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TOP 21 Draft RFP Questions & DHA Responses
HT9402-19-R-0001
| No: |
| Solicitation Citation & Paragraph |
| Question/Comment |
| DHA Response |
| 1 |
| Section C, paragraph C.3.1.1 |
| In addition to TOM, Chapter 24, the PWS also references TOM Chapters 1,3, 5,6,7,8,9,10,11,12, 13,14,17, 18, 25 and appendix B. Will those chapters also be incorporated by reference? It is recommended that the Government include all of the applicable Chapters. |
| The TRICARE Operation Manual (TOM) chapters are incorporated by reference. See Solicitation Section C, paragraphs C.3.1 through C.3.1.1. The TRICARE Program Manuals - 2015 Edition (T-2017) are available at https://manuals.health.mil/ |
| 2 |
| C.3.1.2 |
| In addition to TPM, Chapter 12, the PWS also references TPM Chapters 7, 10, 11, and 18. Will those chapters also be incorporated by reference? It is recommended that the Government include all of the applicable Chapters. |
| All TRICARE Policy Manual (TPM) chapters are incorporated by reference. See Solicitation Section C, paragraph C.3.1.2. |
| 3 |
| C.4.1 |
| This section notes "The Government will provide the contractor with access to the Defense Manpower Data Center’s (DMDC) Defense Enrollment Eligibility Reporting System..." Is there a limit on number of licenses that can be obtained for access to DEERS? |
| No. There is no limit on the number of individuals (contractor/subcontractor) who may obtain access to DEERS. |
| 4 |
| C.7.3 |
| This section references the following website "http://www.tricare.mil/nogovernmentpay/". This link is no longer active, can the Government please provide the updated link. |
| See Solicitation Section C, paragraph C.7.3. |
| 5 |
| C.8.1 |
| This section notes the "contractor shall establish and maintain effective ...training programs…". Are there contract specific training curriculum that the Government wants us to provide or use besides those called out in PWS (e.g., culture training, provider training?) |
| There are no specific training curricula beyond those in the Solicitation. |
| 6 |
| C.11.1.3 |
| This section notes "the contractor shall augment provider network(s) with non-network providers to ensure that the number, mix, and geographic….is sufficient". Will the previous contractor's approved waivers be "grandfathered in" for a new contractor? |
| No. Paragraph C.11.1.3 does not reference waivers. See Solicitation Section C, paragraph C.11.10.3 for what is required when requesting network implementation waivers. |
| 7 |
| C.11.6 |
| This section notes the "contractor shall track and report clinical data that measures quality and maintain such data for inspection by the Government". Will the incoming contractor receive the current quality measures in use by the incumbent for possible consistency? |
| No. |
| 8 |
| C.11.6.1 |
| This section notes the "contractor shall provide the Government with a listing of relevant host nation quality metrics". Is there an expectation on the number of quality metrics used for the network providers? |
| No. Section C, paragraph C.11.6.1. does not specify a minimum or maximum amount of quality metrics required. Paragraph C.11.6.1 only requires that the quality metric is relevant. |
| 9 |
| C.11.6.2 |
| This section notes the "contractor shall develop clinical quality metrics that leverage existing international accreditation agency…" What "international accreditation agency" is referenced here? Is there a specific accreditation resource that the Government prefers? |
| The Solicitation Section C does not identify a specific international accreditation agency and does not have a preferred accreditation resource. |
| 10 |
| C.11.8.2 |
| This section notes "Best effort is defined as the contractor making commercially reasonable efforts on an ongoing basis…". Can the Government please define how "reasonable effort" will be measured? |
| See Solicitation Section C, paragraph C.11.1.5. |
| 11 |
| C.11.10.1 |
| This section notes that "one measure of network adequacy or inadequacy shall be the percentage of paid claims...". Will the percent of paid claims calculation include single case agreements (e.g., providers not yet on a full contract but who agree to provide services at an agreed upon rate level for a particular patient)? |
| Solicitation Section C, paragraph C.11.10.2 requires that the network adequacy calculation is based on the percentage of paid claims for TOP Prime and TOP Prime Remote enrollees that are submitted by network providers. Providers not yet on a full contract but who agree to provide services at an agreed upon rate level for a particular patient are not considered network providers. |
| 12 |
| C.11.10.2 |
| This section notes 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". Would the Government consider modifying this requirement to cap at 90%? Applies to section C.16.9.1. |
| The DHA will keep the target percentage for paid claims by network providers as stated in the Solicitation. |
NOTE: Section C.16.9.1 pertains to claims coding accuracy, not percentage of claims paid to network providers.
