TOP_2021_Draft_Section_G.docx

SECTION G

CONTRACT ADMINISTRATION DATA

DFARS 252.204-7006 BILLING INSTRUCTIONS (OCT 2005)

When submitting a request for payment, the contractor shall:

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

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

(End of Clause)

DFARS 252.232-7003 ELECTRONIC SUBMISSION OF PAYMENT REQUESTS AND RECEIVING REPORTS (JUN 2012)

(a) Definitions. As used in this clause—

(1) Contract financing payment and invoice payment have the meanings given in section

32.001 of the Federal Acquisition Regulation.

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

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

(4) ‘‘Receiving report’’ means the data required by the clause at 252.246–7000, Material Inspection and Receiving Report.

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

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

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

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

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

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

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

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

(End of clause)

DFARS 252.232-7006 WIDE AREA WORKFLOW PAYMENT INSTRUCTIONS (MAY 2013)

(a) Definitions. As used in this clause--

(b) Electronic invoicing. The WAWF system is the method to electronically process vendor payment requests and receiving reports, as authorized by DFARS 252.232-7003, Electronic Submission of Payment Requests and Receiving Reports.

(c) WAWF access. To access WAWF, the Contractor shall--

(d) WAWF training. The Contractor should follow the training instructions of the WAWF Web-Based Training Course and use the Practice Training Site before submitting payment requests through WAWF. Both can be accessed by selecting the ``Web Based Training'' link on the WAWF home page at https://wawf.eb.mil/.

(e) WAWF methods of document submission. Document submissions may be via Web entry, Electronic Data Interchange, or File Transfer Protocol.

(f) WAWF payment instructions. The Contractor must use the following information when submitting payment requests and receiving reports in WAWF for this contract/order:

(1) Document type. The Contractor shall use the following document type(s).

Invoice as 2 In 1 and Cost Voucher (FAR 52.216-7, 52.216-13, 52.216-14, 52.232-7)

Routing Data Table Field Name in WAWF Data to be entered in WAWF Pay Official DoDAAC -- HT0010 Issue By DoDAAC – HT9402 Admin DoDAAC – HT9402 Inspect By DoDAAC Ship To Code – HT0063 Ship From Code Mark For Code Service Approver (DoDAAC) HT0063 Service Acceptor (DoDAAC) – HT0063 Accept at Other DoDAAC LPO DoDAAC DCAA Auditor DoDAAC – N/A Other DoDAAC(s)

(a) Contract Resource Management Office (RM Invoice Mailbox) at dha.buckley.crm.mbx.aur-crm-invoices@mail.mil.

(b) COR as identified below in (g).

(g) WAWF point of contact.

(1) The Contractor may obtain clarification regarding invoicing in WAWF from the following contracting activity's WAWF point of contact.

NAME OF COR and EMAIL: Danielle McCammon; Danielle.H.McCammon.civ@mail.mil

(2) F or technical WAWF help, contact the WAWF helpdesk at 866-618-5988.

(h) Additional WAWF information.

(1) Credit Invoices. WAWF is not able to process any credit invoices and therefore credit invoices must be submitted directly to Contract Resource Management Office (RM Invoice Mailbox) at dha.buckley.crm.mbx.aur-crm-invoices@mail.mil. Credit e-mail invoice(s) must clearly state in subject line ‘WAWF not used’.

(2) Procedure if WAWF is unavailable. When instructed by DHA-A/CRM that the WAWF system is not operating normally, the contractor may submit their invoices directly to Contract Resource Management Office (RM Invoice Mailbox) at dha.buckley.crm.mbx.aur-crm-invoices@mail.mil. E-mail invoice(s) that are not submitted thru WAWF must clearly state in subject line ‘WAWF not used’. The e-mail receipt date shall be used as the invoice receipt date, DHA-A/CRM will work with the contractor to get the Receiving Report signatures necessary for payment.

(End of clause)

G.1. CONTRACT ADMINISTRATION. Defense Health Agency (DHA), Acquisition and Management Support Directorate, will perform contract administration, except as delegated to other Government agencies by the DHA Contracting Officer (CO). The contractor will be provided a copy of all delegations of administration functions. The following individuals will be the Government points of contact during the performance of this contract.

G.1.1. Contracting Officer. The DHA CO is responsible for the administration of this contract and is solely authorized to take action on behalf of the Government that may result in changes to the terms of this contract, including deviation from section C. The address for administration of this contract is:

Contracting Officer Defense Health Agency Contract Operations Division 16401 East Centretech Parkway Aurora, CO 80011-9066

G.1.2. Contracting Officer’s Representative (COR). The CO will designate a COR in writing. The contractor will be provided a copy of COR appointment. The written appointment will delineate the scope of authority of the COR. The COR has no authority to make any commitments or changes that affect any term or condition of the contract.

G.1.3. Contractor Points of Contact Personnel. The following names and addresses of the contractor’s primary and alternate point of contact are authorized to negotiate with the Government and have authority to commit to contract implementation and compliance:

Primary Alternate

G. 1.4. Government Payment Office.

Department of Defense Defense Health Agency ATTN: Contract Resource Management (CRM) 16401 E. Centretech Parkway Aurora, CO 80011-9066 E-mail: dha.buckley.crm.mbx.aur-crm-invoices@mail.mil

G .1.5. Administrative Contracting Officer (ACO). Defense Contract Management Agency (DCMA) ACO. The CO will delegate a limited number of cost accounting functions and state the specific functions from FAR 42 in the delegation letter to the DCMA ACO. The Contractor will be provided copies of all delegation letters with the specific functions.

DCMA Philadelphia P.O. Box 11427 700 Robbins Avenue, Bldg. 4-A Philadelphia, PA 19111-0427

G .1.6. Defense Contract Audit Agency (DCAA). Provide certain audit functions in support of the CO and ACO.

G. 2. ORDERING ACTIVITY/PROCEDURES – ORDERING AUTHORITY. Only the DHA CO has authority to issue orders under this contract.

G .3. PAYMENT INSTRUCTIONS FOR MULTIPLE ACCOUNTING CLASSIFICATION CITATIONS. In accordance with DFARS PGI 204.7108 this subsection provides instructions to the paying office:

G.3.1. Accounting and Appropriation Citations. When obligated, accounting and appropriation citations will be identified in schedule B as informational subline items.

G.3.2. Payments will be applied at the Contract Line Item Number (CLIN) or Sub Line Item Number (SLIN) level.

G.3.3. The contractor shall bill and credit the government at the CLIN level citing SLIN ‘00’. Where there are multiple informational SLINS under a CLIN the payment office will determine the appropriate SLIN to use.

G.3.4. Only one appropriation is allowed per informational SLIN. At the beginning of each federal fiscal year the government shall re-fund all active CLINs by adding a new informational SLIN citing the current federal fiscal year appropriation. The SLIN citing current fiscal year funds shall be used for all transactions occurring in the current fiscal year. All informational SLINs citing expired appropriations (where funds are no longer available for incurring new obligations) shall be deobligated via unilateral contract modification after each fiscal yearend. When deobligating funds at fiscal yearend DHA-A/CRM shall ensure sufficient ‘expired’ funds are set aside to pay for invoices received prior to fiscal year end with payment due dates occurring after fiscal year end. If the payment office (DHA-A/CRM) determines a payment must be made using an expired appropriation, then the government shall take action to add the funds back to the contract. The contractor may request that expired funds remain on the contract but must be able to demonstrate they have unbilled transactions where performance occurred prior to the start of the current fiscal year. The unilateral deobligation of expired funds authority applies only to the CLIN(s) that are re-funded with current funds each new federal fiscal year.

G.4. OTHER INSTRUCTIONS TO PAYING OFFICE.

G.4.1. The paying office will follow paying instructions included in any contract modification, including change order definitization and performance incentive payment modifications.

G.4.2. Revisions to payment instructions may be made as circumstances require. Revisions may be accomplished by correspondence between the contracting office and the paying office.

G.5. PAYMENTS FOR ADMINISTRATIVE CLINS – NON-TED.

G.5.1. Payments for Transition-In CLINs.

G.5.1.1. Transition-In (CLIN 0001). The contractor may invoice for interim payment of 50% of the transition-in price upon the start of health care delivery. The contractor may submit a final invoice for the balance following completion of all transition requirements. CLIN 0001 includes all costs associated with transition-in activities except Contract Data Requirements List (CDRLs) (CLIN 0002), and Performance Readiness Validation/Performance Readiness Assessment and Verification (CLIN 0003).

G.5.1.2. Contract Data Requirements List for Transition-In (CLIN 0002). The contractor may invoice for interim payment for transition-in CDRLs. Invoices shall be based on the value indicated on each completed CDRL and shall be submitted no more frequently than monthly and only after completion of the given month. The contractor may submit a final invoice for the balance following completion of all transition requirements. Supporting documentation shall include a list of transition-in CDRL activities that were performed during the invoice period, identifying the actual costs incurred for each activity.

G.5.1.3. Performance Readiness Validation/Performance Readiness Assessment and Verification (CLIN 0003). The contractor may invoice for interim payment of 50% of the transition-in price for Performance Readiness Validation/Performance Readiness Assessment and Verification upon the start of health care delivery. The contractor may submit a final invoice for the balance following completion of all transition requirements.

G.5.2. Payments for Monthly CLINs.

G.5.2.1. Managed Care Fee.

• Prime Enrolled Members (CLIN X001) and

• Prime Remote Enrolled Members (CLIN X002):

G.5.2.1.1. The Government will retrospectively, unilaterally, determine the number of TOP Prime and TOP Prime Remote enrollees on a monthly basis, based on the contractor’s monthly enrollment report and information contained in the DEERS. This information will be sent to the contractor.

G.5.2.1.2. Submit invoice(s) for these CLINs no more frequently than monthly and only after completion of the given month for the number of enrollees for each program as determined by the Government.

