Tpharm5 Draft Section G 20191202.docx

SECTION G

CONTRACT ADMINISTRATION

G G.1. Contract Clauses.

DFARS 252.204-7006 BILLING INSTRUCTIONS (OCT 2005)

DFARS 252.232-7006 WIDE AREA WORKFLOW PAYMENT INSTRUCTIONS (DEC 2018)

(a) Definitions. As used in this clause— “Department of Defense Activity Address Code (DoDAAC)” is a six position code that uniquely identifies a unit, activity, or organization.

“Document type” means the type of payment request or receiving report available for creation in Wide Area WorkFlow (WAWF).

“Local processing office (LPO)” is the office responsible for payment certification when payment certification is done external to the entitlement system.

“Payment request” and “receiving report” are defined in the clause at Electronic Submission of Payment Requests and Receiving Reports.

(b) Electronic invoicing. The WAWF system provides the method to electronically process vendor payment requests and receiving reports, as authorized by Defense Federal Acquisition Regulation Supplement (DFARS) Electronic Submission of Payment Requests and Receiving Reports.

(c) WAWF access. To access WAWF, the Contractor shall—

(1) Have a designated electronic business point of contact in the System for Award Management at https://www.sam.gov; and

(2) Be registered to use WAWF at https://wawf.eb.mil/ following the step-by-step procedures for self-registration available at this web site.

(d) WAWF training. The Contractor should follow the training instructions of the WAWF Web-Based Training Course and use the Practice Training Site before submitting payment requests through WAWF. Both can be accessed by selecting the “Web Based Training” link on the WAWF home page at https://wawf.eb.mil/

(e) WAWF methods of document submission. Document submissions may be via web entry, Electronic Data Interchange, or File Transfer Protocol.

(f) WAWF payment instructions. The Contractor shall use the following information when submitting payment requests and receiving reports in WAWF for this contract or task or delivery order:

(1) Document type. The Contractor shall submit payment requests using the following document type(s):

(i) For cost-type line items, including labor-hour or time-and-materials, submit a cost voucher.

(ii) For fixed price line items—

(A) That require shipment of a deliverable, submit the invoice and receiving report specified by the Contracting Officer.

The Contractor shall use Invoice as 2 In 1 (DD250 Form).

(B) For services that do not require shipment of a deliverable, submit either the Invoice 2in1, which meets the requirements for the invoice and receiving report, or the applicable invoice and receiving report, as specified by the Contracting Officer.

The Contractor shall use Invoice as 2 In 1 (DD250 Form).

(iii) For customary progress payments based on costs incurred, submit a progress payment request.

(iv) For performance based payments, submit a performance based payment request.

(v) For commercial item financing, submit a commercial item financing request.

(2) Fast Pay requests are only permitted when Federal Acquisition Regulation (FAR) 52.213-1 is included in the contract.

[Note: The Contractor may use a WAWF “combo” document type to create some combinations of invoice and receiving report in one step.]

(3) Document routing. The Contractor shall use the information in the Routing Data Table below only to fill in applicable fields in WAWF when creating payment requests and receiving reports in the system.

Routing Table:

Inspect By DoDAAC

Ship From Code

Mark For Code

Service Approver (DoDAAC)

Service Acceptor (DoDAAC)

Accept at Other DoDAAC

LPO DoDAAC

DCAA Auditor DoDAAC

Other DoDAAC(s)

(4) Payment request. The Contractor shall ensure a payment request includes documentation appropriate to the type of payment request in accordance with the payment clause, contract financing clause, or Federal Acquisition Regulation 52.216-7, Allowable Cost and Payment, as applicable.

(5) Receiving report. The Contractor shall ensure a receiving report meets the requirements of DFARS Appendix F.

(g) WAWF point of contact.

(1) The Contractor may obtain clarification regarding invoicing in WAWF from the following contracting activity’s WAWF point of contact.

The Contractor may obtain clarification regarding invoicing in WAWF from the DHA/CRM Accounting Technician assigned to their contract.

(2) Contact the WAWF helpdesk at 866-618-5988, if assistance is needed.

(End of clause) G.2. Contract Administration. The Defense Health Agency (DHA), Managed Care-Contracting Division (MC-CD) will perform contract administration, except as delegated to other Government agencies by the DHA Contracting Officer. The Contractor will be provided a copy of all delegations of administration functions. The following individuals will be the Government points of contact during the performance of this contract.

G.2.1. Contracting Officer. The Contracting Officer is responsible for the administration of this contract and is solely authorized to take action on behalf of the Government that may result in changes to the terms of this contract, including deviation from section C. The Contracting Officer for administration of this contract is:

Contracting Officer Defense Health Agency Managed Care Contracting Division 16401 East Centretech Parkway Aurora, CO 80011-9066

G.2.2. Contracting Officer’s Representative. The Contracting Officer will designate a Contracting Officer’s Representative (COR) in writing. The Contractor will be provided a copy of COR appointment. The written appointment will delineate the scope of authority of the COR.

G.2.3. Government Payment Office.

Defense Health Agency ATTN: Contract Resource Management (CRM) – Accounting Office 16401 E. Centretech Parkway Aurora, CO 80011-9066

G.3. Billing Instructions.

G.3.1. Electronic Payment Support & Documentation for WAWF.

G.3.1.1. Payment support. Contractors are required to submit their “payment request and receiving report” electronically utilizing the WAWF application. In conjunction with the WAWF application, the Contractor must continue to submit their payment request and backup documents to the Contract Resource Management Office (DHA/CRM) at dha.buckley.crm.mbx.aur-crm-invoices@mail.mil. This will ensure the continuity of payments.

