UPDATED_Section_F_-_T2017_-_01.29.16.pdf

HT9402-15-R-0002 Page F-1 of F-7 Amendment 000009

FAR 52.242-15 Stop-Work Order. (Aug. 1989) – Alternate I (Apr 1984)

F.1. PERIOD OF PERFORMANCE

F.1.1. Base Period (Date of Award to start of healthcare delivery): The Contractor shall begin transition-in activities and complete specific activities by the timelines specified in the TRICARE Operations Manual (TOM) Chapter 2. The Contractor will have a minimum of 9 months to complete transition-in. All transition-in activities shall be completed by the date specified in the Contractor’s IMP/IMS.

F.1.2. Option Periods 1 through 5 will be 12 months each if exercised.

Option Period 1: April 1, 2017 through March 31, 2018

Transition-Out Option (if applicable)

Option Period 2: April 1, 2018 through March 31, 2019

Option Period 3: April 1, 2019 through March 31, 2020

Option Period 4: April 1, 2020 through March 31, 2021

Option Period 5: April 1, 2021 through March 31, 2022

F.1.3. The option periods identified herein are hereby defined as the period in which healthcare is delivered to TRICARE beneficiaries. The start of healthcare delivery is the first day of Option Period 1. In order to meet the requirements of the contract for healthcare delivered for a given period, the Contractor will be performing incidental administrative tasks associated with the given healthcare delivery period beyond that period.

F.1.4. The transition-out period may be exercised during any one of the healthcare delivery periods specified above. The Contractor will begin transition-out activities upon transition-out option exercise and complete the timelines as specified in TOM Chapter 2, Section 1. All transition-out activities shall be completed no later than 9 months after the start of healthcare delivery for the incoming Contractor(s).

F.2. GEOGRAPHIC AREA OF COVERAGE

F.2.1. East Region Contract: The contract shall be referred to as the East Region Contract. It will require development, implementation and operation of a healthcare delivery and support system for TRICARE and other Military Health System (MHS) beneficiaries residing in the states/districts of Alabama, Arkansas, Connecticut, Delaware, District of Columbia, Florida, HT9402-15-R-0002 Page F-2 of F-7 Amendment 000009

Georgia, Illinois, Indiana, Iowa (Rock Island Arsenal area only, see F.2.3.1.), Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Mississippi, Missouri (St. Louis area only, see F.2.3.2.), New Hampshire, New Jersey, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas (excluding areas of Western Texas, see F.2.3.3.), Vermont, Virginia, West Virginia, and Wisconsin. These geographic areas are hereinafter referred to as the East Region Contract. The East Region Contractor shall be responsible for administering and complying with all Continued Health Care Benefit Program (CHCBP) requirements in the entire United States.

F.2.2. West Region Contract: The contract shall be referred to as the West Region Contract. It will require development, implementation and operation of a healthcare delivery and support system for TRICARE and other MHS beneficiaries residing in the states of Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa (except the Rock Island Arsenal area, see F.2.3.1.), Kansas, Minnesota, Missouri (except the St. Louis area, see F.2.3.2.), Montana, Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Texas (areas of Western Texas only, see F.2.3.3.), Utah, Washington, and Wyoming. These geographic areas and states are hereinafter referred to as the West Region Contract.

F.2.3. For the states identified above that cross regional boundaries, the following zip codes define which portion of the state belongs to which region.

