J-18 Draft ADDP QASP.docx

Active Duty Dental Program (ADDP) Quality Assurance Surveillance Plan (QASP)

September 23, 2019

Quality Assurance Surveillance Plan (QASP)

Active Duty Dental Program (ADDP) contract 1 Vision

To ensure the timely delivery of quality dental care services to eligible TRICARE beneficiaries in the most cost-effective way for the Government.

2 Mission The Department of Defense (DoD) through the Defense Health Agency (DHA) has a mission to offer dental care services to eligible TRICARE beneficiaries. In order to fulfill DHAs mission, the contractor shall provide comprehensive dental care services worldwide to eligible TRICARE beneficiaries under the ADDP contract.

3 Purpose This Quality Assurance Surveillance Plan (QASP) is a Government-developed document used to determine if the contractor's performance meets the performance standards contained in the contract. The QASP establishes procedures on how this assessment/inspection process will be conducted. It provides the detailed process for a continuous oversight process:

· What will be monitored

· How monitoring will take place

· Who will conduct the monitoring

· How monitoring efforts and results will be documented The contractor is responsible for implementing and delivering performance that meets contract standards using its Quality Control Plan. The QASP provides the structure for the Government's surveillance of the contractor's performance to assure that it meets contract standards. It is the Government's responsibility to be objective, fair and consistent in evaluating contractor performance.

The QASP is not part of the contract nor is it intended to duplicate the contractor's quality control plan. This QASP is a living document. Flexibility in the QASP is required to allow for an increase or decrease in the level of surveillance necessary based on contractor performance.

The Government may provide a copy of the QASP to the contractor to facilitate open communication. In addition, the QASP should recognize that unforeseen or uncontrollable circumstances might occur that are outside the control of the contractor.

Bottom line, the QASP should ensure early identification and resolution of performance issues to minimize impact on mission performance.

4 Authority Authority for issuance of this QASP is provided under Part 46 of the Federal Acquisition Regulation, Inspection of Services clauses, which provide for inspection, acceptance and documentation of the service called for in the contract or order. This acceptance is to be executed by the contracting officer or a duly authorized representative.

5 Roles and Responsibilities The following personnel shall oversee and coordinate surveillance activities.

5.1 Program / Project Manager

The PM provides primary program oversight, nominates the COR, ensures the COR is trained before performing any COR duties and supports the COR's performance assessment activities. While the PM may serve as a direct conduit to provide Government guidance and feedback to the contractor on technical matters, they are not empowered to make any contractual commitments or any contract changes on the Government's behalf.

Assigned PM: COL Christensen S. Hsu Organization or Agency: Defense Health Agency Telephone: (703) 681-8862 Email: christensen.hsu2.mil@mail.mil

5.2 Contracting Office (CO)

The CO shall ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and shall safeguard the interests of the United States in the contractual relationship. The CO shall also ensure that the contractor receives impartial, fair, and equitable treatment under this contract. Determine and document the final assessment of the contractor's performance in the Government’s past performance tracking system.

Assigned CO: Ms. Margaret A. Zancanella Organization or Agency: Defense Health Agency Telephone: (303) 676-3451 Email: margaret.a.zancanella.civ@mail.mil

5.3 Contracting Officer's Representative (COR)

The COR is responsible for providing continuous technical oversight of the contractor's performance. The COR uses the QASP to conduct the oversight and surveillance processes.

COR: Doug Elsesser Telephone: (303)-676-3679 Email: douglas.n.elsesser.civ@mail.mil

5.4 Contractor Representatives

The following employees of the contractor serve as the contractor's Program Manager and Task Manager for this contract. (Complete this section after the contract award)

Program Manager – Title:

Telephone:

Email:

Task Manager - Title:

Telephone:

Email:

6 Performance Requirements and Method of Surveillance The methods of evaluating contractor compliance may vary depending on the tasks specified by the contract. The COR is responsible for selection of the method(s) to be used and the specific detailing of the method(s). In determining the evaluation method, the COR should consider what the contract specifically calls for, how performance can be observed, and if the method of surveillance is adequate to assure the required level of performance has been achieved. In making this determination, the COR will also consider the contractor’s Quality Control Plan.

