Projected_Transition_Changes.pdf

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1.1. Integrated Master Plan (IMP) and Integrated Master Schedule (IMS)1

1.1.1. The contractor shall submit an IMP and IMS in accordance with contract data requirements list (CDRL) requirements to allow Government oversight of transition progress. The contractor’s IMP shall demonstrate that the contract transition is structured to provide a balanced technical approach, to minimize and control risk, to accomplish up-front summary planning and commitment, and to provide a basis for subsequent detailed planning. The IMP shall include milestones and measurable indicators that can be used to evaluate the contractor’s satisfactory progress toward being fully capable of delivering healthcare services on the first day of healthcare.

1.1.2. The IMP/IMS shall address all processes and interdependencies associated with the provision of services to TRICARE beneficiaries. Interdependencies may include data such as exchanges, interfaces, and documents, from the outgoing contractor and other entities, e.g., Defense Manpower Data Center (DMDC) and Military Treatment Facilities (MTFs).

1.1.3. The contractor shall identify an individual responsible for transition management who will serve as the single point of contact for the Government for all transition activities. This individual will be the overall coordination point for the management of the Integrated Master Plan (IMP) and Integrated Master Schedule (IMS) and coordinate and integrate interdependencies with the outgoing contractor and other entities associated with the transition of the contract.

1.1.4. The IMP shall include the contractor’s in-process verification approaches. The IMP shall provide the government the ability to validate progress in order to make informed decisions. If multiple tasks are combined and identified in the IMP as a single event, sufficient detail shall be provided to clearly identify all subtasks related to the single action.

1.1.5. The contractor’s IMP/IMS will address the contractor’s plan to mitigate identified risks.

The IMP shall be supported by a Risk Management Plan (RMP) that identifies risks to the successful execution of the contractor’s IMP, to include risks resulting from interdependencies on activities by other parties associated with the Transition. The IMP shall include a Risk Management Strategy that clearly demonstrates how the contractor plans to mitigate risks identified in the RMP.

1.1.6. The IMP/IMS shall include a subsection specific to Information Systems (IS). The IS subsection shall identify the management process and schedule to be used to develop and implement all IS, technical interfaces and security protocols. At a minimum, the subsection shall include contractor developed systems/applications, contractor and government security, connectivity with all government interfaces and applications and

1 Department of Defense, Integrated Master Plan and Integrated Master Schedule Preparation and User Guide, Version 9, October 21, 2005 Defense Acquisition University (www.DAU.mil).

T2017 Transition Updates Page 2 testing. The IS subsection shall be maintained and updated as appropriate to reflect changes to development and implementation of IS.

1.1.6.1. The contractor shall coordinate data conversion and testing activities with the government and submit required documents within the timeframes established during integration/testing meetings, i.e. Test Plan, and Test Scenarios as indicated in the IMP/IMS, but no later than 30 days following the Systems Integration Interface Meeting.

1.1.7. The IMP/IMS shall include a subsection that provides a staffing plan that delineates the hiring and training schedule of employees relevant to the stand-up of the contractor’s responsibilities. The Plan and Schedule should be incorporated into the contractor’s IMP/IMS. The training schedule should be developed in order to ensure staff is trained with the requisite knowledge to perform the responsibilities of their position.

1.2. Contractor Weekly Status Reporting

1.2.1. The contractor shall provide a weekly status report of IMP/IMS providing transition schedule progress, identifying schedule modifications and impacts, in accordance with the CDRL. The contractor shall document meetings with formal minutes and submit them in accordance with the CDRL.

2. CRITICAL PROCESSES

2.1. The critical processes are identified for each of the seven key focus areas as defined by the managed care support contract to ensure increased oversight and management during transition. The critical processes identified, beginning with 2.3., are not listed in any order or priority and shall be managed along with all other contract and manual requirements.

2.2. Verification and Validation

2.2.1. Verification: During the transition period the contractor shall verify critical processes are functioning correctly prior to the health care start date and meet Government milestones.

The contractor’s verification methodology and schedule shall be incorporated into the IMP/IMS. Verification may be accomplished by any one or a combination of the following methods:

2.2.1.1.1. Demonstration: The performance of operations at the process/system level where visual observations are the primary means of verification.

Demonstration is used when quantitative assurance is not required for verification of the requirements.

2.2.1.1.2. Examination : The visual inspection of processes, equipment and evaluation of plans used to verify conformance with requirements.

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2.2.1.1.3. Analysis : The use of recognized analytic techniques (including computer models) to interpret or explain the behavior/performance of the system/processes. Analysis of test data or review and analysis of design data shall be used as appropriate measures to verify requirements.

2.2.1.1.4. Test: An activity designed to provide data on functional features and the operation of equipment under fully controlled and traceable conditions. The end data is subsequently used to evaluate quantitative characteristics of functionality and operation of equipment.

2.2.2. Validation: Validation consists of government subject matter experts evaluating the operational effectiveness, operational suitability, sustainability of the contractor’s critical processes using the results of the contractor’s verification processes. Prior to the start of health care delivery (SHCD), the government will validate the results of the contractor’s verification methodologies to assess the contractor’s readiness in accordance with the specific requirements of the critical processes.

