Attachment J-17 TOM Chapter 18 CPD Revision 1 09202023.pdf

DTP PUBLICATION CHANGE FORM - TOM 2021

Project Officer/MCC (ext) Package Name Other Manuals Affected ConReq Updated Through Received Updated

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A C R O N Y M S : CPD - Competitive Plans Demonstration/ EEE - Eligibility, Enrollment, and Encounter / VAIS - value-added items and services

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TRICARE Operations Manual 6010.62-M, April 2021 Chapter 8, Section 2

Jurisdiction

6.5.1.2 The certifying contractor shall follow standard appeal procedures including aging the appeal from the date of receipt by the certifying contractor.

6.5.1.2.1 The contractor shall, if the reconsideration decision is favorable, notify the provider to resubmit any claims denied for lack of TRICARE certification to the servicing contractor with a copy of the reconsideration response.

6.5.1.2.2 The contractor shall ensure a TEPRV for this provider is accepted by DHA within seven calendar days from the date of the appeal decision.

6.5.2 The servicing contractor shall forward to the certifying contractor within five business days of receipt any provider requests for review of claims denied because the certifying contractor was unable to complete the certification process.

6.5.2.1 The servicing contractor shall notify the provider of the transfer with an explanation of the requirement to complete the certification process with the certifying contractor.

6.5.2.2 The certifying contractor shall, upon receipt of the provider’s request, follow its regular TRICARE provider certification procedures. In this case, no basis for an appeal exists. If the provider is determined to meet the certification requirements, the special provider notification and TEPRV submittal requirements apply.

7.0 OUT-OF-JURISDICTION TRICARE CLAIMS

7.1 The contractor shall, when the contractor receives an electronic claim with no services or supplies within its jurisdiction, transfer the claim to the appropriate jurisdictional contractor (including Competitive Plans Demonstration (CPD), TPharm, TOP, TMEP) via a HIPAA-compliant 837 transaction within 72-hours of identifying out-of-jurisdiction on a claim.

7.2 The contractor shall, when it receives a paper claim that is identified as out-of-jurisdiction, transfer the paper claim (and any supporting documents) to the appropriate contractor.

7.3 Partially Out-of-Jurisdiction. The contractor shall process the claim for which services or supplies are within its jurisdiction.

8.0 NON-TRICARE CLAIMS

The contractor shall return claims submitted on other than approved TRICARE claim forms to the sender or transfer to other lines of business, if appropriate.

8.1 Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) Claims

The contractor shall return a claim identified as a CHAMPVA claim to the sender with a letter advising them of the CHAMPVA program’s toll-free telephone number, 1-800-733-8387, and instructing them to send the claim and all future CHAMPVA claims to:

Chief, Business Office Purchased Care

CHAMPVA

P.O. Box 469064 Denver, CO 80246-9064

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Demonstrations, Pilot Projects, and Value-Based Initiatives

Chapter 18 Section 10

Competitive Plans Demonstration (CPD)

Revision:

1.0 PURPOSE

The purpose of the CPD is to implement certain requirements set forth in the National Defense Authorization Act for Fiscal Year 2017 (NDAA FY17), Section 705, Value-Based Purchasing (VBP) and Acquisition of Managed Care Support Contracts (MCSCs) for the TRICARE Program. VBP is an emerging reimbursement strategy in the health care industry that seeks to reward better health outcomes, enhance the beneficiary’s experience of care, and reduce health care costs over time. NDAA FY17, Section 705 requires the Department to develop and implement value-based incentive programs as part of its TRICARE MCSCs. Section 705(c)(3) specifically requires the Department to “ensure that local, regional and national health plans have an opportunity to participate in competition for managed care support contracts under the TRICARE Program” and that contracts awarded to such plans incorporate, among other things, value-based reimbursement methodologies and “financial incentives for contractors and health care providers to receive an equitable share in the cost savings to the Department resulting from improvement in health outcomes for covered beneficiaries and the experience of beneficiaries in receiving health care.” The Defense Health Agency (DHA) will, through the CPD, implement the foregoing aspects of Section 705 and test and evaluate the following:

• Competition between contractors with geographically overlapping networks.

• Impact of a risk adjusted population based Per Member Per Month (PMPM) payment model for the improvement of access to care for covered beneficiaries.

• Impact of a risk adjusted population based capitated PMPM payment model for the improvement of the quality of health care provided to covered beneficiaries.

• Whether a risk adjusted population based capitated PMPM payment model will be cost neutral to the Department of Defense (DoD) per capita costs of health care provided to covered beneficiaries.

• Impact of a risk adjusted population based capitated PMPM payment model on the improvement of health outcomes for covered beneficiaries.

• Cost efficiencies associated with using an external Eligibility, Enrollment, and Encounter (EEE) process (carried out via the Agency’s EEE Pilot).

2.0 BACKGROUND AND OBJECTIVES

2.1 The CPD is a value-based initiative that seeks to improve health outcomes, maintain current health care cost profiles (i.e., achieve cost neutrality), and reduce health care cost risks to the Government. The purpose of the CPD is to test the hypothesis that a risk adjusted population based capitated PMPM payment model with

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Chapter 18, Section 10

Competitive Plans Demonstration (CPD) competition between contractors with geographically overlapping networks will result in higher levels of efficiency, effectiveness of care, and beneficiary satisfaction than currently experienced under the traditional TRICARE MCSC construct.

2.2 The CPD objectives are:

2.2.1 Assess efficacy of having multiple contractors or overlapping networks in the same geographic area with the MCSCs and/or Uniformed Services Family Health Plan (USFHP).

