T-5 FINAL RFP - Amendment 0002.pdf

(x)

HT940220R0005

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1 copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted ; or (c) By separate letter or telegram which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGEMENT TO BE RECEIVED AT

THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted , such change may be made by telegram or letter, provided each telegram or letter makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

x

HT9402

AURORA CO 80011

16401 E CENTRETECH PARKWAY

DEFENSE HEALTH AGENCY-AURORA

DEFENSE HEALTH AGENCY

06/25/20210002

13. THIS ITEM ONLY APPLIES TO MODIFICATION OF CONTRACTS/ORDERS. IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

12. ACCOUNTING AND APPROPRIATION DATA (If required) is not extended.is extended, Items 8 and 15, and returning

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended , by one of the following methods: (a) By completing

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

FACILITY CODE CODE

10B. DATED (SEE ITEM 13)

10A. MODIFICATION OF CONTRACT/ORDER NO.

9B. DATED (SEE ITEM 11)

9A. AMENDMENT OF SOLICITATION NO.

CODE

8. NAME AND ADDRESS OF CONTRACTOR (No., street, county, State and ZIP Code)

7. ADMINISTERED BY (If other than Item 6)CODE 6. ISSUED BY

PAGE OF PAGES

4. REQUISITION/PURCHASE REQ. NO.3. EFFECTIVE DATE2. AMENDMENT/MODIFICATION NO. 5. PROJECT NO. (If applicable)

1. CONTRACT ID CODE

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

04/15/2021

CHECK ONE A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER (Specify type of modification and authority) appropriation date, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

E. IMPORTANT: Contractor is not, is required to sign this document and return __________________ copies to the issuing office.

ORDER NO. IN ITEM 10A.

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

Changes incorporated herein are described in the Summary of Changes on the continuation page of this amendment. This amendment is in response to questions submitted since issuance of the RFP and other identified administrative changes. Offerors are requested to acknowledge receipt of all amendments hereto upon submission of proposal as explained in Block 11.

16A. NAME AND TITLE OF CONTRACTING OFFICER (Type or print)15A. NAME AND TITLE OF SIGNER (Type or print)

15C. DATE SIGNED 16B. UNITED STATES OF AMERICA 15B. CONTRACTOR/OFFEROR 16C. DATE SIGNED

(Signature of person authorized to sign) (Signature of Contracting Officer)

EVAN ZASLOW

STANDARD FORM 30 (REV. 10-83)

Prescribed by GSA

FAR (48 CFR) 53.243

NSN 7540-01-152-8070

Previous edition unusable

Except as provided herein, all terms and conditions of the document referenced in Item 9 A or 10A, as heretofore changed, remains unchanged and in full force and effect .

EVAN.J.ZASLOW.CIV@MAIL.MIL

303-676-3646

HT9402-20-R-0005 Amendment 00022 of 5

A. Changes incorporated herein are described in the Summary of Changes on the continuation pages of this amendment. This amendment is in response to questions submitted since issuance of the RFP and other identified administrative changes. The conforming action described in this amendment does not relieve the Offeror of the requirement to acknowledge receipt of each amendment issued in accordance with instructions in item 11 above as indicated in Block 14 of the SF 33, Solicitation, Offer and Award.

B. Summary of Changes:

Document Section/Paragraph # Change/Revision RFP Section C.1.4. TRICARE Systems Manual (TSM) 7950.3-M, June 23, 2021

TRICARE Operations Manual (TOM) 6010.59-M, June 23, 2021 RFP Section C.2.12.2.1. Sentence revised: “The Contractor shall establish and operate a

QM/QI program that effectively supports ongoing quality improvement efforts.”

RFP Section C.2.12.2.2. Removed language: “the clinical quality of health care rendered and.”

RFP Section C.2.14. Added paragraph.

RFP Section F.3.1.3. Deleted CDRL M560.

RFP Section F.3.1.6. Deleted CDRL A290.

RFP Section H.3.2.1.3. Added “The discount credit will be calculated in the aggregate, not at the individual TED record level.”

RFP Section H.5.6.1. Revised reference from H.5.6.4. to H.5.6.2.

RFP Section H.5.6.2. Revised paragraph entirely and replaced.

RFP Section H.5.6.3. Deleted.

RFP Section H.5.6.4. Deleted.

RFP Section H.5.7.2. Removed “24 hours” and inserted “1 business day.”

RFP Section H.5.7.4. Added sentence: “The total potential Performance Guarantee across all assessments is $3,600,000.”

RFP Section H.5.8.4. Revised sentence: “The Government reserves the right to reassess the Contractor’s performance of the accuracy standard and/or the claims first pass auto-adjudication standard, a maximum of one time, 30 calendar days following the initial assessment.” and added the word “the” into the last sentence.

RFP Section H.5.10. Revised Standard: The Government will assess the contractor’s directory to ensure it meets minimum accuracy standards as described in C.2.1.13.5.3 for all network providers in the region.

The Government will use calculations specified in C.2.1.13.5.5.

For each occurrence when the provider directory accuracy standard is not met at the regional level, a Performance Guarantee of $250,000 shall be applied.

An occurrence is considered an assessment where the Government validates up to 500 network provider directory listings.

RFP Section H.10.3.1.1. Revised sentence: “The Contractor shall forward the claims documentation to the TCRS Contractor and notify the CO of completion via email unless otherwise directed.”

RFP Section J.1. Added Attachment J-22 Crosswalk Matrix RFP Section L.2.3. Added references to Section B and H and adds “Note: This attachment provides a general cross reference between solicitation sections and is not intended to be a substitute for the Offeror's reading and complying with the solicitation

HT9402-20-R-0005 Amendment 00023 of 5 requirements. The Offeror is solely responsible for reading the solicitation and submitting a proposal in compliance with all instructions, requirements, terms and conditions. Attachment L-1 will not be used to limit the scope of the Government's evaluation under the cited Section M references; any information deemed relevant to the evaluation factor may be considered.”

RFP Section L.6.2.1.7. Added “by the referring MTFs.” to last sentence.

RFP Section L.6.2.2.8. Entire paragraph has been revised.

RFP Section L.6.2.4.1. Added language clarifying CMMI Level 4 Certification.

RFP

Section L.8.17.

Removed “costs” and replaced with “CLINS” and updated baseline estimates for underwritten healthcare at CLINS 1001- 8001 for the East and West Regions.

RFP Section M.7.2.1.7. Added “by the referring MTFs.” to last sentence.

RFP Section M.7.2.2.8. Entire paragraph has been revised.

RFP Section M.7.2.3.5. Entire paragraph has been revised.

RFP Section M.7.2.4.1. Entire paragraph has been revised.

RFP Attachment J-3 Revised/Updated.

RFP Attachment J-8 Revised/Updated.

RFP Attachment J-10 File renamed to “KSA Scores by MTF/Code Type.”

RFP Attachment J-13 Revised/Updated.

RFP Attachment J-19 Revised/Updated.

RFP Attachment J-22 Added.

RFP Attachment L-1 Revised/Updated.

RFP Attachment L-2 Revised/Updated.

RFP Attachment L-3e Revised/Updated.

RFP Attachment L-3w Revised/Updated.

RFP Attachment L-5e Revised/Updated.

RFP Attachment L-5w Revised/Updated.

RFP Attachment L-9e Revised/Updated.

RFP Attachment L-9w Revised/Updated.

RFP Attachment L-12 Revised/Updated.

RFP Attachment L-16 Revised/Updated.

CDRL Exhibit A Master

CDRL Listing Updated with 06/16/2021 date.

CDRL P020 Revised/replaced in its entirety.

CDRL P100 Revised/replaced in its entirety.

CDRL P200 Revised/replaced in its entirety.

CDRL M030 Revised/replaced in its entirety.

CDRL M090 Revised/replaced in its entirety.

CDRL M290 Revised/replaced in its entirety.

CDRL M560 Deleted.

CDRL S010 Revised/replaced in its entirety.

CDRL Q120 Revised/replaced in its entirety.

CDRL Q280 Revised/replaced in its entirety.

CDRL R020 Revised/replaced in its entirety.

CDRL R030 Revised/replaced in its entirety.

CDRL A140 Revised/replaced in its entirety.

CDRL A290 Deleted.

CDRL W040 Revised/replaced in its entirety.

HT9402-20-R-0005 Amendment 00024 of 5

TSM Chapter 2, Section 1, Para 1.1.1.

Deleted paragraph in its entirety.

TOM Chapter 1, Section 3, Para 5.2.1.

In the first and third bullets changed “within 24 hours” to “one business day.”

TOM Chapter 1, Section 3, Para 5.2.2.

Inserted “The contractor shall complete a 100% audit of MTF Prime referrals and for Network Prime referrals the contractor shall random sample audit a statistically valid sample size at p = 0.5, at a 95% confidence level, with a margin of error of +-1 for each 12-month option period and provide monthly audit reports based on a minimum of 800 referrals per month” before the last sentence.

TOM Chapter 1, Section 3, Para 6.5.2. and 6.5.3.

Added the following after the first sentence as follows:

“Deferred claims include some claims that are excluded from the total monthly claims volumes. Details for reporting are identified in DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.

Deferred claims excluded from this requirement are defined as:

• Claims requiring development for possible Third Party Liability (TPL) or Other Health insurance (OHI);

• Claims requiring intervention by another Prime contractor;

and

• Claims requiring Government intervention (i.e., claims held for pricing updates, claims held pending the issuance of a policy change or as a result of change orders, etc.).”

TOM Chapter 2, Section 6, Para 2.4.

The first bullet is changed from “one hundred eigth” to “one hundred eighty”

TOM Chapter 2, Section 6, Para 2.4.

Deleted the fifth bullet and replaced with “For the last 30 days of HCD, the outgoing contractor shall transfer records to the incoming contractor weekly. The records shall be transferred no later than the second business day of the week.”

TOM Chapter 2, Section 6, Para 3.4.

Deleted the fifth bullet and replaced with “For the last 30 days of HCD, the outgoing contractor shall transfer records to the incoming contractor weekly. The records shall be transferred no later than the second business day of the week.”

TOM Chapter 2, Section 7, Para 2.1.9.

Deleted “referrals by 8:00 am next for referrals received by 3:00 pm local time” and replace with “all requests within one business day.”

TOM Chapter 5, Section 1, Para 7.6. and 9.5.

Deleted.

TOM Chapter 7, Section 1, Para 4.1.

Inserted “between the Managed Care Support Contractor (MCSC) and TRICARE Pharmacy (T-Pharm) contractor (see DD Form 1423, CDRL, located in Section J of the applicable contract.)” before the last sentence.

TOM Chapter 7, Section 6, Para 6.4.

Inserted “Clinical Quality” after “The Peer Review Committee shall assure all identified”

TOM Chapter 7, Section 6, Para 9.2.

Changed to “The contractor shall partner with network facilities partner and recommend performance improvement strategies and work with them to achieve measurable improvements in outcomes when unfavorable trends are shown within all CQM data monitored in the applicable contract.”

HT9402-20-R-0005 Amendment 00025 of 5

TOM Chapter 11, Section 4, Para 2.0.

Inserted the following:

2.0 Military Health System (MHS) Staff Inquiry Processing

2.1. The contractor shall designate staff with Government

issued Common Access Cards (CACs) to respond to MHS staff customer service inquiries via a Government-designated, bi-directional, encrypted system.

