Section_C_-_T2017_-_6.12.15_-_Amendment_00004.pdf

SECTION C

DESCRIPTION/SPECIFICATIONS/WORK STATEMENT

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C.1. GENERAL

C.1.1. 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 healthcare 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 TRICARE-eligible beneficiaries.

C.1.2. Contract 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 healthcare services to enhance the clinical expertise of providers in the direct care system (see definition of MTF optimization in the TRICARE Operations Manual (TOM), Appendix A) for all TRICARE-eligible 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 healthcare 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 Title 32 Code of Federal Regulations Part 199.2 and the TOM, Appendix A.

C.1.4. Documents: The following documents, 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.

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 Page C-2 of C-15 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 Attachments J-1, Mandatory PSA List -- East Region and J-2, Mandatory PSA List – West Region, and at all sites listed in Attachment J-3, BRAC List – East Region and Attachment 4, BRAC List – West

Region.

C.2.1.1.2. The Contractor’s network programs shall be accredited by a nationally recognized accrediting organization no later than 18 months after the start of healthcare delivery (SHCD) and be maintained in all geographic areas covered by this contract and shall be maintained throughout the contract and all exercised options. National certification, in lieu of accreditation, is insufficient to meet this requirement. 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 Prime Service Areas (PSAs)(see Section F). Network inadequacy is defined as any failure to provide healthcare services within the network of a PSA within the access standards. The Contractor shall submit a Corrective Action Plan (CAP) for instances of network inadequacy. The Contractor shall respond to any inquiries from the Contracting

Officer’s Representative (COR) concerning network inadequacy within two business days from receipt of request.

C.2.1.3. The Contractor shall maintain an on-line directory of network providers with a minimum of __% accuracy (to be proposed by Offerors). “Accuracy” is defined as a directory entry that contains correct information for all of the following data elements: provider name, provider specialty, sub-specialty (if applicable), gender, work address, work fax number, and work telephone number for each service area. Although the directory shall indicate whether network providers are accepting new TRICARE patients, this data field will not be included for purposes of accuracy calculations. The information in the on-line network provider directory

HT9402-15-R-0002 Page C-3 of C-15 shall be current and refreshed no less frequently than once every 24 hours. The on-line network provider directory shall be made accessible to users on a continual (24 hours/7 days a week) basis except for scheduled downtime for system maintenance. To the maximum extent practicable, the Contractor shall schedule system maintenance windows during weekends or non-peak hours to minimize disruption of services to beneficiaries. These requirements for refreshing the data and data accuracy are not applicable to the on-line directory of TRICARE authorized

(non-network) providers; however, the Contractor shall refresh the data contained in the

TRICARE authorized (non-network) provider directory no less than semiannually.

C.2.1.4. 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 life of the contract, including those resulting from unanticipated facility expansion, MTF provider deployment, downsizing and/or closures.

C.2.1.4.1. The Contractor shall adjust provider networks and services to ensure all TRICARE-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 educate network providers about the certified Health Information

Exchanges (HIEs) and meaningful use standards. The Contractor shall include in its network, to the greatest extent possible, network providers who utilize a certified HIE 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 in the

Offeror’s proposal and incorporated into the Network Implementation Plan following contract award.

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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 computer-based method to process referrals between MTFs and MCSCs (including Right of First Refusal

(ROFR) reversals). The Contractor will implement an computer-based referral management system which interfaces with the Government’s Referral Management System (RMS) interface as described in the TOM and TSM. Faxing shall be used only in situations when computer-based means is temporarily unavailable. The Coast Guard does not use the RMS 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 shall provide text explanations in returned HIPAA compliant 278 responses for referrals that are rejected or returned. 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 the Government’s RMS interface, 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. The Contractor shall make a copy of the referral/consult and the authorization letter electronically accessible and printable to the beneficiary. The Contractor shall provide hard copies of these documents upon beneficiary request.

