Exhibit 8 - Draft Quality Assurance Surveillance Plan (QASP) 20240809.docx

HT940224R0002, Exhibit 8

QUALITY ASSURANCE SURVEILLANCE PLAN

TRICARE CLAIMS REVIEW SERVICES (TCRS)

Contract Number: HT940224CXXXX Contract Description: The purpose of the TCRS contract is to assist the Improper Payment Evaluation Branch (IPEB), DHA Contract Resource Management Division, Business Support Directorate, in identifying and reporting improper payments. This contract provides independent impartial review of claims processing procedures, reimbursement determinations, and purchased-care contractor compliance with TRICARE policy and directives. The TCRS contractor shall evaluate the accuracy of claims payment and payment record coding for the MCSCs, TDEFIC, TPharm, TOP, and the ADDP contracts. This contract also supports IPEB’s requirement to assess the potential risk of improper payments and to identify, recover, 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 the Improper Payment Information Act (IPIA) of 2019.

Contractor’s Name: (hereafter referred to as the contractor)

1.0 PURPOSE

1.1 This Quality Assurance Surveillance Plan (QASP) provides a systematic method for the Government to evaluate the contractor’s performance for the stated contract. The QASP explains the following:

· What will be monitored

· How monitoring will take place

· Who will conduct the monitoring

· How monitoring efforts and results will be documented

1.2 The contractor is responsible for implementing and delivering performance that meets contract standards using its Internal Quality Management Program (IQMP) Plan (CDRL AP030). The QASP provides the structure for the government's surveillance of the contractor's performance to assure that it meets contract standards. It is the Government's responsibility to be objective, fair and consistent in evaluating contractor performance.

1.3 The QASP is not part of the contract nor is it intended to duplicate the contractor's quality control plan. This QASP is a living document. Flexibility in the QASP is required to allow for an increase or decrease in the level of surveillance necessary based on contractor performance.

1.4 The Government may provide a copy of the QASP to the contractor to facilitate open communication. In addition, the QASP should recognize that unforeseen or uncontrollable circumstances might occur that are outside the control of the contractor. The QASP should ensure early identification and resolution of performance issues to minimize impact on mission performance.

1.5 Authority: Authority for issuance of this QASP is provided under Federal Acquisition Regulation (FAR) 46, Quality Assurance; which provides for inspection, acceptance and documentation of the service called for in the contract or order.

2.0 GOVERNMENT ROLES AND RESPONSIBILITIES:

The following personnel shall oversee and coordinate surveillance activities:

a. Contracting Officer (CO) - The CO shall ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and shall safeguard the interests of the United States in the contractual relationship. The CO shall also assure that the contractor receives impartial, fair, and equitable treatment under this contract. The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance.

Contracting Officer: Greg Stephens Organization or Agency: Defense Health Agency/COD-A, Aurora, CO Email: gregory.r.stephens3.civ@health.mil

b. Contracting Officer’s Representative (COR) - The COR is responsible for the technical administration of the contract and shall assure proper Government surveillance of the contractor’s performance. The COR shall keep a quality assurance file. At the conclusion of the contract or when requested by the CO, the COR shall provide documentation to the CO. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf. The contractor shall refer any changes it deems may affect contract price, terms, or conditions to the CO for action:

Assigned COR: Laura Kloeppner Organization or Agency: Defense Health Agency/IPEB, Aurora, CO Email: laura.a.kloeppner.civ@health.mil

3.0 CONTRACTOR REPRESENTATIVES:

The following TCRS employees are the contractor’s designated point(s) of contact for contract performance:

a. Program Manager:

Telephone Number:

Email:

b. Task Manager:

Telephone Number:

Email:

c. Other Contract Personnel:

Title:

Telephone Number:

Email:

4.0 PERFORMANCE STANDARDS:

4.1 The performance standards define the level of service required under the contract for the contractor to meet each performance objective in Section C, TCRS Performance Work Statement (PWS). The contract and task orders will specify quality performance metrics and the Acceptable Quality Levels (AQLs) as the standards the Government requires from the contractor’s performance of services. The Government will perform surveillance to determine if the contractor exceeds, meets or does not meet these standards.

4.2 The Government shall compare the contractor’s performance to the minimum Acceptable Quality Levels (AQLs) in the Performance Standards Summary Matrix below.

Table 1, Performance Standards Summary Matrix

Performance Standards: Compliance Reviews - Quarterly/Semi- Annually

Compliance Reviews – Initial:

The contractor shall complete all quarterly and semiannual payment and occurrence compliance reviews as required by paragraphs 5.4.2, 5.4.2.1.4 thru 5.4.2.1.7.1.

Random monitoring of IPEB internal Compliance Review Tracking Log.

Compliance Reviews – Rebuttal:

The contractor shall complete all quarterly and semiannual payment and occurrence rebuttal reviews as required by paragraphs 5.4.2.1.8.1 through 5.4.2.1.8.2.

Compliance Reviews – Second Rebuttal:

The contractor shall complete all quarterly and Semi-annual payment and occurrence second rebuttal reviews as required by paragraph 5.4.2.1.8.3.

