T-5 RFP Industry Questions with Government Responses.pdf

T-5 Managed Care Support Services

HT9402-20-R-0005

Revised Draft and Final RFP Questions and Government Responses

Question Number

Manual Location Subsection Question Government Response

1 M.7. Evaluation of Technical/Management SubFactors

M.7.2.3.2 Do appointment scheduling requirements only apply to beneficiaries who are relocating to a location managed by a different regional contractor, or does this apply to any recently PCS'd beneficiary (including those moving within the same MCSC Region)?

It applies to both beneficiaries changing regions and within the same region.

2 M.7. Evaluation of Technical/Management SubFactors

M.7.2.3.2 M.7.2.3.2. The Government will evaluate the Offeror’s proposal for creating new, first time appointments in the network on beneficiary request and describes a call center capable of handling incoming beneficiary calls and creating appointments with network providers that:

A) Meet the beneficiary's medical needs (appropriate care);

B) Meet the TRICARE appointment access standards (wait and driving time); and C) Ensure the beneficiary continues to pay in-network rates through completion of the episode of care.

Please clarify the government's intention with this requirement and provide some workload information so all potential offerors are developing their solution based on the same assumptions.

TRICARE Prime beneficiaries will have a referral to a specialist type when calling the appointment center. TRICARE Select beneficiaries may have been asked by their primary care manager to see a certain type of specialist, or may see a specialist of their choice.

The appointment center shall book appropriate care to the beneficiaries needs. There is no workload information because this is a new requirement.

3 M.7. Evaluation of Technical/Management SubFactors

M.7.2.3.2 Please provide the count of appointments made by the current T-2017 contractors per year during 2019 and 2020 for each region. That will help bidders understand the potential appointment volume so staffing can be planned appropriately for this time-consuming effort.

There is no requirement in T2017 to make first-time appointments in the network for beneficiaries

4 Other Other Will the Government allow for some combination of on-site and virtual delivery of benefits briefings?

Yes, each request for virtual briefing will be reviewed by the Government and must be supported at the requesting site.

5 Other Other Can the government provide an estimate of the number of benefits briefings expected to be delivered over the course of a normal year?

Requested briefings are in-person . The briefing hours have been provided in the data file in the final RFP. On average, this is 4,000-6,000 hours per quarter- 2,000 on average for the West and 4,000 on average for the East.

6 TRICARE Operations Manual (TOM) Chapter 2, Section 4 Assuming the start of health care delivery for the T-5 contract begins January 1, 2024, can DHA confirm that open enrollment for TRICARE Prime and Select would run from November 6 to December 11, 2023?

Incorrect. Open Season Enrollment for health care delivery beginning on January 1, 2024, would begin on Monday, November 13th,2023 and end on Monday, December 11th, 2023.

7 C.2.2. Enrollment C.2.2.2. The draft RFP states, "The Contractor shall utilize leading industry best practice automation in processing billing and enrollment transactions and include capture of email and other information needed to conduct electronic transactions." Does this requirement allow for the use of electronic enrollment forms created by the contractor?

The only enrollment forms that may be used are those provided by the Government.

Contractors are not authorized to create electronic enrollment forms.

8 H.5. Performance Guarantees (PGs) Would DHA reconsider changing the 97% PRV/PRAV customer service performance standard documented in the most recent draft RFP back to 90%? We believe that 90% represents a high level of customer service and is a more realistic standard for a TRICARE call center. The TRICARE benefit design covers multiple programs and benefit options (Prime, Select, TRR, TYR, TPR, TYA, ECHO, TAMP, etc.), as well as frequent benefit changes resulting from demonstrations and change orders. Using insurance industry standards would not take into account the complexity of the TRICARE program. Therefore, DHA may wish to review the telephonic call audit information in the T2017 Q070 report from both the East and West Regions to determine the most appropriate PRV/PRAV goal.

DHA is not interested in changing or lowering the current 97% requirement which is based on industry standards.

9 L.6. Volume II, Technical Proposal L.6.2.3.7., Response to Question #206 RFP Draft 2.0.- 2.1.

In the response to co-branding for beneficiary facing information, the Government states the MCSC logos can appear "…on a case-by-case basis (for example, not on printed products, okay on secure login website but only in very limited places on public-facing website, such as partners page)." What is the Government's intention for branding and/or marketing in the competitive demonstration? Will the MCSC and other organizations be able to market to beneficiaries with TRICARE and company logos?

The requirement is to seek prior approval before disseminating cobranded marketing materials. All materials disseminated under the TRICARE brand require government approval.

Revised Draft and Final RFP Questions and Government Responses

Question Number

Manual Location Subsection Question Government Response

10 L.6. Volume II, Technical Proposal L.6.2.3.8 Should links to health record information be included in the wireframe mockup of the beneficiary-facing website? What information should be included on the MCSC website?

* Revised Response as of 6/23/21: The mockup should include all images (samples are acceptable), text, and links you propose to put on your beneficiary-facing front page. The beneficiary facing website is the secure site behind the firewall where beneficiaries should be able to conduct secure transactions to include viewing claims, checking authorization and referral statuses, checking eligibility, making a payment, changing payment method, requesting new enrollment card, viewing/updating OHI info, filing claims, viewing claims history, changing PCM, filing grievance online, and viewing along with Explanation of Benefits statements. This requirement does not include the need to link to a beneficiary's health history as with what happens with TOL and MHS GENESIS Patient Portal. The MCSC website is not required to be submitted under the solicitation;

however, the MCSC will have a page or pages on TRICARE.mil to maintain with the public facing information specific to their area of responsibility and link to the MCSC secure site for beneficiary secure information and to access the provider directory. The MCSC will not have a public web site separate from TRICARE.mil for general benefit information

11 TRICARE Operations Manual (TOM) Chapter 12, Sec 4, para 2.4.1 The manual states "The contractor shall document the date that the patient (or representative) and the facility received notice of the initial denial determination."

Written notification of medical necessity denials are sent to the beneficiary via US mail, and therefore, the MCSC is unable to document the exact date the notice was received by the patient (or representative). Can DHA clarify if the intent of 2.4.1 is to document the date the initial denial determination was mailed to the patient (or representative) ?

The date the notification is put in the US mail allows presumption of delivery and would be acceptable. In the course of processing the appeal the date actually received may become known and that should be documented in the record.

12 TRICARE Operations Manual (TOM) Chapter 18, Section 4, 5.3.1. This section states that a Kaiser Permanente enrolled beneficiary is not assessed a cost share when they have a telehealth visit with a provider on the Kaiser Permanente web site under the Atlanta ACO demo. Does this mean that for all ACO and alternative payment models developed by the contractor over the life of the T-5 contract; should the contractor assume that there will be no beneficiary cost-share assessed for any telehealth visits? Does this create an unfair situation for beneficiaries who pay cost-share for telehealth if they are not enrolled in a Beneficiary Choice/ACO option?

No, offeror's should not assume this is the case with all ACO demonstrations and APM arrangements. Specific requirements for the Competitive Demonstrations will be forthcoming in a separate procurement.

Revised Draft and Final RFP Questions and Government Responses

Question Number

Manual Location Subsection Question Government Response

13 TRICARE Systems Manual (TSM) Chapter 1, Section 1.1 In processing the clearances for ADP IT I and II per TSM Chapter 1, Section 1.1: Will the cost for processing the National Agency Check thru the OPM be the responsibility of the contractor or will it be absorbed by the DHA? If the processing expense be on the contractor, what is the current price for adjudication

The cost for processing the National Agency Check will be absorbed by the DHA.

Contractors will be initiated for a Non-Sensitive T1, T2 or T4 Background Investigation which will be used to make a Contractor Fitness Determinations and/or HSPD-12 Credentialing determinations for physical or logical access to Government facilities or IT Systems.

IT I/II/III and new account type equivalents and corresponding minimum investigation requirement:

Information Technology (IT) Level Designation area of reference o Level I is for domain/root level administrator accounts - Privileged User - T5 (or equivalent) o Level II is for administrator accounts - Enhanced User and Core User- T3 (or equivalent) o Level III is for regular access accounts - Authorized User T1 (or equivalent)

Please be advised there is no cost associate with adjudications, adjudications will be determined by the DOD CAF. The only cost will be for the actual background investigation.

The DOD 5200.02 specifically states the DOD Component is responsible for the direction, submission and resourcing of investigation request for contractor personnel outside of the NISP.

14 TRICARE Operations Manual (TOM) Chapter 13, Sec 1, para 2.4.3.2

Is it the intention of the DHA that every medium listed must include the statement that providers have a duty to familiarize themselves with and comply with program requirements?

Yes every medium listed. The contractor shall accomplish this by including information in the provider quarterly newsletter, provider handbooks, email, World Wide Web (WWW), and other social media and by periodic notices on the electronic explanation of benefits and provider remittance advice.

15 TRICARE Operations Manual (TOM) Chapter 13, Sec 1, para 6.2.1.1.5

Did the DHA intend to omit the year to year variance comparison? No. This was an oversight and has been added to the final RFP.

16 TRICARE Operations Manual (TOM) Chapter 13, Sec 2, para 3.1 Is it the intention of the DHA that every bulleted item must be included in administrative action.?

No. It is the contractor's discretion to use the most appropriate administrative action commensurate to the specific situation.G26

17 TRICARE Operations Manual (TOM) Chapter 13, Sec 2, para 3.5.1.4.1.

Does the reference to monitoring the provider or beneficiary on a case by case basis give the Contractor the discretion as to the period of time that the subject should be re-audited?

Yes, the Contractor has discretion.

18 TRICARE Operations Manual (TOM) Chapter 13, Sec 2, para 3.7.2. Is the reference to previous recoupment actions limited to Program Integrity reviews? In this context, yes.

However, if the question is more general regarding recoupment actions - all recoupment action requirements (outside of Program Integrity) are defined in TOM Chapter 10.

19 TRICARE Operations Manual (TOM) Chapter 13, Sec 2, para 3.9.2 Is it the intention of the DHA that every provider who is terminated from the Contractor's Network be reported to DHA PI regardless of whether the termination is Program Integrity related?

No. As it is related to Program Integrity - only those providers terminated due to PI related actions shall be reported.

20 TRICARE Operations Manual (TOM) Chapter 13, Sec 2, para 4.1.3- 4.1.4

Is it the intention of the DHA that every identified administrative error by the Contractor is to be referred to DHA PI regardless of whether the issue is involved in a PI case?

No. Only those related to PI actions shall be reported.

21 TRICARE Operations Manual (TOM) Chapter 13, Sec 2, para 5.2.2 Does this clause mandate that every non-assigned claim require a receipt? No - only those identified as a problem with waiver of copay or cost-share. Not every single non-assigned claim.

