T-5 FINAL RFP - Amendment 0003.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

07/29/20210003

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 0003

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 A, Block 9. Proposal Submission Date & Time Revised to 8/23/2021 0830 MDT.

RFP Section C.1.4. Updated TSM, TOM publish dates to August 3, 2021.

RFP Section C.2.1.13.1. Added language (or “virtual only” if practice is limited to remote telehealth).

RFP Section C.2.1.13.2. Added language (or “virtual only” if practice is limited to remote telehealth).

RFP Section C.2.1.13.5.5. Added sentence: If the place of practice address is “virtual only,” the contractor shall consider the place of practice address data element as correct for the purpose of calculating provider directory accuracy.

RFP Section C.2.12.2.1. Revised language.

RFP Section G Added Section G.14. Alternate Payment Models (APM).

RFP Section H.1.1. Added APM Bonus payments to providers.

RFP Section H.5.8.2. Revised Language “Period between SHCD and 120 days.”

RFP Section H.5.8.3. Revised Language “Period between SHCD and 120 days.”

RFP Section H.16.1.7.8. Deleted “population health” and added “disease management.”

RFP Section H.17.3. Added/Revised Language elements.

RFP Section H.18.1. Revised figures in Table.

RFP Section H.18.2. Revised/Added language for Alternate Payment Models (APM).

RFP Section H.21. Added language for Transition-In Activities.

RFP Section I Added FAR Clause 52.215-22.

RFP Section J Added Attachments J-23a/b.

RFP Section L.4.1. Updated proposal due date to 23 August 2021 at 08:30 AM.

RFP Section L.4.3. Updated Note 2, APM Proposal from 10 to 12 pages, and deleted Note 5.

RFP Section L.6.1. Added additional language as follows: “Strengths associated with increases to Government specified measureable performance or capability requirements will be releasable under the Freedom of Information Act, and the Government does not intend to redact this information from the resulting publically releasable contract. See

CDRL A290.”

RFP Section L.6.2.4.6. Added/Revised Language elements.

RFP Section L.6.2.4.7. Added/Revised Language elements.

RFP Section L.6.2.4.8. Added/Revised Language elements.

RFP Section L.8.5. Added new language.

RFP Section L.8.6. Added new language.

RFP Section L.8.18.4. Removed “The Offeror shall further agree that the guaranteed network provider discount shall not be adjusted for any action by the Government, including unilateral contract changes, allowable rates, and payment methodology.”

RFP Section M.7.2.4.4. Added/Revised Language elements.

RFP Section M.7.2.4.6. Added/Revised Language elements.

RFP Section M.7.2.4.7. Added/Revised Language elements.

RFP Section M.7.2.4.8. Added/Revised Language elements.

RFP Attachment J-9 Revised/Updated.

RFP Attachment J-23a Added new document.

RFP Attachment J-23b Added new document.

RFP Attachment L-3e Revised/Updated.

RFP Attachment L-3w Revised/Updated.

RFP Attachment L-5e Revised/Updated.

RFP Attachment L-5w Revised/Updated.

CDRL CDRL Q120 Revised/replaced in its entirety.

CDRL CDRL M100 Revised/replaced in its entirety.

CDRL CDRL Q200 Revised/replaced in its entirety.

CDRL CDRL P150 Revised/replaced in its entirety.

CDRL CDRL R180 Revised/replaced in its entirety.

CDRL CDRL M090 Revised/replaced in its entirety.

CDRL CDRL A290 Added new document.

TOM Chapter 1, Section 3, Para 3.2.1 Deleted “Averages are not acceptable” from the first line. Added as the third bullet: “If transferred to an individual, 90% of all calls shall be answered by an individual (not an answering machine) within 30 seconds.” Added as the last bullet: “Ninety-nine and one-half percent (99.5%) of all inquiries not fully and completely resolved on the initial call shall be fully and completely resolved to the customer’s satisfaction within 10 business days.”

TOM Chapter 2, Section 5, Para 5.1.1.1

In the second bullet changed the “45” to “20.”

TOM Chapter 2, Section 6, Para 2.3

Deleted “Section 1.”

TOM Chapter 2, Section 6, Paras 2.4 and 3.4

Added the following as the first bullet:

• Thirty (30) calendar days after the Transition Specification (TRANSPEC) meeting, a cross-section representation of DHA records shall be transferred to include the record layouts with specifications, formats, definitions of fields and data elements, access keys, and sort orders, for the following, but not limited to:

o Beneficiary History Files o Claims History Files o TRICARE Encounter Provider Files (TEPRVs) o Enrolled Beneficiary and Primary Care Manager (PCM) Assignment Files o Automated Data Processing (ADP) files, such as the Provider and Pricing Files

TOM Chapter 2, Section 6, Paras 2.4 and 3.4

Changed the days: of the second bullet from one hundred eighty (180) days to two hundred ten (210), of the third bullet from one hundred twenty (120) to one hundred fifty (150) and the fourth bullet from sixty

(60) to ninety (90).