2.2. The contract shall response to routine inquiries from

MHS staff members within 10 business days and priority inquires within 3 business days.

2.3. Inquiries from designated staff shall be processed as

priority for all cases.

2.4. The Government-designated, encrypted

system shall be utilized by the prime contractor and all subcontractors.

And renumbered the subsequent paragraphs.

TOM Chapter 13, Section 1, Para 6.2.2.5.

Inserted “and includes a year to year variance comparison for all periods of the contract.” before the last sentence.

TOM Chapter 13, Section 4, Para 4.5.1.

Changed “two hours” to “two business days”

TOM Chapter 18, Section 3. Deleted Section 3 and replaced in its entirety, same reference.

TOM Chapter 18, Section 4. Section 4 is “Expired.”

C. The solicitation is amended to reflect changes described herein; solicitation sections, attachments, CDRLs, and TRICARE Manuals are provided as reflected on beta.sam.gov. Changed areas are indicated by a vertical line in the left margin, with the exception of the updated attachments and CDRLs, which were replaced in their entirety.

HT940220R0005

SOLICITATION, OFFER AND AWARD

4. TYPE OF SOLICITATION2. CONTRACT NUMBER 3. SOLICITATION NUMBER

7. ISSUED BY CODE 8. ADDRESS OFFER TO (If other than Item 7)

ORDER UNDER DPAS (15 CFR 700)

6. REQUISITION/PURCHASE NUMBER

NOTE: In sealed bid solicitations "offer" and "offeror" mean "bid" and "bidder".

NEGOTIATED (RFP)

SEALED BID (IFB)

5. DATE ISSUED

1. THIS CONTRACT IS A RATED RATING PAGE OF PAGES

1 201

C. E-MAIL ADDRESS

EXT.NUMBERAREA CODE

B. TELEPHONE (NO COLLECT CALLS)A. NAME

10. FOR

INFORMATION

CALL:

CAUTION: LATE Submissions, Modifications, and Withdrawals: See Section L, Provision No. 52.214-7 or 52.215-1. All offers are subject to all terms and conditions contained in this solicitation.

(Date)(Hour) local timeuntildepository located in copies for furnishing the supplies or services in the Schedule will be received at the place specified in Item 8, or if hand carried, in the

SOLICITATION

9. Sealed offers in original and

PART IV - REPRESENTATIONS AND INSTRUCTIONS

OTHER STATEMENTS OF OFFERORS

EVALUATION FACTORS FOR AWARD

INSTRS., CONDS., AND NOTICES TO OFFERORS

REPRESENTATIONS, CERTIFICATIONS AND

LIST OF ATTACHMENTS

CONTRACT CLAUSES

PART III - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACH.

I

J

K

L

M SPECIAL CONTRACT REQUIREMENTS

CONTRACT ADMINISTRATION DATA

DELIVERIES OR PERFORMANCE

INSPECTION AND ACCEPTANCE

PACKAGING AND MARKING

DESCRIPTION/SPECS./WORK STATEMENT

SUPPLIES OR SERVICES AND PRICES/COSTS

SOLICITATION/CONTRACT FORM

PART II - CONTRACT CLAUSESPART I - THE SCHEDULE

H

G

F

E

D

C

B

A

SEC. DESCRIPTION PAGE(S) (X) DESCRIPTION SEC. (X)

11. TABLE OF CONTENTS

18. OFFER DATE17. SIGNATURE

SUCH ADDRESS IN SCHEDULE.

IS DIFFERENT FROM ABOVE - ENTER

15C. CHECK IF REMITTANCE ADDRESS

EXT.NUMBERAREA CODE

15B. TELEPHONE NUMBER

(Type or print)AND

ADDRESS

OF

OFFEROR

CODE FACILITY

16. NAME AND TITLE OF PERSON AUTHORIZED TO SIGN OFFER15A. NAME

DATEAMENDMENT NO.DATEAMENDMENT NO.

and related documents numbered and dated):

amendments to the SOLICITATION for offerors

(The offeror acknowledges receipt of

14. ACKNOWLEDGEMENT OF AMENDMENTS

CALENDAR DAYS (%)30 CALENDAR DAYS (%)20 CALENDAR DAYS (%)10 CALENDAR DAYS (%)

(See Section I, Clause No. 52.232.8)

13. DISCOUNT FOR PROMPT PAYMENT

designated point(s), within the time specified in the schedule.

by the offeror) from the date for receipt of offers specified above, to furnish any or all items upon which prices are offered at the price set opposite each item, delivered at the

12. In compliance with the above, the undersigned agrees, if this offer is accepted within ______________ calendar days (60 calendar days unless a different period is inserted

NOTE: Item 12 does not apply if the solicitation includes the provisions at 52.214-16, Minimum Bid Acceptance Period.

OFFER (Must be fully completed by offeror)

IMPORTANT - Award will be made on this Form, or on Standard Form 26, or by other authorized official written notice.

28. AWARD DATE

(Signature of Contracting Officer)

27. UNITED STATES OF AMERICA

25. PAYMENT WILL BE MADE BY

26. NAME OF CONTRACTING OFFICER (Type or print)

CODE 24. ADMINISTERED BY (If other than Item 7)

ITEM

(4 copies unless otherwise specified)

23. SUBMIT INVOICES TO ADDRESS SHOWN IN

41 U.S.C. 253 (c) ( 10 U.S.C. 2304 (c) (

22. AUTHORITY FOR USING OTHER THAN FULL AND OPEN COMPETITION:

21. ACCOUNTING AND APPROPRIATION20. AMOUNT19. ACCEPTED AS TO ITEMS NUMBERED

AWARD (To be completed by government)

