DRAFT_RFP_TRICARE_Overseas_Program.pdf

HT9402-14-R-0001

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

1 120

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.

I

J

K

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

H

G

F

E

D

C

B

A

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

DEFENSE HEALTH AGENCY

DEFENSE HEALTH AGENCY-AURORA

16401 E CENTRETECH PARKWAY

AURORA CO 80011

1200 MS

Judy Blomquist 303 judith.blomquist@dha.mil

676-3839

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PAGE(S)

TODD M. YOUNG

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 2-14

15-43 44-44 45-45 46-47 48-64 65-83

84-106

107-107

108-119

TBD

TBD

303-676-3675

TODD.YOUNG@dha.mil

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

2 120

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

TRICARE OVERSEAS PROGRAM (TOP)

0001 BASE PERIOD - 1 SEP 2015 - 31 AUG 2016 1 LT

TRANSITION IN (Firm Fixed Price) Planning and implementation of Transition In as stated in the Statement of Work, Section C.44 of the solicitation/contract

0002 CONTRACT DATA REQUIREMENTS LIST (CDRLs) 1 LT for TRANSITION IN (Firm Fixed Price)

Administrative and support cost associated with development and delivery of reports/plans as stated in Technical Exhibit A and Section F of the Solicitation/Contract

0003 CONTRACTING OFFICER DIRECTED TRAVEL

CO directed travel as stated in the Statement of Work, Section C.43 of the Solicitation/Contract (Cost Reimbursement/No Fee) (Government Estimate: $30,000)

0004 CALL CENTER STAFFING (Firm Fixed Price) 1 LT

60 DAYS Prior to Health Care Delivery (HCD) - Administrative and Support cost associated with providing the services as stated in the Statement of Work, Section C.19.10 and H.5.2 of the Solicitation/Contract

1001 OPTION PERIOD 1 - 1 SEP 2016 - 31 AUG 2017 3479304 MM

HEALTH CARE SUPPORT SERVICES - PRIME ENROLLED

MEMBERS (Fixed Unit Price)

Administrative and support costs associated with providing all services as stated in the Statement of Work, Section C.1.2 of the solicitation/contract for the TRICARE Overseas Continued ...

3 120

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

Program (TOP) Prime enrolled population. (Member Per Month)

1002 HEALTH CARE SUPPORT SERVICES - PRIME REMOTE 205812 MM

ENROLLED MEMBERS (Fixed Unit Price)

Administrative and support costs associated with providing all services as stated in the Statement of Work, Section C 1.2. of the solicitation/contract for the TRICARE Overseas Program (TOP) Prime Remote enrolled population (Member per Month)

1003 TRANSIENT CARE MANAGEMENT (Fixed Unit Price) 6221 CS

Administrative and support costs associated with providing the services for urgent/emergency care as stated in the Statement of Work, Sections C.19.9 and C.39 of the Solicitation/Contract.

(Per Case)

1004 TRANSIENT AMBULANCE/AEROMEDICAL EVACUATION 200 CS

SERVICES (Fixed Unit Price)

Administration and support costs associated with providing transient ambulance/aeromedical evacuation services as stated in the Statement of Work, Section C.15 of the Solicitation/Contract (Per Case)

1005 WRITTEN TRANSLATION SERVICES (Fixed Unit Price) 168960 EA

Translation Services as stated in the Statement of Work, Section C.37.1 of the Solicitation/Contract (Priced by EA Page)

1006 CLAIMS PROCESSING FEE - TRICARE ELIGIBLE (DEFENSE 561049 CL

HEALTHCARE PROGRAM (DHP)) (Fixed Unit Price)

Administrative and support costs associated with

4 120

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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(A) (B) (C) (D) (E) (F) providing the services in the Statement of Work, Section C.17 of the solicitation/contract for TRICARE beneficiaries who are non-Medicare eligible. (Per Claim)

1007 CLAIMS PROCESSING FEE - MEDICARE ELIGIBLE 42311 CL

(MEDICARE ELIGIBLE RETIREE HEALTH CARE FUND

(MERHCF)) (Fixed Unit Price)

Administrative and support costs associated with providing the services as stated in the Statement of Work, Section C.17 of the contract for dual-eligible beneficiaries (TRICARE and Medicare eligible). (Per Claim)

1008 ACCESS TO CARE IN KINSHASA, DEMOCRATIC REPUBLIC 360 MM

OF THE CONGO (Fixed Unit Price)

Access to care in Kinshasa, Democratic Republic of the Congo in accordance with the Statement of Work, Section C.45.2. of the solicitation/contract. (Amounts are based on member enrollment - Qtly Fee)

1009 PERFORMANCE INCENTIVE POOL

Performance Incentives in accordance with the Statement of Work, Section H.6 of the solicitation/contract

1010 CONTRACT DATA REQUIREMENTS LIST (CDRLs) 1 LT (Individual Pricing on DD1423) IAW Technical Exhibit A

Administrative and support cost associated with development and delivery of reports/plans as stated in Section F of the Solicitation/Contract

1011 PHASE-OUT Firm Fixed Price - If Exercised 1 LT Invoiced and paid in one lump sum upon

5 120

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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(A) (B) (C) (D) (E) (F) inspection/acceptance