G.5.2.2. Transient Care Management Fee (CLINs X003). Submit invoice no more frequently than monthly and only after completion of the given month. S upporting documentation shall include a list of all beneficiaries receiving care with name, address, SSNs, duty status (ADSM, Prime-enrolled ADFM, etc.), and date of service (DOS). Only one Transient Care Management Fee shall be invoiced per eligible beneficiary per month, regardless of the number of actual health care encounters in that month. Supporting documentation contains Protected Health Information (PHI) and Personal Identifiable Information (PII) therefore all supporting documentation must be submitted securely to DHA-A/CRM ensuring patient’s privacy is protected. The contractor and DHA-A/CRM shall coordinate and agree upon a supporting documentation data submission process that provides the appropriate level of data security.

G.5.2.3. Transient Ambulance/Aeromedical Evacuation Services Management (CLINs X004). Submit invoice no more frequently than monthly and only after completion of the given month. Supporting documentation will include a list of all beneficiaries receiving care with name, address, duty status (AD, retired, FM, etc.), SSNs, DOS, status, and date of service. Supporting documentation contains Protected Health Information (PHI) and Personal Identifiable Information (PII) therefore all supporting documentation must be submitted securely to DHA-A/CRM ensuring patient’s privacy is protected. The contractor and DHA-A/CRM shall coordinate and agree upon a supporting documentation data submission process that provides the appropriate level of data security.

G.5.2.4. Written Translation Services – Routine (CLINs X005) and Written Translation Services – Urgent (CLINs X006). Submit invoice no more frequently than monthly and only after completion of the given month. Support invoice amount with a listing of translation services provided and number of pages.

G.5.2.5. Claims Processing Fee – TRICARE Eligible (CLINs X007) and Claims Processing Fee – Medicare Dual Eligible (CLINs X008). No invoice is needed. Payments are made through TED processing. (See G.6.Payment for “Claims Processing Fees” Of TED Related Claims).

G.5.2.6. Access to care in Kinshasa, Democratic Republic of the Congo (CLINs X009). Submit invoice no more frequently than quarterly and only after completion of the given quarter. Include listing of enrollees and dates of enrollments with invoice.

G.5.2.7. TOP Prime Inpatient Medical Management (CLINs X010). Submit invoice no more frequently than monthly and only after completion of the given month. Include listing of locations (MTFs) supported with inpatient medical management with invoice.

G.5.2.8. Medical Capability Reports (CLINs X011). Submit invoice no more frequently than monthly and only after completion of the given month. Include location covered by report.

G.5.3. Other Payments.

G.5.3.1. Block Overflight Permits (CLINs X012). Submit invoice no more frequently than annually and only after completion of the given year. Include location covered by report and the number of times the permits were used.

G.5.3.2. Performance Incentive Fee (CLINs X013). The contractor shall invoice as instructed by the CO following determination of performance incentive amounts, if any.

G.5.3.3. Transition Out (CLINs X014). Submit invoice following completion of all transition-out requirements.

G.5.3.4. Modifications. The contractor may invoice for change order definitization or other modifications after the CO provides instructions and authorization to invoice via modification.

G.6. PAYMENT FOR “CLAIMS PROCESSING FEE” OF TED RELATED CLAIMS.

G.6.1. Invoice and payment procedures for claims processing fees are the same for both TRICARE Eligible Claims, (CLINS X007), and Medicare Dual Eligible claims, (CLINS X008). Submission of a TED record header to DHA is considered submittal of an invoice. No separate invoices are required for routine claims rate payments. However, invoices are required for non- automated payment requests. For purposes of determining the due date for payment under the Prompt Payment Clause, the “Transmission received end date/time stamp” (derived by TED at end of data transmission) will be used to determine the date of invoice receipt. Transmission received after 10:00AM ET shall be considered as received the next calendar day.

G.6.2. Per Claim Quantity. The contractor is paid the unit price as identified in Section B for each initial submission TED record (as defined under TSM Chapter 2, Section 1.1) that passes all TED edits as specified in the TSM and validated by the TED record edit system. Additionally, the contractor is paid for the first adjustment TED record accepted under this contract that was initially submitted under a previous contract (even if the previous contract was held by the same contractor).

G.6.3. Unit Price and Performance Period. The contractor is paid the claims processing unit price identified in Section B for the contract period in which the contractor submits the initial TED record. The “Batch/Voucher Date” in the voucher header is used to determine the contract option period and applicable unit price. In order for the contractor to receive payment of a claims processing fee, the TED record must pass all TED edits as specified in the TSM and validated by the TED record edit system no later than 180 calendar days following the end date for the contract.

G.6.4. Header Type. The contractor shall submit batch/vouchers under the correct “Header Type Indicator” as specified in the TSM Chapter 2, Section 2.3. to ensure correct payment. Header Type Indicator indicates to the TED processing system if the contractor is requesting a claim rate payment, wants to retain a claim rate payment, does not want a claim rate payment or if the contractor is requesting the claim rate payment previously paid be retracted.

