

DESCRIPTION/SPECS./WORK STATEMENT

SUPPLIES OR SERVICES AND PRICES/COSTS

SOLICITATION/CONTRACT FORM

PART II - CONTRACT CLAUSESPART I - THE SCHEDULE

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SEC. DESCRIPTION PAGE(S) (X) DESCRIPTION SEC. (X)

11. TABLE OF CONTENTS

18. OFFER DATE17. SIGNATURE

SUCH ADDRESS IN SCHEDULE.

IS DIFFERENT FROM ABOVE - ENTER

15C. CHECK IF REMITTANCE ADDRESS

EXT.NUMBERAREA CODE

15B. TELEPHONE NUMBER

(Type or print)AND

ADDRESS

OF

OFFEROR

CODE FACILITY

16. NAME AND TITLE OF PERSON AUTHORIZED TO SIGN OFFER15A. NAME

DATEAMENDMENT NO.DATEAMENDMENT NO.

and related documents numbered and dated):

amendments to the SOLICITATION for offerors

(The offeror acknowledges receipt of

14. ACKNOWLEDGEMENT OF AMENDMENTS

CALENDAR DAYS (%)30 CALENDAR DAYS (%)20 CALENDAR DAYS (%)10 CALENDAR DAYS (%)

(See Section I, Clause No. 52.232.8)

13. DISCOUNT FOR PROMPT PAYMENT

designated point(s), within the time specified in the schedule.

by the offeror) from the date for receipt of offers specified above, to furnish any or all items upon which prices are offered at the price set opposite each item, delivered at the

12. In compliance with the above, the undersigned agrees, if this offer is accepted within ______________ calendar days (60 calendar days unless a different period is inserted

NOTE: Item 12 does not apply if the solicitation includes the provisions at 52.214-16, Minimum Bid Acceptance Period.

OFFER (Must be fully completed by offeror)

IMPORTANT - Award will be made on this Form, or on Standard Form 26, or by other authorized official written notice.

28. AWARD DATE

(Signature of Contracting Officer)

27. UNITED STATES OF AMERICA

25. PAYMENT WILL BE MADE BY

26. NAME OF CONTRACTING OFFICER (Type or print)

CODE 24. ADMINISTERED BY (If other than Item 7)

ITEM

(4 copies unless otherwise specified)

23. SUBMIT INVOICES TO ADDRESS SHOWN IN

41 U.S.C. 253 (c) ( 10 U.S.C. 2304 (c) (

22. AUTHORITY FOR USING OTHER THAN FULL AND OPEN COMPETITION:

21. ACCOUNTING AND APPROPRIATION20. AMOUNT19. ACCEPTED AS TO ITEMS NUMBERED

AWARD (To be completed by government)

CODE

X

HT9402

DEPARTMENT OF DEFENSE

TRICARE MANAGEMENT ACTIVITY COD-AB

16401 E CENTRETECH PARKWAY

AURORA CO 80011-9066

1400 MT

Judy Blomquist,Contract Specialist 303 judith.blomquist@tma.osd.mil

676-3839

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PAGE(S)

Bruce Mitterer

AUTHORIZED FOR LOCAL REPRODUCTION

Previous edition is unusable

STANDARD FORM 33 (Rev. 9-97)

Prescribed by GSA - FAR (48 CFR) 53.214(c)

1-1 2-4

5-28 29-29 30-30 31-32 33-34 35-37

38-49

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80-84 bruce.mitterer@tma.osd.mil jblomquist Draft

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

2 84

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT9402-13-R-0002

(A) (B) (C) (D) (E) (F)

BASE PERIOD

1 August 2013 through 31 July 2014

0001 Transition-In

OPTION PERIOD 1

1 AUGUST 2014 through 31 JULY 2015

1001 Dental Health Care Services by CDT Code (See LT Pricing Table, Section J, Attachment J-22) (Fixed Unit Price)

1002 CONTRACT DATA REQUIREMENTS LIST (CDRLS)

(DELIVERABLES IDENTIFIED IN SECTION J, Attachment J-15) (Not Separately Priced)

1003 Phase-Out LT (Firm fixed-price) Invoiced and paid in one lump sum, if exercised.

OPTION PERIOD 2

1 August 2015 through 31 July 2016

2001 Dental Health Care Services by CDT Code (See LT Pricing Table, Section J, Attachment J-22) Fixed Unit Price

2002 CONTRACT DATA REQUIREMENTS LIST (CDRLS)

(DELIVERABLES IDENTIFIED IN SECTION J, Attachment J-15) (Not Separately Priced)

2003 Phase-Out LT (Firm fixed-price) Invoiced and paid in one lump sum, if exercised.

OPTION PERIOD 3

1 August 2016 through 31 July 2017 Continued ...

3 84

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT9402-13-R-0002

(A) (B) (C) (D) (E) (F)

3001 Dental Health Care Services by CDT Code (See LT Pricing Table, Section J, Attachment J-22) Fixed Unit Price

3002 CONTRACT DATA REQUIREMENTS LIST (CDRLS)

(DELIVERABLES IDENTIFIED IN SECTION J, Attachment J-15) (Not Separately Priced)

3003 Phase-Out LT (Firm fixed-price) Invoiced and paid in one lump sum, if exercised.

OPTION PERIOD 4

1 August 2017 through 31 July 2018

4001 Dental Health Care Services by CDT Code (See LT Pricing Table, Section J, Attachment J-22) Fixed Unit Price

4002 CONTRACT DATA REQUIREMENTS LIST (CDRLS)

(DELIVERABLES IDENTIFIED IN SECTION J, Attachment J-15) (Not Separately Priced)

4003 Phase-Out LT (Firm fixed-price) Invoiced and paid in one lump sum, if exercised.

OPTION PERIOD 5

1 August 2018 through 31 July 2019

5001 Dental Health Care Services by CDT Code (See LT Pricing Table, Section J, Attachment J-22) Fixed Unit Price

5002 CONTRACT DATA REQUIREMENTS LIST (CDRLS)

(DELIVERABLES IDENTIFIED IN SECTION J, Attachment J-15) (Not Separately Priced) Continued ...