F.2.3.1. The state of Iowa is in the West Region except for the following zip codes (Rock Island area) which are in the East Region:

52030 52306 52721 52739 52757 52776 52031 52309 52722 52742 52758 52777 52037 52320 52726 52745 52759 52778 52060 52321 52727 52746 52760 52801 52064 52323 52728 52747 52761 52802 52069 52337 52729 52748 52765 52803 52070 52358 52730 52749 52766 52804 52074 52362 52731 52750 52767 52805 52075 52637 52732 52751 52768 52806 52207 52640 52733 52752 52769 52807 52212 52646 52734 52753 52771 52808 52216 52736 52754 52772 52809 52254 52701 52737 52755 52773 52255 52720 52738 52756 52774

F.2.3.2. The state of Missouri is in the West Region except for the following zip codes (St. Louis area) which are in the East Region:

63001 63040 63088 63128 63177 63350 63005 63041 63089 63129 63178 63351 63006 63042 63090 63130 63179 63352 63010 63043 63091 63131 63180 63353 63011 63044 63099 63132 63182 63357 63012 63045 63101 63133 63188 63359

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63013 63046 63102 63134 63190 63361 63014 63047 63103 63135 63195 63362 63015 63048 63104 63136 63196 63363 63016 63049 63105 63137 63197 63365 63017 63050 63106 63138 63198 63366 63018 63051 63107 63139 63199 63367 63019 63052 63108 63140 63301 63368 63020 63053 63109 63141 63302 63369 63021 63055 63110 63143 63303 63370 63022 63056 63111 63144 63304 63373 63023 63057 63112 63145 63330 63376 63024 63060 63113 63146 63332 63377 63025 63061 63114 63147 63333 63378 63026 63065 63115 63150 63334 63379 63027 63066 63116 63151 63336 63381 63028 63068 63117 63155 63338 63382 63030 63069 63118 63156 63339 63383 63031 63071 63119 63157 63341 63384 63032 63072 63120 63158 63342 63385 63033 63073 63121 63160 63343 63386 63034 63074 63122 63163 63344 63387 63035 63077 63123 63164 63345 63388 63036 63079 63124 63166 63346 63389 63037 63080 63125 63167 63347 63390 63038 63084 63126 63169 63348 63039 63087 63127 63171 63349

F.2.3.3. The state of Texas is in the East Region except for the following zip codes (western portions of the state) which are in the West Region:

79009 79855 79931 79978 88531 88562 79035 79901 79932 79980 88532 88563 79053 79902 79934 79990 88533 88565 79325 79903 79935 79995 88534 88566 79344 79904 79936 79996 88535 88567 79347 79905 79937 79997 88536 88568 79718 79906 79938 79998 88538 88569 79734 79907 79940 79999 88539 88570 79754 79908 79941 88510 88540 88571 79770 79910 79942 88511 88541 88572 79772 79911 79943 88512 88542 88573 79780 79912 79944 88513 88543 88574 79785 79913 79945 88514 88544 88575 79786 79914 79946 88515 88545 88576 79821 79915 79947 88516 88546 88577 79835 79916 79948 88517 88547 88578 79836 79917 79949 88518 88548 88579 79837 79918 79950 88519 88549 88580 79838 79920 79951 88520 88550 88581 79839 79922 79952 88521 88553 88582 79843 79923 79953 88523 88554 88583 79845 79924 79954 88524 88555 88584 79846 79925 79955 88525 88556 88585

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79847 79926 79958 88526 88557 88586 79849 79927 79960 88527 88558 88587 79851 79928 79961 88528 88559 88588 79853 79929 79968 88529 88560 88589 79854 79930 79976 88530 88561 88590 88595

F.3. REPORTS AND PLANS

Unless otherwise specified, the Contractor shall electronically submit all Contract Data Requirements List items (CDRL) (contract plans, reports, etc.) in the specified format using Microsoft Office Excel, Word, PDF, or other specified software. If no format is specified, the Contractor may use its own format. Unless otherwise specified, all CDRL items shall be submitted to the Government via the E-commerce Extranet (https://tma-ecomextranet.ha.osd.mil/logon/logon.cfm). (See the TOM, Chapter 14, Section 1, for report submission requirements.)

F.3.1. The Contractor shall provide all reports and plans that are specified in this Section. The Contractor is accountable for assuring that reports contain accurate and complete data. The Contractor shall prepare written procedures describing the source of information as well as the specific steps followed in the collection and preparation of data for each report. All reports must be supported with sufficient documentation and audit trails. The reports shall be titled as listed.