2.2.2 Test the interoperability and effectiveness of the EEE Pilot to support the CPD contractors.

3.0 APPLICABILITY

The CPD is applicable to designated ZIP codes in the geographic areas designated by DHA. The CPD’s period of performance is subject to the timing of award of the CPD contract(s).

4.0 PROGRAM OVERVIEW

The CPD contractor will deliver the TRICARE Prime option, with the contractor providing Primary Care Managers (PCMs) through its network of providers and coordinating referrals to other CPD network specialty providers. The CPD contractor must provide comprehensive health care services to all eligible CPD Prime enrollees for which the CPD contractor shall receive a monthly capitation payment. The CPD contractor shall provide enrollees access to all CPD network primary and specialty providers in the geographic areas as designated by ZIP codes in accordance with the contract, (e.g., video and virtual health), coordinate medical management and referral services for beneficiaries enrolled in the CPD, to include managing copayments, cost-shares, deductibles, and coinsurance.

5.0 POLICY

5.1 Eligibility

5.1.1 TRICARE Prime-eligible beneficiaries residing in the CPD designated service area may voluntarily elect to enroll in the Demonstration with the following exceptions: Active-Duty Service Members (ADSMs), Guard/ Reserve Service Members, and beneficiaries who are eligible for Medicare are not eligible to enroll into the CPD.

Beneficiaries participating in the following benefit programs are also not eligible to enroll into the CPD:

• TRICARE For Life (TFL)

• TRICARE Reserve Select (TRS)

• TRICARE Reserve Retired (TRR)

• TRICARE Young Adult (TYA)

5.1.2 Due to CPD program design and the Government’s desire to maintain beneficiary continuity of care, beneficiaries participating in or receiving benefits under the following special programs are not eligible to enroll into the CPD:

• Autism Care Demonstration (ACD)

Competitive Plans Demonstration (CPD)

• Extended Care Health Option (ECHO) Program

• Wounded Warrior Program

• Continued Health Care Benefits Program (CHCBP)

5.2 Benefit

5.2.1 The CPD contractor will offer the TRICARE Prime benefit.

5.2.2 The CPD contractor shall link their CPD website to the appropriate TRICARE.mil websites for accurate TRICARE information and may provide a list on their site where benefits and costs differ, for example by listing offered value-added items and services (VAIS). However, the CPD contractor may only use VAIS with prior notification to DHA and only market the VAIS to prospective CPD enrollees with prior approval by DHA. The CPD Contractor may not use the VAIS as an inducement or incentive for beneficiary enrollment, or claim or imply that the VAIS are recommended or endorsed by TRICARE or the DHA. Any notification the CPD contractor sends to its enrollees about the availability of VAIS shall include a disclaimer explaining that the value-added services are not a TRICARE benefit.

5.3 Beneficiary Liability

5.3.1 Under the CPD, beneficiary liability shall match the TRICARE Prime benefit plan with respect to required enrollment fees, copayments, Point of Service (POS) deductibles and cost-shares, and catastrophic caps, unless otherwise identified.

5.3.2 The CPD contractor shall collect medical encounter data showing services provided and report beneficiary cost-share amounts to ensure accurate tracking towards the catastrophic caps.

5.4 CPD Provider Network

5.4.1 The CPD contractor’s provider network shall be sufficiently robust to meet TRICARE Prime access-to-care (ATC) standards, as described in Chapter 5, Section 1, in the CPD designated service area.

5.4.2 The CPD contractor shall monitor, and report care rendered by providers outside the CPD network (see DD Form 1423, Contract Data Requirements List (CDRL), located in Section F of the applicable contract).

5.4.3 The CPD contractor shall educate enrollees on the use of its on-line provider network directories. The contractor’s on-line provider network directory shall include primary and specialty care providers, facilities, vendors for Durable Medical Equipment (DME), ambulance transport, and transplant.

5.5 Enrollment

5.5.1 Enrollment in the CPD will be managed by the EEE contractor. Beneficiaries may enroll in the CPD even if they have not previously been enrolled to, or are not currently to, TRICARE Prime. TRICARE Open Season and Qualifying Life Event (QLE) rules apply to CPD enrollment.

5.5.2 The CPD contractor shall have an interface with the EEE contractor for the exchange of enrollment information.

Competitive Plans Demonstration (CPD)

5.5.3 The CPD contractor shall communicate, collaborate, and coordinate with the EEE contractor for transition in and transition out activities.

5.5.4 The CPD contractor shall coordinate with the EEE contractor to ensure system integration and testing requirements are met within the required timeframe.

5.5.5 At a minimum, the CPD contractor shall meet with the EEE contractor on a monthly basis to discuss any systems changes or updates, unless there are issues with data exchanges between contractors that impact production, testing, and/or processing of data. If such issues arise, the contractors shall coordinate with the Government Designated Authority (GDA) to establish more frequent meetings until the issue(s) is resolved.

Meeting topics shall include, but not be limited to, the following:

• Reviewing the status of system connectivity and communications.

• Issuing software enhancements.

• Implementing system changes required for the implementation of new programs and/or benefits.

• Reviewing data correction issues and corrective actions to be taken (e.g., research and adjustments).

• Monitoring results of contractor testing efforts.

5.5.6 CPD and EEE enrollment processes are described in the Process Flowcharts in Section J of the contract.

5.5.7 Enrollment Fee Waiver

5.5.7.1 The Government will waive the annual TRICARE Prime enrollment fee for the initial 12 months a beneficiary is enrolled in the CPD Demonstration. This is a one-time only enrollment fee waiver.