This section refers only to issues with waiving copays or cost-shares.

22 TRICARE Operations Manual (TOM) Chapter 13, Sec 3, para 1.1. Would the Contractor define the confidence and precision levels with the use of RAT

STATS, or is it a pre-define parameter?

The confidence and precision levels are defined in the CDRL (R080 - Audit Detail Worksheet, Box 8)

Revised Draft and Final RFP Questions and Government Responses

Question Number

Manual Location Subsection Question Government Response

23 TRICARE Operations Manual (TOM) Chapter 13, Sec 3, para 4.1.1- 4.1.4.

How does the DHA intend for patient harm allegations to be reported to DHA PI after the allegations are substantiated by Medical Directors who also must maintain confidentiality in regard to quality investigations?

This is not a new requirement. The requirement spelled out in the identified paragraphs in the T-5 TOM are taken directly from the T-2017 TOM, Chapter 13, Section 3, para 8.1.

24 TRICARE Operations Manual (TOM) Chapter 13, Sec 4, para 1.1.2.1.

This paragraph states that the Contractor shall wait 120 days following an education letter before determining additional corrective actions. In TOM Ch. 13, Sec.2, para 3.1 administrative actions include prepayment review. Does the DHA intend for the Contractor to wait 120 days to place a provider on prepayment review?

The intent of this paragraph is to allow the provider time to correct the suspect behavior.

If the provider repeats the behavior before 120 days, then the contractor shall follow the process set forth in para TOM Chapter 13, Section 4, Paragraph 2.0.

25 TRICARE Operations Manual (TOM) Chapter 13, Sec 4, para 3.1.1. Did the DHA intend to state that the case must be referred on paper, or should this statement include an “or” statement in regard to electronic submission?

No. Cases shall only be submitted electronically. The intent of this paragraph is to advise the contractor if a case is referred on paper.

26 TRICARE Operations Manual (TOM) Chapter 13, Sec 5, para 2.2.1. Will the DHA notify beneficiaries and providers of the claims suspension? DHA will notify the beneficiary or provider who is being suspended of the claims suspension.

DHA does not advise all beneficiaries and providers that may be impacted by the claims suspension.

NOTE: Language in this paragraph was revised in the final RFP.

27 TRICARE Operations Manual (TOM) Chapter 13, Sec 5, para 4.3.4. Did the DHA intend to remove the ability to notify the beneficiary via the EOB reason code?

No, the DHA did not remove the ability to notify the beneficiary via EOB reason code.

28 TRICARE Operations Manual (TOM) Chapter 13, Sec 5, para 9.0 Paragraphs within TOM Ch. 13, Sec 5, para 9 are out of sequence. The sequence was corrected in the final RFP.

29 TRICARE Operations Manual (TOM) Chapter 13, Sec 5, para 9.2.6. Is this section intended to be listed under Contractor Requirements for Termination?

A Contractor does not have authority to suspend payments.

DHA will issue a notice to suspend the provider under Chapter 13 Sec 2 para 3.8 Claims Processing Suspension

30 TRICARE Operations Manual (TOM) Chapter 13, Sec 5, para 9.3 - 9.3.4.5

It appears that these paragraphs are erroneously added to this Chapter. Should this be added under the Contractor's termination of a network agreement?

No. The Government will keep these paragraphs with Chapter 13.

31 TRICARE Operations Manual (TOM) Chapter 13, Sec 5, para 9.3.1.2.1.

Does this statement indicate that the Contractor would not need to notify DHA PI of a network termination? This appears to contradict TOM Ch. 13, Sec. 2, 3.9.2.

No. DHA must be notified of the termination per Chapter 13 Sec 2 para 3.9.2., but DHA does not require a copy of the termination letter.

32 C.2. PERFORMANCE REQUIREMENTS C.2.12.13 What level of historical paid claims information will the incoming contractor have access to during the initial years of T-5 to support the Program Integrity efforts?

The outgoing contractor will provide claims history to the incoming contractor from the T- 2017 transition out phase less proprietary information. At the request of the incoming contractor detailed historical claims data will be provided by the Government.

33 C.2. PERFORMANCE REQUIREMENTS C.2.12.13 If an incoming contractor does not have access to historical claim information, does DHA’s expectations of number of cases referred to the DHA P.I unit change as there will be a limit to the number of claims to be reviewed, especially in OP 1 and OP 2?

See response above. There are no expectations on the number of cases referred as focus of T5 is prevention and deterrence. Case development is a last resort for addressing fraudulent behavior.

34 C.2. PERFORMANCE REQUIREMENTS C.2.12.13 What is the expected number of cases involving over $250,000 of claim potential to be referred to DHA?

DHA-PI is not identifying a case referral requirement at this time. As such, there is no expected number of cases to be referred.

35 C.2. PERFORMANCE REQUIREMENTS C.2.12.13 What has been the volume of providers on prepay review in the past 24 months for each Region?

The information is not available. However, what can be shared is the total dollars for prepayment review: 2019 resulted in $67.4M of cost avoidance program-wide

36 C.2. PERFORMANCE REQUIREMENTS C.2.12.13 What are the performance standards related to prepay analytics? There are no performance standards related to prepay analytics.

37 C.2. PERFORMANCE REQUIREMENTS C.2.12.13 What is the grace period to fully implement the prepay analytics into the claim adjudication process?

