26_TCRS_Section_J_Exhibit_A_CDRLS.pdf

DD FORM 1423-1, FEB 2001

CONTRACT DATA REQUIREMENTS LIST

(1 Data Item)

PREVIOUS EDITION MAY BE USED.

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP ________ TM _______ OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT

REQUIRED

10. FREQUENCY

11. AS OF DATE

12. DATE OF FIRST SUBMISSION

13. DATE OF SUBSEQUENT

SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final

Reg Repro

15. TOTAL

16. REMARKS

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

Page of Pages

A010 National Institutes of Standards and Technology (NIST) Certification of Compliance Report

Initial

TSM, Ch. 1, Sec. 1.1 PAT&IS/IPE&TS

B

See Block 16

See Block 16

See Block 16

See Block 16 Submit through the DHA E-commerce Extranet (Per TOM Ch 14 Sec 2)

0 0

FIRST SUBMISSION:

Frequency: One Time Reporting Period Start Date: Contract Award Due Date: As determined by contract award requirement. If NIST certified, 30 calendar days prior to anniversary date of certification.

SUBSEQUENT SUBMISSION:

Frequency: Annual (Option Period) Reporting Period Start Date: Start of service delivery Due Date: 30 calendar days before the anniversary date during each option period and resubmission during the option period if there has been a change in compliance with any of the IA controls listed on the checklist, due 30 calendar days after the change.

PHI/PII: No FILE FORMAT: No specific file format required

CONTENT DETAILS:

The Contractor shall submit a completed/signed Checklist and Certification for Minimum Level of Enhanced Safeguarding for Unclassified DoD Information and any applicable Written Determinations to document compliance with minimum enhanced Information Assurance (IA) controls that are shown in the Checklist required by National Institutes of Standards and Technology (NIST) Special Publication (SP) 800-53 and NIST SP 800-53A (Rev 4) Apr 2013.

1. Checklist Completion Instructions:

a. Compliance Statement - The Contractor shall select the appropriate response from the form's drop down list to indicate its compliance with specific IA controls.

b. Assessment Method - The Contractor shall select one or more appropriate NIST-based method(s) to show how it assessed corporate compliance with the specific IA control. Details about the assessment methods, which differ for each control and are reflected in the NIST SP 800-53A.

c. Compliance Date - The Contractor shall enter the date it achieved compliance with the specific IA control.

Continued on Page 2

Terry R. Lowery 08/19/2015 Todd Young 04/22/2016

1 2

A. CONTRACT LINE ITEM NO.

DD FORM 1423 1, FEB 2001 Page ___ of ___ Pages

16. REMARKS (Continued)

CONTRACT DATA REQUIREMENTS LIST

(1 Data Item)

F. CONTRACTORE. CONTRACT/PR NO.

C. CATEGORY:

TDP _____ TM _____ OTHER ________________________________

D. SYSTEM/ITEM

B. EXHIBIT

2. Written Determination Report (WDR) – If the Contractor indicates either “No” or “N/A” for any IA control listed on the Checklist, the contractor will submit a WDR, using a format developed by DHA, to explain its decision rationale and/or mitigating course of action(s). The WDR shall comply with the following instructions.

a. Tracking Number to support clear communications: the contractor shall list a simple tracking number at the top of the WDR for each IA control referenced.

b. Vulnerability Reporting:

1) Single Vulnerability – If an IA control has a single vulnerability, then the contractor shall list the planned mitigation activity and date in the WDR.

2) Multiple Vulnerabilities – If an IA control has multiple vulnerabilities with the same mitigation date, then the Contractor shall list them all in the same WDR. If an IA control has multiple vulnerabilities with different mitigation dates, then the Contractor shall group them by date and list the groups in separate WDR.

c. Mitigation Dates – When the Contractor resubmits the Checklist and associated WDR, the Contractor must always list the actual date – rather than the planned date – for when it completed mitigation activities for an identified vulnerability.

