Sections_H.5.2_through_H.5.3.pdf

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H.5.2. PERFORMANCE READINESS VALIDATION (PRV)

H.5.2.1. During contract transition, the Contractor shall conduct validation reviews to assess the Contractor’s readiness to perform in key contract areas upon the start of health care delivery. This self-assessment process is called Performance Readiness Validation (PRV). The key contract areas that are subject to PRV reviews include: (1) referral/authorization processing, (2) Call Center operations (toll-free customer service), (3) systems development/connectivity, (4) provider networks, and (5) claims processing. Specific validation review processes are at the Contractor’s discretion; however, they must meet or exceed the specific performance elements and sample sizes that will be assessed/verified by the Government during the PRAV as discussed in H.5.3. et seq. All PRV reviews must be completed no later than 70 calendar days prior to the start of health care delivery. PRV activities and milestones shall be identified in the Start-Up Plan. See Section J, Exhibit A, Contract Data Requirements List (CDRL) R110 for additional information regarding this reporting requirement.

H.5.2.2. Following the completion of the PRV, the Contractor shall meet with the Government transition team and provide a comprehensive briefing on the processes, results, and findings of all PRV reviews. Results shall be briefed as validated performance against desired PRAV performance levels and contract standards and/or requirements. The briefing shall include a description of specific performance issues and/or risks identified, lessons learned, and a comprehensive discussion of the steps to be taken by the Contractor to ensure full performance readiness at the start of health care delivery. The briefing schedule should incorporate adequate time for Government questions and feedback regarding any aspect of the Contractor’s performance management and performance readiness review activities. A revised Start-Up Plan (CDRL R110) will be submitted if the Contractor anticipates any significant deviation from the stated activities and milestones. The PRV briefing must occur at least 7 calendar days prior to the start of the Performance Readiness Assessment and Verification (PRAV) process as described in H.5.3. below. Refer to TOM Chapter 24, Section 1 for additional information regarding the PRV briefing requirements.

H.5.3. PERFORMANCE READINESS ASSESSMENT AND VERIFICATION (PRAV)

H.5.3.1. Approximately 60 calendar days prior to the start of health care delivery, the Government will conduct PRAV activities to assess and verify the Contractor’s readiness to perform in the key contract areas identified in H.5.2.1. PRAV activities will be conducted by Government transition teams via remote assessment, by telephone, and by onsite testing/inspection at Contractor locations as described below. The PRAV will last approximately 1-2 weeks. Specific PRAV dates, locations, team structure, and sample sizes will be identified by the Government no later than 90 calendar days prior to the start of health care delivery.

H.5.3.2. The Contractor shall fully comply with the auditors and provide adequate space, local and toll-free telephone support, IT support (Internet access, connection to Contractor systems, and assistance with connectivity issues), and unrestricted access to Contractor staff and information in order to assess and verify contractor performance readiness.

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H.5.3.3. Referral/Authorization Processing: the Government’s assessment/verification processes and desired PRAV performance levels for referral/authorization processing are as follows:

H.5.3.3.1. The Government team will conduct onsite verification of the Contractor’s referral/authorization processes at contractor facilities during the PRAV. Referral/authorization processing will be evaluated for timeliness and accuracy. Utilizing RMS (or as an alternative, hard-copy MTF referral scenarios to be provided by the Government), the Contractor shall receive a sample of 300- 500 MTF referrals and perform the following actions: conduct eligibility and covered benefit reviews, identify and return incomplete referrals and/or referrals for ineligible beneficiaries, perform health care finder services, and issue accurate authorizations for required services to the referring MTF.

H.5.3.3.2. For PRAV purposes, referral/authorization processing accuracy and timeliness will be measured against the following five elements: (1) verification of eligibility in Defense Enrollment Eligibility Reporting System (DEERS); (2) application of TRICARE medical benefit policies for covered benefit determinations; (3) disposition of referral (i.e., issue authorization or return referral without action due to missing information, ineligibility, or non-covered services); (4) identification of an appropriate provider/facility (health care finder service) based on the referral; and (5) issuance of an authorization for requested services to the appropriate MTF. For PRAV purposes, the Government will consider a referral to be accurately processed if all of the applicable elements were completed correctly.

Desired PRAV performance levels: 80% of referrals processed accurately within 2 working days and 90% within 3 working days. The date of receipt will not be counted in this assessment.

