TOP_21_Section_H.docx

SECTION H

SPECIAL CONTRACT REQUIREMENTS

CONTRACT CLAUSES.

DFARS 252.203-7000, Requirements Relating to Compensation of Former DoD Officials (Sep 2011)

(a) Definition. Covered DoD official, as used in this clause, means an individual that—

(1) Leaves or left DoD service on or after January 28, 2008; and

(2) (i) Participated personally and substantially in an acquisition as defined in 41 U.S.C. 131 with a value in excess of $10 million, and serves or served—

(A) In an Executive Schedule position under subchapter II of chapter 53 of Title 5, United States Code;

(B) In a position in the Senior Executive Service under subchapter VIII of chapter 53 of Title 5, United States Code; or

(C) In a general or flag officer position compensated at a rate of pay for grade O-7 or above under section 201 of Title 37, United States Code; or

(ii) Serves or served in DoD in one of the following positions: program manager, deputy program manager, procuring contracting officer, administrative contracting officer, source selection authority, member of the source selection evaluation board, or chief of a financial or technical evaluation team for a contract in an amount in excess of $10 million.

(b) The Contractor shall not knowingly provide compensation to a covered DoD official within 2 years after the official leaves DoD service; without first determining that the official has sought and received, or has not received after 30 days of seeking, a written opinion from the appropriate DoD ethics counselor regarding the applicability of post-employment restrictions to the activities that the official is expected to undertake on behalf of the Contractor.

(c) Failure by the Contractor to comply with paragraph (b) of this clause may subject the Contractor to rescission of this contract, suspension, or debarment in accordance with 41 U.S.C. 2105(c).

(End of clause)

H.1. UNDERWRITING OF HEALTH CARE COSTS.

H.1.1. The contractor is not required to underwrite the cost of civilian health care services (also referred to as purchased care), which is defined as care rendered outside the direct care system to eligible beneficiaries receiving care under the scope of this contract. The contractor shall act as a fiscal intermediary for the Government to distribute, or pass-through, Government funds for non-underwritten health care benefits in accordance with Section G, paragraph G.8.

H.1.2. The contractor shall assume full financial liability for services provided to eligible civilian beneficiaries, which fall outside the scope of this contract, when specifically authorized by the contractor. For example, if the contractor issues an authorization for a procedure which is specifically excluded from TRICARE coverage and the beneficiary subsequently obtains the care based on the contractor’s erroneous authorization. The TRICARE Overseas Program Office will make such determinations based solely on the specific services and/or supplies identified in the contractor’s authorization letter and the TRICARE benefit policies in effect at the time the contractor issued the authorization. The contractor shall not be held liable in cases where the beneficiary and/or the provider choose to engage in non-covered services that are beyond the scope of the contractor’s authorization.

H.2. CONFIDENTIALITY.

With regard to confidentiality, the contractor shall comply with TOM, Chapter 1, Section 5. The contractor shall protect records in terms of privacy and security during use, transmission, storage, handling, and destruction. The contractor shall protect all beneficiary records, including but not limited to, Beneficiary History and Deductible Files as described in DoD 6025.18-R, DoD Health Information Privacy Regulation; TOM Chapter 1, Section 5; data as required by 5 USC 552, Freedom of Information Act; 5 USC 552a, Privacy Act of 1975 as implemented by DoD Regulation 5400.11-R, DoD Privacy Program; 42 USC 290dd-2, the Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act; the Health Insurance and Portability Accountability Act (HIPAA) of 1996; and 10 USC 55, Section 1102, Confidentiality of Medical Quality Assurance Records.

H.3. PRIVACY AND SECURITY OF PROTECTED HEALTH INFORMATION.

H.3.1. In accordance with DoD 6025.18-R, the contractor meets the definition of a Business Associate. Therefore, a Business Associate Agreement is required. This Section serves as that agreement whereby the contractor agrees to abide by all applicable HIPAA Privacy and Security requirements regarding health information as defined in this Section and DoD 6025.18-R, as amended. This agreement is in addition to, and does not supersede, any agreement required in this contract.

H.3.2. The contractor agrees to use appropriate safeguards to prevent use or disclosure of Protected Health Information (PHI) or Personally Identifiable Information (PII) except as permitted by this contract.

H.3.3. The contractor agrees to use administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic protected health information that it creates, receives, maintains, or transmits in the execution of this contract.

H.3.4. The contractor agrees to mitigate, to the extent practicable, any harmful effect that is known to the contractor of a use or disclosure of PHI/PII in violation of the requirements of this contract.

H.3.5. The contractor agrees to report to the Government any security incident involving PHI/PII of which it becomes aware.

H.3.6. The contractor agrees to report to the Government any use or disclosure of PHI/PII not provided for by this contract of which the contractor becomes aware.

H.3.7. The contractor agrees to ensure that any agent, including a subcontractor, to whom it provides PHI/PII received from, or created or received by the contractor on behalf of the Government, shall agree to the same restrictions and conditions that apply under this contract to the contractor with respect to such information.

H.3.8. The contractor agrees to ensure that any agent, including a subcontractor, to whom it provides electronic PHI/PII, shall agree to implement reasonable and appropriate safeguards to protect it.