There is currently no standard for a grace-period. Prepayment analytics and other requirements identified for Program Integrity are intended to be implemented no later than start of healthcare delivery.

38 C.2.13 Interoperability C.2.13 Interoperability Can DHA confirm that proposed solutions (i.e. population health, interoperability) can leverage existing DOD hosting capabilities (e.g., DOD/VA Secure Federal Enclave) if approved by their respective governing bodies?

C.2.13. was substantially revised in the final RFP.

39 C.2. Performance Requirements C.2.12.12.2. Please identify the locations that currently have a bi-directional HIE with the MCSC as defined by the ICD.

Which HIE Service firm(s)/practice(s) will be used by the DHA Genesis locations that follow the X12 278 EDI?

DHA does not have bi-directional capability for referrals in any current locations. X12 EDI with the MCSC does not require an HIE.

40 C.2. Performance Requirements C.2.12.12.2. Please provide the timeline for the implementation of the interfaces and HIE Services that will be used by the MHS/DHA.

The timeline for implementation is unknown at this time. It will be released as soon as it becomes available.

Revised Draft and Final RFP Questions and Government Responses

Question Number

Manual Location Subsection Question Government Response

41 C.2.11. Management C.2.11.7. The Draft RFP requires the MCSC to provide DHA and military services personnel with real time access to TRICARE claims data. The assumption is this would be access to fully adjudicated claims data.

Please confirm or correct our understanding.

Yes, fully adjudicated claims data.

42 C.2.11. Management C.2.11.8. C.2.11.8 requirement is to update OHI information stored in the DEERS database for non-active duty service members that have no commercial information on file. It is our understanding that DMDC, as of 3/21/21, will discontinue ability for MCSCs to make real time updates to OHI in DEERS. Will this ability be restored under the T-5 contract?

DMDC is no longer providing a Web application for OHI updates, the contractor still has the same functionality available in the System to System interface. The system to system interface provides the functionality needed to meet the requirements in the contract.

43 C.2.7. Referral Management C.2.7.4 Will the MCSC be provided real-time read-only access to the MTF Genesis EHR or is the MCSC-MTF/Market interface to be limited to establishing connectivity to receive an electronic 278 and any attached documentation provided by the MTF?

No, the MCSC will not be provided real-time access to the MTF GENESIS EHR. Network providers, however, may be able to access MHS GENESIS through a compatible HIE.

44 H. Special Contract Requirements H.18 In the shared savings calculation methodology, can DHA provide an example to the relationship of network discounts, shared savings calculations that meet the threshold of not exceeding the 100% of the CMAC rate and then how the generated savings is shared with the Offeror and the contracted provider?

There are examples in TRM Chapter 18. The contractor is responsible for proposing how the generated savings are shared with the contracted provider.

45 H. Special Contract Requirements H.X Will funds be made available to implement APMs under Category 2 A-C incentives?

How are the Acceptable Quality Level (AQLs) measured?

Yes, DHA will make funds available provided there is savings created from network discounts of allowable charges and detailed in an APM proposal. The AQLs are calculated by dividing the percentage of network payments made under APMs by the total network health care payments during the year.

46 H.10. Claims Processing, TEDS Occurrence Errors and Payment Accuracy Reviews

H.10.1.7 Previous question #180 (Draft RFP 2): The DHA response indicates the Government response to #186 on DRFP1 refers to a post-processed claim and a request for medical documentation after the claim is processed. However, the response to DRFP1 #186 also indicates that “In the absence of sufficient documentation that supports the claim, the entire claim will be errored, which will affect contractor performance standards.” As you may know, submission of medical records with a claim is not a National Uniform Claim Committee (NUCC) billing requirement. The provider signature on the claim form is their attestation to the accuracy of the information making them legally liable for what they billed. This allows the healthcare industry to adjudicate claims based on the information submitted on approved standardized claim forms.

Only in instances where a medical necessity determination is needed would a copy of the medical records be requested before processing a claim. Therefore, it would be inappropriate to use medical records in an audit to make payment error determinations. Question: Is it the intent of DHA to hold the contractor liable for failure to submit medical records that are not supplied by the provider in the post-payment process? If so, will post-payment recoupment action for lack of requested information be acceptable as support for removal of the error?

The requirement is for medical records to support post-payment review in a focused study separate from a quarterly claims payment compliance review. Yes, the intent of DHA is to hold the contractor liable. The error will be reported regardless of the recoupment action in accordance with TPM Ch 1, Section 5, Para 1.

47 H.10. Claims Processing, TEDS Occurrence Errors and Payment Accuracy Reviews

H.10.2.1 Per H.10.2.1, the accuracy standards are stipulated in TOM Chapter 1, Sec 3,"Claims Processing Accuracy" (Para 6.5.1), which states errors will be extrapolated to the universe. However, H.10.2 of the Draft RFP does not include a provision for the Contractor to validate DHA’s quarterly claims universe as it does for the universe for the Annual Underwritten Unallowable Healthcare Cost Audit (H.10.3.3 and H.10.3.3.1).

Would the Government consider adding Contractor universe validation to H.10.2?

No because the quarterly audits are on all claims.

48 H.10. Claims Processing, TEDS Occurrence Errors and Payment Accuracy Reviews

H.10.3.1.1 H.10.3.1.1. states, "the Contractor shall forward the claims documentation to the TCRS Contractor and the CO." H.10.3.4 states the documentation is to be sent to the TCRS Contractor but does not mention the CO.

Are we correct to assume the documents are to be provided only to the TCRS Contractor? The Draft RFP does not contain direction on the format to be used to send documents to the CO.

Please confirm or correct our understanding.

The format for the submission to the CO shall be the same format as submitted to the TCRS Contractor via email unless directed otherwise. The government will update the RFP via an amendment.

Revised Draft and Final RFP Questions and Government Responses

Question Number

Manual Location Subsection Question Government Response

49 I. Contract Clauses DFARS 252.204-7021 DFARS 252.204-7021(b) states, "The Contractor shall have a current (i.e. not older than 3 years) CMMC certificate at the CMMC level required by the contract…" However, there is no corresponding requirement regarding the CMMC level specified in Section C.2.12.6 Information System Security or in the TRICARE Systems Manual (TSM), Chapter 1, Section 1.

Please advise what CMMC level will be required under the T-5 contract.

TSM Chapter 1 was revised to require CMMC when required by contract. DHA does not know when DoD will implement the final CMMC requirement.

50 L.6. Volume II, Technical Proposal L.6.2.4.8.f The Draft RFP asks the Offeror to demonstrate how an APM Model would not exceed the aggregate cost of care that would have been incurred under applicable TRICARE maximum allowable charges. APMs frequently reduce total cost of care by decreasing low value utilization while either increasing unit rates or providing an incentive in addition to FFS reimbursement. Because of this the total cost of care of the model is likely to exceed the TRICARE maximum allowable charges for the services provided under the model. However, the overall cost would be lower than the TRICARE maximum allowable for services provided at historical utilization rates.

If the total cost of the APM model is lower than the TRICARE maximum allowable costs based on historical utilization, will this requirement be considered met?

To simply say that an APM will reduce the costs for services provided at historical utilization rates, does not describe how the offeror plans to measure and implement the APM. However, the response to your question is yes - if the total cost is lower than what would have been spent, the requirement will have been met. The Government would expect the contractor to adjust for variables such as population, acuity, and other factors depending on the model. For example, a model narrowly focused on a specific condition or surgery impacting a small number of beneficiaries may need statistical adjustment to ensure payment is not made at an average rate across the entire population. The comparison group will likely depend on model type, size, and other factors.

51 M.7. Evaluation of Technical/Management SubFactors

M.7.2.1.7 Please clarify if the Offeror will have interoperability access to CommonWell and full view of both the MTF and community contracted provider EMR's?

* Revised Response as of 6/23/21: There is no requirement for the Offeror to have interoperability access to CommonWell or full view of both MTF and community contracted Electronic Medical Records. See answers to questions 535 and 536.

52 OTHER C.2.12.12.1 C.2.12.12.1 states, "The contractor shall establish electronic system interface to ensure all required data needed to perform referral management and referral management messages are completely exchanged between the MHS GENESIS and the Managed Care Support Contractor (MCSC) interface."

Will the MCSC have real-time read only access to the MTF GENESIS EHR in order to obtain additional information supporting medical benefit and medical necessity review?

No. MCSCs will not have a real-time read only access to the MTF GENESIS EHR. See Section C.7.2.4.

53 OTHER C.2.13.3.1 Will the MCSC be expected to obtain, store, and transmit medical documentation recording clinical services and results of ancillary services to the Government?

This section of the final RFP was substantially revised removing the requirement

54 OTHER C.2.13.3.4 Is the connection using HIE of network providers and facilities to be to the MTF for treatment or to the MCSC for operations and payment or both?

This section of the final RFP was substantially revised removing the requirement

55 OTHER W030 - Integrated Master Schedule (IMS) Status Report

Under T2017, the W030 was the Weekly Claims Processing Statistics Report. Did the Government intend to delete the W030 - Weekly Claims Processing Statistics Report?

Under T2017, the W030 reflects the Claims Processing Timeliness Standards found in T- 5 TOM Chapter 1, Section 3, paragraph 6.1-6.3.1.

If this report is to be assigned a new deliverable ID, please provide this information.

Yes, the Government intended to delete the Weekly Claims Processing Statistics Report.

The standards from the weekly W030 are being reported monthly in the M090

56 TRICARE Operations Manual (TOM) Chapter 1, Sec. 3, para 6.5.2 Please provide a description of how the first pass auto-adjudication rate will be calculated. Recommend adding language to exclude from this calculation those claims which are deferred as a result of actions beyond the contractors control, such as temporary deferrals for Government directed change order implementation and routine pricing updates. Additionally, this annual measurement has not been captured within a CDRL or within Section H of the draft contract. Recommend this be added to the M090 CDRL.

The contractor shall report auto-adjudication rate monthly as a function of its claims processing system. The monthly rate is on M090 CDRL. The monthly rate increases 1% each option year.

Revised Draft and Final RFP Questions and Government Responses

Question Number

Manual Location Subsection Question Government Response

57 TRICARE Operations Manual (TOM) Chapter 1, Sec. 3, para 6.5.3 Please provide a description of how the Government will calculate the reprocessing rate. Recommend language to exclude certain categories of claims from this metric, e.g. claims reprocessed at the direction of the Government, retro eligibility changes in DEERs, OHI recapture, duplicate claims identified in the Government's Duplicate Claims System, claims reprocessed as the result of retroactive change order, provider resubmission of corrected claims and any other claims adjustments that are not caused by the MCSC. Additionally, this requirement has not been captured within a CDRL or discussed within Section H of the draft contract. Recommend adding this measurement to the M090 CDRL.