5.5.7.2 If a beneficiary disenrolls from the CPD while an enrollment fee waiver is in effect, the fee waiver will be terminated. If the beneficiary re-enrolls in the CPD before the original 12 months has passed, the fee waiver will be reinstated, ending on the date originally scheduled.

Example: Beneficiary enrolls in CPD beginning January 1, 2025 and is given an enrollment fee waiver that ends December 31, 2025; beneficiary disenrolls from CPD in May 2025, and fee waiver is removed;

beneficiary re-enrolls in CPD October 1, 2025, (within the original 12-month waiver period) and the remaining fee waiver is reinstated, ending December 31,2025.

5.5.8 Disenrollment

5.5.8.1 An enrollee’s violation of the Direct Care (DC) system/Military Medical Treatment Facility (MTF) lockouts (i.e., repeatedly accessing MTFs for other than emergency services or pharmacy benefits) could result in disenrollment of such enrollee.

5.5.8.2 A CPD enrollee shall be disenrolled, in coordination with the GDA, from the CPD when the enrollee no longer satisfies the criteria to participate in the CPD (see paragraph 5.1).

5.5.8.3 The CPD contractor shall, within three business days, notify the EEE contractor (for disenrollment processing purposes) of an enrollee’s disqualification from the CPD.

Competitive Plans Demonstration (CPD)

5.5.8.4 If a CPD enrolled beneficiary is diagnosed with Autism Spectrum Disorder (ASD) and desires to receive services or care related to the diagnosis of autism under the ACD, then the EEE contractor will disenroll the beneficiary from the CPD. The CPD contractor, within three business days of a beneficiary request to participate in the ACD, shall notify the EEE contractor of the beneficiary’s request, for disenrollment processing. A CPD enrollee’s enrollment in the ACD is a QLE (as of the ACD enrollment date) and family members may choose to remain enrolled to the CPD or enroll in another TRICARE health plan based on their eligibility.

5.5.8.5 In all cases involving disenrollment of a beneficiary from the CPD, the CPD contractor shall provide the beneficiary information about other available TRICARE Plans when the event or basis for disenrollment is identified. The beneficiary’s ability to enroll in another TRICARE Plan will be contingent on the beneficiary’s eligibility for other such plans.

5.5.9 PCM Assignment

5.5.9.1 The CPD contractor shall assign all CPD enrollees a PCM.

5.5.9.2 The Contractor shall provide enrollees with a viable and transparent method for changing their CPD PCMs, e.g., on the CPD contractor’s website or via a telephone call with the contractor’s member services.

5.5.10 Clinical Operations (Medical Management (MM), Case Management (CM), Population Health (PH), Utilization Management (UM), Referral Management (RM), and Clinical Quality Management (CQM))

The CPD contractor shall ensure that all care delivery and associated functions meet required TRICARE CPD reporting and performance requirements as outlined in the TRICARE Manuals and the CPD contract.

5.5.11 Nurse Advice Line (NAL)

The CPD contractor shall provide a NAL for CPD enrolled beneficiaries that is available 24 hours a day/7 days a week (24/7).

5.6 Special Programs

The CPD contractor shall ensure that staff managing the interface with the EEE contractor for special and high-profile programs understand the eligibility, benefits, and benefit exclusions of these programs as articulated in the Code of Federal Regulations (CFR), Section 199, relevant TRICARE Manuals, and CPD contract requirements.

5.7 Claims and Encounters

5.7.1 The CPD is a capitated payment demonstration; the DHA will pay the CPD Contractor a capitated payment to deliver healthcare to enrolled beneficiaries. The CPD contractor shall not submit claims to the DHA for payment. The CPD contractor’s claims processing/encounter system shall collect medical encounter data and correctly report copay, TRICARE Prime and POS deductible, and cost-share information to the EEE contractor to be recorded on the beneficiary’s catastrophic cap in accordance with the TRICARE benefit policy as delineated in 32 CFR 199.4, CFR 199.17, CFR 199.18, as well as all applicable sections of the TRICARE Policy Manual (TPM), TRICARE Operations Manual (TOM), and TRICARE Reimbursement Manual (TRM). Any payments collected in error by the CPD (e.g., copayment collected in excess of catastrophic cap limit) will be refunded to the beneficiary by the CPD, and the refund will be reported to the EEE for posting on the catastrophic cap.

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Competitive Plans Demonstration (CPD)

5.7.2 Pharmacy claims data shall be processed, maintained, and captured by the TRICARE Pharmacy (TPharm) contractor.

5.7.3 All other claims will be rejected by DHA by using edits in the TRICARE Encounter Data (TED) system.

5.7.4 The contractor shall use Health Care Delivery Program (HCDP) XXXX for identification and jurisdiction of CPD claims.

5.8 Customer Service and Education

5.8.1 The education of TRICARE beneficiaries and providers about the CPD in the CPD-designated area shall be accomplished with oversight and assistance from DHA, to proactively educate eligible beneficiaries about the CPD through links from the TRICARE website and through marketing materials presented by the contractor. DHA Communications Division approvals shall ensure that such efforts effectively and accurately distribute information about the TRICARE Program and CPD. Marketing materials shall explain the CPD to the beneficiaries while allowing TRICARE sponsors and beneficiaries to make the best choice for their families. The contractor shall ensure that differences in the benefit are explained to the beneficiary before or at the time of enrollment. (See paragraph 5.2.2 regarding marketing of VAIS.)

5.8.2 The CPD contractor shall include informative educational materials for Demonstration enrollees about receiving specialty care, the CPD NAL, and pharmacy services. The contractor shall inform Demonstration enrollees traveling overseas that they will follow TRICARE Prime overseas travel procedures.

