HT940221R0002.pdf

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TRICARE CLAIMS REVIEW SERVICE (TCRS) -- CANCELLED
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HT940221R0002
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HT940221R0002_Amendment 0007.pdf PDF
Exhibit L-5_Price_Proposal_Template_v3.xlsx XLSX spreadsheet
HT940221R0002_Amendment 0004.pdf PDF
HT940221R0002_conformed 0003.pdf PDF
Exhibit L-5_Price_Proposal_Template_v2.xlsx XLSX spreadsheet
HT940221R0002_Amendment 0003.pdf PDF
Exhibit L-5_Price_Proposal_Template v1.xlsx XLSX spreadsheet
Exhibit L-8_Historical TRICARE Overseas Program Data v1.xlsx XLSX spreadsheet
Exhibit L-4_Solicitation Cross-Reference Table (Sections L M and C) v1.pdf PDF
Exhibit L-9_Draft Quality Assurance Surveillance Plan (QASP) v1.docx DOCX document
HT940221R0002_conformed 0002.pdf PDF
Exhibit L-7_TCRS Historical Rebuttal Report (2017-2021) v1.xlsx XLSX spreadsheet
Industry QA -- TCRS RFP Final Consolidated List.pdf PDF
HT940221R0002_Amendment 0002.pdf PDF
Section C_7.1.2 Contractor Employee Mandatory Training (FY22).pdf PDF
Section C_7.1.1 DHA CAC Request Process.pdf PDF
HT940221R0002_Amendment 0001.pdf PDF
Section C_7.1.1 DMDC TASS Application.xlsx XLSX spreadsheet
W030 Audit Status Report v1.pdf PDF
Industry QA -- TCRS RFP Amendment 0001.pdf PDF
R010 Transition In Plan v1.pdf PDF
HT940221R0002_conformed 0001.pdf PDF
Industry QA -- TCRS RFP 5.17.22.pdf PDF
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HT940221R0002

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

1 138

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

X

HT9402

DEFENSE HEALTH AGENCY

DEFENSE HEALTH AGENCY-AURORA

16401 E CENTRETECH PARKWAY

AURORA CO 80011

1700 MS

NICHOLAS R. CECILIANI 303

NICHOLAS.R.CECILIANI.CIV@

MAIL.676-3997

X

X

X

X

X

X

X

X

X

X

X

X

X

PAGE(S)

NICHOLAS R. CECILIANI

AUTHORIZED FOR LOCAL REPRODUCTION

Previous edition is unusable

STANDARD FORM 33 (Rev. 9-97)

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

2-12 C1-C50

F1-F4 G1-G5 H1-H12

I1-I12

J1

K1-K10

L1-L22 M1-M8

303-676-3997

NICHOLAS.R.CECILIANI.CIV@MAIL.MIL

D1 E1

June 16, 2022

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

2 11

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940221R0002

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

Delivery Location Code: HT9402

DEFENSE HEALTH AGENCY

DEFENSE HEALTH AGENCY-AURORA

16401 E CENTRETECH PARKWAY

AURORA CO 80011-9066 USA

Base Period - Transition-in

Period of Performance: September 1, 2022 -

February 28, 2023

0001 Transition-In (Section C Paragraph 5.3.1) 1 LO

(Fixed-Price)

0002 Base Period Deliverables (DD Form 1423-1, Contract Data Requirements List (CDRLs), Section

F Paragraph 6.2)

(Not Separately Priced)

Ordering Period 1

March 1, 2023 - February 29, 2024

1001 Managed Care Support Contracts (MCSCs) Quarterly EA

Compliance Reviews (Section C Paragraph 5.4)

Fixed Price Per Claim

1002 TRICARE Medicare Eligible Program (TMEP) EA

Quarterly Compliance Reviews (Section C Paragraph

5.4)

Fixed Price Per Claim

1003 TRICARE Oversees Program (TOP) Quarterly EA

Compliance Reviews (Section C Paragraph 5.4)

Fixed Price Per Claim

1004 TRICARE Pharmacy Program (Tpharm) Quarterly EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

Continued ...

3 11

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940221R0002

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

1005 Active Duty Dental Program (ADDP) Semiannual EA

Compliance Reviews (Section C, Paragraph 5.4)

Fixed Price Per Claim

1006 Managed Care Support Contracts (MCSCs) Annual EA

Health Care Cost Audits (Section C paragraph 5.4)

1007 Focus Studies (Section C paragraph 5.5.1)

(Not Separately Priced)

1008 Focus Studies -- PIIA Compliance Reviews (Section

C paragraph 5.5.1)

Fixed Price Per Claim

(Not Separately Priced)

1009 Medical Record Reviews (Section C paragraph 5.5.2) EA

Fixed Price Per Record

1010 Transition-Out (Section C paragraph 5.3.2) LO

1011 Deliverables (DD Forms 1423-1, Contract Data

Requirements List (CDRLs))

(Not Separately Priced)

Ordering Period 2

March 1, 2024 - February 28, 2025

2001 Managed Care Support Contracts (MCSCs) Quarterly EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

2002 TRICARE Medicare Eligible Program (TMEP) EA

Quarterly Compliance Reviews (Section C Paragraph

5.4)

4 11

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940221R0002

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

Fixed Price Per Claim

2003 TRICARE Overseas Program (TOP) Quarterly EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

2004 TRICARE Pharmacy Program (Tpharm) Quarterly EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

2005 Active Duty Dental Program (ADDP) Semiannual EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

2006 Managed Care Support Contracts (MCSCs) Annual EA

Health Care Cost Audits (Section C paragraph 5.4)

Fixed Price Per Claim

2007 Focus Studies (Section C Paragraph 5.5.1)

(Not Separately Priced)

2008 Focus Studies -- PIIA Compliance Reviews (Section EA

C paragraph 5.5.1)

Fixed Price Per Claim

2009 Medical Record Reviews (Section C paragraph 5.5.2) EA

Fixed Price Per Record

2010 Transition-Out (Section C paragraph 5.3.2) LO

2011 Deliverables (DD Forms 1423-1, Contract Data

Requirements List (CDRLs))

5 11

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940221R0002

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

(Not Separately Priced)

Ordering Period 3

March 1, 2025 - February 28, 2026

3001 Managed Care Support Contracts (MCSCs) Quarterly EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

3002 TRICARE Medicare Eligible Program (TMEP) EA

Quarterly Compliance Reviews (Section C Paragraph

5.4)

Fixed Price Per Claim

3003 TRICARE Overseas Program (TOP) Quarterly EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

3004 TRICARE Pharmacy Program (Tpharm) Quarterly EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

3005 Active Duty Dental Program (ADDP) Semiannual EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

3006 Managed Care Support Contracts (MCSCs) Annual EA

Health Care Cost Audits (Section C paragraph 5.4)

Fixed Price Per Claim

3007 Focus Studies (Section C paragraph 5.5.1)

(Not Separately Priced)

3008 Focus Studies -- PIIA Compliance Reviews (Section EA

6 11

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940221R0002

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

C paragraph 5.5.1)

Fixed Price Per Claim

3009 Medical Record Reviews (Section C paragraph 5.5.2) EA

Fixed Price Per Record

3010 Transition-Out (Section C paragraph 5.3.2) LO

3011 Deliverables (DD Forms 1423-1, Contract Data

Requirements List (CDRLs))

(Not Separately Priced)

Ordering Period 4

March 1, 2026 - February 28, 2027

4001 Managed Care Support Contracts (MCSCs) Quarterly EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

4002 TRICARE Medicare Eligible Program (TMEP) EA

Quarterly Compliance Reviews (Section C Paragraph

5.4)

Fixed Price Per Claim

4003 TRICARE Overseas Program (TOP) Quarterly EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

4004 TRICARE Pharmacy Program (Tpharm) Quarterly EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

4005 Active Duty Dental Program (ADDP) Semiannual EA

Compliance Reviews (Section C paragraph 5.4)

7 11

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940221R0002

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

Fixed Price Per Claim

4006 Managed Care Support Contracts (MCSCs) Annual EA

Health Care Cost Audits (Section C paragraph 5.4)

Fixed Price Per Claim

4007 Focus Studies (Section C paragraph 5.5.1)

(Not Separately Priced)

4008 Focus Studies -- PIIA Compliance Reviews (Section EA

C paragraph 5.5.1)

Fixed Price Per Claim

4009 Medical Record Reviews (Section C paragraph 5.5.2) EA

Fixed Price Per Record

4010 Transition-Out (Section C paragraph 5.3.2) LO

4011 Deliverables (DD Forms 1423-1, Contract Data

Requirements List (CDRLs))

(Not Separately Priced)

Ordering Period 5

March 1, 2027 - February 29, 2028

5001 Managed Care Support Contracts (MCSCs) Quarterly EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

5002 TRICARE Medicare Eligible Program (TMEP) EA

Quarterly Compliance Reviews (Section C Paragraph

5.4)

8 11

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940221R0002

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

5003 TRICARE Overseas Program (TOP) Quarterly EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

5004 TRICARE Pharmacy Program (Tpharm) Quarterly EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

5005 Active Duty Dental Program (ADDP) Semiannual EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

5006 Managed Care Support Contracts (MCSCs) Annual EA

Health Care Cost Audits (Section C paragraph 5.4)

Fixed Price Per Claim

5007 Focus Studies (Section C paragraph 5.5.1)

(Not Separately Priced)

5008 Focus Studies -- PIIA Compliance Reviews (Section EA

C paragraph 5.5.1)

Fixed Price Per Claim

5009 Medical Record Reviews (Section C paragraph 5.5.2) EA

Fixed Price Per Record

5010 Transition-Out (Section C paragraph 5.3.2) LO

5011 Deliverables (DD Forms 1423-1, Contract Data

Requirements List (CDRLs))

(Not Separately Priced)

9 11

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940221R0002

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

Ordering Period 6

March 1, 2028 - February 28, 2029

6001 Managed Care Support Contracts (MCSCs) Quarterly EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

6002 TRICARE Medicare Eligible Program (TMEP) EA

Quarterly Compliance Reviews (Section C Paragraph

5.4)

Fixed Price Per Claim

6003 TRICARE Overseas Program (TOP) Quarterly EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

6004 TRICARE Pharmacy Program (Tpharm) Quarterly EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

6005 Active Duty Dental Program (ADDP) Semiannual EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

6006 Managed Care Support Contracts (MCSCs) Annual EA

Health Care Cost Audits (Section C paragraph 5.4)

Fixed Price Per Claim

6007 Focus Studies (Section C paragraph 5.5.1)

(Not Separately Priced)

6008 Focus Studies -- PIIA Compliance Reviews (Section EA

C paragraph 5.5.1)

10 11

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940221R0002

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

6009 Medical Record Reviews (Section C paragraph 5.5.2) EA

Fixed Price Per Record

6010 Transition-Out (Section C paragraph 5.3.2) LO

6011 Deliverables (DD Forms 1423-1, Contract Data

Requirements List (CDRLs))

(Not Separately Priced)

52.217-8, Option to Extend Services

March 1, 2029 - August 31, 2029

7001 Managed Care Support Contracts (MCSCs) Quarterly EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

(Option Line Item)

7002 TRICARE Medicare Eligible Program (TMEP) EA

Quarterly Compliance Reviews (Section C Paragraph

5.4)

Fixed Price Per Claim

(Option Line Item)

7003 TRICARE Overseas Program (TOP) Quarterly EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

(Option Line Item)

7004 TRICARE Pharmacy Program (Tpharm) Quarterly EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

(Option Line Item)

11 11

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940221R0002

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

7005 Active Duty Dental Program (ADDP) Semiannual EA

Compliance Reviews (Section C paragraph 5.4)

Fixed Price Per Claim

(Option Line Item)

7006 Managed Care Support Contracts (MCSCs) Annual EA

Health Care Cost Audits (Section C paragraph 5.4)

Fixed Price Per Claim

(Option Line Item)

7007 Focus Studies (Section C paragraph 5.5.1)

(Option Line Item)

(Not Separately Priced)

7008 Focus Studies -- PIIA Compliance Reviews (Section EA

C paragraph 5.5.1)

Fixed Price Per Claim

(Option Line Item)

7009 Medical Record Reviews (Section C paragraph 5.5.2) EA

Fixed Price Per Record

(Option Line Item)

7010 Transition-Out (Section C paragraph 5.3.2) LO

(Option Line Item)

7011 Deliverables (DD Forms 1423-1, Contract Data

Requirements List (CDRLs))

(Option Line Item)

(Not Separately Priced)

SECTION B

SUPPLIES OR SERVICES AND PRICES/COSTS

HT940221R0002 Page 12 of 12

1.0 GUARANTEED CONTRACT MINIMUM AND CONTRACT MAXIMUM: The

resultant contract will be an Indefinite Delivery/Indefinite Quantity (ID/IQ) type contract with

Firm Fixed Price (FFP) Task Orders.

1.1 Minimum Guarantee: The guaranteed minimum is $2,900,000.00 and will be satisfied under the first task order.

1.2 Maximum Contract Value: The value of all task orders placed under the resultant contract may not exceed $62,500,000.00.

(End of Section)

SECTION C

DESCRIPTION/SPECIFICATIONS/STATEMENT OF WORK

HT940221R0002 Page C1 of C50

Department of Defense

Defense Health Agency

Performance Work Statement

TRICARE Claims Review Service (TCRS)

J-8/Deputy Assitant Director, Financial Operations (DAD-FO)

Improper Payment Evaluation Branch

Solicitation Number: HT940221R0002

Version: 1

Date: October 2021

HT940221R0002 Page C2 of C50

PART 1

1.0 GENERAL INFORMATION

1.1 This is a non-personal services contract to provide TRICARE Claims Review Services

(TCRS).

1.2 Description of Services/Introduction: The contractor shall provide all personnel, equipment, supplies, facilities, transportation, tools, materials, supervision, and other items and non-personal services necessary to perform TCRS as defined in this Performance Work

Statement (PWS) except for those items specified as government furnished property and services. The contractor shall perform to the standards in this PWS.

The TCRS contractor manually re-adjudicates claims in accordance with TRICARE regulations and reimbursement requirements to detect errors in automated claims payments and or payment record coding.

1.3 Background: The Defense Health Agency (DHA) supports the delivery of integrated, affordable, and high quality health services for more than 9.6 million beneficiaries of the

Military Health System (MHS) and is responsible for shared services, functions, and activities of the MHS and other common clinical and business processes in support of the Military Services.

The MHS is a complex integrated healthcare system that consists of healthcare delivery, medical education, public health, private sector partnerships and innovative medical research and development. The MHS has two major care delivery systems. The direct care system provides care through military treatment facilities (MTFs). The purchased-care system, TRICARE, is comprised of two health care options, Select and Prime. TRICARE Prime is similar to a health maintenance organization (HMO) with a Point of Service Option and requires beneficiary enrollment. All Active Duty Service Members (ADSM) are TRICARE Prime enrollees; Active

Duty family members may elect to enroll in TRICARE Prime; other eligible beneficiaries pay an enrollment fee to enroll in TRICARE Prime. TRICARE Select is a fee for service type plan in which the beneficiary (non-ADSM) may choose to use a TRICARE-authorized provider without a referral or pre-authorization, in most situations. The two options of TRICARE are described fully in 32 Code of Federal Regulations (CFR) Part 199.17. TRICARE provides care through six purchased-care support contractors, including two Managed Care Support Contracts (MCSCs)

(East and West Regions), TRICARE Overseas Program (TOP), TRICARE Medicare Eligible

Program (TMEP), Active Duty Dental Program (ADDP) and TRICARE Pharmacy Program

(TPharm) contracts. The purchased-care system has more than 400,000 network individual providers (primary care, behavioral health, and specialty care providers) and more than 3,200

TRICARE network acute care hospitals.

1.4 Objectives: The objectives of this contract are to support the missions of the MHS which enable the National Defense Strategy by providing a Medically Ready Force, a Ready Medical

Force, and improving the health of all those entrusted to its care. The objectives below represent the performance outcomes for this contract and are supported by technical requirements. The acceptable performance standards are explained further in the contract.

HT940221R0002 Page C3 of C50

Objective 1, Compliance Reviews. Provide independent, impartial reviews (manual re-adjudication) of claims to include timely and accurate evaluations of each purchased care contractor’s healthcare claims processing and payment record coding procedures.

Objective 2, Focused Studies. Assist the IPEB in studying areas of the TRICARE health benefits program with the potential for incurring a higher than average risk of improper payments, including claims selected for an annual Payment Integrity Information Act of 2019

(PIIA) compliance review.