2001 OPTION PERIOD 2 - 1 SEP 2017 - 31 AUG 2018 3479304 MM

HEALTH CARE SUPPORT SERVICES - PRIME ENROLLED

MEMBERS (Fixed Unit Price)

Administrative and support costs associated with providing all services as stated in the Statement of Work, Section C.1.2 of the solicitation/contract for the TRICARE Overseas Program (TOP) Prime enrolled population. (Member Per Month)

2002 HEALTH CARE SUPPORT SERVICES - PRIME REMOTE 205812 MM

ENROLLED MEMBERS (Fixed Unit Price)

Administrative and support costs associated with providing all services as stated in the Statement of Work, Section C.1.2 of the solicitation/contract for the TRICARE Overseas Program (TOP) Prime Remote enrolled population (Member per Month)

2003 TRANSIENT CARE MANAGEMENT (Fixed Unit Price) 6221 CS

Administrative and support costs associated with providing the services for urgent/emergency care as stated in the Statement of Work, Sections C.19.9 and C.39 of the Solicitation/Contract.

(Per Case)

2004 TRANSIENT AMBULANCE/AEROMEDICAL EVACUATION 200 CS

SERVICES (Fixed Unit Price)

Administration and support costs associated with providing transient ambulance/aeromedical evacuation services as stated in the Statement of Work, Section C.15 of the Solicitation/Contract (Per Case)

6 120

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

2005 WRITTEN TRANSLATION SERVICES (Fixed Unit Price) 168960 EA

Translation Services as stated in the Statement of Work, Section C.37.1 of the Solicitation/Contract (Priced by EA Page)

2006 CLAIMS PROCESSING FEE - TRICARE ELIGIBLE (DEFENSE 561049 CL

HEALTHCARE PROGRAM (DHP)) (Fixed Unit Price)

Administrative and support costs associated with providing the services in the Statement of Work, Section C.17 of the solicitation/contract for TRICARE beneficiaries who are non-Medicare eligible. (Per Claim)

2007 CLAIMS PROCESSING FEE - MEDICARE ELIGIBLE 42311 CL

(MEDICARE ELIGIBLE RETIREE HEALTH CARE FUND

(MERHCF)) (Fixed Unit Price)

Administrative and support costs associated with providing the services as stated in the Statement of Work, Section C.17 of the contract for dual-eligible beneficiaries (TRICARE and Medicare eligible). (Per Claim)

2008 ACCESS TO CARE IN KINSHASA, DEMOCRATIC REPUBLIC 360 MM

OF THE CONGO (Fixed Unit Price)

Access to care in Kinshasa, Democratic Republic of the Congo in accordance with the Statement of Work, Section C.45.2. of the solicitation/contract. (Amounts are based on member enrollment - Qtly Fee)

2009 PERFORMANCE INCENTIVE POOL

Performance Incentives in accordance with the Statement of Work, Section H.6 of the solicitation/contract

7 120

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

2010 CONTRACT DATA REQUIREMENTS LIST (CDRLs) 1 LT (Individual Pricing on DD1423) IAW Technical Exhibit A

Administrative and support cost associated with development and delivery of reports/plans as stated in Section F of the Solicitation/Contract

2011 PHASE-OUT (Firm Fixed Price) - If Exercised 1 LT Invoiced and paid in one lump sum upon inspection/acceptance

3001 OPTION PERIOD 3 - 1 SEP 2018 - 31 AUG 2019 3479304 MM

HEALTH CARE SUPPORT SERVICES - PRIME ENROLLED

MEMBERS (Fixed Unit Price)

Administrative and support costs associated with providing all services as stated in the Statement of Work, Section C.1.2 of the solicitation/contract for the TRICARE Overseas Program (TOP) Prime enrolled population. (Member Per Month)

3002 HEALTH CARE SUPPORT SERVICES - PRIME REMOTE 205812 MM

ENROLLED MEMBERS (Fixed Unit Price)

Administrative and support costs associated with providing all services as stated in the Statement of Work, Section C1.2 of the solicitation/contract for the TRICARE Overseas Program (TOP) Prime Remote enrolled population (Member per Month)

3003 TRANSIENT CARE MANAGEMENT (Fixed Unit Price) 6221 CS

Administrative and support costs associated with providing the services for urgent/emergency care as stated in the Statement of Work, Sections

8 120

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

C.19.9 and C.39 of the Solicitation/Contract.

(Per Case)

3004 TRANSIENT AMBULANCE/AEROMEDICAL EVACUATION 200 CS

SERVICES (Fixed Unit Price)

Administration and support costs associated with providing transient ambulance/aeromedical evacuation services as stated in the Statement of Work, Section C.15 of the Solicitation/Contract (Per Case)

3005 WRITTEN TRANSLATION SERVICES (Fixed Unit Price) 168960 EA

Translation Services as stated in the Statement of Work, Section C.37.1 of the Solicitation/Contract (Priced by EA Page)

3006 CLAIMS PROCESSING FEE - TRICARE ELIGIBLE (DEFENSE 561409 CL

HEALTHCARE PROGRAM (DHP)) (Fixed Unit Price)

Administrative and support costs associated with providing the services in the Statement of Work, Section C.17 of the solicitation/contract for TRICARE beneficiaries who are non-Medicare eligible. (Per Claim)