| 13 |
| C.11.15.3 |
| This section notes the "provider search function shall include the complete list of network and participating non-network providers in all locations." What constitutes a participating non-network provider? |
| Participating non-network providers are those providers which have not signed a network provider agreement, but have agreed to see TRICARE patients on a cashless/claimless basis. See Solicitation Section C, paragraph C.11.15.3. |
| 14 |
| C.12.1 |
| This section notes "Eligibility for TRICARE is determined by the Uniformed Services, not by DHA." Are there published Service instructions that help guide enrollment? |
| The statement "Eligibility for TRICARE is determined by the Uniformed Services, not by DHA." is included to clarify that the Uniformed Services determine TRICARE eligibility and that DEERS is the system of record for establishing eligibility. See Solicitation Section C, paragraph C.12. TOM Ch 6; and Ch 24, Section 5, provide the needed guidance for eligibility and enrollments. |
| 15 |
| C.13.1.3 |
| This section notes 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." Is this care coordinated with the Managed Care Support Contractors (MCSCs) in CONUS? Is there any requirement to coordinate with MTFs in CONUS? If yes, what are the specific requirements (e.g., is this to be manual or electronic for authorizing services to the providers in the US and District of Columbia)? |
| This care is not coordinated with the MCSCs, and the TOP contractor is not required to coordinate care with the MTFs in the 50 United States and the District of Columbia. |
| 16 |
| C.13.1.4 |
| This section notes "the contractor shall assist the beneficiary in scheduling an appointment with the purchased care sector provider...". Does this imply CONUS MTFs as well? |
| The contractor is not required to assist the beneficiary in scheduling an appointment with MTFs in the 50 United States and the District of Columbia. |
| 17 |
| C.13.5.2 |
| This section notes the "contractor’s case management program shall be available to all TRICARE eligible beneficiaries (both enrolled and non-enrolled) who are authorized to receive reimbursement...". Are TRICARE For Life (TFL) included in case management for all other countries not listed? |
| Yes. TRICARE For Life (TFL) beneficiaries are included in case management for all overseas locations not excluded in C.13.5.2. |
| 18 |
| C.16.9.2 |
| This section notes the "contractor shall employ an independent third party contractor to review 100% of the TOP contractor’s audited claims for coding accuracy." What percentage of claims are we required to audit? |
| The TOP contractor will use “best business practices” to select the percentage of claims for its claims audits. |
| 19 |
| C.16.10 |
| This section notes "medications that are considered over-the-counter by U.S. standards are not authorized for reimbursement." What about outpatient prescriptions like antibiotics? Would they not be reimbursed or would they be covered by the T-Pharm contract? |
| If the outpatient prescription is for medication considered over-the-counter by U.S. standards, it is not authorized for reimbursement. Pharmaceuticals purchased from an overseas pharmacy are reimbursed under the TOP Contract. The T-Pharm contract only applies in the 50 United States, District of Columbia, Puerto Rico, the U.S. Islands, Guam, America Samoa, and the Northern Marianas. |
| 20 |
| C.17.4.4 |
| This section notes that Call Centers and systems need to be functional "no later than 80 calendar days prior to the start of health care delivery". TOM Chapter 24 references 30 days prior to the start of health care delivery. Can the Government please note which should be followed? |
| Call centers and systems need to be functional no later than 80 calendar days prior to the start of health care delivery. The TOM Chapter 24, addresses TRICARE Service Centers. If the contractor elects to use the TSCs as their Call Centers; then, yes, they need to be operational 80 days prior to start of health care delivery. |
| 21 |
| C.17.6 |
| TOM Chapter 24, references Heath Care Finder (HCF) services. Is the contractor required to provide the HCFs? |
| The contractor is required to provide Health Care Finder (HCF) services as specified in the Solicitation. |