4 84

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT9402-13-R-0002

(A) (B) (C) (D) (E) (F)

5003 Phase-Out LT (Firm fixed-price) Invoiced and paid in one lump sum, if exercised.

DRAFT SOLICITATION HT9402-13-R-0002 Page 5 of 84

SECTION C – DESCRIPTION/SPECIFICATIONS/WORK STATEMENT

C.1. General.

C.1.1. The Department of Defense (DoD) through TRICARE Management Activity (TMA) has a mission to offer dental coverage to all Active Duty Service Members (ADSMs) of the Uniformed Services, eligible members of the Reserves and National Guard, Reserve Component members discharged after serving more than 30 days on active duty in support of a contingency operation, and those Foreign Forces Members (FFMs) eligible for care pursuant to an approved agreement (e.g., reciprocal health care agreement, North Atlantic Treaty Organization (NATO) Status of Forces Agreement (SOFA), Partnership for Peace (PFP) SOFA). The Uniformed Services include the U.S. Army, the U.S. Navy, the U.S. Air Force, the U.S. Marine Corps, the U. S. Coast Guard, the Commissioned Corps of the National Oceanic and Atmospheric Administration (NOAA), and the Commissioned Corps of the Public Health Service (PHS). The Commissioned Corps of the PHS is not included in this program. However, the Government reserves the right to expand coverage under the contract to include PHS personnel.

C.1.2. In order to fulfill its mission, the Active Duty Dental Program (ADDP) will supplement care provided in the DoD’s Dental Treatment Facilities (DTFs), as well as provide care to those ADSMs living in regions without access to DTFs. The contractor will supplement the DoD’s DTF’s authorized care by developing and maintaining a dental provider network in the United States, District of Columbia, U.S.

Virgin Islands, Guam, Puerto Rico, American Samoa, and the Northern Mariana Islands.

C.1.3. The ADDP has two components: (1) ADSMs referred from military Dental Treatment Facilities (DTFs) for civilian dental care, and (2) ADSMs, having a duty location and residence greater than 50 miles from a DTF. The later component is considered remote members and are required to comply with the requirements and limitations pertaining to remote ADSMs before receiving dental care.

C.2. Statement of Objectives. The statement of objectives represents the desired outcomes of this contract. The objectives are supported by technical requirements stated throughout Section C. The objectives are as follows:

C.2.1. Ensure ADSMs can maintain their dental readiness no matter where they are stationed in the United States and territories.

C.2.2. Provide an easily accessible dental benefit for Reserve Components members in Early Eligible and Transitional Assistance Management Program (TAMP) status.

C.2.3. Provide a dental referral mechanism for military (DTF) use when the DTF cannot meet the required access to care standards.

C.3. Documents. The following documents are incorporated by reference. These documents form an integral part of this contract and have the same force and effect as if set forth in full text. The TRICARE Manuals provide instruction, guidance and responsibilities in addition to the requirements set forth in the incorporated federal statutes and regulations. In the event of a conflict between the manuals and either statute and/or regulation, the statute and/or regulation takes precedence. If there is a conflict between the manuals, the order of precedence is – TRICARE Policy Manual (TPM), TRICARE Systems Manual (TSM) then the TRICARE Operations Manual (TOM). The TRICARE Manuals and the TMA version of CFR 199 are located at http://manuals.tricare.osd.mil/ . If the contractor believes that a conflict exists between the incorporated documents, the contractor shall inform the Contracting Officer.

http://manuals.tricare.osd.mil/

DRAFT SOLICITATION HT9402-13-R-0002 Page 6 of 84

C.3.1. Title 10, United States (U.S.C.), Chapter 55, Section 1074(c)(1).

C.3.2. Title 32 Code of Federal Regulations (CFR) Part 199.3, 199.6 and 199.9.

C.3.3. Title 36 CFR Part 1222 (data created or received and maintained for the Government by contractors).

C.3.4. Title 45 CFR Parts 160, 162 and 164 (the Health Insurance Portability and Accountability Act of 1996 [HIPAA] security and privacy standards, transaction and code set standards, National Provider Identifier [NPI] requirements and implementation specifications).

C.3.5. National Institute of Standards and Technology (NIST) special publications (SP) 800-53 and 800- 53A.

C.3.6. TRICARE Operations Manual (TOM) 6010.56-M, February 1, 2008 (through Change 87). The requirements in the following TOM chapters apply to the ADDP contractor:

• Chapter 1, Section 1 – Organization of the TRICARE Management Activity Section 2 – Contract Administration and Instructions (exclude paragraphs 4.0 and 5.0) Section 4 – Management (excluding paragraphs 2.2, 2.3, 2.4, 3.1, 3.2, 3.4, and 4.0) Section 5 – Compliance with Federal Statutes Section 6 - Legal Matters

• Chapter 2 – Records Management (For Chapter 2, see draft Section J Attachment J-19, which is the prevailing version for the purposes of this solicitation until such time that the manual is updated.)