G.3.1.2. Credit Invoices. WAWF is not able to process any credit invoices and therefore credit invoices, these must be submitted directly to the DHA/CRM mailbox address listed above. Credit e-mail invoice(s) must clearly state in subject line ‘WAWF not used.’

G.3.1.3. Procedure if WAWF is unavailable. When instructed by DHA/CRM that the WAWF system is not operating normally, the Contractor may submit their invoices directly to Contract Resource Management Office at the mailbox address listed above, with an email copy to the COR. E-mail invoice(s) that are not submitted thru WAWF must clearly state in subject line ‘WAWF not used’. The e-mail receipt date shall be used as the invoice receipt date, DHA/CRM will work with the Contractor to get the Receiving Report signatures necessary for payment.

G.3.2. Instructions to Paying Office. The paying office will follow paying instructions included in any contract modification, including change order definitization and performance incentive payment modifications.

G.3.2.1. Revisions to payment instructions may be made as circumstances require. Revisions may be accomplished by correspondence between the contracting office and the paying office.

G.3.3. Payments Due from the Contractor to the Government.

G.3.3.1. Performance Guarantees. Upon determination of the performance guarantee and notification by the CO, the Contractor will follow instructions specified in the demand letter. If payment is not received by the due date specified, then the Government will make collection via payment offset by reducing the appropriate amount from the next payment(s) to the Contractor. If payment terms are not specified, Government will make collection via payment offset by reducing the appropriate amount from the next payment(s) to the Contractor.

G.3.3.2. Other Payments from the Contractor to DHA. Contractor payments will be made electronically following the directions outlined in the modification. If payment is not received by the due date then the Government will make collection via payment offset by reducing the appropriate amount from the next payment(s) to the Contractor. If payment terms are not specified, Government will make collection via payment offset by reducing the appropriate amount from the next payment(s) to the Contractor.

G.3.3.3. Overpayments. DHA reserves the right to collect overpayments made to the Contractor from the payments due to the Contractor (including any contract payments due the Contractor from other contracts it may hold with DHA or other Federal Agencies).

G.3.4. Non-TEDS Instructions Invoice and Payment. The basis for payment to the Contractor shall be the prices specified in Section B of this contract and as specified within this contract.

G.3.4.1. Invoice Submission. Non-TEDS invoices shall be submitted electronically in accordance with G.1 and G.3.1. The Contractor shall submit invoices through WAWF.

G.3.4.1.1. A proper invoice must include the elements identified at FAR 32.905.

G.3.4.1.2. All payments made by the Government will be made by EFT.

G.3.4.1.3. Payments will be made in accordance with Prompt Payment Act, FAR 52.232-25 (i.e. the 30th day after the later of the receipt of a proper invoice, or its acceptance).

G.3.4.1.4. Revisions to payment instructions may be made as circumstances require. This may be accomplished by correspondence between the Contractor and both the contracting office and the paying office.

G.3.4.2. Types of Payments to the Contractor. (X in CLIN designation, refers to same CLIN all option periods).

G.3.4.2.1. CLIN 0001 – Contract Transition-In. Payment for services rendered on this requirement will be made via performance-based payments upon completion of each performance milestone detailed in the performance-based payment table (C.14.1.8) and submission of a monthly payment request. The balance of the transition-in price will be paid upon successful completion of the full transition-in requirement, after the start of pharmacy services.

G.3.4.2.2. CLIN 0002 – Government-Directed Notifications Transition-In. Payment for Government-directed notifications during transition-in will be made by monthly submission of a payment request for CLIN 0002 following completion of any Government-directed notifications.

G.3.4.2.3. CLINs 0003 and X015 – Contract Data Requirements List (CDRL). Payment for deliverables will be made by submission of a payment request at the conclusion of the base period for CLIN 0003 and each option period for CLINs X015.

G.3.4.2.4. CLINs X005 – MTF Prescription, Adjudication Services. The unit price for adjudicating MTF prescriptions will be paid against CLINs X005 by the monthly submission of a payment request. Supporting documentation required to validate this payment request will be sent to the COR. Any excess quantities not utilized will be deobligated and the CLIN will adjusted to reflect the final quantity and price at the end of each option period.

G.3.4.2.5. CLINs X008 – Mail Order Pharmacy Unreplenished Agents. The unit price for Contractor fulfillment of Mail Order Prescriptions (MOP) for which pharmaceutical agents could not be replenished by the National Prime Vendor (NPV) will be paid against CLINs X008 by submission of a payment request at the beginning of each option period.

G.3.4.2.6. CLINs X009 – Market Price Pharmaceutical Program (MPPP) Administrative Fee. The unit price for Contractor administrative fee associated with MPPP accepted offers will be paid against CLINs X009 by the monthly submission of a payment request for accepted offers. Any excess quantities not utilized will be deobligated and the CLIN will adjusted to reflect the final quantity and price at the end of each option period.

G.3.4.2.7. CLINs X010 and X011 – Market Price Pharmaceutical Program (MPPP). The total value of pharmaceutical agents for accepted MPPP offers (allocated by TRICARE-Only Eligible and Dual-Eligible fund type based on utilization) will be paid against CLINs X010 and X011 by the monthly submission of a payment request for fully dispensed MPPP purchases.