| 22 |
| C.18.2 |
| As part of the POC Program referenced in TOM - we understand that the contractor is required to provide education / enrollment activities for arriving and deploying troops. What is the timing of this activity and is this in person or virtual? |
| The POC Program as outlined in TOM Chapter 24, Section 12, does not address education and enrollment for arriving and deploying troops |
| 23 |
| C.19.1 |
| For the translation services requirements, can the Government provide an idea of volume of translations by type that occur on average in a year? |
| The DHA issued Ordering Instructions for potential offers to obtain historical data, including Translation Volumes, via the Federal Business Opportunities website (www.fbo.gov) on January 31, 2019. Offerors may still request this data. See the Solicitation Section B, CLINs X005 and X006, and Section L, Attachment L-1 Ordering Instructions for Data |
| 24 |
| C.19.4 |
| This section notes "Certification is defined as a written attestation ... by a linguist other than the original translator that the English translation (target text) is true, faithful, accurate and complete translation of the source material". Can the Government please confirm that "certification" is second set of eyes? |
| Section C, paragraph C.19.4 requires that the certification must be accomplished by a linguist other than the original translator. |
| 25 |
| C.19.4 |
| This section notes "The requestor, not the contractor, determines whether requests are routine or urgent". Please confirm that "requestor" in this paragraph is intended to be Government customer, not enrollee or beneficiary. What constitutes routine vs urgent? |
| The requestor may be any of the entities identified in Section C, paragraph, C.19.1. |
| 26 |
| C.20.2 |
| This section notes when "the contractor becomes aware of a situation which may require travel for a TOP Prime Remote beneficiary, the contractor shall notify the responsible TAO for consideration and coordination...". Is there a system of record for tracking these requests? Will the TAOs actually be coordinating travel? |
| The contractor will implement a system to track requests. Section C, Paragraph C.20.1. states that “The Services are responsible for determining whether medical travel can be funded on official orders, and for issuing the appropriate funding and travel documents.” |
| 27 |
| C.22.1 |
| This section notes "the contractor shall develop and provide Medical Capability Reports (MCRs) when requested…". Can the Government provide an estimate of the volume of MCRs requested on average and in what geographical area per month? Per year? |
| The DHA issued Ordering Instructions for potential offers to obtain historical data, including Medical Capability Reports, via the Federal Business Opportunities website (www.fbo.gov) on January 31, 2019. Offerors may still request this data. See Solicitation Section L, Attachment L-1 Ordering Instructions for Data |
| 28 |
| C.23.1 |
| This section notes the "contractor shall respond to contingencies/crisis". Can the Government provide an estimated average number of contingencies/crises that occur per month? Per year? |
| No. The number of contingencies/crisis is highly variable and depends on the world situation. |
| 29 |
| C.26.5.4.3 |
| This section provides Performance Readiness Assessment & Verification (PRAV) for call center performance levels. |
Does 80% exclude calls where the caller hangs-up prior to 30 seconds?
The Government team conducting the test calls will not hang up prior to 30 seconds.
| 30 |
| C.26.5.4.3 |
| This section provides PRAV for call center performance levels. How is the government currently measuring First Call Resolution at 80%? |
| The Government team conducting the test call will determine if first call resolution was achieved. |
| 31 |
| C.26.5.4.3 |
| This section notes "80% of all responses provided by call center staff shall be accurate and complete." How is accuracy and completeness determined? |
| The Government team conducting the test call will determine if the call was accurately and completely answered. |
| 32 |
| C.30; TOM Chapter 24, Section 17, Paragraph 1.1 |
| This section referenced TOM Chapter 24, Section 17. |
Paragraph 1.1 - Are non-Command sponsored ADFMs eligible for care?
