TOP_21_Section_C.docx

SECTION C

DESCRIPTION/SPECIFICATIONS/WORK STATEMENT

TRICARE OVERSEAS PROGRAM (TOP)

PERFORMANCE WORK STATEMENT (PWS)

C.1. GENERAL.

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

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

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

C.1.3. Section C includes two categories of outcome-based statements. The Statement of Objectives represents the desired outcomes for this contract. The technical requirements support the objectives. These technical requirements encompass the scope of the contract and represent specific tasks, outcomes, and/or standards that, at a minimum, the contractor must achieve.

C.1.4. Whenever practicable, the technical requirements identified in this section are accompanied by one or more cross-references to the TRICARE Manuals. These cross-references are provided to facilitate the contractor's understanding of the contract requirements and are not all-inclusive. The contractor is responsible for understanding the full scope of the TRICARE program and all TOP requirements as outlined in the contract to include, but not limited to, the documents incorporated by reference in paragraph C.3. Documents.

C.2. STATEMENT OF OBJECTIVES.

The primary objectives (i.e., desired outcomes) of the TOP contract are as follows:

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

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

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

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

C.3. DOCUMENTS.

C.3.1. The following documents form an integral part of this contract and have the same force and effect as if set forth in full text. The TRICARE Manuals provide instruction, guidance, and responsibilities to establish contractual requirements for implementation of federal statutes and regulations. In the event of a conflict between the manuals and either statute and/or regulation, the statute and/or regulation takes precedence. If there is a conflict between the manuals, the order of precedence is: (1) TRICARE Policy Manual (TPM) and TRICARE Reimbursement Manual (TRM), (2) TRICARE Systems Manual (TSM), and (3) TRICARE Operations Manual (TOM). The TRICARE Manuals are located at https://manuals.health.mil/. If the contractor believes that a conflict exists between the incorporated documents, the contractor shall inform the Contracting Officer in writing.

C.3.1.1. TRICARE Manuals.

· TOM 6010.59-M, April, 2015, through Change 50.

· Section J, Attachment J-17, Draft TOM Chapter 24.

· Section J, Attachment J-18, Draft TPM Chapter 12

· TSM 7950.3-M, April 2015, through Change 27.

· TRM 6010.61-M, April 2015, through Change 38.

· TPM 6010.60-M, April 2015, through Change 48.

C.3.1.2. Statutory and Regulatory Authority.

· Title 10, United States Code (USC), Armed Forces, Chapter 55, Medical and Dental Care, (10 USC 55)

· Title 32 Code of Federal Regulations (CFR) National Defense, Part 199, Civilian Health And Medical Program Of The Uniformed Services (32 CFR 199)

· Title 36 CFR Parks, Forests, and Public Property, Part 1222, Creation And Maintenance of Federal Records (data created or received and maintained for the Government by contractors) (36 CFR 1222)

· Title 45 Public Welfare, CFR 160, General Administrative Requirements (45 CFR 160)

· 45 CFR 162, Administrative Requirements

· 45 CFR 164, Security and Privacy

· Public Law 104-191, Health Insurance Portability and Accountability Act of 1996 (HIPAA) security and privacy standards, transaction and code set standards, National Provider Identifier (NPI) requirements and implementation specifications

· 5 USC 552a, Privacy Act of 1975

· 5 USC 552, Freedom of Information Act

· 42 USC 290dd-2, Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) Reorganization Act

· 36 CFR 1222; 36 CFR Subchapter B, Records Management

· 44 USC , Chapters 21, 29, 31, 33, Federal Records Act

· 44 USC, Chapter 35, Paperwork Reduction Act, Section 508, Rehabilitation Act of 1973

C.3.1.3. DoD Issuances. The list of DoD Issuances is not all-inclusive. The contractor shall refer to TOM Chapter 1, Section 5, paragraph 1.3; and TSM Chapter 1, Section 1.1, paragraph 1.10, for additional DoD references.

· DoD Directive, Reserve Component Medical Care and Incapacitation Pay for Line of Duty Conditions

· DoD Instruction 1241.2, Reserve Component Incapacitation System Management.

· DoD 5400.11-R, DoD Privacy Program

· DoDD 5015.2, DoD Records Management Program,

· DoD 6025.18-R, DoD Health Information Privacy Regulation

· DoD 8580.02-R, DoD Health Information Security Regulation

C.3.2. Definitions for the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) are included in Title 32, CFR National Defense, Part 199.2. Definitions with a mixture of TRICARE Regulatory definitions listed in Title 32 National Defense CFR 199.2 and 199.17, operational definitions used by TRICARE personnel and contractors in the daily administration of the TRICARE Program, and terminology found in the Health Insurance Portability and Accountability Act (HIPAA) of 1996, are included in the TOM, Appendix A. Definitions for federal acquisitions are located in Federal Acquisition Regulation (FAR) 2.1 and DoD FAR Supplement (DFARS) 202.1.

C.4. GOVERNMENT INFORMATION SYSTEMS.

C.4.1. The Government will provide the contractor with access to the Defense Manpower Data Center’s (DMDC's) 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 any subcontractors’ staff who will utilize systems, which access and maintain TOP data are compliant with the enhanced safeguarding methods for unclassified DoD information, personnel security, and clearance requirements. The contractor shall refer to paragraph C.25., System Security, for a description of these system requirements. The contractor and its subcontractors shall comply with these requirements no later than 120 calendar days before the start of health care delivery at the beginning of Option Period (OP) 1.

C.4.2. The Defense Medical Information System (DMIS) identifies past and current DoD medical facilities. DMIS Identifiers (DMIS IDs) are recognized throughout the DoD for various medical and military facility identification purposes, including TRICARE enrollment. The contractor shall use DMIS IDs to enroll beneficiaries correctly. The contractor may view DMIS ID tables at:

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

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

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

C.6. TECHNICAL REQUIREMENTS. The technical requirements for the TOP contract are identified below. These requirements are augmented by the statutes, regulations, and other operating guidelines and instructions incorporated by reference as noted in paragraph C.3. Documents.

C.7. MEDICAL BENEFITS.

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

C.7.2. The TOP contract strives to accommodate the cultural differences associated with the delivery of health care overseas. However, the contractor shall not provide services or items, which are specifically excluded or limited in the TOP contract, regulations, or the TRICARE manuals without specific Government direction.

C.7.3. DHA maintains the “No Government Pay Procedure Code List,” which identifies all codes that are excluded from coverage and are not payable under the TRICARE program. This list is available online at https://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement/No-Government-Pay-Procedure-Code-List.

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

C.7.5. The contractor shall administer TRICARE medical benefits in accordance with 32 CFR 199.4 and the TPM. The contractor shall comply with the specific requirements and additional information regarding waivers for the provision of non-covered services to ADSMs under the Supplemental Health Care Program in TOM Chapter 17, Supplemental Health Care Program (SHCP).

C.8. MANAGEMENT.

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

C.8.2. The contractor’s management structure shall respond to Government requirements on a timely basis. The contractor shall work cooperatively with the Government to plan and develop solutions to high priority contract changes.

C.8.3. The contractor shall employ best business practices to facilitate and improve integration between the purchased and direct care systems. The contractor shall collaborate with MTFs to improve integration in, including but not limited to, the following areas; access to care, network development, clinical quality, medical management, referral management, and the beneficiary experience of care.

C.8.4. The contractor shall establish and continuously operate an internal Quality Management/ Quality Improvement (QM/QI) program that will provide the contractor’s management with effective and efficient processes for identifying and correcting problems throughout the duration of the contract. At a minimum, the contractor's QM/QI program shall include the following:

· Quality Practices

· Contractor and Subcontractor Staff Education and Training

· Claims Processing (accuracy, timeliness, coding)

· Internal Controls

· Utilization Review, Claims Review, and Utilization Management Processes

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

· Access to Care Monitoring Procedures

· Delegated Activities and Subcontractor Oversight Management

· Appeals and Grievances Procedures

· Beneficiary Communications

· Provider Communications and Satisfaction Monitoring

· Quality Management Plan (Contract Data Requirements List [CDRL] P100, Internal Quality Management/Quality Improvement Program Plan)

· Quality Management/Quality Improvement Report (CDRL Q020, Internal Quality Management/Quality Improvement Report)

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

· Direct and Purchased-Care Integration

C.8.5. 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. The Health Care Industry’s Consumer Bill of Rights and Responsibilities can be found at https://archive.ahrq.gov/hcqual/.

