J-14 Transition-Out and Residual Services v2.docx

Attachment J-14 Transition-Out and Residual Services

1.0 CONTRACT TRANSITION-OUT and RESIDUAL SERVICES.

1.1. In accordance with Section C.5.3.2 the contractor shall perform the transition-out tasks below. The contract transition-out and residual services requirements listed below are for this contract at its conclusion. The term “transition-out” is the last option period in which the contractor is still providing dental care, but is transferring data to DHA or its designee (for example another contractor) (see Contract Line Item Number [CLIN] X006). Residual services are provided by the contractor for 12 months after the transition-out period, in which the contractor is no longer providing dental care, but the contractor continues to process claims, appeals, grievances, and provide customer service for dental care that was delivered in the previous option period (see CLINs 8001 through 8007).

1.2. If the current contractor is not the successful offeror for the follow-on contract, the contractor shall work to achieve a smooth and efficient transition of activities to the DHA or its designee and to facilitate minimal disruption of services to enrollees and providers. The services required by the Transition-Out CLIN and Residual Services Phase-Out CLIN will only be exercised in the event of a transition. Therefore, the Government will only exercise the CLIN once if and when a transition occurs. If the contractor succeeds itself in the follow-on contract, transition-out costs and residual services costs will not apply, nor will any payment be made on CLINs X006 and 8001 through 8007.

1.3. Transition-Out and Residual Services Plan. The outgoing contractor shall provide to Defense Health Agency (DHA) a proposed Transition-Out and Residual Services Plan within 15 days following award of a successor contract (See Section J, Exhibit B Contract Data Requirements List (CDRL) R040, Transition-Out and Residual Services Plan). This plan shall include a timeline of major events and provide names of key individuals responsible for each of the functional areas involved in the transition-out and processing of residual services inventories (e.g., claims, appeals, grievances, data transfers), staffing and other resources, and activities under this contract, e.g., claims processing, appeals, grievances, support services, finance.

1.4. Transition Specifications Meeting. The outgoing contractor shall attend a 2-4 day meeting with DHA and the incoming contractor within 30 days of the transition start date of the successor contract. Contractor representatives attending this meeting shall have the experience, expertise, and authority to provide approvals and establish project commitments on behalf of their organization. The purpose of this meeting is to finalize the schedule of events associated with the transfer of responsibilities and the incoming contractor’s receipt of files from the Government and outgoing contractor. The meeting will also cover the transition-out and residual services activities and workload from the outgoing contractor. The Contracting Officer Representative (COR) will notify all parties of the meeting dates. The outgoing contractor will incorporate the applicable specifications of the final transition schedule into its Transition-Out and Residual Services Plan and submit the revised plan within 15 days or as agreed to by DHA (See Section J, Exhibit B CDRL R040, Transition-Out and Residual Services Plan). The transition revisions will be incorporated into Transition-Out and Residual Services Plan at no cost.

1.5. Travel Costs. All transition related contractor travel costs shall be at the expense of the contractor.

1.6. Outgoing Contractor Monthly Status Reporting. Until all inventories (e.g., claims, appeals, grievances, data transfers) have been processed, the outgoing contractor shall submit a monthly status report of inventories, and transition-out and residual services activities to DHA beginning 45 days after the end of the contract period through the transfer of records to DHA, unless otherwise notified by the Contracting Officer (CO) to discontinue (See Section J, Exhibit B, CDRL M060, Transition-Out and Residual Services Status Report). This shall be done in accordance with specifications of the final transition schedule.

1.7. Transfer of Information. The outgoing contractor shall provide to the incoming contractor such information as DHA determines is required in which to facilitate transition from the outgoing contractor’s operations to operations under the incoming contract. Such information may include, but is not limited to, the following: orthodontic claims processing history, active cases, active authorizations and referrals, fraud cases, and information about the management of the outgoing contract that is not considered under applicable Federal Law, to be proprietary to the contractor. The outgoing contractor shall provide samples and descriptions of applicable files at the Transition Specifications Meeting and, subsequently, any documentation (e.g., record layouts with specifications, formats, definitions of fields and data elements, access keys, etc.) necessary for read capability and conversion of any electronic files that may be transferred as determined at that meeting. In addition, the table below is provided as a guideline and is not all inclusive or absolute. It may be revised by mutual agreement of the involved parties at the Transition Specifications Meeting.

Transition-Out Information Files Transfers

File/ Information Type

Receipt Date General Description

1.8. Transfer of Automated Data Processing (ADP) Files (Electronic). The outgoing contractor shall prepare all specified ADP files in non-proprietary electronic format and transfer to the incoming contractor in accordance with the schedule set at the Transition Specification Meeting unless otherwise negotiated by the incoming and outgoing contractors, and DHA. The contractor shall include non-proprietary file specifications and documentation as may be necessary for interpretation of these files. The outgoing contractor shall continue to participate in preparation and testing of these files until they are fully readable by the incoming contractor or DHA.

1.9. CONUS and OCONUS Remote Active Duty Service Member (ADSM) Enrollment. The outgoing contractor shall be responsible for entering remote ADSM enrollments into DEERS up to the start of dental care delivery on the new contract. The incoming contractor will start entering remote enrollments into DEERS as of the start of dental care delivery.

1.10. Ongoing Transfer of Orthodontic Claims History Updates. The outgoing contractor shall transfer to the incoming contractor, in a mutually agreed format all processed and ongoing orthodontic claims history in accordance with the specifications in the final transition schedule. The transfer shall occur at least weekly, or in accordance with the specifications in the final transition schedule, until such time that all claim-related processing is completed by the outgoing contractor.

1.11. Claims Processing Dual Operations. During the period in which both the incoming contractor and the outgoing contractor are processing claims (365 days after the start of dental care delivery under this contract which is referred to the Residual Services Phase-Out period for the outgoing contractor), the outgoing contractor shall transfer to the incoming contractor the processed orthodontic claims files following each processing cycle or according to a schedule determined during the Transition Specifications Meeting. The incoming contractor will utilize the processed orthodontic claim history files received from the outgoing contractor for orthodontic claim adjudication beginning with the first claims processing cycle.

1.12. Residual Processing. The filing deadline for residual claims is one year from the date of service for Continental United States (CONUS) claims and three years from date of service for Outside Continental United States (OCONUS) claims (See 10 U.S.C. 55 Section 1106). It is the outgoing contractor’s responsibility to inform their network providers and the TOPDs of the final date that claims will be accepted in order to be paid. The outgoing contractor shall process all residual claims with dates of service prior to the start of dental care delivery of the succeeding contract and received up to 365 days after the date of service. The outgoing contractor shall also complete the processing of written and telephonic inquiries, appeals and grievances (that are timely filed), and adjustments related to timely filed claims for dental care provided prior to the start of dental care delivery of the succeeding contract, until they are fully completed, even if it is past the 365 days after the start of dental care delivery. For example: A claim is filed 364 days after care and denied 5 days later. The ADSM appeals within the contractual time limits and the claim is adjusted 30 days later.

1.13. Transitional Cases. In notifying beneficiaries of the transition to another contractor, both the incoming and outgoing contractors shall include instructions on how the ADSM may obtain assistance with transitional care. The instructions must include at a minimum the date and amount the care is paid up to and the incoming contractor’s contact information. If the outgoing contractor succeeds itself, costs related to each contract will be kept separate for purposes of contract accountability.

1.14. Authorizations and Referrals. The incoming contractor will honor authorizations and referrals from the outgoing contractor.

1.15. Telephones. The outgoing contractor shall maintain toll-free lines and web-based customer service capabilities, accessible to the public through the 12 months for processing residual services (365 days following the expiration of the transition-out period for the last exercised option period) in order to properly respond to inquiries related to claims processed for services incurred during the period of their respective liability. Customer services shall be offered Monday through Friday, 8 hours per day. Inquiry lines will continue to be staffed in order to provide adequate customer service. The outgoing contractor shall maintain their IVR for the residual services period and it will include information on how to contact the incoming contractor.

1.16. Correspondence. The outgoing contractor shall include a message in their Dental Explanation of Benefits (DEOBs) for the final 90 days of the last option period indicating that the contract is transitioning to the new contractor. The statement shall include the new contractor’s name, contact information and the date that dental care delivery starts under the new contractor. The outgoing contractor shall include its contact information with all correspondence related to care delivered by its contract. For claims, appeals, grievances, and adjustments that continue past the residual services period (See paragraph 1.12), the outgoing contractor shall provide the correspondent with the outgoing contractor’s contact information so that inquiries can still be made in regards to that particular service.

1.16. Final Processing Of Outgoing Contractor. The outgoing contractor shall complete processing of all claims that were timely filed, adjustments, written correspondence, telephone inquiries, appeals, and grievances related to services under this contract within the contractually established standards until all have been fully resolved.

1.16.1. Business to Business (B2B) Gateway. The outgoing contractor shall maintain its B2B access or authorized Government access point for a minimum of 180 days after the end of the Residual Services Phase-Out period for submission of Military Health System (MHS) Data Repository (MDR) and report transactions.

1.17. Cost Accounting. If the outgoing contractor succeeds itself, costs related to each contract shall be kept separate for purposes of contract accountability.

1.18. Program Integrity Files. No later than 30 days prior to the start of dental care delivery under the new contract, the outgoing contractor shall provide the incoming contractor with all active Program Integrity case files that have been forwarded to DHA Program Integrity Office (PI). These cases may be provided in hardcopy format. The outgoing contractor shall also provide weekly updates of Program Integrity case file, including new cases initiated through the end of the contract delivery period.

1.19. Records Disposition. The outgoing contractor shall comply with the provisions of TRICARE Operations Manual (TOM) Chapter 9 in final disposition of all files and documentation. TOM, Chapter 9, Section 5, paragraph 3.0 titled “Transfer to Other Contractors/Records Center” reference to TOM Chapter 2, Section 10, paragraph 4.0 does not apply. It does not apply because the dental contractor is responsible for all claims, appeals and correspondence that took place during its period of performance. The outgoing contractor does not transfer all records as stated in TOM Chapter 2, Section 10 paragraph 4.0. The outgoing contractor shall follow TOM, Chapter 9, Section 4, paragraphs 3.0-3.6 titled “Transfer of DHA Electronic Records” and coordinate disposition of any records with the DHA Records Management Officer. The contractor shall include a records disposition plan as part of their Transition-Out/ Residual Services Phase-Out Plan.

1.19.1. Survival. The obligations under TOM Chapter 9, Section 5, paragraph 3.0 – 3.6 will survive the expiration of this contract until such time as the records are properly transferred to DHA and disposed of in accordance with the terms of this agreement.

1.20. Subcontractor Services. The contractor shall be liable, after the termination of services under this contract, for any payments to subcontractors of the contractor arising from events that took place during the period of this contract.