Please see TOM, Chapter 24, Section 5, Paragraph 3.3.
| 33 |
| C.30; TOM Chapter 24, Section 17, Paragraph 2.3 |
| This section referenced TOM Chapter 24, Section 17. |
Paragraph 2.3 Are TOP patients not included in the NDAA 2017 requirement to not require referrals for urgent care and no authorizations for referrals?
Emergent/Urgent care does not require prior authorization; however, the beneficiary should contact their PCM and the TOP contractor as soon as possible to arrange any necessary follow-up care.
ADFMs enrolled in TOP Prime may obtain urgent care from any authorized provider without a PCM (if assigned) referral or overseas contractor authorization. In order to ensure the urgent care visit will be cashless/claimless, the ADFMs enrolled to TOP Prime should contact the TOP contractor to obtain an authorization. Without this authorization, overseas providers may request payment upfront (overseas providers may bill above the TRICARE allowable amount without any limits) and the beneficiary will then have to submit a claim for reimbursement.
| 34 |
| C.30; TOM Chapter 24, Section 17, Paragraph 2.5 |
| This section referenced TOM Chapter 24, Section 17. |
Paragraph 2.5 - Is the HCF a TOP employee or MCSC TOP employee?
The HCF is a TOP contractor employee.
NOTE: The TOP contract is not a MCSC, it is a Health Care Services Support Contract
| 35 |
| C.30; TOM Chapter 24, Section 17, Paragraph 2.10 |
| This section referenced TOM Chapter 24, Section 17. |
Paragraph 2.10 - Who provides the TOP beneficiary information about network providers when traveling in states (e.g., TOP MCSC or the CONUS MCSC)
The TOP Contractor is required to provide the TOP beneficiary information on network providers when traveling in states.
| 36 |
| C.30; TOM Chapter 24, Section 17, Paragraph 3.1 |
| This section referenced TOM Chapter 24, Section 17. |
Paragraph 3.1 - What is a TOP Partnership Provider?
TOP Partnership Providers will not exist in the TOP 2021 contract. The manual language will be updated to remove the reference.
| 37 |
| C.31; TOM Chapter 24, Section 18, Paragraph 2.5 |
| This section referenced TOM Chapter 24, Section 18. Can the Government please confirm that paragraph 2.5 indicates the MCSC has responsibility to find and schedule appointments for TOP PRIME Remote, but it must be authorized by HCF first? |
| The TOP contractor, serving as the PCM for TOP Prime Remote enrollees authorizes the health care. If the beneficiary requests assistance in scheduling an appointment, the TOP contactor shall provide assistance. The HCF is a TOP contractor employee |
| 38 |
| C.42.6 |
| This section notes "...the contractor to embed a bilingual nurse equivalent in the MTF referral management center…". What does "equivalent" nurse mean? |
| Please see Solicitation Section C, paragraph C.42.6. |
| 39 |
| C.42.6 |
| This section notes the "Government may direct the contractor to embed a bilingual nurse equivalent in the MTF referral management center." Will this be an optional task in the CLIN structure? |
| If the Government directs the contractor to embed a nurse, it will not be considered an optional task. The Government will determine the CLIN structure at such time the contractor is directed to embed personnel. |
| 40 |
| C.42.7 |
| This section notes the "Government may direct the contractor to embed care experience personnel in MTFs." Will this be an optional task in the CLIN structure? |
| If the Government directs the contractor to embed care experience personnel, it will not be considered an optional task. The Government will determine the CLIN structure at such time the contractor is directed to embed personnel. |
| 41 |
| C.42.8 |
| This section notes the "Government may direct the contractor to embed behavioral health providers in designated MTFs.". Will this be an optional task in the CLIN structure? |
| If the Government directs the contractor to embed behavioral health providers, it will not be considered an optional task. The Government will determine the CLIN structure at such time the contractor is directed to embed personnel. |
| 42 |
| General |
| Can the Government please provide an estimated procurement timeline for RFP (e.g., RFP release, RFP submission due date, contract award, etc.). |
| The DHA will not provide an estimated timeline for the TOP 2021 acquisition cycle. |
| 43 |
| General - Claims Processing |
| Will there be a requirement to meet General Data Protection Regulation (GDPR) for any of the claims processing for TOP. |
| The TOP contractor is expected to meet GDPR where required. |
| 44 |
| C.9.2 |
| Section C.9.2 indicates that the QM/QI program shall include the Beneficiary and Provider Communications and Satisfaction Monitoring. However, there isn’t any specific information on which strategies will be included (e.g., outbound calls, satisfaction surveys) |
| This question does not correctly cite the TOP 2021 draft RFP Section C. |
See Solicitation Section C, paragraph C.8.4. Offerors are expected to propose their own solutions in accordance with Solicitation Section L, paragraph L.6. The Offeror’s technical approach will be evaluated in accordance with Section M, paragraph M.4.
| 45 |
| C.12.10 |
| For Section C.12.10, could the government identify the threshold languages? Note: Section C.12.14 identified German, Italian, Korean, Japanese, Arabic, Spanish, and Turkish. Should we consider these languages for all outreach and communication activities (e.g., print, web, call center)? Also, does the government mean “interpreters” (vs. translators)? |
| This question does not correctly cite the TOP 2021 draft RFP Section C. |
See Solicitation Section C, paragraphs C.11.12. and C.12.14. The languages specified in C.11.13 are specific to provider education materials.
| 46 |
| C.12.14 |
| For Section C.12.14, how many different regions will the contractor be expected to develop provider education materials? Please define the types of providers that will need to receive awareness strategies. Are there specific types of provider materials envisioned (e.g., fact sheets, flyers, resource guides, newsletters)? |
| This question does not correctly cite the TOP 2021 draft RFP Section C. |
See Solicitation Section C, paragraph C.11.13 Offerors are expected to propose their own solutions in accordance with Solicitation Section L, paragraph L.6. The Offeror’s technical approach will be evaluated in accordance with Solicitation Section M, paragraph M.4.
| 47 |
| C.12.14 |
| For Section C.12.14, is there a centralized location (e.g., website, portal) that maintains existing education and outreach materials? Please identify any technical specifications required (e.g., languages, platforms, software/interfaces required) |
| This question does not correctly cite the TOP 2021 draft RFP Section C. |
See Solicitation Section C, paragraph C.11.13 No additional specifications will be identified. Offerors are expected to propose their own solutions in accordance with Solicitation Section L, paragraph L.6. The Offeror’s technical approach will be evaluated in accordance with Solicitation Section M, paragraph M.4
| 48 |
| C.22.3 |
| Is the number of fraud referrals based on historical data from the TRICARE Overseas Program? What parameters are used to determine inclusion of independent medical opinions? |
| This question does not correctly cite the TOP 2021 draft RFP Section C. |
See Solicitation Section C, paragraph C.28.3. It describes when a qualified medical opinion is required.
| 49 |
| C.37.1 |
| Are there established glossaries for translations? |
| This question does not correctly cite the TOP 2021 draft RFP Section C. |
See Solicitation Section C, paragraph C.19.1.
| 50 |
| C.37.2 |
| Will website/portal content need to be translated? |
| This question does not correctly cite the TOP 2021 draft RFP Section C. |
See Solicitation Section C, paragraph C.19.2.
| 51 |
| C.37.3 |
| Is there a preferred OCR technology for handwritten source material (e.g., treatment notes from office visits)? |
| This question does not correctly cite the TOP 2021 draft RFP Section C. |
See Solicitation Section C, paragraph C.19.3. No.
| 52 |
| C.37.4 |
| Are there credentials for translators that provide original or certified translations (e.g. ATA Certification)? Will translations require local adaption? |
| This question does not correctly cite the TOP 2021 draft RFP Section C. |
See Solicitation Section C, paragraph C.19. Translation Services.
| 53 |
| C.41.1 |
| Is there a preferred Learning Management System (LMS) platform to support web-based trainings? |
| This question does not correctly cite the TOP 2021 draft RFP Section C. |
See Solicitation Section C, paragraph C.24.1. No.