• Chapter 11, Addendum A – TRICARE Logo

• Chapter 13 – Program Integrity

• Chapter 14, Section 2 – Reports and Plans

• Chapter 19 – Health Insurance Portability and Accountability Act (HIPAA) of 1996

• Appendix A – Acronyms and Abbreviations

• Appendix B - Definitions

C.3.7. TRICARE Systems Manual (TSM) 7950.2-M, February 1, 2008 (through Change 44). The requirements in the following TSM chapters apply to the ADDP contractor:

• Chapter 1 – General Automated Data Processing (ADP) Requirements (For Chapter 1, Section 1.1, see draft Section J Attachment J-18a, which is the prevailing version for the purposes of this solicitation until such time that the manual is updated.)

• Chapter 3, Defense Enrollment Eligibility Reporting System (DEERS) (excluding Sections 1.4 and 1.5). (For Chapter 3, Section 1.2, see draft Section J Attachment J-18b, which is the prevailing version for the purposes of this solicitation until such time that the manual is updated.)

C.3.8. TRICARE Policy Manual (TPM) 6010.57-M, February, 2008 (through Change 81). The requirements of the following TPM chapters apply to the ADDP contractor:

• Chapter 10, Section 5.1, paragraph 2.8 – Transitional Assistance Management Program

C.3.9. Definitions. Definitions are included in 32 CFR 199.2, the TOM Appendix B, and Attach J-1.

C.3.10. The contractor shall be current regarding the TRICARE manuals at all times. The TRICARE manuals are updated/revised frequently, though few of these updates/revisions will affect the ADDP. The

DRAFT SOLICITATION HT9402-13-R-0002 Page 7 of 84 updates/revisions will be coordinated with the contractor prior to modification. For those that do apply to the contract, the contractor shall notify the Contracting Officer that there will be a cost impact within 30 calendar days following receipt of the change order.

C.4. Government Information and Applications.

C.4.1. The Government will furnish an electronic file listing of the names, addresses, and other relevant information pertaining to all known remote ADSMs ninety days following award with additional updates regularly thereafter in support of the contractor’s education initiatives.

C.4.2. The official TRICARE logo which must be incorporated in all education materials, may be found at TOM Chapter 11, Addendum A.

C.4.3. The Government will furnish the Contractor with access to the Defense Manpower Data Center’s (DMDC) Defense Eligibility Enrollment Reporting System (DEERS) to perform eligibility inquiries and enrollments. DEERS is the database of record for the ADDP. The Government will provide the appropriate application for enrolling remote ADSMs in DEERS. The Government will furnish access to DEERS only after the Contractor’s staff and all subcontractors’ staff that utilize systems which access and maintain ADDP data are compliant with the enhanced safeguarding methods for unclassified DoD information, personnel security, and clearance requirements. The Contractor and its subcontractors must be in compliance with Section C.22, no later than 120 days before the contract start work date.

C.4.4. The Government will provide any changes to the listing of military DTFs 30 days prior to the start of dental healthcare delivery and when changes occur thereafter.

C.4.5. Beginning with the start of option period 1, DMDC will forward a monthly data file containing changes in the status of ADSMs living within 50 miles of a Military Treatment Facility (MTF) that has no DTF. The contractor will use this file to enroll the newly identified ADSMs in DEERS by entering the remote ADSM Health Care Delivery Program (HCDP) Plan Coverage Code with an end date set to end of eligibility.

C.5. Contractor Furnished Items. The contractor shall furnish all necessary items for the satisfactory performance of this contract, unless the contract specifically states that the Government will be providing such item.

C.6. Dental Benefit.

C.6.1. Benefits will be provided as stated in Section J, Attachment J-2. The contract will only pay for covered dental benefits, non-covered dental benefits specifically authorized by the Dental Service Points of Contact (DSPOCs), and those dental benefits that require and have received preauthorization. The contractor shall be compliant with the most current version of the Code on Dental Procedures and Nomenclature (Code) published in the American Dental Association’s (ADA) Current Dental Terminology (CDT) manual throughout the life of the contract. (Note: For the purposes of this solicitation, the list of covered services in Section J, Attachment J-2, conforms to the ADA’s CDT- 2012/2013 manual.)

C.6.2. The contractor shall promptly notify the Contracting Officer whenever a new version of the ADA CDT manual is published. The contractor shall provide the Contracting Officer with a synopsis of its recommended changes to Section J, Attachment J-2 within 30 calendar days of the release of a new version. Within 45 calendar days of the release of a new version, the contractor and TMA will initiate discussions regarding those recommended changes. Subsequently, based upon these discussions, the

DRAFT SOLICITATION HT9402-13-R-0002 Page 8 of 84 contractor shall then provide the Contracting Officer with a written description of all the changes that need to be made to Section J, Attachment J-2 in order for that attachment to conform to the new version of the ADA CDT manual and Code. The Contracting Officer will review the proposed changes and if warranted, issue a contract modification to implement the changes.

C.6.3. When new CDT codes are added to Section J, Attachment J-2 per a contract modification, the contractor will provide pricing for each new CDT code and adjust any existing CDT code prices as applicable for Section J, Attachment J-<attachment will be incorporated after award>.

C.7. Eligibility.

C.7.1. Active Duty Service Members (ADSMs). All ADSMs on continuous active duty orders for more than 30 days are eligible to receive ADDP dental coverage, subject to the requirements and limitations provided in the ADDP. ADSMs with a duty location and residence greater than 50 miles from a DTF are automatically eligible for remote ADSM benefits (see Section J, Attachment J-3).

C.7.2. National Guard/Reserve Members. National Guard/Reserve members that serve on continuous active duty for more than 30 days are considered ADSMs. National Guard members are only TRICARE eligible if on federally funded orders for more than 30 days. If the National Guard member is on state orders, they are not eligible for TRICARE.

C.7.3. Early Eligibility. Reserve Component (RC) members who are issued delayed-effective-date active duty orders for more than 30 days in support of a contingency operation are eligible for ADDP as defined in DoD Instruction 7730.54 (see Section J, Attachment J-7).

C.7.4. Reserve component members discharged after more than 30 days on active duty in support of a contingency operation using Transitional Assistance Medical Program (TAMP) are eligible and will be considered remote ADSMs. This care will run concurrently with the member’s TAMP coverage.

C.7.5. Line of Duty (LOD). LOD is for RC members who incur or aggravate an injury, illness or disease while serving on active duty for 30 days or less as defined in DoD Instruction 1241.2 (see Section J Attachment J-7).

C.7.6. Foreign Forces Members (FFMs). FFMs on temporary or permanent assignment in the ADDP geographic regions may be eligible to participate in the ADDP pursuant to an approved agreement (e.g., reciprocal health care agreement, North Atlantic Treaty Organization (NATO) Status of Forces Agreement (SOFA), Partnership for Peace (PFP) SOFA) (see Section J Attachment J-7).

C.7.7. Wounded Warrior. ADSMs that are being treated inpatient at a Veterans Affairs (VA) Hospital or ADSMs who are identified as a Wounded Warrior and are receiving inpatient/outpatient care at a VA Hospital are eligible for ADDP (see Section J Attachment J-7).

C.7.8. Eligibility Determinations. The Uniformed Services will be responsible for reporting an ADSM’s eligibility status in the Defense Eligibility Enrollment Reporting System (DEERS). The contractor shall interface with DEERS to determine eligibility and it shall be the primary source for determining eligibility. The contractor will contact the DSPOCs or the applicable local DTF to verify eligibility for those individuals who are indicated on DEERS as not eligible (e.g., not on active duty but who may have a Line of Duty determination entitling the member to dental care). DSPOCs are the final treatment decision authority for eligible ADSMs.

DRAFT SOLICITATION HT9402-13-R-0002 Page 9 of 84

C.8. Remote Active Duty Service Member Enrollment.

C.8.1. There are various types of remote ADSM dental coverage:

• ADSMs enrolled in TRICARE Prime Remote (TPR)

• ADSMs not eligible for TPR who live and work more than 50 miles from a military DTF

• Early Eligibility members

• Reserve component members under TAMP

• LOD members

• Foreign Forces members

• Wounded Warriors

• Automatic enrollment for NOAA ADSMs

• ADSMs stationed overseas requesting care while temporarily in the United States, District of

Columbia, U.S. Virgin Islands, Guam, Puerto Rico, American Samoa, or the Northern Mariana Islands

• Other ADSMs as dictated by the Government

C.8.1.1. Enrollment for Remote ADSMs Enrolled in TPR. Eligibility to enroll in medical TPR requires that the ADSM’s permanent duty location and residence be more than 50 miles from a Military Treatment Facility (MTF) or designated clinic. DEERS will systematically enroll, disenroll, and maintain enrollments for ADSM enrolled in TPR coverage plan based on the ADSM’s medical TPR enrollment.

ADSMs living in a TPR location must enroll in a medical TPR coverage plan to be enrolled as a remote

ADSM.

C.8.1.2. Enrollment for ADSMs Not Eligible for TPR. An ADSM whose permanent duty location and/or residence is less than 50 miles from a MTF or designated clinic is not eligible to enroll in TPR. If the ADSM’s permanent duty location and residence is within 50 miles of an MTF but more than 50 miles from a Dental Treatment Facility (DTF), he or she will not be automatically enrolled as a remote ADSM, but the ADDP contractor will, upon request, manually enroll the member as a remote ADSM.

C.8.1.3. ADSMs with a foreign address in DEERS are eligible for enrollment as a remote ADSM if the member is requesting to receive dental care in the United States, District of Columbia, U.S. Virgin Islands, Guam, Puerto Rico, American Samoa, or the Northern Mariana Islands. The contractor will enroll the ADSM in DEERS by entering the remote ADSM Health Care Delivery Program (HCDP) Plan Coverage Code. The ADSM will be eligible for benefits as a remote ADSM (see Section J, Attachment J- 3).

C.8.1.4. Automatic Enrollment as a remote ADSM. All NOAA ADSMs will be eligible for remote ADSM enrollment. DEERS will systematically enroll, disenroll, and maintain enrollments as remote ADSMS for NOAA members.

C.8.1.5. Enrollment for other remote ADSMs. The contractor shall enroll, disenroll and maintain enrollments for ADSMs that the Dental Program Office authorizes to be enrolled as remote ADSMs.