The contractor shall report reprocessing rate monthly as a function of its claims processing system. The rate is calculated on M090 CDRL

58 H.10.2.3 H.10.2.3 states results from the TED Record Occurrence Compliance Reviews will be used to assess Contractor claims processing performance as stipulated in the TOM, Chapter 1, Sec 3 "Claims Occurrence Errors" but there is no "Claims Occurrence Errors" in TOM Chapter 1, Sec 3.

Correct, this was removed from TOM Chapter 1, Sec 3. It is now addressed in TOM Chpt 3 Sect 5 Para 4.3.2. The change will be made in an upcoming amendment.

59 TRICARE Operations Manual (TOM) Chapter 1, Section 3, paragraph 6.5.1

Quality Standard was changed from "absolute value of the payment errors" to "extrapolated absolute error total" for OP1/OP2, and "absolute error total" for remaining Option Periods.

1-) Does the government intend to measure payments errors in OP1/OP2 differently than the remaining option periods?

2-) Will the government provide an example of the claim payment error calculation for OP1/OP2 and the remaining option periods including a description of how extrapolation will be used in the claim payment error calculations?

All options periods will be calculated using the same formula. See attached sample calculation within Attachment J-21.

60 TRICARE Operations Manual (TOM) Chapter 1, Section 3, paragraph 6.5.3

6.5.3 states "The contractor shall not exceed 2% reprocessing rate of the total monthly claims volume processed for the first two option periods. In all remaining option periods, the contractor shall not exceed 1.75% reprocessing rate of the total monthly claims volume processed."

We have reviewed the prior questions and responses, and would like to request clarification as follows:

There are many categories of adjustments required by TRICARE Policy (as reflected in Additional Info/Rationale) that are not the result of contractor error.

1-) Will the government clarify how it will exclude from this calculation those adjustments where the contractor is required to adjust claims for reasons other than contractor error?

2-) Will the government provide historical TRICARE data or other industry data and information the government used in determining the 2% and 1.75% reprocessing rate performance standards?

All claims pended per Government direction are excluded from this standard. The Government will update the TRICARE Operations Manual to reflect excluded claims.

This is a new government requirement based on the TRICARE Audit error rates (H.10.) so the Government cannot provide historical TRICARE data.

61 C.2. Performance Requirements C.2.13 C.2.13.1

The contractor’s systems claims, referral and population health systems shall be capable of Fast Health Interoperability Resources (FHIR) and CMS-9123-P final rule interoperability standards prior at the Start of Health Care Delivery.

1-) Will the government clarify the FHIR requirements as the relate to claims data?

This section of the final RFP was substantially revised removing the requirement

Revised Draft and Final RFP Questions and Government Responses

Question Number

Manual Location Subsection Question Government Response

62 C.2. Performance Requirements C.2.13.2 The contractor’s system shall provide patient level detail for each encounter and claim that ensures accurate record of services provided and reimbursed an accurate representation of what was reimbursed. In addition, all ancillary services (Lab, Rad, Pharm, DME) results shall be provided to the Government.

1-) Would this data would be exported, imported or transmitted using FHIR standards supported by defined HL7 FHIR implementation guides? If FHIR standards are not leveraged, would x12 5010 HIPAA compliant transactions utilizing SFTP transfer mechanisms be required?

This section of the final RFP was substantially revised removing the requirement

63 C.2. Performance Requirements C.2.13.3 C.2.13.3.1

The contractor shall ensure that encounter data is provided within 30 days of each episode of care.

The contractor shall deliver data to the Government’s clinical data warehouse via interoperability interfaces via secure File Transfer Protocol.

1-) Would this data would be exported, imported or transmitted using FHIR standards supported by defined HL7 FHIR implementation guides? What file and data payload formats are required? (i.e. real-time, bulk data etc.). If not real time, what scheduled interval is required for data transfers?

This section of the final RFP was substantially revised removing the requirement. The requirement for return of clinical information is now C.2.9.

64 C.2. Performance Requirements C.2.13.3.2 The contractor shall be capable of delivering data through a daily feed (objective) or through a weekly secure FTP (threshold).

1-) Would this data would be exported, imported or transmitted using FHIR standards supported by defined HL7 FHIR implementation guides? If FHIR standards are not leveraged, what are the transmission requirements for the data feed? (i.e. zipped batch once every day or week).

This section of the final RFP was substantially revised removing the requirement

65 C.2. Performance Requirements C.2.13.4 C.2.13.4.1

The contractor shall connect private sector care network providers and facilities within MTF referral networks through Health Information Exchange networks (eHealth Exchange and CommonWell Health Alliance) networks.

The contractors shall ensure interoperability (the ability to share data between Electronic Health Records) through the use of standards such as, but not limited to FHIR and X12.

1-) Will the government provide a timeline that accommodates customer development and integration between entities for any non-standard data transmissions?

This section of the final RFP was substantially revised removing the requirement

66 C.2. Performance Requirements C.2.13.4.2 The contractor shall ensure that the interoperability is bi-directional.

1-) Would bidirectional communication being transmitted use FHIR standards supported by defined HL7 FHIR implementation guides or x12?