H.5.3.4. Call Center Operations (toll-free customer service): the Government’s assessment/verification processes and desired PRAV performance levels for Call Center Operations (toll-free customer service) are as follows:

H.5.3.4.1 The Government team will conduct telephonic verification of the Contractor’s Call Center Operations (toll-free customer support) at unannounced times during the PRAV. Government evaluators will initiate a sample of 100-300 calls to Call Center personnel, asking for assistance or information regarding a wide variety of TRICARE issues or scenarios. The Contractor is responsible for providing toll-free telephone number(s) for use by the Government team for this purpose. For PRAV purposes, Automated Response Units (ARUs) will not be utilized; the Contractor shall ensure that all calls are routed to an individual.

H.5.3.4.2. For PRAV purposes, Call Center Operations readiness will be measured against the following elements: (1) response timeliness; (2) total hold time per call; (3) first call resolution rate; and (4) response accuracy. Desired PRAV performance levels: 80% of all calls shall be answered by an individual (not an answering machine) within 30 seconds; total “on hold” time for 80% of all calls shall not exceed 60 seconds during the entire telephone call; 80% of all inquiries shall be fully and completely answered during the initial telephone call; and 80% of all responses provided by Call Center staff shall be accurate and complete according to the terms of the contract and all applicable TRICARE programs and policies.

H.5.3.5. Systems Development/Connectivity: the Government’s assessment/verification processes and desired PRAV performance levels for systems development/connectivity are as follows:

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H.5.3.5.1. The Government team will assess the Contractor’s performance readiness regarding systems development/connectivity via remote connection and/or on-site assessment and verification at Contractor facilities during the PRAV. Systems development/connectivity readiness will be assessed for all non-claims processing systems and the telecommunications interconnections between these systems. This includes the telecommunications links with DHA and DEERS. Upon Government request, the Contractor shall perform an on-site or remote demonstration of the system(s) capabilities.

H.5.3.5.2. For PRAV purposes, systems development/connectivity readiness will be evaluated by DHA by analyzing and testing the telecommunication infrastructure and connectivity between the contractor and MHS systems and DEERS (as identified in the DISA B2B Gateway Questionnaire which shall be completed by the Contractor per TSM Chapter 1, Section 1.1). This evaluation will also incorporate the Government’s assessment of the Contractor’s overall ability to comply with Government requirements and guidance (including technical and communications protocol requirements) based on systems implementation, integration, and participation in testing meetings which will occur between the Contractor and DHA, Defense Manpower Data Center (DMDC), Tri-Service Information Management Program Office (TIMPO) and Defense Information System Agency (DISA) during contract transition.

Desired PRAV performance levels: Overall systems development/connectivity readiness will be assessed by DHA as either acceptable or non-acceptable based on all available information from meetings or testing activities which occurred between the Transition Specification Meeting and the last day of the PRAV. In making this assessment, DHA will consider any mitigating factors that were out of the Contractor’s control which may have adversely impacted systems development/connectivity (e.g., lengthy downtime in one or more non-Contractor system which prevented the Contractor’s successful accomplishment of related tasks or milestones).

H.5.3.6. Provider Networks: the Government’s assessment/verification processes and desired PRAV performance levels for provider networks are as follows:

H.5.3.6.1. The Government team will assess the Contractor’s performance readiness regarding provider networks via remote assessment and/or on-site assessment and verification at Contractor facilities during the PRAV. The Government will evaluate 50-100 provider agreements to confirm execution, compliance with licensure/certification and malpractice insurance requirements, and loading to all applicable Contractor and subcontractor systems and DEERS. Sampled provider agreements will be compared to provider directory entries to verify accuracy and completeness of the provider directory.

The evaluation will also include an assessment of the actual number of signed provider agreements (as of the start date of the PRAV) for 10-20 MTF locations and 20-40 remote locations as compared to the network target by service area. The same sample that is used to evaluate provider agreement and loading to the Contractor’s system and DEERS will be used to assess provider directory accuracy.