Note: This is not an exhaustive list. Educational materials may be provided to beneficiaries regarding additional topics.

5.8.3 The CPD contractor shall not put the last four digits of a Sponsor’s Social Security Number (SSN) on customer service and education materials sent to CPD enrollees.

6.0 EXCHANGE OF BENEFICIARY INFORMATION

The CPD contractor shall communicate, collaborate, and coordinate with the MCSCs, TPharm contractor, EEE contractor, other TRICARE contractors and DHA in order to facilitate the necessary exchange of beneficiary information.

7.0 EXCLUSIONS

The TRICARE Manuals, and all TRICARE Manual sections, apply to this Demonstration except for those Manual Chapter and Section titles and numbers listed in Addendum E.

8.0 REPORTS

The contractor shall submit DD Form 1423, CDRL, as required by Section F of the applicable contract.

9.0 EFFECTIVE DATE

Beneficiary services for the CPD shall commence with activities from the first open enrollment season following award of the contract.

Competitive Plans Demonstration (CPD)

10.0 TRANSITION-IN

10.1 MANAGEMENT AND ADMINISTRATION

10.1.1 Transition Specifications (TRANSPEC) Meeting

10.1.1.1 The CPD contractor shall attend a five-business day meeting with DHA personnel within 14 calendar days following contract award.

10.1.1.2 The DHA will notify the contractor as to the exact date, length, and location of the meeting and will provide the CPD contractor with a meeting agenda prior to the TRANSPEC Meeting.

10.1.2 Interface Meetings

10.1.2.1 The CPD contractor shall meet with DHA Communications within 30 calendar days following contract award to review requirements in Chapter 11 and other DHA Communications associated activities.

10.1.2.2 The CPD contractor shall meet with DHA RM and Contracting Officer (CO) within 30 calendar days following contract award to receive training in accordance with Chapter 9, Section 1 and to establish an understanding of the DHA records requirements in accordance with Chapter 9.

10.1.2.3 The CPD contractor shall conduct site visits within its geographical area of responsibility as designated by DHA.

10.1.2.4 The DHA will notify the CPD contractor as to the exact date, length, and location of all interface meeting(s) and will provide the meeting agenda prior to the meeting(s).

10.1.3 Transition Status Meetings

10.1.3.1 The CPD contractor shall participate in transition-in status meetings to provide the DHA a status or progress of all transition activities.

10.1.3.2 The DHA will notify the CPD contractor as to the frequency and location of such meetings and provide the agenda for the meeting(s).

10.1.4 Transition-In Deliverables

10.1.4.1 The CPD contractor shall deliver an initial Integrated Master Plan (IMP), in the format, and by the date, identified in the DD Form 1423, CDRL, located in Section F of the applicable contract.

10.1.4.2 The CPD contractor shall deliver an initial Integrated Master Schedule (IMS), in the format, and by the date, identified in the DD Form 1423, CDRL, located in Section F of the applicable contract.

10.1.4.3 The DHA will review and either accept or reject the initial IMS and IMP. If the DHA rejects the deliverable, then the CPD contractor shall resubmit the IMS or the IMP within 15 calendar days for the DHA’s review and acceptance.

10.1.4.4 The CPD contractor shall deliver a weekly IMP status report, as identified by DD Form 1423, CDRL, located in Section F of the applicable contract.

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Competitive Plans Demonstration (CPD)

10.1.4.5 The CPD contractor shall deliver a weekly IMS status report, as identified by DD Form 1423, CDRL, located in Section F of the applicable contract.

10.1.4.6 The CPD contractor shall deliver a weekly risk and mitigation report, as identified by DD Form 1423, CDRL, located in Section F of the applicable contract.

10.1.5 Performance Readiness Validation (PRV) - General

10.1.5.1 The CPD contractor shall conduct a PRV to assess their performance readiness in the following:

• Provider Networks

• Enrollments

• Customer Service

• RM

• Claims Processing

• MM

10.1.5.2 The CPD contractor shall provide the DHA a comprehensive briefing on the processes, results, and course of actions of each PRV assessments no later than 14 calendar days after each assessment.

10.1.6 Performance Readiness Assessment And Verification (PRAV)

The DHA will conduct PRAV activities to assess and verify the CPD contractor’s performance readiness in the areas identified in paragraph 10.1.5.

10.1.6.1 The CPD contractor shall comply with the DHA’s approach for assessment and verification of the contractor’s performance readiness in the areas identified in paragraph 10.1.5.

10.1.6.2 The DHA will provide the CPD contractor with projected PRAV dates, location(s), team structure, and specific assessment and verification methods prior to PRAV activities.

10.1.6.3 Following the completion of a PRAV activity, the DHA will provide a brief to the CPD contractor(s) on findings. If, after review, the DHA finds the CPD contractor’s performance readiness to be deficient, the CPD contractor shall submit a detailed mitigation plan no later than 10 calendar days following presentation of the DHA’s findings.

10.2 Systems Development

10.2.1 System Interface Meetings

10.2.1.1 The CPD contractor shall provide to the GDA, at the TRANSPEC meeting, the name, address, and telephone number of the technical Points of Contact (POCs) for each of the systems implementation requirements and shall ensure participation by subject matter experts in all scheduled meetings for the understanding and clarification of systems implementation requirements at the Interface Meetings listed below.

Competitive Plans Demonstration (CPD)

10.2.1.2 The CPD contractor shall coordinate with the GDA no later than 30 calendar days from contract award to schedule a System Interface Meeting with the DHA and EEE contractor to identify all systems interfaces and applications necessary to meet the requirements of this contract.