CODE

04/15/2021 X

HT9402

DEFENSE HEALTH AGENCY

DEFENSE HEALTH AGENCY-AURORA

16401 E CENTRETECH PARKWAY

AURORA CO 80011

1200 MDT 08/13/2021

Marcus R. Webb 303 marcus.r.webb.civ@mail.mil

676-3906

X

X

X

X

X

X

X

X

X

X

X

X

X

PAGE(S)

EVAN ZASLOW

AUTHORIZED FOR LOCAL REPRODUCTION

Previous edition is unusable

STANDARD FORM 33 (Rev. 9-97)

Prescribed by GSA - FAR (48 CFR) 53.214(c)

2-15 C1-C25

F1-F10 G1-G19 H1-H38

I1-I17

J1-J2

K1-K9

L1-L39 M1-M25

303-676-3646

EVAN.J.ZASLOW.CIV@MAIL.MIL

DO-C9

D1 E1

(Refer to L.4. Proposal Preparation)

(Refer to L.4.1. Electronic Proposal Submission and Proposal Due Date)

Amendment 0002

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

2 201

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940220R0005

(A) (B) (C) (D) (E) (F)

BASE YEAR; TRANSITION-IN PERIOD 1 Jan 2023 – 31

December 2023

0001 Transition-In (Firm-Fixed-Price) Planning and

Implementation of Transition-In as stated in

C.2.12.19

BASE YEAR; TRANSITION-IN PERIOD 1 Jan 2023 – 31

December 2023

0001AA Transition Readiness Milestone (5% of CLIN 0001 1 EA

Amount)

(Firm-Fixed-Price)

BASE YEAR; TRANSITION-IN PERIOD 1 Jan 2023 – 31

December 2023

0001AB Pre-Startup Validation Milestone (10% of CLIN 1 EA

0001 Amount)

(Firm-Fixed-Price)

BASE YEAR; TRANSITION-IN PERIOD 1 Jan 2023 – 31

December 2023

0001AC Pre-Open Season Milestone (40% of CLIN 0001 1 EA

Amount)

(Firm-Fixed-Price)

BASE YEAR; TRANSITION-IN PERIOD 1 Jan 2023 – 31

December 2023

0001AD Start of Health Care Delivery Milestone (45% of 1 EA

CLIN 0001 Amount)

(Firm-Fixed-Price)

0002 Contract Data Requirements List (DD Form

Continued ...

NSP

Amendment 0002 aminisini Sticky Note Completed set by aminisini aminisini Sticky Note None set by aminisini

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(A) (B) (C) (D) (E) (F)

1001 1 LO

1002 12 MO

1003AA EA

1003AB EA

1003AC EA

1423-1)(Not Separately Priced)

Transition-In

OPTION PERIOD 1 - 1 Jan 2024 – 31 December 2024

Underwritten Health Care Cost for Contractor

Network Prime Enrollees, Non-Prime Underwritten

Beneficiaries, and MTF Enrollees (Cost Plus Fixed

Fee)(Estimated Cost)

(Option Line Item)

Future Potential Demonstrations ($15,000,000 Government Plug-in Amount)

Anticipated Award Type: Firm-fixed-price (Option Line Item)

Managed Care Support Services

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(1st

Quarter of Calendar Year(CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(2nd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(3rd

Quarter of CY))

(Option Line Item)

Continued ...

15,000,000__________1,250,000

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(A) (B) (C) (D) (E) (F)

1003AD EA

1005 1 LO

1007 1 LO

2001 1 LO

2002 12 MO

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(4th

Quarter of CY))

(Option Line Item)

Clinical Support Agreements

(CSAs)(Firm-Fixed-Price)

(Option Line Item)

MTF/Guard/Reserve/MSO/VSO Briefings ($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

Contract Data Requirements List (DD Form

1423-1)(Not Separately Priced)

(Option Line Item)

Service Assist Teams (Mobile Disaster)($200,000 Ceiling)(Cost Reimbursable) (Option Line Item)

OPTION PERIOD 2 - 1 Jan 2025 – 31 December 2025

Underwritten Health Care Cost for Contractor

Network Prime Enrollees, Non-Prime Underwritten

Beneficiaries, and MTF Enrollees (Cost Plus Fixed

Fee)(Estimated Cost)

(Option Line Item)

Future Potential Demonstrations ($15,000,000 Government Provided Plug-in Amount)

(Option Line Item)

Continued ...

NSP

15,000,000__________1,250,000

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(A) (B) (C) (D) (E) (F)

2003AA EA

2003AB EA

2003AC EA

2003AD EA

2005 1 LO

Managed Care Support Services

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(1st

Quarter of Calendar Year(CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(2nd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(3rd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(4th

Quarter of CY))

(Option Line Item)

Clinical Support Agreements

(CSAs)(Firm-Fixed-Price)

(Option Line Item)

MTF/Guard/Reserve/MSO/VSO Briefings ($200,000 Ceiling) (Cost Reimbursable)

(Option Line Item)

Continued ...

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(A) (B) (C) (D) (E) (F)

2007 1 LO

3001 1 LO

3002 12 MO

3003AA EA

3003AB EA

3003AC EA

Contract Data Requirements List (DD Form

1423-1)(Not Separately Priced)

(Option Line Item)

Service Assist Teams (Mobile Disaster) ($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

OPTION PERIOD 3 - 1 Jan 2026 – 31 December 2026

Underwritten Health Care Cost for Contractor

Network Prime Enrollees, Non-Prime Underwritten

Beneficiaries, and MTF Enrollees (Cost Plus Fixed

Fee)(Estimated Cost)

(Option Line Item)

Future Potential Demonstrations ($15,000,000 Government Plug-in Amount) (Option Line Item)

Managed Care Support Services

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(1st

Quarter of Calendar Year(CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(2nd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

Continued ...