3007 CLAIMS PROCESSING FEE - MEDICARE ELIGIBLE 42311 CL

(MEDICARE ELIGIBLE RETIREE HEALTH CARE FUND

(MERHCF)) (Fixed Unit Price)

Administrative and support costs associated with providing the services as stated in the Statement of Work, Section C.17 of the contract for dual-eligible beneficiaries (TRICARE and Medicare eligible). (Per Claim)

3008 ACCESS TO CARE IN KINSHASA, DEMOCRATIC REPUBLIC 360 MM

OF THE CONGO (Fixed Unit Price)

9 120

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT9402-14-R-0001

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

Access to care in Kinshasa, Democratic Republic of the Congo in accordance with the Statement of Work, Section C.45.2. of the solicitation/contract. (Amounts are based on member enrollment - Qtly Fee)

3009 PERFORMANCE INCENTIVE POOL

Performance Incentives in accordance with the Statement of Work, Section H.6 of the solicitation/contract

3010 CONTRACT DATA REQUIREMENTS LIST (CDRLs) 1 LT (Individual Pricing on DD1423) IAW Technical Exhibit A

Administrative and support cost associated with development and delivery of reports/plans as stated in Section F of the Solicitation/Contract

3011 PHASE-OUT (Firm Fixed Price) - If Exercised 1 LT Invoiced and paid in one lump sum upon inspection/acceptance

4001 OPTION PERIOD 4 - 1 SEP 2019 - 31 AUG 2020 3479304 MM

HEALTH CARE SUPPORT SERVICES - PRIME ENROLLED

MEMBERS (Fixed Unit Price)

Administrative and support costs associated with providing all services as stated in the Statement of Work, Section C.1.2 of the solicitation/contract for the TRICARE Overseas Program (TOP) Prime enrolled population. (Member Per Month)

4002 HEALTH CARE SUPPORT SERVICES - PRIME REMOTE 205812 MM

ENROLLED MEMBERS (Fixed Unit Price)

Administrative and support costs associated with

10 120

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT9402-14-R-0001

(A) (B) (C) (D) (E) (F) providing all services as stated in the Statement of Work, Section C.1.2 of the solicitation/contract for the TRICARE Overseas Program (TOP) Prime Remote enrolled population (Member per Month)

4003 TRANSIENT CARE MANAGEMENT (Fixed Unit Price) 6221 CS

Administrative and support costs associated with providing the services for urgent/emergency care as stated in the Statement of Work, Sections C.19.9 and C.39 of the Solicitation/Contract.

(Per Case)

4004 TRANSIENT AMBULANCE/AEROMEDICAL EVACUATION 200 CS

SERVICES (Fixed Unit Price)

Administration and support costs associated with providing transient ambulance/aeromedical evacuation services as stated in the Statement of Work, Section C.15 of the Solicitation/Contract (Per Case)

4005 WRITTEN TRANSLATION SERVICES (Fixed Unit Price) 168960 EA

Translation Services as stated in the Statement of Work, Section C.37.1 of the Solicitation/Contract (Priced by EA Page)

4006 CLAIMS PROCESSING FEE - TRICARE ELIGIBLE (DEFENSE 561049 CL

HEALTHCARE PROGRAM (DHP)) (Fixed Unit Price)

Administrative and support costs associated with providing the services in the Statement of Work, Section C.17 of the solicitation/contract for TRICARE beneficiaries who are non-Medicare eligible. (Per Claim)

4007 CLAIMS PROCESSING FEE - MEDICARE ELIGIBLE 42311 CL

(MEDICARE ELIGIBLE RETIRE HEALTH CARE FUND

11 120

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

(MERHCF)) (Fixed Unit Price)

Administrative and support costs associated with providing the services as stated in the Statement of Work, Section C.17 of the contract for dual-eligible beneficiaries (TRICARE and Medicare eligible). (Per Claim)

4008 ACCESS TO CARE IN KINSHASA, DEMOCRATIC REPUBLIC 360 MM

OF THE CONGO (Fixed Unit Price)

Access to care in Kinshasha, Democratic Republic of the Congo in accordance with the Statement of Work, Section C.45.2. of the solicitation/contract. (Amounts are based on member enrollment - Qtly Fee)

4009 PERFORMANCE INCENTIVE POOL

Performance Incentives in accordance with the Statement of Work, Section H.6 of the solicitation/contract

4010 CONTRACT DATA REQUIREMENTS LIST (CDRLs) 1 LT (Individual Pricing on DD1423) IAW Technical Exhibit A

Administrative and support cost associated with development and delivery of reports/plans as stated in Section F of the Solicitation/Contract

4011 PHASE-OUT (Firm Fixed Price) - If Exercised 1 LT Invoiced and paid in one lump sum upon inspection/acceptance

5001 OPTION PERIOD 5 - 1 SEP 2020 - 31 AUG 2021 3479304 MM

HEALTH CARE SUPPORT SERVICES - PRIME ENROLLED

MEMBERS (Fixed Unit Price)

12 120

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT9402-14-R-0001

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

Administrative and support costs associated with providing all services as stated in the Statement of Work, Section C.1.2 of the solicitation/contract for the TRICARE Overseas Program (TOP) Prime enrolled population. (Member Per Month)

5002 MANAGED CARE FEE - PRIME REMOTE ENROLLED MEMBERS 205812 MM

(Fixed Unit Price)

Administrative and support costs associated with providing all services as stated in the Statement of Work, Section C1.2 of the solicitation/contract for the TRICARE Overseas Program (TOP) Prime Remote enrolled population (Member per Month)

5003 TRANSIENT CARE MANAGEMENT (Fixed Unit Price) 6221 CS

Administrative and support costs associated with providing the services for urgent/emergency care as stated in the Statement of Work, Sections C.19.9 and C.39 of the Solicitation/Contract.