G.6.4.1. Eligible TED Records. If the TED record is eligible to receive or retain a previous payment under the claims processing CLIN, then the TED record (with the exception of Type of Submission “C” complete cancellation to TED record data, see G.6.4.3.) shall be submitted by the contractor to DHA using a Header Type Indicator of “6” or “9” (even if the TED record has already received payment under the claims processing CLIN).

G.6.4.2. Ineligible TED Records. If the TED record submitted is not eligible to receive payment or the contractor wants DHA to retract a previous claim rate payment under the claims processing CLIN, the contractor shall submit the TED record to DHA using a Header Type Indicator of “0” or “5”. No payment under the claims processing CLIN can occur on any TED record grouped in a Batch/Voucher with Header Type Indicator of “0” or “5.” Only no-pay and credits (where DHA retracts any previous claim rate) can be processed under these header types.

G.6.4.3. Cancelled TED Records. For a TED record submitted with a Type of Submission “C” by the contractor, the contractor shall determine if the TED record is still eligible to receive payment under the claims processing CLIN. The following criteria shall be used to determine if a TED record is still eligible for payment:

G.6.4.3.1. A TED record cancelled for any of the following reasons is eligible to retain the claims processing fee previously paid and shall be submitted with Header Type Indicator “6” or “9”:

· Cancellation was at Government direction.

· Government data error.

· Stale dated/voided checks.

· New initial TED record is required by the Government.

· Incorrect DEERS response.

· Check is returned in undeliverable mail.

· Beneficiary or provider requests stop payment due to non-receipt of check prior to stale date time period.

· Beneficiary or provider returns check because payment was received from other health insurance carrier whose responsibility was previously unknown to contractor.

· Provider returns check because beneficiary has erroneously paid the provider and believes that the TRICARE benefit check is a duplicate payment.

· Claim processed in good faith by the contractor but later identified as an error due to additional information received or learned.

· Claim processed by multiple contractors resulting in duplicate processing.

· TQMC case resolutions resulting in an error.

· Program Integrity cases that are recouped retrospectively after investigation.

· Provider requested claims to be reissued to a new provider Tax Identifier.

G.6.4.3.2. A TED record cancelled for any of the following reasons is not eligible to retain the claims processing fee previously paid and shall be submitted with Header Type Indicator “0” or “5”:

· Cancellation where a new initial TED record is required to correct a contractor error.

· Cancellation due to contractor error or an inability to adjust.

· Cancellation of a claim that was not DHA’s responsibility so it should not have been paid.

· Any other cancellations for a reason not identified in paragraph G.7.4.3.1 above.

If the contractor cannot determine the reason for the TED record cancellation, then the TED record submitted is not eligible to retain the claims processing fee previously paid. The cancellation of the cancelled TED record shall be submitted under Header Type Indicator “0” or “5.”

G.6.5. Procedure if DHA’s TED is Unavailable. Upon CO’s notification that the TED Record processing system is not operating normally, the contractor may submit invoices outside of the TED to the CO and CRM. The invoice shall list the number of claims processed by CLIN. This may be submitted daily or grouped by no more than 5 days of claims. These payments will be treated as an interim payment and will be a credit to the amount due as determined by the TED Record processing system when it is operating normally again. This process will not be used unless the payment will be paid past the Prompt Payment Act 30 day due date. If TED processing or CRM accounting system processes are delayed less than 30 days, the automated due dates on payments generated by TED will be adjusted for any delay in TED processing.

G.6.6. End of Health Care Delivery. Claims received by the contractor during its period of services delivery are required to be processed to completion within 180 calendar days following the end of health care delivery. There will be no claims processing fee paid to the contractor if the 180 calendar day requirement is not met.

G.7. BENEFIT PAYMENTS - SET UP AND PROCESS FOR PAYMENT OF BENEFITS.

G.7.1. The contractor acts as a fiscal intermediary for the Government to distribute, or pass- through, Government funds for health care benefits. These are not costs to the contractor and are not reimbursed by the Government, so the contractor may not collect or hold pass-through health care funds before dissemination to the beneficiary or provider and the contractor shall return any collections to the Government as described in Section G.11.

G.7.1.1. Pass-through health care payments by the contractor on behalf of the Government will be facilitated by allowing the contractor (through the contractor’s financial institution/bank) to draw money from the designated Federal Reserve Bank (FRB). These draws may only be done for benefit payments that have previously been submitted on TED or as a non-TED pass-through health care voucher, and, which have been approved for release by DHA-A/CRM, and, are clearing the contractor’s financial institution on the day the draw is being accomplished. Advance payments are not allowed. Draws will be reduced by available deposits made to the account. No bank fees or other bank charges shall be paid from this account and no money should be drawn from the FRB for these charges.

G.7.1.2. All payments for pass-through health care claims processed by the contractor must be approved by the DHA-A/CRM Budget Office before the contractor may make payments to the beneficiary or provider. Unapproved draws and payments by the contractor may be immediately collected and subject the contractor to penalties.