H.3.9. The contractor agrees to provide access, to PHI/PII in a Designated Record Set at the request of the Government, and in the timeframe and manner designated by the Government. The contractor shall provide this access to the Government, or as directed by the Government, to an individual in order to meet the requirements under 45 CFR 164.524, Security and Privacy.

H.3.10. The contractor agrees to make any amendment(s) to PHI/PII in a Designated Record Set that the Government directs or agrees to pursuant to 45 CFR 164.526, Security and Privacy, at the request of the Government or an individual, and in the timeframe and manner designated by the Government at no increase in contract price.

H.3.11. The contractor agrees to make available to the Government its internal practices, books, and records relating to the use and disclosure of PHI/PII received from, or created or received by the contractor on behalf of the Government, in accordance with 45 CFR 164.528.

H.3.12. The contractor agrees to document such disclosures of PHI/PII and information related to such disclosures as would be required for the Government to respond to a request by an individual for an accounting of disclosures of PHI in accordance with 45 CFR 164.528.

H.3.13. The contractor agrees to provide to the Government or an individual, in time and manner designated by the Government, information collected in accordance with this Section of the contract, to permit the Government to respond to a request by an individual for an accounting of disclosures of PHI in accordance with 45 CFR 164.528.

H.3.14. General Use and Disclosure Provisions. Except as otherwise limited in this Section, the contractor may use or disclose PHI on behalf of, or to provide services to, the Government for treatment, payment, or health care operations purposes, in accordance with the specific use and disclosure provisions below, if such use or disclosure of PHI would not violate the 45 CFR 164, Security and Privacy, or DOD 6025.18-R if done by the Government.

H.3.15. Specific Use and Disclosure Provisions.

H.3.15.1. Except as otherwise limited in this Section, the contractor may use PHI for the proper management and administration of the contract or to carry out the legal responsibilities of the contractor.

H.3.15.2. Except as otherwise limited in this Section, the contractor may disclose PHI for the proper management and administration of this contract, provided that disclosures are required by law, or the contractor obtains reasonable assurances from the person to whom the information is disclosed that it will remain confidential and used or further disclosed only as required by law or for the purpose for which it was disclosed to the person, and the person notifies the contractor of any instances of which it is aware in which the confidentiality of the information has been breached.

H.3.15.3. Except as otherwise limited in this Section, the contractor may use PHI to provide data aggregation services to the Government as permitted by 45 CFR 164.504(e)(2)(i)(B).

H.3.15.4. The contractor may use PHI to report violations of law to appropriate Federal and State authorities, consistent with 45 CFR 164.502(j)(1).

H.3.16. Actions of the Government.

H.3.16.1. Upon request, the Government will provide the contractor with the notice of privacy practices that the Government produces in accordance with 45 CFR 164.520, as well as any changes to such notice.

H.3.16.2. The Government will provide the contractor with any changes in, or revocation of, permission by an individual to use or disclose PHI if such changes affect the contractor's permitted or required uses and disclosures.

H.3.16.3. The Government will notify the contractor of any restriction to the use or disclosure of PHI that the Government has agreed to in accordance with 45 CFR 164.522, except for providing data aggregation services to the Government and for management and administrative activities of the contractor as otherwise permitted by this Section.

H.3.17. Permissible Requests by the Government. The Government will not request the contractor to use or disclose PHI in any manner that would not be permissible under 45 CFR 164, Security and Privacy, if done by the Government.

H.3.18. The Government reserves its rights and remedies set forth in FAR Clause 52.246-4, Inspection of Services, and FAR Clause 52.249-8, Default, if the contractor does not conform with the requirements stated in this section.

H.3.19. Effect of Termination/Conclusion of Contract. The contractor shall handle all records subject to this Section in accordance with the records management requirements of this contract. Notwithstanding the records management requirements, the contractor shall return or destroy all PHI received from the Government, or created or received by the contractor on behalf of the Government. This provision shall apply to PHI that is in the possession of subcontractors or agents of the contractor. The contractor shall retain no copies of the PHI.

H.3.20. Regulatory References. A reference in the requirements of this Section to a reference in DOD 6025.18-R; 45 CFR 160; 45 CFR 164, Subparts A and E, Security and Privacy means the reference is in effect or as amended, and for which compliance is required.

H.3.21. Survival. The respective rights and obligations of a Business Associate under paragraph H.3.19 of this Section shall survive the termination of this contract.

H.3.22. Interpretation. Any ambiguity in this Section shall be resolved in favor of a meaning that permits the Government to comply with DoD 6025.18-R; 45 CFR 160; and 45 CFR 164, Subparts A and E, Security and Privacy.

H.4. COMPLIANCE WITH FEDERAL, STATE, LOCAL, AND FOREIGN REQUIREMENTS.

H.4.1. The contractor shall comply with all applicable state insurance and license requirements necessary for performance under this contract except where preempted by Federal Law. The 10 USC 1103 provides for preemption of state and local laws that relate to health insurance, prepaid health plans, or other health care delivery or financing methods. In order to identify those state and local laws that should be preempted, the contractor shall notify the CO of those state and local laws the contractor deems should be preempted, with supporting documentation no later than 30 calendar days after the date the contract is awarded. The contractor may also be required to comply with foreign laws, depending on its business structure and physical location of services.

H.4.2. In addition to the insurance and license requirements, the contractor, consultants, and providers shall obtain and maintain all other permits, licenses, etc., required to perform the services in the contract.

H.5. OTHER TERMS, CONDITIONS AND PROVISIONS.

H.5.1. Protection of Information.

H.5.1.1. Security. The contractor does not require access to classified data. However, the contractor may require access to information, which is to be handled as For Official Use Only, and which may be covered by 5 USC 552a, Privacy Act and the HIPAA. The contractor shall ensure that staff assigned to this task understand the meaning of these categories of data and handle them accordingly.

H.5.1.2. DEERS Personnel Security Requirements. The contractor shall comply with the requirement to obtain Automatic Data Processing (ADP) II personnel security investigations as prescribed by DoD 5200.2-R, Personnel Security Program for contractor/subcontractor personnel that will be accessing DEERS via the Government provided eligibility inquiry tool. The appropriate investigation forms, fingerprint cards, and questionnaires shall be completed as required and submitted to the appropriate Government Security Office for processing. Access to the Government provided eligibility inquiry tool will not be granted until appropriate paperwork and questionnaires have been submitted to the Government. If at any time the individual receives unfavorable NAC adjudication, or if at any time information that would result in an unfavorable NAC becomes known, the contractor shall immediately remove the employee from non-critical sensitive positions.

H.5.1.2.1. Non-US citizens employed by the contractor and working in Military Treatment Facilities (MTFs) may be granted access to the Government provided eligibility inquiry tool if a background check which meets host-nation background investigations is acceptable to the installation commander. The non-US citizen may have to meet additional requirements imposed by the installation commander.

H.5.1.3. Dissemination of Information/Publishing. The contractor shall not disseminate or publicize information developed under this contract or contained in reports provided pursuant to this contract, without prior written approval of the DHA COR or the CO. This does not apply to dissemination of information within and between the contractor and any subcontractors or specified Integrated Process Team (IPT) members who have a need to know. DHA approval for publication requires provisions, which protect the intellectual property and patent rights of both DHA and the contractor.

H.5.1.4. Identification of Contractor Employees. All contract personnel attending meetings, answering Government telephones, and working in other situations where their contractor status is not obvious to third parties, are required to identify themselves as such to avoid creating an impression in the minds of members of the public or Congress that they are Government officials, unless, in the judgment of the agency, no harm can come from failing to identify themselves. They must also ensure that all documents or reports produced by contractors are suitably marked as contractor products or that contractor participation is appropriately disclosed.

H.5.2. Organizational Conflicts of Interest.

H.5.2.1. The contractor’s attention is directed to FAR 9.5, Organizational and Consultant Conflicts of Interest. DHA has made a determination that an actual or significant potential organizational conflict of interest exist, or the nature of the work to be performed may create an actual or significant potential organizational conflict of interest in future acquisitions.

H.5.2.2. For the purpose of these clauses, the term contractor means the contractor, its subsidiaries, affiliates, partners, market consultants, or any of its successors or assignees.

H.5.2.3. It may become necessary in the performance of this contract to review proprietary information from other contractors. The contractor shall protect all proprietary information from unauthorized use or disclosure and refrain from using the information for any purpose other than that for which it was furnished. At the request of the CO, the contractor agrees to execute agreements with third party companies furnishing data in connection with work performed under this contract. Safeguards shall be implemented to restrict access to proprietary information and to avoid, neutralize, or mitigate potential conflicts of interest. Non-disclosure agreements shall be completed by the contractor, all employees, and subcontractors who obtain access to proprietary information, and provided to the CO.

H.5.2.4. The contractor agrees that if an actual or potential organizational conflict of interest is discovered after the award of this contract, the contractor will immediately notify the CO, in writing, of the nature of the conflict. The contractor shall submit a mitigation plan to the CO within 30 calendar days of notification, outlining the actions the contractor has taken or proposes to take to avoid, neutralize, or mitigate the actual or potential organizational conflict of interest.

H.5.2.5. The above restrictions shall be included in all subcontracts, teaming arrangements, and other agreements calling for performance of work which is subject to the organizational conflict of interest restrictions identified in these clauses.

H.5.2.6. The contractor acknowledges the full force and effect of the above clauses. The Government reserves the right, in case of a breach, misrepresentation or nondisclosure, to terminate this contract, disqualify the contractor from subsequent related contractual efforts, or pursue any remedy permitted by law or this contract.

H.5.2.7. Impaired Objectivity. The contractor is responsible to prevent, avoid, or mitigate any situation where the contractor may have potential performance conflicts of interests due to contractor financial interests, multiple internal allegiance or impaired objectivity where the best interests of the Government could be compromised. This includes, but is not limited to, the contractor's role as a fiscal intermediary and in its role in pursuing waste, fraud and abuse (TOM Chapter 13) involving providers, facilities, or entities in which the contractor has a financial interest and who provide health care support services to TOP enrollees. If situations that had not previously been addressed before award of the contract change or emerge after the award of this contract, and at any time during performance of the contract, the contractor will immediately notify the CO, in writing, of the nature of the actual or potential performance conflict. The contractor shall submit a plan of action to the CO within 30 calendar days of notification, outlining the actions the contractor has taken or proposes to take to avoid, neutralize, or mitigate the actual or potential performance conflicts of interest.

H.6. PERFORMANCE INCENTIVES.

H.6.1. Introduction. This section addresses the positive and negative incentives that have been incorporated into this contract. The contractor may receive a performance incentive payment for performance above a fully satisfactory level for claims accuracy and for delivering a high level of satisfaction with the TOP Prime inpatient medical management program. If the contractor fails to meet the minimum standard for network adequacy, a negative incentive will be applied.

H.6.2. Incentive Administration. The Government will measure the contractor’s performance for a given Option Period (OP) 60 calendar days after completion of each OP.

H.6.2.1. The Government will measure the contractor’s performance in accordance with paragraphs H.6.3 and H.6.4, and determine if the contractor is due a performance incentive or if a negative incentive will be assessed.

H.6.2.2. If the Government determines that the contractor’s performance exceeds the standards specified in paragraph H.6.3, the Government will apply the incentive amount in accordance with paragraphs H.6.3 and the contractor will be paid from Contract Line Item Number (CLIN) X012, Performance Incentive Pool.

H.6.2.3. If the Government determines that the contractor fails to meet the minimum standard stated in paragraph H.6.4, the Government will apply the negative incentive in accordance with paragraph H.6.4 and the negative incentive amount will be withheld from the next available contract payment under CLIN X001, Healthcare Support Services, Prime Enrolled Members.

H.6.3. Claims Payment Accuracy—Standard. The absolute value of the payment errors for sampled TED claims shall not exceed 1.5%. Sampled TED claims include initial submissions, resubmissions, and adjustments/cancellation submissions.

H.6.3.1. When the contractor decreases the payment error rate to 1.0% or below based on sampled TED records, the Government will apply a percentage of the incentive pool for claims payment accuracy. The performance incentive pool for claims payment accuracy is calculated by multiplying the total administrative payment for claims processing (CLINs X007 and X008) for the evaluated OP by 2%. Within 60 business days following the end of each OP, the Government will evaluate the contractor’s performance to determine whether the contractor’s level of performance warrants an incentive payment. This incentive can only result in either no payment or a positive payment amount.

H.6.3.2. The positive incentive payment amount for payment error rates of 1.0% or below will be:

· If more than 0.75% and less than or equal to 1.0% = 50% of the performance incentive pool.

· If more than 0.50% and less than or equal to 0.75% = 75% of the performance incentive pool.

If less than or equal to 0.50% = 100% of the performance incentive pool.

For example, if the performance incentive pool is calculated at $500,000 per OP for claims accuracy incentives, and the contractor’s error rate is 0.75% based on sampled TED, the contractor is eligible for a positive incentive payment of $375,000. Amounts not awarded will not be available during the follow on OPs.

H.6.4. Network Adequacy—Percent of TOP Prime/TOP Prime Remote Claims from a Purchased Care Sector Provider Standard. The established targets for the percentage of paid claims submitted by network purchased care sector providers for TOP enrollees, including TOP Prime and TOP Prime Remote, after excluding certain claims, as described in Section J, Attachment J-6, Network Adequacy Calculations/Exclusions are:

· OP 1: 70% of all claims

· OP 2: 74% of all claims

· OP 3: 78% of all claims

· OP 4: 82% of all claims

· OP 5: 86% of all claims

· OP 6: 90% of all claims

· OP 7: 94% of all claims

H.6.4.1. The term “paid claim” refers to any claim that results in payment to either the provider or the beneficiary. The Government will measure contractor performance based on the number of purchased care sector network provider claims for TOP enrollees compared with the total number of purchased care sector provider claims for these beneficiaries, after excluding certain claims as described in Section J, Attachment J-6, Network Adequacy Calculations/Exclusions. This adjusted value shall be referred to as the network penetration rate. Beginning in OP 2, the Government will assess a negative incentive for performance that fails to achieve the target network penetration rate for each OP. This incentive can only result in either no payment or a negative payment amount.

H.6.4.2. Beginning in OP 2, if the network penetration rate meets or exceeds the specified standard as described above for a given OP, no negative incentive will be applied. If the network penetration rate falls below the specified standard for a given OP, the Government shall apply a negative incentive on a per-claim basis. The Government will evaluate the contractor’s performance 60 business days after the OP to determine whether the contractor’s level of performance warrants the application of a negative incentive. The Government will determine the contractor’s performance based on the percentage corridors described below. The Government will apply larger negative incentives for successively larger discrepancies between the standard and the observed level of performance.

H.6.4.3. The amount assessed per claim when the network penetration rate falls below the specified standard is based on the percentage below the standard as follows:

OP 2:

· If less than 74% and more than or equal to 72% = $7.00 per claim

· If less than 72% and more than or equal to 70% = $14.00 per claim

· If less than 70% and more than or equal to 68% = $21.00 per claim

· less than 68% = $28.00 per claim

OP 3:

· If less than 78% and more than or equal to 76% = $7.00 per claim

· If less than 76% and more than or equal to 74% = $14.00 per claim

· If less than 74% and more than or equal to 72% = $21.00 per claim

· If less than 72% = $28.00 per claim

OP 4:

· If less than 82% and more than or equal to 80% = $7.00 per claim

· If less than 80% and more than or equal to 78% = $14.00 per claim

· If less than 78% and more than or equal to 76% = $21.00 per claim

· If less than 76% = $28.00 per claim

OP 5:

· If less than 86% and more than or equal to 84% = $7.00 per claim

· If less than 84% and more than or equal to 82% = $14.00 per claim

· If less than 82% and more than or equal to 80% = $21.00 per claim

· If less than 80% = $28.00 per claim

OP 6:

· If less than 90% and more than or equal to 88% = $7.00 per claim

· If less than 88% and more than or equal to 86% = $14.00 per claim

· If less than 86% and more than or equal to 84% = $21.00 per claim

· If less than 84% = $28.00 per claim

OP 7:

· If less than 94% and more than or equal to 92% = $7.00 per claim

· If less than 92% and more than or equal to 90% = $14.00 per claim

· If less than 90% and more than or equal to 88% = $21.00 per claim

· If less than 88% = $28.00 per claim

H.6.4.4. The Government will apply the highest per claim amount to all claims failing the standard. The Government will not stratify the performance incentive based on the variable per claim amounts. For purposes of performance incentive assessment, the Government will round actual percentages to the nearest one-tenth of a percent.

H.7. PERFORMANCE GUARANTEES.

H.7.1. Introduction. The performance guarantee described in this section is the contractor’s guarantee that the contractor’s performance will not be less than the performance standards described below.

H.7.2. Rights and Remedies. The rights of the Government and remedies described in the Performance Guarantee paragraphs are in accordance with, and in addition to all other rights and remedies of the Government. Specifically, the Government reserves the rights and remedies set forth in FAR Clause 52.246-4, Inspection of Services and FAR Clause 52.249-8, Default.

H.7.3. Performance Guarantee Administration. The contractor guarantees that its performance will meet or exceed the standards in this provision. For each occurrence the contractor fails to meet each guaranteed standard, the Government will withhold the amount listed for each standard below from the contractor’s payment. The total OP amount will be divided equally among the stated performance guarantees. The Government will continue to assess a specific performance guarantee until the guarantee amount for the respective guarantee (i.e., 1/8 of the total OP amount) is depleted or the contractor’s performance improves to meet or exceed the standard. The Government will measure the contractor’s performance as specified below. The Government will notify the contractor of performance guarantee withholds on a semiannual basis via a unilateral modification in accordance with FAR 43.103(b)(3), citing this Section as the authority for the modification. Withholds will be made from the next available contract payment under CLIN X001, Healthcare Support Services, Prime Enrolled Members. The amount of the performance guarantee will not change after contract award. For the purposes of this provision, the term “performance standard” is defined as the contract standards that are stated in this provision. For purposes of performance guarantee assessment, the Government will round actual percentages to the nearest one-tenth of a percent.

H.7.4. Performance Guarantee Amounts.

· OP 1

· OP 2

· OP 3

· OP 4

· OP 5

· OP 6

· OP 7

H.7.5. Performance Guarantee 1—Authorization Processing Timeliness.

H.7.5.1. Standard. Following the date of receipt of a valid (i.e., complete) referral for a TOP Prime or TOP Prime Remote enrollee, the contractor shall issue a referral authorization or denial on at least 90% of all referrals within 2 business days, and 100% of all referrals within 3 business days.

H.7.5.2. Administration. For each month the contractor does not meet the minimum authorization timeliness standards, the Government will assess a performance guarantee. Based on the contractor’s monthly authorization report (CDRL M070), the Government will assess a performance guarantee of $10.00 per referral not meeting the performance standard. For example, if the actual percent of authorizations issued within 2 business days is 87%, then a performance guarantee equal to 3% of all referrals will be assessed (3% represents the difference between the actual number of referrals not processed timely and the standard). If 3% equates to 500 referrals not meeting the standard, the performance guarantee withhold will be $5,000.00, (500 referrals x $10.00= $5,000.00).

H.7.5.3. Independent Application of Authorization Processing Timeliness Performance Guarantees. The Government will assess a performance guarantee independently to each authorization processing timeliness standard for referrals that fail to meet the minimum performance. For example, a referral that received a performance withhold because the 90% standard/2 business day standard was not met, is again subject to withhold if it is not completed within 3 business days.

H.7.6. Performance Guarantee 2—Claims Processing Timeliness (30 calendar days).

H.7.6.1. Standard. 90% of retained claims and adjustment claims shall be processed to completion within 30 calendar days from the date of receipt.