Performance Standards: Compliance Reviews - Annual Health Care Cost (AHCC)

Annual Compliance Reviews – Initial:

The contractor shall complete all quarterly and semiannual payment and occurrence compliance reviews as required by paragraphs 5.4.2.1, 5.4.2.1.4, 5.4.2.1.6 through 5.4.2.1.7.1.

Compliance Review Tracking Log.

Annual Compliance Reviews – Rebuttal:

The contractor shall complete all quarterly and semiannual payment and occurrence rebuttal reviews as required by paragraphs 5.4.2.1.8 and 5.4.2.1.8.1..

Annual Compliance Reviews – Second Rebuttal:

The contractor shall complete all quarterly and Semi-annual payment and occurrence second rebuttal reviews as required by paragraph 5.4.2.1.8.3.

Performance Standards: Report Submissions

Performance Standards: Government QA Reviews

5.0 METHODOLOGIES OF QA SURVEILLANCE:

5.1. Various methods exist to monitor performance. The COR may use the surveillance methods listed below in the administration of this QASP.

5.2 Regardless of the surveillance method, the COR will contact the contractor’s designated point of contract when a defect is identified and inform the manager of the specifics of the problem. The COR shall be responsible for monitoring the contractor’s performance in meeting a specific performance standard or acceptable quality level (AQL).

a. Direct Observations: Can be performed periodically or through 100% surveillance.

· Compliance reviews (i.e., initial, rebuttal, second rebuttal) findings and analysis reports provided in complete and timely manner.

· Focus studies and medical record reviews are complete, thorough and clearly address topical issues.

· Internal quality assurance reviews identify issues with review procedures and identified issues are thoroughly addressed in timely manner.

b. Management Information Systems (MIS): Evaluates outputs through the use of management information reports. Best used for general surveillance and may need to be supplemented by periodic inspections. DHA E-Commerce Extranet Performance Assessment Tool (PAT).

· Study work products including methodology, Data Use Agreement, Memorandums of Understanding are complete and provided in a timely manner.

c. Periodic Inspection: Uses a comprehensive evaluation of selected outputs. Inspections may be scheduled Daily, Weekly, Monthly, Quarterly, or annually or unscheduled as required.

· Availability and utilization of Document Management System is appropriate.

· QA results meet contract performance standards.

· Medical record reviews performed by certified or otherwise qualified auditor and in an appropriate manner.

6.1.2. Customer Input. The SME may receive customer (e.g. internal Government staff) input about the quality of services performed under the contract. These inputs maximize the Government’s resource potential and are considered in regular assessments as they may identify contractor process improvement opportunities or required corrective actions. The SME will validate any input before corrective action is required by the contractor.

6.1.3. Periodic Inspection:. Performance reviews are an effective tool for keeping performance on course, measuring performance levels, and making adjustments as necessary. More frequent opportunities than the required contract briefings with the contractor are essential in maintaining focus on critical program areas and may occur as deemed necessary. The SME will identify the specific review items to the contractor in writing. The contractor will provide the SME with written documentation of their internal processes of the specified review items. The SME will review this documentation and perform an onsite review if deemed necessary. The SME may be accompanied on the site visit by other Government employees when warranted.

7.0 RATINGS:

Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and AQL. A rating scale shall be used to determine a positive, neutral, or negative outcome. The following ratings shall be used:

Table 2, Performance Ratings

8.0 DOCUMENTING PERFORMANCE:

a. Acceptable Performance: The Government shall document positive performance as part of its ongoing surveillance.

b. Unacceptable Performance: Unacceptable performance is contractor performance that is less than satisfactory or fails to meet the stated AQLs or other contract requirements. When unacceptable performance occurs, the COR shall notify the contractor in writing unless circumstances necessitate verbal communication. In any case the COR shall document the discussion of unacceptable performance with a courtesy copy to the CO and place it in the COR file.

The COR will specify if the contractor is required to prepare a corrective action plan to document how the contractor shall correct the unacceptable performance and avoid a recurrence. The COR will also state how long after receipt the contractor has to present this corrective action plan to the COR. The Government shall review the contractor's corrective action plan to determine acceptability.

The contractor shall acknowledge receipt in writing of the COR’s notification of unacceptable performance. Any COR notifications of unacceptable performance may become a part of the supporting documentation for contract payment deductions, or other actions deemed necessary by the CO.

c. The COR and CO will use all performance documentation to complete the annual contractor’s performance evaluation in the Contractor Performance Assessment Report System (CPARS) per FAR 42.15, Contractor Performance Information.

9.0 FREQUENCY OF MEASUREMENT:

a. Frequency of Measurement:

During contract/task order performance, the COR shall take periodic measurements, as specified in the AQL column of the Performance Standards Summary Matrix, and shall analyze whether the negotiated frequency of measurement is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings:

The COR shall meet with the contractor as often as necessary to assess performance. If performance is less than satisfactory, the COR shall meet more frequently until the contractor’s performance is at least satisfactory. The COR shall document all performance assessment meetings, including the topics discussed, action items and their status until closed. The COR shall provide a copy of performance meetings to the CO

Prepared by:

Signature – Contracting Officer’s Representative

PERFORMANCE REPORT

1. CONTRACT NUMBER:

2. Prepared by: (Name of COR)

3. Date and time of observation:

4. Observation:

Prepared by: