Section_C_-_T-2017.pdf

SECTION C

DESCRIPTION/SPECIFICATIONS/WORK STATEMENT

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C.1. General

C.1.1. Purpose: The purpose of this contract is to provide Managed Care Support (MCS) to the Department of Defense (DoD) TRICARE program. The MCS Contractor (MCSC) shall assist the Military Health System (MHS) in operating an integrated health care delivery system combining resources of the military’s direct medical care system and the Contractor’s managed care support to provide health, medical and administrative support services to eligible beneficiaries.

C.1.2. Objectives

C.1.2.1. Objective 1 Readiness: Support the MHS readiness mission by partnering with the Military Treatment Facilities (MTFs) to optimize the delivery of health care services in the direct care system (see definition of MTF optimization in the TRICARE Operations Manual (TOM), Appendix B) for all MHS beneficiaries (active duty personnel, MTF enrollees, civilian network enrollees, and non-enrollees).

C.1.2.2. Objective 2 Experience of Care: Provide a care experience that is patient and family-centered, compassionate, convenient, equitable, safe and always of the highest quality.

C.1.2.3. Objective 3 Manage Per Capita Cost: Create value by focusing on quality, eliminating waste, and reducing unwarranted variation; considering the total cost of care over time, not just the cost of an individual health care activity.

C.1.2.4. Objective 4 Population Health: Within the constraints, boundaries, and benefits of the current program, encourage beneficiaries and providers to seek ways to improve health.

C.1.3. Definitions: Definitions are included in the TOM, Appendix A.

C.1.4. Documents: The following documents, including the changes identified below, are hereby incorporated by reference and form an integral part of this contract. Documentation incorporated into this contract by reference has the same force and effect as if set forth in full text.

• Title 10, United States Code, Chapter 55

• 32 Code of Federal Regulations Part 199

• TRICARE Operations Manual (TOM) 6010.59-M, dated April 1, 2015.

• TRICARE Policy Manual (TPM) 6010.60-M, dated April 1, 2015.

• TRICARE Reimbursement Manual (TRM) 6010.61-M, dated April 1, 2015.

• TRICARE Systems Manual (TSM) 7950.3-M, dated April 1, 2015.TRICARE

C.1.4.1. The TRICARE Manuals provide instruction, guidance and responsibilities in addition to the requirements set forth in the incorporated federal statutes and regulations and may not be

HT9402-15-R-0002, T2017 Page C-2 interpreted in contradiction thereto. Among the Manuals the TRICARE Policy Manual takes precedence over the other three TRICARE Manuals. The TRICARE Reimbursement Manual takes precedence over the TRICARE Systems Manual and the TRICARE Operations Manual.

The TRICARE Systems Manual takes precedence over the TRICARE Operations Manual.

C.2. Performance Requirements

C.2.1. Provider Networks

C.2.1.1 The Contractor shall establish and maintain networks of individual and institutional providers for TRICARE Prime and Extra which produce the best quality clinical outcomes for TRICARE beneficiaries.

C.2.1.1.1. All network providers must be Medicare participating providers (unless they are not eligible to be participating providers under Medicare) and shall be sufficient in number, mix, and geographic distribution to provide the full scope of benefits for which all Prime enrollees are eligible under this contract, as described in 32 CFR 199.4, 199.5, and 199.17. The Contractor shall provide Prime Service Areas (PSAs) at all MTF locations listed in Attachment J-1, Government Required MTF Prime Service Areas, and at all sites listed in Attachment J-2, Government Required BRAC Site Prime Service Areas.

C.2.1.1.2. . The Contractor’s network and utilization management, and case management programs shall be accredited by a nationally recognized accrediting organization no later than 18 months after the start of health care delivery and be maintained in all geographic areas covered by this contract and shall be maintained throughout the contract and all exercised options. When this contract and the accrediting body have differing standards for the same activity, the higher standard shall apply.

C.2.1.2. The Contractor shall inform the Government in a monthly report of any instances of network inadequacy relative to the Prime service areas (see Section F). Network inadequacy is defined as any failure to provide health care services within the network of a PSA within the access standards. The Contractor will submit a Corrective Action Plan (CAP) for instances of network inadequacy. The Contractor shall respond to any inquiries by appropriate DHA representatives concerning network inadequacy within two business days from receipt of request.

C.2.1.3. The Contractor shall maintain a real-time, on-line list of network providers with a minimum of __% accuracy (to be proposed by offerors).

C.2.1.4. The Contractor shall adjust provider networks and services to meet changes in MTF capabilities.

C.2.1.4.1. The Contractor shall adjust provider networks and services as necessary to compensate for changes in MTF capabilities and capacities, when and where they occur over the

HT9402-15-R-0002, T2017 Page C-3 life of the contract, including those resulting from unanticipated facility expansion, MTF provider deployment, downsizing and/or closures.

C.2.1.4.2. The Contractor shall adjust provider networks and services to ensure all eligible beneficiaries who live in PSAs have the opportunity to enroll, add additional family members, or remain enrolled in the Prime program.

C.2.1.5. The Contractor shall provide an education program for network providers in accordance with TOM, Chapter 11.

C.2.1.5.1. The Contractor shall provide an outreach and education program on TRICARE requirements for all network and TRICARE-authorized providers. The program shall include education on applicable TRICARE program requirements, policies, and procedures to allow providers to carry out the requirements of this contract in an efficient and effective manner which promotes beneficiary satisfaction. The outreach program shall include information on the Centers for Medicare and Medicaid Services (CMS) Meaningful Use (MU) Program.

C.2.1.6. The Contractor shall encourage network providers to interface with certified health information exchanges. The Contractor shall encourage, to the greatest extent possible, network providers to utilize a certified health information exchange which will provide an opportunity for providers to exchange information with the DHA.

C.2.1.7. The Contractor provider agreements shall require network providers to render individual consultation reports to referring MTFs. The contractor shall establish a process that includes an operational definition of consult result non-compliance, thresholds of non-compliance that will evoke action by the contractor, what actions the contractor will take to encourage compliance, process to receive information regarding non-compliant providers from the MTFs, and roles, responsibilities and points of contact for the process. This process shall be included as part of the Network Implementation Plan.

C.2.2. Referral Management

C.2.2.1 The Contractor shall establish and maintain a referral management program in accordance with the TOM, Chapter 8, Section 5.

C.2.2.2. The Contractor shall utilize a secure HIPAA and Government compliant electronic method to process referrals between MTFs and MCSCs. The Contractor will implement an electronic referral management system which integrates with the Government’s electronic Referral Management interface as described in the TOM and TSM. Faxing shall be used only in situations when electronic means is temporarily unavailable. The Coast Guard does not use the Referral Management interface and faxing is permissible for Coast Guard referrals.

C.2.2.2.1 In addition to the standard HIPAA compliant 278 returned/rejected responses, the MCSC will provide text explanations in returned HIPAA compliant 278 response for referrals

HT9402-15-R-0002, T2017 Page C-4 that are rejected or returned referrals. The text explanations shall describe why the MCSC is returning or rejecting the referral including the name of the data element that needs to be corrected, and what the MCSC wants the MTF to correct on the referral before resubmitting the referral for review and authorization determination. In cases where the Government cannot resolve issues associated with rejected/returned referrals via electronic means, referral related information may be faxed for clarification.

C.2.2.2.2. The referral information provided, and the methods of communicating the information, will be addressed in the MTF/MCSC Memorandum of Understanding (MOU).

C.2.2.3. The Contractor shall utilize leading industry best practice automation in processing referral and authorization, episodes of care, procedure and diagnosis coding. Referrals and authorizations notification will be electronically accessible to the beneficiary.

C.2.3. Enrollment

C.2.3.1. The Contractor shall perform enrollments, re-enrollments, disenrollments, transfer enrollments, correct enrollment discrepancies, and assign or change the PCM in accordance with the provisions of the TOM Chapter 6. The Contractor shall utilize leading industry best practice automation in processing billing and enrollment transactions. This shall include capture of email and other information needed to conduct electronic transactions.