10.2.1.3 The GDA will collaborate with the CPD contractor as to the exact date, length, and location of all interface meeting(s), and will provide the meeting agenda prior to the meeting(s).

10.2.2 Cybersecurity Requirements

The CPD contractor shall complete and submit all required forms (e.g., System Security Plan (SSP)) in accordance with the TRICARE Systems Manual (TSM), Chapter 1.

10.2.3 Personnel Security And User Access Requirements

10.2.3.1 The CPD contractor’s Facility Security Officer (FSO) shall attend a meeting with the DHA Personnel Security Branch (PSB) within 30 calendar days after contract award to review Personnel Security requirements and procedures for requesting background checks and Common Access Cards (CACs) in accordance with the TSM, Chapter 1, Section 1.1.

10.2.3.2 The CPD contractor shall ensure the necessary personnel complete appropriate background and security checks in accordance with TSM, Chapter 1, Section 1.1.

10.2.3.3 The CPD contractor’s personnel shall obtain CACs from Real-Time Automated Personnel Identification System (RAPIDS) sites.

10.2.3.4 The CPD contractor shall build in the distance and appointment capacity for obtaining CACs in accordance with the transition requirements.

10.2.3.5 The CPD contractor shall use the RAPIDS locator website (https://idco.dmdc.osd.mil/idco/) for scheduling personnel who require CACs.

10.2.4 Systems Development

10.2.4.1 The DHA, no later than 120 calendar days prior to the start of health care delivery (SHCD), will test the CPD contractor’s non-claims processing systems and the telecommunications interconnections capabilities, to determine whether the systems meet the requirements of the Government and the contract.

10.2.4.2 The CPD contractor shall provide the DHA a demonstration of its non-claims processing system(s) and its telecommunications interconnections capabilities, no later than 120 calendar days prior to the SHCD.

10.2.4.3 The CPD contractor shall effectively address any corrective actions (to its non-claims processing systems and telecommunications interconnection capabilities) required by DHA no later than 30 calendar days prior to the SHCD.

10.2.5 PERFORMANCE ASSESSMENT REPORTING

The CPD contractor shall schedule initial training on the submission of CDRLs via the E-Commerce system within 30 calendar days after award. Additional training for new E-Commerce users will be provided throughout the contract upon request.

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Competitive Plans Demonstration (CPD)

10.2.6 Transaction Testing

10.2.6.1 The CPD contractor shall comply with Health Insurance Portability and Accountability Act (HIPAA) requirements and follow CO written direction regarding transaction testing. At a minimum, testing shall include the following:

• The CPD contractor shall conduct initial testing and compliance with all HIPAA mandated Transactions, Code Sets, and Identifiers (TCS&I) adopted by the HIPAA Final Rule in the Federal Register (see Chapter 19, Section 4, paragraph 1.0) prior to the SHCD, except for those TCS&I the DHA specifically identifies as not applying to use by the DHA.

• The CPD contractor shall test its capability to create, send, and receive compliant transactions and shall provide written evidence (e.g., certification from a transaction testing service) of successful testing of its capabilities to create, send, and receive compliant transactions to the CO no later than 60 calendar days prior to the SHCD.

• The CPD contractor shall test its capability no later than 60 calendar days prior to the SHCD to comply with any TCS&I Final Rule(s) adopted in the Federal Register prior to the SHCD but with required compliance date after the SHCD.

• The CPD contractor shall provide written evidence (e.g., certification from a transaction testing service) of successful testing of their compliance with the requirements of the adopted Final Rule(s) to the contracting offices no later than 60 calendar days prior to the applicable mandated implementation date(s) of the Final Rule(s).

10.2.6.2 The CPD contractor shall make necessary corrections and re-test until a successful outcome is achieved in the event transaction compliance failures occur during testing. Failure to certify HIPAA TCS&I compliance with HIPAA named and adopted TCS&I no later than 60 calendar days prior to the SHCD may result in delay of the SHCD.

10.2.6.3 The CPD contractor shall test its capability to process standard transactions. This testing shall be “cradle-to-grave” testing from receipt of the transactions, through processing, and completion of all associated functions including creating and transmitting associated response transactions.

Note: The TRICARE Health Plan (THP) (including business associate contractors) may be selected for a no-notice HIPAA transactions compliance audit at any time, initiated by the Centers for Medicare and Medicaid Services (CMS) through the HIPAA Compliance Review Program.

10.3 Critical Process-Networks

10.3.1 The CPD contractor shall ensure its network of providers has the capability and capacity to allow the enrollment of all beneficiaries eligible for participation in the CPD, in accordance with the contract, no later than 60 calendar days prior to the start of the open enrollment period.

10.3.2 The CPD contractor shall submit a Network Implementation Plan (NIP), as identified in DD Form 1423, CDRL, located in Section F of the applicable contract. Submission of the NIP shall be no later than 240 calendar days prior to the SHCD.

10.3.2.1 The CPD contractor shall include in the NIP a Network Sizing Model establishing contracting targets sufficient to support the program’s access standards for all TRICARE beneficiaries.

Competitive Plans Demonstration (CPD)

10.3.2.2 The DHA will review and either accept or reject the initial NIP. If the NIP is rejected, the incoming contractor shall resubmit the revised NIP within 15 calendar days for the DHA’s review and acceptance.

10.3.3 The contractor shall begin reporting on network status (Network Status Report), as identified in DD Form 1423, CDRL, located in Section J of the applicable contract. Reporting shall start 150 calendar days prior to the start of the SHCD.