H.5.3.6.2. For PRAV purposes, provider network readiness will be assessed against the following six elements: (1) execution of network provider agreements, (2) documentation of provider licensure/certification and compliance with malpractice insurance requirements, (3) loading of network provider agreements to all applicable Contractor and subcontractor systems, (4) loading of network provider files into DEERS, (5) number of signed network agreements as compared to the Contractor’s

HT9402-14-R-0001 TRICARE OVERSEAS PROGRAM (TOP) PAGE 4 of 5 target in their network sizing model as identified in CDRL AP030, Network Implementation Plan, and (6) online provider directory accuracy. Desired PRAV performance levels: (1) 90% of all sampled network provider agreements shall be executed (all information complete with appropriate signatures) , (2) 90% of all sampled network provider files shall contain evidence of current licensure/certification and malpractice insurance coverage (when required by the host country), (3) 90% of all sampled network provider agreements shall be loaded into the applicable Contractor and subcontractor systems, (4) 90% of all sampled network provider files shall be loaded into DEERS, (5) actual number of signed network agreements for each sampled location is greater than or equal to 90% of the target identified in the Contractor’s network sizing model, and (6) 90% accuracy rate of provider directory information as compared to the Contractor’s provider file and the provider agreement (required elements include provider or facility name, specialty or type of facility, subspecialty, gender, service area, work address, work fax number, work telephone number, any limitations of service, and whether the provider is accepting new TRICARE patients) . For PRAV purposes, a provider directory entry will be considered accurate if all of the required elements in the directory match the information in the Contractor’s provider file and the provider agreement.

H.5.3.6. Claims Processing : the Government’s assessment/verification processes and desired PRAV performance levels for claims processing are as follows:

H.5.3.6.1. The Government team will conduct onsite assessment and verification of claims processing readiness at the Contractor’s claims processing facility during the PRAV. Claims processing activities will be evaluated for timeliness and accuracy, utilizing a Government-provided sample of 150-300 claim scenarios designed to test a multitude of claim conditions. The evaluation will consist of 3-5 cycles or batches of claims. Each cycle may be submitted on consecutive days. Each cycle after the initial one will include new test claims, as well as claims not completed or completed with errors during preceding cycles. At the Government’s discretion, any of the following aspects of claims processing may be tested:

receiving and sending electronic transactions, provider file development and maintenance, eligibility verification, coding, TRICARE Encounter Data (TED) record submission, translation of claims submitted in foreign languages, data entry, editing, pricing and payment methodologies, application of OHI and third party liability rules, data management, data linking, record building, and access control. The evaluation may be conducted on the Contractor’s production system(s) or an identical copy of the production system (i.e., test system). Since certain external systems and files (e.g., DEERS) are an integral component of accurate claims processing, the Contractor shall ensure that direct interface with any required external system is established and operational on the production or test system prior to the PRAV. Specific details regarding PRAV claims processing evaluation will be identified no later than 90 calendar days prior to the start of health care delivery.

H.5.3.6.2. For PRAV purposes, the Government will assess/verify the Contractor’s readiness to process claims accurately by comparing the Contractor’s actual performance as compared to the Government’s predetermined solutions for each test scenario. Accuracy will be measured for each scenario as either acceptable or non-acceptable. For PRAV purposes, the Government will assess/verify the contractor’s readiness to process claims in a timely manner by evaluating the Contractor’s actual performance in processing test claims within one business day of receipt. The date of receipt will not be counted in this

HT9402-14-R-0001 TRICARE OVERSEAS PROGRAM (TOP) PAGE 5 of 5 assessment. Claims that process with errors will be resubmitted to the Contractor for correction in a subsequent cycle; however, these claims will be excluded from PRAV performance level calculations.

Desired PRAV performance levels: 80% of test claims (excluding resubmissions) will be processed accurately within one business day of receipt, and 90% of test claims (excluding resubmissions) will be processed accurately by the conclusion of the PRAV.

H.5.3.7. Following the completion of the PRAV, the Government shall provide a summary outbriefing to the Contractor on the processes, results, and findings of all PRAV activities. Results will be briefed as assessed or verified performance against desired PRAV performance levels and contract standards and/or requirements. At the Government’s discretion, this briefing will be conducted onsite at one of the Contractor’s facilities on the final day of the PRAV, or via teleconference within 10 working days following the conclusion of the PRAV. If the Government chooses to provide an onsite briefing, the Contractor shall provide toll-free teleconference support to allow participation by all Government transition team members regardless of their location. The outbriefing schedule will incorporate adequate time for Contractor questions and feedback regarding any aspect of the PRAV.

H.5.3.8. If the Government determines that corrective actions are required as a result of the PRV/PRAV process, the CO will notify the contractor in writing of the performance readiness issues to be resolved prior to the start of health care delivery. Corrective actions that must be taken by the Contractor to correct performance readiness issues and reduce risk, resulting from Contractor actions, are the responsibility of the Contractor. This provision does not limit the Government’s right to take other contractual actions as appropriate to ensure the continued delivery of health care support services to TRICARE Overseas Program eligible beneficiaries.