C.2.4. Medical Management

C.2.4.1. The Contractor shall establish and maintain a medical management program for MHS-eligible beneficiaries receiving care in the civilian sector in accordance with the TOM, Chapter

7. The Contractor shall ensure that care provided, including mental health care, is medically necessary and appropriate and complies with the TRICARE benefits contained in 32 CFR 199.4 and 199.5. The Contractor shall use its best practices in managing, reviewing and authorizing health care services, and shall comply with the provisions of 32 CFR 199.4, 32 CFR 199.5 and the TRICARE Policy Manual when reviewing and approving medical care and establishing medical management programs to carry out this activity to the extent authorized by law. The Contractor's Medical Management program shall fully support the services within the MTF and described in the MOUs.

C.2.4.1.1. The Contractor shall coordinate the care and transfer of stabilized patients during normal business hours. In cooperation with the MTF, the Contractor shall coordinate the care and transfer of stabilized patients who require a transfer from one location to another. This function shall include coordination with the primary clinician at the losing and gaining sites and the patient’s family; arranging medically appropriate patient transport; ensuring all necessary supplies are available during the transport and at the receiving location; arranging for and ensuring the presence of all necessary medical equipment during transport and at the receiving location; and identifying and ensuring the availability of necessary resources to accomplish the transfer. Transfers may occur as a result of medical, social, or financial reasons and include

HT9402-15-R-0002, T2017 Page C-5 moves of non-institutionalized and institutionalized patients. Transportation will be coordinated using Government resources when appropriate and available.

C.2.4.1.2. The Contractor shall provide access to DoD pharmacy information which allows civilian providers to view and print their patients' medication lists. The medication lists will include medications dispensed by MTFs, the TRICARE Mail Order Pharmacy and retail pharmacies. The contractor will make this information available via the Contractor’s website for Primary Care Managers (PCMs) and specialists who register for this capability. PCMs will have access to medication lists for all of their assigned TRICARE patients; specialist access will be limited to those patients for whom they have a referral or authorization.

C.2.4.1.3. The Contractor shall review the quality of ambulatory care for +-MHS beneficiaries.

The Contractor shall conduct at least three comprehensive focused reviews of a statistically valid sample or 30 records, whichever is greater, of medical records per option period focused on ambulatory medical necessity and quality of care provided in high risk settings such as, but not limited to, Emergency Room, Ambulatory Surgical Centers and Urgent Care Centers. The Government will provide to the contractor specific review topics, criteria for selection and the time frame from which the sample is to be drawn for these focused reviews 60 calendar days prior to each option period. This information shall be included in the annual clinical quality report.

C.2.4.1.4. The Contractor shall operate a fully electronic data system for the Medical Management/Utilization Management program that will offer real-time access, reporting and information to the government. Access to the Contractor's medical management/utilization information shall be provided through a user friendly web-based interface. The Contractor will provide training on the interface's use to authorized Government personnel.

C.2.4.6. The Contractor shall apply its utilization management practices for MTF enrollees receiving care in the purchased care system. The Contractor shall provide a copy of these utilization management decisions by secure electronic means to the MTF Commander the day the decision is made.

C.2.4.6.1. The Contractor’s Utilization Management Programs shall be accredited by a nationally recognized accrediting organization in all geographic areas covered by this contract. When this contract and accreditation body has differing standards for the same activity, the higher standard shall apply.

C.2.4.7. The Contractor shall manage and implement a clinical quality management and safety program for MHS beneficiaries. The Contractor’s credentialing program shall be accredited by a nationally recognized accrediting organization in all geographic areas covered by this contract no later than the start of the second option period. When this contract and the accreditation body have differing standards for the same activity, the higher standard shall apply.

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C.2.4.8. The Contractor shall use industry best practices to identify, and reduce gaps in care, medical errors, and quality issues for Prime Beneficiaries.

C.2.4.8.1. The Contractor shall establish a Beneficiary-centric data warehouse and industry analytic tools/system and provide the Government with access to this Prime Beneficiary-centric data warehouse and industry analytic tools/system to view all data for a Prime beneficiary enrolled to a civilian PCM and to exhibit a sophisticated data analysis technique with evidence-based algorithms. The Contractor will implement this beneficiary-centric data analytic tools/system to integrate data from multiple sources to allow a consolidated view of all data related to each Prime beneficiary. The Contractor’s system will process this information against industry-respected sources of evidence-based medicine to identify gaps in care, medical errors, and quality issues.