G.7.2. Establishment of Pass-Through Health Care Bank Accounts.

G.7.2.1. The contractor shall establish and use a minimum of two separate bank accounts to reimburse claims in accordance with this section. One bank account will be used for payments and other transactions related to beneficiaries who are covered by TRICARE, but not Medicare (TRICARE-Only Eligible). T he second bank account will be used for payments and other transactions related to dual eligible beneficiaries who are eligible for coverage under both Medicare and TRICARE (Medicare-Dual Eligible).

G.7.2.2. The contractor shall establish bank accounts for benefit related transactions with a commercial bank that has FEDWIRE capability.

G.7.2.3. The contractor shall submit bank information to DHA-A/CRM not later than 60 calendar days prior to the beginning of processing claims on a new account. The information shall include:

· Name of Bank.

· Overnight mail address.

· American Banking Association (ABA) routing number/Routing Number (RTN).

· DUNS number for both the bank and the contractor.

· Taxpayer Identification Number (TIN) for contractor (must be the same TIN used for benefit payments)

· TIN for the bank.

· Contractor’s bank account number (if separate checking and deposit accounts are used, both account numbers need to be provided).

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

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

G.7.2.4. DHA-A/CRM will establish the bank accounts on the Department of Treasury’s Automated Standard Application for Payment System (ASAP). ASAP, along with FEDWIRE, provide a mechanism for disbursement of Government funds for health care services received by TRICARE beneficiaries. After authorization by DHA-A/CRM, these systems allow the contractor to draw cash directly from the FRB to cover payments as they clear the contractor’s bank account. ASAP is used by the Treasury, the FRB and DHA-A/CRM to verify the authorization to make draws and to track transactions made by the contractor’s bank. FEDWIRE is used by the contractor’s bank to actually draw funds from the FRB. The contractor will not access ASAP.

G.7.2.5. DHA-A/CRM will notify the bank and the contractor once the bank account(s) have been established and provide codes or other information necessary for the bank to make draws against the FRB using FEDWIRE.

G.7.3. Draws on the Federal Reserve.

G.7.3.1. Draws are only allowed for TED and manually submitted vouchers that have been submitted to DHA and have been approved for release/mailing by DHA-A/CRM Budget Office. See submission instructions below in Section G.8 for TED and Section G.9 for Non- TED/Manual Vouchers.

G.7.3.2. The contractor shall ensure that cash drawdowns do not exceed the payments that have been authorized, as they clear the bank on a given day, less available deposits. The contractor shall ensure that any excess draws are immediately returned to the FRB. Interest and a penalty will be charged beginning the day after the overdraw and will continue until the overdrawn amount is returned. Interest will accrue daily and is based on the Treasury Current Value of Funds Rate. The penalty will accrue daily and is 6% per year based on the penalty rate in 31 CFR 5.5, Procedures to Collect Treasury Debts. DHA-A/CRM may initiate immediate payment offset against any payments to the contractor involved for the interest, penalties and/or the overdrawn amount.

G.7.3.3. The total amount of a cash draw down on the FRB is based on the daily total of benefit payments presented to the bank for payment. If estimates are needed due to timing of reports from check clearinghouses or the FRB, the draws shall be adjusted the next business day.

G.7.3.4. Computation of the amount of the draw must include any available deposits of funds into the account. These deposits will reduce the amount of cash needed for the draw down.

G.7.3.5. Currently ASAP has a requirement to set an upward dollar limit that may be drawn on the FRB. This dollar limit, established by DHA-A/CRM, only represents an administrative ceiling at the FRB, and does not constitute any authority to draw funds. Accounts will also have daily limits for the amount that can be drawn. The contractor will be notified of these limits by DHA-A/CRM. DHA-A/CRM will be able to increase or decrease these limits as needed.

G.7.4. Transfers between Bank Accounts.

G.7.4.1. Contractors with more than one bank account shall ensure transactions are properly accounted for to prevent the commingling of funds. Failure to properly associate transactions with the correct bank account could result in the over-execution of DHA-A/CRM budget authority.

G.7.4.2. Transfers of funds between bank accounts are strictly prohibited except deposits identified later as having been made to the wrong account. Any transactions reported under one bank account and identified later as belonging to a different bank account shall be reported immediately to DHA-A/CRM when identified. DHA-A/CRM will instruct the contractor as to what action to take based on the circumstances.

G.7.5. Fiscal Year Start-up of Pass-Through Health Care ASAP Accounts.

G.7.5.1. The contractor shall establish a separate bank account for each new Government fiscal year. All payments issued for benefit payments and all refunds received shall be processed against the new account effective the first day of the new fiscal year. The contractor shall also transfer all recoupment installment payments to the new account from the previous year’s account.

G.7.5.2. Cash drawdowns against the prior fiscal year’s bank account may continue, if required, until all payments from the prior year have either cleared or have been canceled, but no longer than the end of May of the following year or eight months after the last payments have been made on an account (in the case of a contract closeout).

