TOP_2021_Draft_Section_C.docx

SECTION C

TRICARE OVERSEAS PROGRAM (TOP) PERFORMANCE WORK STATEMENT (PWS)

C.1. GENERAL.

C.1.1. The Department of Defense (DoD), through the Defense Health Agency (DHA), has a mission to provide TRICARE services to eligible beneficiaries in locations outside the fifty United States and the District of Columbia.

C.1.2. In order to accomplish this mission, the TRICARE Overseas Program (TOP) contract will supplement the services that are provided to Active Duty Service Members (ADSMs) and certain Active Duty Family Members (ADFMs) via the direct care system in designated Military Treatment Facility (MTF) locations. The TOP contract will provide comprehensive health care support services to ADSMs and certain ADFMs in designated remote overseas locations. Health care support services include the development of purchased care provider networks, referral management activities, TRICARE eligibility verification and enrollment, medically-necessary evacuations (medevacs), medical documentation, translation services, medical management services, customer service/call center activities, beneficiary and provider education and marketing, and claims processing and coding.

C.1.2.1. The TOP Contractor shall provide limited services to other TRICARE eligible beneficiaries as specified in this section.

C.1.3. Section C includes two categories of outcome-based statements. The “Statement of Objectives” represents the desired outcomes for this contract. The objectives are supported by “Technical Requirements.” These requirements encompass the scope of the contract and represent specific tasks, outcomes, and/or standards that, at a minimum, must be achieved.

C.1.4. Whenever practicable, the technical requirements identified in this section are accompanied by one or more cross-references to related language contained in the TRICARE Manuals. These cross-references are provided as a convenience to facilitate understanding of the contract requirements and are not intended to be all-inclusive. The contractor is responsible for understanding the full scope of the TRICARE program and all TOP requirements as outlined in the contract (to include the documents incorporated by reference in C.3. below).

C.2. STATEMENT OF OBJECTIVES. The primary objectives (i.e., desired outcomes) of the TOP contract are as follows:

C.2.1. Objective 1 – Optimal Beneficiary Experience of Care. Create the best possible experience for the beneficiary though all phases of health care delivery by providing guidance through the complexities of overseas healthcare while generating heightened understanding of the quality of care being provided by the purchased care sector providers.

C.2.2. Objective 2 – Flexible, Versatile, and Adaptable Overseas Health Care Delivery System. Innovative, flexible purchased care system which can quickly adapt to changes in overseas healthcare environments and deliver health care solutions to MTFs/beneficiaries, and Combatant Commands which meet mission needs and increase readiness.

C.2.3. Objective 3 – Highest Level of Clinical Quality. Delivery of the highest quality of care through a robust, data driven clinical quality program which employs high-quality provider networks to ensure patients are treated in accordance with the highest medical standards of the host nation.

C.2.4. Objective 4 – Efficient and Integrated Overseas Health Care Delivery. Implement an overseas healthcare system which integrates purchased and direct care, reduces beneficiary/ provider administrative burdens, and meets all claims processing/coding, referral/authorization and all other TRICARE standards.

C.3. DOCUMENTS.

C.3.1. The following documents form an integral part of this contract and have the same force and effect as if set forth in full text. The TRICARE Manuals provide instruction, guidance and responsibilities to establish contractual requirements for implementation of federal statutes and regulations. When a statute, regulation or manual has changed, there is no change to the contract requirements until the Contracting Officer changes the contract by modification to the contract. In the event of a conflict between the manuals and either statute and/or regulation, the statute and/or regulation takes precedence. If there is a conflict between the manuals, the order of precedence is: (1) TRICARE Policy Manual (TPM) and TRICARE Reimbursement Manual (TRM), (2) TRICARE Systems Manual (TSM), and (3) TRICARE Operations Manual (TOM). The TRICARE Manuals are located at: http://manuals.tricare.osd.mil/. If the contractor believes that a conflict exists between the incorporated documents, the contractor shall inform the Contracting Officer.

C.3.1.1. Attachment J-17, Draft TOM, Chapter 24

C.3.1.2. Attachment J-18, Draft TPM, Chapter 12

C.3.1.3. TSM 7950.2-M, April 2015, through Change XXX.

C.3.1.4. TRM 6010.61-M, April 2015, through Change XXX.

C.3.1.5. Statutory and Regulatory Authority.

· Title 10, United States Code (U.S.C.), Chapter 55, Section 1074(c)(1)

· Title 32 CFR Parts 199.

· Title 36 CFR Part 1222 (data created or received and maintained for the Government by contractors)

· Title 45 CFR Parts 160, 162 and 164 of Health Insurance Portability and Accountability Act of 1996 (HIPAA) security and privacy standards, transaction and code set standards, National Provider Identifier (NPI) requirements and implementation specifications.

· National Institute of Standards and Technology (NIST) Special Publication (SP) 800-171 and 800-171A

C.3.2. Definitions are included in Title 32, Code of Federal Regulations (CFR) Part 199.2 and TOM Appendix B.

C.4. GOVERNMENT INFORMATION AND APPLICATIONS.

C.4.1. The Government will provide the contractor with access to the Defense Manpower Data Center’s (DMDC) Defense Enrollment Eligibility Reporting System (DEERS) to perform eligibility inquiries and enrollments. DEERS is the database of record for TRICARE eligibility for the TOP contract. The Government will grant access to DEERS only after the contractor’s staff and all subcontractors’ staff that utilize systems which access and maintain TOP data are compliant with the enhanced safeguarding methods for unclassified DoD information, personnel security, and clearance requirements (see C.25. below for a description of these system requirements). The contractor and its subcontractors must be in compliance with these requirements no later than 120 days before the start of health care delivery.

C.4.2. The Defense Medical Information System (DMIS) is a service of the DoD which identifies past and current DoD medical facilities. DMIS Identifiers (DMIS IDs) are recognized throughout the DoD for various medical and military facility identification purposes, including TRICARE enrollment. DMIS ID tables may be viewed at:

https://www.health.mil/Military-Health-Topics/Technology/Support-Areas/Geographic-Reference-Information/DMIS-ID-Tables

C.4.3. The Government will grant the contractor access to the designated Government system(s) for the purpose of receiving referrals and returning authorizations. Access is subject to the same information technology and personnel security and clearance requirements discussed in C.4.1.

C.5. CONTRACTOR FURNISHED ITEMS. The contractor shall furnish all necessary items (e.g., facilities, labor, services, supplies, etc.) for the satisfactory performance of this contract, unless the contract specifically states that the Government will be providing such items (as identified in Attachment J-4 or elsewhere within the contract).

C.6. TECHNICAL REQUIREMENTS. The technical requirements for the TOP contract are identified below. These requirements are augmented by the statutes, regulations, and other operating guidelines and instructions incorporated by reference as noted in Section C.3. To facilitate better understanding of the contract requirements, key cross-references to the TRICARE Manuals and other reference materials have been included.

C.7. MEDICAL BENEFITS.

C.7.1. Medical benefit policy applies to the scope of services and items which may be considered for cost-sharing by TRICARE within the intent of 32 CFR 199. Explicit medical benefit requirements, limitations, or exclusions are identified in 32 CFR 199 and augmented by the TPM.

C.7.2. The TOP contract strives to accommodate the cultural differences associated with the delivery of health care overseas; however, services or items which are specifically excluded or limited in the regulation or the TRICARE manuals cannot be provided under the TOP contract without specific Government direction.

C.7.3. DHA maintains a “No Government Pay Procedure Code List” which identifies all codes that are excluded from coverage and are not payable under the TRICARE program. This list is available online at http://www.tricare.mil/nogovernmentpay/.

C.7.4. Active Duty Service Members (ADSMs) in the locations specified in Attachment J-9 are authorized to receive private accommodations in a hospital or other authorized institution, regardless of whether semiprivate accommodations are available.

C.7.5. Refer to 32 CFR 199.4 and the TPM for additional information regarding TRICARE medical benefits. Refer to TOM Chapter 17 for specific requirements and additional information regarding waivers for the provision of non-covered services to ADSMs under the Supplemental Health Care Program.

C.8. MANAGEMENT.

C.8.1. The contractor shall establish and maintain effective management strategies, staff education and training programs, lines of authority, and reporting and coordination interfaces with the Government.

C.8.2. The contractor shall implement a management structure which can respond to changing Government requirements in an expedited manner. The contractor shall work cooperatively with the Government to plan and develop solutions to high priority changes quickly.

C.8.3. The contractor shall establish and continuously operate an internal Quality Management/ Quality Improvement (QM/QI) program that will provide the contractor’s management with effective and efficient processes for identifying and correcting problems throughout the duration of the contract. At a minimum, the QM/QI program shall include the following:

· Quality Practices

· Contractor and Subcontractor Staff Education and Training

· Claims Processing (accuracy, timeliness, coding)

· Internal Controls

· Utilization Review, Claims Review, and Utilization Management Processes

· Provider and Facility Credentialing, Re-Credentialing, and Certification Activities

· Access to Care Monitoring Procedures

· Delegated Activities and Subcontractor Oversight Management

· Appeals and Grievances Procedures

· Beneficiary Communications

· Provider Communications and Satisfaction Monitoring

· Quality Management Plan

· Translation Quality Monitoring (applies to any translation action performed by the contractor or subcontractor, not just translated documents prepared under CLINs X005 and X006)

C.8.4. The contractor shall implement processes and procedures to promote and assure health care quality and value according to the general principles outlined in the Health Care Industry’s Consumer Bill of Rights and Responsibilities as developed by the President’s Advisory Commission on Consumer Protection and Quality (see http://archive.ahrq.gov/hcqual/).

C.8.5. The contractor shall develop and implement a course on military culture. All training materials will be provided to the Government for review six months prior to the start of healthcare delivery. All contractor and subcontractor employees shall be required to participate in the course and the contractor shall document employee attendance.

C.8.6. The contractor shall document and employ management procedures to ensure confidentiality of all beneficiary and provider information. This includes the protection of rights of the individual in accordance with the provisions of the Privacy Act (5 U.S.C. 552a); the Freedom of Information Act (5 U.S.C. 552); the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) Reorganization Act (42 U.S.C. 290dd-2) (see the TOM, Chapter 1, Section 5). The contractor shall prevent unauthorized use of files. The contractor must also comply with all applicable requirements of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 including DoD Health Information Privacy Regulation – DoD 6025.18-R (as amended), the DoD 8580.02-R, Department of Defense Health Information Security Regulation, and the TRICARE Manuals.

C.8.7. Refer to TOM Chapter 1 and TOM Chapter 24, Section 1 for specific requirements and additional information regarding management.

C.9. RECORDS MANAGEMENT.

C.9.1. Pursuant to FAR Part 24, the requirements of the Privacy Act (5 U.S.C. 552a) and the Department of Defense Privacy Program (DoD 5400.11-R) are applicable to this contract and the systems of records operated and maintained by the contractor on behalf of DHA. These systems of records are found at 65 Federal Register 30966 (Health Benefits Authorization Files, Medical/Dental Care and Claims Inquiry Files, Medical/Dental Claim History Files), 69 Federal Register 50171 and 71 Federal Register 16127 (Military Health Information System), and 64 Federal Register 22837 (Health Affairs Survey Data Base). The records systems operated and maintained by the contractor are records systems operated and maintained by a DoD Agency (DHA). See TOM Chapter 1, Section 5; Chapter 9, Section 1; and Chapter 9, Section 2. All contractor records generated under this contract shall be maintained in accordance with 36 CFR 1222; 36 CFR Subchapter B (Records Management); Federal Records Act (Title 44 United States Code (USC), Chapters 21, 29, 31, 33); Paperwork Reduction Act (Title 44 USC, Chapter 35); and DoD Directive (DoDD) 5015.2, “DoD Records Management Program,” March 6, 2000; TOM Chapter 9; and TOM Chapter 24, Section 2.

C.9.2. There shall be no dissemination or publication of information developed under this contract or contained in the reports to be furnished pursuant to this contract, except within and between the contractor, subcontractors, and DHA, without prior written approval from the Contracting Officer.

C.9.3. TOP records may not be used by the contractor for commercial marketing purposes or any other purpose not directly related to the TOP contract. This does not include contractor- maintained TOP provider records for purchased care sector providers who provide care to other corporate business clients of the contractor.

C.9.4. Freedom of Information Act (FOIA) Requests. In the event the contractor receives a FOIA request, the contractor shall return it to the requestor for submission to the DHA FOIA officer at the following address: Defense Health Agency (DHA), Attention: FOIA Officer, 16401 East Centretech Parkway, Aurora, CO 80011-9066.

C.9.5. Refer to TOM Chapter 9 and TOM Chapter 24, Section 2 for specific requirements and additional information regarding records management.

C.10. FINANCIAL ADMINISTRATION. Refer to TOM Chapter 3; TOM Chapter 24, Section 3; and Section G for specific requirements, instructions and additional information regarding financial administration.

C.11. PURCHASED CARE SECTOR PROVIDERS AND FACILITIES.

C.11.1. Network Development. The contractor shall provide a managed, stable, high-quality network of individual and institutional purchased care sector providers which promotes access, clinical quality, beneficiary and provider satisfaction, and “best value health care” for TOP enrollees in the MTF locations identified in Attachment J-1 and the network-designated remote locations identified in Attachment J-2 (see TOM, Appendix B, for definition of “best value health care”).

C.11.1.1. In MTF locations, provider networks shall be developed to support TOP Prime enrollees by complementing the clinical capability and capacity of the MTF. The contractor shall collaborate with the MTFs and the TRICARE Area Offices (TAOs) to ensure the most efficient mix of healthcare delivery between the direct care system and the contractor's network. Collaboration includes, but is not limited to preventive care, overflow capacity for primary and specialty care, and ancillary services.

C.11.1.2. In network-designated TOP Prime Remote locations, provider networks shall be developed to provide primary and specialty care to TOP Prime Remote enrollees.

C.11.1.3. When necessary, the contractor shall augment provider network(s) with non-network providers to ensure that the number, mix, and geographic distribution of purchased care sector providers is sufficient to provide all TRICARE reimbursable services under this contract to TOP enrollees in all MTF areas identified in Attachment J-1 and all network-designated remote areas identified in Attachment J-2. The contractor’s provider network(s) shall also support the requirements of special programs described in the TPM and the TOM (e.g., the Extended Care Health Option (ECHO)) for TOP enrollees in MTF and network-designated remote locations.

C.11.1.4. In all Puerto Rico MTF locations, the contractor shall provide a network of Primary Care Managers (PCMs) to support TOP Prime enrollment of ADFMs who are command sponsored or otherwise eligible for TOP Prime enrollment.

C.11.1.5. Development of purchased care sector provider (PCSP) networks and the delivery of cashless, claimless services in non-network designated remote locations shall be on a “best effort” basis. Non-network designated remote locations are those locations in which ADSMs/ADFMs are assigned, but a TOP Prime Remote site is not established. Non-network designated remote locations are identified in Attachment J-3. The contractor will automatically add non-network designated remote locations when ADSMs/ADFMs are assigned to overseas locations in which a TOP Prime or a TOP Prime Remote/non-network designated remote location does not exist. With respect to non-network designated remote locations, “best effort” is defined as the contractor making commercially reasonable efforts on an ongoing basis to achieve the stated outcomes for network adequacy and cashless, claimless health care. Under these conditions, failure to achieve the stated outcomes will not result in a negative performance evaluation by the Government.

C.11.1.6. Networks shall be right sized to include only the number of high quality providers required to meet contract requirements.

C.11.2. Network Provider Accreditation. All Network hospitals and other places of institutional care shall meet the minimum accreditation standards of the specific host nation/U.S. commonwealth/territory. The contractor shall establish processes to evaluate the quality, safety, and compliance with licensure/certification and malpractice insurance requirements of purchased care sector institutions and maintain such evaluations for inspection by the Government. Evaluations shall be updated every three years at a minimum unless specifically waived by the Contracting Officer.

C.11.2.1. The contractor shall identify the international and national medical accreditation program(s) for the locations identified in attachments J-1 and J-2. In locations where medical accreditation programs exist, a minimum of 85% of all applicable institutional network providers will be accredited by an internationally/nationally accepted accreditation program for the host nation. The contractor shall maintain copies of providers’ accreditation in their provider files.

C.11.3. Provider Certification/Credentialing. The contractor shall establish and operate a provider certification/recertification program to ensure that all purchased care sector providers who provide services to TOP enrolled beneficiaries are qualified to provide high quality care which is commensurate with the TOP contract and local requirements. This requirement also applies to purchased care sector network providers who provide services to transient beneficiaries when the beneficiaries have sought care via the contractor’s health care finder service.

C.11.3.1. The contractor shall establish business processes to track and monitor the credentials of all purchased care sector network providers working under this contract, including the individual provider credentials, credentialing organization, date of credentials and date of credentials expiration. Credentials for network providers shall be verified during the network development/network agreement process. The contractor shall verify credentials for non-network providers upon receipt of the first TRICARE claim and prior to payment of the claim, unless specifically waived by the Contracting Officer.

C.11.3.2. During the certification/recertification process, the contractor shall check the U.S. Department of Health and Human Services (DHHS) Sanction List (http://exclusions.oig.hhs.gov/) for all providers. Providers listed on the DHHS Sanction List are excluded from providing services under all federal programs. This restriction remains in place even if a provider begins practicing in another country.

C.11.3.3. The contractor shall perform on-site verification during provider certification in the Philippines. The Government may expand this on-site verification requirement to other locations during the life of the contract.

C.11.4. Medical malpractice insurance. All Network providers must meet the medical malpractice insurance standards for their host nation or U.S. commonwealth/territory (if applicable). The contractor is responsible for determining the medical malpractice coverage required in the country, province, state, commonwealth/territory, etc., (including country, province, state, commonwealth/territory, etc., risk pools if applicable) for each network provider (both professional and institutional) and ensuring that each network provider is in compliance with this standard. Each network provider agreement must indicate the provider has the required malpractice coverage. Evidence documenting the required coverage of each network provider under the contract shall be provided to the government upon request.

C.11.4.1. In the absence of any country, province, state, commonwealth/territory, etc., legal requirement for medical malpractice insurance coverage, the contractor is responsible for determining the local community standard for medical malpractice coverage, and the contractor must maintain documentation evidencing both the standard and compliance by network providers.

C.11.4.2. The TRICARE Overseas Program Office (TOPO) retains the authority to determine whether country, province, state, commonwealth/territory, etc., and/or local requirements and/or community standards for medical malpractice coverage have been met by a network provider and whether the contractor has documented the required coverage.

C.11.4.3. The contractor shall provide the Government with a listing of the requirements for, and the availability of malpractice insurance and licensure/certification requirements for all countries included in Attachment J-1, network-designated locations in Attachment J-2, and non-network designated locations in Attachment J-3. See Malpractice Insurance and License Certification Requirements, (Contract Data Requirements List (CDRL) R050) for additional information regarding this reporting requirement.

C.11.5. Telehealth. The (TOP) contractor shall utilize synchronous or asynchronous telemedicine, if allowed by the host nation, to provide diagnostic and treatment services as a means of delivering healthcare services to all ADSMs and ADFMs enrolled in TOP Prime/Prime Remote.

C.11.5.1. In TOP Prime locations, the contractor’s telehealth program shall include primary, specialty, behavioral health and ancillary services that augment MTF capabilities. In TOP Prime Remote locations, the contractor shall employ primary, specialty, behavioral health, and ancillary telemedicine services to augment TOP provider networks.

C.11.5.2. The contractor shall ensure telemedicine consultation is considered as part of the patient’s plan for medical care prior to, or in conjunction with recommending Medical Temporary Duty (TDY).