C.8.2. The contractor shall record all enrollments, re-enrollments, disenrollments, and correct enrollment discrepancies on the Defense Enrollment Eligibility Reporting System (DEERS), as specified in the TSM Chapter 3, Section 1.6. DEERS is the primary source for verifying eligibility and enrollment as a remote ADSM. The contractor shall interface directly with DEERS through the Government provided on-line enrollment software. All eligibility information will be provided to the contractor through this Government provided on-line enrollment software and all enrollments/terminations will be performed

DRAFT SOLICITATION HT9402-13-R-0002 Page 10 of 84 using this web based system. Enrollment/termination information input by the contractor, will be applied to the DEERS database and an enrollment transaction will be sent by DEERS to the contractor who must be able to apply the enrollment information sent by DEERS to their system. Sensitive enrollment/eligibility information that is subject to the Privacy Act shall be maintained in the contractor’s owned and operated IT system during the period of contract performance.

C.8.3. The Defense Manpower Data Center (DMDC) shall print and mail the remote ADSM coverage cards directly to the enrollee at the residential mailing address specified on the enrollment application after the receipt of the enrollment record. DMDC will also provide written notification for new enrollments, plan type changes, disenrollments, and the replacement of the remote ADSM coverage card (see TSM Chapter 3, Section 1.6). The return address on the envelope mailed by DMDC will be that of the ADDP contractor and will also include the statement: “Address Service Requested” (Note: the contractor will be responsible for paying the U.S. Postal Service for this service). In the case of receiving returned mail, the ADDP contractor shall develop a process to ensure the delivery to the enrollee. When the contractor is notified of an address change, the contractor shall update their systems and DEERS to reflect the new address.

C.9. Referrals and Authorizations.

C.9.1. The contractor will track referrals and authorizations and will establish a HIPAA compliant mechanism by which referrals and authorizations will be electronically transmitted to the contractor by the DTFs, DSPOCs or the TMA Dental Program Office.

C.9.1.1. The system will be Public Key Infrastructure (PKI) compliant (i.e. Common Access Card (CAC) enabled). The contractor shall send emails to DTFs, DSPOCs or the TMA Dental Program Office via the PKI complaint system and not through the contractor’s proprietary secure email system.

C.9.1.2. The system will only allow the referral/appointment to be made if the ADSM is reflected as DEERS eligible.

C.9.1.3. The system will have two options by which to select CDT codes for inclusion in the referral: 1) A drop down box for CDT codes; 2) An option for the CDT code to be manually typed in. There will be no limit to the number of CDT codes entered for that referral.

C.9.1.4. The system will link the referral, authorization, and information on reimbursement of dentists.

C.9.1.5. The system must allow for the digital radiograph and/or supporting documents to be attached or systematically linked to the referral for transmission purposes.

C.9.1.6. The system will indicate referrals differentiated by appointment; date of the appointment, and the completed date.

C.9.1.7. The system will have the ability to identify remote authorizations, whether they were approved or disapproved, and the dollar values (amount paid to the Government and the amount paid to the provider).

C.9.1.8. The system will indicate authorized care that was not completed.

C.9.1.9. The contractor will train (initial and refresher) and provide secure means to access the system(s) to the POCs of the DTFs, DSPOCs and TMA Dental Program Office. Initial training shall be completed no later than 30 days prior to the start of Option Period 1. Refresher training shall be provided annually at

DRAFT SOLICITATION HT9402-13-R-0002 Page 11 of 84 a minimum. The contractor may provide the training on-site or electronically.

C.9.2. Referrals can be made by the ADSM (self-referral), DTF, or DSPOC. Authorizations for treatment can only be made by a DTF, DSPOC, or the TMA Dental Program Office. The contractor will not reimburse dental care without an authorization or a referral unless the care is an emergency, meets the DTF referral exceptions identified in Section C.9.3., or it meets remote ADSM conditions as stipulated in Section C.9.5 and Section J, Attachment J-3. Authorization is not required for emergency dental care (see Section J, Attachments J-2 and J-3). All authorizations are valid for nine months from the authorization date. Claims for care received more than nine months after the authorization date shall be denied. An appeal of the denial may be submitted and shall follow the appeals process detailed in C.15.

C.9.3. DTF Referral and Authorizations. Referrals for ADSMs assigned to units that have DTF availability will receive an authorization from that DTF when they are referred out of the DTF for civilian dental care (see Section J, Attachment J-11 for the DTF list). The contractor will reimburse dental care as specified on the DTF referral/authorization unless alteration is authorized under Section J, Attachment J-5, Similar or Alternate Dental Procedure Codes Accepted for Referral/Authorization Claims.

C.9.3.1. DTF Referred Orthodontics. Each Service Headquarters will have one dentist Representative, with approval authority, who will review their Service’s DTF referred orthodontics. The contractor will electronically forward all DTF referred orthodontics to the Service’s Representative for approval/denial.

The Service Representative will electronically forward the approved/denied cases to the contractor.

C.9.4. DSPOC Referrals and Authorizations. The remote ADSM’s DSPOC is required to authorize all care for which the remote ADSM cannot self-refer. The contractor shall utilize the Dental Service Point of Contact (DSPOC) Review Codes listed in Section J, Attachment J-9 in conveying DSPOC approval/disapproval of authorization requests. The contractor may approve routine care the first time a member uses a non-network provider without authorization, if the DTF, member or the provider appeals the initial denial. Otherwise, all non-network care, regardless of cost or treatment category, must be authorized by the DSPOC, unless the treatment qualifies as emergency dental care. The contractor shall submit all authorization requests, including the patient’s case documents, in an electronic format to the DSPOC (see C.9.1).