10.3.4 Telehealth Network

The CPD contractor shall develop a Telehealth Implementation Plan in accordance with DD Form 1423, CDRL, located in Section F of the applicable contract.

10.3.5 Provider Network PRV

10.3.5.1 The CPD contractor shall validate it has established an adequate provider network in its geographical area of responsibility for PCMs, Behavioral Health (BH) providers, specialty care providers, and inpatient health care facilities (institutional providers) no later than 60 calendar days prior to the start of the open enrollment period.

10.3.5.2 The CPD contractor shall validate its online network provider directory is accessible to users (i.e., beneficiaries, providers, partner contractors, and Government stakeholders) no later than 60 calendar days prior to the start of the open enrollment period.

10.3.5.3 The CPD contractor shall validate its system for continuously monitoring and evaluating network adequacy and appointment availability for all provider types and for reporting network adequacy or access issues to the DHA no later than 30 calendar days prior to the SHCD.

10.3.5.4 The CPD contractor shall validate its mechanisms to evaluate network providers using the quality metrics specified in the Chapter 7, Section 6, no later than 30 calendar days prior to the SHCD.

10.3.5.5 The CPD contractor shall validate it displays meaningful quality metrics, at the individual provider and facility level, in an easily understood and accessible format on its website, commencing no later than 60 calendar days prior to the start of SCHD and continuing throughout the life of the contract.

10.4 Critical Processes - Enrollment

10.4.1 The CPD contractor shall have, 60 days prior to the start of the open enrollment period, a system that can receive beneficiary enrollment information from the EEE contractor.

10.4.2 Enrollments PRV

The CPD contractor shall validate that their enrollment system is operational and has the ability to receive beneficiary enrollment information from the EEE contractor and meet all contract requirements no later than 60 calendar days prior to the open enrollment period.

10.5 Critical Process - Customer Service

10.5.1 The CPD contractor’s TRICARE call center shall be fully operational in accordance with Chapter 11, Section 7 and able to meet the standards in Chapter 1, Section 3 no later than 60 calendar days prior to the SHCD.

Competitive Plans Demonstration (CPD)

10.5.2 The CPD contractor shall include in its IMP and IMS the details and schedule of activities related to all customer service functions as identified by DD Form 1423, CDRL, located in Section J of the applicable contract.

10.5.3 The CPD contractor shall begin validating call center capabilities no later than 90 calendar days prior to SHCD and continue to validate call center capabilities until full operating capability is reached.

10.5.4 The CPD contractor shall ensure call center staffing meets the following milestones:

• Fifty percent (50%) onboard and trained at 90 calendar days prior to SHCD;

• Seventy-five percent (75%) onboard and trained at 60 calendar days prior to SHCD; and

• One hundred percent (100%) onboard and trained at 30 calendar days prior to SHCD.

10.5.5 The CPD contractor shall demonstrate that it has the correct number of call center staff onboard to manage volumes at the SHCD.

10.5.6 The CPD contractor’s training documents and response scripts shall be available for the DHA to review upon request.

10.5.7 The CPD contractor shall ensure that its customer service personnel receive training on military culture and life prior to SHCD.

Note: The DHA will provide instructions to the CPD contractor on how to obtain military culture, training, and life at the TRANSPEC Meeting.

10.5.8 The CPD contractor shall provide a risk mitigation plan to address potential call center system failure and projected call volumes including stress testing efforts. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.

10.5.9 Customer Service PRV

10.5.9.1 The CPD contractor shall conduct an initial validation of its ability to receive calls, document calls, provide correct answers, have supervisors ready to assist with difficult calls, and perform any handoffs to other contractors. The contractor’s initial validation shall be conducted no later than 90 calendar days prior to SHCD.

10.5.9.2 The CPD contractor shall validate in its initial PRV its ability to meet the following standards. If realistic volume is not available to test, the CPD contractor shall provide a detailed plan to meet the standards.

• Blockage rates less than 5%.

• The AVERAGE time elapsed between INITIATED telephone ringing and connection with Automated Response Unit (ARU) shall not exceed 20 seconds.

• On hold times less than two minutes 95% of the time.

• Call resolution in first call 85% of the time.

• Response accuracy 95% (responses provided by call center staff shall be accurate and complete according to

Competitive Plans Demonstration (CPD) the terms of the contract and all applicable TRICARE programs and policies).

10.5.9.3 The CPD contractor shall provide a call center quality monitoring report for the PRV call center validation. For reporting requirements, see DD Form 1423, CDRL, located in Section F of the applicable contract.

10.5.9.4 The CPD contractor shall provide the DHA with a comprehensive briefing on its initial PRV processes, test results, and findings within 14 calendar days of PRV completion. This briefing should summarize information that was reported in the contractor’s weekly IMP and IMS report. The contractor shall brief results as validated performance against desired performance levels and contract standards and/or requirements.

10.5.9.5 The CPD contractor shall conduct a re-validation of its call center operational capabilities no later than 60 calendar days prior to SHCD. The contractor shall test its ability to receive calls, document calls, provide correct answers, have supervisors ready to assist with difficult calls, and perform any handoffs to other contractor personnel with no problems. The contractor shall test its capability against each of the standards referenced above and provide the results to the DHA.

10.5.9.6 The CPD contractor shall include in its validation a demonstration that its staff is fully trained.

10.5.9.7 The CPD contractor shall provide the DHA transition team with a comprehensive briefing on the processes, test results, and findings of the 60-day re-validation no later than 14 calendar days after PRV. This briefing shall summarize the information that was reported in its weekly IMP and IMS report. Results shall be briefed as validated performance against desired performance levels and contract standards and/or requirements.

10.6 Critical Process - RM

10.6.1 The CPD contractor shall have, no later than 60 days prior to the SHCD, a fully operational RM program to facilitate the delivery of specialty care for beneficiaries in accordance with TRICARE access standards.

10.6.2 RM PRV

The CPD contractor shall validate, no later than 60 days prior to the SHCD, a fully operational RM program to facilitate the delivery of specialty care for beneficiaries in accordance with TRICARE access standards.

10.7 Critical Process - Claims Processing

10.7.1 The CPD contractor shall include in its IMP and IMS the details and schedule of activities to begin interoperability with the EEE contractor with processing/encounter data and conclude with a fully functional system at the SHCD as identified by DD Form 1423, CDRL, located in Section J of the applicable contract.

10.7.2 The CPD contractor’s claims processing/encounter system shall correctly report copays collected, TRICARE Prime and POS deductibles, and cost-share amounts to the EEE contractor for posting to the catastrophic cap (as appropriate) in accordance with the TRICARE benefit policy as described in the contract no later than 30 days prior to the SHCD.

10.7.3 Claims Processing PRV

10.7.3.1 The CPD contractor shall validate its ability to receive updates from the EEE contractor for catastrophic cap/deductible cap/deductible information as available and receive an X12 271 Health Care Eligibility Benefit response transaction with a minimum of 98% accuracy no later than 60 days prior to the SHCD. Testing shall

Competitive Plans Demonstration (CPD) include multiple claim types that represent a level of complexity involved in claims for TRICARE benefits. Validation shall include claims processing at the operational volume and stress testing at projected claims volumes.

10.7.3.2 The CPD contractor shall validate, no later than 60 days prior to the SHCD, its ability to send X12 835 (claim and advice) and X12 837 (remittance) transactions to the EEE contractor with 98% accuracy.

10.7.3.3 The CPD contractor shall validate, no later than 60 days prior to the SHCD, its ability to submit all medical and pharmacy encounters, provider, and beneficiary copay, cost-share, and deductible data to the EEE contractor with 98% accuracy.

10.7.3.4 The CPD contractor shall provide validation results, to include test scenarios used, to the DHA within 14 calendar days following conclusion of the contractor’s validation.

10.8 Critical Process - Clinical Operations

10.8.1 MM

10.8.1.1 The CPD contractor shall develop and implement a MM Program that addresses all aspects of MM as described in Chapter 7, to include: RM, CM, BH, UM, and PH.

10.8.1.2 The CPD contractor shall ensure that all aspects of its MM Program are fully operational no later than 30 calendar days prior to the SHCD.

10.8.1.3 The CPD contractor shall report the development and integration progress on an on-going basis at the transition meetings.

10.8.2 MM PRV

10.8.2.1 The CPD contractor shall begin the MM validation process by demonstrating its planned web-based application which will provide access, reporting, and detailed information to the DHA no later than 60 calendar days prior to the SHCD.

10.8.2.2 The CPD contractor shall validate that its web-based MM electronic data system can connect to the DHA Pharmacy Operations Center no later than 60 calendar days prior to the SHCD.

11.0 TRANSITION-OUT

11.1 Customer Service

11.1.1 The CPD contractor shall maintain toll-free lines and web-based customer service capabilities, accessible to the public, for 90 calendar days after the end of health care delivery (HCD) to properly respond to inquiries.

11.1.2 The CPD contractor shall maintain appropriate staff for beneficiary inquiry lines as defined in the contract.

11.1.3 The CPD contractor shall maintain adequate toll-free line coverage to ensure that the blockage rate does not exceed the blockage rate on the contractor’s most critical private or other government business access line.

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Competitive Plans Demonstration (CPD)

11.2 Records Management

11.2.1 The CPD contractor shall develop an outgoing Records Transfer Report that details the process and timeliness of the transfer of all DHA records. For report submission requirements, see DD Form 1423, Contract Data Requirement List (CDRL), located in Section J of the applicable contract.

11.2.2 The Government will review and set up a meeting if necessary to discuss the initial outgoing Records Transfer Report.

11.2.3 The CPD contractor shall transfer all DHA records not eligible for destruction, along with the associated metadata, to the incoming contractor or DHA Records Management in accordance with Chapter 9.

11.2.4 The CPD contractor shall transfer DHA records to the appropriate receiving party (i.e., incoming contractor or DHA Records Management) no later than the following timeline, and this timeline is applicable only for records management tracking purposes:

• Ninety (90) calendar days prior to the end of HCD, the CPD contractor shall transfer records from the SHCD delivery to 90 days prior to the end of HCD.

• Thirty (30) calendar days prior to the end of HCD, the CPD contractor shall transfer records from 89 days to 30 days from the end of HCD.

• For the last 30 days of HCD, the CPD contractor shall transfer records to the incoming contractor weekly. The records shall be transferred no later than the second business day of the week.

• Ninety (90) calendar days after the end of HCD, the CPD contractor shall deliver all remaining records.

11.2.5 The CPD contractor shall transfer all electronic records to DHA Records Management that are responsive to a records freeze or that are considered the contractor’s proprietary records.

11.2.5.1 The CPD contractor shall transfer all records to DHA Records Management if there is no incoming contractor.

11.2.5.2 The CPD contractor shall request approval from the DHA Records Management Officer (RMO) prior to transferring records to the DHA RMO.

11.2.5.3 The CPD contractor shall follow electronic records transfer procedures as described in Chapter 9, Section 4 and Chapter 9, Addendum B to transfer electronic records to DHA.

11.2.5.4 The CPD contractor shall provide records in the native electronic format in which the record was created or received. Mainframe screen shots or any other system screenshots are not acceptable record formats.