C.8.6. The contractor shall develop and implement staff training on military culture. All training materials will be provided to the Government for review 180 calendar days prior to the start of health care delivery at the beginning of OP 1 as part of the contractor’s Education Plan (CDRL P090). The TRICARE Overseas Program Office (TOPO) will provide feedback and/or approval on the materials within 21 calendar days after receipt. All contractor and subcontractor employees shall be required to complete the training within 60 calendar days after their start work date and the contractor shall document employee compliance.

C.8.7. The contractor shall document and employ management procedures to ensure confidentiality of all beneficiary and provider information as stated in Section H, paragraph H.2.

C.8.8. The contractor shall ensure its management complies with the specific requirements and additional information regarding management in TOM Chapter 1 and Draft TOM Chapter 24, Section 1.

C.9. RECORDS MANAGEMENT.

C.9.1. Pursuant to FAR 24, Protection of Privacy and Freedom of Information, the requirements of 5 UCS 552a, Privacy Act and the DoD 5400.11-R, DoD Privacy Program, are applicable to this contract and the systems of records operated and maintained by the contractor on behalf of DHA. These systems of records are found at 5 USC 552, Freedom of Information Act (Health Benefits Authorization Files, Medical/Dental Care and Claims Inquiry Files, Medical/Dental Claim History Files); 69 Federal Register 50171 and 71 Federal Register 16127 (Military Health Information System); and 64 Federal Register 22837 (Health Affairs Survey Data Base). The records systems operated and maintained by the contractor are records systems operated and maintained by a DoD Agency (DHA). The contractor shall refer to TOM Chapter 1, Section 5; and Chapter 9, Sections 1 and 2. The contractor shall maintain all contractor records generated under this contract in accordance with 36 CFR 1222; 36 CFR Subchapter B, Records Management; 44 USC, Chapters 21, 29, 31, and 33, Federal Records Act; 44 USC, Chapter 35, Paperwork Reduction Act; DoDD 5015.2, DoD Records Management Program; TOM Chapter 9; and Section J, Attachment J-17, Draft TOM Chapter 24, Section 2.

C.9.2. The contractor shall not disseminate or publish information developed or contained in the reports furnished to DHA pursuant to this contract without prior written approval from the Contracting Officer.

C.9.3. The contractor shall not use TOP records for commercial marketing purposes or any other purpose not directly related to the TOP contract. This does not include contractor-maintained provider records for PCSPs who are part of the TOP contractor’s network and provide care to the contractor’s other corporate business clients.

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 and instruct the requestor to submit the request to DHA.FOIA@mail.mil, or DHA Freedom of Information Service Center 7700 Arlington Boulevard, Suite 5101 Falls Church, Virginia 22042-5101 Phone: 1-703-275-6363 Fax: 1-703-275-6386 C.9.5. The contractor shall comply with records management requirements in TOM Chapter 9 and Section J, Attachment J-17, Draft TOM Chapter 24, Section 2.

C.10. FINANCIAL ADMINISTRATION. The contractor shall comply with the financial administration requirements in Section G, Contract Administration Data; TOM Chapter 3; and Section J, Attachment J-17, Draft TOM Chapter 24, Section 3.

C.11. PURCHASED-CARE SECTOR PROVIDERS (PCSP) AND FACILITIES.

