UPDATED_Section_G_-_T2017_-_1.20.16.pdf

SECTION G

CONTRACT ADMINISTRATION DATA

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G.1. DFARS 252.204-7006 Billing Instructions. (OCT 2005)

When submitting a request for payment, the Contractor shall--

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

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

(End of Clause)

G.2. DFARS 252.232-7003 Electronic Submission Of Payment Requests And Receiving Reports. (JUN 2012)

(a) Definitions. As used in this clause—

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

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

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

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

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

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

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

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

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

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

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

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

(End of clause)

G.3. CONTRACT ADMINISTRATION

G.3.1. Procuring Contracting Officer (PCO):

The PCO is responsible for the administration of this contract and is solely authorized to take action on behalf of the Government. Unless specified otherwise within this contract, the PCO is referred to as the Contracting Officer. The Contacting Officer for this contract is:

Contracting Officer Defense Health Agency

Contracting Operations Division – Aurora (COD-A) 16401 East Centretech Parkway Aurora, CO 80011-9066

G.3.2. Administrative Contracting Officer (ACO):

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

G.3.3. Contracting Officer’s Representative (COR):

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The Contracting Officer will designate a Contracting Officer’s Representative in writing, and provide a copy of the designation letter to the Contractor. The designation letter will delineate the scope of authority of the COR to act on behalf of the Contracting Officer.

The COR has no authority to make any commitments or changes that affect any term or condition of the contract.

G.3.4. Contractor Points of Contact personnel:

The names and addresses of the Contractor’s primary and alternate point of contact (POC) for contract implementation and compliance are as follows:

Primary: Alternate:

G.3.5. Paying office:

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

G.3.5.1. RESERVED.

G.4. RESERVED

G.5. PAYMENT INSTRUCTIONS FOR MULTIPLE ACCOUNTING

CLASSIFICATION CITATIONS

In accordance with DFARS PGI 204.7108, this subsection provides instructions to the paying office:

G.5.1. Accounting & appropriation citations: When obligated, any multiple accounting and appropriation citations will be identified in Section B as informational subline items.

G.5.2. Each CLIN is a separate contract type. Payments will be applied at the CLIN or SubLine Item (SLIN) level. The paying office will assign payments to the accounting classification citation(s) based on the anticipated work performance under each CLIN as follows:

G.5.2.1. Where there is a single line of accounting under a CLIN, the payment office will make payments with the funds established for that CLIN. If there is more than one line of accounting within a CLIN, the payment office will determine the appropriate line of accounting to use based on period of performance.

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G.6. OTHER INSTRUCTIONS TO PAYING OFFICE

G.6.1. The paying office will follow paying instructions included in any contract modification, including change order definitizations and performance incentive payment modifications.

G.6.2. The due date for making invoice payments to the Contractor is specified in the Prompt Payment clause, FAR 52.232-25, included in this contract (i.e.: 30th day from receipt of proper invoice or acceptance). The Prompt Payment clause with its Alternate I apply to Underwritten Health Care Cost and Disease Management CLINs. For all line items except for Underwritten Health Care Cost, the paying office will make invoice payments on or before the due date, but not earlier than 7 calendar days prior to the due date. For Underwritten Health Care Cost, the paying office should make invoice payments on the 7th calendar day from receipt or acceptance of a proper invoice/voucher.

As specified in Alternate I of the Prompt Payment clause, the payment office will use the due date (30th day after receipt of a proper invoice or acceptance) for computing any late payment interest penalties that may apply. For the Underwritten Health Care Cost processed using the TED system, the completion of the batch TRICARE Encounter Data (TED) submission (end date/time) is sent to DHA and will be used to determine the date of receipt. In the event that the payment office is informed of an audit or other review of a specific payment request to ensure compliance with the terms and conditions of the contract, or there are disagreements on the payment amounts, the payment office is not compelled to make payment by the above dates.

G.6.3. Revisions to payment instructions may be made as circumstances require. This may be accomplished by correspondence between the contracting office and the paying office.

G.7. PMPM MILITARY HEALTH SYSTEM (MHS) ELIGIBLE BENEFICIARIES

G.7.1. For the purpose of this CLIN, counts of MHS eligible beneficiaries under the PMPM includes all MHS eligible beneficiaries, underwritten and non-underwritten, with the exception of those covered under Uniformed Services Family Health Plan (USFHP).

The contract region’s count of MHS eligible beneficiaries under the PMPM CLINs is based on the eligible beneficiary’s address as contained in Defense Enrollment Eligibility Reporting System (DEERS). This includes Prime enrollees who may be enrolled in a different region. The count is taken from the MHS Data Repository (MDR) Point-in- Time Extract (PITE). The MDR PITE is derived monthly from the DEERS PITE, which is a snapshot of the DEERS database reflecting beneficiary status and address at the end of each month.