2.3. Provider Networks

2.3.1. The contractor shall establish an adequate network of providers in accordance with access standards outlined in TOM Chapter 5, Section 1 and 45 CFR 156.230, with minimal impact to beneficiaries. Provider network development shall be completed no later than 30 days prior to SHCD. The contractor shall establish an adequate network of providers for PSAs in the Region. For the purposes of assessing adequacy, standards shall apply to all PSAs in the Region.

2.3.2. The contractor shall ensure accurate and complete provider information is entered into contractor and government automated provider files that interface directly with the Defense Enrollment and Eligibility Reporting System (DEERS), contractor medical management systems, and supporting medical management systems identified by the government not later than 30 days prior to SHCD.

2.3.2.1. Provider information for PCM/BH care providers shall be entered in the automated provider file to ensure the following thresholds are accomplished within the timeframes indicated:

2.3.2.1.1. 50% of PCM/BH care providers entered no later than 120 days prior to

SHCD.

2.3.2.1.2. 75% of PCM/BH care providers entered no later than 90 days prior to

SHCD.

2.3.2.1.3. 100% of PCM/BH care providers entered no later than 60 days prior to

2.3.2.2. Verification and Validation

2.3.2.2.1. The contractor shall verify they meet the thresholds specified in section 2.3.2.1.

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2.3.2.2.2. The contractor’s entry of PCM/BH care providers shall be validated to ensure thresholds specified in 2.3.2.1. are met.

2.3.2.3. Provider information for specialty providers and health care facilities shall be entered in the automated provider file to ensure the following thresholds are accomplished within the timeframes indicated.

2.3.2.3.1. 50% of specialty care providers and health care facilities entered no later than 90 days prior to SHCD.

2.3.2.3.2. 75% of specialty care providers and health care facilities entered no later than 60 days prior to SHCD.

2.3.2.3.3. 100% of specialty care providers and health care facilities entered no later than 30 days prior to SHCD.

2.3.2.4. Verification and Validation:

2.3.2.4.1. The contractor shall verify they meet the thresholds specified in section 2.3.2.3.

2.3.2.4.2. The contractor’s entry of specialty care providers shall be validated to ensure the thresholds specified in 2.3.2.3. are met.

2.3.3. The contractor shall develop and maintain a real-time, on-line directory of network providers in accordance with Section C of the contract. The provider directory shall reflect accurate and current information specific to each provider.

2.3.3.1. The provider directory shall be on-line and available 120 days prior to the

2.3.3.2. The contractor shall demonstrate electronic access is available for beneficiaries no later than 30 days prior to the SHCD.

2.3.3.3. Verification and Validation: The contractor’s on-line directory will be validated for compliance with accuracy standards as specified in Section C of the contract.

2.4. Enrollment

2.4.1. The contractor shall have an enrollment system that supports all enrollment related activities, i.e., DEERS enrollment applications, and MTF enrollment guidelines.

2.4.1.1. The enrollment system shall meet all TSM requirements, including at a minimum, the following:

• Meet all system access requirements

• Ensure installation of all hardware

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• Ensure loading of all software

• Ensure completion of all required forms

• Interface with government systems

2.4.1.2. The enrollment system shall be fully operational 60 days prior to the SHCD.

2.4.1.3. Verification and Validation

2.4.1.3.1. For validation purposes, 60 days prior to the SHCD, the contractor will demonstrate they can accurately perform enrollments according to contract standards in the TSM, Chapter 3 and the TOM, Chapter 6.

2.5. Customer Service

2.5.1. The contractor shall operate call centers that will provide accurate and timely responses to TRICARE customers in accordance with TOM Chapter 1, Section 3.

2.5.1.1. The contractor shall begin demonstrating call center capabilities no later than 120 days prior to SHCD, and shall continue to demonstrate call center capabilities until full operating capability is reached. The contractor’s TRICARE call center capability shall be satisfactorily operational no later than 60 days prior to SHCD.

2.5.1.2. Training documents and response scripts shall be available for review at each of the contractor demonstration events.

2.5.1.3. The contractor shall ensure staff is fully trained and knowledgeable about TRICARE 45 days prior to the SHCD. Trained staff shall be able to accurately respond to customer inquiries.

2.5.1.4. Verification and Validation

2.5.1.4.1. For Verification purposes, Call Center Operations readiness will be measured against the following elements:

(1) Blockage Rates

(2) Call Abandonment Rate

(3) Average Speed of Answer

(4) On hold Times

(5) Call resolution

(6) Response Accuracy

2.5.1.4.2. The contractor’s Call Center Operational readiness will be validated to meet the following expected performance levels:

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(1) Blockage Rates less than 5%

(2) Call Abandonment Rates less than 5%

(3) Average Speed of Answer less than 45 seconds

(4) On hold Times less than 30 seconds 95% of the time

(5) Call resolution in first call 85% of the time

(6) Response accuracy 90% (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).

2.5.1.4.3. As part of validation, the Contractor’s Call Center Operations (toll-free customer support) will be subject to review at unannounced times during the 120 days prior to SHCD to demonstrate call center capabilities. The Contractor is responsible for providing toll-free telephone number(s) for use by the Government team for this purpose.

2.5.1.4.4. These documents will be reviewed for quality and accuracy at the discretion of the government. Each demonstration event shall identify how these documents contribute to the overall readiness of the TRICARE call center.

2.5.2. The contractor shall use contemporary avenues to communicate with beneficiaries (e.g., electronic mail World Wide Web, telephone texting, smart phone applications and social media) in accordance with Section C of the contract.

2.5.2.1. The contractor shall demonstrate contemporary avenues of beneficiary communication are fully operational and accessible 60 days prior to the SHCD and again 30 days prior to SHCD.

2.5.2.2. Verification and Validation:

2.5.2.2.1. The contractor will verify contemporary avenues of beneficiary communication are fully operational and accessible 60 days prior to the SHCD and again 30 days prior to SHCD.

2.5.2.2.2. The contractor’s avenues of communication shall be validated through the review of the contractor’s electronic mail, web page, telephone texting process, smart phone applications and social media outlets. Expected outcomes are accurate, user-friendly communication avenues.

2.6. Management

2.6.1. Military Treatment Facility (MTF) Visits

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2.6.1.1. The contractor’s key personnel shall conduct site visits to key government healthcare locations at enhanced multi-service market offices, Intermediate Service Commands, Coast Guard leadership, and MTFs. The purpose of these visits, at a minimum, will be to enhance current understanding of available opportunities, develop an understanding of the military healthcare culture, identify any special needs applicable to each type of location and to begin the development of the Memorandum of Understanding (MOU). Site visits shall be completed in accordance with Table 1.4.

Days Following Transition Specification Meeting

Required Visit

30 days Enhanced Multi-Service Market offices, Intermediate Service Commands, Coast Guard leadership

100 days

MTFs (Bedded, Non-Bedded, ASCs)

Table 1.4

2.6.1.2. Verification and Validation

2.6.1.2.1. The contractor will verify they have accomplished required sites visits in accordance with 2.6.1.1. The contractor’s accomplishment of site visits shall be validated in accordance with 2.6.1.1.

2.7. Referral Management

2.7.1. The contractor shall implement an electronic referral management system (RMS) which integrates with the government’s electronic Referral Management interface in accordance with the contract. The contractor shall ensure referral management processes are consistent with Section C of the contract and the TRICARE Operations Manual, Chapter 8, Section 5.

2.7.1.1. The contractor’s RMS shall interface with the government RMS at each

MTF. Interfaces shall be accomplished at the following minimum thresholds:

50% of MTF interfaces are established 90 days prior to SHCD.

75% of MTF interfaces are established 75 days prior to SHCD.

95% of MTF interfaces are established 60 days prior to SHCD.

2.7.1.1.1. The contractor’s RMS shall also include the results of the contractor’s alternate referral management processes with Coast Guard facilities.

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2.7.1.1.2. Referrals processed shall meet Program requirements with a 95% accuracy rate.

2.7.1.1.3. The contractor’s RMS process will include the Right Of First

Refusal (ROFR) management and inbound/outbound referrals are processed accurately and timely. The contractor’s RMS shall reflect the ability to process 80% of referrals within 2 working days and 90% within 3 working days.

2.7.1.2. Verification and Validation

2.7.1.2.1. For purposes of verification, the contractor will ensure the contractor’s RMS can interface with MTFs in accordance with 2.7.1.1 and 2.7.1.1.1.

2.7.1.2.2. The contractor will verify it can process referrals in accordance with 2.7.1.1.2. and 2.7.1.1.3.

2.7.1.2.3. For validation purposes, the government will review the contractor’s ability to accurately process referrals in accordance with timeliness standards. Required validation performance levels: Accuracy: 95% of referrals are accurately processed following the date of receipt.

Timeliness: 80% of referrals shall be processed within 2 working days and 90% shall be processed within 3 working days.

2.7.1.2.4. The contractor’s ability to accurately process the projected daily volume of referrals as stated in 2.7.1.1.3. will be validated.

2.8. Claims Processing

2.8.1. The contractor shall ensure the claims processing system complies with the TRICARE

Operations Manual, Chapter 8 and the contract.

2.8.2. Claims processing system evaluations for customer service claims inquiries shall be accomplished 60 days prior to the start of healthcare delivery. Test results shall be provided to the government within 10 days of test completion.

2.8.3. The contractor must be able to process all TRICARE claims types with a minimum of a

95% accuracy rate 30 days prior to SHCD. The test shall include claim types that represent a level of complexity that supports TRICARE benefits.

2.8.4. Verification and Validation

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2.8.4.1. Expected performance outcomes are that the contractor accurately processes 95% of the claims in accordance with claims processing standards.

2.8.4.2. The contractor’s claims processing system shall be validated to ensure it is capable of processing the projected daily claims volume within a 24-hour period. Expected validation outcome is that the contractor demonstrates they can process 95% of the expected claims volume.

2.8.4.3. The contractor’s claims processing system will be capable of responding to customer service claims inquiries 60 days prior to SHCD.