HT9402-15-R-0001_Amendment_0001.pdf

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The following have been modified:

BLK 14 CONTINUATION

C. Summary of Changes:

Document Section/Paragraph # Change/Revision RFP Section A, SF 33 Blk 9 Revised the solicitation receive date from

April 20, 2015 to April 28, 2015.

RFP Section A, SF 33 Blk 10c Revised the email address.

RFP Section C, Paragraph C.2.6. Revised “through change 130” to “134” RFP Section C, Paragraph C.2.7. Revised “through change 141” to “143” RFP Section C, Paragraph C.3.3.4. Revised OCONUS Claims AQL from “95% within 14 business days of receipt” to “95% within 21 business days of receipt”

RFP Section C, Paragraph C.3.3.4. Clarified the Claims Payment Accuracy Standard and Claims Error Corrections Standard apply separately to both CONUS and OCONUS claims.

RFP Section C, Paragraph C.3.3.7. Revised language in Performance Standards

a) from “Non-priority” to “Routine”.

RFP Section G, Paragraph G.3.5. Removed (to be completed at award).

RFP Section H, Paragraph H.4.1.1. Revised paragraph from “primary residence” to “place of residence”.

RFP Section I, Page I11 Removed duplicate clause DFARS 252.232-

7003 from Section I; clause located in Section G.

RFP Section J, Attachment J-2 Revised #2-General Policies #8 from “90th percentile” to “95th percentile” for OCONUS payment allowances.

RFP Section J, Attachment J-5, Paragraph 8.4

Removed duplicative language and added reference to Section H.2 Liability and Indemnification.

RFP Section J, Attachment J-6a, Paragraph 7.0

Added reference to Attachment J-5, paragraph 8.

RFP Section J, Attachment J-6c Replaced sample OCONUS NARF with updated version which removes the implant requirement.

RFP Section J, Attachment J-10 Added “Military Rank” to the description of TDP Claims Data File Elements.

RFP Section J, Attachment J-15 Added clarification to # 1 TDP Eligibles Report, to state the report is the current number of eligibles that are not enrolled in the TDP.

RFP Section L, Paragraph L.4.1. Table Removed Reference to Wage Determinations or CBA’s (Section L.5.5.2.)

RFP Section L, Paragraph L.4.1. Table Revised Points of Contact Reference from Section G.1.3. to Section G.3.5.

RFP Section L, Paragraph L.4.3. Revised paragraph to include more descriptive language describing required proposal information.

RFP Section L, Paragraph L.4.4. Revised and added more descriptive language regarding page definitions.

RFP Section L, Paragraph L.5.5. Revised Point of Contact Reference from Section G.1.3. to Section G.3.5.

RFP Section L, Paragraph L.7.7. Revised paragraph to include first tier subcontractor(s).

RFP Section L, Paragraph L.7.11. Revised and added more descriptive language in regarding submissions.

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RFP Section M, Paragraph M.3.2. Revised the language and clarified that an offeror must be rated as “acceptable” in the small business participation factor in order to be eligible for award.

RFP Section M, Paragraph M.7.1. Added reference and clarified that an offeror must be rated as “acceptable” in the small business participation factor in order to be eligible for award.

RFP Section M, Paragraph M.7.2. Clarified language in regards to Small Business Goals.

RFP Section J, Exhibit A, CDRL M010 Revised language to include additional reporting requirements.

D. The solicitation is amended to reflect changes described herein; a conformed solicitation is provided as an attachment to this amendment. Changed areas in the conformed solicitation are indicated by a vertical line in the left margin, with the exception of J-6c Sample OCONUS Non-Availability and Referral Form and Instructions and CDRL M010, which were replaced in their entirety.

G. All other terms and conditions of the solicitation remain the same.

HT9402-15-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

DO-C9 1 92

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

JACK DIEMER 303

jack.r.diemer.civ@mail.mil

676-3664

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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)

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303-676-3675 todd.m.young.civ@mail.mil jdiemer Typewritten Text jdiemer Typewritten Text jdiemer Typewritten Text jdiemer Typewritten Text jdiemer Typewritten Text Mail Room jdiemer Typewritten Text jdiemer Typewritten Text See L.4.

jdiemer Typewritten Text jdiemer Typewritten Text jdiemer Typewritten Text April 28, 2015 jdiemer Typewritten Text 03/11/2015 jdiemer Typewritten Text jdiemer Typewritten Text jdiemer Typewritten Text jdiemer Line jdiemer Line

SECTION C

DESCRIPTION/SPECIFICATIONS/WORK STATEMENT

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C.1. MISSION

The Department of Defense (DoD) through the Defense Health Agency (DHA) has a mission to offer dental care services to eligible TRICARE beneficiaries. In order to fulfill DHA’s mission, the contractor shall provide comprehensive dental care services worldwide to eligible TRICARE beneficiaries under the TRICARE Dental Program (TDP).

