FINAL_Sections_C-M_Amend_1_22Mar2013.rtf

SOLICITATION HT9402-13-R-0002 Amendment 1 Page 80 of 80

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.

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 DTFs for civilian dental care, and (2) ADSMs, having a duty location and residence greater than 50 miles from a DTF. The latter component of ADSMs are considered to be remote ADSMs 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.

C.3.1. The following 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 to establish contractual requirements for implementation of federal statutes and regulations. When a statute, regulation, or manual changes, there is no change to the contract requirements until the Contracting Officer changes the contract by modification to the contract. 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 – (1) TRICARE Policy Manual (TPM), (2) TRICARE Systems Manual (TSM), and (3) TRICARE Operations Manual (TOM). The TRICARE Manuals 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.

C.3.2.1. The following requirements of TRICARE Operations Manual (TOM) 6010.56-M, February 1, 2008 (through Change 96) apply to this contract:.

Chapter 1, Section 1 – Organization of the TRICARE Management Activity

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.3.2.2. The following requirements of TRICARE Systems Manual (TSM) 7950.2-M, February 1, 2008 (through Change 46) apply to this contract:

Chapter 1 – General Automated Data Processing (ADP) Requirements (Except for Chapter 1, Section 1.1, requirements of Section J Attachment J-18a apply).Chapter 3, Defense Enrollment Eligibility Reporting System (DEERS) (excluding Sections 1.4 and 1.5). (Except for Chapter 3, Section 1.2, requirements of Section J Attachment J-18b apply).

C.3.2.3. The following requirements of TRICARE Policy Manual (TPM) 6010.57-M, February, 2008 (through Change 86) apply to this contract.

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

C.3.2.4. Definitions. Definitions are included in the TOM Appendix B, and Attach J-1.

C.3.2.5. The TRICARE manuals are updated/revised frequently, though few of these updates/revisions will affect the ADDP. The contractor will generally be provided the opportunity for comment prior to these updates/revisions. The contractor shall utilize the most current version of the TMA manuals in order to keep the manual requirements stated above (C.3.2.1 through C.3.2.4) in sync with the rest of the manuals.

C.3.2.6. Statutory and Regulatory Authority.

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

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

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

Title 45 CFR Parts 160, 162 and 164 of (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).

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

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 30 days post certification of meeting Information Assurance (IA) security requirements with additional updates regularly thereafter in support of the contractor’s education initiatives. (see Section J Attachment J-16, Transition Requirements).

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 grant the contractor with access to the Defense Manpower Data Center’s (DMDC) 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 grant 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 start of dental healthcare delivery.

C.4.4. The Government will provide any changes to the listing at Section J Attachment J-11, Uniformed Services DTFs/DMIS IDs, 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, Benefits, Limitations, and Exclusions, which will be updated for evolving accepted standards as defined by the American Dental Association (ADA). 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 utilize the most current version of the Code on Dental Procedures and Nomenclature (Code) published in the ADA’s Current Dental Terminology (CDT) manual throughout the life of the contract.

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 updates to Section J, Attachment J-2 within 30 calendar days of the release of a new version, then subsequently discuss those recommendations with TMA. Based upon these discussions, the contractor shall then provide the Contracting Officer with a written description of recommended updates to Section J, Attachment J-2 that conforms to the new version of the ADA CDT manual and Code.

C.7. Eligibility.

C.7.1. Eligibility Determinations. The Uniformed Services are responsible for reporting an ADSM’s eligibility status in 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). The current eligibles are as follows:

C.7.1.1. Active Duty Service Members. 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, Instructions to Services, ADSMs, and Network Providers for Remote ADSMs).

C.7.1.2. 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.7.1.3. 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, Procedures for Additional Eligible Member Categories).

C.7.1.4. 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.7.1.5. 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.7.1.6. Foreign Forces Members. 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, NATO SOFA, PFP SOFA) (see Section J Attachment J-7).

C.7.1.7. 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.8. Remote Active Duty Service Member Enrollment.

C.8.1. The contractor shall record all enrollments, re-enrollments, disenrollments, and correct enrollment discrepancies on 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 DEERS which is Government provided on-line enrollment software and all enrollments/terminations will be performed 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 the contractor’s 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.8.2.. The contractor shall verify the following types of remote ADSM dental coverage (see Section J, Attachments J-3 and J-7):

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.8.2.1. 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 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.8.2.2. 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 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.8.2.3. ADSMs with a foreign address in DEERS are eligible for enrollment as a remote ADSM if the ADSM 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 HCDP Plan Coverage Code. The ADSM will be eligible for benefits as a remote ADSM (see Section J, Attachments J-3 and J-7).

C.8.2.4. 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 ADSMs.

C.8.2.5. 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.8.3. The DMDC prints and mails 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 also provides 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 includes 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 the contractor’s 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 compliant 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 claim information except for dollar amounts.

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. All radiographs need to be of diagnostic quality.

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 and whether they were approved or disapproved.

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

C.9.1.9. The contractor shall train (initial and refresher) and provide secure means for the POCs of the DTFs, DSPOCs and TMA Dental Program Office to access the system(s) for viewing and/or utilization.. 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 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 shall 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. The contractor shall deny claims for care received more than nine months after the authorization date. If an appeal of the denial is submitted the contractor 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 has one dentist Representative, with approval authority, who reviews their Service’s DTF referred orthodontics. The contractor shall electronically forward all DTF referred orthodontics to the Service’s Representative for approval/denial. The Service Representative electronically forwards 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 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 an ADSM uses a non-network provider without authorization, if the DTF, ADSM 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, all supporting documentation, and 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.

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 healthcare delivery and 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, Exhibit B, Contract Data Requirements Lists (CDRLs).

C.10.3. Network Provider Directory. The contractor shall make available a web based directory of network providers, searchable by zip code, distance, address, and by individual provider name. The directory 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 contractor shall maintain the information so that it is 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 ADSMs. ADSMs shall not be billed for this care, nor be liable for any co-payments or cost-shares.

C.10.4.2. 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 prior to approving/disapproving payment.

C.10.4.3. Hold Harmless Provision. The contractor shall educate their network providers and the ADSMs on the hold harmless requirements. 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. ADSMs will not be charged for these services (see Section J, Attachment J-8).

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

C.10.7. Dental Services Agreement. The contractor will enter into a Dental Services Agreement with the Department of Veterans Affairs 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 furnishes 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. For services rendered, the VA files claims to the contractor for reimbursement, in accordance with the contractor's Maximum Allowable Charge (see Section J, Exhibit A, CDT Pricing Table).

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 prior to receiving care, the ADSM contacts 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.10.4.3).

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, ADSM or provider appeals the initial denial, the contractor may approve the claim for payment one time. If the contractor approves the initial denial, the contractor shall process the claim for billed charges. If the ADSM 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 billed charges. If the billed charges are less than the negotiated contract rate the Government will pay the lower billed charges. If the billed charges are higher than the negotiated contract rate then the Government will pay the difference.

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 prior to approving/disapproving payment.

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 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.12.2.1. Each network provider agreement must indicate the required coverage and the provider’s compliance with the requirements of C.12.

C.12.2.2. Prior to inclusion of a provider in the network, and retention in the network, the contractor will ensure that the provider meets the state and/or local requirements for dental malpractice coverage and documentation thereof complies with the requirements of this contract. Evidence documenting the required coverage of each network provider under the contract shall be provided to the Contracting Officer upon request.

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 ADSM 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 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.

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 is 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. The contractor shall ensure that any appeal of a denial is in writing and received by e mail, fax or other delivery within 90 calendar days of the ADSM, ADSM’s command, or dental provider receiving notice of the denial. The contractor shall electronically forward the appeal to the DSPOC, within seven calendar days of receipt. The DSPOC issues a decision electronically 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 if the ADSM, ADSM’s command, dental provider or the ADSM’s authorized representative has filed a request for additional review of the DSPOC’s decision, the contractor shall ensure that it was received within 30 calendar days of the denial. In order to obtain further review of the DSPOC’s decision, the ADSM, ADSM’s command, dental provider or the ADSM’s authorized representative submits to the contractor their written request for review of the DSPOC’s decision. The request for review must include a copy of the DSPOC’s decision. The contractor shall electronically forward the request to the DSPOC within seven calendar days of receipt for a second and separate DSPOC review. The DSPOC issues a decision electronically 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, and the contractor shall ensure that a written request was received within 30 calendar days of receipt of the second decision. The written request must include copies of the First and Second level decisions. The contractor shall electronically forward the request to the DSPOC within seven calendar days of receipt. The DSPOC electronically forwards the request to the Surgeon General or designee for the ADSM’s Branch of Service, with a copy to the TMA Dental Program Office, within 7 calendar days. The Surgeon General or designee for the ADSM’s Branch of Service decision is 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. The contractor shall ensure that 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 believe he/she is entitled. Grievances may be filed for or on behalf of the ADSM, by the ADSM 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 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.

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. 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 service representative. The contractor shall send to the ADSM electronic scheduling reminders, appointment reminders, and failed appointment notices in order to ensure scheduling and appointment compliance. The contractor shall send the reminders/notices via PKI compliant (i.e. CAC enabled) and not through the contractor’s proprietary secure email system. If the ADSM requests non-PHI/PII be sent to their non-secure account (e.g. their personal email address) the contractor may comply with the ADSM’s request. The contractor shall make appointments and complete authorization requests in accordance with C.18.2.

C.16.4. The contractor shall provide prompt responses to written correspondence received either via hardcopy or electronic media in accordance with the standards in C.18.4.

C.16.5. Once a dental claim has been processed to completion, the contractor will send an e-mail (PKI compliant/CAC enabled or if requested, to a non-secure email account, see C.16.3), to the ADSM, which contains a link for the ADSM to participate in a patient satisfaction survey. The survey will be administered by the Tri-Service Center for Oral Health Studies or other DoD approved agency.

C.17. Education.

C.17.1. ADSM Education. The contractor will prepare and submit to TMA, Beneficiary Education and Support (BE&S) an annual education plan (Section J, Exhibit B, CDRL AP020) to inform remote ADSMs, DTFs, and DSPOCs of services offered by the ADDP.

C.17.1.1. Provider Education. The contractor shall educate network providers on the ADDP dental benefit and requirements of treating ADSMs. The contractor shall make the educational training available on line to the providers. The contractor shall ensure network providers are familiar with referral and authorization requirements, claim submittal process, Dental Readiness Classification procedures, and supporting documentation requirements to accompany claims and/or dental care authorization requests.

C.17.2. The contractor’s education strategy will be sufficiently comprehensive to meet the information needs of the customer base. The contractor’s strategy may include a broad array of tools to include, but not limited to, printed mass communications materials, use of current World Wide Web technology, advertisements in publications that target the eligible population, regular participation at conferences, seminars, trade fairs, family support association and council meetings, and military/reserve association meetings that are attended by eligible persons or Government representatives that train or support eligible persons (i.e., Beneficiary Counseling and Assistance Coordinators-BCAC), and presentations to Reserve Component units.

C.17.3. The contractor shall use the Government’s national suite of TRICARE educational materials pertaining to specific aspects of the TRICARE benefit and programs. The contractor shall use the Government’s mandatory formats to ensure “one look and feel” of all educational material. The educational materials must cite the Web site www.tricare.mil/dental. This Web site will direct the beneficiary and provider to the correct dental site.

C.17.3.1. The contractor will meet with and establish a Memorandum of Understanding (MOU) with TMA BE&S (Section J, Exhibit B, CDRL SR120). The MOU will establish the review and approval process for annual education plans and identify desired education materials.

C.17.3.2. BE&S collaborates with the contractor in the design and development of content for all education materials. All materials developed supports the contractor’s approved education plan and shall be distributed by the contractor. Timeframes to support design, development, printing and distribution of education materials will be as specified in the MOU between the contractor and BE&S. The contractor shall ensure that all education materials are coordinated with the Contracting Officer’s Representative prior to approval and release for printing. BE&S prints all educational materials, including written materials, briefings, and other methods of publicizing the ADDP. BE&S ships all materials to the contractor; and the contractor shall be responsible for all storage, handling and distribution of printed materials.

C.17.4. The contractor shall participate in monthly TRICARE beneficiary and provider workgroup meetings, comprised of other TMA programs’ representatives and the TRICARE Beneficiary Publications Office/BE&S. As an advisor, the contractor shall provide unique perspectives, ideas, and recommendations regarding the development and maintenance of TRICARE educational materials to the group. Meetings may be attended via teleconference, video telecommunications, or in person which is typically in the Washington D.C. area.

C.17.5. In coordination with BE&S, the contractor shall develop and e-mail up to two electronic newsletters per year to the remote ADSMs and the DTFs.

C.17.6. Printed Mass Communication Materials. The contractor shall post all current versions of approved mass communications materials on its Web site.

C.18. Standards.

C.18.1. Network Provider Access.

CATEGORY

STANDARD

Remote ADSMs access to a general dentistry network 95% of all remote ADSMs will have access to a general dentistry network provider within 40 driving miles of their home address DTF referral network access 95% of all DTF referrals will have access to a network provider within 25 driving miles of the DTF as defined by the DTF service area ZIP codes Routine appointments 95% of all ADSMs will be able to obtain a routine appointment within 21 calendar days of requesting an appointment Specialty consultation appointments 95% of all ADSMs will have access to a specialty consultation appointment from an appropriate dental specialist within 28 calendar days of requesting an appointment Endodontic referrals 85% of all DTF referred endodontic procedures will be completed by an Endodontist Oral surgery referrals 80% of all DTF referred oral surgeries will be completed by an Oral Surgeon

C.18.2. Appointments and Authorizations.

CATEGORY

STANDARD

Schedule Appointments 90% of appointments will be scheduled within two working days Authorizations Completed

1) 90% of authorization requests will be electronically sent to the DSPOC within four business days of receipt of a complete authorization request (to include required documentation).

100% of authorization requests will be electronically sent to the DSPOC within six business days of receipt of a complete authorization request (to include required documentation).

2) 90% of authorization requests will be completed within two working days of receiving all required information from the DTF or DSPOC 100% of authorization requests will be completed within three working days of receiving all required information from the DTF or DSPOC

C.18.3. Claims Processing.

CATEGORY

STANDARD

Process Claims to Completion 90% within 14 calendar days of receipt 98% within 30 calendar days of receipt 99.9% within 60 calendar days of receipt 100% within 365 calendar days of receipt Claim Payment Accuracy 98% Coding Accuracy 98% Payment and coding errors shall be corrected Within 14 calendar days of identification of the error.

C.18.3.1. For purposes of computing claims processing cycle times, the process to completion date will be computed as defined in the TOM, Appendix B for the definition “Processed to Completion”.

C.18.4. Telephone and Correspondence Standards.

CATEGORY

STANDARD

Telephone answered by Automated Response Unit (ARU)

98% within 20 seconds Telephone answered by Customer Service Representative (CSR) 80% within 30 seconds of selection by caller Telephone call blockage rate 5% or less at all times (measured, at a minimum, hourly) Telephone calls completed 80% during the initial call 99.9% within 10 business days Priority written and e-mail correspondence (final response) 95% within 7 business days of receipt 99.9% within 20 business days of receipt Non-priority written and e-mail correspondence 85% within 10 business days 99.9% within 25 business days

C.18.4.1. For purposes of computing telephone call processing cycle times, the date of completion shall be computed as defined in the TOM, Appendix B (Processed to Completion, Telephonic Inquiry).

C.18.4.2.