G.7.6. Annual Closeout of Pass-Through Health Care ASAP Accounts.

G.7.6.1. Bank accounts shall be closed no later than the end of May, following the fiscal year end, or one month after the last payment on an account has stale dated. A final bank account reconciliation shall be made within 30 calendar days following the last authorized transactions. All transactions that were not previously approved by DHA-A/CRM shall be explained with supporting documentation on the final bank reconciliation report (See Section J, Exhibit A, CDRLs M240 and M250). DHA-A/CRM reserves the right to not accept these transactions.

G.7.6.2. Any outstanding balance in the account shall be reimbursed to DHA no later than the required submission date of the final bank account reconciliation. This balance may be subject to interest if it includes overdrawn amounts that were required to be submitted at an earlier date.

G.7.7. Reporting and Reconciliation of Bank Accounts. Bank accounts reconciliations will be done monthly and submitted per CDRLs M190 and M200 for the bank accounts established to pay benefit payments as described above. Bank Account Statements from the bank will also be sent monthly per CDRLs M210 and M220.

G.8. BENEFIT PAYMENTS—TED SUBMISSIONS.

G.8.1. TED shall be submitted per TSM requirements and the ASAP System ID for pass- through health care claims. Adjustments and cancellations may be included with initial submissions.

G.8.2. Voucher Transmission Requirements.

G.8.2.1. TED data transmissions shall comply with the file naming convention specified in the TSM Chapter 1, Section 1.1, Paragraph 7.7.3.1.5 et seq. (File Naming Convention). TED data transmissions (TD files) must be separated between TRICARE Only (CLIN/ASAP Account Numbers with 1889 in positions 1-4) and Medicare Dual Eligible (CLIN/ASAP Account Numbers with 18D9 in position 1-4) healthcare. CLIN/ASAP Account Numbers that have 0’s in position 1-4 (Batches) can be grouped under any header or can be submitted separately under their own header. This should be done routinely.

G.8.2.2. Pass-through health care batches/vouchers received after 10:00 AM Eastern Time Zone shall be considered received the next business day for the ‘Claims Processing Fee’ payment due date calculation.

G.8.2.3. Batches/Vouchers must pass all TED header edits as specified in the TSM. If all header edits are not passed, the Batch/Voucher will be rejected and returned to the contractor.

G.8.3. Voucher Integrity. Voucher header and detail amounts transmitted by the contractor become “fixed” data elements in the finance and accounting system for purposes of control and integrity. Corrections or adjustments to reported (payment) amounts must be accomplished on separate voucher transmissions.

G.8.4. Payment Suspension and TED Processing During Partial Funding Shortages.

G.8.4.1. Some of the funding DHA receives may be restricted in use to a specific federal agency, military department and/or to a particular health care program. Funding for these special purpose programs may run out before funding for other DHA programs. Therefore, the contractor shall have the ability to suspend claims payment and the associated submission of institutional TED records or non-institutional TED line item(s) to DHA based on values contained in the following TED record fields as specified in the TSM, Chapter 2:

· Enrollment/Health Plan Code (E/HPC) (Section 2.5).

· Health Care Delivery Program Coverage Code (Addendum L).

· Service Branch Classification Code (Sponsor)(SBCC)(Section 2.8).

· Special Processing Code (SP) (Section 2.8).

G.8.4.2. The suspension of claims payment and TED records may be based on a single value (e.g., SBCC=A) or a combination of values (e.g., SBCC=A & E/HPC=SR). Suspension of TED records (institutional) or TED line items (non-institutional) containing specific values shall be implemented by the contractor within five workdays after receiving notification from the CO. On the sixth workday, DHA-A/CRM will implement immediate payment offset against contractor invoices of any claims paid by the contractor from their pass-through health care bank account(s) for institutional TED records or non-institutional TED line items containing suspended value(s). The contractor shall NOT, without prior CO approval, initiate payment offset against any provider or beneficiary for payments made against suspended transactions and offset by DHA-A/CRM on contractor invoices.

G.8.4.3. For all suspended transactions, the contractor shall hold the claim information until receiving instructions from the CO to do otherwise. The contractor shall not reject the claims or return any information to the providers or beneficiaries unless instructed by the CO. Once the C O lifts the TED data submission restriction, the contractor may submit all withheld TED data on the next appropriate (batch/voucher) data submission. DHA-A/CRM will reimburse the contractor (without interest) for any invoice payment offsets done for TED suspended transaction that have not been recouped by the contractor.

G.8.5. Federal Fiscal Year-End Processing (September Month-End).

G.8.5.1. All TED data must be received no later than 10:00 AM EST, (8:00 AM MST; 7:00 AM PST) on September 28. Any Batch/Voucher received after 10:00 AM EST will be rejected by DHA and must be resubmitted by the contractor using next fiscal year Batch/Voucher CLIN/ASAP Account Numbers. The contractor should not submit batch/vouchers with dates of September 29 and September 30. Any payment processed after September 28th, must use the next fiscal year Batch/Voucher CLIN/ASAP Account Numbers and must utilize the new fiscal year check stock, as applicable. The contractor shall not submit Batch/Vouchers to DHA between September 28, 10:00 AM Eastern Time or before October 1, 12:01 AM Eastern Time. Transmission Files (TD Files) sent on September 28th cannot exceed 300,000 records.