C.1.2. Scope

The TDP offers worldwide coverage to all eligible family members of Uniformed Service active duty personnel and to members of the Selected Reserve and Individual Ready Reserve (IRR) and their eligible family members. The TDP geographic area of coverage for the Continental United States (CONUS) includes the 50 United States, the District of Columbia, Puerto Rico, Guam and the U.S. Virgin Islands. Outside the Continental United States (OCONUS) service area includes all other countries, island masses and territorial waters.

C.2. APPLICABLE DIRECTIVES

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. In the event of a conflict between the manuals and either statute and/or regulation, which are incorporated in to this contract, the statute and/or regulation takes precedence. When a statute, regulation, or manual changes, the contract requirements will not change until the Contracting Officer changes the contract by modification to the contract. 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. Where the TRICARE Manuals state "TRICARE Management Activity" or "TMA" it shall be understood that the name references mean the same as "Defense Health Agency" or

"DHA".

C.2.1. Title 10, United States Code (U.S.C.)., Chapter 55.

C.2.2. 32 CFR Part 199.3, 199.6, 199.9, 199.10 and 199.13.

C.2.3. 36 CFR Part 1222 (data created or received and maintained for the Government by contractors).

C.2.4. 45 CFR Parts 160, 162 and 164 (the Health Insurance Portability and Accountability Act of 1996 (HIPAA) security and privacy standards, transaction and code set standards, National Provider Identifier (NPI) requirements and implementation specifications).

C.2.5. National Institute of Standards and Technology (NIST) Special Publications (SP) 800-53 and 800-53A.

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C.2.6. TRICARE Policy Manual (TPM) 6010.57-M, February 1, 2008 (through change 134).

The following TPM Sections apply:

• Chapter 8, Section 13.1 Adjunctive Dental Care

• Chapter 8, Section 13.2 Dental Anesthesia

C.2.7. TRICARE Operations Manual (TOM) 6010.56-M, February 1, 2008 (through change 143). The following TOM chapters apply:

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

• Chapter 2, Records Management

• Chapter 11, Section 8 - Grievances and Grievance Processing

Addendum A TRICARE Logo

• Chapter 12, Appeals and Hearings

• Chapter 13, Program Integrity

• Chapter 14, Section 2 - Reports and Plans

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

• Chapter 24, Section 12 - TRICARE Overseas Program (TOP) Point of Contract (POC)

Program

• Appendix A, Acronyms and Abbreviations

• Appendix B, Definitions

C.2.8. TRICARE Systems Manual (TSM) 7950.2-M, February 1, 2008 (through change 73).

The following TSM chapters apply:

• Chapter 1, General Automated Data Processing (ADP) Requirements (Section 1.1, paragraphs 3.4, 3.5 through 3.5.1.7, and 6.0 do not apply to TDP. Paragraph 3.5.2 is optional. Paragraph 11.5.5 does not apply. See Attachment J-5 for further guidance.)

• Chapter 3, Defense Enrollment Eligibility Reporting System (DEERS) (Section 1.4 does not apply to TDP)

C.3. PERFORMANCE REQUIREMENTS

The following section specifies the performance objectives which must be achieved and related tasks for the contract.

C.3.1. The contractor shall sustain or increase enrollment percentage for eligible beneficiaries.

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C.3.1.1. The contractor shall offer multiple avenues of access for continuous and portable open enrollment. Minimum avenues of access will be telephone, paper, and on-line enrollment.

The definition for portable is members’ enrollment can transfer between active duty, Selected Reserve and IRR status (see Attachment J-3 and J-5).

Performance Standards

a) Standard: Enrollment actions shall be processed and monitored in accordance with the TSM Chapter 3, Section 1.5 and Section J, Attachment J-5.

Acceptable Quality Level (AQL): 99% of entries will be accurate and complete.

b) Standard: If an enrollment application and premium payment are received after the 20th day of the month, enrollment will begin on the first day of the second month after the month in which the contractor received the application.

AQL: 95% of applications will be processed timely.

Deliverables M010 Management Report M080 Enrollment and Fee Reconciliation Analysis Report Q030 Enrollment Activity Summary Report S050 Survivor Covered Lives and Utilization Report

C.3.1.2. The contractor shall inform and educate beneficiaries and providers about program benefits.

Performance Standards

a) Standard: The contractor shall comply with its education plan in accordance with Section J, Attachments J-5 and J-6a. Any deviations must be approved by the DHA Dental Care Office 30 calendar days prior to implementation.

Deliverables AP010 Beneficiary and Provider Education Plan R120 MOU with DHA Communications

C.3.2. The contractor shall increase utilization for diagnostic and preventive services.

C.3.2.1. The contractor shall educate beneficiaries about the benefit of utilizing diagnostic and preventive services.

Performance Standards

a) Standard: The contractor shall comply with its education plan in accordance with Section J, Attachments J-5 and J-6a. Any deviations must be approved by the DHA Dental Care Office 30 calendar days prior to implementation.