| 54 |
| H7: H.5.3.4.1. |
| Recommend adding Quality Procedures such as speech analytics and feedback management to capture the Voice of the Customer (VoCA) and better understand completely quality improvements with agents’ performance, scripts being used, policies and/or procedures implemented. It provides a methodology that puts focus on the customer and customer service feedback across channels, measures and interprets the data and visualizes the data on a dashboard for the agency to drive customer engagement. Using Speech analytics would also increase the Government sample size in automating the evaluation the contract staff’s performance. |
| This question does not correctly cite the TOP 2021 draft RFP Section H. |
The DHA acknowledges receipt of the potential offeror's recommendation.
| 55 |
| General |
| Aside from the Government team conducting telephonic verification, are there any quality standards that the contractor should meet in the number of calls they should be monitoring per day or week? |
| All call standards are defined in the Solicitation and TRICARE manuals. |
| 56 |
| General |
| Recommend using a feedback management solution & tools such as Qualtrics or Medallia to ensure that DHA understands their customers and allow them to make changes that will improve customer satisfaction metrics and increase scores for the Government Performance & Results Act (GPRA) reporting. |
| The DHA acknowledges receipt of the potential offeror's recommendation. |
| 57 |
| 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. |
| Please define “all phases” of health care delivery. |
| “All phases” of health care delivery pertain to all aspects of health care delivery defined throughout the Solicitation and TRICARE Manuals. |
| 58 |
| 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. |
| Please confirm this requirement applies only to those subcontractors with access to TOP covered data. |
| This requirement applies to the TOP contractor and all of its subcontractors that utilize systems which access and maintain TOP data. |
| 59 |
| 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. |
| To allow offerors to accurately estimate TOP costs, please provide a list of the “designated Government system(s)” under this requirement. |
| TOP referrals are currently processed through the Referral Management System (RMS). The Government reserves the right to change systems. |
| 60 |
| 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/). |
| There are no portions of the Health Care Industry’s Consumer Bill of Rights and Responsibilities that are titled “general principles.” To ensure all offerors make consistent assumptions regarding the cost implications of this requirement, please more clearly define the Government’s meaning under this requirement. |
| Paragraph C.8.4. refers to the general principles outlined throughout all sections of the Health Care Industry’s Consumer Bill of Rights and Responsibilities, not a section under that title. |
| 61 |
| 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. |
| For implementation planning purposes, please confirm the timeline in which the Government will return feedback and/or approval on the materials. |
| Please see Solicitation Section C, paragraph C.8.5. |
| 62 |
| 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. |
| Please clearly define what records are considered “TOP records.” |
| TOP records are all records associated with the TOP contract. The term “record” is defined in the TOM Chapter 9, Section 1. |
With respect to provider records, if a provider belongs to the both the TOP network and the contractor’s commercial network, the contractor may use the provider record for commercial use.
| 63 |
| 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. |
| To allow offerors to determine a fair and reasonable administrative price, please provide the number of FOIA requests received by the current contractor for the most recent three years. |
| The Government does not know any of FOIA requests received by the current contractor. |
| 64 |
| C.11. PURCHASED CARE SECTOR PROVIDERS AND FACILITIES. |
| Given that the Contractor’s Network will be required to adjust to the clinical capability and capacity of the MTF (C.11.1.1) within 90 calendar days of notification (C.11.9); would a larger network therefore be considered as a strength of an offerors proposal? |
| The Source Selection Evaluation Team will evaluate the offeror’s proposal in accordance with Solicitation Section M, paragraph M.4.1.1. |
| 65 |
| 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”). |
| To allow prospective offerors to begin to prepare for RFP release, please provide the number of network providers currently delivering services in each country. |
| The number of network providers associated with the current contract is proprietary to the incumbent and will not be released. |
| 66 |
| C.11.1. Network Development. The contractor shall provide a managed, stable, high-quality network |
| To allow offerors to develop a network management approach to meet DHA’s objectives, please provide statistics and/or measures that DHA would apply that would determine a network as managed and stable. For example, is the definition of a “managed” network one that submits a higher percentage of clean claims within timeliness standards? Is the definition of a “stable” network one with fewer than 20% of providers leaving the network? |
| Each offeror is expected to apply its best business practices to provide managed, stable, high-quality network in accordance with the Solicitation. Any DHA specific network requirements are defined in the Solicitation. |
| 67 |
| 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.11.1.6. Networks shall be right sized to include only the number of high quality providers required to meet contract requirements.