G.3.4.2.8. CLINs X014 – TRICARE Pharmacy Services, Administrative Support. The monthly per member per month (PMPM) price will be paid against CLINs X014 by the monthly submission of a payment request for no more than one-twelfth (rounded to the nearest dollar) of the extended CLIN amount.

G.3.4.2.8.1. For the purpose of this CLIN, counts of MHS eligible beneficiaries under the PMPM includes all MHS eligible beneficiaries. The count is taken from the MHS Data Repository (MDR) Point-in- Time Extract (PITE). The MDR PITE is derived monthly from the DEERS PITE, which is a snapshot of the DEERS database reflecting beneficiary status and address at the end of each month. The Government will unilaterally determine the number of MHS eligible beneficiaries prospectively each option period. This number will be based on an average of the 12 previous months of eligible beneficiaries as reported above. Using the number of MHS eligible beneficiaries, the Government will calculate the PMPM quantity for the next annual period as follows: The number of MHS eligible beneficiaries multiplied by the number of months (12) equals the number of member months (the quantity). The number of member months is then multiplied by the fixed unit price to determine the extended amount for the period.

G.3.4.2.9. CLINs X016 – Retail Network Cost Control Incentive. Any performance incentive earned by the Contractor for Retail Network Cost Control (H.4.2.) will be paid against CLINs X016. The Contractor may submit its payment request upon receipt of the contract modification implementing the incentive assessment.

G.3.4.2.10. CLINs X017 – Specialty Network Cost Control Incentive. Any performance incentive earned by the Contractor for Specialty Network Cost control (H.4.3.) will be paid against CLINs X017. The Contractor may submit its payment request upon receipt of the contract modification implementing the incentive assessment.

G.3.4.2.11. CLINs X018 – Market Price Pharmaceutical Program (MPPP) (Savings Offers Only) - Cost Control Incentive. Any performance incentive earned by the Contractor for savings on generic drugs (savings offers only) (H.4.4.) will be paid against CLINs X018. The Contractor may submit its payment request upon receipt of the contract modification implementing the incentive assessment.

G.3.4.2.12. SUBCLINs X019AA/AB – Award Fee Pool. Any Award Fee earned by the Contractor will be paid against CLINs X019AA/AB. The Contractor may submit its payment request upon receipt of the Award Fee Determination made by the Government in accordance with Section H.8.

G.3.4.2.13. CLINS X020 or X021 – Transition-Out. The Contractor will be paid against CLINs X020 or X021 (Transition-Out) activities only once during the contract. Once exercised, the Contractor may submit a payment request only after all transition-out tasks have been completed.

G.3.5. TEDS Instructions – Invoice and Payment for Claim Rate.

G.3.5.1. TEDS Record Submissions. The Contractor will generate TEDS records for each prescription filled per the TSM, Chapter 2. TEDS are reported on separate headers for TRICARE and TRICARE Medicare Dual Eligible.

G.3.5.2. Due Date. Invoice and payment procedures for claims processing fees are the same for paper and electronic claims. Submission of a TEDS record header to DHA is considered submittal of an invoice. No separate invoices are required for routine claims rate payments. However, invoices are required for non-automated payment requests. For purposes of determining the due date for payment under the Prompt Payment Clause, the "Transmission received end date/time stamp" (derived by TEDS at end of data transmission) will be used to determine the date of invoice receipt. Transmission received after 10:00AM ET shall be considered as received the next calendar day.

G.3.5.3. Unit Price. The Contractor is paid the claims processing unit price identified in Section B for the contract period in which the Contractor submits the initial TEDS record. The Contractor is paid the unit price for each initial submission TEDS record (as defined under TSM 7950.3-M, April 1, 2015, Chapter 2, Section 1.1) that passes all TEDS edits as specified in the TSM and validated by the TEDS record edit system. Additionally, the Contractor is paid for the first adjustment TEDS record accepted under this contract that was initially submitted under a previous contract (even if the previous contract was held by the new Contractor).

G.3.5.4. Appropriate Option Period. The Contractor is paid the claims processing unit price identified in Section B for the contract period in which the Contractor submits the initial TEDS record. The "Batch/Voucher Date" in the voucher header is used to determine the contract option period. The Contractor is paid the claims processing unit price identified in Section B for the contract period in which the Contractor submits the initial TEDS record.

G.3.5.5. Payment. In order for the Contractor to receive payment of a claims processing fee, the TEDS record must pass all TEDS edits as specified in the TSM and validated by the TEDS record edit system no later than 210 calendar days following the end date for the contract.

G.3.5.6. Header Type Indicator. The Contractor shall submit batch/vouchers under the correct "Header Type Indicator" as specified in the TSM Chapter 2, Section 2.3. to ensure correct payment. Header Type Indicator indicates to the TEDS processing system if the Contractor is requesting a claim rate payment, wants to retain a claim rate payment, does not want a claim rate payment or if the Contractor is requesting the claim rate payment previously paid be retracted.

G.3.5.6.1. Eligible TEDS Records. If the TEDS record is eligible to receive or retain a previous payment under the claims processing CLIN, then the TEDS record (with the exception of Type of Submission "C" complete cancellation to TEDS record data, see (G.3.5.6.3) shall be submitted by the Contractor to DHA using a Header Type Indicator of"6" or"9"(even if the TEDS record has already received payment under the claims processing CLIN).

G.3.5.6.2. Ineligible TEDS Records. If the TEDS record submitted is not eligible to receive payment or the Contractor wants DHA to retract a previous claim rate payment under the claims processing CLIN, the Contractor shall submit the TEDS record to DHA using a Header Type Indicator of "0" or "5". No payment under the claims processing CLIN can occur on any TEDS record grouped in a Batch/Voucher with Header Type Indicator of "0" or "5." Only no-pay and credits (where DHA retracts any previous claim rate) can be processed under these header types.