6.1 Contract Surveillance

This section describes the available methods to be used in verifying the contractor’s compliance with the contract requirements. Periodic (scheduled or non-scheduled) performance assessments will be accomplished utilizing a combination of assessment methods and metrics as identified in Appendix 1 that contains performance objectives, performance indicators, and frequencies and monitoring methods extracted from sections of the contract. Listed below are some methods to be used:

· Contractor Self Reporting. The Government will use the contractor’s reports as part of its surveillance process for monitoring the performance of the contract requirements. The Government has specified the content, format and/or frequency of reports to be generated by the contractor as stated in Section J, Exhibit B of the contract.

· Customer Input. The COR may receive customer (e.g., beneficiaries, internal Government staff) input about the quality of services performed under the contract. These inputs maximize the Government’s resource potential and are considered in regular assessments as they may identify contractor process improvement opportunities or required corrective actions. The COR will validate any input before corrective action is required by the contractor.

· Periodic Performance Reviews. Performance reviews are an effective tool for keeping performance on course, measuring performance levels, and making adjustments as necessary. More frequent opportunities than the required contract briefings with the contractor are essential in maintaining focus on critical program areas and may occur as deemed necessary.

· The COR will identify the specific review items to the contractor in writing. The contractor will provide the COR with written documentation of their internal processes of the specified review items. The COR will review this documentation and perform an onsite review if deemed necessary. The COR may be accompanied on the site visit by other Government employees when warranted.

The COR will review contractor deliverables and other submittals (reports or plans) or any other information available and document evaluations in the Performance Assessment Tool (PAT) in accordance with DHA established policies. The PAT system has been developed to provide standardized assessment and documentation of contractor performance throughout the Military Health System. As the system of record for all TRICARE contracts, candid and fact based assessment of contractor performance will be documented in PAT throughout the year.

6.2 Surveillance Matrix

The Surveillance Matrix (Appendix 1) is the list of performance objectives and standards that must be performed by the contractor. This matrix details the method of surveillance the COR will use to validate and inspect these performance elements. Inspection of each element will be documented in the COR file.

Performance objectives define the desired outcomes. Performance Standards define the level of service required under the contract to successfully meet the performance objective. The inspection methodology defines how, when, and what will be assessed in measuring performance. The Government performs surveillance, using this QASP, to determine the quality of the contractor's performance as it relates to the performance element standards.

In evaluating the quality of contractor’s performance, the following performance ratings may be used.

Performance Rating Criteria

Appendix 1 - Surveillance Matrix

C.4.1. The contractor shall provide worldwide dental care services for ADSMs.

C.4.1.1. The contractor shall comply with the most current version of American Dental Association's (ADA) Current Dental Terminology (CDT) manual for covered services and update its systems.

a) Standard: Whenever the ADA issues an updated CDT manual, the contractor shall identify CDT codes to be added, deleted and/or revised for Section J, Attachment J-2, Benefits, Exclusions and Limitations. The contractor shall provide the DHA Dental Program Section with its recommended changes for approval. The ADA updates CDT codes approximately once a year and the revisions are effective January 1 of the following year (see Section H.1, Current Dental Terminology).

AQL: The contractor shall submit its CDT recommendation within 30 calendar days of the release of the ADA’s updated CDT manual.

b) Standard: The contractor shall update its systems to reflect the DHA Dental Program Section’s approved CDT code changes no later than January 1 of the following year.

AQL: System updates shall be completed no later than January 1 100% of the time.

What: Annual CDT code updates.

How: Review contractor’s recommended annual CDT code updates. Approve updates as directed by the DHA Dental Program Manager Who: ADDP COR and DHA Dental Program Manager Standards: a and b

C.4.1.2. The contractor shall process remote ADSMs’ enrollments.

Deliverables:

M010 Management Report

a) Standard: The contractor shall process remote ADSMs’ enrollment actions in accordance with TRICARE Systems Manual (TSM), Chapter 3; and Section J, Attachment J-3a, Program Operations.

AQL: 99% of remote ADSM enrollment actions shall be accurate and complete.

What: M010 Management Report How: Monthly and quarterly review of applicable reports.

Periodic review of source data.

Who: ADDP COR Standard: a

C.4.1.3. The contractor shall provide and maintain access to general and specialty network providers for ADSMs.