TOM Chapter 2, Section 8 Added new paragraph as follows: “4.1.7 The outgoing contractor shall retain sufficient resources to ensure correction (and reprocessing through DHA) of all TRICARE Encounter Data (TED) record edit errors no later than 210 calendar days following the start of the incoming contractor’s health care delivery.”

TOM Chapter 7, Section 6, Para 2.2.

Deleted the seventh bullet “Consumer Assessment of Healthcare Providers and Systems (CAHPS).”

TOM Chapter 11, Section 4 Deleted paragraph 2.2 and renumber the subsequent paragraphs.

TOM Chapter 11, Section 6 Changed paragraph 4.4.2 to read as follows: The contractor shall print and mail out a welcome packet to each new beneficiary or household when there is a change in eligibility status (active duty versus retiree) or when there is a change in TRICARE plan coverage (Prime to Select and vice versa). Welcome packets shall include a welcome letter, costs and fees sheet, wallet card, and the appropriate plan or program handbook. DHA communications develops the packet contents.

TOM Chapter 11, Section 6 Added paragraph 10.6 as follows: 10.6 The contractor shall analyze Government beneficiary satisfactory surveys. For survey results scoring below the national benchmark, the contractor shall develop an action plan to improve customer satisfaction. A quarterly after action executive summary report shall be provided to the TRICARE Health Plan (THP), Managed Care Support Branch Office (MCSBO) outlining the actions taken and the outcomes of those actions. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.

TOM Chapter 27, Section 1 Changed paragraph 2.1.4 to read as follows: “The contractor shall obtain and maintain nationally recognized accrediting organization accreditation for its telehealth network of virtual-only telehealth providers. The offeror’s Health Network accreditation is sufficient for providers who deliver care via physical office locations and who have integrated a HIPAA-compliant virtual care delivery option into their practices. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.

TOM Chapter 28, Section 3, Para 2.3.2.2.

Changed the paragraph reference from 2.2.2.1 to 3.0.

TSM Chapter 2, Section 2.1 Replaced with the new Section 2.1.

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 or tracked changes text, 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

1 205

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

0830 MDT 08/23/2021

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)

2-14 C1-C26

F1-F10 G1-G21 H1-H40

I1-I17

J1-J2

K1-K9

L1-L39 M1-M24

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 0003

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

2 205

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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 0003 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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CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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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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CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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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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CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

5003AD EA

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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6003AA EA

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 ...

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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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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 ...

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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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9001 Transition Out 6 Q1

(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

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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, June 23, 2021 August 3, 2021

TRICARE Operations Manual (TOM) 6010.59-M, June 23, 2021 August 3, 2021

1Definitions are available at:

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

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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 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

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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.

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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.

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

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.

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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.

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

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, 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 (or “virtual only” if practice is limited to remote telehealth)

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

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3. Provider place of practice and address (or “virtual only” if practice is limited to remote telehealth)

4. Provider billing address

5. Provider Type

6. Provider Specialty

7. Provider Subspecialty

8. Provider quality indicator(s)

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.

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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. If the place of practice address is “virtual only,” the contractor shall consider the place of practice address data element as correct for the purpose of calculating provider directory accuracy. 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 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, HT940220R0005 Page C8 of C26 Amendment 0003 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.

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 in the categories identified in TOM Chapter 7, Section 2. If a beneficiary declines case management services, the Contractor shall offer care coordination navigation and a dedicated

POC until an issue is resolved.

C.2.4.3. The Contractor shall use tools and assessments to identify beneficiaries in need of in-home CM services and offer in-home CM services to beneficiaries who have a high-need for care and are at high-risk of re-admission for 30 calendar days following discharge from an inpatient setting. In such cases, the contractor shall ensure that a case manager makes an in-home visit 48 to 72 hours post discharge.

C.2.5. Population Health (PH) Care

C.2.5.1. The Contractor shall develop, implement, and maintain integrated, whole person PH care within the constraints, boundaries, and benefits of the Current TRICARE program and in accordance with the TOM Chapter 7, Section 3.

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C.2.5.2. The Contractor shall incorporate Chronic Care/Disease Management (CC/DM) conditions into its PH care.

C.2.5.3. The Contractor shall collaborate annually with the Government Designated Authority

(GDA) to identify targeted diseases.

C.2.5.4. The Contractor shall establish a process for MTFs and network providers to refer beneficiaries for CC/DM services and shall communicate this process to all MTFs via its MTF

MOUs (see paragraph C.2.12.9) and to all network providers via its provider handbook.

C.2.6. Utilization…