G.3.5.6.3. Cancelled TEDS Records. For a TEDS record submitted with a Type of Submission "C" by the Contractor, the Contractor shall determine if the TEDS record is still eligible to receive payment under the claims processing CLIN. The following criteria shall be used to determine if a TEDS record is still eligible for payment:

G.3.5.6.3.1. A TEDS record cancelled for any of the following reasons is eligible to retain the claims processing fee previously paid and shall be submitted with Header Type Indicator "6" or ''9":

· Cancellation was at Government direction.

· Government data error.

· Stale dated/voided checks.

· New initial TEDS record is required by the Government.

· Incorrect DEERS response.

· Check is returned in undeliverable mail.

· Beneficiary or provider requests stop payment due to non-receipt of check prior to stale date time period.

· Beneficiary or provider returns check because payment was received from other health insurance carrier whose responsibility was previously unknown to Contractor.

· Provider returns check because beneficiary has erroneously paid the provider and believes that the TRICARE benefit check is a duplicate payment.

· Claim processed in good faith by the Contractor but later identified as an error due to additional information received or learned.

· Claim processed by multiple Contractors resulting in duplicate processing.

· TQMC case resolutions resulting in an error.

· Program Integrity cases that are recouped retrospectively after investigation.

· Provider requested claims to be reissued to a new provider Tax Identifier.

G.3.5.6.3.2. A TEDS record cancelled for any of the following reasons is not eligible to retain the claims processing fee previously paid and shall be submitted with Header Type Indicator "0" or ''5":

· Cancellation where a new initial TEDS record is required to correct a Contractor error.

· Cancellation due to Contractor error or an inability to adjust.

· Cancellation of a claim that was not DHA's responsibility so it should not have been paid.

· Any other cancellations for a reason not identified in paragraph G.3.5.6.3.

G.3.5.6.4. If the Contractor cannot determine the reason for the TEDS record cancellation, then the TEDS record submitted is not eligible to retain the claims processing fee previously paid. The cancellation of the cancelled TEDS record shall be submitted under Header Type Indicator "0" or "5."

G.3.5.7. Co-Payments (Retail, Specialty, MOP). The Government will offset unit price payments based on the calculated co-payment amounts (i.e. what was required to be collected by the Contractor from the beneficiary) to determine the net amount due the Contractor or Government. Payments shall be reported on the disbursing document showing the amounts paid by CLIN, co-payment offsets shall be separately reported on the disbursing document citing ‘9999CP’ in the CLIN field (NOTE ‘9999CP’ is not a CLIN but is used by DHA, CRM to report co-payment amounts). Co-payment offsets shall be calculated on a Net 30 basis and based on the same due date calculation used for processing fee payments. The Government shall pay the amount due to the Contractor in accordance with the Prompt Payment Act, after acceptance of the TEDS record.

G.3.5.8. Types of Payments to the Contractor. (X in CLIN designation, refers to same CLIN all option periods).

G.3.5.8.1. CLINs X001 and X002 – Retail Network Claims. Invoice and payment procedures for Retail Claims, (CLINs X001 and X002) differ as detailed in the payment instructions provided in G.3.4. Submission of a TEDS record to DHA is considered submittal of an invoice and follows the rules laid out in G.3.5. Any excess quantities not utilized will be deobligated and the CLIN will adjusted to reflect the final quantity and price at the end of each option period.

G.3.5.8.2. CLINs X003 and X004 – Specialty Network Claims. Payment of processing fees for Specialty Network Claims will be made against CLINs X003 or X004, depending upon the beneficiary’s eligibility. The offset to processing fee payments based on the calculated co-payment amounts will be the same as described in G.3.5. Any excess quantities not utilized will be deobligated and the CLIN will adjusted to reflect the final quantity and price at the end of each option period.

G.3.5.8.3. CLINs X006 or X007 – Mail Order Pharmacy, Prescription Fill. Payment for processing Mail Order Pharmacy will be made against X006 or X007, depending upon the beneficiary’s eligibility. Payment will be based on the CLIN unit price multiplied by the number of eligible records for that CLIN. The Contractor shall be paid one processing fee per TEDS record indicator number. Submission of a TEDS record to DHA is considered submittal of an invoice and follows the rules laid out in G.3.5. Any excess quantities not utilized will be deobligated and the CLIN will adjusted to reflect the final quantity and price at the end of each option period.

G.3.5.8.3.1. For MOP Prescription Fill, the Contractor will not submit a TEDs (invoice) for the processing fee for a replacement shipment, where the original shipment has not been received, or was received in unusable condition (C.5.2.12.)

G.3.5.8.4. CLINs X012 or X013 – Clinical Reviews. Clinical reviews are performed for both retail claims and mail order transactions. Payment for each clinical review (i.e. PAs/MNs) will be based on submission of a separate TEDS record and paid against CLIN X012 or X013. Any excess quantities not utilized will be deobligated and the CLIN will adjusted to reflect the final quantity and price at the end of each option period. The Contractor may:

· Submit a TEDS (invoice) for performing each clinical review as described at C.7.2.3.

· Not submit a TEDS (invoice) where a PA/MN already exists for the same purpose at C.7.2.3.1.

· Not submit a TEDS (invoice) Not be paid a transaction fee for any administrative (i.e. automated) reviews as described at C.7.5.