C.11.1. Network Development. The contractor shall provide a managed, stable, high-quality network of individual and institutional PCSPs which promotes access, clinical quality, beneficiary and provider satisfaction, and best value health care for TOP enrollees in the MTF locations identified in Section J, Attachment J-1, TOP Prime Locations, and the network-designated remote locations identified in Attachment J-2, TOP Prime Remote Locations. The contractor shall refer to TOM, Appendix B, for definition of best value health care.

C.11.1.1. In MTF locations, the contractor shall develop provider networks 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 health care 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. The contractor shall refer to paragraph C.29. TAO/MTF and Contractor Interfaces.

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

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

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

C.11.1.5. The contractor shall develop and maintain PCSP networks and implement the delivery of cashless, claimless services in non-network designated remote locations on a “best effort” basis. A non-network designated remote location is a location where ADSMs/ADFMs are assigned, but the Government has not designated it as a TOP Prime Remote site. Non-network designated remote locations are identified in Section J, Attachment J-3, Non-network Designated Remote Locations. The contractor shall 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 and notify the TOPO who will request the Contracting Officer to modify the contract to add the location to Section J, Attachment J-3. 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.

C.11.1.6. The contractor shall establish the size of its networks to include only the number of high quality providers required to meet contract requirements.

C.11.2. Network Provider Accreditation. All network hospitals and other places of institutional care shall meet the minimum accreditation standards of the specific host-nation or US commonwealth/territory. The contractor shall establish processes to evaluate the quality, safety, and compliance with licensure/certification and malpractice insurance requirements of purchased-care sector institutions. The contractor shall maintain such evaluations for Government inspection. The contractor shall update its evaluations every 3 years at a minimum unless the Contracting Officer specifically waives the requirement in writing.

C.11.2.1. The contractor shall identify the international and national medical accreditation program(s) for the locations in Section J, Attachments J-1 and J-2. In locations where medical accreditation programs exist, the contractor shall have a minimum of 85% of its network providers accredited by those internationally/nationally accepted accreditation programs. The contractor shall maintain copies of each provider's accreditation and make them available for Government inspection upon request.

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

C.11.3.1. The contractor shall establish business processes to track and monitor the credentials of all network PCSPs working under this contract, including the individual provider credentials, credentialing organization, date of credentials and date of credentials expiration. The contractor shall verify credentials for network providers during the network development/network agreement process. The contractor shall verify credentials for non-network PCSPs upon receipt of the first TRICARE claim and prior to payment of the claim, unless the Contracting Officer specifically waives this requirement in writing.

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

C.11.3.3. The Government will audit 800 to 1,200 random provider files per option period. For each provider file which does not meet the standard for certification/ licensing, medical malpractice insurance, and provider accreditation, a performance guarantee will be applied in accordance with Section H, paragraph H.7.11.

C.11.3.4. The contractor shall perform on-site verification during provider certification in the Philippines. The Government may expand this on-site verification requirement to other locations during the life of the contract.

C.11.4. Medical malpractice insurance. The contractor shall determine the medical malpractice insurance required in the country, province, state, commonwealth/territory (if applicable). The contractor shall ensure all network providers (professional and institutional) meet the medical malpractice insurance standards for their host-nation or US commonwealth/territory if applicable. The contractor shall ensure each network provider agreement clearly identifies the provider has the required malpractice insurance. The contractor shall maintain and provide medical malpractice insurance documentation to the Government upon request.

C.11.4.1. In the absence of any country, province, state, commonwealth/territory, etc., legal requirement for medical malpractice insurance, the contractor shall determine the local community standard for medical malpractice insurance, establish the minimum malpractice insurance which providers are required to obtain, and maintain documentation evidencing both the standard and compliance by network providers.

C.11.4.2. The TOPO retains the authority to determine whether a network provider met the standards for medical malpractice insurance and whether the contractor has documented the required insurance.

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

C.11.5. Telehealth. If allowed by the host-nation, the contractor shall utilize synchronous or asynchronous telemedicine to provide supplemental diagnostic and treatment services if medically appropriate as a means of delivering health care services in support of the purchased-care sector network to all ADSMs and ADFMs enrolled in TOP Prime/Prime Remote.