C.2.4.8.2. The Contractor shall utilize its analytic tools to promote health, identify at-risk individuals and populations, treat chronic diseases (to include, but not limited to, cancer, heart disease, diabetes, asthma, chronic obstructive pulmonary disease (COPD), depression, and anxiety disorder) and shall demonstrate to the Government its methods to engage beneficiaries and their providers in appropriate care and treatment.

C.2.4.8.3. The Contractor shall provide targeted health messaging to Prime beneficiaries enrolled to a civilian PCM for cases of high risk, high cost procedures, and those beneficiaries identified by the analytical system for other reasons.

C.2.4.8.4. The Contractor shall provide the Government with access to individual patient information in its analytical system for review of patient outreach, interventions, and health care outcomes. The Contractor will also aggregate this data at the PSA level and make this data available to the Government.

C.2.4.9. The Contractor shall operate case management and care coordination programs for TRICARE eligible beneficiaries. The Contractor shall use best business practices to operate case management programs designed to support and manage the health care of individuals with high-cost conditions, to include but not limited to those receiving J-coded drugs, or with specific diseases for which evidenced-based clinical management programs exist. These programs shall be available to TRICARE-eligible beneficiaries authorized to receive reimbursement for civilian health care per 32 CFR 199 and Active Duty personnel whose care occurs or is projected to occur in whole or in part in the civilian sector. These programs shall exclude non-Active Duty TRICARE/Medicare dual eligible beneficiaries. When care occurs outside an MTF, the Contractor is responsible for coordinating the care with the MTF clinical staff as well as the civilian providers. The Contractor shall propose medical management programs and patient selection criteria for review and concurrence of the Government prior to implementation and annually thereafter.

C.2.4.10. The Contractor shall use best business practices to implement, and maintain a Disease Management Program for MHS beneficiaries. At a minimum, the Contractor shall include the

HT9402-15-R-0002, T2017 Page C-7 following diseases in their Disease Management Program: Cancer, Asthma, Heart Disease, Diabetes, Chronic Obstructive Pulmonary Disease (COPD), Depression and Anxiety Disorder.

The objectives of the Disease Management Program will be to improve the clinical and satisfaction outcomes for TRICARE beneficiaries with the above conditions while reducing the financial burden to the Government.

C.2.4.10.1. The Contractor shall improve clinical and satisfaction outcomes for Prime beneficiaries in the Disease Management Program. The contractor will use best business practices for population identification and methodology, risk stratification, intervention, and care coordination activities based on the stratification levels, care transition plans for hospitalized Disease Management participants, provider communication, and integration. The Contractor will establish the process for beneficiaries to be referred for Disease Management services from the MTFs. The program will incorporate nationally recognized evidence-based guidelines and protocols to include DoD/VA guidelines when available and appropriate.

C.2.4.10.2. The Contractor shall develop program performance metrics that will be provided to the Government, which when combined with other Government-generated data will allow for effective evaluation of the Disease Management Program, in accordance with the Government-provided Disease Management outcome metrics. The Contractor shall include metrics for accounting and reporting on the cost and performance for each of the disease states managed, the methodology used, and plans to improve outcomes when metrics/standards are not met. The Contractor will demonstrate how their Disease Management Program reduces health care costs for the Government.

C.2.4.10.3. The Contractor’s Disease Management Program shall be accredited by a nationally recognized accrediting organization in all geographic areas covered by this contract. When this contract and the accreditation body have differing standards for the same activity, the higher standard shall apply.

C.2.5. Customer Service

C.2.5.1. The Contractor shall provide comprehensive readily accessible customer services for MHS beneficiaries and providers. The Contractor shall utilize industry best practices in its outreach and communication with all MHS customers consistent with that offered to its commercial customers. Customer services shall include multiple contemporary avenues of access (for example, e-mail, World Wide Web, telephone, texting, and smart phone applications, and other social media) for the MHS beneficiary. The Contractor shall perform all customer service functions with knowledgeable, courteous, responsive staff that results in highly-satisfied beneficiaries. Customer services shall be delivered in a manner that achieves the objectives of this contract without charge to beneficiaries or providers. The Contractor’s call center shall be accredited by a national accrediting agency.

C.2.5.2. The Contractor shall provide customer service support for MTFs and Regional Director.

The Contractor shall provide customer service support hours to each MTF as stated in

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Attachment J-X, Government MTF Education Requirement, to be used at the discretion of and for the purpose specified by each MTF Commander. Examples of possible uses of this time include in-processing briefings/enrollments, TRICARE briefings, and specialty briefings on specific components of TRICARE or focused to a specific subset of TRICARE beneficiaries.

This is in addition to the requirements for briefings and attendance at meetings specified in the TRICARE Operations Manual.

C.2.5.2.1. The Contractor shall provide customer service support up to forty hours per month to be used at the discretion of and for the purpose specified by the Regional Director. The designated hours for the Regional Director may be used at various locations and outside normal business hours.

C.2.5.2.2. The Contractor shall provide training support up to 40 hours per month to be distributed to Guard and Reserve units at the direction of the Regional Director.

C.2.5.3. The Contractor shall provide customer service functions to disaster areas.

The Contractor shall deploy mobile Service Assist Team (SATs) necessary to perform customer service functions to disaster areas, Active Component and Reserve Component troop mobilization areas, BRAC areas, or to any area deemed necessary and requested by the Regional Director (RD). A modification will be issued by the Contracting Officer defining the requirement for each SAT. SATs shall be deployed on an as needed basis for a finite period of time as defined in the modification. Within seven calendar days’ notice, the Contractor shall deploy one or more teams. SATs shall provide assistance with beneficiary enrollment, provide assistance with access to and referral for care, and provide TRICARE program information.

C.2.6. Claims Processing

C.2.6.1. The Contractor shall maintain and establish an automated claims processing system for TRICARE claims. The Contractor shall implement an adaptable, scalable claims processing system which incorporates industry best practices. The system shall utilize state of the art software which can be configured such that changes are quickly made at the lowest possible cost to the Government. The Contractor's claims processing system shall process claims in accordance with the TRICARE benefit policy as delineated in 32 CFR Part 199.4 and 199.5, the TPM, and TRM. The Contractor's claims processing system shall correctly apply deductible, co-pay/coinsurance, cost shares, catastrophic cap, authorization requirements, and point-of-service provisions in accordance with the TRICARE benefit policy as delineated in 32 CFR Part 199.4 and 199.5, 199.17 and 199.18, the TPM, and TRM. As required by 32 CFR 199.8, the TPM, and TRM, the Contractor's claims processing system shall accurately coordinate benefits with other health insurances to which the beneficiary is entitled

C.2.6.2. The Contractor's claims processing system shall interface with and accurately determine eligibility and enrollment status based on the DEERS in accordance with the TSM.

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C.2.6.3. The Contractor shall issue an Explanation of Benefits (EOB) to beneficiaries. The EOB shall be provided through electronic means, including but not limited to a web based portal. A paper monthly summary EOB shall be made available to the beneficiary upon request.

C.2.6.4. The Contractor shall capture and report TRICARE Encounter Data (TED) related to claims adjudication in accordance with TRICARE manuals.

C.2.6.5. The Contractor shall provide real-time access to claims data for designated Defense Health Agency (DHA) and Services personnel. The Contractor shall furnish to any DHA designated site(s) and DHA designated key personnel real- time, read-only access to claims data.

The Contractor shall provide training and ongoing customer support for this access.

C.2.6.6. The Contractor shall manage enrollments, collect premiums, accurately identify and adjudicate claims and perform all requirements for Continued Health Care Benefit Program (CHCBP) according to the TPM.

C.2.6.7. The Contractor shall use commercial best business practices to identify and update Other Health Insurance (OHI) information stored in Defense Enrollment Eligibility Reporting System (DEERS) database for non-active duty service member beneficiaries that have no commercial health insurance information on file.

C.2.6.7.1. The Contractor shall establish a process by which they continually update existing OHI information stored in the OHI repository in the Defense Enrollment Eligibility Reporting System (DEERS) database. The Contractor shall provide OHI Data in a format that can be directly utilized by the existing DMDC OHI web service to load the data to the DEERS OHI repository. The data must comply with HIPAA data elements and values. Data file discrepancies shall be corrected within 5 calendar days and resubmitted to the Government. The OHI data file must be imported back into DEERS without manipulation by the Government 95% of the time.