G.8.5.2. All payments not included in the contractor’s final fiscal year data submission on September 28 must have a Batch/Voucher Date on or after October 1. Contractors will be able to test their new fiscal year’s transactions in benchmark starting September 1. Like production, benchmark data must be received at DHA by 10AM EST on September 28. After 10 AM EST on September 28 until October 1, 12:01 AM Eastern Time no benchmark data can be transmitted to DHA.

G.8.6. Procedures for Benefit Payment Release When the TED Record Processing System Is Not Available.

G.8.6.1. Upon notification by the CO that the TED Record processing system is not operating normally, the contractor will send an email or fax with a listing of specific vouchers to DHA- A/CRM to request release of payments. This may be done daily. Contractor requests will include the following Header information for each voucher (See TSM Chapter 2, Section 2.2):

G.8.6.2. DHA-A/CRM will return to the contractor a signed release so the contractor can pay the providers and beneficiaries without delay. The contractor must not release payments until this approval is received.

G.8.6.3. Upon notification by the CO that the TED Record processing system is operating again, this process can be discontinued.

G.8.7. Financial Editing of Detail Claims Data for Pass-Through Health Care Claims.

G.8.7.1. The TED system allows for the categorization of claim errors based on the type or classification error failed during the edit process. DHA-A/CRM will use the edits specified in the TSM, Chapter 2, Section 8.1, Financial Edits, to determine the propriety of payments.

G.8.7.2. Uncorrected (Bad Master) TED records that have failed the TED Edits specified in the TSM, will be “flagged” by DHA-A/CRM as having inadequate payment information. The contractor shall correct the claims flagged by DHA-A/CRM within 90 calendar days. If not corrected in 90 calendar days, DHA-A/CRM will send a demand letter requiring resolution or reimbursement for all claims identified through TED as edit failures. The contractor shall respond within 30 calendar days as to why the claim(s) in question cannot be corrected. If resolution cannot be reached between DHA-A/CRM and the contractor, the total amount of improper payments still in dispute will be collected by DHA-A/CRM. The contractor shall take no recourse against TRICARE beneficiaries or providers under the situations described in this paragraph without prior DHA approval.

G.8.8. Authorization to Release TED Related Benefit Payments.

G.8.8.1. TED data submissions for pass-through health care payments shall be grouped into TED Vouchers by the ”Batch/Voucher CLIN/ASAP Account Number” field (defined in TSM, Chapter 2, Section 2.2). The contractor shall not release pass-through health care payments without prior authorization from the DHA-A/CRM Budget Office. Authorization from DHA- A/CRM to release payments will be sent to the contractor via fax or e-mail NLT than 5:00 PM Eastern Time the day of receipt. Authorization will specify contract number, ASAP Account ID#, initial transmission received date, and total dollar amount of funds that may be released based on information contained in the Batch/Voucher header. Approval for funds release will be given provided the following criteria are met:

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

· DHA-A/CRM Budget Officer has confirmed that funding is available to cover benefit payments.

G.8.8.2. Benefit payments in U.S. dollars shall be released/mailed no later than two workdays after DHA-A/CRM has approved the release of payments. Benefit payments via foreign drafts shall be released/mailed no later than four workdays after DHA-A/CRM has approved the release of payments. Check date shall be the same date as the Initial Transmission Date (derived by DHA and equal to the calendar date the Batch/Voucher was transmitted to DHA.

G.8.8.3. Authorization to release payments does not constitute DHA’s acceptance that all payments are valid and/or correct. Detailed records will be audited for financial compliance. All transactions in these bank accounts must be valid and justified. Any unreported/unauthorized disbursements identified by DHA will be subject to immediate payment offset against any payments being made to the contractor. All disputed amounts will remain in the possession of the Government until no longer in dispute.

G.8.9. Residual Benefit Claims. Claims for service provided prior to start of the contract will be paid as benefits under this contract as described in Section G.8 or, if necessary, under Section G.9. for non-routine payments.

G.9. OTHER BENEFIT PAYMENTS—NON-TED/MANUAL VOUCHERS. The contractor shall group and process each type of Non-TED voucher by each pass-through health care program identified below.

G.9.1. Capital and Direct Medical Education Costs (CAP/DME): Paid by the contractor from the pass-through health care bank account to hospitals requesting reimbursement under the TRICARE DRG-Based Payment System (excludes children’s hospitals) (see TRM Chapter 6, Section 8).