C.11.5.3. The contractor’s Network Implementation Plan (CDRL P030) shall detail how the contractor plans to maximize the effective use of telemedicine in all TOP Prime and TOP Prime Remote locations, which allow telehealth. The plan shall include:

· Telemedicine-specific regulatory, licensing, credentialing and privileging, malpractice and insurance laws and rules for each host nation

· The synchronous/asynchronous/virtual technologies the contractor intends to employ

· The contractor’s plan for implementing telemedicine around each TOP Prime location (stratified by specialty, mental health, and ancillary telemedicine services)

· The contractor’s plan for implementing telemedicine around each TOM Prime Remote location (stratified by primary, specialty, mental health, and ancillary telemedicine services)

· Education of MTFs/Beneficiaries

C.11.6. Clinical Quality Metrics. The contractor shall track and report clinical data that measures quality and maintain such data for inspection by the Government. The contractor shall develop, deliver, and maintain clinical quality metrics for overseas network PCSPs that is consistent with the needs of the TOP Prime/Prime Remote beneficiary population served. This data will be provided to the TOPO for review prior to dissemination and, when approved, the contractor shall make this data available to MTFs/TAOs to assist in directing patients to high quality providers. Metric types should include structural, process, and outcome metrics.

C.11.6.1. The contractor shall provide the Government with a listing of relevant host nation quality metrics for all countries included in Attachment J–1 (countries/territories with TOP Prime MTFs) and TOP Prime Remote countries included in Attachment J-2. The contractor shall report on the clinical quality of network institutional providers compared to clinical quality metrics established for the country. The TOP contractor may request a clinical quality metrics waiver for any location in which clinical quality metrics cannot be established. Such waiver requests should be directed to the appropriate TAO and should include the reason(s) for the waiver request (e.g., clinical quality metrics are not collected by commercial/governmental entities). Final approval of clinical quality metrics waivers is made by the TOPO. If the request is approved, the contractor will be notified of the clinical quality metrics waiver.

C.11.6.2. The contractor shall include their methodology for developing clinical quality metrics in the Clinical Quality Management Program/Clinical Quality Oversight Plan in accordance with CDRL P010. The contractor shall describe how clinical quality metrics are incorporated in their assessment of quality of care rendered by purchased care sector providers and how providers’ performance is accurately compared to host nation standards using clinical quality data. The contractor shall develop clinical quality metrics that leverage existing international accreditation agency and national clinical quality data, and which are medically meaningful and statistically reliable (e.g. risk adjusted based on a wide range of patient population characteristics). The developed metrics shall be patient-centered (e.g. considering the patient’s needs, values and preferences), and evidence-based. The contractor shall report on the implementation and utilization of clinical quality metrics in the Clinical Quality Management Program/Clinical Quality Oversight Report (CDRL A110).

C.11.6.3. The contractor shall respond to any inquiries from the Government concerning any aspect of clinical quality measurement within four working days. The contractor shall maintain this quality measurement database to which Government personnel (when approved by the TOPO ) will be granted access. Clinical quality measurement documentation shall be made available to the Government during routine meetings, audits or focused reviews.

C.11.7. High Clinical Quality Outcomes. The contractor shall actively seek institutional and individual providers for their network that produce the highest quality clinical outcomes and use evidence-based medicine.

C.11.7.1. The contractor shall profile and monitor provider performance in an ongoing manner using profiling/monitoring parameters that address, but are not limited to, cost of care, clinical quality of care to include population health/prevention practices as appropriate, patient complaints and access. These profiles and parameters shall be based on the host nation’s current and evolving sources of outcomes and performance data to include outcome data, preventive measures data, and laboratory data.

C.11.7.2. The contractor shall incorporate the clinical quality metrics identified in C.11.6 into its profiling/monitoring parameters and establish a clinical quality rating system. The methodology used for developing a clinical quality rating system shall be clearly articulated in its Clinical Quality Management Program/Clinical Quality Oversight Plan (CDRL P010). Use of the clinical quality rating system shall be reported on in the Clinical Quality Management Program Report (CDRL A110). In locations identified in attachments J-1 and J-2, the contractor shall ensure 75% of network providers are in the 75% percentile or higher with respect to clinical quality as defined in C.11.6. The contractor’s methodology for determining the 75% percentile shall be clearly articulated in its Network Implementation Plan (CRDL P030). In its role as Health Care Finder, the contractor will direct beneficiaries to the network providers with the highest quality outcomes.

C.11.8. Access to Care. The contractor shall make their best effort to ensure that the TRICARE standards for access, in terms of beneficiary travel time, appointment wait time, and office wait time are met for TOP Prime and TOP Prime Remote enrollees.

C.11.8.1. Access standards include emergency care 24 hours per day, 7 days per week in the service area; acute care appointments within 24 hours; routine care appointments within 7 calendar days; wellness care appointments within four weeks; specialty care appointments within four weeks or per provider designation (not to exceed four weeks); no more than 60 minutes drive time from the sponsor’s duty location for specialty care (no more than 30 minutes for other types of care); office wait times will generally not exceed 30 minutes for non-emergency care.

C.11.8.2. Best effort is defined as the contractor making commercially reasonable efforts on an ongoing basis to achieve the stated outcomes for access to care. Under these conditions, failure to achieve the stated outcomes will not result in a negative performance evaluation by the Government. The contractor shall inform the Government of locations where access to care is severely impaired (in terms of beneficiary travel time, appointment wait time, and/or office wait time) and shall implement corrective actions as appropriate to improve access in those areas.