NSP

15,000,0001,250,000___________

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(A) (B) (C) (D) (E) (F)

3003AD EA

3005 1 LO

3007 1 LO

4001 1 LO

4002 12 MO

(Firm-Fixed-Price)(Estimated Quantity)(3rd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(4th

Quarter of CY))

(Option Line Item)

Clinical Support Agreements

(CSAs)(Firm-Fixed-Price)

(Option Line Item)

MTF/Guard/Reserve/MSO/VSO Briefings ($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

Contract Data Requirements List (DD Form

1423-1)(Not Separately Priced)

(Option Line Item)

Service Assist Teams (Mobile Disaster) ($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

OPTION PERIOD 4 - 1 Jan 2027 – 31 December 2027

Underwritten Health Care Cost for Contractor

Network Prime Enrollees, Non-Prime Underwritten

Beneficiaries, and MTF Enrollees (Cost Plus Fixed

Fee)(Estimated Cost)

(Option Line Item)

Planned Competitive Demonstrations Transition-Out ($3,000,000 Government Plug-in Amount) (Option Line Item)

Continued ...

NSP

3,000,000250,000________

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(A) (B) (C) (D) (E) (F)

4003AA EA

4003AB EA

4003AC EA

4003AD EA

4005 1 LO

Managed Care Support Services

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(1st

Quarter of Calendar Year(CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(2nd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(3rd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(4th

Quarter of CY))

(Option Line Item)

Clinical Support Agreements

(CSAs)(Firm-Fixed-Price)

(Option Line Item)

MTF/Guard/Reserve/MSO/VSO Briefings ($200,000 Ceiling) (Cost Reimbursable)

(Option Line Item)

Contract Data Requirements List (DD Form

Continued ...

NSP

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(A) (B) (C) (D) (E) (F)

4007 1 LO

5001 1 LO

5002 12 MO

5003AA EA

5003AB EA

5003AC EA

1423-1)(Not Separately Priced)

(Option Line Item)

Service Assist Teams (Mobile Disaster) ($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

OPTION PERIOD 5 - 1 Jan 2028 – 31 December 2028

Underwritten Health Care Cost for Contractor

Network Prime Enrollees, Non-Prime Underwritten

Beneficiaries, and MTF Enrollees (Cost Plus Fixed

Fee)(Estimated Cost)

(Option Line Item)

Future Potential Demonstrations

(Option Line Item)

Managed Care Support Services

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(1st

Quarter of Calendar Year(CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(2nd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(3rd

Quarter of CY))

(Option Line Item)

Continued ...

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5005 1 LO

5007 1 LO

6001 1 LO

6002 12 MO

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(4th

Quarter of CY))

(Option Line Item)

Clinical Support Agreements

(CSAs)(Firm-Fixed-Price)

(Option Line Item)

MTF/Guard/Reserve/MSO/VSO Briefings

($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

Contract Data Requirements List (DD Form

1423-1)(Not Separately Priced)

(Option Line Item)

Service Assist Teams (Mobile Disaster) ($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

OPTION PERIOD 6 - 1 Jan 2029 – 31 December 2029

Underwritten Health Care Cost for Contractor

Network Prime Enrollees, Non-Prime Underwritten

Beneficiaries, and MTF Enrollees (Cost Plus Fixed

Fee)(Estimated Cost)

(Option Line Item)

Future Potential Demonstrations

(Option Line Item)

Managed Care Support Services

(Option Line Item)

Continued ...

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6003AB EA

6003AC EA

6003AD EA

6005 1 LO

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(1st

Quarter of Calendar Year(CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(2nd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(3rd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(4th

Quarter of CY))

(Option Line Item)

Clinical Support Agreements

(CSAs)(Firm-Fixed-Price)

(Option Line Item)

MTF/Guard/Reserve/MSO/VSO Briefings ($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

Contract Data Requirements List (DD Form

1423-1)(Not Separately Priced)

(Option Line Item)

Continued ...

NSP

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6007 1 LO

7001 1 LO

7002 12 MO

7003AA EA

7003AB EA

7003AC EA

7003AD EA

Service Assist Teams (Mobile Disaster) ($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

OPTION PERIOD 7 - 1 Jan 2030 – 31 December 2030

Underwritten Health Care Cost for Contractor

Network Prime Enrollees, Non-Prime Underwritten

Beneficiaries, and MTF Enrollees (Cost Plus Fixed

Fee)(Estimated Cost)

(Option Line Item)

Future Potential Demonstrations

(Option Line Item)

Managed Care Support Services

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(1st

Quarter of Calendar Year(CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(2nd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(3rd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Continued ...

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7005 1 LO

7007 1 LO

8001 1 LO

8002 12 MO

8003AA EA

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(4th

Quarter of CY))

(Option Line Item)

Clinical Support Agreements

(CSAs)(Firm-Fixed-Price)

(Option Line Item)

MTF/Guard/Reserve/MSO/VSO Briefings ($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

Contract Data Requirements List (DD Form

1423-1)(Not Separately Priced)

(Option Line Item)

Service Assist Teams (Mobile Disaster) ($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

OPTION PERIOD 8 - 1 Jan 2031 – 31 December 2031

Underwritten Health Care Cost for Contractor

Network Prime Enrollees, Non-Prime Underwritten

Beneficiaries, and MTF Enrollees (Cost Plus Fixed

Fee)(Estimated Cost)

(Option Line Item)

Future Potential Demonstrations

(Option Line Item)

Managed Care Support Services

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

Continued ...

NSP

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8003AB EA

8003AC EA

8003AD EA

8005 1 LO

8007 1 LO

(Firm-Fixed-Price)(Estimated Quantity)(1st

Quarter of Calendar Year(CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(2nd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(3rd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(4th

Quarter of CY))

(Option Line Item)

Clinical Support Agreements

(CSAs)(Firm-Fixed-Price)

(Option Line Item)

MTF/Guard/Reserve/MSO/VSO Briefings ($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

Contract Data Requirements List (DD Form

1423-1)(Not Separately Priced)

(Option Line Item)

Service Assist Teams (Mobile Disaster)

($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

Continued ...