G.3.6. Invoice and Payment – Fiscal Intermediary Function Payments.

G.3.6.1. Retail and Unreplenished Specialty Pharmacy Benefit Payment. The Government will bear the cost of retail prescriptions and those specialty prescriptions not replenished by the NPV dispensed under this contract. The Contractor acts as a Fiscal Intermediary (Fl) for the Government to disburse Government funds for health care benefits (also known as "pass-through payments" or “non-underwritten payments”). These are not costs to the Contractor, so the Contractor shall not collect or hold health care benefit funds before dissemination to the beneficiary or provider. The Contractor shall immediately return any collections to the Government. No bank fees or other bank charges shall be paid from this account and no money should be drawn from the Federal Reserve Bank (FRB) for these charges.

G.3.6.1.1. Prior Authorization. The Contractor shall not release non-underwritten benefit payments without prior authorization from the DHA/CRM Budget Office. See Section G.3.6.12 Authorization to Release TEDS Non-Underwritten Benefit Payments, for additional details.

G.3.6.1.2. Source of Funding. Funding for benefit payments made by the Contractor on behalf of the Government will be facilitated by allowing the Contractor (through the Contractor's financial institution) to draw money from the designated FRB. These draws may only be done for benefit payments that have previously been submitted on TEDS or as a non-TEDS voucher, that were approved for release by DHA/CRM and that are clearing the Contractor's financial institution on the day the draw is being accomplished. No advance payments are authorized.

G.3.6.1.3. Voucher Integrity. Voucher header and detail amounts transmitted by the Contractor become "fixed" data elements in the finance and accounting system for purposes of control and integrity. Corrections or adjustments to reported (payment) amounts must be accomplished on separate voucher transmissions.

G.3.6.1.4. Incorrect TEDS. All TEDS record based payments where the Contractor has billed using an incorrect Batch/Voucher CLIN/ASAP Account Number in the Batch/Voucher Header and a payment transfer has occurred shall be reported daily on the Contractors Resource Center (CRC) website by TEDS Record Indicator (TRI) by line item usually the day following receipt of TEDS data by DHA.

G.3.6.2. Non-Underwritten Bank Accounts.

G.3.6.2.1. Establishment. The Department of Treasury's Automated Standard Application for Payment System (ASAP) and FEDWIRE provide a mechanism for disbursement of Government funds for health care services received by TRICARE beneficiaries. After authorization by DHA/CRM, these systems allow the Contractor, through their bank, to draw cash directly from the FRB to cover payments as they clear the Contractor's bank account. ASAP is used by the Treasury, the FRB and DHA/CRM to verify the authorization to make draws and to track transactions made by the Contractor's bank. FEDWIRE is used by the Contractor's bank to actually draw funds from the FRB.

G.3.6.2.2. Separate Accounts. The Contractor shall establish a minimum of two (2) bank accounts for benefit-related transactions with a commercial bank that has FEDWIRE capability in accordance with current Treasury requirements. If the Contractor requires additional bank accounts, a request specifying the purpose of the additional accounts should be submitted to DHA/CRM for approval.

G.3.6.2.2.1. One bank account will be used for claims eligible for the Medicare Dual-Eligible Health Care Fund (see Accrual Fund Check in the TSM Chapter 2, Section 4.1, Element 0-025- 05R). The second account will be for claims that are not eligible for this fund (such as beneficiaries with an active duty sponsor). TEDS will be submitted separately for each account. Funds used to pay for TRICARE-only and Medicare Dual Eligible claims come from separate and distinct appropriations. The Contractor shall therefore ensure that bank transactions are properly accounted for in order to prevent the comingling of funds. Failure to properly associate transactions with the correct bank account could result in the over-execution of DHA/CRM budget authority. The transfer of funds between bank accounts is strictly prohibited (except when authorized to correct an earlier deposit found to have been made to the wrong account). Any transactions reported under one bank account and later identified as belonging to a different bank account shall be reported immediately. DHA/CRM will instruct the Contractor as to what corrective action to take.

G.3.6.2.3. New Accounts. The Contractor shall submit bank information to DHA/CRM not later than 60 calendar days prior to the beginning of processing claims on a new account. The information shall include:’

· Name of Bank

· Overnight mail address

· American Banking Association (ABA) number/Routing Number (RTN).

· Contractor Taxpayer Identification Number (TIN)

· Data Universal Numbering System (DUNS) number for the Contractor and the bank.

· Taxpayer Identification Number (TIN) for the bank

· Contractor's bank account number (if separate checking and deposit account numbers are used, both shall be provided and identified)

· Individual point of contact at the bank and an alternate, including their phone numbers, and e-mail addresses

· Individual point of contact at the Contractor and an alternate, including their phone numbers, and e-mail addresses

G.3.6.2.3.1. DHA/CRM will establish the bank accounts on ASAP. ASAP, along with FEDWIRE, provide a mechanism for disbursement of Government funds for health care services received by TRICARE beneficiaries. DHA/CRM will notify the bank and the Contractor once the bank accounts have been established and provide codes or other information necessary for the bank to make draws against the FRB using FEDWIRE. Currently, ASAP has a requirement to identify a total dollar amount that may be drawn on the FRB. This total dollar limit only represents an administrative ceiling at the FRB and does not constitute any authority to draw funds. Accounts will also have daily limits for the amount that can be drawn. The Contractor will be notified of these limits by DHA/CRM. DHA/CRM is able to increase or decrease these limits as needed.