C.9.5. Remote ADSM Self-Referrals. In accordance with Section J,-Attachment J-3, remote ADSM’s self-refer for all covered benefits except for care over $750 per procedure or appointment or cumulative total of $1500 or more for treatment plans completed within a consecutive 12 month period, and certain designated specialty procedures. This includes appointments where routine care under $750 may be combined with specialty care provided on the same date of service. In these cases, authorization for all care is required even if a portion of it has been previously approved. Remote ADSMs can only self-refer to network providers. When ADSMs self-refer to a non-network provider for non-emergency care when a network provider is available per the standards specified in Section C.18.1, the contractor will contact the DSPOC as specified in Section C.11.

C.9.5.1. Due to rapid changes in eligibility for Reserve Component members, there may be occurrences of care erroneously paid or denied under the TRICARE Dental Program (TDP) contract that should have been paid under the ADDP contract or vice versa. When these instances occur, the contractor will coordinate with the TDP contractor to correct the claim payment, per the Memorandum of Agreement (MOA) with the TDP contractor. In these cases, where the member received care under the TDP, and subsequently was determined to be eligible under the ADDP, the contractor shall pay the claim in full without requiring DSPOC authorization, so long as the care received was a covered benefit under the ADDP. This applies to paid claims and to claims denied under the TDP due to being a non-covered benefit.

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C.10. Network Providers.

C.10.1. Network Provider Access. The contractor shall establish provider networks for the delivery of dental services in the United States, District of Columbia, U.S. Virgin Islands, Guam, Puerto Rico, American Samoa, and the Northern Mariana Islands. The contractor shall ensure that the network provider access standards listed in C.18.1 are met at the start of dental care delivery and continuously maintained thereafter.

C.10.2. Network Adequacy. The contractor shall provide the Contracting Officer with written notification of any instances of provider network inadequacy relative to the access standards specified in C.18.1, and shall submit a corrective action plan with each notice of an instance of provider network inadequacy. Provider network inadequacy is defined as any failure to meet the access standard. This information shall be submitted in accordance with the network access reports listed in Section J, Attachment J-15.

C.10.3. Network Provider Listing. The contractor shall make available a web based listing of network providers, searchable by zip code, distance, address, and by individual provider name. The listing shall include the provider’s name, specialty, gender, address, phone number, fax number, whether the provider is accepting new patients, and whether the provider performs amalgam restorations (CDT D2140, D2150, D2160, or D2161). The information shall be current within the last 30 calendar days.

C.10.4. Network Provider Reimbursement.

C.10.4.1. Network providers shall submit claims to the contractor for all authorized and/or covered dental care provided to eligible members. ADSMs shall not be billed for this care, nor be liable for any co-payments or cost-shares.

C.10.4.2. Hold Harmless Provision. If an ADSM elects to receive a non-covered dental service from a network provider, the ADSM must be informed by the provider in advance of receiving the service that the service is excluded from coverage and the ADSM agrees nevertheless to pay for the service. Such agreement to pay by the ADSM will constitute a waiver of the ADSM’s right to be held harmless and will be evidenced in writing, either by written agreement or in clinical notes entered into the ADSM’s dental record contemporaneously with the time, date of agreement and the ADSM’s signature. The ADSM’s decision to receive such service, without written evidence of the ADSM’s agreement to pay notwithstanding exclusion from coverage, will not constitute a waiver of the ADSM’s right to be held harmless. The ADSM will not be held harmless from financial liability if the ADSM fails to advise the network provider, in advance of receiving the service that he or she is an ADSM. Under “hold harmless,” the ADSM has no financial liability and therefore has no further appeal rights for care that is denied coverage. If the ADSM waives his or her right to be held harmless, the ADSM will be financially liable for the care received.

C.10.5. Dental Readiness Classification (DRC). The contractor will collect the remote ADSM’s DRC information from providers and will report this information on the ADDP Data Elements Report (see Section J, Attachment J-13). The classification definitions are listed in Section J, Attachment J-1. The contractor will only report either DRC 1, 2, or 3; DRC 4 is not used for this contract. One dental classification will be reported for the claim, not a dental classification for each procedure. Claims from providers that do not include the DRC, when required, shall be denied until resubmitted with the DRC.

Annually, network providers will complete and give to the ADSM a DD Form 2813, Active Duty/Reserve Forces Dental Examination Form for all remote ADSMs’ annual dental examinations upon request.

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ADSMs will not be charged for these services (see Section J, Attachment J-8).

C.10.6. If requested, network providers shall provide, within 10 business days of request, copies of the treatment narrative summaries to the ADSMs and DTFs at no additional charge.

C.10.7. Dental Services Agreement. The contractor will enter into a Dental Services Agreement with the Department of Veterans Affairs (VA) to refer ADSMs requiring dental services to participating VA dental clinics, on a space available basis, as authorized by Section 20 I of the Veterans Health Care Act of 1992, Public Law 102-585, 38 USC 8111. The VA agrees to furnish the contractor with a current list of Participating Providers which the contractor will add to its Participating Provider Network for the specific purpose of providing dental care under the provisions of the ADDP contract. The VA will file claims, for services rendered to the contractor for reimbursement, in accordance with the contractor's Maximum Allowable Charge (see Section J, Attachment J-<Pricing table will be added as an attachment after award of the contract>). Specific provisions of the Dental Services Agreement between the VA and the contractor are found at Section J, Attachment <The Agreement will be added as an attachment after award of the contract>.

C.11. Non-Network Providers.

C.11.1. The contractor’s education program will provide guidance for ADSMs using non-network providers and how to obtain assistance for provider reimbursement when faced with a provider who demands payment at time of service.

