J-3c Program Ops Data v2.docx

Attachment J-3c Program Operations for Data Systems

1.0. DATA SYSTEMS ACCESS AND TRAINING

1.1. The contractor shall provide access to the full Active Duty Dental Program (ADDP) data set and the ADDP dashboard (stated below) for the Defense Health Agency (DHA) Dental Program Section, Contracting Officer, Contract Specialist, Contracting Officer’s Representative, and the Tri-Service Center for Oral Health Studies (TSCOHS), for a total of 10-15 user accounts. The contractor shall train (initial and refresher) and provide secure means for the Points of Contact (POCs) to access the system(s) for viewing and/or utilization in accordance with Section C.4.3.1. The contractor shall provide the initial and refresher training at any location determined by the DHA Dental Program Office (e.g. contractor’s place of business, DHA, webinar, etc.). The contractor shall provide a dedicated manager responsible for training, issues, process suggestions and provide assistance to the user when requested.

1.2. The contractor shall provide access to the referral and tracking system (stated below) for the Government POCs, to include Dental Treatment Facility (DTF) staff, Dental Service Point of Contacts (DSPOCs) and DHA Dental Program Section, Health Benefits Advisors, Beneficiary Counseling and Assistance Coordinators, and any other personnel identified by the Government. The contractor shall train (initial and refresher) and provide secure means for the POCs to access the system(s) for viewing and/or utilization in accordance with Section C.4.3.1. The contractor shall offer training to accommodate military schedules and differing time zones. The contractor shall upload online guides, tutorials and assessments, available 24/7, and provide a dedicated manager responsible for training, issues, and process suggestions. The training approach shall include onsite, webinar, online, and distributed materials. DTFs and Government POCs will have the option to sign up for email blasts that will inform them of program changes and system guide updates. The online training shall include a Government-approved assessment, with results tracked and certificates provided upon successful assessment completion.

1.3. All contractor data systems shall be available 99% of the time, excluding scheduled maintenance. To the maximum extent practicable, the contractor shall schedule system maintenance windows during weekends or non-peak hours to minimize disruption of services to Government users. To the extent practicable, the contractor shall notify the DHA, Dental Program Section 24 hours in advance of system maintenance if it will disrupt services during peak hours.

2.0. FULL DATA SET. The contractor shall provide the Government with read-only access to their full ADDP data set with download capability for data manipulation purposes with the ability to download any of the data elements associated with the ADDP contract (see Section C.4.3.2). The data system shall allow the Government the ability to parse and manipulate the data by downloading only the specific data elements desired and run reports using only those specific data elements. Access shall be on-line, and the data and any updates shall be available as soon as the source system provides it.

3.0. ADDP Dashboard. The contractor shall provide an ADDP dashboard that provides current performance information on the ADDP contract and monitors outcome measures (see Section C.4.3.3). The ADDP dashboard shall allow the Government the ability to trend and extrapolate specific information with visualization graphic display and analytic options. The ADDP dashboard shall be provided in a consolidated manner in which the DHA Dental Program Section may easily view the data without having to manipulate the data in order to retrieve the information. The information shall be easy to access, for example: point and click on a graphic; enter a ZIP code or state/country to see network access rates; identify how many enrollees and providers are in a location; or view any of the performance standards. The data shall be as current as possible and shall be totaled monthly and summarized quarterly.

3.1. The ADDP dashboard shall include, but not be limited to, information on network providers, non-network providers, TRICARE Overseas Preferred Dentists (TOPDs), remote ADSM enrollment information, claims processing, claims payment, ADSM dental care and service data. The ADDP dashboard shall allow for monitoring and displaying outcome measures and trends for the ADDP contract:

· monitor provider access and satisfaction

· utilization by Current Dental Terminology (CDT) code and by user selected group

· effectiveness of care

· Dental Readiness Classification (DRC) levels of ADSMs

· ADSM type (regular ADSM, Reserve/NG, early eligibility, Foreign Forces, etc.), military service, and age group

· utilization of prophylaxes of pregnant and diabetic personnel

· utilization of scaling and root planing of diabetic personnel

4.0. REFERRALS AND AUTHORIZATIONS

4.1. The contractor shall track referrals and authorizations by establishing a Health Insurance Portability & Accountability Act (HIPAA) compliant mechanism in which referrals and authorizations will be electronically transmitted to the contractor by the DTFs, DSPOCs or the DHA Dental Program Section. The system will also track authorizations approved by the contractor. The system will distinguish between Continental United States (CONUS) and Outside Continental United States (OCONUS) authorizations (see Section J, Attachment J-3a, Program Operations, for referral and authorization requirements).

4.1.1. The system will be Public Key Infrastructure (PKI) compliant (i.e. Common Access Card (CAC) enabled). The contractor shall send emails to DTFs, DSPOCs or the DHA Dental Program Section via the PKI compliant system. The contractor’s proprietary secure email system shall only be used for corresponding with the DTFs, DSPOCs or the DHA Dental Program Section when a digital certificate is not established between the corresponding parties.

4.1.2. The system will only allow the referral/appointment to be made if the ADSM is reflected as Defense Enrollment Eligibility Reporting System (DEERS) eligible and for verified Line of Duty (LOD) conditions when the Service member does not appear in DEERS. The system will auto-populate DTF information, such as DTF identification code and contact information for the staff member making the referral, and ADSM contact information, such as email, phone, rank, active duty/reserve status, if they are remote, and eligibility. In addition the system will indicate if there are any previous referrals and authorizations with a link to them.

4.1.3. The system will allow for instant Appointment Control Number (ACN) generation.

4.1.4. The system will indicate if the referral or appointment is with a network provider or non-network provider in accordance with the authorization requirements stated in Section J, Attachment J-3a, Program Operations. In addition, the system will indicate who authorized the non-network provider and why. Only the contractor, DSPOC, or the DHA Dental Program Section shall authorize care by a non-network provider, unless it is an emergency.

4.1.5. The system will have two options by which to select CDT codes for inclusion in the referral: 1) A drop down box for CDT codes which will recognize like groupings and procedure codes based on the first couple of numbers input and suggest procedure codes to choose from; 2) An option for the CDT code to be manually typed in. There will be no limit to the number of CDT codes entered for that referral. The system will indicate on the CDT code if additional approval is needed from the DSPOCs (e.g. implants and related services) in accordance with Section J, Attachment J-2, Benefits, Limitations and Exclusions. The system will generate an automated email to the DSPOC when additional approval is required to be reviewed with a link to the referral. Once the DSPOC has approved, denied, or requests additional information, the system will generate an automated email to the referring DTF that information is available for review.

4.1.6. The system will show the codes and narrative for the Authorizations Service Determination Reason.

4.1.7. Each referral will include a request for a treatment narrative summary in accordance with the requirements stated in Section J, Attachment J-3a, Program Operations. The system will track receipt of the treatment narrative summaries and any radiographs completed for that treatment session. The system will send an email notification to the referring DTF when the treatment summary and any radiographs are available for review/download from the referral and authorization tracking system. The contractor shall inform network providers that the claim will be denied if the treatment narrative summary and any radiographs are not provided (see Section J, Attachment J-3a, Program Operations). The system will indicate when a claim is denied for the network provider not submitting the treatment narrative summary and any applicable radiographs.

4.1.8. The system will allow for searches to be performed by ACN, referral and authorization.

4.1.9. The system will allow DTFs, DSPOCs and the DHA Dental Program Section to pull ADSM history, including any stored images for the current claim or for previous claims allowing for a full history view, not just one isolated encounter.

4.1.10. The system will link the referral, authorization, treatment narrative summaries, and claim information except for dollar amounts.