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(Option Line Item)

9002 Contract Data Requirements List (DD Form 1423-1)

Transition-Out (Not Separately Priced)

(Option Line Item)

EXTENSION PERIOD 1 JAN 2032 - 30 JUN 2032

9003 Extension of Services (FAR 52.217-8) 6-Month 6 MO

Option Period Extension, If Required

(Option Line Item)

NSP

SECTION C

DESCRIPTION/SPECIFICATIONS/STATEMENT OF WORK

HT940220R0005 Page C1 of C25 Amendment 0002

C.1. GENERAL

C.1.1. The purpose of this contract is to provide Managed Care Support (MCS) to the Department of Defense (DoD) TRICARE program. The MCS Contractor shall assist the Military Health System (MHS) in operating an integrated healthcare delivery system combining resources of the military’s direct medical care system and the Contractor’s managed care support to provide health, medical, and administrative support services to TRICARE-eligible beneficiaries.

C.1.2. Contract Objectives

C.1.2.1. Objective 1 - Readiness: Support the MHS readiness mission by partnering with the Military Medical Treatment Facilities (MTFs) to optimize the delivery of health care services to enhance the clinical expertise of providers in the direct care system (see definition of MTF optimization in the TRICARE Manual, Definitions1) for all TRICARE-eligible beneficiaries (see definition at Title 32 Code of Federal Regulations (CFR) Part 199.17(a)(6)(i)).

C.1.2.2. Objective 2 - Experience of Care: Provide a care experience that is patient and family centered, compassionate, convenient, equitable, safe, and always of the highest quality.

C.1.2.3. Objective 3 - Manage Per Capita Cost: Create value by focusing on quality, eliminating waste, and reducing unwarranted variation; considering the total cost of care over time, not just the cost of an individual health care activity.

C.1.2.4. Objective 4 - Population Health: Within the constraints, boundaries, and benefits of the current program, encourage beneficiaries and providers to seek ways to improve health.

C.1.3. Definitions of terms are provided in 32 CFR Part 199.2 and the TRICARE Manual, Definitions.

C.1.4. The following documents are hereby incorporated by reference and form an integral part of this contract. Documentation incorporated into this contract by reference has the same force and effect as if set forth in full text.

• Title 10, United States Code, Chapter 55

• 32 CFR Part 199

• TRICARE Policy Manual (TPM) 6010.60-M, April 2021

• TRICARE Reimbursement Manual (TRM) 6010.61-M, April 2021

• TRICARE Systems Manual (TSM) 7950.3-M, April 2021 June 23, 2021

• TRICARE Operations Manual (TOM) 6010.59-M, April 2021 June 23, 2021

C.1.4.1. The TRICARE Manuals provide instruction, guidance, and responsibilities in addition to the requirements set forth in the incorporated federal statutes and regulations and may not be

1Definitions are available at:

https://manuals.health.mil/pages/v3/DownloadManualFile.aspx?Filename=Definitions.pdf

HT940220R0005 Page C2 of C25 Amendment 0002 interpreted in contradiction thereto. Among the Manuals, the TPM takes precedence over the other three TRICARE Manuals. The TRM takes precedence over the TSM and the TOM. The TSM takes precedence over the TOM.

C.2. PERFORMANCE REQUIREMENTS

C.2.1. Provider Networks

C.2.1.1. The Contractor shall establish and maintain a preferred provider network of individual and institutional providers (see 32 CFR 199.17(p)) who produce high quality clinical outcomes for TRICARE beneficiaries.

C.2.1.1.1. The Contractor shall ensure that all of its network providers are Medicare participating providers (unless they are not eligible to be participating providers under Medicare) and that the providers in its network are sufficient in number, mix, and geographic distribution to provide the full scope of benefits for which all TRICARE enrollees are eligible under this contract, as described in 32 CFR 199.4, 32 CFR 199.5, and 32 CFR 199.17.

C.2.1.1.2. The Contractor shall provide Prime Service Areas (PSAs) at all locations listed in the attachments applicable to its geographic area of responsibility: Attachments J-1 through J-6, Mandatory Government Required PSA Lists; and J-1a through J-2a, Mandatory Government Required Base Relocation and Closure (BRAC) PSA Lists.

C.2.1.1.3. The Contractor shall adjust provider networks and services as necessary to compensate for changes in Market/MTF capabilities and capacities when and where they occur over the life of the contract, including those resulting from unanticipated facility expansions, Market/MTF provider deployments, facility downsizing, or facility closures.

C.2.1.1.4. The Contractor shall submit a network implementation plan detailing all phases of its network development and implementation in accordance with the TOM, Chapter 2, Section 3.

For plan details see DD Form 1423-1, Contract Data Requirements List (CDRL), located in Section J.

C.2.1.2. The Contractor’s network implementation plan shall address all components of network development, including the Contractor's network sizing model and the formula(s) used to derive network specialty targets, by provider specialty in its geographic area of responsibility.

C.2.1.3. TRICARE Minimum Appointment Access Standards

C.2.1.3.1. The Contractor’s network shall meet minimum appointment access standards (see 32 CFR 199.17(p)(5)) for all provider types in the network.

C.2.1.4. TRICARE Minimum Travel Time Standards

HT940220R0005 Page C3 of C25 Amendment 0002

C.2.1.4.1. The Contractor shall, at a minimum, take into account normal traffic conditions and geographic barriers such as bridges, mountains, and tunnels in calculating beneficiary travel times.

C.2.1.4.2. The Contractor shall not use telemedicine access in the calculation of minimum travel time standards.

C.2.1.5. Network Service Area Reporting

C.2.1.5.1. The Contractor shall specify areas, through ZIP codes, where its network is available to TRICARE beneficiaries.

C.2.1.5.2. The Contractor shall ensure its network ZIP code list is updated with changes from DHA and that such changes are implemented within its systems each month. For reporting requirements see DD Form 1423-1, CDRL, located in Section J.

C.2.1.6. The Contractor’s network shall meet all access to care standards listed in 32 CFR 199.17(p)(5). The Contractor’s network shall provide network coverage for at least 85 percent of TRICARE Select enrollees. For reporting requirements, see DD Form 1423-1, CDRL, located in Section J.

C.2.1.6.1. The Contractor shall develop and implement a system for continuously monitoring, and evaluating network adequacy and for reporting network adequacy or access issues to the Government. For reporting requirements see DD Form 1423-1, CDRL, located in Section J.

C.2.1.6.2. The Contractor shall submit a plan for reporting on access to care for TRICARE beneficiaries. The Contractor’s plan shall explain how the Contractor will report access to care data at the PSA, Market, and State level for the Contractor’s geographic area of responsibility.

The Contractor shall report on how it measured appointment availability (e.g., by employing surveys). For plan reporting requirements see DD Form 1423-1, CDRL, located in Section J.

C.2.1.7. The contractor shall develop and implement a system for continuously monitoring network appointment availability for all provider and facility types. The Contractor shall assess appointment availability for each provider type in its network, at a minimum annually and otherwise as requested by the Government, to ensure beneficiary access to care. When directed by the Government, the contractor shall assess bed availability for each type of network facility.

For reporting requirements see DD Form 1423-1, CDRL, located in Section J.

C.2.1.8. The Contractor shall measure enrolled beneficiary access to telehealth services in rural, remote, and isolated areas. For reporting requirements see DD Form 1423-1, CDRL, located in Section J.

C.2.1.9. The Contractor shall monitor and report, on a monthly basis, all complaints by beneficiaries with respect to network adequacy or the availability of health care providers. For reporting requirements, see DD Form 1423-1, CDRL, located in Section J.

HT940220R0005 Page C4 of C25 Amendment 0002

C.2.1.10. The Contractor shall inform the Government, in a monthly report, of any instances of network inadequacy and shall submit a corresponding Corrective Action Plan (CAP).

Network inadequacy is defined as any failure to provide health care services within the network within the access standards, unless a Network Adequacy Waiver applies. The Contractor shall respond within two business days upon receipt of any inquiries from the Contracting Officer’s Representative (COR) concerning network inadequacy. For reporting requirements see DD Form 1423-1, CDRL, located in Section J.

C.2.1.11. Network Adequacy Waivers

C.2.1.11.1. The Contractor may apply for a waiver of network adequacy for a single provider type in a geographic area. Such an application must:

1. Be made in writing,

2. Identify the provider saturation rate for the specified geographic area: Calculated by dividing Providers Recruited into Network divided by number of providers (of the same type) in the specified area,

3. Identify all good faith efforts to bring providers into the network. If no providers of the specific provider type is available in the geographic area, the Contractor shall submit documentation to the Government and,

4. Demonstrate that the Contractor has exhausted its efforts to create a locality-based reimbursement rate waiver (see TRM, Chapter 5, Section 2).

C.2.1.11.2. The Contractor may remove a provider category from the network adequacy calculation in a geographic area (for the time period specified in the waiver) if the Government grants a Network Adequacy Waiver for that provider category.

C.2.1.12. Network Quality

C.2.1.12.1. The Contractor shall maintain accreditation by a national accrediting organization of its healthcare network in all geographic areas of responsibility throughout the life of this contract and all exercised options. National certification, in lieu of accreditation, is insufficient to meet this requirement. For reporting requirements, see DD Form 1423-1, CDRL, located in Section J.

Network accreditation shall be from a national body that considers quality benchmarks for network management, provider credentialing, quality management and improvement, and consumer protection.

C.2.1.12.2. The Contractor shall ensure the higher standard applies when this contract and the accrediting body have differing standards for the same activity.

C.2.1.12.3. The Contractor shall establish mechanisms to evaluate network providers using the quality metrics specified in the TOM Chapter 7, Section 6 and attachment J-11. The Contractor shall display meaningful quality metrics, at the individual provider and facility level, in an easily understood and accessible format as part of its online network directory.

HT940220R0005 Page C5 of C25 Amendment 0002

C.2.1.12.4. The Contractor shall develop and submit a value-based steerage model for referrals.

The Contractor’s steerage model shall be constructed to achieve the following outcomes: (1) improved access to care, (2) utilization of high quality health care providers, (3) MTF optimization (see paragraph C.2.12.10) and readiness of the force (e.g., taking into account provider effectiveness in returning clinical information to referring MTFs (see paragraph C.2.9) (when applicable), and (4) lowering average per capita healthcare costs. For plan reporting requirements see DD Form 1423-1, CDRL, located in Section J.

C.2.1.12.4.1. The Contractor shall submit a monthly report on its Value-Based Steerage Model/Plan’s performance on each of the four elements described in C.2.1.12.4, at the Market level, as an expression of total value. For reporting requirements see DD Form 1423-1, CDRL, located in Section J.

