HT940226R0001-20260923.pdf
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- Solicitation number
- HT940226R0001
- Issued by
-
Defense Health Agency
About this file
This is a Request for Proposals (RFP) for the TRICARE Medicare Eligible Program Second Generation (TMEP2), issued by the Defense Health Agency (DHA). The solicitation number is HT940226R0001, and the contract represents a full and open competitive acquisition using best value trade-off procedures. The Government seeks a contractor to provide comprehensive claims processing and customer support services for Medicare-eligible TRICARE beneficiaries receiving medical services in the United States, