3_TCRS_Section_C_as_of_11-10-16.pdf

SECTION C, DESCRIPTION/SPECIFICATION/WORK STATEMENT

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TRICARE Claims Review Services (TCRS) Performance Work Statement (PWS)

1.0 GENERAL

1.1 The Defense Health Agency (DHA) supports the delivery of integrated, affordable, and high quality health services for more than 9.4 million beneficiaries of the Military Health System (MHS) and is responsible for shared services, functions, and activities of the MHS and other common clinical and business processes in support of the Military Services.

1.1.1 The MHS is a complex integrated healthcare system that consists of healthcare delivery, medical education, public health, private sector partnerships and innovative medical research and development. The MHS has two major care delivery systems. The direct care system provides care through military treatment facilities (MTFs). The purchased-care system provides care through private sector contractors, including the three Managed Care Support Contracts (MCSCs) (i.e. North, South and West Regions), TRICARE Overseas Program (TOP), TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC), Active Duty Dental Program (ADDP) and TRICARE Pharmacy Program (TPharm) contracts. The purchased-care system has more than 400,000 network individual providers (primary care, behavioral health, and specialty care providers) and more than 3,200 TRICARE network acute care hospitals.

1.1.2 The purpose of this contract is to assist the DHA Improper Payment Evaluation and Transition Section (IPE&TS), DHP Management Control & Financial Studies Branch, Budget & Resource Management Division, Business Support Directorate, in identifying and reporting improper payments and discrepancies in payment record coding. This contract provides an independent impartial review of claims processing procedures and reimbursement methodologies utilized by purchased-care contractors, and assesses purchased-care contractor compliance with TRICARE policies and directives. The contractor shall evaluate the accuracy of claims payment and payment record coding for the MCSC, TDEFIC, TPharm, TOP, and the ADDP contracts.

1.1.3 This contract also supports IPE&TB’s requirement to assess the potential risk of improper payments, identify, and report improper payments to the Office of Management and Budget (OMB) for publication in the Department of Defense (DoD), Agency Financial Report (AFR) pursuant to Public Laws 107-300, Improper Payment Information Act (IPIA) of 2002, and 111- 204, Improper Payment Elimination and Recovery Act (IPERA) of 2010.

1.2 Objectives. The objectives of this contract are two fold: To support the MHS mission of greater integration of the purchased-care delivery system, and to support the MHS’s Quadruple Aim of Readiness, Population Health, Experience of Care, and Control per Capita Cost.

1.2.1 The objectives below represent the performance outcomes for this contract and are supported by technical requirements. The acceptable performance standards are explained further in the contract.

1.2.2 Objective 1, Compliance Reviews. Provide timely and accurate evaluations of each purchased-care contractor’s healthcare claims processing and payment record coding procedures.

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1.2.3 Objective 2, Focused Studies. Assist the IPE&TB in studying areas of the TRICARE health benefits program with the potential for incurring a higher than average risk of improper payments.

1.2.4 Objective 3, Medical Record Reviews. Validate healthcare services documented in a patient’s medical record is correctly invoiced to the Government for payment.

1.2.5 Objective 4, Continuity of Review Services. Maintain effective management solutions to provide the necessary claims review services, incorporating DHA and healthcare standards and best practices.

1.3 Proper Identification of Contractor Personnel

1.3.1 Contractors, including subcontractors at all tiers, shall provide for a clear distinction from Government personnel. Contractor employees shall not act, advertise, or presume to be Government employees, agents, or representatives. Contractor employees are required to appropriately identify themselves as contractor employees at all times, including in telephone conversations, formal and informal written correspondence, paper and electronic, and in any other situation where their actions could be construed as acts of Government officials, unless, in the judgment of the Government, no harm can come from failing to identify themselves.

Contractor employees shall be introduced as contractor personnel and display distinguishing visible identification at all times whether in conversations, meetings, or other forms of communication with Government personnel.

1.3.2 Contractor personnel, while performing in a contractor capacity, shall refrain from using their retired or reserve component military rank or title (if applicable) in written or verbal communications associated with the contracts for which they provide services.

1.3.3 The Contractor shall incorporate the substance of this requirement in all subcontracts awarded under this contract.

2.0 DOCUMENTS. The contractor shall abide by the current version of all applicable regulations, publications, manuals, and local policies and procedures. The list below includes key directives and websites related to the contract. The list not intended to be all inclusive: The following documents are hereby incorporated by reference to the contract:

Title 10, United States Code (USC), Chapter 55.

Title 32 Code of Federal Regulations (CFR) National Defense, Parts 199.3, 199.6, 199.9,

199.10 and 199.13.

Title 36 CFR Part 1222 Creation and Maintenance of Federal Records.

Title 45 CFR, Parts 160, 162 and 164 of Health Insurance Portability and Accountability Act (HIPAA) of 1996.

National Institute of Standards and Technology (NIST) Special Publications (SP) 800-53 and 800-53 A.

DoD 6025.18-R, Department of Defense Health Information Privacy Regulation, DoD 8580.02-R, Department of Defense Health Information Security Regulation, TCRS HT9402-17-R-0002, Section C Page C3 of C27

DODD 5000.1 Defense Acquisition Systems, DoD Directive 8500.1, Information Assurance (IA), DoD Instruction 8500.2, Information Assurance (IA) Implementation DoD Directive 5400.11, DoD Privacy Program DoD 5200.2-R, Personnel Security Program Requirements, Federal Information Security Management Act of 2002 DOD Instruction (DoDI) 8582.01, Security of Unclassified DoD Information on Non-DoD Information Systems,

2.1 TRICARE Manuals. The TRICARE Manuals apply to this contract as referenced in Section C, Section J attachments, and in the DD Forms 1423-1, Contract Data Requirements List (CDRL). The contractor shall utilize the most appropriate versions of the TRICARE Manuals when evaluating healthcare claims. TRICARE Manuals are located at http://manuals.tricare.osd.mil.

3.0 ACRONYMS & ABBREVIATIONS, AND DEFINITIONS. Each TRICARE Manual (TRICARE Operations Manual (TOM) 6016.56-M, TRICARE Policy Manual (TPM) 6010.57- M, TRICARE Reimbursements Manual (TRM) 6010.58-M, and TRICARE Systems Manual (TSM) 7950.2-M) has an Appendix A, Acronyms and Abbreviations. Definitions are in TOM, Appendix B.

4.0 GOVERNMENT FURNISHED INFORMATION (GFI)

4.1 TRICARE Purchased-Care Contracts. The Contracting Officer’s Representative (COR) will provide redacted and conformed copies of TRICARE purchased-care contracts deemed pertinent to the performance of the compliance reviews. The purchased-care contract information is provided as reference material and is integral to the contractor’s ability to successfully evaluate the claims processing performance of the MCSC, TDEFIC, TPharm, TOP, and ADDP contracts.

4.2 Access to Government System(s) and/or Application(s)

4.2.1 Defense Manpower Data Center (DMDC) Defense Enrollment Eligibility Reporting System (DEERS). The Government will provide the contractor with access to the DMDC’s General Inquiry DEERS (GIQD) and the Catastrophic Cap and Deductible Research Application (CCD Web Research) interface environment for the use of validating medical eligibility and beneficiary deductible and cost-share liability under the TRICARE benefit program.

Connectivity to DEERS shall be in accordance with TSM, Chapter 1, Section 1.1.

4.2.2 The Government will provide the contractor with access to the TRICARE Patient Encounter Processing and Reporting (PEPR) portal to access the TRICARE Encounter Data (TED) Audit (TA) application and the PEPR Care Detail Information System (CDIS) web-based applications (Section J, Attachment J-1, PEPR Account Activation Request Form (AARF).

4.2.2.1 TA Application. The TA application is the primary online application used by the contractor and Government. The TA application provides:

http://manuals.tricare.osd.mil/

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• A mechanism for the contractor and Government to track and monitor the claims processing performance of purchased-care contractors;

• Allows for the retention of a compliance review trail with the appropriate error codes and error amounts; and

• Facilitates the input of a detailed explanation for error code and error amount assessment.

4.2.2.2 PCDIS. The PCDIS functions as a “search window” into the purchased-care claims database. PCDIS is utilized to:

• Verify provider information (i.e. Provider Identification/National Provider Identification numbers, Medicare numbers, Area Wage Index, etc.);

• Verify provider network/non-network status;

• Identify duplicate claim submissions;

• Query TED detail claims and summary data for institutional and professional purchased-care data; and to

• Query patient or sponsor healthcare medical and pharmacy claims history.

4.3 Department of Health and Human Services (DHHS) Sanctioned Provider List. The contractor shall use the DHHS sanctioned healthcare provider list to determine if purchased-care contractors are erroneously reimbursing sanctioned healthcare providers.

5.0 CONTRACTOR FURNISHED ITEMS. Except as provided in paragraph 4.0 above, the contractor shall furnish all necessary facilities, systems, equipment, labor, supplies, and any other items required for the satisfactory performance of this contract.

6.0 TECHNICAL REQUIREMENTS. These technical requirements represent specific tasks, outcomes, and/or standards to which the contractor shall perform in support of the above objectives.

6.1 Staffing/Program Management

6.1.1 Staffing. The contractor shall designate a single point of contact (POC) to oversee the tasks of this contract, supervise staff assigned to the tasks, and ensure that the tasks of the contract are performed efficiently, accurately, on time, and in compliance with the requirements of this document. The POC shall provide the COR with ongoing status updates of the tasks and any issues relating to the contract.

6.1.1.1 The contractor shall ensure all personnel, to include subcontractors, are qualified to perform their assigned responsibilities (i.e. claims auditing, medical record reviews, etc.), including credentials, certifications, (for those positions requiring such accreditation) education, training and experience consistent with industry standards and best practices.

6.1.1.2 The contractor shall provide position descriptions for all staff/labor categories including required education, training, certifications, experience, and the number of full time equivalents (FTE) assigned to each labor category. At the minimum, each position description shall include the following information:

• Labor Category;

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• Supervisory or non-supervisory position;

• Minimum education;

• Minimum professional experience;

• Minimum professional certifications, licensure, and/or registrations; and

• Description of tasks performed and solicitation task reference

6.1.1.3 The contractor shall ensure that a sufficient number of qualified staff with the appropriate knowledge, skill, experience and credentialing are available to meet all aspects of the contract.

In addition, the contractor shall ensure that staff assigned to conduct medical record reviews have the appropriate knowledge, skills, experience, and credentialing such as Certified Professional Coder (CPC), Certified Professional Coder - Outpatient Hospital (COC), Certified Coder-Payer (CPC-P), Evaluation and Management Certified Coding Specialists and Certified Professional Medical Record Auditor (CPMA) (this is Not an all-inclusive list), necessary to form an opinion consistent with industry standards and best practices.

6.1.2 Program Management: The contractor shall develop a Program Management Plan (PMP) (CDRL AP020). The PMP shall consist of control policies and procedures for project administration, execution and tracking consistent with program management best practices and standards.

6.1.2.1 The contractor shall notify the COR of key milestones and issues that are directly related to the scope of the contract both verbally and in writing. At a minimum, the contractor shall address the following in its PMP:

• All technical activities (including documentation development)

• An estimate of the timing, and level of effort (by labor category) for all performance elements

• A matrix of all personnel assigned to the program and total aggregate level of effort for each performance element

• Project plan with a detailed schedule that identifies all tasks and key milestones in a format agreed to by the COR

• Quality assurance processes and monitoring methods;

• Risk management procedures

• HIPAA risk assessment (CDRL A100, Risk Assessment Letter of Assurance)

• The contractor’s training program which ensures the accurate evaluation of healthcare claims under the TRICARE health benefits program

• The contractor’s process for tracking the status of deliverables

• The contractor’s Data Use Agreements (DUA)/Data Share Agreement (DSA)

• The contractor's personnel clearances to access DOD data systems

• NIST Certification of Compliance Report (CDRL A010), and

• Disaster Recovery Test Results Report (CDRL A090)

6.1.3 Weekly Workload and Activity Status Reports. The contractor shall ensure the timely and accurate completion of ongoing compliance reviews in accordance with the contract’s performance requirements. The contractor shall develop and submit weekly status reports in accordance with CDRL W030, Audit Status Report, and CDRL W040, Audit Workload Report.

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6.1.3.1 The contractor shall provide a written analysis of errors report of each quarterly, semiannual and annual compliance review findings. The contractor shall monitor and analyze patterns, trends and variations in claims processing procedures among the purchased-care contracts that conflict or contradict with TRICARE policy and/or reimbursement methodologies.

(See specific Analysis of Errors CDRLs below)

6.1.3.2 Results of these analyses shall be produced upon completion of each second rebuttal review or upon notification from the COR, that second rebuttal review comments are not being submitted by the respective purchased-care contractor. The contractor shall reference the following CDRLs for additional information regarding report format, report content and submission requirements:

• R020, Analysis of Errors Report, North Region

• R030, Analysis of Errors Report, South Region

• R040, Analysis of Errors Report, West Region

• R050, Analysis of Errors Report, TOP

• R060, Analysis of Errors, TDEFIC

• R070, Analysis of Errors Report, TPharm

• R080, Analysis of Errors Report, ADDP

6.1.4 TRICARE Manual Changes. Upon receiving DHA notification of a draft TRICARE Manual change, the contractor shall review and, if appropriate, provide timely comment on the proposed change to the government. Once manual changes are published, the contractor shall notify its staff of the specific TRICARE Manual change and ensure its staff uses the appropriate version of the TRICARE Manuals when evaluating healthcare claims based on the claim’s “processed to completion” date.

6.1.5 The contractor shall develop compliance review procedural guidelines, desk instructions, and reference materials for its staff. The contractor shall maintain current procedural guidelines, desk instructions and reference materials. See CDRL R310, Compliance Review Procedural Guidelines, Desk Instructions and Reference Materials.

6.1.6 The contractor shall ensure the following software/applications are readily available for use by its staff. The contractor shall maintain the current versions as well as predecessor versions of the following software.

6.1.6.1 Diagnosis-Related Groups (DRGs) Software. This software will enable staff to group and price inpatient hospital claims processed under the TRICARE DRG reimbursement methodology.

6.1.6.2 TRICARE Outpatient Prospective Payment System (OPPS). The contractor shall maintain the TRICARE OPPS software and quarterly updates to ensure compliance with OPPS pricing procedures.

6.1.6.3 ClaimCheckTM or Equivalent Code Auditing Software. The contractor shall use a healthcare-recognized Commercially Available off the Shelf (COTS) comprehensive code

TCRS HT9402-17-R-0002, Section C Page C7 of C27 auditing software which enables the contractor to evaluate the accuracy of billing and coding of claims selected for review as well as identifying incidental procedure codes and the bundling or unbundling of procedural codes. Claims processed under the OPPS, Skilled Nursing Facility (SNF), Home Health (HH) and other institutional reimbursement methodologies are not subject to the utilization of this software. Salient characteristics for comprehensive code auditing software include:

• Capability to identify billed services that may have used incorrect codes and provide the reasons for denial, based on your medical policies

• Recommended fixes for incorrect procedure codes on professional and outpatient facility claims based on Correct Coding Initiative (CCI) guidelines

• Capability to flags procedure submissions that may require additional documentation or review

• Incorporates guidelines from industry-standard and essential clinical coding sources, including:

• Current Procedural Terminology (CPT®)

• Healthcare Common Procedure Coding System (HCPCS)

• International Classification of Diseases Clinical Modification (ICD-CM)

• American Medical Association (AMA) and Centers for Medicare and Medicaid

Services (CMS) guidelines

• Specialty society guidelines

• Medical policy and literature research and standards

• Input from academic affiliations

6.1.6.4 The contractor shall ensure that staff has readily available access to the following web-based applications, pricing systems or websites:

• Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Prospective Payment System (PPS). The SNF PPS PC Pricer software enables staff to accurately re-adjudicate claims subject to reimbursement under the SNF PPS. The SNF PPS Pricer is available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/SNFPPS/index.html.

• CMS Home Health (HH) PPS. The HH PPS PC Pricer enables staff to accurately re-adjudicate claims subject to reimbursement under the HH PPS. The HH PPS pricer is available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/PCPricer/HH.html

• TRICARE Rates and Reimbursement Website. Access enable staff to verify the appropriate reimbursement rates (i.e., Ambulatory Surgery, Anesthesia, CHAMPUS Maximum Allowable Charge (CMAC), Foreign Rates, etc.), or TRICARE reimbursement restrictions (i.e., Age/Gender restrictions) applicable when re-adjudicating healthcare claims. Information regarding TRICARE reimbursement rates is available at the following website http://www.tricare.mil/tma/Rates.aspx.

• DEERS/Catastrophic Cap and Deductible applications. Access enable staff to verify TRICARE benefit eligibility and cost share/deductible fee requirements, of patients for whom compliance review claims is received.

• PEPR TA and PCDIS Applications. The contractor shall access the TA application to input detailed explanations for assessing errors and error amounts. The contractor shall http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/index.html http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/index.html http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PCPricer/HH.html http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PCPricer/HH.html http://www.tricare.mil/tma/Rates.aspx

TCRS HT9402-17-R-0002, Section C Page C8 of C27 access the PCDIS application to query patient and/or sponsor healthcare medical and pharmacy claims history and to verify provider information.

6.1.7 Document Management System (DMS). Pursuant to 36 CFR Part 1222, the contractor shall control and manage compliance review documentation and patient claims history received electronically from purchased-care contractors on behalf of the Defense Health Agency. This includes operating and maintaining systems of records, including the collection, use, and dissemination of Government records. Government records in these systems of records include records related to beneficiary health care services and/or claims and supporting documentation which are received or developed under the contract. See TOM, Chapter 2, Section 1, paragraph 3.2.

6.1.7.1 The contractor shall maintain a DMS capable of securely accepting, storing, and maintaining Protected Health Information/Personally Identifiable Information (PHI/PHI) healthcare and dental claims information transmitted in electronic or paper format to the contractor by purchased-care contractors pursuant to 36 CFR, Part 1222; 45 CFR, Parts 160, 162 and 164 of HIPAA and security and privacy standards; and DFARS Clause 252.204-7012.

6.1.7.2 The DMS shall have the capability to store, organize and categorize documentation based on contract type, review cycle, submission type (i.e. initial, rebuttal, second rebuttal), and shall facilitate the preservation, retrieval, use and disposition of compliance review documentation.

The system shall allow retrieval of compliance review documentation prior to, during, and/or after completion of an initial, rebuttal and/or second rebuttal compliance review.

6.1.7.3 The DMS shall capture metadata about the documents/records it manages and be able to identify each document/record sufficiently to enable authorized users to easily retrieve, protect, and carry out the disposition of the documents/records in the system. Appropriate information may include:

• Contractor Name

• Contract Number

• Review Cycle

• Review Stage (i.e. initial, rebuttal, second rebuttal)

• Patient Identification Number

• TED Internal Control Number (ICN)

• Preserve transmission and receipt dates

• Retain names of addresses

6.1.7.4 The system must retrieve documents/records and be able to:

• Permit easy retrieval in a timely fashion

• Ensure documents/records are accessible by individuals who have a business need for information in the documents/records

• Provide a method for all authorized users of the system to retrieve desired documents/records, such as an indexing or text search system

• Permit retrieval of both individual records and files or other groupings of related documents/records

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6.1.7.5 The system must ensure the integrity of the documents/records it manages and be able to:

• Minimize the risk of unauthorized alteration or erasure of the documents/records

• Allow only authorized personnel access to the documents/records in the system

• Allow only authorized personnel to perform administrative functions such as creating or deleting directories, altering the parameters of metadata fields, and assigning access rights

6.1.7.6 The contractor shall grant the Government access to its DMS. The COR will determine what government personnel require access to the DMS and provide a list to the contractor by the start of Option Period 1. The contractor shall provide training to the Government on the functionality and utilization of its DMS.