The network provider’s practice shall be in a fixed structure in order to contribute to determining network compliance. “Driving miles” do not include alternative means of transportation (e.g. ferries, trains, or planes) in order for the ADSM to access the provider’s office.

· “Rural” is defined as less than 1,000 residents per square mile.

· “Suburban” is defined as 1,000 to 3,000 residents per square mile.

· “Urban” is defined as more than 3,000 residents per square mile (See Section H.5.1, Network Provider Retention incentive; and Section J, Attachments J-3a, Program Operations, for provider requirements).

Deliverables:

M030 Provider Network Access Report

a) Standard: The contractor shall establish networks for general dental care in the 50 United States, the District of Columbia, U.S. Virgin Islands, Guam, Puerto Rico, American Samoa, and the Northern Mariana Islands.

AQL: (1) For Rural: 97% of ADSMs shall have access to two general dentists within 21 calendar days of requesting a periodic or initial (non-emergency) appointment and within 35 driving miles of ADSM DTF referred care and place of residence for remote ADSMs.

AQL: (2) For Suburban: 97% of ADSMs shall have access to two general dentists within 21 calendar days of requesting a periodic or initial (non-emergency) appointment and within 15 driving miles ADSM DTF referred care and place of residence for remote ADSMs.

AQL: (3) For Urban: 97% of ADSMs shall have access to one general dentist within 21 calendar days of requesting a periodic or initial (non-emergency) appointment and within 5 driving miles of ADSM DTF referred care and place of residence for remote ADSMs.

b) Standard: The contractor shall establish networks for specialty dental care in the 50 United States, the District of Columbia, U.S. Virgin Islands, Guam, Puerto Rico, American Samoa, and the Northern Mariana Islands.

AQL: (1) 90% of ADSMs shall have access to an orthodontist within 28 calendar days of requesting an appointment and within 35 driving miles of ADSM DTF referred care and place of residence for remote ADSMs.

AQL: (2) 95% of ADSMs shall have access to an oral surgeon within 28 calendar days of requesting an appointment and within 35 driving miles of ADSM DTF referred care and place of residence for remote ADSMs.

AQL: (4) 85% of ADSMs shall have access to an endodontist within 28 calendar days of requesting an appointment and within 35 driving miles of ADSM DTF referred care and place of residence for remote ADSMs.

AQL: (5) 85% of ADSMs shall have access to a periodontist within 28 calendar days of requesting an appointment and within 35 driving miles of ADSM DTF referred care and place of residence for remote ADSMs.

AQL: (6) 80% of ADSMs shall have access to a prosthodontist within 28 calendar days of requesting an appointment and within 35 driving miles of ADSM DTF referred care and place of residence for remote ADSMs.

c) Standard: The contractor shall maintain a network provider retention rate in accordance with Section J, Exhibit B, Contract Data Requirements List (CDRL) M030, Provider Network Access Report. For Option Period 1 the COR shall validate the baseline 6 months after start of dental care delivery. The baseline shall be reset at the beginning of each Option Period, and the COR shall re-validate at the end of the Option Period.

AQL: 95% of network providers shall be retained annually.

What: M030 Provider Network Access Report How: Monthly review of applicable report.

Periodic review of source data.

Standards: a, b and c

C.4.1.4. The contractor shall develop, maintain and make available to ADSMs, providers and Government representatives an up-to-date directory of network providers.

a) Standard: The contractor shall post the updated directory on the contractor’s website in accordance with Section J, Attachment J-3a, Program Operations.

AQL: 100% updated within 5 business days of receipt of the updated information.

What: Directory of network providers How: Periodic review of source data when contractor requests review of non-compliant areas so that the areas may be deemed compliant (i.e., network provider available)

C.4.1.5. The contractor shall develop and maintain agreements with TRICARE OCONUS Preferred Dentists (TOPDs).

W010 Transition-In Status Report M010 Management Report R010 MOU with TRICARE Overseas Program (TOP) Contractor

a) Standard: The contractor shall complete agreements with existing providers identified by the Government and for any new providers identified each option period in accordance with Section J, Attachments J-3b, Program Operations for OCONUS; and J-13, Transition-In.

AQL: The contractor shall complete agreements with 95% of those existing providers identified by the DHA COR prior to Option Period 1 and any new providers identified each option period.

b) Standard: The contractor shall make available to beneficiaries, TOPDs and Government representatives an up-to-date list of TOPDs in accordance with Section J, Attachment J-3b, Program Operations for OCONUS.