Deliverables S010 Utilization by Uniformed Services Active Duty (AD) Report

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S020 Utilization by Uniformed Services National Guard Reserve (NGR) Report AP010 Beneficiary and Provider Education Plan

C.3.2.2. The contractor shall educate sponsors/guardians about the benefits of utilizing dental services by one to four year olds.

Performance Standards

a) Standard: The contractor shall comply with its education plan in accordance with Section J, Attachments J-5 and J-6a. Any deviations must be approved by the DHA Dental Care Office 30 calendar days prior to implementation.

Deliverables S010 Utilization by Uniformed Services Active Duty (AD) Report S020 Utilization by Uniformed Services National Guard Reserve (NGR) Report AP010 Beneficiary and Provider Education Plan

C.3.3. The contractor shall provide cost-effective dental care services for enrollees.

C.3.3.1. The contractor shall comply with the most current version of American Dental Association's (ADA) Current Dental Terminology (CDT) manual for covered services and update their systems.

Performance Standards

a) Standard: Within 30 calendar days of the release of the new version, the contractor shall provide the DHA Dental Care Office with a synopsis of their recommended changes for Section J, Attachment J-2, including CDT codes to be added, deleted and/or updated.

AQL: The required recommendation will be submitted within 30 calendar days 100% of the time.

b) Standard: The contractor shall update their systems to reflect the DHA Dental Care Office’s approved CDT code changes no later than January 1st of the effective year.

AQL: System updates will be completed no later than January 1st 100% of the time.

C.3.3.2. The contractor shall provide and maintain access to general and specialty network providers for enrollees.

Performance Standards

a) Standard: The contractor shall establish networks for general dental care in the United States, the District of Columbia, Puerto Rico, Guam and the U.S. Virgin Islands in accordance with 32 CFR 199.13 and Section J, Attachment J-5.

AQL: 95% of enrollees shall have access to a general dentist within 35 driving miles of their place of residence and 21 days of requesting an appointment.

b) Standard: The contractor shall develop, maintain and make available to enrollees, providers and Government representatives an up-to-date list of network providers. This list shall be

HT9402-15-R-0001 Page C5 of C13 Amendment 0001 updated monthly at a minimum. The contractor shall post a provider list on the contractor’s Web site that will allow for searches by multiple criteria.

Deliverables M030 Provider Network Access Report

C.3.3.3. The contractor shall develop agreements with TRICARE OCONUS Preferred Dentists (TOPDs).

Performance Standards

a) Standard: The contractor shall complete agreements with existing providers identified by the Government and for any new providers identified each option period in accordance with Section J, Attachment J-6a.

AQL: The contractor shall complete agreements with 95% of those existing providers identified and any new providers identified each option period.

b)Standard: The contractor shall maintain and make available to enrollees, providers and Government representatives an up-to-date list of TOPDs in accordance with Section J, Attachment J-6a. This list shall be updated monthly at a minimum.

Deliverables M010 Management Report Q040 OCONUS Utilization by Provider Location Report Q050 Location of TRICARE OCONUS Preferred Dentist (TOPD) Agreements

C.3.3.4. The contractor shall process claims to completion for enrollees and providers.

Process to completion is defined in the TOM, Appendix B. Not less than 60 days prior to the start work date, the contractor shall provide the DHA Dental Care Office a copy of the definition and methodology employed for computing claims payment accuracy.

Performance Standards

a) Standard: Process claims to completion in accordance with Section J, Attachments J-5 and J- 6a.

AQL: CONUS Claims 95% within 14 business days of receipt 98% within 30 business days of receipt 100% within 60 business days of receipt

OCONUS Claims 95% within 21 business days of receipt 98% within 30 business days of receipt 100% within 60 business days of receipt

b) Standard: Claim Payment Accuracy in accordance with Section J, Attachments, J-2, J-5 and J- 6a. This standard applies separately to CONUS and OCONUS claims (i.e. not combined).

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AQL: 97% are accurately paid

c) Standard: Claims errors shall be corrected within 10 calendar days of identification of the error. This standard applies separately to CONUS and OCONUS claims (i.e. not combined).

AQL: 99% are corrected

Deliverables M010 Management Report M040 OCONUS Payment Report M060 Worldwide Incurred/Paid Claims Report Q060 OCONUS Denied Services Report S010 Utilization Report by Uniformed Services AD S020 Utilization Report by Uniformed Service NGR S030 Utilization Report CONUS/OCONUS Frequency & Dollar S040 Utilization Report CONUS/OCONUS Denied Services S050 Survivor Covered Lives and Utilization Report A010 Average Allowed Charges Report

C.3.3.5. The contractor shall process appeals to completion for enrollees and providers.

a) Standard: Appeals shall be processed in accordance with 32 CFR 199.22(k) and the TOM, Chapter 12 (Use Section J, Attachment J-9 in place of Figure 12.A-2 of the TOM).

b) Standard: The contractor shall process non-expedited medical necessity and factual reconsiderations to completion.

AQL: 95% within 60 calendar days of receipt 100% within 90 calendar days of receipt

c) Standard: The contractor shall process to completion determinations reversed by appeals.

AQL: 100% within 21 calendar days of receipt

Deliverables M020 Appeals Report R140 Appeals Processing Guidelines, Desk Instructions and Reference Materials

C.3.3.6. The contractor shall process grievances to completion for enrollees and providers.

a) Standard: The contractor shall process grievances to completion in accordance with the TOM, Chapter 11, Section 8.

AQL: 95% within 60 calendar days of receipt

Deliverables M010 Management Report

C.3.3.7. The contractor shall provide readily accessible comprehensive customer service for beneficiaries and providers.

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Performance Standards

a) Standard: The contractor shall provide customer service in accordance with Section J, Attachment J-5.

AQL: Telephone answered by Automated Response Unit - 100% 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 Call Resolution - 80% during the initial call; 99.9% within 3 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.

Routine Written and E-mail Correspondence - 85% within 10 business days; 99.9% within 25 business days.

b) Standard: The contractor shall maintain overall customer satisfaction with TDP. The measurement will be based on the annual average of the quarterly customer satisfaction phone surveys conducted by DHA, Defense Health Cost Assessment and Program Evaluation (DHCAPE). The results will be provided to the contractor within 30 calendar days of completing each of the quarterly surveys.

AQL: At least 95% of those surveyed will indicate that, overall, they are at a minimum “somewhat satisfied”.

Deliverables M010 Management Report

C.3.3.8. The contractor shall process orthodontic treatment plan reviews to completion.

This requirement applies only if CLINs X010 and/or X011 are exercised.

a) Standard: Orthodontic treatment plan reviews shall be processed to completion in accordance with Section J, Attachment J-12.

AQL: 95% processed to completion within 10 business days of receipt.

Deliverables M010 Management Report

C.4. Additional Requirements

The following sub-sections provide details of additional requirements for this contract.

C.4.1. System Security

The contractor shall acquire, develop and maintain processes for safeguarding unclassified sensitive DoD information on all contractor/subcontractor systems/networks that store, process or access Government sensitive information in accordance with TSM, Chapter 1, Section 1.1 and Section J, Attachment J-5. The contractor shall implement a minimum level of enhanced

HT9402-15-R-0001 Page C8 of C13 Amendment 0001 safeguarding for unclassified DoD information as defined in the NIST SP 800-53 and 53A, Privacy Act Program Requirements (DoD 5400.11-R), and the Personnel Security Program (DoD 5200.2-R). Government acknowledgement of the contractor's Annual Checklist and Certification for Minimum Level of Enhanced Safeguarding for Unclassified DoD Information (also known as the "Checklist") is required prior to accessing DoD data or interconnectivity with the Government system and testing.

Deliverables M090 Employee Access to DoD IS/Networks Report A050 NIST Certification of Compliance Report A070 Disaster Recovery Test Results Report AP020 Continuity of Operations Plan (COOP) R130 Privacy Impact Assessment

C.4.2. Health Insurance Portability and Accountability Act (HIPAA).

The contractor shall comply with the HIPAA requirements of TOM, Chapter 19.

Deliverables M050 HIPAA/Privacy Complaint Report A060 Risk Assessment Letter of Assurance

R010 Breach Report R080 Designated Standards Maintenance Organization (DSMO) Meeting Summary Report

C.4.3. Transition

The transition-in, transition-out and phase-out of this contract will be conducted according to the requirements stated in Section J, Attachment J-11.

Deliverables W010 Transition-In Status Report W020 Transition-Out and Phase-Out Status Report R030 Transition-In Plan R040 Transition-Out and Phase-Out Plan

C.4.4. Government Furnished Information

C.4.4.1. The Government will furnish an electronic flat file listing of the names and addresses of all known sponsors. The electronic flat file listing will be provided to the contractor no later than the date initial education materials are approved. The contractor must comply with the security requirements stated in C.4.1 prior to receiving the data. Thereafter, a list of newly identified sponsors will be furnished quarterly every Option Period.

C.4.4.2. The Government will provide the contractor the appropriate application software required to access the Defense Manpower Data Center's (DMDC) Defense Eligibility Enrollment

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Reporting System (DEERS) to perform eligibility inquiries and enrollments. The Government will grant the contractor access to DEERS only after the contractor's staff and all subcontractors' staff, that utilize systems which access and maintain TDP data, are compliant with the safeguarding methods for unclassified DoD information, personnel security and clearance requirements stated in C.4.1. The contractor and its subcontractors must be in compliance with C.4.1, no later than 120 days after award.

C.4.4.3. The Government will print and provide to the contractor educational documents as identified in Section J, Attachment J-5.

C.4.5. Records Management

All contractor records generated under this contract shall be maintained in accordance with 36 CFR 1222 and the TOM, Chapter 2.

C.4.6. Management Strategies.