H.7.6.2. Administration. For each month the contractor does not meet the claims processing timeliness standard, the Government will assess a performance guarantee. Based on data from the DHA TED database, the Government will assess a performance guarantee amount by multiplying the claims processing unit price per claim (CLIN X007) by the number of retained claims that did not meet the 90% standard. For example, if the actual percent of retained claims processed in 30 calendar days is 86%, a performance guarantee equal to 4% of the retained claims processed that month will be assessed (4% represents the difference between the actual performance of 86% and the standard of 90%). If 4% equates to 600 retained claims not processed in 30 calendar days and the claims processing unit price is $20.00, the performance guarantee withhold will be $12,000.00 (600 x $20.00=$12,000.00).

H.7.6.3. Processing Time Calculation. The Government will calculate the claim processing time based on data submitted on TED. The processing time is calculated as one plus the difference between the Julian date that the claim or adjustment claim was processed to completion and the Julian date of receipt or the Julian date the claim was identified as an adjustment. Only a single processing time will be calculated per claim. This processing time will be calculated using all unedited TED initial submission batch/vouchers (Batch/Voucher Resubmission Number equals zero) which are received by DHA during the reporting period and which pass the batch/voucher header edits. TED in batches/vouchers which fail the batch/voucher header edits or which cannot be processed as submitted by the contractor and TED in resubmission batch/vouchers (batch/voucher resubmission number is greater than zero) will be excluded from the claim processing time calculation.

H.7.7. Performance Guarantee 3—Claim Processing Timeliness (90 calendar days).

H.7.7.1. Standard. 100% of all claims, both retained and excluded, including adjustments, shall be processed to completion within 90 calendar days unless the COR or the CO specifically directs the contractor to continue pending a claim or group of claims. Philippines claims are excluded from the standard.

H.7.7.2. Administration. For each month that the claims processing timeliness standard is not met, a performance guarantee shall be applied as follows: Based on data from the DHA TED database, the Government will assess a performance guarantee amount by multiplying the number of claims not meeting the 100% standard by twice the claims processing unit price per claim (CLINs X007). For example, if the actual percent of all claims processed in 90 calendar days is 98%, a performance guarantee equal to 2% of all claims processed that month will be assessed (2% represents the difference between the actual performance of 98% and the standard of 100%). If 2% equates to 450 claims not processed in 90 calendar days and the claims processing unit price is $20.00, the performance guarantee withhold will be $18,000.00 (450 x (2 x $20.00)=$18,000.00).

H.7.7.3. Processing Time Calculation. The Government will calculate the claim processing time based on data submitted on TED. The processing time is calculated as one plus the difference between the Julian date that the claim or adjustment claim was processed to completion and the Julian date of receipt or the Julian date the claim was identified as an adjustment. Only a single processing time will be calculated per claim. This processing time will be calculated using all unedited TED initial submission batches/vouchers (batch/voucher resubmission number equals zero) which are received by DHA during the reporting period and which pass the batch/voucher header edits. TED batches/vouchers which fail the batch/voucher header edits or cannot be processed as submitted by the contractor and TED in resubmission batches/vouchers (batch/voucher resubmission number is greater than zero) will be excluded from the claim processing time calculation.

H.7.7.4. Independent Application of Claims Processing Timeliness Performance Guarantees. A performance guarantee assessment will be applied independently to each claim processing timeliness performance guarantee (Performance Guarantees 2 and 3) for claims that fail to meet the minimum performance. For example, a retained claim that received a performance withhold because the 90% in 30 calendar day standard was not met, is again subject to withhold if it is not processed in 90 calendar days (and the contractor’s performance is below the minimum standard of 100%).

H.7.8. Performance Guarantee 4—TED Edit Accuracy.

H.7.8.1. Standard. Following the start of health care delivery, the accuracy rate for TED edits shall not be less than 80% in months one through three; not less than 85% in months four through six; not less than 90% in months seven through nine; not less than 95% in months ten through eleven; not less than 96% in months 12 through 23; and not less than 97% beginning in the 24th month and continuing at no less than 97% through contract close.

H.7.8.2. Administration. Beginning in month 7 of OP 1, for each month that the accuracy rate for TED edits is not met, a performance guarantee shall be applied as follows. Based on data from the DHA TED database, if the contractor fails to meet the standard, a performance guarantee amount of $3.00 for each TED record not meeting the standard will be assessed. For example, if only 85% of all TED pass editing in month seven, then a performance guarantee amount equal to 5% of all TED edits submitted during the month will be assessed (5% equals the difference between the contractor’s actual performance and the standard in this example). If 5% equates to 1,000 TED edits, the performance guarantee amount will be $3,000.00 (1,000 x $3.00=$3,000.00).

H.7.9. Performance Guarantee 5—Customer Calls.

H.7.9.1. Standard. Eighty-five percent (85%) of all telephone caller inquiries shall achieve resolution in the first call and a complete and accurate response shall be provided to the caller.

H.7.9.2. Administration. The Government will audit 500-1,000 pre-recorded customer service phone calls per OP.

H.7.9.2.1. Based on audit results, the Government will assess a performance guarantee amount of $250 per call which exceeds the 85% first call resolution standard. For example, if the contractor resolves 750 of 1,000 calls on the first call. Eighty-five percent (85%) of 1,000 is 850; so the contractor may have 150 calls, which are not resolved on the first call. In the example, there were 250 calls, which were not resolved on the on first call, so the Government assesses the performance guarantee against 100 calls (250-150=100). In this case, the Government will assess a performance guarantee amount of $10,000 (100 x $100).

H.7.9.2.2. Based on audit results, the Government will assess a performance guarantee amount of $250 per call which does not provide a complete and accurate response. If the call center provides multiple inaccuracies in the response, an additional performance guarantee amount will not be assessed for each individual inaccuracy. The Government will make the final determination as to the completeness and accuracy of responses.

H.7.9.3. Independent Application of Customer Calls Performance Guarantees. A performance guarantee assessment will be applied independently to the first call resolution and completeness/accuracy of response.

H.7.10. Performance Guarantee 6—Medical Document Translations.

H.7.10.1. Standard. The contractor shall provide complete and accurate rendering of medical documentation (source material) into grammatically correct products using words or expressions ordinarily used in US English.

H.7.10.2.3. Administration. At their discretion MTFs may review translation results utilizing local resources. If a MTF finds that medically important information was translated inaccurately, the document will be forwarded to the appropriate TAO Medical Director for review. The TAO Medical Director will evaluate the contractor’s translation and MTF’s review and determine if the document incorrectly translated medically appropriate/useful information. The Government will assess a performance guarantee amount of $500 per incorrectly translated document that resulted in a Potential Quality Issue (PQI). The TAO Medical Director is final determining authority as to whether or not a document was incorrectly translated.

H.7.11. Performance Guarantee 7—Provider Files.

H.7.11.1. Standard. Providers must be licensed in accordance with the country’s certification/ licensing standards and provider agreements must be signed. All Network providers must meet the medical malpractice insurance standards for their host nation or U.S. commonwealth/territory (if applicable). In locations where medical accreditation programs exist, a minimum of 85% of all applicable institutional network providers will be accredited by an internationally/nationally accepted accreditation program for the host nation.

H.7.11.2. Administration. The Government will audit 800-1,200 random provider files per OP.

H.7.11.2.1. For each provider file which does not meet the standard, a performance guarantee shall be applied. Based on the results of the provider file audit, the Government will assess a performance guarantee amount of $200 per error in the file. If a provider file fails to meet more than one aspect of the standard, an additional performance guarantee amount will be assessed. For example, if a provider file is not signed, does not show evidence of malpractice insurance and does not contain license, the contractor will be assessed $600.00 ($200 per error x 3 errors=$600.00).

H.7.11.2.2. Starting in OP 3, based on audit results, the Government will assess a performance guarantee amount of $250 per provider file which fails to meet the standard mandating 85% of institutional network providers are accredited by an internationally/nationally accepted accreditation program for the host nation. For example, if 500 institutional provider files are reviewed, a minimum of 425 provider files must show evidence of an accreditation program. If 400 provider files show evidence of an accreditation program, the performance guaranteed is accessed against 25 files (425-400=25) for a total of $6,250.00 (25 x $250=$6,250.00).

H.7.11.3. Independent Application of Provider File Guarantees. A performance guarantee assessment will be applied independently to the standard requiring 85% of institutional network providers will be accredited by an internationally/nationally accepted accreditation and file completeness.

H.7.12. Performance Guarantee 8—Aeromedical Evacuations Narratives.

H.7.12.1. Standard. The contractor shall provide a comprehensive written narrative in a format agreed to by the Government describing all medical care that was rendered during the patient movement within 96 hours following the conclusion of the patient movement.

H.7.12.2. Administration. Beginning with OP 2, based on audit results, the Government will assess a performance guarantee amount of $300 per patient narrative which does not fully describe all medical care in the agreed upon format.

H.8. CLAIMS CYCLE TIME MEASUREMENT. The Government will calculate claims cycle time based on data submitted on TED. The cycle time is calculated as one plus the difference between the Julian date of receipt or the Julian date the claim was identified as an adjustment. Only a single cycle time will be calculated per claim. This cycle time will be calculated using all unedited TED initial submission vouchers (voucher resubmission number equals zero) which are received by DHA during each quarter and which pass the voucher header edits. TED in vouchers which fail the voucher header edits or which cannot be processed as submitted by the contractor and TED in resubmission vouchers (voucher resubmission number is greater than zero) will be excluded from the claim cycle time calculation.

H.9. DHA QUARTERLY CLAIMS PROCESSING ACCURACY COMPLIANCE REVIEWS.

H.9.1. TRICARE Encounter Data (TED) batch/voucher payment records are utilized to validate the accuracy of claims payment and/or denial and TED record coding for this compliance review. Results from this review will be used to measure the contractor’s claims processing performance and assess the contractor’s compliance with TRICARE claims processing performance standards as stipulated in the TOM, Chapter 1, Section 3, paragraphs 1.6.1- Claims Payment Errors and 1.6.2 - Claims Occurrence Errors, and to determine contractor compliance with TRICARE policy, regulations and contract requirements.

H.9.2. DHA Quarterly Compliance Review Sampling Methodologies, Required Contractor Documentation, Error Determinations and Error Codes, Rebuttal Procedures, Process and Documentation Error Codes.