C.2.1.13. Network Provider Directory

C.2.1.13.1. The Contractor’s network provider directory shall clearly communicate the following information to beneficiaries:

1. Provider Name

2. Provider Gender

3. Provider place of practice address

4. Provider appointment telephone number

5. Primary Care Manager (PCM) (Y/N)

6. TRICARE Provider Readiness Designation (Y/N)

7. Provider Type [Primary Care, Urgent Care, Behavioral Health, Specialists, Hospital/Clinic/Other Facilities.]

8. Provider Specialty

9. Provider Subspecialty

10. Provider quality indicator(s)

11. Provider website (if available)

12. Telehealth availability

C.2.1.13.2. The provider directory shall clearly communicate the following information to the

DHA:

1. Provider Name

2. Provider Gender

3. Provider place of practice and address

4. Provider billing address

5. Provider Type

6. Provider Specialty

7. Provider Subspecialty

8. Provider quality indicator(s)

HT940220R0005 Page C6 of C25 Amendment 0002

9. Provider website (if available)

10. Provider business phone number

11. Provider appointment phone number

12. Provider fax number

13. Provider electronic address (Health Information Service Provider (HISP) address)

14. Participates in Health Information Exchange (Y/N)

C.2.1.13.3. The Contractor shall ensure that its on-line network provider directory is accessible to users on a continual (24 hours/7 days a week) basis except for scheduled downtime for system maintenance.

C.2.1.13.4. The Contractor shall schedule downtime for system maintenance of its on-line directory in accordance with the TRICARE Systems Manual.

C.2.1.13.4.1. The Contractor shall provide access on its website to a directory of TRICARE authorized, non-network providers who have submitted a claim to TRICARE over the past 14 months. The Contractor shall refresh this directory no less than semi-annually.

C.2.1.13.5. Provider Directory Accuracy

C.2.1.13.5.1. The Contractor shall use electronic means of verification in addition to manual outreach efforts to continuously maintain provider directory accuracy.

C.2.1.13.5.2. If a provider has not submitted a claim within 14 months or if there is no response from a provider through electronic or manual outreach efforts, the Contractor shall not display the provider in the directory.

C.2.1.13.5.3. The Contractor shall maintain a minimum network provider directory accuracy rate as follows:

OP1 OP2 OP3 OP4 OP5 OP6 OP7 OP8 Extension 74% 75% 76% 77% 78% 78% 79% 80% 81%

C.2.1.13.5.4. The Contractor shall calculate provider directory accuracy for each PSA and non- PSA area.

C.2.1.13.5.5. The Contractor shall calculate the network provider directory accuracy with the following data elements: provider name, provider specialty, provider sub-specialty, provider place of practice address, provider fax number and provider appointment telephone number.

Accuracy is defined as a directory record that contains correct information for all of the above data elements listed in this paragraph. The Contractor shall calculate network provider directory accuracy by dividing the total number of directory entries (records) that contain 100% correct information (no data element errors) by the total number of records. Requirements for data

HT940220R0005 Page C7 of C25 Amendment 0002 accuracy are not applicable to the on-line directory of TRICARE authorized, non-network providers.

C.2.1.13.5.6. Provider directory accuracy shall be reported monthly in accordance with DD Form 1423-1, CDRL, located in Section J.

C.2.1.13.5.7. The Contractor shall contact network providers biannually to validate information contained in the network provider directory.

C.2.2. Enrollment

C.2.2.1. The Contractor shall perform enrollments, re-enrollments, dis-enrollments, transfer enrollments, correct enrollment discrepancies, and assign or change beneficiary PCMs in accordance with the requirements of the TOM Chapter 6.

C.2.2.2. The Contractor shall utilize leading industry best practice automation in processing billing and enrollment transactions and such automation shall include the capability to capture email and other information needed to conduct electronic transactions.

C.2.3. Medical Management (MM)

C.2.3.1. The Contractor shall develop, implement, and maintain a MM Program, that includes behavioral health, in accordance with the requirements in the TOM Chapter 7, as well as complies with the TRICARE benefits provisions of 32 CFR 199.4, 32 CFR 199.5, and the TPM in order to provide health care for eligible beneficiaries to the extent authorized by law.

C.2.3.1.1. The Contractor’s MM programs shall support all services provided within each Market/MTF and shall be described in its Memorandum of Understanding (MOU) with each Market/MTF (see paragraph C.2.12.9).

C.2.3.2. The Contractor shall develop, implement, and maintain an electronic MM data system that complies with the TOM, Chapter 7, Sections 1, 2 and 3.

C.2.3.3. The Contractor shall use predictive analytics in the operation of its MM program (as described in the TOM Chapter 7, Section 1, Paragraph 5), which are designed to support and manage the health care of individuals with high-cost conditions and complex medical conditions, inpatient admissions and discharges, pharmacy (specialty drugs, multiple medications or pharmacies), and beneficiaries receiving low quality care.

C.2.3.3.1. The Contractor, in order to provide the operations described in paragraph C.2.3.3, shall establish a beneficiary-centric data warehouse (for data pertaining to TRICARE Prime and Select enrolled beneficiaries) and employ industry best practice analytic tools/systems to exhibit sophisticated data analysis techniques with evidence-based algorithms. The Contractor shall provide the Government with real-time access to view all such data.

HT940220R0005 Page C8 of C25 Amendment 0002

C.2.3.4. The Contractor shall obtain and maintain throughout the life of the contract accreditation from a nationally recognized accrediting organization for the following MM programs: utilization management, case management, and disease management.

C.2.3.4.1. The Contractor shall obtain accreditation no later than 18 months after the Start of Healthcare Delivery (SHCD) and shall maintain such accreditation in all geographic areas of responsibility throughout the life of the contract, inclusive of all exercised option periods.

National certification, in lieu of accreditation, is insufficient to meet this requirement.

C.2.3.4.2. The Contractor shall submit letters of accreditation and re-accreditation and supporting documentation to the Government within 5 business days of receipt of the documents from the accrediting organization.

C.2.4. Case Management (CM)

C.2.4.1. The Contractor shall develop, implement, and maintain a CM Program in accordance with the TOM Chapter 7, Section 2.

C.2.4.2. The Contractor shall provide CM services via a dedicated point of contact for beneficiaries with sensitive, rare, high-profile, or high-visibility needs, as well as beneficiaries…