C.2.2.4. The Contractor shall provide each enhanced Multi-Service Market (eMSM) with an onsite Care Management Liaison to facilitate effective collaboration between the Contractor, the eMSM referral coordinators, and the referral personnel at each MTF within the eMSM to facilitate the resolution of any clinical questions or issues that arise during the referral/authorization process. Care Management Liaison personnel will be located within the eMSM and staff shall be available on a full-time basis whenever the eMSM is in operation. The

Government will provide computers, desk space and supplies necessary to execute the mission.

At the discretion of the Government, the workspace may be physically located within the eMSM office or at any of the MTFs associated with that eMSM. FAR 52.245-1, Government Furnished

Property (GFP) describes the Contractor’s management responsibilities and use of GFP. GFP is provided on an “as-is” condition and subject to terms discussed in the referenced FAR clause.

GFP inventory will be identified in the MOU applicable to the eMSM where the GFP resides.

C.2.3. Enrollment

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C.2.3.1. The Contractor shall perform enrollments, re-enrollments, disenrollments, transfer enrollments, correct enrollment discrepancies, and assign or change the Primary Care Manager

(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 that includes the requirements in TOM, Chapter 7. The Contractor shall ensure that care provided, including mental healthcare, 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 healthcare services, and shall comply with the provisions of 32 CFR 199.4, 32 CFR 199.5 and the TPM 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 support all services provided 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. The Contractor shall coordinate 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 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

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 TRICARE-eligible beneficiaries. The Contractor shall conduct at least two 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

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Centers. These reviews are in addition to the quarterly focused reviews required by TOM

Chapter 7, Section 1, Paragraph 8.0. 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 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 access, reporting and information to the Government at the beneficiary and MTF level. The electronic data system for the Medical

Management/Utilization Management program shall be made accessible to users on a continual

(24 hours per day/7 days per week) basis except for scheduled downtime for system maintenance. To the maximum extent practicable, the Contractor shall schedule system maintenance windows during weekends or non-peak hours to minimize disruption of services to

Government users. 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 Medical Management/Utilization Management interface's use to authorized Government personnel.

C.2.4.2. The Contractor shall apply its utilization management practices for all TRICARE-eligible beneficiaries receiving care in the purchased care system. For MTF or civilian network

Prime enrollees, 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. The Contractor shall notify MTF and civilian network PCMs of inpatient admissions for all Prime enrollees within 24 hours of the Contractor becoming aware of the admission. The Contractor shall also provide a monthly report for MTF and civilian network PCMs that identifies all Prime enrollees who have utilized Emergency Room (ER) care four or more times within the last 12 months (on a rolling 12-month basis) according to the CDRL (M380).

C.2.4.2.1. The Contractor’s utilization management, and case management programs shall be accredited by a nationally recognized accrediting organization no later than 18 months after the

SHCD and be maintained in all geographic areas covered by this contract and shall be maintained throughout the contract and all exercised options. National certification, in lieu of accreditation, is insufficient to meet this requirement. When this contract and the accrediting body have differing standards for the same activity, the higher standard shall apply.

C.2.4.3. The Contractor shall manage and implement a clinical quality management and patient safety program for all TRICARE-eligible beneficiaries. The Contractor’s provider credentialing program shall be accredited by a nationally recognized accrediting organization in all geographic areas covered by this contract no later than 18 months after the SCHD. National certification is insufficient to meet this requirement. When this contract and the accreditation body have differing standards for the same activity, the higher standard shall apply.

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C.2.4.4. The Contractor shall collect and report HEDIS measures and use industry best practices to identify, and reduce gaps in care (including gaps in preventative care), medical errors, and quality issues for all network Prime-enrolled beneficiaries.

C.2.4.4.1. The Contractor shall establish a Network Prime beneficiary-centric data warehouse and industry analytic tools/system (including predictive analytics) and provide the Government with access 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 (including, but not limited to, Government-provided MTF data) to allow a consolidated view of all data related to each Network 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.2.4.4.2. The Contractor shall utilize its analytic tools, to include predictive analytics, to promote health, identify at-risk individuals and populations, treat chronic diseases (to include, but not limited to, cancer screening, heart disease, diabetes, asthma, chronic obstructive pulmonary disease (COPD), depression, and anxiety disorder) and shall describe and report to the Government its methods to engage all TRICARE-eligible beneficiaries and their providers in appropriate care and treatment.

C.2.4.4.3. The Contractor shall provide targeted health messaging to all TRICARE-eligible beneficiaries for cases of high-risk, high-cost procedures, and those beneficiaries identified by the analytical system for other reasons.

C.2.4.4.4. The Contractor shall provide the Government with access to individual patient information on all TRICARE-eligible beneficiaries and Active Duty personnel in its analytical system for review of patient outreach, interventions, and healthcare outcomes. The Contractor will also aggregate this data at the PSA level and make this data available to the Government.

C.2.4.5. The Contractor shall use best business practices, including predictive analytics, in the operation of their medical management programs (including utilization management, case management, and chronic care/disease management) which are designed to support and manage the healthcare 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 healthcare 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. Additionally, when the

Contractor is managing the care of an Active Duty Service Member, they shall notify the member’s enrolled MTF within 2 days of the care taking place, or notify the DHA-Great Lakes within 2 days for members enrolled to civilian PCMs. The Contractor shall propose medical

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Government prior to implementation and annually thereafter.

C.2.4.6. As part of their medical management program, the Contractor shall use best business practices to implement and maintain an integrated Chronic Care/Disease Management Program for all TRICARE-eligible beneficiaries. Chronic Care/Disease Management shall be incorporated into the Contractor’s overall medical management program(s). At a minimum, the Contractor shall include the following preventive screenings and diseases in their Chronic Care/Disease

Management Program: cancer screening, asthma, heart disease, diabetes, chronic obstructive pulmonary disease (COPD),and depression and anxiety disorders. The Chronic Care/Disease

Management program shall be a part of the Contractor’s overall medical management program and amongst the objectives will be an objective to improve the clinical and satisfaction outcomes for all TRICARE-eligible beneficiaries with the above conditions while reducing healthcare costs for the Government. The contractor shall submit an annual program plan in accordance with the CDRL (AP070)."

C.2.4.6.1. The Contractor will use best business practices for population identification and methodology, identification of clinical and satisfaction baseline and measurement levels, risk stratification, intervention, and care coordination activities based on the stratification levels, care transition plans for hospitalized Chronic Care/Disease Management participants, provider communication, and integration. The Contractor will establish the process for beneficiaries to be referred for Chronic Care/Disease Management services from the MTFs and will communicate this process via the MTF MOUs. The program will incorporate nationally recognized evidence-based guidelines and protocols to include DoD/VA guidelines when available and appropriate.

C.2.4.6.2. 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 Chronic Care/Disease Management Program. Specifically, the

Contractor shall evaluate whether the Chronic Care/Disease Management Program results in improved clinical and satisfaction outcomes over time (as compared to their baseline states) while reducing healthcare costs for the Government.

C.2.4.6.3. The Contractor’s Chronic Care/Disease Management Program shall be accredited by a nationally recognized accrediting organization in all geographic areas covered by this contract.

National certification is insufficient to meet this requirement. Accreditation shall be completed no later than 18 months after the SHCD, and shall be maintained throughout the life of this contract and all exercised options.When this contract and the accreditation body have differing standards for the same activity, the higher standard shall apply.

C.2.4.6.4. The Contractor shall provide the MTFs with visibility of medical management information via dashboard-based access. At a minimum, this information shall provide notification to the MTFs whenever an MTF Prime enrollee is assigned to Case Management or

Chronic Care/Disease Management, to include the contact information for the specific care

HT9402-15-R-0002 Page C-9 of C-15 coordinator(s) assigned to the enrollee. The information in the dashboard shall be current and refreshed no less frequently than once every 24 hours. The dashboard shall be made accessible to users on a continual (24 hours per day/7 days per week) basis except for scheduled downtime for system maintenance. To the maximum extent practicable, the Contractor shall schedule system maintenance windows during weekends or non-peak hours to minimize disruption of services to

MTF users.

C.2.4.6.5. The contractor shall submit reports regarding all medical management processes (to include case management, utilization management, and chronic care/disease management) in accordance with the CDRLs (M080 and M100).

C.2.5. Customer Service

C.2.5.1. The Contractor shall provide comprehensive readily accessible customer services for

TRICARE-eligible beneficiaries and providers. The Contractor shall utilize industry best practices in its outreach and communication 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, smart phone applications, and other social media) for the TRICARE-eligible beneficiary. The Contractor shall perform all customer service functions with knowledgeable, courteous, responsive staff that results in highly-satisfied beneficiaries. Customer service shall be delivered in a manner that achieves the objectives of this contract without charge to beneficiaries or providers. The Contractor shall offer an automated telephone critique to 100% of toll free service line callers who interact with a live customer service representative. The Contractor’s call center shall be certified by a nationally-recognized certification agency or program no later than 18 months after the SHCD, and be maintained throughout the life of this contract and all exercised options.

C.2.5.2. The Contractor shall provide customer service support for MTFs and the Director, TRICARE Regional Offices (TRO). The Contractor shall provide customer service support hours to each MTF as stated in Attachment J-5, MTF Educational 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 TOM.

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 TRO

Director. A modification will be issued by the CO 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 days’ notice, the Contractor shall deploy one or more teams. SATs shall provide

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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 modern 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 Defense Enrollment Eligibility Reporting System

(DEERS) in accordance with the TSM.

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 access to claims data for designated Defense Health

Agency (DHA) and Services personnel (including Services personnel at the MTF level). The

Contractor shall furnish any DHA designated site(s) and DHA designated key personnel with read-only access to all claims data, regardless of the Region/location of the Government personnel. The information in the read-only claims data system shall be current and refreshed no less frequently than once every 24 hours. The read-only claims data system shall be made accessible to users on a continual (24 hours per day/7 days per week) basis except for scheduled downtime for system maintenance. To the maximum extent practicable, the Contractor shall schedule system maintenance windows during weekends or non-peak hours to minimize disruption of services to Government users. The Contractor shall provide training and ongoing customer support for this access.

C.2.6.6. [For the East Region]: The Contractor shall manage enrollments, collect premiums/fees, accurately identify and adjudicate claims and perform all requirements for Continued Healthcare

Benefit Program (CHCBP) according to the TPM.

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C.2.6.7. The Contractor shall use commercial best business practices to identify and update

Other Health Insurance (OHI) information stored in DEERS database for non-active duty service member beneficiaries that have no commercial health insurance information on file. These commercial best practices may include, but are not limited to the use of an external data base to achieve the goal of identification of accurate and complete OHI information. All OHI information data fields shall be populated to ensure that MTFs can perform their Third Party

Collections functions efficiently (see Attachment J-6). The contractor shall submit a monthly report on OHI discovery and validation activities in accordance with the CDRL (M370).

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 DEERS. 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 five 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 TRO Director or designated Government representative, the Contractor will provide senior level team member(s) who has the ability to make management decisions for the Contractor within the scope of the contract, to attend meeting(s) with the TRO Director or designated representative(s), either via telephone conference call, video teleconference (VTC), or other agreed-upon electronic media. For urgent matters, the Contractor will provide a senior level team member(s) with the ability to obligate resources within the scope of the contract and to attend in-person meeting(s) with the TRO Director or designated representative(s) within one work day at a location identified by the TRO Director or designated representative.

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 process improvements 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 coordination of healthcare delivery between the direct care system and the Contractor's network. The Contractor shall collaborate with the MTF

Commanders/eMSM Managers, and TRO staff to ensure the most efficient mix of healthcare

HT9402-15-R-0002 Page C-12 of C-15 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 CO 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, ROFRs for designated specialty care, and beneficiary enrollment according to the CDRL (R140).

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 disasters. The Contractor shall develop and implement a contingency program designed to ensure that healthcare 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 including regionally coordinated table-top contingency exercises if requested by the MTF Commander or eMSM

Manager (for MTFs listed in Attachments J-1 through J-4) up to twice each calendar year per each MTF and each eMSM.

C.2.7.6. The Contractor shall develop and maintain an information system/data repository which includes access to data at the beneficiary non-institutional and institutional level. The information in this information system/data repository shall be current and refreshed no less frequently than once every 24 hours. The information system/data repository shall be made accessible to users on a continual (24 hours per day/7 days per week) basis except for scheduled downtime for system maintenance. To the maximum extent practicable, the Contractor shall schedule system maintenance windows during weekends or non-peak hours to minimize disruption of services to Government users. This requirement is in addition to the Medical

Management/Utilization Management data access requirement in C.2.4.1.4. and the Network

Prime beneficiary-centric data warehouse and analytic tools/system in C.2.4.4.1.

C.2.7.6.1. The Contractor shall provide system access to Government personnel. Minimum system access authorizations shall include two authorizations at each MTF and USCG clinic, two authorizations at each enhanced Multi-Service Market (eMSM) Office, two authorizations at each Intermediate Service Command two authorizations at each Surgeons General Office, five authorizations at the Director, TRICARE Regional Offices’s Office, five authorizations at DHA

(various locations), two authorizations at Health Affairs, two authorizations at DHA-Falls

Church, two 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 management, chronic care/disease management, utilization management, and medical management). All data shall be current and refreshed no less frequently than once every 24 hours and accessible to all users identified in C.2.7.6.1. The read-only claims data system shall be made accessible to users on a continual (24 hours per day/7 days per week) basis except for

HT9402-15-R-0002 Page C-13 of C-15 scheduled downtime for system maintenance. To the maximum extent practicable, the Contractor shall schedule system maintenance windows during weekends or non-peak hours to minimize disruption of services to Government users. 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 the SHCD.

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. The

Contractor shall deploy this training no later than 75 days prior to the SHCD and shall make additional training available on an ongoing basis. The Contractor shall provide customer service support to assist Government users during normal business hours for all time zones in the region.

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 TSM.

C.2.7.8. The Contractor shall establish and maintain a privacy program which meets 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.

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 Memorandums of

Understanding (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:

HT9402-15-R-0002 Page C-14 of C-15

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 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

(TDEFIC), TRICARE Pharmacy contractor (TPHARM), the Nurse Advice Line (NAL) contractor, and the Claims Processing and Compliance Accuracy contractor.

C.2.7.12.3. Government agencies: Air Force Medical Service (AFMS) for integration 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 Government, to support MTF and eMSM optimization.

C.2.7.14. The Contractor shall use commercially available web-based mapping software to calculate distance and time standards. The Contractor shall provide user access to this software for up to 12 Government users at no additional cost no later than 120 days prior to the SHCD to enable the Government to evaluate the Contractor’s calculations. The Contractor shall utilize the

Government-provided Catchment Area Directory (CAD) file to update their processes/files as appropriate.

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 MCS 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, MCSCs, 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.2.8.2. The Contractor shall ensure that all operational areas and systems related to the seven key contract areas being evaluated during Performance Readiness Validation (PRV) and

Performance Readiness Assessment and Verification (PRAV) are staffed with a sufficient number of qualified, trained personnel and that all systems and programs are functional prior to

HT9402-15-R-0002 Page C-15 of C-15 the SHCD in accordance with the timelines and performance thresholds identified in TOM

Chapter 2, Section 1. This will facilitate the evaluation of performance readiness in the following key contract areas: (1) provider networks, (2) enrollment, (3) customer service, (4) management,

(5) referral management, (6) claims processing, and (7) medical management. See TOM Chapter

2 for a description of the PRV/PRAV processes and specific requirements.

C.2.9. Program Integrity

C.2.9.1. The Contractor shall refer cases for disposition to DHA Program Integrity that involve

$100,000 or greater in potential losses to the Government following procedures prescribed in the

TOM, Chapter 13, Section 3, Paragraph 5.0.

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.