G.3.6.3. Fiscal Year Start-up of Bank Accounts. The Contractor shall establish separate bank accounts for each new Federal Government fiscal year (October – September) following the procedures specified in G.3.6.2.1 "Establishment". All payments issued for benefit payments and all refunds received shall be processed against the new account effective the first day of the new fiscal year. The Contractor shall also transfer all recoupment installment payments to the new account from the previous year's account.

G.3.6.4. Closing Bank Accounts. Bank accounts shall be closed no later than the end of February, following the fiscal year end, or the end of the month after the month that the last payment on an account has cleared the account or been voided.

G.3.6.4.1. Cash drawdowns against the prior fiscal year's bank account may continue, if required, until all payments from the prior year have either cleared or been canceled, but no longer than the end of February of the following year or five months after the last payments have been cut on an account (in the case of a contract closeout).

G.3.6.4.2. All TEDS Bad Master for that Fiscal Year must be cleared or request for a manual clearing per G.3.6.9.

G.3.6.4.3. The final bank account reconciliations shall be made by the end of the month following the month having the last authorized transactions. All transactions that were not previously approved by DHA/CRM shall be explained with supporting documentation on the final bank reconciliation report (See G.3.6.6 and CDRLs M160, M180, M190). DHA/CRM reserves the right to not accept these transactions.

G.3.6.4.4. Any outstanding balance in the account shall be reimbursed to DHA no later than the required submission date of the final bank account reconciliation. This balance may be subject to interest if it includes overdrawn amounts that were required to be submitted at an earlier date.

G.3.6.5. Draws on the Federal Reserve Bank. The total amount of a cash draw down on the FRB is based on the daily total of benefit payments presented to the bank for payment. Computation of the amount of the draw must also include available funds from deposits into the account. These deposits will reduce the amount of cash needed for the draw down on the day the deposit fund become available for transactions. If estimates are needed due to timing of reports from check clearinghouses or the FRB, the draws shall be adjusted the next business day.

G.3.6.5.1. The Contractor shall ensure that cash drawdowns do not exceed the payments that have been authorized by DHA. The Contractor shall ensure that any excess draws are immediately returned to the FRB.

G.3.6.5.2. Unapproved draws or unauthorized payments by the Contractor may be immediately collected and may subject the Contractor to interest and penalties. Interest and a penalty will be charged beginning the day after the over-draw and interest will continue until the overdrawn amount is returned. Interest will accrue daily and is based on the Treasury Current Value of Funds Rate. The penalty is a one-time payment and is based on the penalty rate in the CFR, Title 31, Chapter IX, paragraph 901.9. DHA/CRM may initiate immediate payment offset against any payments to the Contractor involved for the interest, penalties and/or the overdrawn amount.

G.3.6.5.3. The Contractor shall ensure transactions are properly accounted for to prevent the commingling of funds between bank accounts. Failure to properly associate transactions with the correct bank account could result in the over-execution of DHA/CRM budget authority. Transfers of funds between bank accounts are strictly prohibited except for correcting deposits that are in the wrong account. Any other transactions reported under one bank account and erroneously charged against a different bank account shall be reported immediately to DHA/CRM when identified. DHA/CRM will instruct the Contractor as to what action to take depending on the situation.

G.3.6.5.3.1. The Contractor is financially liable for all amounts drawn by them from the FRB until paid to the authorized payee and any collections received by them on behalf of DHA until deposited into the FRB. The Contractor must immediately notify DHA/CRM of any loss or suspected loss of DHA funds. Any loss of funds must be refunded to the DHA within 2 business days after identification of the loss. If the funds are not returned to DHA within 2 business days interest and a penalty will be charged beginning the 3rd business days after the loss of DHA funds is identified and interest will continue until the missing funds are returned to DHA. Interest will accrue daily and is based on the Treasury Current Value of Funds Rate. The penalty is a one-time payment and is based on the penalty rate in the CFR, Title 31, Chapter IX, paragraph 901.9. DHA/CRM may initiate immediate payment offset against any payments to the Contractor involved for the interest, penalties and/or any unpaid amount due DHA. Once the funds have been returned to the DHA the Contractor shall reissue payment to the authorized payees (if needed) in accordance with paragraph 12.4. The Contractor may appeal their liability for the loss of funds to the Contracting Officer if they can demonstrate that the loss was caused by erroneous information provided to them by the;

· TRICARE beneficiary or

· Department of Defense (e.g. DHA, DEERS, etc.) or

· Centers for Medicare and Medicaid Services (CMS

· If the loss occurred because of the actions taken by a federal agency outside the DoD (U.S Treasury, FRB, etc.) or CMS the Contractor is still liable for the loss to DHA and they must pursue recovery of monies with the agency involved.

G.3.6.6. Reporting. Monthly bank reconciliations and the associated bank account statements are required for each account until the bank account is closed. Reports are to be submitted to CRM. See CDRLs M160, M180, and M190 for the descriptions of reporting requirements.

G.3.6.7. Benefit Payments and TEDS Submissions. TEDS data submissions for benefit payments shall be grouped into TEDS Vouchers by the "Batch/Voucher CLIN/ASAP Account Number" field (defined in TSM, Chapter 2, Section 2.3).

G.3.6.7.1. Voucher Transmission Requirements. Batch/Vouchers shall be transmitted by 10:00 AM Eastern Time to be considered for that day's business. Batch/Vouchers received after 10:00 AM Eastern Time shall be considered received the next calendar day for payment and check release authorization purposes. Batch/Vouchers must pass all TEDS header edits as specified in the TSM. If all header edits are not passed, the Batch/Voucher will be rejected and returned to the Contractor.