C.11.9. Provider capability and capacity adjustments. The contractor shall ensure that purchased care sector network and non-network provider capabilities and capacities can be adjusted as necessary to compensate for changes in MTF capabilities and capacities (due to facility downsizing or closure, MTF expansion, establishment of new clinics, provider deployment or reassignment, etc.), which may change frequently over the life of the contract. The contractor shall adjust the capabilities and capacities of available purchased care sector providers to compensate for such changes when and where they occur within 90 calendar days of notification by the Government.

C.11.10. Network inadequacy. The contractor shall assess network adequacy on an ongoing basis, and shall inform the Government of any instances of network inadequacy. The contractor will submit a corrective action plan for instances of network inadequacy that are significant (e.g., the only provider in a certain specialty leaves the network and there are no other local providers capable of providing similar services) or likely to persist for more than 30 calendar days. The contractor shall respond to any inquiries from the Government concerning any aspect of network adequacy within four working days.

C.11.10.1. One measure of network adequacy or inadequacy shall be the percentage of paid claims for TOP Prime and TOP Prime Remote enrollees that are submitted by network providers, after excluding certain claims associated with care that was not specifically authorized by the contractor (including, but not limited to Point of Service (POS) claims, Other Health Insurance (OHI), pharmaceuticals, ancillary services (except MRIs and PET scans), any DME items that do not require an authorization, preventive services, medical supplies that do not require an authorization, emergency care, etc.). Refer to Section H.6.4. for a description of the network adequacy calculation. Attachment J-6 identifies those services and supplies which will be excluded from the Government’s network adequacy calculations.

C.11.10.2. The contractor shall ensure that the purchased care sector provider networks are sufficient in number, mix, and geographic distribution to achieve the target of 70% for the percentage of paid claims for TOP Prime and TOP Prime Remote enrollees submitted by network providers during Option Period 1. The target for percentage of paid claims for TOP Prime and TOP Prime Remote enrollees submitted by network providers shall increase by 4% in each succeeding option period.

C.11.10.3 The TOP contractor may request a network implementation waiver for any location identified in Attachment J-2 which would otherwise require the development of a purchased care sector provider network. Such waiver requests should be directed to the appropriate TAO and should include the reason(s) for the waiver request (e.g., safety concerns, lack of providers, security risks), as well as a recommended strategy to ensure access to care for TOP Prime Remote enrollees. Final approval of network waivers is made by the Contracting Officer. If the request is approved, the contractor will be notified of the network implementation waiver.

C.11.11. Negotiated Rates. The contractor shall negotiate reduced rates for healthcare provided by purchased-care network providers in the countries designated in attachment J-12. Through negotiating rates, the contractor shall achieve a reduction in the average cost-per-claim compared to a pre-established baseline established by the contractor (C.11.11.1). The contractor shall negotiate rates in such manner as not to jeopardize access to care.

C.11.11.1. The contractor shall establish the cost-per-claim baseline utilizing claims data from FY17-FY20. The cost-per-claim baseline shall be adjusted by the contractor based on the healthcare inflationary factor for each country or region within a country and converted to FY20 dollars. Specifically, the contractor will convert FY17, FY18, FY19 claim costs to FY20 dollars when establishing the average cost-per-claim baseline for Option Period 1. The Contactor shall adjust the average cost-per-claim baseline in each succeeding OP to account for the healthcare inflationary factor each year. The contractor will use the healthcare inflationary factor established by the respective country (or region within a country). A separate cost-per-claim baseline shall be established for each country identified in Attachment J-12.

C.11.11.2. The contractor will ensure its claims processing systems are structured such that network discounts are clearly identified and, on request, provide Ad Hoc Management Reports (CDRL R010) demonstrating the cost savings achieved by negotiating rates in each country identified in Attachment J-12.

C.11.11.3. In the absence of any specific reimbursement rates or reimbursement methodology mandated by DHA, the contractor may negotiate reimbursement rates with purchased care sector providers. The contractor may also negotiate rates in locations where DHA has directed a specific reimbursement rate; however, the negotiated rate cannot exceed the DHA-directed rate. The contractor shall maintain copies of all documents used to establish reasonable and customary local reimbursement rates, and shall make these documents available for Government inspection upon request.

C.11.12. English Speaking Network Providers. Network providers shall be able to communicate in English, both orally and in writing, or provide translation services at the time of service. At a minimum, network providers (or their translators) shall be able to demonstrate proficiency and fluency in the English language at the “Level 3 – General Professional Proficiency” level (for oral and written communications) as defined by the Interagency Language Roundtable guidelines which can be found at http://www.govtilr.org. Non-network providers are not required to communicate in English or provide translation services; however, in these cases, the contractor shall provide real-time toll-free telephonic translation support services at the time of service upon beneficiary request.

C.11.13. Provider Education. The contractor shall have an active provider education program designed to enhance and maintain purchased care sector provider awareness of applicable TRICARE requirements, policies, and procedures. The provider education program will ensure purchased care sector providers are able to carry out the requirements of this contract in an efficient and effective manner that promotes beneficiary and provider satisfaction.