| To encourage competition, new offerors require a significant amount of time to plan their network strategy well in advance of RFP release. In order to meet the needs of TOP enrollees, please provide the specialties, by country, required for an adequate and accurate network. Additionally, historical utilization data is important for offerors to calculate the numbers of each specialty type. Please provide historical data at least six months in advance of anticipated RFP release to allow new offerors to prepare their network strategy. |
| The contractor is expected to determine the specialty mix required in each location using its network implementation model. |
The DHA issued Ordering Instructions for potential offers to obtain historical data, including referral data on the Federal Business Opportunities website (www.fbo.gov) on January 31, 2019. Offerors may still request this data. See Solicitation Section L, Attachment L-1 Ordering Instructions for Data
| 68 |
| 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. |
| What is an acceptable mix of network vs. non-network providers? |
The contractor is expected to determine the ratio of network vs. non-network providers such that network adequacy standards are met and access to care standards are met on best effort basis.
| 69 |
| 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. |
| To allow prospective offerors to begin planning for network development, please provide the percentage of care, for each country, that is currently being delivered by non-network providers. |
| The percentage of care, for each country, that is currently being delivered by non-network providers is proprietary to the incumbent and will not be released. |
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| 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.11.8.2. 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.
| How many attempts per year would be considered a reasonable effort? |
| The contractor is expected to make commercially reasonable efforts on an ongoing basis to achieve the stated outcomes for network adequacy and cashless, claimless health care. The Government will not specify the specific number of attempts required to achieve the stated outcomes for network adequacy and cashless, claimless health care. |
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| 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. |
| In instances where the TOP contract and local requirements conflict for certification/recertification, we assume the contractor would follow local requirements. Please confirm by adding language to C.11.3. If this assumption is incorrect, please describe the process the contractor should use to reconcile the differences. |
| The TOM Chapter 24, Section 5, paragraph 2.1 provides clarification. Specifically: |
2.1. The TOP contractor shall be responsible for provider certification oversight, and monitoring of provider/institution quality. The contractor shall use Chapter 4, 32 CFR 199.6, and TPM, Chapter 11 to the maximum extent possible for the certification of purchased care sector providers. The contractor is not required to follow TRICARE requirements for U.S. credentialing standards, except when TRICARE requires the facility/agency to be Medicare certified (e.g., home health, hospice, Skilled Nursing Facility (SNF) care). Also, Psychiatric Residential Treatment Centers (RTCs), Substance Use Disorder Rehabilitation Facilities (SUDRFs), and Psychiatric Partial Hospitalization Programs (PHPs) that are located in Puerto Rico require approval by the TOP contractor. Except for these services and facilities, the TOP contractor shall establish purchased care sector provider certification processes based on the accepted licensure and credentialing requirements for the purchased care sector.