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. The contractor shall comply with the management guidance in the TOM, Chapter 1, Sections 1, 2 (excluding paragraphs 4.0 and 5.0), 4 (excluding paragraphs 2.2, 2.3, 2.4, 3.1, 3.2,3.4 and 4.0), 5, and 6.

Deliverables A040 Proposed Freedom of Information Act (FOIA) Releasable Contract R020 Identification of Systems of Records Report

C.4.7. Quality

The following sub-sections provide details of the quality control components of this contract.

C.4.7.1. Quality Control Program (QCP)

C.4.7.1.1. The contractor shall develop and implement a QCP in accordance with the TOM, Chapter 1, Section 4 (excluding paragraph 2.2, 2.3, 2.4, 3.1, 3.2, 3.4 and 4.0). The contractor shall maintain a QCP that ensures that services are performed in accordance with the contract.

The contractor shall develop and implement procedures to identify, prevent, and correct problems for the duration of the contract.

Deliverables Q010 Quality Control Program (QCP) Report AP30 Quality Control Program (QCP) Plan

C.4.7.1.2. The contractor shall also provide a Web based dental health plan report card that monitors outcome measures for the program. This report card will, at a minimum, monitor access and satisfaction, use of services, effectiveness of care, utilization, membership, utilization

HT9402-15-R-0001 Page C10 of C13 Amendment 0001 of prophylaxes of pregnant and diabetic enrollees, utilization of scaling and root planning of diabetic enrollees, and utilization of the dental accident coverage. The data will be updated on a monthly basis and summarized quarterly.

Deliverables M100 Dental Health Plan Report Card

C.4.7.2. Quality Assurance Surveillance Plan (QASP)

The Government shall monitor the contractors’ performance under this contract in accordance with the Government’s QASP.

C.4.8. Disaster Action Plan

The contractor shall develop a Disaster Action Plan to be implemented when the President of the United States declares an area of the United States or any U.S. territory with a provider network to be a "National Disaster Area" (see Section J, Attachment J-5).

Deliverables R050 National Disaster Action Report

C.4.9. Fraud and Abuse

C.4.9.1. The contractor shall implement a Fraud and Abuse program in accordance with TOM, Chapter 13.

Deliverables Q020 Fraud and Abuse Summary Report A020 Letter of Assurance (Internal Management Control Reviews) A030 OCONUS Summary Report AP040 Fraud Detection and Prevention Strategy and Internal Procedures Plan R060 Terrorist/Beneficiary/Provider Threats Report R070 Free Commerce Interference Report R100 Standard Operating Procedures (Desk Procedures)

C.4.9.2. Potential Fraud and Abuse Cases. The contractor shall refer to DHA any potential case that involves more than a $10,000 loss to the Government and any case involving any loss where patient harm has occurred. See TOM, Chapter 13, Section 2 for further requirements.

C.4.9.3. Post Payment Utilization Reviews. When performing post payment utilization reviews, the contractor shall consider high volume beneficiaries as those beneficiaries whose charges exceed $25,000 during a 12 month reporting period. High volume providers are considered institutional providers whose payments exceed $750,000; individual providers whose payments exceed $100,000; group/clinics whose payments exceed $100,000 (the threshold average is $25,000 per professional provider within the group) during a 12 month reporting period. See TOM, Chapter 13, Section 4 for further requirements.

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C.4.10. Required Data

C.4.10.1. The contractor shall provide the Government with read-only access to their full TDP data set with download capability for data manipulation purposes. Access shall be on-line, and as near real-time as possible. The data set shall include, but not be limited to network providers, non-network providers, enrollment information, claims processing, claims payment, enrollee care and service data. Access is required for the DHA Dental Care Office, Contracting Officer, Contract Specialist, Contracting Officer’s Representative, and the Tri-Service Center for Oral Health Studies (TSCOHS), for a total of 10-15 user accounts.

C.4.10.1.1. The contractor shall train (initial and refresher) and provide secure means for the POCs 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.4.10.2. The contractor shall work with the Government during transition on the report formats (see Section J, Exhibit A). The contractor shall work with the Government to fully describe the format/data elements (i.e., field descriptions, field lengths, list of allowed entries for each field) to be used for each report and to build/test the reports to be forwarded to the Government.

During the term of the contract the Government may require additional changes to the makeup of these reports (e.g., add or delete data elements or change the format) and the contractor shall implement these changes at no change to the contract price.

C.4.10.3. Military Health System (MHS) Data Repository (MDR). The contractor shall work with the DHA Dental Care Office and DHA, Defense Health Services Systems (DHSS) in developing a TDP Interface Control Document (ICD) describing the data exchange to the MDR.

The purpose of the TDP ICD is to describe the interface that provides the TDP records from the contractor's automated information systems in support of the TDP.

C.4.10.3.1. The contractor shall submit the claims and provider data in accordance with the ICD and Section J, Attachment J-10.