C.11.2. When the ADSM receives care from a non-network provider who demands payment up front, the ADSM will contact the contractor who will arrange reimbursement to the provider. When an ADSM has paid a non-network provider (e.g., an emergency situation) and seeks reimbursement, the contractor will reimburse the ADSM. If the ADSM elects to use a non-network provider for non-covered dental services they waive their right to be held harmless (see C.10.4.2).

C.11.3. If the contractor receives a request for payment of routine services which are covered under the ADDP but the provider of care is not a network provider and a network provider is available, the contractor shall deny the claim for using a non-network provider. If the DTF, member or provider appeals the initial denial, the contractor may approve the claim for payment one time. If the member continues to use a non-network provider, the contractor shall contact the DSPOC for a coverage determination (see C.9.4). The DSPOC will direct the contractor to either pay for the service in full; pay the network charge and direct the ADSM to pay the difference; or direct the ADSM to pay all charges. If the DSPOC authorizes care for services received from a non-network provider when a network provider was available, the Government will be responsible for paying the difference between billed charges and the negotiated contract rate.

C.11.4. If a contractor receives a request for payment of services from a non-network provider that qualify as emergency dental care, the contractor shall pay the claim.

C.11.5. If the contractor receives a request for payment of services that are not covered under the ADDP, the contractor shall contact the DSPOC for a coverage determination.

C.12. Provider Standards.

C.12.1. Prior to the payment of any claim for dental services, the contractor shall ensure that the provider has complied with the licensure requirements established by the 32 CFR 199.6 and the locality (e.g., state, country, territory, etc.) in which the services were rendered, including national and/or lower level

DRAFT SOLICITATION HT9402-13-R-0002 Page 14 of 84 requirements as appropriate. Claims for services rendered by providers who do not meet applicable licensure requirements shall be denied.

C.12.2. The contractor is responsible for determining the standard dental malpractice coverage required in the state (including state risk pools if applicable) for each network provider (both professional and institutional). In the absence of a state law requirement for dental malpractice insurance coverage, the contractor is responsible for determining the local community standard for dental malpractice coverage, and the contractor must maintain the documentation evidencing both the standard and compliance by network providers. In those cases where there are no state and/or community requirements, the contractor shall use its corporate/commercial network provider dental malpractice insurance requirements for dental malpractice insurance coverage.

C.12.3. Each network provider agreement must indicate the required coverage and the provider’s compliance with the requirements.

C.12.4. Evidence documenting the required coverage of each network provider under the contract shall be provided to the Contracting Officer upon request. The Contracting Officer retains the authority to determine whether state and/or local requirements for dental malpractice coverage have been met by a network provider and whether the evidence documenting the required coverage complies with contract requirements.

C.12.5. The contractor shall be solely liable for and expressly agrees to indemnify the Government with respect to any liability producing acts or omissions by it or by its employees or agents. Further, the contractor agrees to be liable for and expressly agrees to indemnify the Government for any liability resulting from services provided under the contract to eligible beneficiaries for care provided by contractor network providers, or, in the alternative, the contractor agrees that all network provider agreements used by the contractor shall contain a requirement, directly or indirectly by reference to applicable regulations or TMA policies, that the provider agrees to indemnify the Government from any liabilities arising from any acts or omissions in the provision of services by the provider to eligible beneficiaries for care provided under this contract.

C.13. Preemption of State Laws. Pursuant to 10 U.S.C. 1103(a), the preemption of U.S. state and local law applies to this program.

C.14. Claims Processing.

C.14.1. The contractor shall process dental care claims to completion (payment or denial) in an accurate and timely manner (as defined in C.18.3.1), in accordance with the standards at C.18.3. Payment will be made to the network provider who submitted the claim. If a non-network provider submits the claim, payment shall be made to the provider. Payment shall only be made to ADSMs under extraordinary circumstances where the member was required to pay for covered care from a non-network provider. The contractor shall retain all claims that contain sufficient information to allow processing and all claims for which missing information may be developed from in-house sources, including DEERS and contractor-operated or maintained electronic, paper, or film files. All other claims shall be denied pending receipt of complete information.

C.14.2. Non-Network Provider Claim Form. The Contractor shall accept any American Dental Association (ADA) approved claim form from non-network providers and from enrollees using non-network providers. The Contractor shall stock and distribute ADA approved claim forms that enrollees may use for non-network provider claims. The Contractor shall maintain at least one ADA approved form on its Web site allowing enrollees to complete the form online and then download for submittal.

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C.15. Appeal and Grievance Process.

C.15.1. The contractor shall establish and maintain appeal procedures in support of ADSMs.

C.15.1.1. If the DSPOC and/or contractor denies a request for reimbursement of service or written request for authorization, the dental provider, ADSM, and ADSM’s command will be notified in writing.

The ADSM, ADSM’s command, dental provider or the ADSMs authorized representative, may appeal the denial as long as they comply with the provision herein for appealing the denial.

C.15.1.2. First Level. Any appeal of a denial must be in writing and must be either mailed, faxed or otherwise delivered to the contractor within 90 calendar days of the ADSM, ADSM’s command, or dental provider receiving notice of the denial. The contractor shall forward the appeal to the DSPOC, within seven calendar days of receipt. The DSPOC shall issue a decision to the contractor, within 10 calendar days of receipt, by either granting the appeal, denying the appeal or requesting additional information.

The contractor shall notify the appealing party within 14 calendar days of receipt of the DSPOC’s decision.