G.7.2. The Government will unilaterally determine the number of MHS eligible beneficiaries prospectively two times for each option period under each PMPM SLIN, once for the first six months of each option period under SLIN X003AA and once for the

HT9402-15-R-0002 Page G-5 of G-21 Amendment 000008 seventh through twelfth month of each option period under SLIN X003AB. This number will be based on an average of six of the seven previous months of eligible beneficiaries as reported above. Using the number of MHS eligible beneficiaries, the Government will calculate the PMPM quantity for the next bi-annual period as follows: The number of MHS eligible beneficiaries multiplied by the number of months (6) equals the number of member months (the quantity). The number of member months is then multiplied by the fixed unit price to determine the extended amount for the period.

G.8. INVOICE AND PAYMENT – NON-TEDS

Non-TEDs invoice and vouchers shall be submitted electronically in accordance with G.2 above. A proper invoice must include the elements identified at FAR 32.905.

G.8.1. Transition-In: The Contractor may request an interim payment of 50% of the transition-in price upon the start of health care delivery at the conclusion of the base period (transition). The Contractor may request payment of the remaining 50% of the transition-in price after the first full month of healthcare delivery.

G.8.2. Underwritten Health Care - Fixed Fee: Submit voucher (i.e. SF1034) no more frequently than monthly and only after completion of the given month.

G.8.3. PMPM: Submit invoice no more frequently than monthly and only after completion of the given month for no more than one-sixth (rounded to the nearest dollar) of the extended SLIN amount.

G.8.4. Earned Performance Incentive: The Contractor shall invoice as instructed by the Contracting Officer following determination of any performance incentive amounts.

G.8.5. Transition-Out: Interim cost reimbursement vouchers (i.e. SF1034) shall be submitted no more frequently than monthly, and only after completion of the given month, to the cognizant Defense Contract Audit Agency (DCAA) office for approval with a copy provided to the Contracting Officer and CRM.

G.8.5.1. Transition-Out Fixed Fee: The Contractor shall submit a voucher after accomplishing the required Transition-Out requirements. The voucher shall be sent to the Contracting Officer’s Representative for the fixed fee upon completion of all transition-out requirements with a copy provided to the Contracting Officer and CRM.

G.8.6. Modifications: The Contractor may invoice for change order definitizations, Clinical Support Agreements, Service Assist Teams, or other modifications after the Contracting Officer provides instructions and authorization to invoice via modification.

G.9. RESERVED (INVOICE AND PAYMENT – CLAIMS PROCESSING CLINs)

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G.10. TEDS SUBMITTAL INSTRUCTIONS (UNDERWRITTEN AND NON-

UNDERWRITTEN HEALTH CARE):

G.10.1. TEDS shall be submitted per TSM requirements. TEDS shall be grouped under the correct Batch/Voucher CLIN/ASAP Account Number (assigned by DHA/CRM) in accordance with TSM Chapter 2, Section 1.1., Paragraph 6.0. Adjustments and cancellations may be included with initial submissions.

• All TED record based payments where the Contractor has billed using an incorrect Batch/Voucher CLIN/ASAP Account Number in the Batch/Voucher Header and a payment transfer has occurred shall be reported daily on the Contractors Resource Center (CRC) website by TED Record Indicator (TRI) by line item usually the day following receipt of TED data by DHA.

G.10.2. Voucher Transmission Requirements: Underwritten Batch/Vouchers shall be transmitted by 10 AM Eastern Time to be considered for that day’s business. Non-underwritten Batch/Vouchers received after 10:00 AM Eastern Time shall be considered received the next business day for payment and check release authorization purposes.

Batch/Vouchers must pass all TED header edits as specified in the TSM. If all header edits are not passed, the Batch/Voucher will be rejected and returned to the Contractor.

G.10.3. Voucher Integrity: Voucher header and detail amounts transmitted by the Contractor become “fixed” data elements in the finance and accounting system for purposes of control and integrity. Corrections or adjustments to reported (payment) amounts must be accomplished on separate voucher transmissions. Voucher submissions (non-underwritten payments) later determined to be underwritten benefits shall be corrected using the voucher process to reverse the submission and resubmitted under the batch process and vice versa (see TSM, Chapter 2, Section 1.1, paragraph 3.5.).

G.10.4. Payment Suspension and TED Processing During Partial Funding Shortages:

G.10.4.1. Some of the funding DHA receives may be restricted in use to a specific federal agency, military department and/or to a particular health care program. Funding for these special purpose programs may run out before funding for other DHA programs.

Therefore, the Contractor shall have the ability to suspend claims payment and the associated submission of institutional TED records or non-institutional TED line item(s) to DHA based on values contained in the following TED record fields:

• Service Branch Classification Code (Sponsor), SBCC - As specified in the TSM, Chapter 2, Section 2.8.

• Enrollment/Health Plan Code (E/HPC) - As specified in the TSM, Chapter 2, Section 2.5.

• Special Processing Code (SP) - As specified in the TSM, Chapter 2, Section 2.8.

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• Health Care Delivery Program Coverage Code - As specified in the TSM, Chapter 2, Addendum M.

• By Batch/Voucher CLIN/ASAP Account Number – As specified in the TSM Chapter 2, Section 2.3.

G.10.4.2. The suspension of claims payment and TED records may be based on a single value (e.g., SBCC=A) or a combination of values (e.g., SBCC=A & E/HPC=SR).