AQL: 100% updated within 5 business days of receipt of the updated information.

What: W010 Transition-In Status Report M010 Management Report How: Weekly and monthly review of applicable reports.

Periodic review of source data.

C.4.1.6. The contractor shall process referrals, appointments and authorizations for ADSMs.

M010 Management Report

a) Standard: The contractor shall schedule appointments as requested in accordance with Section J, Attachment J-3a, Program Operations.

AQL: 90% of appointments shall be scheduled within 5 business of the request.

b) Standard: The contractor shall complete authorization requests in accordance with Section J, Attachment J-3a, Program Operations.

AQL: (1) 95% of authorization requests shall be electronically sent to the Dental Service Point of Contact (DSPOC) within 5 business days of receipt of a complete authorization request (to include required documentation).

AQL: (2) 100% of authorization requests shall be electronically sent to the DSPOC within 7 business days of receipt of a complete authorization request (to include required documentation).

AQL: (3) 95% of authorization requests shall be completed within 5 business days of receiving all required information from the DSPOC.

AQL: (4) 100% of authorization requests shall be completed within 7 business days of receiving all required information from the DSPOC.

What: M010 Management Report How: Monthly review of applicable reports.

Periodic review of source data.

Who: ADDP COR and DHA Dental Program Manager

C.4.1.7. The contractor shall process claims to completion for ADSMs and providers.

“Process to completion” is defined in the TOM, Appendix A.

Deliverables:

M010 Management Report M020 Market Basket Comparison/CDT Summary Report M080 OCONUS Payment Report A010 Market Basket Comparison/CDT Summary Report A070 MOU with TRICARE Claims Review Services (TCRS) Contractor

a) Standard: Process claims to completion.

AQL: (1) CONUS Claims 95% within 14 calendar days of receipt.

98% within 30 calendar days of receipt.

100% within 60 calendar days of receipt.

AQL: (2) OCONUS Claims 95% within 21 calendar days of receipt.

98% within 45 calendar days of receipt.

100% within 60 calendar days of receipt.

b) Standard: Claims shall be accurately paid in accordance with the covered benefit. CONUS and OCONUS claims shall be separately tracked.

AQL: 98% are accurately paid on initial submission of the claim.

c) Standard: Claim errors shall be corrected. CONUS and OCONUS claims shall be separately tracked.

AQL: 99% are corrected within 10 calendar days after contractor identifies the error.

What: M010 Management Report M020 Market Basket Comparison/CDT Summary Report M080 OCONUS Payment Report A010 Market Basket Comparison/CDT Summary Report How: Monthly and annual review of applicable reports. Annual onsite visit.

Periodic review of source data.

C.4.1.8. The contractor shall process all appeals to completion.

M010 Management Report

a) Standard: The contractor shall process provider, ADSM and remote ADSM appeals in accordance with Section J, Attachment J-3a, Program Operations.

AQL: (1) 100% of completed appeal packages shall be forwarded to the DSPOC within 7 calendar days of receipt.

AQL: (2) The appealing party will be notified of the decision within 14 calendar days after receipt 100% or the time.

What: M010 Management Report How: Monthly review of applicable reports.

Standards: a

C.4.1.9. The contractor shall process all grievances to completion in accordance with Section J, Attachment J-3a, Program Operations.

M010 Management Report

a) Standard: The contractor shall process provider, ADSM and remote ADSM grievances to completion in accordance with Section J, Attachment J-3a, Program Operations.

AQL: 95% within 60 calendar days of receipt.

99.9% within 90 calendar days of receipt.

What: M010 Management Report How: Monthly review of applicable reports.

Standards: a

C.4.1.10. The contractor shall provide readily accessible comprehensive customer service for beneficiaries and providers.

M010 Management Report

a) Standard: The contractor shall provide customer service in accordance with Section J, Attachment J-3a, Program Operations.

AQL: (1) 98% of telephone calls answered by Automated Response Unit within 30 seconds.

AQL: (2) 80% of telephone calls answered by Customer Service Representative (CSR) - within 30 seconds of selection by caller.

AQL: (3) 5% or less telephone calls blocked at all times (measured at least hourly).