The Contractor shall submit a negative report if there is no data to report. Required reports include:

F.3.1.1. Daily Reports D010 Non-Financially Underwritten Contractor Payment/Check Issue Data D020 Financially Underwritten Contractor Payment/Check Issue Data

F.3.1.2. Weekly Reports W010 Integrated Master Plan (IMP) and Integrated Master Schedule (IMS) Status Report W020 Transition-Out (Phase-Out) Status Report W030 Weekly Claims Processing Statistics Report W040 Deferred Claims Report

F.3.1.3. Monthly Reports M010 Enrollment Plan Implementation Report M020 Customer Satisfaction Report M030 Education Presentation Report M040 Clinical Support Agreement (CSA) Report M050 HIPAA Privacy Complaint Report M060 TRICARE Reserve Select (TRS)/TRICARE Young Adult (TYA)/TRICARE Retired Reserve (TRR) Premium Activity Report M070 Beneficiary Services Report M080 Case Management (CM) and Chronic Care/Disease Management (DM) Report M090 Management Report M100 Medical Management Report M110 Network Adequacy Report (NAR) M120 Network Inadequacy Report

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M130 Non-Financially Underwritten Accounts Receivable Summary Report (Government) M140 Non-Financially Underwritten Accounts Receivable Summary Report (Non-Government) M150 Non-Financially Underwritten Bank Account Reconciliation Report M160 Non-Financially Underwritten Bank Cleared Payment Data M170 Financially Underwritten Bank Cleared Payment Data M180 Non-Financially Underwritten Bank Account Statement Report M190 Overpayment Cases Against VA Facilities M200 Customer Support Hours Used M210 Access Standards Report M220 Network Adequacy/Access - Referrals to MTF & Network Report M230 Continued Health Care Benefit Program (CHCBP) Adjusted Premiums Report (East Region) M240 Continued Health Care Benefit Program (CHCBP) Enrollment Premium Report (East Region) M250 Continued Health Care Benefit Program (CHCBP) Enrollment Report (East Region) M260 Continued Health Care Benefit Program (CHCBP) Premiums Summary Report (East Region) M270 Continued Health Care Benefit Program (CHCBP) Workload Report (East Region) M280 Right of First Refusal Referrals (ROFR) Report M290 Behavioral Health Un-activated Referrals M300 Comprehensive Autism Care Demonstration Report (M) M310 Employee Access to DoD IS/Networks Report M320 Directed Referrals Report M330 Clinical Quality Management (CQM) Quality Intervention Report M340 Contractor Records Accountability Report M350 ADSM Enrollment Report M360 DHA-GL Deferred Claims Report M370 OHI Discovery and Validation M380 Emergency Room (ER) Outliers Report M390 Preauthorizations/Authorizations and Referral Timeliness/Accuracy M400 Integrated Disability Evaluation System (IDES) Memorandum of Agreement (MOA) Claims Without Authorization M410 Adjudicated Referral/Claims Report M420 TRICARE Prime Enrollment Fees Wire Transfers Report

F.3.1.4. Quarterly Reports Q010 Retrospective Review for Other than Diagnostic Related Group (DRG) Validation Report Q020 Claims Audit Report Q030 Beneficiary Access Assistance Report Q040 Fraud and Abuse Summary Report Q050 Referrals Received by Specialty Report Q060 Evolving Practices Report Q070 Quality Assessment Report Q080 Capital and Direct Medical Education Update Report (Quarterly) Q090 MTF Level Contingency Exercise Participation Q100 Comprehensive Autism Care Demonstration Report (Q) Q110 Mental Health Counselor Status Report Q120 Beneficiary Satisfaction Survey Report Q130 Predictive Modeling Report Q140 Listing of Prime Service Areas (PSA) Zip Codes Q150 Health System area Assessment Report Q160 TRICARE Quality Monitoring Contract (TQMC) Findings Response Report