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| 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. |
| Is the TOP Contractor required to credential non-network providers prior to processing and paying claims? |
| The TOP Contractor is required to certify non-network providers prior to processing and paying claims (See TOM Chapter 4, Section 1). |
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| 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. |
| Please describe the process the TOPO uses to review community standards of medical malpractice. |
| The TOPO will use all resources at its disposal 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. |
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| 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. |
| To increase competition and encourage new offerors to submit proposals for TOP, please provide the malpractice and licensure/certification requirements that apply under the current contract. |
| The list of malpractice insurance and licensure/certification requirements for all countries is proprietary to the incumbent and will not be released. |
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| 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
| To increase competition and encourage new offerors to submit proposals for TOP, please provide the current telemedicine information for each host country with the release of the RFP data package. |
| This is a new requirement and the information is not available. |
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| 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. |
· Telemedicine-specific regulatory, licensing, credentialing and privileging, malpractice and insurance laws and rules for each host nation
| Does this requirement intend to restrict Contractors to only utilize local (host country) providers as the telehealth/telemedicine resource for a beneficiary? |
| No. |
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| 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. |
| Will the 75% measurement be per host country or total network? Will the denominator exclude host countries or specialties for which clinical quality metrics were unable to be defined, as noted in C.11.6? |
| The 75% measurement pertains to the total network. Countries with approved waivers will not be included in the calculation. See Solicitation Section C, paragraph C.11.7.2. |
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| 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. |
| For an non-incumbent offeror, are claims costs based on an Offeror’s current claims costs? Are there factors to adjudicating and paying claims that would change this amount? |
Assuming that the FY17 – FY19 claim costs are the current TOP contract costs, please provide this data to prospective offerors with the RFP data release.
The DHA issued Ordering Instructions for potential offers to obtain historical data, including claims data, via the Federal Business Opportunities website (www.fbo.gov) on January 31, 2019. Offerors may still request this data. See Solicitation Section L, Attachment L-1 Ordering Instructions for Data.
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| 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. |
| Languages such as Arabic and Spanish have more than one dialect (not including more specific regional dialects), depending on the host country. Is DHA requiring a Contractor to provide materials translated into the host country’s dialect of a language? If not, please provide which dialect of a language for each country. |
| The contractor will be expected to translate materials into the dialect of the host nation. |
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| 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. |
| Please confirm this requirement applies to hardcopy materials only. |
| All provider educational materials, both electronic and hard copy must be translated. |
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| 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. |
| Please clarify the difference, if any, between “initial marketing materials” and provider education materials. Industry best practice would consider initial marketing materials to be those materials sent in advance of contracting and before a provider joins the network, and in some cases, prior to contract award. By requiring contractors to receive approval for initial marketing materials, the Government is restricting offerors to begin network development after contract award. To ensure competitive proposals and deliver an adequate network, some prospective offerors may choose to begin network development prior to contract award. If the government only requires approval of provider education program materials and not initial marketing materials, please update this requirement accordingly. |
| See Solicitation Section C, paragraph C.11.13.2. |
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| 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. |
| To allow prospective offerors to properly plan their bid and proposal budgets, please provide the “mandatory formats for all contractor-produced regional educational material” with the next draft RFP. |
| See Solicitation Section C, paragraph C.11.13.2. |
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| 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. |
| Is this requirement for Government Indemnification in force under the current contract? If so, what percentage of current network providers are under a provider agreement that contains the clause required therein? |
As this requirement is written, and without the benefit of additional information, each offeror will make an assumption about the financial exposure due to the unknown risk. This potential financial exposure will be added into the administrative price of an offerors proposal. This presents DHA several challenges: 1) the inability to do an assessment of fair and reasonable costs due to each offerors’ assumptions regarding this risk; 2) an unfair competitive advantage to the incumbent due to their knowledge regarding information under the current contract.
While we understand the Government’s objective with such a requirement, we have an obligation to identify the challenges this clause creates. Savvy offerors are not going to simply accept this unknown financial risk and hope for a positive outcome. Given the varied nature of delivering healthcare services overseas, this clause has the potential to present millions of dollars of risk to an offeror. Additional information will allow an offerors actuaries to more accurately predict the financial risk that would result in more accurate administrative pricing. In the absence of additional information, we recommend the Government include a fixed-price, pre-populated CLIN to cover a reasonable amount of risk that would apply to all offerors and provide for a more reasonable and fair price evaluation.
The requirement for Government Indemnification is in force under the current contract.
The percentage of current network providers are under a provider agreement that contains the clause required therein is proprietary to the incumbent.
The Government does not plan on modifying the CLIN structure with a Government Indemnification CLIN.
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| 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. |
| In what languages must the provider directory search be available? |
| The Provider Directory must be available in English. |
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