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Written Determination <Insert Reference #> in Support of

DoDI 8582.01 Checklist for Minimum Security Controls

<Insert Date>

Contract Reference # Contractor Name Street Address City, ST ZIP

Information Assurance (IA) Control #: <Enter the specific IA Control # from the “Checklist”> IA Control Nomenclature: <Enter the specific IA Control’s Nomenclature> Compliance Statement: <Restate the Contractor’s compliance with the IA Control.> Issue:

<Provide basic “business” description for why the contractor cannot / will not meet the requirements of the NIST 800-53/A IA control as listed on Checklist and Certification for Minimum Level of Enhanced Safeguarding for Unclassified DoD Information for Minimum Security Controls.> Contractor-identified Solution:

<Provide a business-level description of the contractor’s alternative plan to satisfy the security requirements associated with the Checklist’s specific IA control.> Mitigation / Remediation Plan:

<As appropriate, provide a business-level description of the contractor’s plan of action and milestone for implementing the solution listed above.> Risk Acceptance Statement <Provide a statement the contractor accepts the risk of either implementing a technical solution different from the NIST guidance or contract operations until the NIST control can be implemented.>

(1 Data Item)

PREVIOUS EDITION MAY BE USED.

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP ________ TM _______ OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT

REQUIRED

10. FREQUENCY

11. AS OF DATE

12. DATE OF FIRST SUBMISSION

13. DATE OF SUBSEQUENT

SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final

Reg Repro

15. TOTAL

16. REMARKS

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

Page of Pages

A020 Memorandum of Understanding Electronic Submission of Claims Documentation - North Region

Initial

Section C, Para 6.1.8 BSD/IPE&TS

B

See Block 16

See Block 16

See Block 16

See Block 16 Submit through the DHA e-Commerce Extranet.

(Per TOM Ch 14 Sec 2)

0 0 0

FIRST SUBMISSION:

Frequency: Annual (Option Period) Reporting Period Start Date: Start of service delivery Due Date: 60 calendar days before start of reporting period

SUBSEQUENT SUBMISSION: SAME AS FIRST SUBMISSION

PHI/PII: No FILE FORMAT: Microsoft Word (.doc / docx)

CONTENT DETAILS:

The Contractor shall execute a Memorandum of Understanding with the North Region contractor for the safe, secure, and positive electronic transmittal of claims processing documentation/information. The contractor shall establish a process for accepting claims review documentation via a secure file transfer protocol (SFTP).

At a minimum the MOU shall address:

* Any necessary cooperation and exchange of information;

* Identify contract points of contact (POCs);

* Appropriate system resources;

* Node information (if appropriate);

* File organization and naming conventions

* Documentation- format (i.e., word, .pdf, etc.)

The MOU will specifically address the frequency of file transmissions, receipt confirmation procedures (i.e., file acceptance or rejection), quality assurance procedures for validating file content, file and document formatting and any additional information needed to ensure the successful receipt, acceptance and utilization of claims documentation.

Within one year of previous submission, the Contractor shall submit an updated MOU or notification to the government that the MOU has been reviewed and no updates were required.

04/22/2016 04/22/2016

1 1

Todd YoungKarla M. Johnson-Griffith

(1 Data Item)

PREVIOUS EDITION MAY BE USED.

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP ________ TM _______ OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT

REQUIRED

10. FREQUENCY

11. AS OF DATE

12. DATE OF FIRST SUBMISSION

13. DATE OF SUBSEQUENT

SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final

Reg Repro

15. TOTAL

16. REMARKS

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

Page of Pages

A030 Memorandum of Understanding Electronic Submission of Claims Documentation - South Region

Initial

Section C, Para 6.1.8 BSD/IPE&TS

B

See Block 16

See Block 16

See Block 16

See Block 16 Submit through the DHA e-Commerce Extranet.

(Per TOM Ch 14 Sec 2)

0 0 0

FIRST SUBMISSION:

Frequency: Annual (Option Period) Reporting Period Start Date: Start of service delivery Due Date: 60 calendar days before start of reporting period

SUBSEQUENT SUBMISSION: SAME AS FIRST SUBMISSION

PHI/PII: No FILE FORMAT: Microsoft Word (.doc / docx)

CONTENT DETAILS:

The Contractor shall establish a Memorandum of Understanding with the South Region contractor for the safe, secure, and positive electronic transmittal of claims processing documentation/information. The contractor shall establish a process for accepting claims review documentation via a secure file transfer protocol (SFTP).