The Contractor’s review must accurately review and document the existence of billable health insurance information for all non-active duty beneficiaries.

C.2.7. Management

C.2.7.1. The Contractor shall establish and maintain experienced and qualified key personnel and sufficient staffing and management support to meet the requirements of this contract. Within 15 minutes of contact by the RD or designated representative the Contractor will provide a senior level team member(s) with the ability to obligate resources within the scope of the contract to attend meetings with the RD or designated representative(s), either via telephone conference call, video teleconference (VTC) call, or other agreed-upon electronic media. For urgent serious matters, within one work day the Contractor will provide a senior level team member(s) with the ability to obligate resources within the scope of the contract to attend in-person meetings with the RD or designated representative(s) at a location identified by the RD or designated representative.

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C.2.7.2. The contractor shall establish and operate a quality management and quality improvement (QM/QI) program. QM processes will focus on problem identification and resolution and will foster a consistent, efficient TRICARE program for the beneficiaries; QI processes will focus on improvements to stable processes and will foster innovation. These programs shall be comprehensive and coordinated, covering all aspects of the TRICARE program, with oversight by top leadership ensuring that QM/QI information flows across the entire enterprise. The contractor will provide visibility of QM/QI processes and reports to the government on a routine basis to be determined and adjusted by the government as needed.

C.2.7.3. The Contractor shall ensure efficient integration of health care delivery between the direct care system and the Contractor's network. The Contractor shall collaborate with the MTF Commanders/eMSM and TRO to ensure the most efficient mix of health care delivery between the direct care system and the Contractor's network within their Region and prepare the MOU (See TOM, Chapter 15) for approval by the Contracting Officer upon coordination with the MTF Commanders and Regional Office. Collaboration includes, but is not limited to preventive care, overflow capacity for primary and specialty care, ancillary services, and ROFRs for designated specialty care.

C.2.7.4. The Contractor shall ensure continuous provision of care for TRICARE eligible beneficiaries as MTFs respond to war, operations other than war, deployments, training, contingencies, special operations, and natural disaster. The Contractor shall develop and implement a contingency program designed to ensure that health care services are continuously available for TRICARE-eligible beneficiaries in the event of such changes in MTF capacity.

C.2.7.5. The Contractor shall participate in contingency exercises. The Contractor shall participate in regionally coordinated table-top contingency exercises as required by Government.

If requested by the MTF Commander or eMSM Manager (for MTFs listed in attachment J-1), the Contractor shall participate in contingency exercises up to twice each calendar year.

C.2.7.6. The Contractor shall develop and maintain an information system/data repository which includes real-time access to data at the beneficiary non-institutional and institutional level.

C.2.7.6.1. The Contractor shall provide access to Government personnel. Minimum access shall include two (2) authorizations at each MTF and USCG clinic, two (2) authorizations at each enhanced Multi-Service Market (eMSM) Office, two (2) authorizations at each Intermediate Service Command two (2) authorizations at each Surgeons General Office, five (5) authorizations at the Regional Director’s Office, five (5) authorizations at DHA (various locations), two (2) authorizations at Health Affairs, two (2) authorizations at DHA-Northern Virginia, two (2) authorizations at DHA-Aurora. The Contractor shall make available an additional 30 authorizations to be assigned at the discretion of the Government.

C.2.7.6.2. Data elements shall include, at a minimum, details concerning the provider network, referrals, authorizations, claims processing, program administration, beneficiary satisfaction and services, incurred healthcare costs, enrollment, geo-mapped data elements and clinical data (case

HT9402-15-R-0002, T2017 Page C-11 management, disease management, utilization management, and medical management). All data must be current, accurate, complete and accessible in real-time. Complete information includes all data pertaining to the execution of Prime, Extra and Standard benefits both inside and outside PSAs/eMSMs. Ad-hoc capability, standardized reports, and special report requests must satisfy the user’s requirement within mutually agreed upon timelines but within a maximum of five working days. Search capabilities must be built into systems and must be user-friendly. The data shall be, at a minimum, available for queries on a Regional, MTF PSA, and standard geographic area (State, County, and Zip Code) basis. The data access interface will be mutually agreed upon by the TRO and MCSC and available prior to start of health care delivery.