This section of the final RFP was substantially revised removing the requirement

Revised Draft and Final RFP Questions and Government Responses

Question Number

Manual Location Subsection Question Government Response

67 C.2. Performance Requirements C.2.13.4.3 The contractor shall ensure that MTFs have secure access to data in referral hospital and network provider EHRs.

1-) Will the government confirm that hospital and network provider EHRs will stand up, support and maintain FHIR API endpoints and follow HL7 implementation guidelines for data transmission and ingestion given integration with the contractors systems will require FHIR or x12 standards to communicate?

2-) How will the contractor ensure that MTFs have access to hospital and provider EHR data?

The new requirement is at C.2.9.4. that requires MTFs in referral networks have access to network providers though an HIE

68 C.2. Performance Requirements C.2.13.4.4 The contractor shall ensure connectivity to state and regional health information exchange networks.

1-) Will the government clarify the data transactions and standards that are to be utilized between state and regional health information exchange networks?

This section of the final RFP was substantially revised removing the requirement

69 C.2.13. C.2.13.1. The draft RFP states, "The contractor’s systems claims, referral and population health systems shall be capable of Fast Health Interoperability Resources (FHIR) and CMS-9123-P final rule interoperability standards prior at the Start of Health Care Delivery."

Will all Government systems that the contractor is required to interface with (e.g., DEERS, MTF points of interface, MHS Genesis, etc.) meet the interoperability standards added under C 2 13 ?

C.2.13.1. has been revised under the final RFP. Specifically, only claims, referral, and population health systems shall be capable of CMS-9123-P. The requirement for FHIR has been removed.

70 H.3. Healthcare Underwriting Incentives H.10.3.7. H.10.3.7. The draft RFP states, "Results: The Government will extrapolate the error rate to the Option Period universe to determine the total unallowed cost. The extrapolation will be based on the estimated average overpayments to payments in the compliance review universe. Underpayments from the sample will be considered to have an improper payment amount of zero dollars so as to not offset overpayments from the sample."

Please identify how the "estimated average" will be calculated and applied.

The "estimated average" is calculated separately for each stratum, as the total overpayments identified in the sample divided by the number of claims sampled. For example, if our reviews identified $200 in overpayments for stratum 1, and 100 claims were sampled, the estimated average for that stratum would be $2.00.

To complete the extrapolation, the estimated average is then multiplied by the number of claims in the universe for that stratum. Continuing this example, if the universe contained 400,000 claims for stratum 1, the estimated overpayments in the universe for that stratum would be $800,000 ($2.00 x 400,000).

This calculation is repeated for each stratum, and the totals are summed together to yield the overall estimate.

71 H.16. Future Potential Demonstrations H.16.1.5. H.16.1.5.1. The draft RFP states, "The Contractor’s provider network shall include Clinically Integrated Networks (CINs) that have demonstrated high quality outcomes, lower cost and reduction of waste. CIN arrangements shall include value-based incentives that motivate providers to invest in and adopt new approaches to care delivery."

In modeling Value Based Payments, will cost reduction resulting from techniques such as decreased utilization, lower cost site of care, chronic care management, etc., be considered when evaluating the allowability of those payments?

* Revised Response as of 6/23/21: During the development of the demonstrations, the Contractor and DHA will mutually agree upon metrics and cost reduction techniques that will be considered in evaluating the allowability of these payments.

Revised Draft and Final RFP Questions and Government Responses

Question Number

Manual Location Subsection Question Government Response

72 H.16. Future Potential Demonstrations H.16.1.5. H.16.1.5.1. The draft RFP states, "The Contractor’s provider network shall include Clinically Integrated Networks (CINs) that have demonstrated high quality outcomes, lower cost and reduction of waste. CIN arrangements shall include value-based incentives that motivate providers to invest in and adopt new approaches to care delivery."

Is it intended that these cost reductions by a provider will offset value-based incentive payments and administrative costs that are required to achieve those cost savings?

Yes, cost reductions as a result of provider efforts will offset or can be used to offset monetary incentive payments that are required to achieve those savings. The Contractor may also propose alternative methods for generating payment funding during the development of the demonstrations.

73 L.6.2.3. Subfactor 3 - Administrative and Customer Service

L.6.2.3.7. Section L.6.2.3.7. states, The Offeror's proposal shall describe its plan and timeline to craft its internal beneficiary-facing website, including timeline for testing compliance with all applicable requirements and testing user accessibility. The proposal shall include a wireframe mockup of the front page to demonstrate the ability to meet the TRICARE brand standard."

Please confirm that the wireframe website page does not count towards the Technical Proposal page limitations.

The mockup page counts toward the technical volume page limitations.

74 L.6.2.4. Subfactor 4 - Claims and Systems L.6.2.4.4.2. Section L.6.2.4.4.2. states, "The Offeror shall deliver their system security plan (SSP), or extracts thereof, (NIST SP 800-171 security requirement #3.12.4), and any associated plans of action (NIST SP 800-171 security requirement #3.12.2) with their technical proposal."

The System Security Plan is a significant document, larger than the Technical Proposal page limitations, please confirm that it does not count towards the Technical Proposal page limitations

L.6.2.4.4.2. has been removed from the final RFP.