C.11.13.1. The contractor shall produce regional provider education materials. Education materials must be reviewed and approved by the Government prior to dissemination. Provider education materials will be produced in the following languages: German, Italian, Korean, Japanese, Arabic, Spanish, French, Turkish.

C.11.13.2. A detailed description of the contractor’s provider education program shall be incorporated into the contractor’s network development plan. Contractor distribution of initial marketing materials to network providers shall occur no earlier than 60 calendar days and no later than 30 calendar days prior to the start of health care delivery. Ongoing provider education efforts shall be in accordance with the Government-approved plan. The Government will provide mandatory formats for all contractor-produced regional educational material to ensure that all TRICARE marketing products have a consistent look and feel and are appropriate for that specific region. Material must be reviewed by the Government prior to dissemination. The contractor shall produce TOP provider education material in accordance with the TOM Chapter 11, Section 1 and TOM Chapter 24, Section 11.

C.11.14. Government Indemnification. The contractor agrees to be liable for and expressly agrees to indemnify the Government for any liability resulting from services provided under the contract to MHS eligible beneficiaries for care provided by contractor network providers, or, in the alternative, the contractor agrees that all network provider agreements used by the contractor shall contain a requirement, directly or indirectly by reference to applicable regulations or DHA policies, that the network provider agrees to indemnify the Government from any liabilities arising from any acts or omissions in the provision of medical services by the provider to MHS eligible beneficiaries for care provided by contractor network providers.

C.11.15. Provider Directory. The contractor shall maintain an accurate, readily accessible, up-to-date searchable list identifying all network providers for each service area identified in Attachment J-1, network-designated areas identified in Attachment J-2, and non-network designated remote locations identified in Attachment J-3. This list must be user-friendly and readily searchable by provider or facility name, specialty or type of facility, subspecialty, gender (for individual providers), service area, work address, work telephone number, any limitations of service, and whether the provider is accepting new TRICARE patients.

C.11.15.1. The contractor shall provide easy access to this list via a user-friendly World Wide Web site and any other means established at the contractor’s discretion. The information contained in an electronic list shall be current within the last 30 calendar days. All network provider lists shall include a brief statement geared specifically towards TOP enrollees, advising them of appropriate referral/authorization processes and the possible consequences of self-referral for specialty care. The contractor shall make the web-based provider directory available to the public at the start of health care delivery. The provider directory shall provide a user friendly method for downloading a list of providers stratified by location (as specified in attachments J-1 and J-2) and specialty.

C.11.15.2. The contractor shall assign a Country Medical Risk rating to each overseas country. The rating shall be based on a range of factors, including, but not limited to: the standard and accessibility of local medical care, the risk of infectious disease, and cultural, language, or administrative barriers to accessing health care. The contractor shall classify countries as being Very High, High, Medium, or Low Medical Risk. Country Medical Risk ratings shall be included in the provider directory.

C.11.15.3. The contractor shall provide the MTF PCMs and the medical staff at the Embassy Health Units with an enhanced provider search capability. The provider search function shall include the complete list of network and participating non-network providers in all locations. The directory will include the distance from the US Embassy/MTF, the provider’s clinical quality rating (C.11.7.2.), and the contractor’s internal notes on the provider’s capability.

C.11.16. The contractor provider agreements shall require network providers to render individual consultation reports to referring MTFs. The contractor shall establish a process to ensure consult reports are returned to the referring MTF within 30 work days after the appointment. This process shall be included in the Offeror's proposal and incorporated into the Network Implementation Plan following contract award.

C.11.17. The contractor shall clearly identify any contractor-owned facilities or entities providing health care to TOP enrollees and shall work cooperatively with the Government to develop a plan to mitigate the appearance of a potential general conflict of interest. This includes, but is not limited to, contractor-owned clinics, hospitals, pharmacies, medical evacuation/ambulance service companies, etc. See Section H.5.2. for additional information regarding Organizational Conflict of Interest and Impaired Objectivity.

C.11.18. Refer to TPM Chapters 7 and 11, TOM Chapter 5, and TOM Chapter 24, Section 4 for specific requirements and additional information regarding purchased care sector providers and facilities.

C.12. TOP ELGIBILTY AND ENROLLMENT.

C.12.1. Eligibility. Eligibility for TRICARE is determined by the Uniformed Services, not by DHA. Except for newborns/newly adopted children and Reserve Component (RC) members on active duty for less than 31 calendar days, all individuals who are determined by the applicable Uniformed Service as meeting the TRICARE eligibility reporting requirements under 32 CFR 199.3 will be reflected as eligible in DEERS. The contractor shall establish business processes to verify eligibility in DEERS for all associated TRICARE actions (e.g., enrollment, referrals/authorizations, claims processing, etc.).

C.12.2. In addition to verifying DEERS eligibility status, the contractor shall establish business processes to verify additional eligibility information that may be required based on beneficiary category as discussed below.