At a minimum the MOU shall address:

* Any necessary cooperation and exchange of information;

* Identify contract points of contact (POCs);

* Appropriate system resources;

* Node information (if appropriate);

* File organization and naming conventions

* Documentation- format (i.e., word, .pdf, etc.)

The MOU will specifically address the frequency of file transmissions, receipt confirmation procedures (i.e., file acceptance or rejection), quality assurance procedures for validating file content, file and document formatting and any additional information needed to ensure the successful receipt, acceptance and utilization of claims documentation.

Within one year of previous submission, the Contractor shall submit an updated MOU or notification to the government that the MOU has been reviewed and no updates were required.

04/22/2016 04/22/2016

(1 Data Item)

PREVIOUS EDITION MAY BE USED.

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP ________ TM _______ OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT

REQUIRED

10. FREQUENCY

11. AS OF DATE

12. DATE OF FIRST SUBMISSION

13. DATE OF SUBSEQUENT

SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final

Reg Repro

15. TOTAL

16. REMARKS

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

Page of Pages

A040 Memorandum of Understanding Electronic Submission of Claims Documentation - West Region

Initial

Section C, Para 6.1.8 BSD/IPE&TS

B

See Block 16

See Block 16

See Block 16

See Block 16 Submit through the DHA e-Commerce Extranet.

(Per TOM Ch 14 Sec 2)

0 0 0

FIRST SUBMISSION:

Frequency: Annual (Option Period) Reporting Period Start Date: Start of service delivery Due Date: 60 calendar days before start of reporting period

SUBSEQUENT SUBMISSION: SAME AS FIRST SUBMISSION

PHI/PII: No FILE FORMAT: Microsoft Word (.doc / docx)

CONTENT DETAILS:

The Contractor shall execute a Memorandum of Understanding with the West Region contractor for the safe, secure, and positive electronic transmittal of claims processing documentation /information. The contractor shall establish a process for accepting claims review documentation via a secure file transfer protocol

(SFTP).

At a minimum the MOU shall address:

* Any necessary cooperation and exchange of information;

* Identify contract points of contact (POCs);

* Appropriate system resources;

* Node information (if appropriate);

* File organization and naming conventions

* Documentation- format (i.e., word, .pdf, etc.)

The MOU will specifically address the frequency of file transmissions, receipt confirmation procedures (i.e., file acceptance or rejection), quality assurance procedures for validating file content, file and document formatting and any additional information needed to ensure the successful receipt, acceptance and utilization of claims documentation.

Within one year of previous submission, the Contractor shall submit an updated MOU or notification to the government that the MOU has been reviewed and no updates were required.

04/22/2016 04/22/2016

(1 Data Item)

PREVIOUS EDITION MAY BE USED.

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP ________ TM _______ OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT

REQUIRED

10. FREQUENCY

11. AS OF DATE

12. DATE OF FIRST SUBMISSION

13. DATE OF SUBSEQUENT

SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final

Reg Repro

15. TOTAL

16. REMARKS

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

Page of Pages

A050 Memorandum of Understanding Electronic Submission of Claims Documentation - TRICARE Overseas Program (TOP)

Initial

Section C, Para 6.1.8 BSD/IPE&TS

B

See Block 16

See Block 16

See Block 16

See Block 16 Submit through the DHA e-Commerce Extranet.

(Per TOM Ch 14 Sec 2)

0 0 0

FIRST SUBMISSION:

Frequency: Annual (Option Period) Reporting Period Start Date: Start of service delivery Due Date: 60 calendar days before start of reporting period

SUBSEQUENT SUBMISSION: SAME AS FIRST SUBMISSION

PHI/PII: No FILE FORMAT: Microsoft Word (.doc / docx)

CONTENT DETAILS:

The Contractor shall execute a Memorandum of Understanding with the TOP contractor for the safe, secure, and positive electronic transmittal of claims processing documentation/information. The contractor shall establish a process for accepting claims review documentation via a secure file transfer protocol (SFTP).

At a minimum the MOU shall address:

* Any necessary cooperation and exchange of information;

* Identify contract points of contact (POCs);

* Appropriate system resources;

* Node information (if appropriate);

* File organization and naming conventions

* Documentation- format (i.e., word, .pdf, etc.)

The MOU will specifically address the frequency of file transmissions, receipt confirmation procedures (i.e., file acceptance or rejection), quality assurance procedures for validating file content, file and document formatting and any additional information needed to ensure the successful receipt, acceptance and utilization of claims documentation.

Within one year of previous submission, the Contractor shall submit an updated MOU or notification to the government that the MOU has been reviewed and no updates were required.

04/22/2016 04/22/2016

(1 Data Item)

PREVIOUS EDITION MAY BE USED.

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP ________ TM _______ OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT

REQUIRED

10. FREQUENCY

11. AS OF DATE

12. DATE OF FIRST SUBMISSION

13. DATE OF SUBSEQUENT

SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final

Reg Repro

15. TOTAL

16. REMARKS

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

Page of Pages

A060 Memorandum of Understanding Electronic Submission of Claims Documentation - TRICARE Dual Eligible Fiscal Intermediary Contract

(TDEFIC)

Initial

Section C, Para 6.1.8 BSD/IPE&TS

B

See Block 16

See Block 16

See Block 16

See Block 16 Submit through the DHA e-Commerce Extranet.

(Per TOM Ch 14 Sec 2)

0 0 0

FIRST SUBMISSION:

Frequency: Annual (Option Period) Reporting Period Start Date: Start of service delivery Due Date: 60 calendar days before start of reporting period

SUBSEQUENT SUBMISSION: SAME AS FIRST SUBMISSION

PHI/PII: No FILE FORMAT: Microsoft Word (.doc / docx)

CONTENT DETAILS:

The Contractor shall execute a Memorandum of Understanding with the TDEFIC contractor for the safe, secure, and positive electronic transmittal of claims processing documentation/information. The contractor shall establish a process for accepting claims review documentation via a secure file transfer protocol (SFTP).

At a minimum the MOU shall address:

* Any necessary cooperation and exchange of information;

* Identify contract points of contact (POCs);

* Appropriate system resources;

* Node information (if appropriate);

* File organization and naming conventions

* Documentation- format (i.e., word, .pdf, etc.)

The MOU will specifically address the frequency of file transmissions, receipt confirmation procedures (i.e., file acceptance or rejection), file and document formatting and any additional information needed to ensure the successful acceptance and utilization of claims documentation.

Within one year of previous submission, the Contractor shall submit an updated MOU or notification to the government that the MOU has been reviewed and no updates were required.

04/22/2016 04/22/2016

(1 Data Item)

PREVIOUS EDITION MAY BE USED.

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP ________ TM _______ OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT

REQUIRED

10. FREQUENCY

11. AS OF DATE

12. DATE OF FIRST SUBMISSION

13. DATE OF SUBSEQUENT

SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final

Reg Repro

15. TOTAL

16. REMARKS

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

Page of Pages

A070 Memorandum of Understanding Electronic Submission of Claims Documentation - TRICARE Pharmacy Program (TPharm)

Initial

Section C, Para 6.1.8 BSD/IPE&TS

B

See Block 16

See Block 16

See Block 16

See Block 16 Submit through the DHA e-Commerce Extranet.

(Per TOM Ch 14 Sec 2)

0 0 0

FIRST SUBMISSION:

Frequency: Annual (Option Period) Reporting Period Start Date: Start of service delivery Due Date: 60 calendar days before start of reporting period

SUBSEQUENT SUBMISSION: SAME AS FIRST SUBMISSION

PHI/PII: No FILE FORMAT: Microsoft Word (.doc / docx)

CONTENT DETAILS:

The Contractor shall execute a Memorandum of Understanding with the TPharm contractor for the safe, secure, and positive electronic transmittal of claims processing documentation/information. The contractor shall establish a process for accepting claims review documentation via a secure file transfer protocol (SFTP).