6.1.8 Memorandum of Understanding (MOU) Electronic Claim Submission. The contractor shall execute a MOU with each purchased-care contractor establishing procedures for the secure transmission of compliance review and medical record documentation electronically. The contractor shall reference the following CDRLs for additional instruction regarding the development of MOUs:

• A020 MOU Electronic Submission of Claims Documentation – North Region

• A030 MOU Electronic Submission of Claims Documentation – South Region

• A040 MOU Electronic Submission of Claims Documentation – West Region

• A050 MOU Electronic Submission of Claims Documentation – TOP

• A060 MOU Electronic Submission of Claims Documentation – TDEFIC

• A070 MOU Electronic Submission of Claims Documentation – TPharm

• A080 MOU Electronic Submission of Claims Documentation – ADDP

6.1.9. MOU - Patient Claims History. The contractor shall execute a MOU with each purchased-care contractor for the secure submission and acceptance of processed patient claims history for each quarterly and annual compliance review. The contractor shall reference the following CDRLs for further instructions on development of an MOU:

• OT020 MOU Patient Claims History, North Region

• OT030 MOU Patient Claims History, South Region

• OT040 MOU Patient Claims History, West Region

• OT050 MOU Patient Claims History, TOP

• OT060 MOU Patient Claims History, TDEFIC

• OT070 MOU Patient Claims History, TPharm

6.1.10 Translation Services. The contractor shall ensure that translation services are available to review claims submitted by host nation providers in any format, including narrative format and processed by the TOP purchased-care contractor to the appropriate medical and diagnostic codes.

6.1.11 Continuity of Operations Plan (COOP). The contractor shall prepare and submit a COOP to the Government ten (10) days after contract award, and shall maintain an up-to-date plan with annual submission (CDRL AP010, Continuity of Operations Plan). The COOP shall

TCRS HT9402-17-R-0002, Section C Page C10 of C27 document contractor plans and procedures to maintain DHA support should an actual disaster be declared affecting normal operations.

6.1.11.1 The Government and contractor must make use of the resources and tools available to continue DHA contracted functions to the maximum extent possible under disaster circumstances. Contractors must obtain approval from the COR and CO prior to incurring costs exceeding those allowed under the terms of this contract. Regardless of contract type, and of work location, contractors performing work in support of authorized tasks within the scope of their contract shall charge those hours accurately in accordance with the terms of this contract.

6.1.12 Records Manager. The contractor shall identify its Records Manager to the CO within 10 days after contract award. Following contract award, the contractor shall schedule its Records Manager to attend the next available DHA records management class presented in Denver, Colorado. The Records Manager will be required to attend the course annually thereafter.

6.1.13 System Security Administrator. The contractor shall assign personnel to function as the system(s) security administrator. The contractor shall provide the names of personnel appointed to serve as the contract system(s) security administrator to the CO and COR upon award of the contract. The primary function of the security administrator is to provide the DHA System Security Officer and Personnel Security Branch with required information, and names of contractor personnel requiring Government ADP systems access. (CDRL M010, Employee Access to DoD IS/Networks Report).

6.2 Quality Control

6.2.1 Quality Management. The contractor shall establish and continuously operate an Internal Quality Management Program (IQMP) consistent with healthcare compliance review best practices and standards, which covers every aspect of the contractor’s operation to ensure control, accuracy, and timeliness effective at the start of Option Period 1 and continuing through the life of the contract.

6.2.1.1 The contractor shall assess its compliance with its qualitative and quantitative standards, identify problems, and identify corrective action planned or to be initiated. The IQMP plan (CDRL AP030, Internal Quality Management Program Plan) will detail all aspects of the contractor's quality program including the major components of the program, quality control activities, quality assurance functions, risk management, organizational responsibilities for quality management, and how identified quality problems will be monitored and resolved. The contractor shall submit a quarterly report detailing its compliance with these quality program elements as described in its IQMP Plan (CDRL Q010, Internal Quality Management Report).

6.2.2 Contractor (Internal) Quality Assurance (QA) Reviews. The contractor shall conduct ongoing internal QA reviews that evaluate the performance and quality of compliance reviews performed by its staff. Internal reviews results shall be used to refine or update procedural guidelines, enhance the contractors training program, and to correct errors. The contractor shall ensure that errors discovered as part of its ongoing QA process such as error omissions, incorrect error determinations and/or amounts, are corrected and error corrections are reflected/updated in

TCRS HT9402-17-R-0002, Section C Page C11 of C27 the TA application. The contractor shall follow instructions regarding internal QA frequency and minimum sample size and shall submit review results to the COR in accordance with the following CDRLs:

• R090, Internal Quality Assurance Review Results Report, North Region

• R100, Internal Quality Assurance Review Results Report, South Region

• R110, Internal Quality Assurance Review Results Report, West Region

• R120, Internal Quality Assurance Review Results Report, TOP

• R130, Internal Quality Assurance Review Results Report, TDEFIC

• R140, Internal Quality Assurance Review Results Report, TPharm

• R150, Internal Quality Assurance Review Results Report, ADDP

6.2.3 Government (External) QA Reviews. The Government will conduct ongoing evaluations of finalized contractor reviewed claims. The Government will randomly select approximately five percent (5%) of previously reviewed purchased-care contractors’ claims for the external QA review. The purpose of these evaluations is to identify incorrect error determinations and omissions by the contractor.

6.2.3.1 Frequency - Government (External) QA Review. The Government will conduct periodic quality assurance reviews of finalized contractor reviewed claims to identify incorrect error determinations and/or omissions by the contractor when performing compliance reviews.

6.2.3.2 The contractor shall support these reviews by providing legible copies of processed claims information (i.e., CMS 1500, UB04, Dental Expense Claim Form, etc.), claims processing documentation and any additional information received by the contractor from purchased-care contractors on initial, rebuttal and second rebuttal review. Claim information shall be submitted electronically (i.e. Compact Disk (CD)) and organized by folder identification based on either the TED ICN or Dental Claim number.

6.2.3.3 For the claims selected for review, the contractor shall provide legible copies of its annotated TRICARE Audit Detail Reports (TADRs) and/or ADDP Audit Detail Reports (AADRs) (see paragraph 6.4 below) , as well as any additional documentation developed by and/or used by the contractor in the course of performing the compliance review. The documentation shall support the contractor’s compliance review determinations at the time the claims were reviewed. Examples of required documentation are (this is not an all-inclusive list):

• Contractor query or pricing screens or screen shots from the following applications or systems:

• ClaimCheck or equivalent code auditing software

• DEERS eligibility and CAT/CAP

• SNF PPS pricer

• HH PPS pricer

• OPPS Grouper/Pricer worksheet

• DRG (grouper and pricing information sheets)

• Patient claims history obtained from purchased-care contractors

• Calculation worksheets and or application screen shots for reimbursement/per-diem determinations:

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• Psychiatric Hospital (i.e. low volume)

• Residential Treatment Center (RTC) (i.e. per-diem)

• Other Health Insurance (OHI) (i.e., 3-step calculation for coordination of benefits)

• Reimbursement, benefit or other information obtained from the TRICARE Rates and

Reimbursement website

• CMAC screen shots used to validate each purchased-care contractor’s pricing of claim

6.2.3.4 The contractor shall clearly annotate and date stamp all documents which the contractor developed, used or produced. The date shall be the date the claim was reviewed. The contractor shall submit the required documentation to the COR within 7 days from receiving the QA notification letter.

6.2.3.5 Rebuttals. If the contractor disagrees with the Government’s error assessment, the contractor may submit rebuttal comments to the COR. The contractor shall submit its rebuttal responses to the COR within 5 days after receipt of QA report.

6.2.3.6 Payment Error Rate Calculation. The error rate percentage for government external QA payment reviews is calculated by dividing the sum of the absolute payment error amount (overpayments and underpayments) assessed by the total claims paid amount, multiplied by one hundred (100).

6.2.3.7 Occurrence Error Rate Calculation. The error rate percentage for occurrence reviews is calculated by dividing the total number of TEDs or dental data field errors by the number of TEDs or dental data fields reviewed, multiplied by one hundred (100).

6.3 Transition

6.3.1 Transition-in. The contractor will have time-critical tasks to perform during the transition-in period prior to the first day of Option Period 1. The contractor may accomplish some of these tasks concurrently with others. However, there are certain tasks which the contractor must accomplish and receive government approval before the contractor can proceed.

6.3.1.2 Transition-in Plan. The contractor shall submit a comprehensive Transition-in Plan to the COR following contract award (CDRL R010, Transition-in Plan). The plan shall address all events and milestones that need to occur for each functional area described in this contract to start services under this contract. The plan will be used to manage, track and evaluate the contractor’s performance during transition-in. This plan shall clearly describe the contractor’s control policies and procedures for project administration, execution and tracking to ensure a seamless transition consistent with project management best practices and standards.

6.3.1.2.1 The contractor shall keep the COR informed on its progress during transition-in via a weekly report including key transition milestones and issues as directed in CDRL W010, Transition-in Weekly Report.

6.3.1.3 Contractor Readiness Testing. Prior to the start of Option Period 1; the contractor shall demonstrate the ability to accurately review purchased-care contract claims. A readiness test

TCRS HT9402-17-R-0002, Section C Page C13 of C27 will be administered and finalized by the COR and other Government and/or contract personnel at least sixty (60) days prior to Option Period 1.

6.3.1.3.1 The readiness test will consist of up to 300 test scenarios developed by the government consisting of various hospital, physician, pharmacy, and dental claims. All aspects of the contractor’s compliance review functions and procedures will be tested, such as evaluating the contractor’s:

• Ability to access and operate the following systems/applications:

• DEERS (verify eligibility and catastrophic cap/deductible balance)

• DHA pricing files (i.e., CMAC, DRG calculator worksheets, etc.)

• DRG Grouper, SNF PP, HHF PP OPPS

• ClaimCheck or COT auditing software

• TA and PCDIS

• Method for translating TOP claims

• Ability to respond to readiness review findings via a rebuttal process

6.3.1.3.2 Readiness Test. At the time of the scheduled Readiness Test, a DHA Readiness Team consisting of the contract COR and various government/contract personnel will arrive at the contractor’s work site to conduct the test and evaluate the contractor’s review results on a claim-by-claim basis.

6.3.1.3.3 At least 15 days prior to the Readiness Test the COR will send, via secured and encrypted email correspondence, information regarding the administration and dates of the readiness test and electronic copies of health care claim packages to be reviewed by the contractor. Claim packages will consist of medical, dental or pharmacy health care claim forms (i.e. CMS 1500, UB04, Dental Expense Claim Form, etc.), associated TADRs/ADDRs and related claims processing documentation. The contractor will review the claim packages and assess error determinations (if applicable) prior to the first day of the Readiness Test.

6.3.1.3.4 On the first day of the Readiness Test, an entrance conference will be held with the appropriate readiness team members and contractor personnel to discuss ensuing events, expectations, and additional instructions as required. At that time, the contractor shall provide both paper and electronic copies of their review results for each claim evaluated. The review results must include copies of annotated TADRs and AADRs and all associated documentation that supports the contractor’s review procedures and error determinations.