G.3.6.7.2. Voucher Integrity. Voucher header and detail amounts transmitted by the Contractor become "fixed" data elements in the finance and accounting system for purposes of control and integrity. Corrections or adjustments to reported (payment) amounts must be accomplished on separate voucher transmissions.

G.3.6.8. Payment Suspension and TEDS Processing During Partial Funding Shortages.

G.3.6.8.1. Some of the funding DHA receives may be restricted in use to a specific federal agency, military department and/or to a particular health care program. Funding for these special purpose programs may run out before funding for other DHA programs. Therefore, the Contractor shall have the ability to suspend claims payment and the associated submission of institutional TEDS records or non-institutional TEDS line item(s) to DHA based on values contained in the following TEDS record fields:

· Service Branch Classification Code (Sponsor), SBCC: As specified in the TSM, Chapter 2, Section 2.8.

· Enrollment/Health Plan Code (E/HPC): As specified in the TSM, Chapter 2, Section 2.5.

· Special Processing Code (SPC) - As specified in the TSM, Chapter 2, Section 2.8.

· Health Care Delivery Program Coverage Code: As specified in the TSM, Chapter 2, Addendum L.

G.3.6.8.2. The suspension of claims payment and TEDS records may be based on a single value (e.g., SBCC=A) or a combination of values (e.g., SBCC=A & E/HPC=SR). Suspension of TEDS records (institutional) or TEDS line items (non- institutional) containing specific values shall be implemented by the Contractor within five workdays after receiving notification from the CO. On the sixth workday, DHA CRM will implement immediate payment offset against Contractor invoices of any amounts paid by the Contractor from their bank account(s) for institutional TEDS records or non-institutional TEDS line items containing suspended value(s). The Contractor shall not, without prior CO approval, initiate payment offset against any provider or beneficiary for payments made against suspended transactions and offset by DHA/CRM on Contractor invoices.

G.3.6.8.3. For all suspended transactions, the Contractor shall hold the claim information until receiving instructions from the CO to do otherwise. The Contractor shall not reject the claims or return any information to the providers or beneficiaries unless instructed by the CO. Once the CO lifts the TEDS data submission restriction, the Contractor may submit all withheld TEDS data on the next appropriate (batch/voucher) data submission. DHA/CRM will reimburse the Contractor (without interest) for any invoice payment offsets done for TEDS suspended transaction that have not been recouped by the Contractor.

G.3.6.9. Uncorrected (Bad Master) TEDS. DHA will use the edits specified in the TSM, Chapter 2, Section 8.1, “Financial Edits”, to determine the propriety of the payments. TEDS records that fail the edits specified in the TSM will be "flagged" by DHA/CRM as inadequate payment information. The Contractor shall correct the claims identified to them, by DHA/CRM, within 90 calendar days. If not corrected in 90 days, DHA/CRM will send a demand letter requiring resolution or reimbursement for all claims identified through TEDS as edit failures. The Contractor shall respond within 30 calendar days as to why the claim(s) in question cannot be corrected. If resolution cannot be reached between DHA CRM and the Contractor, the total amount of improper payments still in dispute will be collected by DHA CRM.

G.3.6.9.1. If resolution cannot be reached between DHA and the Contractor, the total amount of the improper payments still in dispute will be collected by DHA.

G.3.6.9.2. The Contractor shall take no recourse against TRICARE beneficiaries or providers under the situations described in this paragraph without prior DHA approval.

G.3.6.10. Residual Benefit Claims. Claims for service provided prior to start of the contract will be paid as benefits under this contract as described in paragraph G.3.6.7 and G.3.6.11 or, if necessary, under paragraph G.3.7 for non-routine payments.

G.3.6.11. Miscellaneous.

G.3.6.11.1. Claims from network pharmacies will be paid in accordance with the agreements which exist between the Contractor and its network pharmacies, e.g., WAC plus/minus price adjustment, plus Dispensing Fee, minus the collected co-payment. Network pharmacy payments may be accumulated until the agreed to payment date (e.g. weekly, biweekly, etc.).

G.3.6.11.2. For TRICARE-authorized vaccine claims submitted by network pharmacies, the pass-through payments will be in accordance with the agreements that exist between the Contractor and its network pharmacies, e.g., vaccine WAC, plus / minus price adjustment, plus a Dispensing Fee, plus an administration fee, also known as a Professional Service Fee (PSF). No Co-pay ($0) will be subtracted for TRICARE-authorized vaccinations.

G.3.6.11.3. For non-network pharmacy claims, the Contractor shall, on a daily basis, reimburse the submitter of the claim, billed charges minus applicable co-payments and deductibles in accordance with the TRICARE Reimbursement Manual (TRM), Chapter 2, Addendum B.

G.3.6.11.4. The Contractor shall submit TEDS records to DHA on a daily basis (business days), following a ten-day hold for each retail Electronic Media Claim (EMC) transaction. The ten-day hold does not apply to paper claims, clearinghouse claims, State Medicaid agency claims, specialty pharmacy transactions or mail order pharmacy transactions. TEDS records for all non-electronic claims will be submitted in accordance with TOM Chapter 1, Section 3, 1.8. DHA will confirm that the voucher header is valid, and that it balances with the dollar amount of the related records.

G.3.6.12. Authorization to Release TEDS Non-Underwritten Benefit Payments. The Contractor shall not release benefit payments without prior authorization from the DHA/CRM Budget Office. Authorization from DHA/CRM to release payments will be sent to the Contractor via fax or e-mail no later than 5:00 PM Eastern Time the day of receipt. Authorization will specify contract number, ASAP Account ID#, initial transmission received date, and total dollar amount of funds that may be released based on information contained in the Batch/Voucher header. Approval for funds release will be given provided the following criteria are met:

G.3.6.12.1. Voucher submissions must pass all header edits as specified in TSM Chapter 2, Section 4.1.

G.3.6.12.2. DHA/CRM Budget Officer has confirmed that funding is available to cover payments.

G.3.6.12.3. Payment Release. Benefit payments shall be released/mailed no later than two workdays after DHA/CRM has approved the release of payments.

G.3.6.12.4. DHA Acceptance. Authorization to release payments does not constitute DHA's acceptance that all payments are valid and/or correct. Detailed records will be audited for financial compliance. All transactions in these bank accounts must be valid and justified. Any unreported/unauthorized disbursements identified by DHA will be subject to immediate payment offset against any payments being made to the Contractor. All disputed amounts will remain in the possession of the Government until no longer in dispute.

G.3.6.13. Benefit Payment Adjustments.

G.3.6.13.1. Underpayments. When the Contractor makes an additional payment due to a prior underpayment, these payments shall be reported as an adjustment to the original TEDS record or manual voucher, but in the current fiscal year and current CLIN/ASAP ID regardless of the fiscal year or CLIN/ASAP ID of the original payment.

G.3.6.13.2. Overpayment. The Contractor shall follow recoupment procedures specified in the TOM, Chapter 10, to include offsetting overpayments against future payments. When reporting collections the Contractor makes, whether cash or offset, the collection shall be accomplished as a separate credit transaction as an adjustment to the original TEDS record or manual voucher. Identified debts shall be reported on the Accounts Receivable Report in accordance with CDRLs M170 (see G13.3 below).

G.3.6.14. Voided, Stale-dated Payments, or Replacement Checks/EFTs G.3.6.14.1. For voided or stale-dated payments over $10.00, a credit voucher through TEDS records must be processed in accordance with the standards detailed in TSM Chapter 3, Section 4. Or, if the check was issued as a manual voucher per G.3.7.5., the credit should be submitted as a similar manual voucher on a monthly basis.

G.3.6.14.2. For voided/stale-dated payments of $10.00 or less, the Contractor may elect either to create a credit voucher for the payment using a TEDS or manual voucher, or the Contractor may include the credit as a listing of under $10.00 credit transactions and submit it monthly in the Bank Account Reconciliation Report.

G.3.6.14.3. Replacement of Pharmacy Benefit Payments.

G.3.6.14.3.1. Reissuance of payments will be made against the current fiscal year bank account in use at the time of the reissuance.

G.3.6.14.3.2. Replacement payments may be issued upon request of the payee or authorized representative. If the check is not returned by the payee, the payee must provide a statement describing the loss or destruction of the check. Before a replacement check is issued, a stop payment order for the original check must have been issued and accepted by the bank.

G.3.6.14.3.3. The Contractor shall report the reissuance using the same procedure as was used to void/staledate the original (i.e. on a TED or on a manual approval).

G.3.6.14.3.4. If the reissuance is for a check that cannot be done as a TED record and a void was already reported to CRM, the Contractor shall submit a request for approval of check release to DHA/CRM within 10 workdays of the request by payee. Supporting documentation shall include the original check, the sponsor’s SSN, branch of service, a copy of the EOB or other documentation showing the computation, and, if needed, a statement as described in G.3.6.14.3.1 above.

G.3.6.14.3.5. If no credit voucher was reported to DHA in the voiding/staledating of the check, no credit voucher is required for the reissue (i.e. if the Contractor gets a returned check and immediately reissues from the same bank account, no TED or other voucher needs to be done). If the reissuance involves a check from a prior year, a TED or other voucher will need to be done to report the reissuance from the current year as well as a void for the original check.

G.3.6.14.3.6. If the amount of a staledated/voided check to be reissued is $10.00 or less, the Contractor shall use the same procedure in the reissuance as was used for the staledating. If no credit voucher was made in the staledating of the check, no credit voucher is required for the reissue. The Contractor shall reissue the payment and include the amount in the Pharmacy Bank Account Reconciliation Report.

G.3.6.14.3.7. Re-issuance of checks When Original Payee is deceased: Checks/EFTs issued by the Contractor shall be made payable to the legal representative of the estate of the person concerned with an additional line stating “For the estate of _____.” Checks shall not be payable to the “estate of” a decedent, nor to a deceased person. Checks shall be delivered to the named payee or mailed to the payee’s address of record.

G.3.6.15. Federal Fiscal Year-end Processing/Fiscal Year Start-up.

G.3.6.15.1. Federal Fiscal Year-end Processing All TEDS records must be received no later than 10:00 AM Eastern Daylight Time (EDT), (8:00 AM Mountain Daylight Time (MDT); 7:00 AM Pacific Daylight Time (PDT) on September 28. Any Batch/Voucher received after 10:00 AM EDT will be rejected by DHA and must be resubmitted by the Contractor using next fiscal year Batch/Voucher CLIN/ASAP Account Numbers. The Contractor should not submit Batch/Vouchers with dates of September 29 and September 30. Any payment processed after September 28 must use the next fiscal year Batch/Voucher CLIN/ASAP Account Numbers and must utilize the new fiscal year check stock, as applicable.