75 L.6. Volume II, Technical Proposal L.6.2.4.6. L.6.2.4.6. The draft RFP states, "The Offeror’s proposal shall describe its approach to designing and implementing Alternate Payment Models (APMs) that incorporate the following characteristics (TRICARE Reimbursement Manual, Chapter 18, Section 4.3.1):

a) Cost neutral

b) Calculated at a population or model-based level for implementing an APM

c) Based on historical utilization

d) Risk and wage adjustment

e) Any additional factors that would require approval by the Government"

Can the Offeror's proposed model to demonstrate cost neutrality consider cost reduction resulting from techniques such as decreased utilization, lower cost site of care, improved chronic care management, etc., as an offset [to] value incentive payments and administrative costs that are required to achieve those cost savings?

The offeror may propose tools, techniques and processes to benchmark cost and achieve cost savings from APMs that are cost neutral to the government.

76 L.6. Volume II, Technical Proposal L.6.2.4.7. L.6.2.4.7. The draft RFP states, "the Offeror will target APM arrangements that constitute 15% of healthcare payments to network providers...".

Please clarify whether the requirement is 15% of providers (Section H.18) or 15% of payments (Section L.6.2.4.7).

The Government has revised the final RFP under L.6.2.4.7. The requirement is 15% of total network healthcare dollars paid under APMs.

77 M.7. Evaluation of Technical/Management SubFactors

M.7.2.4.7 In this section it is still referring to 15% of payments, not aligned with the changes made to table in section H.18 where it is calling for 15% of network providers. Can the government please clarify?

Section L language was revised to be consistent with M.7.2.4.7. The requirement is 15% of total network healthcare dollars paid under APMs.

Revised Draft and Final RFP Questions and Government Responses

Question Number

Manual Location Subsection Question Government Response

78 Other Q & A Answer 165 In the Q&A (165) the Government’s response indicated it utilizes the Assistance Reporting Tool (ART) for secured bidirectional communications There are no specifications in any of the manuals or the draft RFPs that provides details about ART.

We have the following questions about ART:

· When is ART access required to be used by the Contractor?

· What is the productivity measurement in using ART, e.g. how many ART entries are usually completed within an hour? The bidders may need to add labor cost to accommodate for ART workload.

· Does contractor access to ART require a CAC card?

· How is the system to be used (will the government provide access to work instructions prior to proposal submission)?

· Please provide details and historic 2019 and 2020 volume of incumbent contractors’ use of ART.

* Revised Response as of 6/23/21: The Chapter 11, Section 4 of the TOM has been Amended to include the specific requirement for the use of the tool.

In response to the questions, the following is provided:

1) When is ART access required to be used by the Contractor?

Access to a Government-designated system, currently ART, will be provided to contractors 2 months prior to the start of health care delivery (SHCD) for training purposes. The contractor shall use it at the start of health delivery and throughout the contract period.

2) What is the productivity measurement in using ART, e.g. how many ART entries are usually completed within an hour? The bidders may need to add labor cost to accommodate for ART workload.

ART case numbers vary. Cases from DHA are considered high priority and should be acknowledged within 24 hours (by just placing a note in the ART file). All other cases from BCAC/DCAOs should generally be answered within 10 days or include information justifying the needs to additional time. ART users consist of DHA Staff, BCACs/DCAOs, National Guard and Reserve family support staff, Recruiting support staffs and other approved staff. ART is used to send cases needing contact intervention, and is a secure, web-based tool used in lieu of a telephone call to the BCAC priority line. This is not additional work, but work that would have come into the contractor for assistance regardless. The ART system simply allows for detailed information along with documents to be securely transferred to the contractors/subcontractors.

3) Does contractor access to ART require a CAC card?

Yes. ART, or whichever system the Government designates for use, is CAC-enforced.

4) How is the system to be used (will the Government provide access to work instructions prior to proposal submission)?

There are detailed work instructions available and the Government can provide AD HOC training for the ART tool, or whichever Government system may be utilized, as necessary and requested.

5) Please provide details and historic 2019 and 2020 volume of incumbent contractors’ use of ART.

The following is total number of cases referred to the MCSCs and claims processors in 2019 and 2020. Rows noted with an asterisk (*) indicate only DHA THP staff has the ability to refer to those groups.

CY 2019 CY 2020

HNFS-West 746 696 *HNFS-West-B&E-DHA-ONLY 50 43 *HNFS-West-CC-DHA-ONLY 317 542 *HNFS-West-Congressional-DHA-ONLY 256 157 PGBA-West-HNFS 8,323 6,564

TOTAL CASES 9,692 8,002

CY 2019 CY 2020

*Humana East Routine-DHA-ONLY 4,406 5,363 Humana East-Congressional & Priority 1,078 570 Humana East-DCAO Assistance 0 0

79 TRICARE Reimbursement Manual (TRM) Chapter 18, Section 1 TRM Ch 18 S1 - 4.3.1 states the contractor shall have APMs that at minimum are cost-neutral. Does the Government provide any funding for the APM? If so, what is the funding level?

The government will not provide any funding for the APM.

Revised Draft and Final RFP Questions and Government Responses

Question Number

Manual Location Subsection Question Government Response

80 TRICARE Reimbursement Manual (TRM) Chapter 18, Section 1 TRM Ch 18 S1 - 4.3.2 states that Section H.18 of the contract specifies annual percentages for the share of in-network health care expenditures to be covered by APMs, including any requirements regarding the mix of HCPLAN categories. However, in Section H.18 the table is stating that the Standard is a % of network health care providers under required APM contracts.