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

C.11.5.2. The contractor shall ensure telemedicine consultation is considered as part of the patient’s plan for medical care prior to, or in conjunction with recommending Medical Temporary Duty (TDY). Telemedicine shall be utilized only when the patient’s standard of care is guaranteed to be the same whether the patient is seen in person or via teleconsultation.

C.11.5.3. Outside of the MTFs or US consulates, physicians shall be licensed in the patient’s jurisdiction and work in compliance with local health regulations. They shall also have the ability to prescribe remotely to the patient, with a detailed knowledge of local drug names, availability, and prescribing regulations.

C.11.5.4. The contractor 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 in the Network Implementation Plan (CDRL P030). The plan shall include:

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

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

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

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

· Education of MTFs/Beneficiaries.

C.11.6. Clinical Quality Metrics. The contractor shall track and report clinical data that measure quality and shall maintain such data for the Government’s inspection. The contractor shall develop, deliver, and maintain clinical quality metrics for overseas network PCSPs that are consistent with the needs of the TOP Prime/Prime Remote beneficiary population served. The metrics should be focused on the most relevant and most highly utilized diagnoses of the TOP population. The contractor shall detail clinical quality metrics in the Clinical Quality Management Program/Clinical Quality Oversight Report (CDRL A110). The contractor shall provide this data to the TOPO for review prior to dissemination. After the TOPO approves the data, the contractor shall make this data available to MTFs/TAOs to assist in directing patients to high quality providers. Metric types should include structural, process, and outcome metrics.

C.11.6.1. The contractor shall provide the Government with a listing of relevant host-nation quality metrics for all countries included in Section J, Attachment J-1 (countries/territories with TOP Prime MTFs) and TOP Prime Remote countries included in Attachment J-2. The contractor shall report on the clinical quality of network providers compared to clinical quality metrics established for the country in CDRL A110. The TOP contractor may request a clinical quality metrics waiver for any location in which clinical quality metrics cannot be established. Such waiver requests shall be directed to the appropriate TAO and shall include the reason(s) for the waiver request (e.g., clinical quality metrics are not collected by commercial/Governmental entities). The TOPO will approve clinical quality metrics waivers. If the TOPO approves the contractor’s waiver request, the TOPO will notify the contractor of the clinical quality metrics waiver.

C.11.6.2. The contractor shall clearly state its methodology for developing clinical quality metrics in the Clinical Quality Management Program/Clinical Quality Oversight Plan (CDRL P010). The contractor shall describe how it incorporated clinical quality metrics in the contractor's assessment of the quality of care rendered by PCSPs and how the contractor uses clinical quality data to compare providers’ performance to host-nation standards. The contractor shall develop clinical quality metrics that leverage existing international accreditation agency and host-nation clinical quality data and are medically meaningful and statistically reliable (e.g. risk adjusted based on a wide range of patient population characteristics). The contractor's metrics shall be patient-centered (e.g. considering the patient’s needs, values and preferences), and evidence-based. The contractor shall report on the implementation and utilization of clinical quality metrics in CDRL A110.

C.11.6.3. The contractor shall respond to any Government inquiries concerning any aspect of clinical quality measurement within 4 business days. The contractor shall maintain an online clinical quality database, which provides information on the clinical quality metrics established for the specified countries. The contractor shall refer to paragraph C.11.6.1. Government personnel will be granted access upon TOPO approval. Clinical quality measurement documentation shall be made available to the Government during routine meetings, audits or focused reviews.

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

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

C.11.7.2. The contractor shall incorporate the clinical quality metrics identified in paragraph C.11.6 into its profiling/monitoring parameters and establish a clinical quality rating system. The contractor shall clearly state the methodology it used for developing its clinical quality rating system in its Clinical Quality Management Program/Clinical Quality Oversight Plan (CDRL P010). The contractor shall report on the outcome of implementing the clinical quality rating system in accordance with the Clinical Quality Management Program Report (CDRL A110). In locations identified in Section J, 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 paragraph C.11.6. This metric pertains to the total network as a whole. The contractor shall clearly state its methodology for determining the 75% percentile in its Network Implementation Plan (CRDL P030). In its role as Health Care Finder, the contractor shall direct beneficiaries to the network providers with the highest quality outcomes.