(Per Case)

5004 TRANSIENT AMBULANCE/AEROMEDICAL EVACUATION 200 CS

SERVICES (Fixed Unit Price)

Administration and support costs associated with providing transient ambulance/aeromedical evacuation services as stated in the Statement of Work, Section C.15 of the Solicitation/Contract (Per Case)

5005 WRITTEN TRANSLATION SERVICES (Fixed Unit Price) 168960 EA

Translation Services as stated in the Statement of Work, Section C.37.1 of the Solicitation/Contract (Priced by EA Page)

13 120

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

5006 CLAIMS PROCESSING FEE - TRICARE ELIGIBLE (DEFENSE 561049 CL

HEALTHCARE PROGRAM (DHP)) (Fixed Unit Price)

Administrative and support costs associated with providing the services in the Statement of Work, Section C.17 of the solicitation/contract for TRICARE beneficiaries who are non-Medicare eligible. (Per Claim)

5007 CLAIMS PROCESSING FEE - MEDICARE ELIGIBLE 42311 CL

(MEDICARE ELIGIBLE RETIREE HEALTH CARE FUND

(MERHCF)) (Fixed Unit Price)

Administrative and support costs associated with providing the services as stated in the Statement of Work, Section C.17 of the contract for dual-eligible beneficiaries (TRICARE and Medicare eligible). (Per Claim)

5008 ACCESS TO CARE IN KINSHASA, DEMOCRATIC REPUBLIC 360 MM

OF THE CONGO (Fixed Unit Price)

Access to care in Kinshasa, Democratic Republic of the Congo in accordance with the Statement of Work, Section C.45.2. of the solicitation/contract. (Amounts are based on member enrollment - Qtly Fee)

5009 PERFORMANCE INCENTIVE POOL

Performance Incentives in accordance with the Statement of Work, Section H.6 of the solicitation/contract

5010 CONTRACT DATA REQUIREMENTS LIST (CDRLs) 1 LT (Individual Pricing on DD1423) IAW Technical Exhibit A

Administrative and support cost associated with development and delivery of reports/plans as stated in Section F of the Solicitation/Contract

14 120

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT9402-14-R-0001

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

5011 PHASE-OUT (Firm Fixed Price) - If Exercised 1 LT Invoiced and paid in one lump sum upon inspection/acceptance

HT9402-14-R-0001 TRICARE OVERSEAS PROGRAM (TOP) PAGE 15 of 120

SECTION C – DESCRIPTION/SPECIFICATIONS/WORK STATEMENT

C.1. General.

C.1.1. The Department of Defense (DoD), through the Defense Health Agency (DHA), has a mission to provide TRICARE services to eligible beneficiaries in locations outside the 50 United States and the District of Columbia.

C.1.2. In order to accomplish this mission, the TRICARE Overseas Program (TOP) contract will supplement the services that are provided by the direct care system in designated Military Treatment Facility (MTF) locations, and provide comprehensive health care support services to Active Duty Service Members (ADSMs) and certain Active Duty Family Members (ADFMs) living in designated MTF and remote overseas locations. The contract will also provide dental care services and support for ADSMs in remote overseas locations (not including U.S. territories and commonwealths).

Additionally, the contract will provide specific services (e.g., customer support, preauthorizations, claims processing, etc.) to all TRICARE-eligible beneficiaries according to the requirements of the contract. Finally, the TOP contract will provide other health care support services (e.g., translation services, access to data, etc.) designed to assist the Government in operating an integrated health care delivery system for all eligible beneficiaries overseas.

C.1.3. Section C includes two categories of outcome-based statements. The “Statement of Objectives” represents the desired outcomes for this contract. The objectives are supported by “Technical Requirements.”

These requirements encompass the scope of the contract and represent specific tasks, outcomes, and/or standards that, at a minimum, must be achieved.

C.1.4. Whenever practicable, the technical requirements identified in this section are accompanied by one or more cross-references to specific language contained in the TRICARE Manuals or relevant statutory or regulatory documents. These cross-references are provided as a convenience to facilitate understanding of the contract requirements and are not intended to be all-inclusive. The Contractor is responsible for understanding the full scope of the TRICARE program and all TOP requirements as outlined in the contract (to include the documents incorporated by reference in C.3. below).

C.2. Statement of Objectives. The primary objectives (i.e., desired outcomes) of the TOP contract are as follows:

C.2.1. Objective 1 – Claims Processing. Timely and accurate processing of all TRICARE claims that fall within the scope of the contract, to include full compliance with TRICARE’s requirements for development, coding, processing, medical/dental review, authorization, and data record submission.

C.2.2. Objective 2 – Beneficiary and Provider Satisfaction. Beneficiary and provider satisfaction at the highest level possible throughout the period of performance, through the delivery of world-class health care and customer-friendly services.