Deliverables M070 MDR Data Claims and Provider Files

C.4.10.3.2. The contractor shall protect the data in accordance with the C2-level protection standards mandated for all "Sensitive Unclassified Systems" as required in the DoD Directive

5200.28 since the data exchanged in this interface contains protected patient level identifiable information and the aggregate data being transmitted by DHSS becomes part of a database that contains sensitive data.

C.4.10.3.3. The contractor shall perform validation checks such as record counts, file formats, source stamps, and date-time stamps on data transferred from the contractor to the MDR as defined in the MDR ICD. When errors are discovered in the data exchange, the contractor will

HT9402-15-R-0001 Page C12 of C13 Amendment 0001 be notified immediately by DHSS operations personnel. If there are systemic problems, Interface Working Group (IWG) counterparts will be contacted by DHSS to work the issues.

C.4.10.4. If data submission mistakes are discovered (e.g., the manner in which the data is submitted leads to incorrect data reporting) during the term of the contract, the contractor shall correct the mistakes within 30 calendar days of notification.

C.4.11. Special Request Reports.

C.4.11.1. Ad Hoc Reports. The Government may request the contractor to submit up to four ad hoc reports per option period at no additional cost.

Deliverables R090 Ad Hoc Management Reports

C.4.11.2. Consolidated Historical Data File. The Government may request the contractor to submit a historical data file up to two times over the life of the contract.

Deliverables R110 Consolidated TDP Historical Data File

C.4.12. Government and Contractor Visits/Meetings

Generally, a 14 calendar day notice will be provided for all meetings hosted by DHA, at one of its Government locations. These meetings are in addition to those stated Section J, Attachment J-11. All contractor travel costs associated with any of these meetings shall be the responsibility of the contractor.

C 4.13. Proper Identification of Contractor Personnel

C.4.13.1. Contractors, including subcontractors at all tiers, shall provide for a clear distinction from Government personnel. Contractor employees shall not act, advertise, or presume to be Government employees, agents, or representatives. Contractor employees are required to appropriately identify themselves as contractor employees at all times, including in telephone conversations, formal and informal written correspondence, paper and electronic, and in any other situation where their actions could be construed as acts of Government officials, unless, in the judgment of the Government, no harm can come from failing to identify themselves.

Contractor employees shall be introduced as contractor personnel and display distinguishing visible identification at all times whether in conversations, meetings, or other forms of communication with Government personnel.

C.4.13.2. Contractor personnel, while performing in a contractor capacity, shall refrain from using their retired or reserve component military rank or title (if applicable) in written or verbal communications associated with the contracts for which they provide services.

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C.4.13.3. The Contractor shall incorporate the substance of this requirement in all subcontracts awarded under this contract.

C.5. Reports and Plans

The contractor shall provide all reports and plans in accordance with Section F.5.

(End of Section)

SECTION G

CONTRACT ADMINISTRATION DATA

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G.1. DFARS 252.204-7006 BILLING INSTRUCTIONS (OCT 2005)

When submitting a request for payment, the Contractor shall—

(a) Identify the contract line item(s) on the payment request that reasonably reflect contract work performance; and

(b) Separately identify a payment amount for each contract line item included in the payment request.`

(End of clause)

G.2. DFARS 252.232-7003 ELECTRONIC SUBMISSION OF PAYMENT REQUESTS

AND RECEIVING REPORTS (JUN 2012)

(a) Definitions. As used in this clause—

(1) “Contract financing payment” and “invoice payment” have the meanings given in section 32.001 of the Federal Acquisition Regulation.

(2) “Electronic form” means any automated system that transmits information electronically from the initiating system to all affected systems. Facsimile, e-mail, and scanned documents are not acceptable electronic forms for submission of payment requests. However, scanned documents are acceptable when they are part of a submission of a payment request made using Wide Area WorkFlow (WAWF) or another electronic form authorized by the Contracting Officer.

(3) “Payment request” means any request for contract financing payment or invoice payment submitted by the Contractor under this contract.

(4) “Receiving report” means the data required by the clause at 252.246-7000, Material Inspection and Receiving Report.

(b) Except as provided in paragraph (c) of this clause, the Contractor shall submit payment requests and receiving reports using WAWF, in one of the following electronic formats that WAWF accepts: Electronic Data Interchange, Secure File Transfer Protocol, or World Wide Web input. Information regarding WAWF is available on the Internet at https://wawf.eb.mil/.

(c) The Contractor may submit a payment request and receiving report using other than WAWF only when—

(1) The Contracting Officer administering the contract for payment has determined, in writing, that electronic submission would be unduly burdensome to the Contractor. In such cases, the Contractor shall include a copy of the Contracting Officer’s determination with each request for payment;

http://www.acq.osd.mil/dpap/dars/dfars/html/current/252246.htm https://wawf.eb.mil/

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(2) DoD makes payment for commercial transportation services provided under a Government rate tender or a contract for transportation services using a DoD-approved electronic third party payment system or other exempted vendor payment/invoicing system (e.g., PowerTrack, Transportation Financial Management System, and Cargo and Billing System);

(3) DoD makes payment for rendered health care services using the TRICARE Encounter Data System (TEDS) as the electronic format; or

(4) When the Governmentwide commercial purchase card is used as the method of payment, only submission of the receiving report in electronic form is required.