C.11.8. Access to Care. The contractor shall make its best effort to ensure the TRICARE standards in 32 CFR 199.17, paragraph (p)(5), for access, in terms of beneficiary travel time, appointment wait time, and office wait time, are met for TOP Prime and TOP Prime Remote enrollees.

C.11.8.1. Access standards include emergency care available 24 hours per day, 7 calendar days per week in the service area; acute care appointments available within 24 hours; routine care appointments within 7 calendar days; wellness care appointments within 4 weeks; specialty care appointments within 4 weeks or per provider designation, not to exceed four weeks; no more than a 60 minute drive time from the sponsor’s duty location for specialty care, but no more than 30 minutes for other types of care; office wait times will generally not exceed 30 minutes for nonemergency care.

C.11.8.2. The term "best effort" is defined as the contractor making commercially reasonable efforts on an ongoing basis to achieve the stated access standards. Under best effort, the Government will not negatively evaluate the contractor's performance if the contractor does not achieve the stated access standards. The contractor shall inform the TOPO 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 to improve access in those areas (CDRL M100, Network Adequacy/Inadequacy Report).

C.11.9. Provider Capability and Capacity Adjustments. The contractor shall adjust its network and non-network PCSP capabilities and capacities as necessary to address changes in MTF capabilities and capacities, which may occur due to facility downsizing or closure, MTF expansion, establishment of new clinics, and provider deployment or reassignment. These changes may occur frequently over the life of the contract. The contractor shall adjust its network and non-network PCSP capabilities and capacities to compensate for changes to MTF capabilities and capacities, when and where they occur within 90 calendar days after Government notification of such changes.

C.11.10. Network Adequacy. The contractor shall assess network adequacy on an ongoing basis and shall inform the Government of any instances of network inadequacy as defined in the Network Implementation Plan (CDRL P030). The contractor will submit a corrective action plan for instances of network inadequacy that are significant (e.g., the only provider in a certain specialty leaves the network and there are no other local providers capable of providing similar services) or likely to persist for more than 30 calendar days. The contractor shall respond to any Government inquiries concerning any aspect of network adequacy within 4 business days.

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

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

C.11.10.3. The TOP contractor may request a network implementation waiver for any location identified in Section J, Attachment J-2, TOP Prime Remote Locations, which would otherwise require the development of a PCSP network. The contractor shall submit such waiver requests the appropriate TAO and should include the reason(s) for the waiver request (e.g., safety concerns, lack of providers, security risks), as well as a recommended strategy to ensure access to care for TOP Prime Remote enrollees. The Contracting Officer will approve network waivers in writing.

C.11.11. Negotiated Rates. The contractor shall negotiate reduced rates for health care provided by network PCSPs in the countries designated in Section J, Attachment J-12, Negotiated Rate Locations. Through negotiating rates, the contractor shall achieve a reduction in the average cost-per-claim compared to the contractor's pre-established baseline. The contractor shall negotiate rates in such manner as not to jeopardize access to care.

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

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

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

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

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

C.11.13.1. The contractor shall produce regional provider education materials. The DHA Strategic Communications and the TOPO will review and approve education materials prior to the contractor disseminating them. The contractor shall produce provider education materials in the following languages: German, Italian, Korean, Japanese, Arabic, Spanish, French, and Turkish.

C.11.13.2. The contractor shall incorporate a detailed description of the contractor’s provider education program into the contractor’s Education Plan (CDRL P090). The contractor shall distribute initial provider education materials to network providers no earlier than 60 calendar days and no later than 30 calendar days prior to the start of health care delivery. The contractor shall conduct ongoing provider education in accordance with the Government-approved plan. Ongoing provider education material must be reviewed by DHA Strategic Communications and the TOPO prior to dissemination. The contractor shall produce TOP provider education material in accordance with the TOM Chapter 11, Section 1; and Section J, Attachment J-17, Draft TOM Chapter 24, Section 11.