C.2.3. Objective 3 – Provider Networks. Development and management of high-quality purchased care sector provider networks (augmented by non-network providers, as necessary) capable of providing access to TRICARE-covered medical benefits and services in designated MTF and remote locations, as well as access to ADSM dental care in designated remote locations, in accordance with the contract requirements.

C.2.4. Objective 4 – Management. Provision of efficient and effective management processes which will ensure the successful delivery of health care support and translation services as required by the contract (including, but not limited to appropriate staffing levels, staff education and training, internal

HT9402-14-R-0001 TRICARE OVERSEAS PROGRAM (TOP) PAGE 16 of 120 quality management/quality improvement program, lines of authority, and reporting and coordination interfaces with the Government).

C.2.5. Objective 5 – Transitions. Fully operational systems and processes at the start of health care delivery with minimal disruption to beneficiaries, providers, and MTFs in terms of seamless transfer of enrollments, claims, referrals/authorizations, and medical management data from the outgoing Contractor to the incoming Contractor.

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 has changed, 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) and TRICARE Reimbursement Manual (TRM), (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.3.1.1. TPM 6010.57-M, February 2008 (through Change 105), unless specifically changed, waived, or superseded by the provisions of DRAFT TPM Chapters 9 and 12 (Attachment J-8), DRAFT TOM Chapter 24 (Attachment J-10), or this section. For purposes of the instant solicitation, offerors shall disregard the requirements in TPM 6010.57-M, Chapters 9 and 12, and substitute the requirements in DRAFT TPM Chapters 9 and 12 at Attachment J-8. Following contract award, it is the Government’s intention to publish the draft language contained at Attachment J-8 in the TPM and integrate this language into the TOP contract via a contract modification.

C.3.1.2. TRM 6010.58-M, February 2008 (through Change 93)

C.3.1.3. TSM 7950.2-M, February 2008 (through Change 55)

C.3.1.4. TOM 6010.56-M, February 1, 2008 (through Change 114), unless specifically changed, waived, or superseded by the provisions of DRAFT TOM Chapter 24 (Attachment J-10), DRAFT TPM Chapters 9 and 12 (Attachment J-8), or this section. For purposes of the instant solicitation, offerors shall disregard the requirements in TOM Chapter 24 and substitute the requirements in DRAFT TOM Chapter 24 at Attachment J-10. Following contract award, it is the Government’s intention to publish the draft language contained at Attachment J-10 in the TOM and integrate this language into the TOP contract via a contract modification.

C.3.1.5. Definitions are included in Title 32, Code of Federal Regulations (CFR) Part 199.2 and TOM Appendix B.

C.3.1.6. The TRICARE manuals are updated/revised frequently. TRICARE Contractors will generally be provided the opportunity for comment prior to these updates/revisions. The TOP Contractor shall establish business processes to ensure that the most current version of the TRICARE manuals (as implemented via contract modifications) is used by Contractor and subcontractor personnel in the performance of their duties in support of the TOP contract.

http://manuals/tricare.osd.mil

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C.3.1.7. Statutory and Regulatory Authority

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

• Title 32 CFR Parts 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 Publication (SP) 800-53 (current revision) and 800-53A (current revision).

C.4. Government Information and Applications

C.4.1. The Government will provide the Contractor with access to the Defense Manpower Data Center’s (DMDC) Defense Enrollment Eligibility Reporting System (DEERS) to perform eligibility inquiries and enrollments. DEERS is the database of record for TRICARE eligibility for the TOP contract. The Government will grant access to DEERS only after the Contractor’s staff and all subcontractors’ staff that utilize systems which access and maintain TOP data are compliant with the enhanced safeguarding methods for unclassified DoD information, personnel security, and clearance requirements (see C.42.1 below for a description of these system requirements). The Contractor and its subcontractors must be in compliance with these requirements no later than 120 days before the start of health care delivery.

C.4.2. The Defense Medical Information System (DMIS) is a service of the DoD which identifies past and current DoD medical facilities. DMIS Identifiers (DMIS IDs) are recognized throughout the DoD for various medical and military facility identification purposes, including TRICARE enrollment. A listing of DMIS IDs that are associated with the TOP contract is at Attachments J-1 and J-2. The Government will provide the Contractor with any changes to the listings no later than 60 days prior to the start of health care delivery and when changes occur thereafter. DMIS ID tables may be viewed at http://www.tricare.mil/tma/gri/dmis/downloads.aspx.

C.4.3. The Referral Management System (RMS) is a Government application that creates a standard referral form based on the data entered in the Composite Health Care System (CHCS)/the Armed Forces Health Longitudinal Technology Application (AHLTA) and automatically formats the referral to contain the minimum mandatory clinical and administration information required in TOM Chapter 8, Section 5.

RMS transmits referrals to the Contractor electronically where they are processed and returned electronically to the MTF. Subject to the same information technology and personnel security and clearance requirements discussed in C.4.1. above, the Government will grant the Contractor access to RMS for the purpose of receiving referrals and returning authorizations, unless a different process has been specified by the Government.

C.5. Contractor Furnished Items. The Contractor shall furnish all necessary items (e.g., facilities, labor, services, supplies, etc.) for the satisfactory performance of this contract, unless the contract specifically states that the Government will be providing such item (as identified in Attachment J-3 or elsewhere within the contract).

C.6. Technical Requirements. The technical requirements for the TOP contract are identified below. These requirements are augmented by the statutes, regulations, and other operating guidelines and instructions incorporated by reference as noted in Section C.3. To facilitate better understanding of the contract

HT9402-14-R-0001 TRICARE OVERSEAS PROGRAM (TOP) PAGE 18 of 120 requirements, key cross-references have been included in the technical requirements listed below. These cross-references are provided as a courtesy and are not intended to be all-inclusive. Offerors are responsible for ensuring that they are familiar with and understand all of the contract requirements.

C.7. Eligibility

C.7.1. Eligibility for TRICARE is determined by the Uniformed Services, not by DHA. Except for newborns, all individuals who are determined by the applicable Uniformed Service as meeting the TRICARE eligibility reporting requirements under 32 CFR 199.3 will be reflected as eligible on the DEERS. The Contractor shall establish business processes to verify eligibility in DEERS for all associated TRICARE actions (e.g., enrollment, referrals/authorizations, claims processing, etc.).

C.7.2. In addition to verifying DEERS eligibility status, the Contractor shall establish business processes to verify additional eligibility information that may be required based on beneficiary category as discussed below.

C.7.2.1. Unless a specific exception exists, the Contractor shall verify ADFM command sponsorship status prior to enrolling an ADFM in TOP Prime or TOP Prime Remote. ADFM enrollment requests must coincide with the specific timeframe and country location designated on the command sponsorship orders (i.e., an ADFM who is command sponsored to a location in Korea cannot be enrolled in TOP Prime in Germany). See TOM Chapter 24, Section 5, paragraph 5.1 for a list of specific exceptions to the command sponsorship requirement.

C.7.2.2. Reserve Component (RC) members who incur or aggravate an injury, illness or disease while serving on active duty for 30 days or less are eligible for Line of Duty (LOD) care as defined in DoD Instruction 1241.2.

These members will not be identified as TRICARE-eligible in DEERS; therefore, additional documentation is required to establish their eligibility for LOD care. For MTF referrals, the MTF shall verify LOD eligibility prior to issuing the referral. The Contractor shall establish business processes to accept MTF LOD referrals, issue care authorizations, and process claims as if the member was eligible in DEERS. For RC members who are not referred by an MTF, prior to issuing the LOD care authorization, the Contractor shall establish business processes as follows: to verify LOD eligibility with the Military Medical Support Office (MMSO) for care in the U.S. Virgin Islands; or the applicable military unit or command for care in all other overseas locations.

Verbal attestation of duty status alone is not sufficient to establish LOD eligibility; there must be written documentation from MMSO or the applicable military unit or command which confirms that the member’s eligibility for LOD care. The Contractor shall ensure that claims associated with the LOD authorization are processed as if the member was eligible in DEERS. Claims for care that are not associated with the LOD authorization shall be denied.

C.7.3. Retirees and retiree family members are not eligible to enroll in TOP.

C.7.4. TRICARE Extra is not available outside the 50 United States and the District of Columbia.

C.7.5. Foreign Forces Members on temporary or permanent assignment in the TOP geographic regions are eligible for care in the direct care system only. MTF referrals or claims for purchased sector care for Foreign Forces Members will not be authorized or paid by TRICARE.

C.7.6. Refer to TPM Chapter 10, Section 1.1 and TOM Chapter 24, Section 5 for additional information regarding TRICARE and TOP eligibility requirements.

C.8. Medical Benefits

C.8.1. Medical benefit policy applies to the scope of services and items which may be considered for cost-sharing by TRICARE within the intent of 32 CFR 199. Explicit medical benefit requirements, limitations, or exclusions are identified in 32 CFR 199 and augmented by the TPM.

C.8.2. The TOP contract strives to accommodate the cultural differences associated with the delivery of health

HT9402-14-R-0001 TRICARE OVERSEAS PROGRAM (TOP) PAGE 19 of 120 care overseas; however, services or items which are specifically excluded or limited in the regulation or the TRICARE manuals cannot be provided under the TOP contract without specific Government direction.

C.8.3. DHA maintains a “No Government Pay Procedure Code List” which identifies all codes that are excluded from coverage and are not payable under the TRICARE program. This list is available online at http://www.tricare.mil/nogovernmentpay/.

C.8.4. Refer to 32 CFR 199.4 and the TPM for additional information regarding TRICARE medical benefits.

Refer to TOM Chapter 17 for additional information regarding waivers for the provision of non-covered services to ADSMs under the Supplemental Health Care Program.

C.9. Management

C.9.1. The Contractor shall establish and maintain effective management strategies, staff education and training programs, lines of authority, and reporting and coordination interfaces with the Government.

C.9.2. The Contractor shall establish and continuously operate an internal Quality Management/Quality Improvement (QM/QI) program that will provide the Contractor’s management with effective and efficient processes for identifying and correcting problems throughout the duration of the contract. At a minimum, the QM/QI program shall include the following:

• Quality Practices

• Staff Education and Training

• Claims Processing

• Internal Controls

• Utilization Review, Claims Review, and Utilization Management Processes

• Provider and Facility Credentialing, Re-Credentialing, and Certification Activities

• Access to Care Monitoring Procedures

• Delegated Activities and Subcontractor Oversight Management

• Appeals and Grievances Procedures

• Beneficiary and Provider Communications and Satisfaction Monitoring

• Quality Management Plan

• Translation Quality Monitoring

C.9.3. The Contractor shall implement processes and procedures to achieve the goals and objectives of the most current version of the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry’s Consumer Bill of Rights and Responsibilities (see http://archive.ahrq.gov/hcqual/

C.9.4. The Contractor shall document and employ management procedures to ensure confidentiality of all beneficiary and provider information. This includes the protection of rights of the individual in accordance with the provisions of the Privacy Act (5 U.S.C. 552a); the Freedom of Information Act (5 U.S.C. 552); the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) Reorganization Act (42 U.S.C. 290dd-2) (see the TOM, Chapter 1, Section 5). The Contractor shall prevent unauthorized use of files. The Contractor must also comply with all applicable requirements of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 including DoD Health Information Privacy Regulation – DoD 6025.18-R (as amended), the DoD 8580.02-R, Department of Defense Health Information Security Regulation, and the TRICARE Manuals.

C.9.5. Refer to TOM Chapter 1 and TOM Chapter 24, Section 1 for specific requirements and additional information regarding management.

http://www.tricare.mil/nogovernmentpay/

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C.10. Records Management

C.10.1. Pursuant to FAR Part 24, the requirements of the Privacy Act (5 U.S.C. 552a) and the Department of Defense Privacy Program (DoD 5400.11-R) are applicable to this contract and the systems of records operated and maintained by the Contractor on behalf of DHA. These systems of records are found at 65 Federal Register 30966 (Health Benefits Authorization Files, Medical/Dental Care and Claims Inquiry Files, Medical/Dental Claim History Files), 69 Federal Register 50171 and 71 Federal Register 16127 (Military Health Information System), and 64 Federal Register 22837 (Health Affairs Survey Data Base). The records systems operated and maintained by the Contractor are records systems operated and maintained by a DoD Agency (DHA). (See TOM Chapter 1, Section 5;

Chapter 2, Section 1; and Chapter 2, Section 2). All Contractor records generated under this contract shall be maintained in accordance with 36 CFR 1222; 36 CFR Subchapter B (Records Management);

Federal Records Act (Title 44 United States Code (USC), Chapters 21, 29, 31, 33); Paperwork Reduction Act (Title 44 USC, Chapter 35); and DoD Directive (DoDD) 5015.2, “DoD Records Management Program,” March 6, 2000; TOM Chapter 2; and TOM Chapter 24, Section 2.

C.10.2. The Contractor will identify its Records Manager to the Contracting Officer within ten calendar days of award. Following contract award, the Contractor shall schedule its Records Manager to attend the next available DHA records management class (a five day course) presented in Aurora, CO. The Contractor’s Records Manager shall continue to attend the records management course annually thereafter. Contractor travel for records management training shall be at the Contractor’s expense.

C.10.3. There shall be no dissemination or publication of information developed under this contract or contained in the reports to be furnished pursuant to this contract, except within and between the Contractor, subcontractors, and DHA, without prior written approval from the Contracting Officer.

C.10.4. TOP records may not be used by the Contractor for any other purpose not directly related to the contract.

C.10.5. Refer to TOM Chapter 2 and TOM Chapter 24, Section 2 for additional information regarding records management.

C.11. Financial Administration

C.11.1. Refer to TOM Chapter 3; TOM Chapter 24, Section 3; and Section G for instructions and additional information regarding financial administration.

C.12. Purchased Care Sector Providers and Facilities

C.12.1. The Contractor shall provide a managed, stable, high-quality network or networks of individual and institutional purchased care sector providers which promotes access, quality, beneficiary and provider satisfaction, and “best value health care” for TOP enrollees in the MTF and remote locations identified in Attachments J-1 and J-2 (see TOM, Appendix B, for definition of “best value health care”). In MTF locations, provider networks shall be developed to support TOP Prime enrollees by complementing the clinical capability and capacity of the MTF. In remote locations, provider networks shall be developed to provide primary and specialty care to TOP Prime Remote enrollees, as well as dental care services to ADSMs in designated remote overseas locations. When necessary, the Contractor shall augment provider network(s) with non-network providers to ensure that the number, mix, and geographic distribution of purchased care sector providers is sufficient to provide all TRICARE reimbursable services under this contract to TOP enrollees in all MTF and

HT9402-14-R-0001 TRICARE OVERSEAS PROGRAM (TOP) PAGE 21 of 120 remote areas identified in Attachments J-1 and J-2, unless otherwise determined and agreed to in writing by the Contracting Officer not to be practicable. The Contractor’s provider network(s) shall also support the requirements of special programs described in the TPM and the TOM (e.g., the Extended Care Health Option (ECHO)) for TOP enrollees. The Contractor shall provide copies of network provider agreements when requested by the Contracting Officer (CO) or the Contracting Officer Representative (COR).