(d) The Contractor shall submit any non-electronic payment requests using the method or methods specified in Section G of the contract.

(e) In addition to the requirements of this clause, the Contractor shall meet the requirements of the appropriate payment clauses in this contract when submitting payment requests.

(End of clause)

G.3. CONTRACT ADMINISTRATION

G.3.1. The Procuring Contracting Officer (PCO) is responsible for the administration of this contract and is solely authorized to take action on behalf of the Government. Unless specified otherwise within this contract, the PCO is referred to as the Contracting Officer (CO).

G.3.2. Administrative Contracting Officer (ACO): Defense Contract Management Agency (DCMA) ACO. The CO will delegate a limited number of functions listed in FAR 42 to the DCMA ACO. The contractor will be provided copies of all delegation letters.

G.3.3. Defense Contract Audit Agency (DCAA) will provide certain audit functions in support of the CO and ACO.

G.3.4. Contracting Officer’s Representative (COR): The CO will designate a COR in writing and provide a copy of the designation letter to the contractor. The designation letter will delineate the scope of authority of the COR to act on behalf of the CO. The COR has no authority to make any commitments or changes that affect any term or condition of the contract.

G.3.5. Contractor Points of Contact Personnel: The names and addresses of the contractor’s primary and alternate point of contact (POC) for contract implementation and compliance are as follows:

Primary:

Company Name:

Address:

Telephone:

FAX:

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Alternate:

Company Name:

Address:

Telephone:

FAX:

G.3.6. Paying Office.

Department of Defense Defense Health Agency ATTN: Contract Resource Management (CRM) 16401 E. Centretech Parkway Aurora, CO 80011-9066

G.4. ENROLLEE PREMIUM COLLECTION.

G.4.1. Active Duty Enrollees. The Government will collect the enrollee's share of the premium through a Uniformed Services Finance Center for the enrollee’s family members, if sufficient funds are available at the time of collection.

G.4.2. Reserve Enrollees. Reserve enrollees on plans where the Government pays a portion of the premium, may choose to have the Government collect their premium share and remit to the contractor if there is a payroll account and if sufficient funds are available at the time of collection. Alternatively, the enrollee may choose to have the contractor direct bill them.

Reserve enrollees that are on plans where they pay 100% of the premium may only pay the premium through the direct bill method that is described in G.4.3.1.

G.4.2.1. Partial-month premiums will not be collected from the previously enrolled Selected Reserve and IRR members newly released from active duty, nor will the payment be made by the Government for the partial month coverage period. The last full month premium paid to the contractor for coverage during the month the member status changed to active duty will be deemed to apply to the partial month re-enrollment period. When the contractor receives the re-enrollment notification from DEERS, the contractor is required to notify the member of the premium payment amount that is owed and re-establish the premium collection process to be used to collect the member’s portion of the premium payment.

G.4.3. Enrollees shall not be required to pay more than one month's premium in a single payment, except for retroactive periods of enrollment. If the enrollee fails to pay premiums or disenrolls for an invalid reason, the Government will not pay any portion of the premium (Government or enrollee share) for the remaining months. If it is determined that an enrollee has been erroneously disenrolled, the contractor shall process retroactive enrollments and apply the correct premiums. Once an enrollee begins a payroll allotment through a Uniformed Service Finance Center, the enrollee cannot stop it during the 12-month period, except for a valid disenrollment reason.

G.4.3.1. Contractor Direct Billing. If there are insufficient funds or no payroll account is available at the time of collection, premium costs will be paid by the enrollee by means of the direct payment (or "direct bill") method by or on behalf of the enrollee. When this occurs, the premium collection will migrate from the Uniformed Service Finance Center payroll allotment or

HT9402-15-R-0001 Page G4 of G5 Amendment 0001 deduction to the direct payment method and the contractor shall allow at least a 30 day grace period before consideration for disenrollment. The contractor shall use its best business practices in establishing the date the grace period begins. The contractor shall immediately direct bill for premiums due from IRR members and IRR and Selected Reserve family members.

G.4.3.2. Uniformed Services Finance Centers and DHA Interface. The contractor shall interface with the Uniformed Services Finance Centers through the MHS B2B Gateway as described in TSM Chapter 1 and Section J, Attachment J-5. The files transmitted between the contractor and the finance centers will be in accordance with the TDP Finance File Layouts and Communication Protocols. The contractor shall notify the Uniformed Services Finance Center when a payroll allotment or deduction is initiated, changed or terminated as a result of information received from the sponsor or DEERS. The contractor’s Uniformed Services Finance Center interfaces shall be ready to begin testing approximately 30 days after the Government’s acknowledgement of the contractor's Annual Checklist and Certification for Minimum Level of Enhanced Safeguarding for Unclassified DoD Information (also known as the "Checklist") (see Exhibit A, CDRL A050).