6.3.1.3.5 Each day of the onsite the DHA Readiness Team will review claims to determine the accuracy of the contractor’s review procedures and error determinations and will present those results back to the contractor as formal Government Initial Review findings (reference Section J, Attachment J-2 Readiness Test Findings). Within one (1) day of receiving the Government’s initial review comments, the contractor shall review the results and if in disagreement of any error assessments, submit rebuttal comments the following day.

6.3.1.3.6 During the readiness testing, the DHA Readiness Team will periodically brief the contractor staff on its review findings. All appropriate contractor and Readiness Team personnel shall be present to answer any questions raised. At the conclusion of the readiness test, an exit

TCRS HT9402-17-R-0002, Section C Page C14 of C27 conference will be held with the contractor staff to brief the contractor on all findings identified during the readiness test. Any outstanding claims to be reviewed or re-reviewed will be noted and a schedule for completing all review activities will be established by the Government and communicated back to the contractor.

6.3.1.3.7 The COR shall send the Initial Readiness Test Report (Section J, Attachment J-3, Sample Initial Readiness Test Report) to the contractor within 30 days of the last day of the test or upon completion of all review activities, whichever is later. The contractor shall submit to the COR a written response to the Initial Readiness Test within 15 days from the date of the Initial Readiness Test Report. If there are any claim review errors with which the contractor disagrees, the contractor shall include in their response a written description of the disagreement along with supporting references. The COR shall provide the final Readiness Test Report to the contractor within 15 days (Section J, Attachment J-4, Sample Final Readiness Test Report) of the contractors response to the initial report. Prior to the contract start work date, the contractor shall correct all errors noted in the readiness test and provide the results to the COR.

6.3.2 Transition-Out

6.3.2.1 Upon receipt of the contracting officer’s written notification, the contractor shall submit a Transition-out Plan (CDRL OT010) for the COR’s review. The contractor and COR shall use the Transition-out Plan to manage, track and evaluate the contractor’s transition-out performance consistent with the contract requirements.

6.3.2.2 The contractor shall complete all work assigned and all reconsideration appeal requests received during the option period to include all associated reports.

6.3.2.3 The contractor shall maintain sufficient qualified staff to meet all requirements of the contract to include final processing of all compliance reviews that are pending final resolution.

6.3.2.4 The contractor shall notify the COR of its progress during the transition-out phase via a weekly report (CDRL W020, Transition-Out Status Report).

6.3.2.5 For all active files the contractor shall organize the files and prepare a transmittal document detailing their status. The contractor shall package all data and documents to transfer any files that have not been completed as directed by the COR in accordance with Section H, paragraph 1.4, Records Management. The preferred method for transmission of all documents, files, and data is electronic, via CD/DVD or other secure means. Throughout the transition-out the contractor shall promptly and thoroughly answer in writing any questions from a successor or the COR within 5 days after receipt.

6.3.2.6 The contractor shall participate in any transition-out meetings between the Government and the successor, if any.

6.3.2.7 The contractor shall transition all remaining contract data back to the Government as directed by the COR.

TCRS HT9402-17-R-0002, Section C Page C15 of C27

6.4 Compliance Reviews

6.4.1 The contractor shall develop compliance review procedures and policies that ensure independent and objective healthcare compliance reviews consistent with DHA and healthcare standards and best practices.

6.4.1.1 The contractor shall determine if each purchased-care contractor is adhering to TRICARE policy, regulations, government directives and contract requirements when processing healthcare claims under the TRICARE health benefits program. When evaluating purchased-care contractor’s compliance, if a conflict exists between the manuals and either statue and/or regulation, the statute and/or regulation takes precedence. If there is a conflict between the manuals, the order of precedence is (1) TPM and TRM; (2) TSM; and (3) TOM. If the contractor believes that a conflict exists between the incorporated documents, the contractor shall inform the COR in writing.

6.4.1.2 The contractor shall review and report on the accuracy of reimbursement determinations and payment record coding procedures utilized by purchased-care contractors. DHA uses the compliance review results to evaluate and measure the each purchased-care contractor’s performance against claims processing performance standards referenced in the TOM, Chapter 1, Section 3, Claims Payment Errors and Claims Occurrence Errors, and/or against performance standards (if applicable) as stipulated under the terms of the purchased-care contract(s). DHA also uses the compliance review results to report the Agency’s improper payment error rate for the Military Health Benefits Program, which is published annually in the DoD AFR.

6.4.1.3 The Government will develop and maintain the sampling methodology and process for selecting sample claims. Details of the Government’s sampling approach for each purchased-care contract and sample type (e.g. non-denied payment, denied payment, occurrence, etc.) is provided in Section J, Attachment J-5, DHA Sampling Methodology.

6.4.1.4 Claim volume estimates may fluctuate over the course of the TCRS contract as the result of changes to the Government’s sampling requirements, as TRICARE purchased-care contracts expire, and/or as follow-on contracts are awarded over the performance period of the TCRS contract. The Government reserves the right to change the sampling approach for any compliance review. The contract compliance review schedule and estimated claim volumes are provided in Section J, Attachment J-6, TCRS Compliance Review Schedule.