C.2.7.6.3. The Contractor shall provide training and ongoing customer support for accessing the Contractor's data information system/data repository. Web-based training is acceptable.

C.2.7.7. The Contractor shall provide information management and information technology support as needed to accomplish the stated functional and operational requirement of the TRICARE program and in accordance with the TRICARE Systems Manual

C.2.7.8. The Contractor shall establish and maintain a privacy program which meets the Federal, DoD, and DHA privacy requirements detailed in the TSM and TOM.

C.2.7.9. The Contractor shall implement a personnel security program which meets TSM requirements.

C.2.7.10. The Contractor’s information systems shall meet DHA Information Security compliance requirements described in the TSM and National Institute for Standards and Technology (NIST) Special Publication 800-53. The Contractor shall provide their NIST Certification to Government in accordance with applicable CDRL.

C.2.7.11. The Contractor shall ensure their employees appropriately identify themselves as contractor employees at all times. Contractor employees shall not act or advertise as Government employees, agents, or representatives; including in telephone conversations, formal and informal written correspondence, paper and electronic; and in any other situation where their actions could be mistakenly construed as acts of Government officials.

C.2.7.12. The Contractor shall maintain open communication and develop MOUs with other TRICARE contractors, listed below. As part of the MOU, special attention shall be given to delineation of each Contractor’s responsibilities when beneficiaries and beneficiary information cross contract boundaries. The MOUs shall be executed no later than 60 days prior to the start of healthcare delivery. MOUs will be developed for, but are not limited to, the following:

C.2.7.12.1. Other purchased care contractors: the other regional MCSC, the TRICARE Dental Contractors, and the TRICARE Overseas Program Contractor. Topics addressed in these MOUs may include, but are not limited to, case management, care coordination, medication

HT9402-15-R-0002, T2017 Page C-12 reconciliation, referrals/authorizations, beneficiary notifications, claims, OHI, disease surveillance/prevention, and beneficiary facility transfers.

C.2.7.12.2. Other contractors: TRICARE Dual-Eligible Fiscal Intermediary Contractor, TRICARE Pharmacy Contractor, the Nurse Advice Line Contractor, and the Claims Audit Contractor.

C.2.7.12.3. Government agencies: Air Force Medical Service (AFMS) for intergration with the Government’s Referral Management Suite (RMS)

C.2.7.13. The Contractor shall support MTF/eMSM business plan objectives. The Contractor shall collaborate with the Regional Director and each MTF/eMSM to support MTF and eMSM optimization.

C.2.7.14. The Contractor shall use commercially available web-based mapping software to enable the Government to evaluate the Contractor’s calculation of the distance and time standards. The Contractor shall provide the Government with access to the software at no additional cost.

C.2.7.15. The Government anticipates the development and implementation of the Defense Health Medical Systems Modernization (DHMSM) Electronic Health Record System (EHRS) that will allow DoD to share health data with the private sector.

When the Government begins implementation of the initiative, DHA anticipates that the Managed Care Support Contract will be modified to require the contractor to develop and implement a time-phased Interoperability Plan to achieve machine-to-machine interoperability between the Direct Care System, Managed Care Support Contractor and Network Providers. The Government anticipates implementation will begin in Quarter 3 FY2017 and end in Quarter 3

FY2020.

C.2.8. Transition

C.2.8.1. The Contractor shall employ the necessary resources to complete all transition in requirements outlined in the TOM/TSM. The Contractor shall ensure fully operational services and systems at the start of healthcare delivery and minimal disruption to the beneficiaries and MTFs. The Contractor shall also fully comply with all necessary outgoing requirements.

C.2.9. Program Integrity

C.2.9.1 The Contractor shall refer cases for disposition to DHA Program Integrity that involve $75,000 or greater in potential losses to the Government following procedures prescribed in the TRICARE Operations Manual (TOM), Chapter 13, Section 3, 5.0.

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C.2.9.1.1 For the East Region: The Contractor shall refer a minimum of 20 cases per year for disposition to DHA Program Integrity that meet the dollar threshold and procedures identified in the above paragraph C.2.9.1.

C.2.9.1.2. For the West Region: The Contractor shall refer a minimum of 10 cases per year for disposition to DHA Program Integrity that meet the dollar threshold and procedures identified in the above paragraph C.2.9.1.

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