G.4.3.3. Payment of the Government Share of the Monthly Premium. To invoice for payment of the Government share, the contractor shall submit a proper invoice as required by the Contracting Officer. The original invoice shall be submitted electronically to the disbursing office (DHA – Contract Resource Management) with copies furnished to the CO and COR. The amount invoiced shall be the actual enrollment figures for that month, plus any retroactive enrollments and adjustments for retro-disenrollments. The COR will provide the actual enrollment figures within ten working days after the first of each month to the contractor based on enrollment information resident in DEERS, the Government's database of record. The contractor shall not report to the Government for payment any enrollee who has lost coverage due to failure to pay his/her share of the monthly premium, has disenrolled or who is no longer eligible in DEERS. The contractor shall coordinate the proper format for the invoice with the CO prior to the first voucher cycle. The proper monthly invoice will include the following line items:

• Single Enrollment Premiums (CLIN X001)

• Family Enrollment Premiums (CLIN X002)

• Survivor Benefit - Single Enrollment Premiums (CLIN X003)

• Survivor Benefit - Family Enrollment Premiums (CLIN X004)

G.4.3.4. Release of the Government Held Enrollee Share of the Monthly Premium (Payroll Deductions). For those premium shares that have been withheld from the active duty and Selected Reserve member's pay, the Government shall render payment on a monthly basis via Electronic Funds Transfer (EFT). Information required by which to establish the EFT shall be submitted to the Uniformed Services Finance Center, no later than seven months prior to the start work date of the contract.

G.5. PAYMENT FOR REIMBURSEMENT FOR COSTS IN EXCESS OF ALLOWABLE

CHARGES FOR OCONUS CLAIMS (CLIN X005); REIMBURSEMENT FOR COST

SHARES AND ADDITIONAL ALLOWABLE CHARGES FOR ORTHODONTIC

COSTS CHARGE FOR OCONUS CLAIMS (CLIN X006); TRANSITION-IN (CLINs 0001 and 0002); NIST AND PHYSICAL & PERSONNEL SECURITY (CLIN X007);

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INCENTIVES (CLIN X008); TRANSITION-OUT (CLIN X012); PHASE-OUT (CLIN

600X).

G.5.1. For all invoices, the original invoice shall be submitted to the disbursing office (DHA – Contract Resource Management) with copies furnished to the CO and COR. The contractor shall submit a proper invoice as required by the CO on a monthly basis to invoice for the following line items:

• Reimbursement for Costs in Excess of Allowable Charges for OCONUS Claims (CLIN X005) (must include itemized supporting documentation)

• Reimbursement for Cost Shares and Additional Allowable Charges for Orthodontic Costs for OCONUS Claims (CLIN X006) (must include itemized supporting documentation)

• NIST and Physical & Personnel Security (CLIN X007)

G.5.2. For reimbursement of OCONUS balance billed amounts (see Section J, Attachments J-6a and J-6b), the contractor shall specify the amounts owed by the Government by enrollee name, sponsor SSN, date of service, and amount owed. The contractor shall further specify any amounts improperly or erroneously paid by the Government that are being offset from the invoice by enrollee name, sponsor SSN, date of service, and amount owed. These amounts shall be offset on the next invoice following identification of the improper or erroneous payment. The contractor has the option to pursue recoupment of any improper or erroneous payments regardless of the reason for the payment. The reimbursable amount shall not include any other costs other than the balance billed amount. It shall not include any direct costs, indirect costs or profit/fee as these costs are in the premiums.

G.5.3. For reimbursement of OCONUS orthodontic costs and certain specified cost shares (see Section J, Attachment J-6, the contractor shall specify the amounts owed by the Government by enrollee name, sponsor SSN, date of service, and amount owed. The contractor shall further specify any amounts improperly or erroneously paid by the Government that are being offset from the invoice by enrollee name, sponsor SSN, date of service, and amount owed. These amounts shall be offset on the next invoice following identification of the improper or erroneous payment.

G.5.4. The contractor shall submit a proper invoice as required by the CO after completion of the tasks for each of the following prescribed line items:

• Phase-In (CLINs 0001 & 0002)

• Transition-Out (CLIN X0012)

• Phase-Out (CLIN 600X)

G.5.5. PAYMENT FOR INCENTIVES (CLIN X008). Upon notification by the CO that a determination has been made that the contractor has earned an incentive, the contractor may invoice for the amount authorized by the CO (see Sections H.3).

SECTION H

SPECIAL CONTRACT REQUIREMENTS

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H.1. PAYMENT OF FOREIGN TAXES

Foreign taxes are not preempted under the preemption language contained within 32 CFR 199.13(a)(4). There is the possibility that foreign governments or other individuals may separately bill the contractor for OCONUS claims payments or include foreign taxes in the billed charge.

H.2. LIABILITY AND INDEMNIFICATION

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

H.3. POSITIVE…