Suspension of TED records (institutional) or TED line items (non-institutional) containing specific values shall be implemented by the Contractor within five workdays after receiving notification from the Contracting Officer. On the sixth workday, DHA/CRM will implement immediate payment offset against Contractor invoices of any amounts paid by the Contractor from their Non-Underwritten Bank Account(s) for institutional TED records or non-institutional TED line items containing suspended value(s). The Contractor shall not, without prior Contracting Officer approval, initiate payment offset against any provider or beneficiary for payments made against suspended transactions and offset by DHA/CRM on Contractor invoices.

G.10.4.3. For all suspended transactions, the Contractor shall hold the claim information until receiving instructions from the Contracting Officer to do otherwise. The Contractor shall not reject the claims or return any information to the providers or beneficiaries unless instructed by the Contracting Officer. Once the Contracting Officer lifts the TED data submission restriction, the Contractor may submit all withheld TED data on the next appropriate (batch/voucher) data submission. DHA/CRM will reimburse the Contractor (without interest) for any invoice payment offsets done for TED suspended transaction that have not been recouped by the Contractor.

G.10.5. Federal Fiscal Year-end Processing:

G.10.5.1. All TED data must be received no later than 10:00 AM EDT, (8:00 AM MDT;

7:00 AM PDT) on September 28. Any Batch/Voucher received after 10:00 AM EDT will be rejected by DHA and must be resubmitted by the Contractor using next fiscal year Batch/Voucher CLIN/ASAP Account Numbers. The Contractor should not submit Batch/Vouchers with dates of September 29 and September 30. Any payment processed after September 28th, must use the next fiscal year Batch/Voucher CLIN/ASAP Account Numbers and must utilize the new fiscal year check stock, as applicable. The Contractor shall not submit Batch/Vouchers to DHA between September 28, 10:00 AM Eastern Time or before October 1, 12:01 AM Eastern Time.

G.10.5.1.1. For Underwritten Claims – Any rejected Batch/Voucher must be resubmitted with a Batch/Voucher Date of, or after, October 1. No change is needed to the Batch/Voucher CLIN/ASAP Account Numbers.

G.10.5.1.2. For Non-Underwritten Claims – Any rejected Batch/Voucher must be resubmitted by the Contractor using next fiscal year’s Batch/Voucher CLIN/ASAP

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Account Numbers. Any payments related to a rejected TED Batch/Voucher and any payment processed after September 28th must use the next fiscal year Batch/Voucher CLIN/ASAP Account Numbers and must utilize the new fiscal year check stock, as applicable. Any collections related to a rejected Batch/Voucher should be moved to the bank account for the next fiscal year. TEDs related to Voided/Stale-dated payments will always be submitted based on the Batch/Voucher CLIN/ASAP Account Numbers of the original TED, matching the original bank account.

G.10.5.2. All payments not included in the Contractor’s final fiscal year data submission on September 28 must have a Batch/Voucher Date on or after October 1. Contractors will be able to test their new fiscal year’s transactions in benchmark starting September 1.

Like production, benchmark data must be received at DHA by 10AM EDT on September

28. After 10 AM EDT on September 28 until October 1, 12:01 AM Eastern Time no benchmark data can be transmitted to DHA.

G.11. UNDERWRITTEN HEALTH CARE (COST REIMBURSEMENT) - TEDS

G.11.l. Underwritten claims are reimbursed upon all TED records within a TED header clearing all TED Header edits and each record clearing all TED Detail edits. DHA/CRM will render payment to the Contractor based on the payment terms specified by CLIN in the contract. Negative TED records (credits) do not have to pass all TED Detail edits, DHA/CRM will collect all Underwritten credits within seven (7)calendar days of receipt.

G.11.2. TED Adjustment Procedure for Additional Payment or collections citing an Active CLIN (Also see TOM Chapter 11 for Underwritten Underpayment): When the Contractor makes an additional payment due to a prior underpayment or collects monies due to a prior overpayment, these payments/collections shall be reported as an adjustment to the original TED record. The Contractor shall use the Begin Date of Care for non-institutional or Admission Date for institutional claims to determine option period and then select the appropriate CLIN/ASAP ID. This should be the same CLIN/ASAP ID used to report the original payment/collection on TED records.

G.11.3. TED Underwritten CLIN Closure Procedures: Underwritten healthcare CLINs will be closed at Government convenience no earlier than 13 months after the expiration of the option period - except for the final Option Period where CLIN closure will occur no earlier than 30 days after the end of healthcare delivery. DHA will notify the Contractor at least 30 days before the underwritten CLIN closure process is initiated.

Upon notification of CLIN closure the Contractor must attempt to clear all rejected (Bad Master) claims before the scheduled CLIN closure date. On the date the CLIN is scheduled to be closed and after all TED data received before the 10 AM ET cutoff has been processed, DHA/CRM will change the CLIN status from ‘Active’ to ‘Closed’.

When the CLIN is closed any Batch/Vouchers that are in a resubmission status will be manually closed by DHA/CRM. Any new TED data submissions received after CLIN closure and citing the ‘Closed’ CLIN shall be rejected.