AQL: (4) 80% of telephone call –resolved during the initial call; 99.9% within 7 business days.

AQL: (5) Priority Written and E-mail Correspondence (final response). Priority correspondence is that which is received from Members of Congress, DoD leadership and DHA leadership.

AQL: (6) Non-priority (routine) Written and E-mail Correspondence (final response).

What: M010 Management Report How: Monthly and annual review of applicable reports, the DHA Quarterly Satisfaction Survey, and the contractor’s Network Provider Satisfaction Survey. Annual onsite visit.

C.4.2 The contractor shall promote utilization of diagnostic and preventive services.

C.4.2.1. The contractor shall inform and educate ADSMs, providers, and Military Dental Treatment Facilities (DTF) staff about the program benefits with emphasis to the ADSMs about the benefit of utilizing diagnostic and preventive services.

AP010 ADSM, Provider, and DTF Education Plan R120 MOU with DHA Communications

a) Standard: The contractor shall comply with its education plan in accordance with Section J, Attachment J-3a, Program Operations. The contractor shall allow 30 calendar days for the DHA Dental Program Section to approve/deny any changes to the contractor’s education plan. Timing of the publication and/or implementation shall be mutually agreed upon between the contractor and DHA Dental Program Section.

AQL: 99% of planned education activities shall be completed within the option period.

What: AP010 ADSM, Provider, and DTF Education Plan How: Review annual education plan.

Periodic review of education plan actions.

Standard(s): a

C.4.3. The contractor shall provide data systems to coordinate care between the Dental Program Section, Military DTF ADSM referred care, remote ADSM dental care authorizations, and the means in which to monitor dental health plan data and outcome measures for all dental care rendered.

C.4.3.1. The contractor shall provide training for the users on the data systems stated in Section J, Attachment J-3c, Program Operations for Data Interfaces.

M010 Management Report

a) Standard: The contractor shall train (initial and refresher) and provide secure means for the users to access the systems for viewing and/or utilization. The contractor may provide the training on-site or electronically.

AQL: (1) Initial system training conducted during the Transition-In period shall be completed no later than 30 calendar days prior to Option Period 1.

AQL: (2) After start of Option Period 1, new users shall receive initial training no later than 30 calendar days after identification is made to the contractor.

AQL: (3) Refresher training shall be provided quarterly.

What: M010 Management Report How: Monthly review of applicable reports.

C.4.3.2. The contractor shall provide Government designated users with read-only access to the contractor’s full ADDP data set.

M010 Management Report

a) Standard: The user shall have the ability to download any of the data elements for manipulation purposes in accordance with Section J, Attachment J-3c, Program Operations for Data Interfaces.

AQL: The system shall be available 99% of the time 24 hours, 7 days a week (excluding downtime for scheduled maintenance).

What: M010 Management Report How: Monthly review of applicable reports.

C.4.3.3. The contractor shall provide Government designated users with read-only access to an ADDP dashboard.

M010 Management Report

a) Standard: The ADDP data shall be provided in a consolidated manner in which the user shall have the ability to easily view dental health plan data and the outcome measurements without having to manipulate the data in order to retrieve the information in accordance with Section J, Attachment J-3c, Program Operations for Data Interfaces.

AQL: The system shall be available 99% of the time 24 hours, 7 days a week (excluding downtime for scheduled maintenance).

What: M010 Management Report How: Monthly review of applicable reports and dental health plan data.

Periodic review of source data.

C.4.3.4. The contractor shall establish an electronic means to track and transmit ADSM referrals and authorizations.

M010 Management Report

a) Standard: The system will be Health Insurance Portability and Accountability Act (HIPAA) and Public Key Infrastructure (PKI) compliant, which shall allow the user the ability to search, process, and transmit referrals and authorizations in accordance with Section J, Attachment J-3c, Program Operations for Data Interfaces.

AQL: The system shall be available 99% of the time 24 hours, 7 days a week (excluding downtime for scheduled maintenance).

What: M010 Management Report How: Monthly review of applicable reports.

Periodic review of source data.

C.4.3.5. The contractor’s system shall interface with the Military Health Services (MHS) Genesis/Defense Health Medical Systems Modernization (DHMSM) Electronic Health Record System (EHRS).

DHA will implement the MHS Genesis/DHMSM EHRS at a later date (See Section J, Attachment J-3c, Program Operations for Data Interfaces).

Deliverables:

M010 Management Report R180 MHS Genesis Interface Plan

a) Standard: The contractor’s interface shall include technical methodologies and capabilities to support referral management industry standards and dental record sharing in accordance with Section J, Attachment J-3c, Program Operations for Data Interfaces.

AQL: The system shall be available 99% of the time 24 hours, 7 days a week (excluding downtime for scheduled maintenance).

b) Standard: The contractor shall upload the ADSMs’ dental care record in accordance with Section J, Attachment J-3c, Program Operations for Data Interfaces.

AQL: 95% within 14 calendar days of receipt of dental care documents.

100% within 30 calendar days of receipt of dental care documents.

What: M010 Management Report R180 MHS Genesis Interface Plan How: Monthly review of applicable report and the MHS Genesis Interface Plan actions.

Periodic review of source data.

Standard: a and b

C.4.3.6. The contractor shall correct any data submission mistakes identified by the Government or the contractor.

M010 Management Report

a) Standard: If the Government or the contractor identify data submission mistakes (e.g., the manner in which the data is submitted leads to incorrect data reporting), the contractor shall correct the mistakes.

AQL: 99% within 30 calendar days of identification.

100% within 60 calendar days of identification.

What: M010 Management Report How: Monthly review of applicable report.

Periodic review of source data.

Appendix 2 - Corrective Action Report (CAR)

CORRECTIVE ACTION REPORT (CAR)

(If more space is needed, use reverse and identify by number)

1. CONTRACTOR

2. CONTRACT NUMBER

3. TYPE OF SERVICES

4. FUNCTIONAL AREA

5. SUSPENSE DATE

6. CONTROL NUMBER

7. DEFICIENCY |_| MAJOR |_| MINOR

FINDING:

FINDING IMPACT:

Please respond with a written corrective action plan that details the corrective action of the cited deficiency, the cause of the deficiency, and actions taken to prevent recurrence by Suspense Date in Block 5. If date was not entered in Block 5, the contractor is not required to provide a response.

8. QUALITY ASSURANCE PERSONNEL (COR)

TYPED NAME AND GRADE

SIGNATURE AND DATE

9. ISSUING AUTHORITY

TYPED NAME AND GRADE

SIGNATURE AND DATE

10. COR RESPONSE TO CONTRACTOR CORRECTIVE ACTION AND ACTION TAKEN TO PREVENT RECURRENCE

11. COR DETERMINATION

|_| ACCEPTED |_| REJECTED

12. CLOSE DATE

Appendix 3 - Customer Complaint Record

CUSTOMER COMPLAINT RECORD

DATE/TIME OF COMPLAINT

SOURCE OF COMPLAINT

ORGANIZATION

BUILDING NUMBER

INDIVIDUAL

PHONE NUMBER

NATURE OF COMPLAINT

CONTRACT REFERENCE

VALIDATION

DATE/TIME CONTRACTOR INFORMED OF COMPLAINT

ACTION TAKEN BY CONTRACTOR

RECEIVED/VALIDATED BY

Appendix 4 - Performance Assessment Report (PAR)

PERFORMANCE ASSESSMENT REPORT (PAR)

(If more space is needed, use reverse and identify by number)

4. QUALITY ASSURANCE PERSONNEL (COR) SIGNATURE AND DATE

I. PERFORMANCE

7. |_| DEFICIENCY (CHECK ALL BOXES THAT APPLY)

|_| NEW

|_| REPEAT

|_| NO DEFICIENCY NOTED

8. SERVICES SUMMARY or PWS PARAGRAPH ITEM REVIEWED

II. CONTRACTOR VALIDATION

11. CONTRACTOR REPRESENTATIVE |_| CONCUR |_| NON-CONCUR

12. CORRECTIVE ACTION ESTIMATED COMPLETION DATE

13. CONTRACTOR REPRESENTATIVE CORRECTIVE ACTION AND PREVENTION OF RECURRENCE OR REASON FOR NON-CONCURRENCE OF COR CITED DEFICIENCY

III. ACTION CORRECTED

14. |_| CONCUR |_| NON-CONCUR COR SIGNATURE AND DATE

15. COR REMARKS (REQUIRED)

6. CONTRACTOR REPRESENTATIVE REMARKS