G.9.1.1. The contractor shall electronically submit a monthly CAP/DME voucher to DHA- A/CRM no later than the 15th calendar day of the month following receipt of the hospital’s request for payment. This voucher shall be a listing of the hospitals to be paid, addresses of the hospitals, time period for the claim, amount of the Direct Medical Education, amount of the Capital Costs and a total being paid for that period for each hospital. The voucher shall have separate subtotals for Active Duty and for Non Active Duty, by fiscal year. Supporting documentation, including copies of the hospital’s claim and the payment calculation, shall be submitted electronically using approved formats specified in TSM Chapter 2.

G.9.1.2. After funding approval by DHA-A/CRM, the contractor shall make payment within 2 work days. Payments will not be released without approval from DHA-A/CRM Budget Office.

G.9.1.3. If the contractor makes an underpayment, the contractor shall determine the amount and include the additional payment with the next month’s voucher.

G.9.1.4. If the contractor overpays a hospital, the contractor shall recoup this amount and document as follows:

· Offset collections or cash collections shall be included as credits on the monthly CAP/DME voucher for the month the credits were processed.

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

G.9.2. Bonus Payments for Health Professional Shortage Areas (HPSAs) and for Physician Scarcity Areas (PSAs).

G.9.2.1. Health Professional Shortage Areas (HPSAs) and Physician Scarcity Areas (PSAs) are locations where bonus payments are made to providers who provide services in medically underserved areas. They are paid in addition to the claim amounts normally paid under the allowable charge methodology (See TRM, Chapter 1, Section 33). Payments will only be calculated for the United States and US Territories.

G.9.2.2. On a quarterly basis, the contractor shall submit the voucher electronically as a pass- through payment. Supporting documentation including lists of doctors, their addresses, and the calculation of the payment, shall also be sent electronically based on approved formats as specified in the TSM, Chapter 2. After receiving clearance from, DHA-A/CRM the contractor shall process and mail the providers check.

G.9.2.3. The voucher shall contain the following:

· Format for Vouchers:

· Period Covered (Quarter)

· Physician Name

· Physician Address

· Physician Provider Number

· Amount Paid/Collected for Bonus

· Total Bonus Paid(5 and/or 10 percent of the above bullet)

· Total of all Bonuses being paid

· Sort for Vouchers:

· By Contract

· By Automated Standard Application for Payment System (ASAP) ID (Fiscal Year) of Bank Account

· By Type (e.g., standard or active duty)

· By Coverage (Prime, Extra, Standard)

· By State

· By Physician

· By Physician Number

· By Specialty

· By Address & Zip

· By Participating & Non-Participating

· By Contracted (Network) and Not Contracted (Non-network)

· By Modifier (“QB”, “QU” or “AR”)

G.9.3. Demonstrations. These are trial programs and they may vary in many ways from TRICARE benefits. TED will be used if possible but if the data associated with demonstrations is incompatible with TED data formats, the contractor shall submit a separate voucher to DHA-A/CRM no more frequently than monthly to obtain clearance to make pass-through health care bank account transactions. Vouchers must contain details of the payments being made. Voucher and payment information should be included with a modification to the contract that details the demonstration.

G.9.4. Other Payments.

G.9.4.1. Other adjustments are rare situations where a payment needs to be made but does not fall into routine processing such as TED, CAP/DME, etc. For example, these payments may be the result of a very old case or a legal settlement that doesn’t apply to a given individual.

G.9.4.2. These must be submitted to the CO and to DHA-A/CRM with supporting documentation explaining the issues that don’t allow a TED record along with the claim, computation and other applicable documents.

G.9.4.3. After funding approval by DHA-A/CRM, the contractor shall make payment within 2 work days.

G.9.5. Federal Fiscal Year-end Processing of Manual Vouchers (September month-end). Vouchers that are normally submitted for September processing but in the month of October should utilize the October fiscal year check stock.

G.10. BENEFIT PAYMENTS - VOID AND REISSUANCE OF PAYMENTS.

G.10.1. Staledated or Voided Payments.

G.10.1.1. For payments that are voided or staledated that are over $10, a credit voucher through TED must be processed in accordance with the standards detailed in TOM Chapter 1, Section 3. If the check was issued as a manual voucher, the credit should be submitted as a similar manual voucher. The only exception to issuing a credit voucher would be staledates under $10.00.

G.10.1.2. For voided/staledated payments of $10.00 or less, the contractor may elect either to:

· Affect a credit voucher for the check using automated means,

· Or, instead of making a voucher transaction, a memorandum for record shall be prepared and included on a listing of transactions as submitted monthly in the CDRLs M240 and M250 Pass-Through Health Care Funds Bank Account Reconciliation Reports.

G.10.2. Replacement Payments.

G.10.2.1. Reissuance of payments will be made against the current fiscal year bank account.

G.10.2.2. Replacement payments may be issued upon request of the payee or authorized representative. If the check is not returned by the payee, the payee must provide a statement describing the loss or destruction of the check. Before a replacement check is issued, a stop payment order for the original check must have been issued and accepted by the bank.

G.10.2.3. If the claim history is not available to the contractor, the contractor shall submit a request for approval of check release to…