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G.11.3.1. Settling the CLOSED CLIN: The Government and the Contractor will conduct a reconciliation of the CLIN to determine the total amount billed against the CLIN based on all Contractor invoices (TED data submissions and any non-TED vouchers) citing the CLIN prior to CLIN closure (including any Batch/Vouchers that were manually closed by DHA/CRM). The Government shall determine the value of the CLIN based on the payments made by DHA/CRM taking into account incorrect billings, manual closures, transfers, etc., therefore the total amount billed against the CLIN and the total (paid) value of the CLIN may be different. The Government shall account for all Contractor invoiced amounts citing the closed CLIN(s) itemizing all billing corrections where the billed CLIN (Contractor) and the paid CLIN (Government) are not equal. CLIN closure does not constitute final settlement of the value of the CLIN, closure only ends the transactional phase (billing and payment); contract specified audits and future events may also affect the final value of the CLIN.

G.11.3.2. Debt: For uncollected underwritten debt identified prior to CLIN closure and reimbursed to the Government, the Contractor shall follow procedures of TOM Chapter 3, Section 3, paragraph 2.2.1. All new debt identified after CLIN closure shall be classified as non-underwritten debt and shall be collected and reimbursed to the Government in accordance with the collection and deposit requirements specified in the TOM Chapter 3, Section 3, Paragraph 2.1.

G.11.3.3. Resuming TED Claims Processing: All healthcare claims with dates of care that fall within a closed CLIN(s) period of performance shall be processed (payments and collections) as Non-Underwritten health care costs using the current fiscal year Non- Underwritten Bank Account. Claims processing as non-Underwritten can resume immediately after CLIN closure.

G.11.4. Fiscal Year Start-Up of Underwritten Batch/Voucher CLIN/ASAP Account Numbers: After fiscal year end (September 30th) TED data submissions can resume on October 1st. Underwritten CLINs shall use the same Batch/Voucher CLIN/ASAP Account Numbers for the life of the contract. All Batch/Voucher Headers submitted for the new fiscal year must have a Batch/Voucher Date equal to or greater than October 1st(including any rejected data submissions received after 10 AM ET on September 28th).

G.11.5. Alternate payment process for underwritten benefits due to problems with DHA TED record processing: DHA will not be using WAWF for the invoicing of Underwritten Healthcare CLINS during temporary claims processing system outages. Upon notification by the Contracting Officer that the TED Record processing system is not operating normally, manual invoices shall be submitted by the Contractor as email attachments and sent to rm.invoices@dha.mil. Underwritten invoices (email attachments) manually billed to DHA/CRM shall itemize amounts due by the Batch/Voucher Headers (data elements listed below) that will be submitted to DHA when mailto:rm.invoices@dha.mil

HT9402-15-R-0002 Page G-10 of G-21 Amendment 000008 claim processing resumes. The Contractor requests will include the following Header information for each voucher (See TRICARE Systems Manual, Chapter 2, Section 2.2):

ELN Element Name

0-001 Header Type Indicator 0-005 Contract Identifier 0-010 Contract Number 0-015 Batch/Voucher Identifier 0-020 Batch/Voucher Number 0-025 Batch/Voucher ASAP Account Number 0-030 Batch/Voucher Date YYYYDDD 0-035 Batch/Voucher Sequence Number 0-040 Batch/Voucher Resubmission Number 0-045 Total Number of Records 0-050 Total Amount Paid

Manual payments will be made within seven (7) calendar days of receipt of invoice. All amounts paid based on manual invoices submitted during healthcare claims processing system outages shall be considered interim payments and will be offset against payments based on actual TED data submissions when claim processing resumes. The Contractor shall have 30 days to clear all vouchers where interim payments have been made thru the TED header edits (as specified in the TRICARE Systems Manual, Chapter 2). Failure to clear all header edits for any vouchers where the Contractor was paid under this contingency process shall result in the Government collecting back any missing/rejected voucher header(s) totals via payment offset. When the missing/rejected vouchers clear the header edits, any monies collected via payment offset shall be refunded to the Contractor (without interest or penalty.

G.11.6. Closing Vouchers on Bad Master: If a Contractor feels a TED record will never clear edits, the Contractor may request they be paid for any related claims and claim processing fees and that the voucher be manually closed. The request shall be submitted to CRM and shall include the specific TRIs involved. The request shall be verified by CRM and the Performance Analysis and Transition Branch. If it is confirmed that the TRIs cannot clear the TED edits, CRM shall pay the Contractor the amounts due within seven (7) calendar days of verification and the voucher will be closed on the Bad Master.

Closing Vouchers on Bad Master: If a Contractor feels a TED record will never clear edits, the Contractor may request they be paid for any related claims and claim processing fees and that the voucher be manually closed. The request shall be submitted to CRM and shall include the specific TRIs involved. The request shall be verified by CRM and the Performance Analysis and Transition Branch. If it is confirmed that the TRIs cannot clear the TED edits, CRM shall pay the Contractor the amounts due within seven (7) calendar days of verification and the voucher will be closed on the Bad Master.

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G.12. NON-UNDERWRITTEN HEALTH CARE (PASS THROUGH) – TEDS

G.12.1. The Contractor acts as a Fiscal Intermediary for the Government to distribute, or pass-through, Government funds for certain non-underwritten health care benefits. These are not costs to the Contractor and are not reimbursed by the Government, so the Contractor shall not collect or hold non-underwritten benefit funds before dissemination to the beneficiary or provider and the Contractor shall immediately return any collections to the Government.

G.12.1.1. Non-underwritten benefit payments by the Contractor on behalf of the Government will be facilitated by allowing the Contractor (through the Contractor's financial institution) to draw money from the designated Federal Reserve Bank (FRB).

These draws may only be done for benefit payments that have previously been submitted on TEDs or as a non-TED, non-underwritten voucher and approved for release by DHA/CRM and are clearing the Contractor's financial institution on the day the draw is being accomplished. Advance payments are not allowed. No bank fees or other bank charges shall be paid from this account and no money should be drawn from the FRB for these charges.

G.12.1.2. All payments for non-underwritten claims processed by the Contractor must be approved by the DHA/CRM Budget Office before the Contractor may make payments to the beneficiary or provider. Unapproved draws and payments by the Contractor will be immediately collected and subject the Contractor to interest and penalties.

G.12.1.3. TED records that do not pass all TED detail edits are considered insufficient justification to support draws from the Federal Reserve Bank. TEDs must pass all TED detail edits within ninety (90) days after initial notice of edit failures is sent to the Contractor by DHA. If not corrected in 90 days, DHA/CRM may send a demand letter requiring resolution or reimbursement for all claims identified as edit failures. The Contractor shall respond within thirty (30) calendar days of the demand letter as to why the claim(s) in question cannot be corrected. If resolution cannot be reached between CRM and the Contractor, the total amount of improper payments still in dispute, as well as any applicable administrative claim payment amounts will be collected by CRM by offsetting other payments to the Contractor. These collections may be returned to the Contractor upon correction of the TEDs involved or some other resolution is reached.

The Contractor shall take no recourse against TRICARE beneficiaries or providers without prior DHA approval.

G.12.2. Establishment of Non-Underwritten Bank Accounts:

G.12.2.1. The Department of Treasury’s Automated Standard Application for Payment System (ASAP), along with FEDWIRE, provide a mechanism for disbursement of Government funds for health care services received by TRICARE beneficiaries that are not underwritten by the Contractor. After authorization by DHA/CRM, these systems

HT9402-15-R-0002 Page G-12 of G-21 Amendment 000008 allow the Contractor to draw cash directly from the FRB to cover payments as they clear the Contractor’s bank account. ASAP is used by the Treasury, the FRB and DHA/CRM to verify the authorization to make draws and to track transactions made by the Contractor’s bank. FEDWIRE is used by the Contractor’s bank to actually draw funds from the FRB.

G.12.2.2. The Contractor shall establish bank account(s) for non-underwritten transactions with a commercial bank that has FEDWIRE capability following Treasury requirements. The Contractor shall submit bank information to DHA/CRM not later than 60 calendar days prior to the beginning of processing claims on a new account. The information shall include:

• Name of Bank

• Overnight mail address

• American Banking Association (ABA) routing number

• The Contractor’s DUNS number

• The Bank’s DUNS number

• Taxpayer Identification Number (TIN) (must be the same TIN used for payment)Contractor’s bank account number (if separate checking and deposit accounts are used, both need to be provided

• Individual point of contact at the bank and an alternate, including their phone numbers and e-mail addresses

• Individual point of contact at the Contractor and an alternate, including their phone numbers and e-mail addresses.

G.12.2.3. DHA/CRM will establish the bank account(s) on ASAP with the Treasury Department. DHA/CRM will notify the bank and the Contractor once the bank account(s) have been established and provide codes or other information necessary for the bank to make draws against the FRB using FEDWIRE. Currently, ASAP has a requirement to identify a total dollar amount that may be drawn on the FRB. This dollar limit, established by DHA/CRM, only represents an administrative ceiling at the FRB, and does not constitute any authority to draw funds. Accounts will also have daily limits for the amount that can be drawn. The Contractor will be notified of these limits by DHA/CRM. DHA/CRM will be able to increase these limits as needed.

G.12.3. Authorization to Release Non-Underwritten Payments: The Contractor shall not release non-underwritten benefit payments without prior authorization from the DHA/CRM Budget Office. Authorization from DHA/CRM to release payments for all TED data submissions received before the 10 AM Eastern Time cutoff (Section G.10.2.)

will be sent to the Contractor via fax or e-mail no later than 5:00 PM Eastern Time the day of receipt. Authorization will specify contract number, ASAP Account ID#, initial transmission received date, and total dollar amount of funds that may be released based on information contained in the Batch/Voucher Header. Approval for funds release will be given provided the following criteria are met:

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• Voucher submissions must pass all header edits as specified in TSM, Chapter 2, Section 2.3.

• DHA/CRM Budget Officer has confirmed that funding is available to cover payments.

G.12.3.1. Benefit payments shall be released/mailed no later than two workdays after DHA/CRM has approved the release of payments.

G.12.3.2. Authorization to release payments does not constitute DHA’s acceptance that all payments are valid and/or correct. Detailed records will be audited for financial compliance. All transactions in these bank accounts must be valid and justified. Any unreported/unauthorized disbursements identified by DHA will be subject to immediate payment offset against any payments being made to the Contractor. All disputed amounts will remain in the possession of the Government until no longer in dispute.

G.12.3.3. Alternate Check Release process for non-underwritten benefits due to problems with DHA TED record processing: Upon notification by the Contracting Officer that the TED Record processing system is not operating normally, manual check release requests shall be submitted by the Contractor as email attachments and sent to RM_Budget@dha.mil. Non-underwritten check release requests (email attachments) manually submitted to DHA/CRM shall itemize amounts due by the Batch/Voucher Headers (data elements listed below) that will be submitted to DHA when claim processing resumes. The Contractor requests will include the following Header information for each voucher (See TRICARE Systems Manual, Chapter 2, Section 2.2):

ELN Element Name

0-001 Header Type Indicator 0-005 Contract Identifier 0-010 Contract Number 0-015 Batch/Voucher Identifier 0-020 Batch/Voucher Number 0-025 Batch/Voucher ASAP Account Number 0-030 Batch/Voucher Date YYYYDDD 0-035 Batch/Voucher Sequence Number 0-040 Batch/Voucher Resubmission Number 0-045 Total Number of Records 0-050 Total Amount Paid

DHA/CRM will return to the Contractor a signed release so the Contractor can pay the providers and beneficiaries without delay. The Contractor must not release payments until this approval is received. Upon notification by the Contracting Officer that the TED Record processing system is operating again, this process can be discontinued and the

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Contractor shall have 30 days to clear all vouchers where payments have been released thru the TED header edits (as specified in the TRICARE Systems Manual, Chapter 2).

Failure to clear all header edits for any vouchers where the Contractor was authorized under this contingency process to release payments shall result in the Government collecting back the rejected voucher header totals via payment offset. When the vouchers clear the header edits, the monies collected via payment offset shall be refunded to the Contractor (without interest or penalty).

G.12.4. Draws on the Federal Reserve:

G.12.4.1. The Contractor shall ensure that cash drawdowns do not exceed the payments authorized, as they clear the bank on a given day, less deposits. The Contractor shall ensure that any excess draws are immediately returned to the FRB. Interest and a penalty will be charged beginning the day after the account is overdrawn and will continue until the overdrawn amount is returned. Interest will accrue daily and is based on the Treasury Current Value of Funds Rate. The penalty will accrue daily and is based on the penalty rates in the Code of Federal Regulations, Title 31, Volume 1, PART 5, Subpart B Sec.5.5.

DHA/CRM may initiate immediate payment offset against any payments to the Contractor for the interest, penalties and/or the overdrawn amount.

G.12.4.2. Contractors with more than one bank account shall ensure transactions are properly accounted for to prevent the commingling of funds. Failure to properly associate transactions with the correct bank account could result in the over-execution of DHA/CRM budget authority. Transfers of funds between bank accounts are strictly prohibited except for correcting deposits that are in the wrong account. Any transactions reported under one bank account and erroneously charged against a different bank account shall be reported immediately to DHA/CRM when identified. DHA/CRM will instruct the Contractor as to what action to take.

G.12.4.3. The total amount of a cash draw down on the FRB is based on the daily total of benefit payments presented to the bank for payment. If estimates are needed due to timing of reports from check clearinghouses or the FRB, the draws shall be adjusted the next business day.

G.12.4.4. Computation of the amount of the draw must include any deposits of funds into the account. These deposits will reduce the amount of cash needed for the draw down on the day of the deposit.

G.12.5. Fiscal Year Start-up of Non-Underwritten ASAP Accounts:

G.12.5.1. The Contractor shall establish a separate bank account for each new Government fiscal year following the procedures specified in G.12.2. “Establishment of Non-Underwritten Bank Accounts”. All payments issued for benefit payments and all refunds received shall be processed against the new account effective the first day of the

HT9402-15-R-0002 Page G-15 of G-21 Amendment 000008 new fiscal year. The Contractor shall also transfer all recoupment installment payments to the new account from the previous year’s account.

G.12.5.2. Cash drawdowns against the prior fiscal year’s bank account may continue, if required, until all payments from the prior year have either cleared or have been canceled, but no longer than the end of February of the following year or five months after the last payments have been cut on an account (in the case of a contract closeout).

G.12.5.3. Bank accounts shall be closed no later than the end of February, following the fiscal year end, or one month after the last payment on an account has been made or voided. Final bank account reconciliation shall be made within 30 calendar days following the last authorized transactions. All transactions that were not previously approved by DHA/CRM shall be explained with supporting documentation on the final bank reconciliation report (Section F) DHA/CRM reserves the right to not accept these transactions.

G.12.5.4. Any outstanding balance in the account shall be reimbursed to DHA no later than the required submission date of the final bank account reconciliation. This balance may be subject to interest if it includes overdrawn amounts that were required to be submitted at an earlier date.

G.12.6. Voided or Stale-dated Payments:

G.12.6.1. For payments that are voided or stale-dated that are over $10, a credit voucher through TEDs must be processed in accordance with the standards detailed in TSM Chapter 1, Section 1.1, paragraph 3. If the check was issued as a manual voucher, the credit should be submitted as a similar manual voucher. The only exception to issuing a credit voucher would be stale-dates under $10.00.

G.12.6.2. For voided/stale-dated payments of $10.00 or less, the Contractor may elect either to:

• Affect a credit voucher for the check using automated means, or

• Instead of making a voucher transaction, a memorandum record shall be prepared and included on a listing of transactions as submitted monthly in the Non- Underwritten Funds Bank Account Reconciliation Report.

G.12.6.3. Replacement Payments:

G.12.6.3.1. Reissuance of payments will be made against the current fiscal year bank account.

G.12.6.3.2. Replacement payments may be issued upon request of the payee or authorized representative. If the check is not returned by the payee, the payee must

HT9402-15-R-0002 Page G-16 of G-21 Amendment 000008 provide a statement describing the loss or destruction of the check. Before a replacement check is issued, a stop payment order for the original check must have been issued and accepted by the bank.

G.12.6.3.3. If the claim history is not available to the Contractor, the Contractor shall submit a request for approval of check release to DHA/CRM within 10 workdays from the request by payee. Supporting documentation shall include the original check, the sponsor’s SSN, a copy of the EOB, (if available) or other documentation showing the computation and payment of the original check, and the check or copy or statement as described in G.12.6.3.2. above.

G.12.6.3.4. The Contractor shall report the reissuance using the same procedure as was used to void/stale-date the original.

G.12.6.3.4.1. If no credit voucher was made in voiding/stale-dating of the check, no credit voucher is required for the reissue (i.e. if the Contractor gets a returned check and immediately reissues from the same bank account, no TED or other voucher needs to be done). If the reissuance involves a check from a prior year, a TED or other voucher will need to be done to report the reissuance from the current year.

G.12.6.3.4.2. If the amount of the stale-dated check to be reissued is $10.00 or less, the Contractor shall use the same procedure in the reissuance as was used for the stale-dating.

If no credit voucher was made in the stale-dating of the check, no credit voucher is required for the reissue. The Contractor shall reissue the payment and include the amount in the Non-Underwritten Funds Bank Account Reconciliation Report.

G.12.6.3.5. Reissuance of Payments When Original Payee is Deceased: Payments issued by the Contractor shall be made payable to the legal representative of the estate of the person concerned with an additional line stating “For the estate of _____.” Payments shall not be payable to the “estate of” a decedent, nor to a deceased person. Payments shall be to the named payee or mailed to the payee’s address of record.

G.12.7. Non-Underwritten Under Payments: When the Contractor makes an additional payment due to a prior underpayment, these payments shall be reported as an adjustment to the original TED record, but in the current fiscal year and current CLIN/ASAP ID regardless of the fiscal year or CLIN/ASAP ID of the original payment.

G.12.8. Non-Underwritten Overpayments: When reporting collections the Contractor makes (whether cash or offset), the collection shall be accomplished as a separate credit transaction as an adjustment to the original TED record. Identified debts shall be reported on the Accounts Receivable Report in accordance with Section F.

G.13. INVOICE AND PAYMENT NON-UNDERWRITTEN - NON-TEDS

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The Contractor shall group and electronically process each type of Non-TED voucher by each non-underwritten cost category identified below as a pass-through payment.

G.13.1. Capital and Direct Medical Education Costs (CAP/DME): Are paid by the Contractor from the Non-Underwritten Bank Account to hospitals requesting reimbursement under the TRICARE/CHAMPUS DRG-Based Payment System (excludes children’s hospitals). (See TRM Chapter 6, Section 8).

G.13.1.1. The Contractor shall submit a monthly CAP/DME voucher in either .csv format or Excel format to DHA/CRM no later than the 20th calendar day of the month following receipt of the hospital’s request for payment. The format for the file is attached in Section J, Attachment 11, CAP DME Data File Format Requirements. Supporting documentation, including copies of the hospital’s claim and the payment calculation, shall be submitted electronically using approved formats specified in TOM Chapter 9, Section 4. Within two calendar days after receiving disbursement clearance from DHA/CRM, the Contractor shall complete the process by making payment to the hospital.

G.13.1.2. If the Contractor makes an underpayment, the Contractor shall determine the amount and pay any amount due to the hospital with the next group of payments made. If the Contractor overpays a hospital, the Contractor shall recoup this amount and document as follows:

a. Offset funds shall be included as credits on the monthly CAP/DME voucher for the month the credits were processed.

b. Collections shall be included as credits indicating the month the collection was deposited (normally the prior month).

c. Debts established under this paragraph and related transactions shall be reported on the monthly Accounts Receivable Report.

G.13.1.3. Federal Fiscal Year-end Processing of Non-TED Vouchers: September CAP/DME vouchers that are submitted in the month of October shall utilize the October new fiscal year check stock.

G.13.2. Bonus Payments (HPSA/PSA): Bonus payments are an addition to the amount normally paid under the allowable charge methodology in order to provide services in medically underserved areas [Health Professional Shortage Areas (HPSA) and Physician Scarcity Areas (PSA)]. On a quarterly basis, the Contractor shall submit the voucher electronically as a pass-through payment. Supporting documentation including lists of doctors, their addresses, and the calculation of the payment, shall also be sent electronically based on approved formats as specified in the TOM, Chapter 2. The Contractor shall process and make payment within two (2) business days after receipt of clearance from DHA/CRM. Any other HPSA/PSA transactions (e.g., voids, stale-dated checks, additional payments) shall either be reported to CRM on the quarterly voucher or, HT9402-15-R-0002 Page G-18 of G-21 Amendment 000008 if not on the quarterly voucher, on a monthly voucher with supporting documentation and notations as to the type of transaction, e.g., void, refund, etc.).

G.13.2.1. Vouchers shall contain the following:

a. Format for Vouchers Period Covered (Quarter) Physician Name Physician Address Physician Provider Number Amount Paid/Collected for Bonus Total Bonus Paid [5 and/or 10 percent of the above bullet] Total of all Bonuses being paid

b. Sort for Vouchers

By Contract By Automated Standard Application for Payment System (ASAP) ID (Fiscal Year) of Bank Account By Type (e.g., standard or active duty) By Coverage (Prime, Extra, Standard) By State By Physician By Physician Number By Specialty By Address & Zip By Participating & Non-Participating By Contracted (Network) and Not Contracted (Non-network) By Modifier (“QB”, “QU” or “AR”)

G.13.2.2. Federal Fiscal Year-end Processing: September HPSA vouchers that are submitted in the month of October shall utilize the October new fiscal year check stock.

G.13.3. Demonstrations and other New Benefit Programs: These are trial or other new programs and they may vary in many ways from routine TRICARE benefits. TEDs will be used if possible but if the data associated with demonstrations is incompatible with TED data formats, the Contractor shall submit a separate voucher to DHA/CRM, with supporting documentation, no more frequently than monthly to obtain approval prior to making payments on the Non-Underwritten Bank Account. More detailed instructions may be given in contract modifications when these programs are established. These payments and any related credits or collections shall be identified on the bank reconciliations as additional lines listed by program.

G.13.4. Other Payments: Other adjustments are rare situations where a payment needs to be made but does not fall into routine processing such as TEDs, etc. For example, these

HT9402-15-R-0002 Page G-19 of G-21 Amendment 000008 payments may be the result of a very old claim, or legal settlements that do not apply to a given individual or payments directed by DHA. These must be submitted to the Contracting Officer and to DHA/CRM with supporting documentation explaining the issues that do not allow a TED record to be created, a copy of the claim, computation of the amount to be paid, and other applicable documents. After release approval by DHA/CRM, the Contractor shall make payment within two (2) working days. The Contractor shall report these payments on the Bank Reconciliation Report under DHA approved manual transactions.

G.14. TRICARE RESERVE SELECT/TRICARE RETIRED RESERVE,

TRICARE YOUNG ADULT, CHCBP (EAST REGION), AND PRIME

FEES/PREMIUMS:

The Contractor shall establish separate non-interest bearing account for the collection and disbursement of premiums. The Contractor shall make daily deposits of premium collections to the established account. The Contractor shall wire-transfer the premium collections, net of refund payments, monthly to a specified Government account as directed by DHA/CRM Finance and Accounting Office. The Government will provide the Contractor with information for this Government account. The Contractor shall notify the DHA/CRM by e-mail within one business day of the deposit specifying the date and amount of the deposit. The Contractor shall submit a monthly report with premium activity supporting the wire transfer of dollars, including premium billings, collections, and enrollments (Section F) for each type of premium.

G.15. REPORTING

Annually, the Contractor shall provide a copy of the Contractor’s Statement of Standards for Attestation Engagements (SSAE) 16 and sub-Contractor’s (if applicable) SSAE 16 per the CDRL requirements (A050 and A060).

G.16 STANDARDS ROUNDING LANGUAGE

Performance Standard Reporting: All numerical representations of performance standards need to be interpreted by the context of the standard and accompanying language. Absent any narrative, normal rounding and significant digit convention shall be used. If any inconsistencies exist for the performance standard throughout the contract, then the Order of Precedence – Uniform Contract Format shall apply (see FAR 52.215-8). Performance standards represented in dollars or units shall be rounded to the nearest dollar or unit using standard rounding conventions (round half up).

For Government performance standards represented as percentages, each Contractor calculated performance standard percentage shall meet or exceed the respective Government contract performance standard to the hundredth of a percent in order to remain in compliance with the contract.

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To ensure consistent practices for rounding and reporting of performance standards stated as percentages, all Contractor performance standard calculations and reporting shall be completed as follows:

Step 1 - Contractor Actual Performance Calculations:

The Contractor shall carry out its performance standard calculations to the hundred thousandths decimal place. All digits following hundred thousandths decimal place shall be dropped.

Step 2 - Percentage Conversion: The calculated…