4.1.11. The system must allow for the digital radiograph and/or supporting documents to be attached or systematically linked to the referral for transmission purposes. All radiographs need to be of diagnostic quality. All radiographs shall be labeled according to the tooth or quadrant being treated.

4.1.12. The system will generate an automated email to the DSPOC or service consultant when a request is ready to be reviewed with a link to the referral.

4.1.13. The system will indicate referrals differentiated by appointment; date of the appointment, and the completed date.

4.1.14. The system will have the ability to identify remote authorizations and whether they were approved or disapproved.

4.1.15. The system will indicate authorized care that was not completed.

4.1.16. The system will track appeals and all related documentation in accordance with Section J, Attachment J-3a, Program Operations.

4.1.17. Upon implementation of MHS Genesis the system will track requests to revise a procedure’s DRC from a DRC 2 to a DRC 3. The system will link and/or attach all supporting documents to the request (see paragraph 5.2.1).

5.0. MILITARY HEALTH SERVICES (MHS) GENESIS/DEFENSE HEALTH MEDICAL SYSTEMS MODERNIZATION (DHMSM) ELECTRONIC HEALTH RECORD SYSTEM (EHRS)

5.1. DHA anticipates developing and implementing DHMSM EHRS for the ADDP contract that will allow Department of Defense to share dental health data with the private sector. DHA will provide further details on the technical specifications at a later time. At this time the DHMSM EHRS will not replace the contractor’s authorization, referral and tracking system stated above. Upon implementation of the contractor’s interface with MHS Genesis/DHMSM EHRS, the contractor shall continue operation of its authorization, referral and tracking system until the Government determines that the authorization, referral and tracking system is no longer needed. .

5.2. The contractor shall develop and implement a time-phased interface plan to achieve machine-to-machine interface between DTFs, the ADDP contractor, and network providers (see Section J, Exhibit B, CDRL R070, MHS Genesis Interface Plan). The contractor shall coordinate with DHA on the development and implementation of this interface system. The contractor shall develop an interface system that will allow their network providers and DTFs to submit and retrieve patient data through the contractor. Providers will not be allowed direct access to the MHS Genesis/DHMSM EHRS. Network providers will access the data via the contractor’s interface system. The contractor shall upload all diagnosis, treatment plans, completed treatment, Dental Readiness Classifications (DRCs), and radiographs (this is not an inclusive list) to the MHS Genesis/DHMSM EHRS via the contractor’s interface system. The contractor shall convert any non-network provider care data or other data such as paper submissions that do not comply with the interface submission requirements so that it may be submitted to the MHS Genesis/DHMSM EHRS via the contractor’s interface system. The contractor’s interface system shall also allow the DHA Dental Program Section personnel to submit and retrieve data via the contractor’s interface system.

5.2.1. The contractor shall ensure that a DRC is assigned to each diagnosis and/or procedure listed on a treatment plan for ADSMs. Once a biannual exam has been completed, only DSPOCs may approve changing a DRC 2 procedure to a DRC 3 procedure. When a contractor’s review of the treatment plan or claim determines that a DRC 2 procedure should be changed to a DRC 3 procedure, the contractor shall forward to the DSPOCs all documentation and their reasoning for the change. The contractor shall track these requests to change the DRC level in accordance with paragraph 4.0 above.

5.3. The technologies stated below are under review and are subject to evolving industry standards. It is anticipated that the contractor’s interface system shall include technical methodologies and capabilities to dental record sharing utilizing these technologies or something like them. The Government will update these technologies as needed prior to starting implementation of the interface system.

· Electronic Data Exchange (EDI) 278.

· Health Level 7 (HL7) Standards to include but not limited to

· Consolidated Clinical Document Architecture (C-CDA)

· HL7v2

· Fast Healthcare Interoperability Resources (FHIR)

· HIPAA compliant Secure Messaging Technologies to include but not limited to

· DIRECT Messaging

· DirectTrust.org.