The acceptable formats of records are detailed in Chapter 9, Section 3.

11.2.5.5 The CPD contractor shall include required metadata files that support the accessibility, usability, searchability, and retrievability of the images. This includes any unique identifiers used to accurately retrieve electronic records or record objects.

11.2.6 The CPD contractor shall communicate, collaborate, and coordinate with the incoming contractor and DHA Records Management to report and resolve issues related to records transfer activities.

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Competitive Plans Demonstration (CPD)

11.2.6.1 The CPD contractor shall inform the CO and DHA RMO of any records it considers proprietary.

11.2.6.2 The CPD contractor shall identify proprietary data in records within 30 calendar days of contract award.

11.2.7 The CPD contractor shall communicate, collaborate, and coordinate with the incoming contractor and DHA Records Management to conduct Proof of Concept testing to ensure the file format is acceptable and records are accessible, usable, searchable, and retrievable no later than 30 calendar days prior to the start of records transfer.

11.2.8 The CPD contractor shall communicate, collaborate, and coordinate with the GDA and the incoming contractor to provide a monthly update of transfer records activity in accordance with the outgoing Records Transfer Report, IMP and IMS.

11.2.9 Records Disposition

11.2.9.1 The CPD contractor shall comply with the provisions of Chapter 9, Section 1 for final disposition of all files and documentation.

11.2.9.2 The CPD contractor shall destroy all copies, to include backup data, in accordance with 36 CFR Part 1226, “Implementing Disposition” once the transition of records and materials has been accomplished as outlined in above paragraphs.

11.2.9.3 The CPD contractor shall not dispose of or destroy any copies or backup data prior to formal written notification from the DHA CO and DHA RMO.

11.2.9.4 The CPD contractor shall follow the provisions of Chapter 9, Section 5, Destruction of Records.

11.2.9.5 The CPD contractor shall document the removal of extra copies of records after a successful transfer of electronic records to the incoming contractor, as identified by DD Form 1423, CDRL, located in Section J of the applicable contract, Declaration of Transfer and Destruction of Records, and in accordance with 36 CFR Chapter XII, Subchapter B, Department of Defense Manual (DoDM) 5200.01, and DoD Instruction (DoDI) 8510.01.

11.2.10 Transition-Out (Phase-Out) Deliverables

11.2.10.1 No later than 90 days prior to start of Transition-Out (Phase-Out), the CPD contractor shall develop a Transition-Out (Phase-Out) plan and submit it for DHA approval (see DD Form 1423, CDRL, located in Section J of the applicable contract).

11.2.10.2 During Transition-Out (Phase-Out), the CPD contractor shall submit weekly status reports documenting progress towards achieving the milestones and activities identified in the transition-out plan (see DD Form 1423, CDRL, located in Section J of the applicable contract).

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Demonstrations, Pilot Projects, and Value-Based Initiatives

Chapter 18 Addendum E

Competitive Plans Demonstration (CPD) - TRICARE Manuals Exclusion List

Revision:

Chapter and Section titles and numbers listed below are current as of June 26, 2023. The Addendum may be updated by the Government if there are significant changes to the TRICARE Manual’s structure.

Reminder: The TRICARE manuals provide instruction, guidance, and responsibilities in addition to the requirements set forth in the incorporated Federal statutes and regulations and may not be interpreted in contradiction thereto.

Among the manuals the TRICARE Policy Manual (TPM) takes precedence over the other three TRICARE manuals.

The TRICARE Reimbursement Manual (TRM) takes precedence over the TRICARE Systems Manual (TSM) and the TRICARE Operations Manual (TOM). The TSM takes precedence over the TOM.

Legend: None means no exceptions to the Section.

Notes in the Exceptions and Rationale column are specific exclusions or changes to that Section/paragraph.

FIGURE 18.E-1 TRICARE OPERATIONS MANUAL (TOM) 6010.62-M

CHAPTER SECTION TITLE EXCEPTIONS AND RATIONALE

All references to DEERS should be changed in this manual to EEE.

1 Administration 1 Organization Of The Defense Health Agency

(DHA)

None

2 Contract Administration and Instructions None

3 TRICARE Processing Standards Paragraphs 2.3, 2.5 - EEE will process enrollments Paragraphs 2.7, 2.8, 4.0 - Not Applicable Paragraph 5.2.2 - Referral accuracy OP 4 and 5 - Not Applicable Paragraphs 6.4, 6.5.1, 6.5.2, 6.5.3 - Not Applicable

4 Management Paragraph 8.0 - Not Applicable unless the CPD enrollees will be surveyed.

5 Compliance With Federal Statutes None

6 Legal Matters None

Chapter 18, Addendum E

Competitive Plans Demonstration (CPD) - TRICARE Manuals Exclusion List

2 Transitions 1 Management And Administration Not Applicable.

2 Systems Development Not Applicable.

3 Critical Processes (CPs) - Provider Networks Not Applicable

4 Critical Processes (CPs) - Enrollment Not Applicable

5 Critical Processes (CPs) - Customer Service Not Applicable

6 Critical Processes (CPs) - Records Management Not Applicable

7 Critical Processes (CPs) - Referral Management Not Applicable

8 Critical Processes (CPs) - Claims Processing Not Applicable.

9 Critical Processes (CPs) – Clinical Operations Not Applicable

10 Other Requirements Not Applicable

3 Financial Administration 1 General None

2 Payments To Beneficiaries/Providers Not Applicable

3 Claim Refund And Collection Procedures Not Applicable

4 Lost, Stolen, Stale-Dated, Damaged,…