6.4.2 The contractor shall conduct quarterly compliance reviews of institutional (inpatient hospital) and non-institutional (outpatient hospital, laboratory, radiology or physician) healthcare claims processed by each MCSC, TDEFIC, TPharm, and TOP. The contractor shall perform separate semiannual compliance reviews of ADDP outpatient dental claims. Quarterly and semiannual review cycles are based on the respective purchased-care contractor’s contract period of performance.

6.4.2.1 The contractor shall conduct annual healthcare cost compliance reviews of underwritten inpatient and outpatient healthcare claims processed by each MCSC contractor. The annual

TCRS HT9402-17-R-0002, Section C Page C16 of C27 healthcare cost review cycle is based on the start and end dates for each purchased-care contract’s option periods of performance.

6.4.2.1.1 Upon initiation of a compliance review, the COR will distribute a list of TED or dental records selected to be reviewed by the TCRS contractor, to the appropriate purchased-care contractor(s). The transmittal letter instructs the purchased-care contractor(s) to (for each record/claim selected for review) compile and submit directly to the TCRS contractor, legible copies of processed claims information (i.e., medical claim forms (CMS 1500, UB92, UB04), Explanations of Benefits (EOBs), eligibility determinations, etc.) and any additional claims processing documentation and/or information (i.e. network negotiation rates, medical necessity determinations, referral/authorization requirements, etc.) used to substantiate the reimbursement or coding procedures utilized by the purchased care contractor in the course of adjudicating the health care claim form . The COR will simultaneously send a copy of the purchased-care contractors transmittal letter to the contractor. Purchased-care contractors typically have 45 days from the date of the transmittal letter to send required documentation directly to the contractor.

6.4.2.1.2 After the contractor receives the transmittal letter the contractor shall access the TA application and download the list of TED and/or dental records/claims selected for review, along with the associated TADRs and/or ADDP AADRs. The contractor shall download TED and/and or dental record listings for the respective purchased-care contract and review cycle as indicated in the transmittal letter. The contractor shall use the TADR when reviewing MCSC, TDEFIC, TOP and TPharm medical or pharmacy claims and the AADR when reviewing ADDP dental claims.

6.4.2.1.3 The TADR is the TED payment record as reported by the MCSC, TDEFIC, TOP and TPharm contractors, while the AADR is the active duty dental payment record as reported by the ADDP purchased-care contractor. Data field definitions and processing requirement for the TADR are in the TSM, Chapter 2, Section 2.2., while the data field definitions and processing requirements for the AADR are in the ADDP contract (Section J, Attachment J-7, ADDP MDR Data Elements). Data fields in the TADR and AADR are identified by abbreviated name, and labeled with an alphanumeric code, which is used for recording error conditions. Additional information on the purpose and use of the TADR and AADR, as well as report examples, are provided in Section J, Attachments J-8, Example of TADR, J-9, Example of AADR and J-10, DHA Compliance Review Guidelines.

6.4.2.1.4 Payment Error Determinations. The contractor shall evaluate the accuracy of payment determinations by purchased-care contractors based on the claim, claim documentation, claims history data, and other documentation used in the adjudication of the medical, dental or pharmacy claims. The contractor shall compare the purchased-care contractor’s payment actions as indicated on the TADR or AADR with TRICARE policy/regulations requirements, purchased-care contract requirements, and any additional supporting documentation provided by the purchased-care contractor.

6.4.2.1.5 Occurrence Error Determinations. The contractor shall evaluate the accuracy of payment record coding procedures utilized by purchased-care contractor in the course of adjudicating a claim. Compliance review determinations are based on the claim, claim

TCRS HT9402-17-R-0002, Section C Page C17 of C27 documentation, electronic claims history data, and other documents or information provided by the purchased-care contractor to substantiate the procedures used when adjudicating the claim.

Evaluations are made by comparing the medical, pharmacy or dental claims information, to the information reported on the TADR or AADR. The contractor shall validate every data field reported on the TADR and/or AADR.

6.4.2.1.6 Throughout the course of the compliance review process, the contractor shall clearly and legibly annotate in narrative form on the respective TADR or AADR the reason for assessing either a payment or an occurrence error.

6.4.2.1.7 When entering compliance review results in the TA application, the contractor shall utilize the correct and/or appropriate payment or occurrence error codes and provide a clear, concise and thorough explanation of the reason for assessing an error. See Section J, Attachment J-10, DHA Compliance Review Guidelines, for a complete list of error codes and error code definitions. The contractor shall notify the COR of the completion of compliance reviews at each stage of the review process (i.e. initial, rebuttal and second rebuttal) by utilizing the notification option in the TA application and by sending a follow-up email confirming receipt of the TA system notification by the COR.

6.4.2.1.7.1 Upon completion of the initial compliance, review process the contractor shall submit DRG grouper/pricing and OPPS grouper/pricer/schedule information worksheets produced from the contractors DRG and OPPS pricer applications for each claim subject to the DRG or OPPS reimbursement methodology. The contractor shall follow instructions for submitting DRG and OPPS information worksheets using the following CDRLs:

• R011, DRG/OPPS Pricing Worksheets, North Region

• R012, DRG/OPPS Pricing…