C.12.2. The Contractor shall make their best effort to ensure that the TRICARE standards for access, in terms of beneficiary travel time, appointment wait time, and office wait time are met for TOP Prime and TOP Prime Remote enrollees (emergency care 24 hours per day, 7 days per week in the service area; acute care appointments within 24 hours; routine care appointments within 7 calendar days;

wellness care appointments within four weeks; specialty care appointments within four weeks or per provider designation (not to exceed four weeks); no more than 60 minutes drive time from the beneficiary’s residence for specialty care (no more than 30 minutes for other types of care); office wait times will generally not exceed 30 minutes for non-emergency care). The Contractor shall inform the Government of locations where access to care is severely impaired (in terms of beneficiary travel time, appointment wait time, and/or office wait time) and shall implement corrective actions as appropriate to improve access in these areas.

C.12.3. The Contractor shall ensure that purchased care sector network and non-network provider capabilities and capacities can be adjusted as necessary to compensate for changes in MTF capabilities and capacities (due to facility downsizing or closure, MTF expansion, establishment of new clinics, provider deployment or reassignment, etc.), which may change frequently over the life of the contract.

The Contractor shall adjust the capabilities and capacities of available purchased care sector providers to compensate for such changes when and where they occur within 90 calendar days of notification by the Government. Attachment J-12 identifies facilities which are projected for downsizing or closure during the life of the contract; however, due to the dynamic nature of DoD operations, these actions are subject to change and are not guaranteed to occur.

C.12.4. One measure of network adequacy or inadequacy shall be the percentage of paid claims for TOP Prime and TOP Prime Remote enrollees that are submitted by network providers, after excluding certain claims associated with care that was not specifically authorized by the Contractor (including, but not limited to Point of Service (POS) claims, Other Health Insurance (OHI), pharmaceuticals, ancillary services (except MRIs and PET scans), any DME items that do not require an authorization, preventive services, medical supplies that do not require an authorization, emergency care, etc.). Refer to Section H.6.4 for a description of network adequacy calculation. Attachment J-6 identifies those services and supplies which will be excluded from the Government’s network adequacy calculations.

C.12.5. The Contractor shall ensure that the purchased care sector provider networks are sufficient in number, mix, and geographic distribution to achieve the Government’s target of 80% for the percentage of paid claims for TOP Prime and TOP Prime Remote enrollees submitted by network providers during Option Period 1. This percentage of network claims shall increase by an additional 1% per option period for Option Periods 2 through 5.

C.12.6. The Contractor shall assess network adequacy on an ongoing basis, and shall inform the Government of any instances of network inadequacy. The Contractor will submit a corrective action plan for instances of network inadequacy that are significant (e.g., the only provider in a certain specialty leaves the network and there are no other local providers capable of providing similar services) or likely to persist for more than 30 calendar days. The Contractor shall respond to any inquiries from the Government concerning any aspect of network adequacy from a CO, COR, TRICARE Overseas Program Office (TOPO) staff member, or TRICARE Area Office (TAO) staff

HT9402-14-R-0001 TRICARE OVERSEAS PROGRAM (TOP) PAGE 22 of 120 member within two working days.

C.12.7. In the absence of any specific reimbursement rates or reimbursement methodology mandated by DHA, the Contractor may negotiate reimbursement rates with purchased care sector providers. The Contractor may also negotiate rates in locations where DHA has directed a specific reimbursement rate; however, the negotiated rate cannot exceed the DHA-directed rate. The Contractor shall maintain copies of all documents used to establish reasonable and customary local reimbursement rates, and shall make these documents available for Government inspection upon request.

C.12.8. The Contractor shall establish and operate a provider certification/recertification program to ensure that all purchased care sector providers who provide services to TRICARE beneficiaries are qualified to provide high quality of care that is commensurate with the TOP contract and local requirements. This program shall track and monitor the credentials of all health care providers working under this contract, including the individual provider credentials, credentialing organization, date of credentials and date of credentials expiration. Network providers must meet the medical malpractice insurance standards for their host nation or U.S. commonwealth/territory (if applicable).

C.12.9. During the certification/recertification process, the Contractor shall check the DHHS Sanction List (http://exclusions.oig.hhs.gov/) for all providers.

Providers listed on the DHHS Sanction List are excluded from providing services under all federal programs. This restriction remains in place even if a provider begins practicing in another country.

Credentials for network providers shall be verified during the network development/network agreement process. When required by DHA, credentials for non-network providers shall be verified upon receipt of the first TRICARE claim from a non-network provider, and prior to payment of the claim. Primary source verification may include verification performed by host nation or U.S.

commonwealth/territorial licensing bodies, certification (as applicable), and licensure, as well as evaluating the provider’s office to determine hygiene, appropriate health care setting, and that universal infection control procedures are in place.

C.12.10. Network providers shall be able to communicate in English, both orally and in writing, or provide translation services at the time of service. Non-network providers who augment the Contractor’s network are not required to communicate in English or provide translation services;

however, in these cases, the Contractor shall provide toll-free telephonic translation support services at the time of service upon beneficiary request.

C.12.11. The Contractor shall submit information on all providers authorized by the Contractor, to the DHA centralized TRICARE Encounter Provider Records (TEPRV) system in accordance with the provisions of the TSM Chapter 2, Section 1.2.

C.12.12. The Contractor shall perform on-site verification during provider certification in the Philippines. The Government may expand this on-site verification requirement to other locations during the life of the contract.

C.12.13. Network hospitals and other places of institutional care shall meet accreditation standards…