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F.3.1.5. Semiannual Reports SA010 Comprehensive Autism Care Demonstration Report (SA) SA020 Ambulatory Retrospective Review Report SA030 Agency for Healthcare Research and Quality Patient Safety Indicators Report

F.3.1.6. Annual Reports A010 Clinical Quality Management Program (CQMP) Report A020 Indirect Medical Education (IDME) Ratios for Children’s Hospitals Report A030 Third Party Recoveries for Fiscal Year Report A040 State Prevailing Annual Update Report A050 Statement on Standards for Attestation Engagements SSAE No. 16 (Prime) A060 Statement on Standards for Attestation Engagements SSAE No. 16 (Sub-Contractor) A070 Capital and Direct Medical Education Report (Annual) A080 National Institutes of Standards and Technology (NIST) Certification of Compliance Report A090 Disaster Recovery Test Results Report A100 Risk Assessment Letter of Assurance A110 Freedom of Information Act (FOIA) Releasable Contract A120 Memorandum of Understanding (MOU) with (MTF/eMSM Name) A130 Fraud Detection and Prevention Strategy and Internal Procedures A140 MOU with TRICARE Regional Office A150 MOU with (East/West Contractor Name) A160 MOU with (TPharm Contractor Name) A170 MOU with (TDEFIC Contractor Name) A180 MOU with (TOP Contractor Name) A190 MOU with US Coast Guard A191 MOU with (Nurse Advice Line Contractor Name) A192 MOU with (TRICARE Claims Review Services Contractor Name) A193 MOU with (Air Force Medical Service for Referral Management Suite Contractor Name) A194 MOU with (Active Duty Dental Program Contractor Name) A195 MOU with (TRICARE Dental Program Contractor Name) A196 MOU with (TRICARE Retiree Dental Program Contractor Name) A200 Provider Credentialing and Privileging File Audit Report A210 Affordable Care Act Information Reporting for CHCBP Enrollees (East Region)

F.3.1.7. Annual Plans AP010 Enrollment Plan AP020 Medical Management (MM)/Utilization Management (UM) Plan AP030 Clinical Quality Management Program (CQMP) Plan AP040 External Resource Sharing Plan AP050 Contingency Program Plan AP060 Education Plan AP070 Chronic Care/Disease Management Program Plan AP080 Network Implementation Plan AP090 Continuity of Operation Plan (COOP) AP100 Internal Quality Management/Quality Improvement (QM/QI) Program Plan

F.3.1.8. As Required Plans/Reports R010 Integrated Master Plan (IMP) and Integrated Master Schedule (IMS) R020 Serious Reportable Events (SREs) R030 Accreditation and Certification Reports and Documentation

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R040 Service Assist Team (SAT) After-Action Report R050 Designated Standards Maintenance Organization (DSMO) Meeting Summary Report R060 DHA/MTF Fraud & Abuse Referral Cover Sheet R070 Fraud/Abuse Patient Harm-Initial Notification Checklist R080 Random Sample Audit Worksheet R090 Standard Operating Procedures (Desk Procedures) R100 Threats Report R110 Breach Report R120 Appeals, Processing Guidelines, Desk Instructions and Reference Materials R130 Purchased Care MTF Prime Enrollment Inpatient Report R140 Right of First Refusal (ROFR) Capability Report R150 Declaration of Transfer and Destruction of Records R160 MOU with DHA Communications R170 TPR Claims Processed to Completion R180 Inpatient Admission Notification Report R190 Special Programming Ad Hoc Reports R200 CHCBP Ad Hoc Reports (East Region) R210 Internal QM/QI Report R220 Systems Integration Test Plans R230 B2B Gateway Questionnaire R240 TRICARE Quality Monitoring Contract (TQMC) Findings Response Report

F.3.1.9 One Time OT010 Transition-Out (Phase-Out) Plan OT020 Access to Care Plan