C.15.1.3. Second Level. In the event the DSPOC denies the appeal, then the ADSM, ADSM’s command, dental provider or the ADSM’s authorized representative may, within 30 calendar days of receipt of the denial, seek additional review of the DSPOC’s decision. In order to obtain further review of the DSPOC’s decision, the ADSM, ADSM’s command, dental provider or the ADSM’s authorized representative shall submit to the contractor their written request for review of the DSPOC’s decision.

The request for review shall include a copy of the DSPOC’s decision. The contractor shall forward the request to the DSPOC within seven calendar days of receipt for a second and separate DSPOC review.

The DSPOC shall issue a decision to the contractor, within 15 calendar days of receipt, either affirming or reversing the initial DSPOC’s first level decision. The decision may overrule the previous decision in whole or in part. The contractor shall notify the appealing party within 14 calendar days of receipt of the DSPOC’s decision.

C.15.1.4. Final Level. In the event that the DSPOC affirms their first level decision, the ADSM, ADSM’s command, dental provider or the ADSM’s authorized representative may seek further review by submitting a written request to the contractor within 30 calendar days of receipt of the second decision.

The written request shall include copies of the First and Second level decisions. The contractor shall forward the request to the DSPOC within seven calendar days of receipt. The DSPOC shall forward the request to the Surgeon General or designee for the ADSM’s Branch of Service, with a copy to the TMA Dental Care Branch, within 7 calendar days. The Surgeon General or designee for the ADSM’s Branch of Service decision shall be final and not subject to further appeal. The contractor shall notify the appealing party within 14 calendar days of receipt of the final decision.

C.15.1.5. Any appealable issue may only be appealed through the above process one time. Once a final decision is rendered, the issue may not be appealed again.

C.15.2. The contractor is responsible for processing grievances filed by or on behalf of the ADSM.

C.15.2.1. 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 a network provider, contractor, or subcontractor personnel to furnish the level or quality of care and/or service to which the ADSM may

DRAFT SOLICITATION HT9402-13-R-0002 Page 16 of 84 believe he/she is entitled. Grievances may be filed for or on behalf of the ADSM by the member or by the referring DTF. All grievances must be submitted in writing. The subjects of grievances may be, but are not limited to, such issues as the refusal of a network provider to provide services or to refer a beneficiary to a specialist, the length of the waiting period to obtain an appointment, undue delays at an office when an appointment has been made, poor quality of care, or other factors which reflect upon the quality of the care provided or the quality and/or timeliness of the service. If the written complaint reveals an appealable issue, the correspondence shall be forwarded to the contractor’s appeals unit for a reconsideration review.

C.15.2.2. Grievances may be mailed, faxed or delivered to the contractor. In addition to these methods of delivery the contractor shall offer on their Web site a fillable online grievance form that may be submitted through an online process. The Web application will include the ability to include supporting documentation.

C.15.2.3. It is the contractor’s responsibility to conduct an investigation and, if possible, resolve the aggrieved party’s problem or concern. In this responsibility, the contractor shall:

C.15.2.3.1 Ensure that information for filing of grievances is readily available to all ADSMs.

C.15.2.3.2. Maintain a system of receipt, identification, and control which will enable accurate and timely handling. All grievances shall be stamped upon receipt with the actual date of receipt.

C.15.2.3.3. Investigate the grievance and document the results for 95% of grievances within 60 calendar days of receipt of the grievance. Investigate the grievance and document the results for 100% of grievances within 90 calendar days of receipt. The contractor shall notify the Contracting Officer’s Representative (COR) of all grievances for which reviews were not completed within 60 days of receipt.

C.15.2.3.4. Provide interim written responses by the 30th calendar day after receipt for all grievances not Processed To Completion (PTC) by that date.

C.15.2.3.5. Take positive steps to resolve any problem identified within 60 days of the problem identification. If the problem cannot be resolved within that period of time, the Contracting Officer’s Representative (COR) shall be informed of the nature of the problem and the expected date of resolution.

If there is no resolution to the problem, the contractor shall acknowledge receipt of the grievance and explain to the grievant why the problem cannot be resolved.

C.15.2.3.6. Written notification of the results of the review shall be submitted to the ADSM and DTF (where applicable) within 60 days of the original receipt of the grievance. The letter will indicate who the grievant may contact to obtain more information and provide an opportunity for the grievant, if not satisfied with the resolution, to request a second review by a different individual.

C.15.2.3.7. Ensure the involvement in the grievance review process of appropriate dental personnel, including personnel responsible for the contractor’s quality assurance program in any case where the grievance is related to the quality of medical care or impacts on utilization review activities.

C.15.2.3.8. Maintain records for all grievances, including copies of the correspondence, the results of the review/investigation and the action taken to resolve any problems which are identified through the grievance.

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C.16. Beneficiary and Network Provider Services.

C.16.1. The contractor shall provide comprehensive, readily accessible customer services that include multiple, contemporary avenues of access such as telephone, facsimile, written, e-mail and World Wide Web for beneficiaries and providers. Customer services shall be delivered in a manner that achieves the standards in C.18.4.

C.16.2. The customer service department shall be open from 7:00 A.M. to 7:00 P.M. Central Time (CT) Monday through Friday and 7:00 A.M. to 4 P.M. Central Time (CT) on Saturdays, except for Federal Holidays.

C.16.3. The contractor shall schedule appointments for the ADSM, when requested by the ADSM, through the contractor’s Web site or via telephone with a customer…