At a minimum the MOU shall address:

* Any necessary cooperation and exchange of information;

* Identify contract points of contact (POCs);

* Appropriate system resources;

* Node information (if appropriate);

* File organization and naming conventions

* Documentation- format (i.e., word, .pdf, etc.)

The MOU will specifically address the frequency of file transmissions, receipt confirmation procedures (i.e., file acceptance or rejection), file and document formatting and any additional information needed to ensure the successful acceptance and utilization of claims documentation.

Within one year of previous submission, the Contractor shall submit an updated MOU or notification to the government that the MOU has been reviewed and no updates were required.

04/22/2016 04/22/2016

(1 Data Item)

PREVIOUS EDITION MAY BE USED.

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP ________ TM _______ OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT

REQUIRED

10. FREQUENCY

11. AS OF DATE

12. DATE OF FIRST SUBMISSION

13. DATE OF SUBSEQUENT

SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final

Reg Repro

15. TOTAL

16. REMARKS

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

Page of Pages

A080 Memorandum of Understanding Electronic Submission of Claims Documentation - Active Duty Dental Program (ADDP)

Initial

Section C, Para 6.1.8 BSD/IPE&TS

B

See Block 16

See Block 16

See Block 16

See Block 16 Submit through the DHA e-Commerce Extranet.

(Per TOM Ch 14 Sec 2)

0 0 0

FIRST SUBMISSION:

Frequency: Annual (Option Period) Reporting Period Start Date: Start of service delivery Due Date: 60 calendar days before start of reporting period

SUBSEQUENT SUBMISSION: SAME AS FIRST SUBMISSION

PHI/PII: No FILE FORMAT: Microsoft Word (.doc / docx)

CONTENT DETAILS:

The Contractor shall execute a Memorandum of Understanding with the ADDP contractor for the safe, secure, and positive electronic transmittal of claims processing documentation/information. The contractor shall establish a process for accepting claims review documentation via a secure file transfer protocol (SFTP).

At a minimum the MOU shall address:

* Any necessary cooperation and exchange of information;

* Identify contract points of contact (POCs);

* Appropriate system resources;

* Node information (if appropriate);

* File organization and naming conventions

* Documentation- format (i.e., word, .pdf, etc.)

The MOU will specifically address the frequency of file transmissions, receipt confirmation procedures (i.e., file acceptance or rejection), file and document formatting and any additional information needed to ensure the successful acceptance and utilization of claims documentation.

Within one year of previous submission, the Contractor shall submit an updated MOU or notification to the government that the MOU has been reviewed and no updates were required.

04/22/2016 04/22/2016

(1 Data Item)

PREVIOUS EDITION MAY BE USED.

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP ________ TM _______ OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT

REQUIRED

10. FREQUENCY

11. AS OF DATE

12. DATE OF FIRST SUBMISSION

13. DATE OF SUBSEQUENT

SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final

Reg Repro

15. TOTAL

16. REMARKS

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

Page of Pages

A090 Disaster Recovery Test Results Report Initial

TSM, Ch.1, Sec. 1.1 PAT&IS/IPE&TS

B

See Block 16

See Block 16

See Block 16

See Block 16 Submit through the DHA e-Commerce Extranet.

(Per TOM Ch 14 Sec 2)

0 0 0

FIRST SUBMISSION:

Frequency: Annual (Option Period) Reporting Period Start Date: Start of service delivery Due Date: Within 10 business days of completion of test

SUBSEQUENT SUBMISSION: SAME AS FIRST SUBMISSION

PHI/PII: No FILE FORMAT: No specific file format required

CONTENT DETAILS:

In all cases, the results of the review and/or test results shall be reported. The report shall include if any additional testing is required or if corrective actions are required as a result of the disaster recovery test. The notice of additional testing requirements or corrective actions to be taken should be submitted along with the proposed date for retesting and the completion date for any corrective actions required.

05/13/2015 04/22/2016

Todd YoungTerry R. Lowery

(1 Data Item)

PREVIOUS EDITION MAY BE USED.

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP ________ TM _______ OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT

REQUIRED

10. FREQUENCY

11. AS OF DATE

12. DATE OF FIRST SUBMISSION

13. DATE OF SUBSEQUENT

SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final

Reg Repro

15. TOTAL

16. REMARKS

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

Page of Pages

A100 Risk Assessment Letter of Assurance Initial

TOM, Ch. 19, Sec. 3 Privacy Office/IPE&TS

B

See Block 16

See Block 16

See Block 16

See Block 16 Submit through the DHA e-Commerce Extranet.

(Per TOM Ch 14 Sec 2)

0 0 0

FIRST SUBMISSION:

Frequency: One Time Reporting Period Start Date: Contract Award Due Date: Not later than 9 months after start of reporting period

SUBSEQUENT SUBMISSION:

Frequency: Annual (Option Period) Reporting Period Start Date: Start of service delivery Due Date: No later than the anniversary date of previous report

PHI/PII: No FILE FORMAT: No specific file format required

CONTENT DETAILS:

The contractor shall submit letter of assurance representing that it has conducted its initial or annual Health Insurance Portability and Accountability Act (HIPAA) risk assessment and, if necessary, develop an action plan to address any deficiencies identified, in compliance with Department of Defense (DoD) HIPAA requirements applicable to the contractor.

Sample is attached.

05/13/2015 04/22/2016

Todd YoungLinda S. Thomas

ANNUAL RISK ASSESSMENT LETTER OF ASSURANCE (SAMPLE)

Defense Health Agency (DHA)/Contract Management 16401 E Centretech Parkway Aurora, CO 80011 ATTN: Administrative Contracting Officer (ACO)

Dear ________:

An annual risk analysis of all systems, policies, procedures and practices of (name of contractor) in effect during the year ended (date) was performed in accordance with requirements outlined in the TRICARE Operations Manual (TOM), Chapter 19, Section 3, and the HHS HIPAA Privacy Rule.

The objectives of the risk analysis were to:

1. Consider both organizational and technical assessments that address all areas of privacy and security.

2. Assess the potential risks and vulnerabilities to the confidentiality, integrity and availability of all PHI (electronic, paper, and oral) created, received, stored or transmitted by the contractor.

3. Take into account all relevant losses that would be expected if privacy and security measures were not in place, including losses caused by unauthorized uses and disclosures, as well as losses of data integrity or accuracy.

4. Determine residual risk.

5. Identify and document an action plan from prioritized findings to mitigate risk to an acceptable level.

The results of the risk assessment, assurances given by appropriate (name of contractor) officials, and other information provided, indicate that the procedures and policies of (name of contractor) in effect during the year ended (Date), comply with the requirements in the TOM, Chapter 19, Section

3. The following action plans describe the risk identified during the annual assessment and the plan to correct deficiencies and achieve compliance. Please indicate “NONE” if the annual risk analysis did not identify weaknesses.

Attachment A to this statement contains (1) the (Name of Contractor) plans and schedules for correcting such weaknesses, and (2) the status of actions taken to correct weaknesses identified in prior years’ reports.

Sincerely, Name, Title and Office cc: Regional Director (RD) DHA Procuring Contracting Officer (PCO) HA/DHA Privacy Officer HA/DHA Contracting Officer’s Representative (COR)

Enclosure(s) (if any)

Note to Contractor

(1) If there are no material weaknesses, this sentence should be deleted, and there would be no list or Attachment A containing plans and schedules for correcting such weaknesses.

(2) If there were no actions taken during the past year to correct weaknesses, or no identified weaknesses for which corrective actions remain to be taken, this phrase would be deleted.

(1 Data Item)

PREVIOUS EDITION MAY BE USED.

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP ________ TM _______ OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT

REQUIRED

10. FREQUENCY

11. AS OF DATE

12. DATE OF FIRST SUBMISSION

13. DATE OF SUBSEQUENT

SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final

Reg Repro

15. TOTAL

16. REMARKS

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

Page of Pages

A110 Freedom of Information Act (FOIA) Releasable Contract Initial

Section H, Para 1.5 OGC

B

See Block 16

See Block 16

See Block 16

See Block 16 Submit through the DHA e-Commerce Extranet.

(Per TOM Ch 14 Sec 2)

0 0 0

FIRST SUBMISSION:

Frequency: One Time Reporting Period Start Date: Contract Award Due Date: 60 calendar days after contract award

SUBSEQUENT SUBMISSION:

Frequency: Annual (Option Period) Reporting Period Start Date: Start of service delivery Due Date: 30 calendar days after the end of reporting period

PHI/PII: No FILE FORMAT: Microsoft Word or PDF

CONTENT DETAILS:

For the initial submission:

1. The contractor shall provide a bracketed copy of the original signed, executed contract with attachments and exhibits. Indicate with brackets, the information proposed as exempt from release, if any, and cite the applicable FOIA Exemption

(s) invoked within each bracketed area, pursuant to 5 USC § 552. The brackets may be made electronically or hand marked and the proposed FOIA Exemptions written in the margins.

2. To assist the Agency in its final determination of a releasable version of the contract, the contractor shall provide a letter addressing its justification and/or rationale for the proposed non-releasable portions of the contract.

For the subsequent submission:

1. The contractor shall provide a copy of the original signed, executed contract, attachments, and exhibits, with the modifications incorporated into the original contract as a conformed contract. The contractor shall identify the last modification (P00NNN and date) incorporated into the contract. Indicate with brackets, the information proposed as exempt from release, if any, and cite the applicable FOIA Exemption(s) invoked within each bracketed area, pursuant to 5 USC § 552. The brackets may be made electronically or hand marked with the proposed FOIA Exemptions written in the margins.

2. To assist the Agency in its final determination of a releasable version of the contract, the contractor shall provide a letter addressing its justification and/or rationale for the proposed non-releasable portions of the contract.

08/10/2015 04/22/2016

Todd YoungRhonda Bershok

(1 Data Item)

PREVIOUS EDITION MAY BE USED.

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP ________ TM _______ OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT

REQUIRED

10. FREQUENCY

11. AS OF DATE

12. DATE OF FIRST SUBMISSION

13. DATE OF SUBSEQUENT

SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final

Reg Repro

15. TOTAL

16. REMARKS

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

Page of Pages

AP010 Continuity of Operation Plan (COOP) Initial

Section C, Para 6.1.11 BSD/IPE&TS

B

See Block 16

See Block 16

See Block 16

See Block 16 Submit through the DHA e-Commerce Extranet.

(Per TOM Ch 14 Sec 2)

0 0 0

FIRST SUBMISSION:

Frequency: Annual (Option Period) Reporting Period Start Date: Start of service delivery Due Date: 30 calendar days before start of reporting period

SUBSEQUENT SUBMISSION: SAME AS FIRST SUBMISSION

PHI/PII: No FILE FORMAT: No specific file format required

CONTENT DETAILS:

The COOP shall document contractor plans and procedures to maintain DHA support should an actual disaster be declared affecting normal operations. The COOP shall include the following:

• A description of the contractor’s disaster management procedures and policy,

• A description of how the contractor will account for their employees during a disaster,

• Planned temporary work locations or alternate facilities,

• How the contractor will communicate with DHA during disasters,

• A list of primary and alternate contractor points of contact, each with primary and alternate:

• Telephone numbers

• e-Mail addresses,

• Procedures for protecting Government furnished equipment (if any),

• Procedures for safeguarding sensitive and/or classified Government information (if applicable) to include PHI and PII.

The COOP shall be activated immediately after determining that a disaster has occurred, shall be operational within 12 hours of activation, and shall be sustainable until the disaster situation is resolved and normal conditions are restored or the contract is terminated, whichever comes first. In case of a threat to life, the COR shall immediately make contact with the contractor to ascertain the status of any contractor personnel who were located in Government controlled space affected by the disaster. When any disruption of normal, daily operations occur, the contractor and COR shall promptly open an effective means of communication and verify:

• Key points of contact (Government and contractor),

• Temporary work locations (alternate office spaces, telework, virtual offices, etc.),

• Means of communication available under the circumstances (e.g. email, webmail, telephone, FAX, courier, etc.),

• Essential work products expected to continue production by priority.

04/22/2016 04/22/2016

Todd YoungKarla Johsnon-Griffith

(1 Data Item)

PREVIOUS EDITION MAY BE USED.

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B.