Objective 3, Medical Record Reviews. Validate healthcare services documented in a patient’s medical record is correctly invoiced to the Government for payment.

Objective 4, Continuity of Review Services. Maintain effective management solutions to provide the necessary claims review services, incorporating DHA and healthcare standards and best practices.

1.5 Scope: The purpose of this contract is to assist the Office of the Assistant Secretary of

Defense for Health Affairs (OASD-HA), the Office of Management and Budget (OMB), and the

DHA Improper Payment Evaluation Branch (IPEB), in identifying and reporting improper payments and discrepancies in payment record coding. This contract provides an independent, impartial review of claims processing procedures and reimbursement methodologies utilized by purchased-care contractors, assesses purchased-care contractor compliance with TRICARE policies and directives, and monitors the claims processing performance of DHA TRICARE purchased-care support contractors. The contractor shall evaluate the accuracy of claims payment and payment record coding for the six purchased-care contractors.

This contract also supports IPEB’s requirement to assess the potential risk of improper payments, identify, and report improper payments to the Office of Management and Budget (OMB) for publication in the Department of Defense (DoD), Agency Financial Report (AFR) pursuant to

Public Law (PL) 116-117 – Payment Integrity Information Act (PIIA) of 2019.

1.6 Period of Performance (PoP): The anticipated period of performance is as follows:

Transition In 09/01/2022-02/28/2023

Ordering Period 1 03/01/2023-02/29/2024

Ordering Period 2 03/01/2024-02/28/2025

Ordering Period 3 03/01/2025-02/28/2026

Ordering Period 4 03/01/2026-02/28/2027

Ordering Period 5 03/01/2027-02/29/2028

Ordering Period 6 03/01/2028-02/28/2029

1.6.1 Transition: Transition-in/transition-out period

1.6.1.1 Transition-in period: Full performance start date is March 1, 2023. Transition-in performance is defined at PWS paragraph 5.3.1.

HT940221R0002 Page C4 of C50

1.6.1.1.1 The contractor shall comply with transition-in requirements of the DHA, as listed in paragraph 1.11.1, for contractors needing to be issued Common Access Card (CAC) identification, including Department of Defense (DoD) and DHA-directed training and forms submission, prior to network access.

1.6.1.2 Transition-out period: The transition-out plan shall facilitate the accomplishment of a seamless transition from the incumbent to an incoming contractor/Government personnel at the expiration of the contract. See PWS paragraph 5.3.2.

1.6.1.2.1 The contractor shall comply with transition-out requirements of the DHA for contractors who have been issued a CAC or who generate “records”, as defined by DoD (records manual), including DoD-directed disposition of records, and others displayed on the In/Out (I/O)

Processing Portal.

1.7 Administrative Specifications

1.7.1 Place of performance: The work shall be performed at the contractor’s facility or in a remote environment as long as the required security precations are documented and followed.

1.7.2 Recognized Federal holidays: The contractor is not required to perform services on the following holidays.

New Year’s Day Labor Day

Martin Luther King Jr.’s Birthday Columbus Day

President’s Day Veteran’s Day

Memorial Day Thanksgiving Day

Juneteenth Day Christmas Day

Independence Day

1.7.3 Hours of operation: The contractor is responsible for conducting business Monday thru

Friday except Federal holidays or when the Government facility is closed due to local or national emergencies, administrative closings, or similar Government directed facility closings. The contractor must at all times maintain an adequate workforce for the uninterrupted performance of all tasks defined within this PWS when the Government facility is not closed for the above reasons.

1.7.4 Emergency Services:. Reserved

1.8 Contractor Travel: The contractor shall be required to travel within the Continental United

States (CONUS) to attend meetings held by DHA. Generally, a 14 day notice will be provided for all meetings hosted by DHA, at one of its Government locations. Contractor should assume two meetings per year. All contractor travel costs associated with any of these meetings shall be the responsibility of the contractor.

1.9 Other Direct Costs (ODC): Reserved

HT940221R0002 Page C5 of C50

1.10 Quality

1.10.1 Quality Control (QC): The contractor shall develop and maintain an effective QC program to ensure services are performed in accordance with this PWS. The contractor shall develop and implement procedures to identify, prevent, and ensure nonrecurrence of defective services. The contractor’s QC program is the means by which the work complies with stated requirements. Please see PWS paragraph 5.2 for additional information on Quality Control.

1.10.2 Quality assurance (QA): The government will evaluate the contractor’s performance under this contract in accordance with the Quality Assurance Surveillance Plan (QASP). This plan provides a systematic method for the Government to evaluate performance and to ensure that the contractor has performed in accordance with the performance standards. It defines how the performance standards will be applied, the frequency of surveillance, and the minimum acceptable defect rate(s).

1.11 Contractor Personnel

1.11.1 CAC requirements: For all contractors performing work on behalf of the Government, the Facilities Security Officer (FSO)/Company's Security point of contact (POC) will provide the

Government all the required information per the DHA CAC request process current version 2.1, January 2018, or more recent when updated. See process attached at Part 7 Section 7.1.1 of the

PWS. A CAC is the standard identification for eligible DoD contractor personnel.

1.11.1.1 The contractor shall return all CACs to the COR upon the departure of the contractor(s).

1.11.2 Contractor onboarding and training. The contractor shall complete all requirements, training, and forms as prescribed in the following requirements:

1.11.2.1 The DHA’s “Onboarding Checklist for Contractor Employees” is located at the DHA

Onboarding and Offboarding Portal at https://info.health.mil/cos/admin/hr/IO/SitePages/Home.aspx

1.11.2.2 The DHA’s contractor training instructions embedded at Part 7 Section 7.1.2.

1.11.2.3 The contractor shall comply with onboarding requirements of the DHA for contractors needing to be issued CAC identification, including DoD- and DHA-directed training and forms submission, prior to network access, as displayed in the In/Out-Processing Portal at:

https://info.health.mil/cos/admin/hr/IO/SitePages/home.aspx (note: Public Key Infrastructure

(PKI)-restricted, printed versions available).

1.11.3 Physical Security: The contractor shall be responsible for safeguarding all government equipment, information and property provided for contractor use. At the close of each work period, government facilities, equipment, and materials shall be secured.

1.11.4 Key control: Reserved

https://info.health.mil/cos/admin/hr/IO/SitePages/Home.aspx https://info.health.mil/cos/admin/hr/IO/SitePages/home.aspx

HT940221R0002 Page C6 of C50

1.11.5 Lock combinations: Reserved

1.12 Key Personnel (Contractor): Reserved

1.13 Data Rights: Reserved

1.14 Reporting

1.14.1 Contractor Manpower Reporting (CMR): Reserved

1.14.2 Non-Disclosure Agreement (NDA): All contractor personnel who will obtain access to proprietary, classified, or confidential information or any information release of which is protected or governed by law or regulation associated with DHA acquisitions shall be required to complete and sign a DHA contractor NDA (DHA Form 49) prior to beginning work on the subject contract. The contractor shall execute an NDA on behalf of the company and shall ensure that all staff assigned to, including all subcontractors and consultants, or other personnel performing on contract/Task order execute an NDA protecting the procurement sensitive information of the Government and the proprietary information of other contractors. The NDA shall be executed not later than first day of employment and annually thereafter. Assignment of staff who has not executed this statement or failure to adhere to this statement shall constitute default on the part of the contractor. The contractor shall maintain originally signed NDAs of individual employees and provide copy to the COR.

1.14.3 Government’s COR: The COR monitors all technical aspects of the contract and assists in contract administration. The COR is authorized to perform the following functions: assure that the contractor performs the technical requirements of the contract; perform inspections necessary in connection with contract performance; maintain written and oral communications with the contractor concerning technical aspects of the contract; issue written interpretations of technical requirements, including Government drawings, designs, specifications; monitor contractor's performance and notifies both the CO and contractor of any deficiencies; coordinate availability of government furnished property; and provide site entry of contractor personnel. A letter of designation issued to the COR, a copy of which is sent to the contractor, states the responsibilities and limitations of the COR, especially with regard to changes in cost or price, estimates or changes in delivery dates. The COR is not authorized to change any of the terms and conditions of the resulting contract.

1.14.4 Post award conference/periodic progress meetings: The contractor agrees to attend any post award conference convened by the contracting activity or contract administration office in accordance with FAR Subpart 42.5. The CO, COR, and other Government personnel, as appropriate, may meet periodically with the contractor to review the contractor's performance.

At these meetings the CO will apprise the contractor of how the government views the contractor's performance and the contractor will apprise the Government of problems, if any, being experienced. Appropriate action shall be taken to resolve outstanding issues. These meetings shall be at no additional cost to the government.

HT940221R0002 Page C7 of C50

1.15 Contractor Identification

1.15.1 Contractor personnel performing services in a contractor capacity in a Government facility are required to possess and wear an identification badge that displays his or her name and the name of their company. All contractor personnel shall identify themselves as contractor support personnel in all forms of communication with all entities with whom DHA/Deputy

Assistant Director for Acquisition (DAD-A)/Head of the Contracting Activity (HCA) has business dealings. The contractor shall: Answer all telephone calls and have a personalized voice message with an introductory statement that includes the fact that the person is contractor support personnel. Ensure all those with whom the person interacts in any face-to-face dealings while supporting the DAD-A understands that the person is contractor support personnel.

Include a title block in all emails that states the fact that the person is contractor support personnel. Ensure all those with whom the person interacts in any face-to-face dealings while supporting DHA/DAD-A/HCA understands that the person is contractor support personnel.

1.15.2 Contractor personnel will be required to attend meetings or otherwise communicate with

Government and/or other contract representatives to meet the requirements of this order.

Contractor personnel shall make their contractor status known during introductions.

1.15.3 Contractor personnel, while performing in a contractor capacity, are prohibited from using their retired or reserve component military rank or title in any written or verbal communications associated with the contracts in which they provide services.

1.16 Contractor Access to Health Affairs (HA)/DHA Network(s)

1.16.1 FSO/Company's Security POC shall notify the DHA Personnel Security Office after being awarded a contract that requires access to a DoD system . Contractor personnel requiring access to the HA/DHA networks for performance of their tasks require a background investigation and the security awareness training. The contractor shall be prepared for this process as it could take two (2) or more weeks. The FSO/Security POC shall submit a Standard

Form (SF) 85/86 to DHA's Personnel Security Office for a background investigation.

1.16.2 Company's FSO/Security POC must notify the Personnel Security Office when the contractor has submitted the SF-85/86. The FSO/Security POC, or the COR must notify the

DHA Personnel Security Office in writing of a contractor's termination from the contract, including the termination date.

1.17 Personnel Security

1.17.1 The contractor shall comply with DoD 8570.01-M, “Information Assurance Workforce

Improvement Program, CH4” November 10, 2015 as amended; 8500.01, “Cybersecurity”, dated

March 14, 2014; DoD Manual (DoDM) 6025.18, “Implementation of the Health Insurance

Portability and Accountability Act (HIPAA) Privacy Rule Compliance in DoD Health Care

Programs” dated March 3, 2019, Department of Defense Instruction (DoDI) 6025.18 “HIPAA

Privacy Rule Compliance in DoD Health Care Programs”, dated March 13, 2019; and DoDM

5200.02 “Procedures for the DoD Personnel Security Program (PSP),” incorporation change 3, HT940221R0002 Page C8 of C50 effective September 24, 2020. Contractor responsibilities for ensuring personnel security include, but are not limited to, meeting the following requirements:

1.17.1.1 Follow the DHA Personnel Security Office guidelines for submittal of security clearances. Contact the DHA Personnel Security Office for guidance on the appropriate background investigation required for personnel on the contract. The DHA Personnel Security

Office can be reached at (703) 275-6038.

1.17.1.2 Initiate, maintain, and document personnel security investigations appropriate to the individual’s responsibilities and required access to Controlled Unclassified Information (CUI).

1.17.1.3 DHA Personnel Security Office does not deny any access to any automated information system (AIS), network, or Controlled Unclassified Information (CUI). If a contractor receives an unfavorable background investigation, the request for access will be sent back to the FSO for further action. Any unfavorable adjudication will result in DHA Personnel Security Office not signing off on any access request.

HT940221R0002 Page C9 of C50

PART 2

2.0 DEFINITIONS, ACRONYMS, AND APPLICABLE

PUBLICATIONS/INSTRUCTIONS

2.1 Definitions:

2.1.1 Category D: Information Technology (IT) and Telecommunications Services (called D-

Services)

2.1.2 Category R: Support (Professional/Administrative/Management) Services (called R-

Services)

2.1.3 Contracting Officer (CO): A person with the authority to enter into, administer, and/or terminate contracts and make related determinations and findings.

2.1.4 Contracting Officer’s Representative (COR): An individual, including a contracting officer’s technical representative (COTR), designated and authorized in writing by the CO to perform specific technical or administrative functions. This individual does NOT have authority to change the terms and conditions of the contract.

2.1.5 Nonpersonal services contract: a contract under which the personnel rendering the services are not subject, either by the contract’s terms or by the manner of its administration, to the supervision and control usually prevailing in relationships between the Government and its employees.

2.1.6 Quality Assurance Surveillance Plan (QASP): An organized written document specifying the surveillance methodology to be used for surveillance of contractor performance. The

Government may either prepare the QASP or require the offerors to submit a proposed quality assurance surveillance plan for the Government’s consideration in development of the

Government’s plan.

2.1.7 Additional definitions are listed in the TRICARE Operations Manual (TOM), Appendix A.

2.2 Acronyms:

AIS Automated Information System

APL Approved Products List APL

AQL Acceptable Quality Level

ARRT Acquisition Requirements Roadmap Tool

B2B Business-2-Business

CAC Common Access Card

CCEVS Common Criteria Cybersecurity Evaluation and Validation Scheme

CE Computer Environment

CDRL Contract Data Requirement List

CJCSM Chairman of the Joint Chiefs of Staff Manual

CMR Contractor Manpower Reporting

HT940221R0002 Page C10 of C50

CNSSI Committee on National Security Systems Instruction

CO Contracting Officer(s)

CONUS Continental United States (excludes Alaska and Hawaii)

COR Contracting Officer Representative

COTR Contracting Officer's Technical Representative

CSP Cloud Service Provider

CUI Controlled Unclassified Information

DAD-A Deputy Assistant Director for Acquisition

DD Form 254 Department of Defense Contract Security Requirement List (if applicable)

DB Design-Build

DBB Design-Bid-Build

DFARS Defense Federal Acquisition Regulation Supplement

DHA Defense Health Agency

DoD Department of Defense

DoDD Department of Defense Directive

DoDI Department of Defense Instruction

DSAs Data Sharing Agreements

DSAA Data Sharing Agreement Application

DMZ Demilitarized Zone

DoDM Department of Defense Manual

DPCLO DHA Privacy and Civil Liberties Office

DUA Data Use Agreement eMSM Enhanced Multi-Service Markets

EULA End User License Agreement

EVM Earned Value Management

FAR Federal Acquisition Regulation

FCI Federal contract information

FE Facilities Enterprise

FISMA Federal Information Security Modernization Act

FSO Facilities Security Officer

HA Health Affairs

HIPAA Health Insurance Portability and Accountability Act

HCA Head of the Contracting Activity

IGCE Independent Government Cost Estimate

IA Information Assurance

IO Initial Outfitting

I/O In/Out Processing Portal

IPv Internet Protocol Version

IS Information System

ISP Internet Service Provider

IT Information Technology

ISCM Information Security Continuous Monitoring

IV&V Independent Verification & Validation

MedCOI Medical Community of Interest

MHS Military Health System

MIL-STD Military Standard

HT940221R0002 Page C11 of C50

MTFs Military Treatment Facilities

NCR National Capitol Region

NDA Non-Disclosure Agreement

NIAP National Information Assurance Partnership

NIST National Institute of Standards and Technology

OCONUS Outside Continental United States (includes Alaska and Hawaii)

ODC Other Direct Costs

OPM Office of Personal Management

OSD Office of the Secretary of Defense

P-ATO Personal Authorization to Operate

P&R Personnel and Readiness

PGI Procedures, Guidance and Information

PDT Project Delivery Team

PHI Protected Health Information

PII Personally Identifiable Information

PK Public Key

PKI Public Key Infrastructure

POA&M Plan of Action and Milestones

POC Point of Contact

PMO Program Management Office

PoP Period of Performance

PP Personal Property

PRS Performance Requirements Summary

PSP Personnel Security Program

PWS Performance Work Statement

QA Quality Assurance

QAP Quality Assurance Program

QASP Quality Assurance Surveillance Plan

QC Quality Control

QCP Quality Control Plan

RFP Request for Proposal

RFQ Request for Quotation

SP Special Publication

SPRS Supplier Performance Risk System

SRM Sustainment, Restoration and Modernization

SRG Security Requirements Guides

STIG Security Technical Implementation Guides

TOS Terms of Service

US United States

UFC Unified Facilities Criteria

VPN Virtual Private Network

XML Extensible Markup Language

Additional Acronyms are listed in the TOM as a .pdf attachment “Acronyms”.

2.3 Applicable Publications, DHA Administrative Instructions (AI), etc. The contractor

HT940221R0002 Page C12 of C50 shall abide by the current version of all applicable regulations, publications, manuals, and local policies and procedures. The list below includes key directives and websites related to the contract. The list is not intended to be all inclusive. The following documents are hereby incorporated by reference to the contract:

Title 10, United States Code (USC), Chapter 55

Title 32 Code of Federal Regulations (CFR) National Defense, Parts 199.3, 199.6, 199.9, 199.10 and 199.13.

Title 36 CFR Part 1222 Creation and Maintenance of Federal Records.

Title 45 CFR, Parts 160, 162 and 164 of Health Insurance Portability and

Accountability Act (HIPAA) of 1996.

National Institute of Standards and Technology (NIST) 800-171 Rev 2, Protecting

Controlled Unclassified Information in Nonfederal Systems and Organizations.

DoD 6025.18, Implementation of the Health Insurance Portability and

Accountability Act (HIPAA) Privacy Rule in DoD Health Care Programs.

DoD Instruction 8582.01, Security of Non-DoD information Systems Processing

Unclassified Nonpublic DoD information.

DoD 8580.02-R, Department of Defense Health Information Security Regulation.

DODD 5000.01, Defense Acquisition Systems.

DoD Directive 8500.01, Cybersecurity.

DoD Directive 5400.11-R, DoD Privacy Program.

DoD Instruction 5200.02, DoD Personnel Security Program .

Federal Information Security Management Act of 2002.

2.3.1 TRICARE Manuals. The TRICARE Manuals apply to this contract as referenced in

Section C, Section J attachments, and in the DD Forms 1423-1, Contract Data Requirements

List (CDRL). The contractor shall utilize the most appropriate versions of the TRICARE

Manuals when evaluating healthcare claims. TRICARE Manuals are located at http://manuals.health.mil.

http://manuals.health.mil/

HT940221R0002 Page C13 of C50

PART 3

3.0 GOVERNMENT FURNISHED PROPERTY, EQUIPMENT, AND SERVICES

The Requiring Activity Authority has assessed the need for Government Furnished Property, Equipment, and Services and determined:

3.1 Services: The Government:

☒ Will NOT provide Government Furnished Services in support of this contract/task order. As a result, this paragraph is Not Applicable.

☐ WILL provide Government Furnished Services required in support of this contract/task orders. These Services are described below:

3.2 Facilities: The Government:

☒ Will NOT provide Facilities in support of this contract/task order. As a result, this paragraph is Not Applicable.

☐ WILL provide Facilities in support of this contract/task orders. The Government provided

Facilities are described below:

3.3 Utilities: The Government:

☒ Will NOT provide Utilities in support of this contract/task order. As a result, this paragraph is

Not Applicable.

☐ WILL provide Utilities in support of this contract/task orders. The Government provided

Utilities are described below:

3.4 Equipment: The Government:

☒ Will NOT provide Equipment in support of this contract/task order. As a result, this paragraph is Not Applicable.

☐ WILL provide Equipment in support of this contract/task orders. The Government provided

Equipment is described below:

3.4.1 Procurement Integrated Enterprise (PIEE), GFP Module Application. Reserved

3.5 Materials: The Government:

☐ Will NOT provide Materials in support of this contract/task order. As a result, this paragraph is Not Applicable.

HT940221R0002 Page C14 of C50

☒ IS providing Materials in support of this contract/task orders. The Government-provided

Materials are described below:

TRICARE Purchased-Care Contracts. The Contracting Officer’s Representative (COR) will provide redacted and conformed copies of TRICARE purchased care contracts deemed pertinent to the performance of the compliance reviews. The purchased-care contractor information is provided as reference material and is integral to the contractor’s ability to successfully evaluate the claims processing performance of the MCSCs, TMEP, TPharm, TOP, and ADDP contracts.

The Government will provide copies of Common Letters issued by DHA Contracting Officers

(COs) to purchased-care contractors. A “common letter” is any written correspondence, to multiple contractors, that has the same content and is used by all affected COs to convey information, data, or request a response. The common letter may or may not be in response to a contractor’s inquiry. It may originate from any organization involved with administration of

TRICARE purchased-care contracts and their inherent requirements. A common letter addresses technical and/or administrative information within the existing scope and dollar value of affected

TRICARE purchased-care contracts. Common letters can impact claims processing procedures or reimbursement determination utilized by a TRICARE purchased-care contractor which are not published in TRICARE manuals or regulations, yet requires the purchased-care contractor to comply with the letters directive.

Department of Health and Human Services (DHHS) Sanctioned Provider List. The contractor shall use the DHHS sanctioned healthcare provider list at https://oig.hhs.gov/exclusions/exclusions_list.asp to determine if purchased-care contractors are erroneously reimbursing sanctioned healthcare providers.

Access to the following Government System(s) and/or Application(s). The Government will grant access to the following systems only after the contractor and its subcontractor’s staffs that utilize systems are compliant with the enhanced safeguarding methods for unclassified

DoD information, personnel security, and clearance requirements.

Defense Manpower Data Center (DMDC) Defense Enrollment Eligibility Reporting System

(DEERS). The Government will provide the contractor with access to the DMDC’s General

Inquiry DEERS (GIQD) and the Catastrophic Cap and Deductible Research Application (CCD

Web Research) interface environment for the use of validating medical eligibility and beneficiary deductible and cost-share liability under the TRICARE benefit program. Connectivity to DEERS shall be in accordance with TSM, Chapter 1, Section 1.1.

The Government will provide the contractor with access to the TRICARE Patient Encounter

Processing and Reporting (PEPR) portal to access the TRICARE Encounter Data (TED) Audit

(TA) application and the PEPR Care Detail Information System (PCDIS) web-based applications

(Section J, Attachment J-1, PEPR Account Activation Request Form (AARF)).

TA Application. The TA application is the primary online application used by the contractor and Government. Reports generated from the TA application are used to assess the claims processing performance of TRICARE purchased-care contractors against Government claims

HT940221R0002 Page C15 of C50 processing performance standards and to support the Agency’s reporting of PIIA activities. (See

Section J, Attachment J-10 for examples of TA reports). The TA application provides:

A mechanism for the contractor and Government to track and monitor the claims processing performance of TRICARE purchased care contractors;

Allows for the retention of a compliance review trail with the appropriate error codes and error amounts; and

Facilitates the input of a detailed explanation for error code and error amount assessment.

PCDIS. The PCDIS functions as a “search window” into the purchased care claims database.

PCDIS data includes all processed TED claims for care provided to TRICARE beneficiaries by civilian network or non-network providers. PCDIS is utilized to:

Verify provider information (i.e. Provider Identification/National Provider Identification numbers, Medicare numbers, Area Wage Index, etc.);

Verify provider network/non-network status;

Identify duplicate claim submissions;

Query TED detail claims and summary data for institutional and professional purchased-care data; and, to

Query patient or sponsor healthcare medical and pharmacy claims history.

HT940221R0002 Page C16 of C50

PART 4

4.0 CONTRACTOR FURNISHED ITEMS AND SERVICES

4.1 Services: The Contractor:

☒ Will NOT provide Contractor Furnished Services in support of this contract/task order. As a result, this paragraph is Not Applicable.

☐ WILL provide Contractor Furnished Services required in support of this contract/task orders.

These Services are described below:

4.2 General: The contractor shall furnish all supplies, equipment, facilities and services required to perform work listed under Section 5 of this PWS.

4.3 Secret Facility Clearance: Reserved

4.4 Materials: Reserved

4.5 Equipment: Reserved

4.6 Facilities: Reserved

HT940221R0002 Page C17 of C50

PART 5

5.0 SPECIFIC TASKS

These technical requirements represent specific tasks, outcomes, and/or standards to which the contractor shall perform in support of the above objectives.

5.1 Staffing/Program Management

5.1.1 Staffing. The contractor shall designate a single point of contact (POC) to oversee the tasks of this contract, supervise staff assigned to the tasks, and ensure that the tasks of the contract are performed efficiently, accurately, on time, and in compliance with the requirements of this document. The POC shall provide the Contracting Officer’s Representative (COR) with on-going status updates of the tasks and any issues relating to the contract.

5.1.1.1 The contractor shall ensure all personnel, to include subcontractors, are qualified to perform their assigned responsibilities (i.e. claims auditing, medical record reviews, etc.), including credentials, certifications (for those positions requiring such accreditation), education, training, and experience consistent with industry standards and best practices.

5.1.1.2 The contractor shall ensure that a sufficient number of qualified staff with the appropriate knowledge, skills, experience and credentialing are available to meet all aspects of the contract.

In addition, the contractor shall ensure that staff assigned to conduct medical record reviews have the appropriate knowledge, skills, experience, and credentialing such as Certified

Professional Coder (CPC), Certified Professional Coder - Outpatient Hospital (COC), Certified

Coder-Payer (CPC-P), Evaluation and Management Certified Coding Specialists and Certified

Professional Medical Record Auditor (CPMA) (this is not an all-inclusive list), necessary to form an opinion consistent with industry standards and best practices.

5.1.2 Program Management: The contractor shall develop a Program Management Plan (PMP)

(CDRL AP020). The PMP shall consist of control policies and procedures for project administration, execution and tracking consistent with program management best practices and standards.

5.1.2.1 The contractor shall notify the COR of key milestones and issues that are directly related to the scope of the contract both verbally and in writing. At a minimum, the contractor shall address the following in its PMP:

All technical activities (including documentation development)

An estimate of the timing, and level of effort (by labor category) for all performance elements

A matrix of all personnel assigned to the program and total aggregate level of effort for each performance element

Project plan with a detailed schedule that identifies all tasks and key milestones in a format agreed to by the COR

Quality assurance processes and monitoring methods

Risk management procedures

HIPAA risk assessment (CDRL A100, Risk Assessment Letter of Assurance)

HT940221R0002 Page C18 of C50

The contractor’s training program which ensures the accurate evaluation of healthcare claims under the TRICARE health benefits program

The contractor’s process for tracking the status of deliverables

The contractor’s Data Use Agreements (DUA)/Data Share Agreement (DSA)

The contractor's personnel clearances to access DOD data systems

System Security Plan and Associated Plans of Action for a Contractor’s Internal

Unclassified Information System (CDRL P010), and

Disaster Recovery Test Results Report (CDRL A090)

5.1.3 Weekly Workload and Activity Status Reports. The contractor shall ensure the timely and accurate completion of on-going compliance reviews in accordance with the contract’s performance requirements. The contractor shall develop and submit weekly status reports in accordance with CDRL W030, Audit Status Report, and CDRL W040, Audit Workload Report.

5.1.3.1 The contractor shall provide a written analysis of errors report of each quarterly, semiannual and annual compliance review findings.

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