C.11.14. Government Indemnification. The contractor agrees to be liable for and expressly agrees to indemnify the Government from any liability resulting from services provided under the TOP contract to enrolled TRICARE 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 enrolled beneficiaries for care provided by contractor network providers.

C.11.15. Provider Directory. The contractor shall maintain an accurate, up-to-date searchable provider directory, which includes all network providers for each service area identified in Section J, Attachment J-1, TOP Prime Locations; network-designated areas identified in Attachment J-2, TOP Prime Remote Locations; and non-network designated remote locations identified in Attachment J-3, Non-network designated Remote Locations. The contractor shall ensure its provider directory is user-friendly and readily searchable by provider or facility name, specialty or type of facility, subspecialty, gender (for individual providers), service area, work address, work telephone number, any limitations of service, and whether the provider is accepting new TRICARE patients.

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

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

C.11.15.3. The contractor shall provide the MTF PCMs and the medical staff at the US Embassy Health Units with an enhanced provider search capability. US Embassy medical staff provide primary care to enrolled TRICARE beneficiaries and require access to the location of location of specialty care providers. The provider search function shall include the complete list of network and participating non-network providers in all locations. 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. The directory will include the distance from the US Embassy/MTF.

C.11.16. The contractor shall establish a process to ensure consult reports are translated and returned to the referring MTF within 30 business days after the appointment. The contractor shall employ strategies to maximize obtaining medical documentation within constraints imposed by host-nation privacy laws. MTFs with internal translation capability may elect to receive untranslated consult reports. The contractor shall document the decision by a MTF not to receive translated consult reports in the statement of responsibility. This process shall be included in the Network Implementation Plan (CRDL P030).

C.11.16.1. The contractor shall ensure network providers provide a complete trauma medical report at the time of transfer to the MTF for all TRICARE Prime and Prime Remote trauma patients. The contractor shall ensure a complete copy of the medical report is provided to the MTF within 3 calendar days after transfer of a TRICARE Prime or Prime Remote trauma patient from a non-network facility to a MTF.

C.11.16.1.1. The contractor shall use the American Trauma Society definition for trauma patients. The American Trauma Society defines a trauma patient as someone who has suffered a serious or life threatening injury as a result of an event such as a car accident, gunshot wound or fall. Traumatic injuries may affect many parts of the body, including the brain, the extremities and internal organs. The severity of injuries can range from minor to life-threatening.

C.11.16.1.2. A complete trauma medical report shall include an admission history and physical, operative reports, copies of all diagnostic reports (MRIs, CAT Scans, x-rays, labs, etc.), and a formal discharge summary. On a best effort basis, the contractor shall ensure operative reports include pre-and-post surgery diagnoses, patient position and preparation, narrative summary of the surgical techniques and approaches, specimens or tissue samples removed, specific type/brand/location of any implants inserted, estimated blood loss, unexpected findings and/or complications, how the operative site was closed, and patient condition at the end of the operation.

C.11.17. The contractor shall clearly identify any contractor-owned facilities or entities providing health care to TOP enrollees in its Contractor Owned Facilities Mitigation Plan (CDRL P080). The contractor shall work cooperatively with the Government to develop a plan to mitigate the appearance of a potential general conflict of interest. This includes, but is not limited to, contractor-owned clinics, hospitals, pharmacies, medical evacuation/ambulance service companies, etc. The contractor shall refer to Section H, paragraph H.5.2., for additional information regarding Organizational Conflict of Interest and Impaired Objectivity.

C.11.18. The contractor shall comply with the specific requirements and additional information regarding PCSPs and facilities in TPM Chapters 7 and 11, TOM Chapter 5, and Section J, Attachment J-17, Draft TOM Chapter 24, Section 4.

C.12. TOP ELIGIBILITY AND ENROLLMENT.

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

C.12.2. In addition to verifying DEERS eligibility status, the contractor shall establish business processes to…