H.9.2.1. At the time of the quarterly compliance sample pulls, TED records in batch/vouchers that have not passed TEDS validity edits or which cannot be processed as submitted by the contractor will be excluded from that specific review sample. TED records to be sampled will be net records (i.e. the sum of transaction records available at the time the sample was drawn related to the initial transaction record).

H.9.2.1.1. Payment Accuracy Sampling Methodology: There will be one non-denied payment sample type for this compliance review. Records to be sampled will be net records (i.e., the sum of transaction records available at the time the sample was drawn related to the initial transaction record). Payment samples will be stratified at multiple levels, either by payment amount or by other claims-based parameters, such as type of care and/or type of provider (variables of the stratification will be defined prior to the data pull). Samples will be drawn from all TED records with Government payment amounts greater than zero, although the Government may choose to exclude certain TED record strata from the sampling frame (i.e., TED records with a Government payment amount of less than $100). In addition, the Government will conduct a one-hundred percent (100%) review of all TED records with Government payment amounts meeting or exceeding a high dollar threshold determined by the Government (i.e., $100,000).

H.9.2.1.2. Denied Payment Accuracy Sampling Methodology: The Government shall review denied claims (i.e., TED records with Type of Submission equal to ‘D - denied’, ‘C - cancelled’ or ‘O – 100% other health insurance’) with Government Paid Amount equal to zero, to ensure that healthcare services/supplies are not being denied inappropriately; to validate the correct application of other health insurance (OHI) payments that render a claim with zero government liability and to ensure TED record cancellations are done in accordance with TRICARE policy requirements. The Government will select for review one-hundred percent (100%) of all denied TED records with a Government Billed Amount meeting or exceeding a high dollar threshold determined by the Government (i.e., $100,000). TED records with billed amounts below a low dollar threshold (i.e., $100) may be excluded. TED records with billed amounts between the high dollar and low dollar thresholds will be stratified and randomly selected for review.

H.9.2.1.3. Occurrence Review Sampling Methodology. There will be one sample type for this compliance review. The occurrence sample will be drawn from TED records which passed TEDS validity edits. The sample universe will include TED records for denied and non-denied payment types. For each compliance review cycle the Government will randomly select up to 350 TED records for review.

H.9.2.2. Required Contractor Documentation: On a quarterly basis, the Government will transmit a list of TED records selected from each sample type (i.e. payment, denied payment, and occurrence) to be reviewed by the Government’s designated compliance review contractor. Upon receipt of the TED record Internal Control Number (ICN) listing from the DHA, the contractor shall retrieve and compile claims processing documentation for each selected TED record. All documentation must be received at DHA or the designated compliance review contractor within 45 calendar days from the date of the DHA letter transmitting the ICN listing. The contractor shall submit one legible copy of each healthcare claim form (i.e., CMS 1500, UB 92/04, etc.) associated with the selected TED record and the following required documents. Required documentation includes, but is not limited to, the following:

a) Claim-related correspondence when attached to claim or related to the adjudication action, such as status inquiries, written and/or telephone, development records, and other telephone conversation records.

b) Other claim-related documentation, such as medical reports and medical review records, coding sheets, all authorization and referral forms and their supporting documentation, referrals for civilian medical care (e.g. SF Forms 513 or 2161), other health insurance and third party liability documents, discounted rate agreements to include the following information:

1) Provider name and identification number; and

2) Effective and termination dates of agreements.

c) Negotiated rate(s), per diem rate(s), state prevailing fee(s) or fee schedule(s), Diagnosis Related Group (DRG), Hospital Outpatient Prospective Payment System (OPPS), Skilled Nursing Facility (SNF), pricing information and such other documents as are required to support the reimbursement action(s) taken on the claim.

d) Copy of the Explanation of Benefits (EOB) (or EOB facsimile) for each claim selected.

e) Documentation to support DHA or contractor approved beneficiary participation in any DHA demonstration program.

f) Any additional documentation (i.e. DHA directives or unique instructions) that supports the adjudication of selected claim.

Documentation shall be electronically transmitted in the agreed upon file format as stipulated in the Memorandum of Understanding (MOU) established between the contractor and the designated compliance review contractor (CDRL A160).

H.9.2.2.1. In addition to the above listed claims processing documentation, the contractor shall also send, via electronic data input, the current patient/family history (15 to 27 months) for each selected TED record/claim as identified in the DHA ICN transmittal letter. This electronic data file shall be formatted and transmitted in accordance with the guidelines described in the MOU established between the Contactor and the designated compliance review contractor (CDRL A160) and shall contain all agreed to and required data fields. The data file must be received by the DHA or the designated compliance review contractor within 45 calendar days from the date of the DHA ICN transmittal letter.

H.9.2.2.2. Additional Data to be Furnished by the Contractor—Claims Processing Guidelines and Instructions.

a) Description of data element by field position in the patient/family history file printouts and field definitions for pricing, Other Health Insurance (OHI), authorization and/or referral screens, etc.).

b) Claims adjudication guidelines used by processors; field…