C.12.2.1. Unless a specific exception exists, the contractor shall verify ADFM command sponsorship status prior to enrolling an ADFM in TOP Prime or TOP Prime Remote. ADFM enrollment requests must coincide with the specific timeframe and country location designated on the command sponsorship orders (i.e., an ADFM who is command sponsored to a location in Korea cannot be enrolled in TOP Prime in Germany). See TOM Chapter 24, Section 5, paragraph 5.1 et seq. for a list of specific exceptions to the command sponsorship requirement.

C.12.2.2. RC members who incur or aggravate an injury, illness or disease while serving on active duty for 30 days or less are eligible for Line of Duty (LOD) care as defined in DoD Directive 1241.1 and DoD Instruction 1241.2. These members will not be identified as TRICARE-eligible in DEERS; therefore, additional documentation is required to establish their eligibility for LOD care. For MTF referrals, the MTF shall verify LOD eligibility prior to issuing the referral. The contractor shall establish business processes to accept MTF LOD referrals, issue care authorizations, and process claims as if the member was eligible in DEERS. For RC members who are not referred by an MTF, prior to issuing the LOD care authorization, the contractor shall establish business processes to verify LOD eligibility with the DHA-Great Lakes (for care in the U.S. Virgin Islands only) or the applicable military unit or command for care in all other overseas locations. Verbal attestation of duty status alone is not sufficient to establish LOD eligibility; there must be written documentation from DHA-Great Lakes or the applicable military unit or command which confirms the member’s eligibility for LOD care. The contractor shall ensure that claims associated with the LOD authorization are processed as if the member was eligible in DEERS. Claims for care that are not associated with the LOD authorization shall be denied.

C.12.3. Retirees and retiree family members are not eligible to enroll in TRICARE Prime or Prime Remote, but may enroll in TRICARE Select.

C.12.4. Foreign Forces Members on temporary or permanent assignment in the TOP geographic regions are eligible for care in the direct care system only. MTF referrals or claims for purchased sector care for Foreign Forces Members shall not be authorized or paid by TRICARE.

C.12.5. Refer to TPM Chapter 10 and TOM Chapter 24, Section 5 for specific requirements and additional information regarding TRICARE and TOP eligibility requirements.

C.12.6. Enrollments. The contractor shall perform all enrollments, re-enrollments, disenrollments, and enrollment transfers; clear enrollment discrepancies; and assign or change PCMs in accordance with the provisions of the TOM and the TSM. This includes enrollment activities associated with TOP Prime, TOP Prime Remote, TRICARE Select, TRICARE Plus, TRICARE Reserve Select, TRICARE Retired Reserve, and TRICARE Young Adult; and disenrollment actions associated with non-command sponsored ADFMs, retirees, and retiree family members who move from the 50 United States and District of Columbia to an overseas location.

C.12.7. The contractor shall use the current TRICARE Enrollment/Disenrollment Form or other approved forms or processes, including a Government furnished web-based enrollment system/application to effect enrollment, PCM changes, and disenrollment actions. The contractor shall reproduce the forms as necessary to ensure ready availability to all potential enrollees and individuals requesting enrollment, PCM changes, or disenrollment.

C.12.8. The contractor shall follow MTF enrollment and PCM empanelment guidance (between the contractor and the MTF Commanders) for beneficiaries living within MTF enrollment areas.

C.12.9. The contractor shall follow TAO Director guidance for enrolling beneficiaries to TOP Prime Remote. If the contractor receives a TOP Prime Remote enrollment request for a city/country that is not included in Attachment J-2, the beneficiary will be enrolled to the non- network designated remote location where the beneficiary is located and the location will be designated a non-network remote location.

C.12.10. Refer to TPM Chapter 10, TOM Chapter 6, and TOM Chapter 24, Section 5 for specific requirements and additional information regarding TRICARE and TOP eligibility and enrollment.

C.13. MEDICAL MANAGEMENT

C.13.1. Referral Management.

C.13.1.1. The contractor shall operate a referral management program for specialty and inpatient services provided to TOP Prime and TOP Prime Remote enrollees.

C.13.1.2. MTFs will determine if they have the capability and capacity to provide needed specialty inpatient care. Submission of a MTF referral shall signify that the referring MTF has determined that the care cannot be provided by the direct care system. In Puerto Rico, the local MTF must have the opportunity to review each referral from a purchased care sector PCM to determine if the MTF has the capability and capacity to provide the care. Specific language regarding this process shall be incorporated into each Statement of Responsibility (SOR) with all MTFs in Puerto Rico.

C.13.1.3. When care cannot be provided by an MTF within the TRICARE access standards, or in remote areas where MTF care is not available, the contractor shall ensure that required care is authorized and delivered by a qualified network or non-network purchased care sector provider. The contractor shall provide health care finder services; locate an appropriate network or non-network provider to provide the authorized services; and provide the referring MTF, the provider, and the beneficiary with a copy of the referral/authorization. These requirements apply regardless of where the purchased care sector provider is located. In some cases, this will mean that the contractor will perform health care finder services and authorize care to providers in the 50 United States and the District of Columbia.

C.13.1.4. Upon beneficiary request, the contractor shall assist the beneficiary in scheduling an appointment with the…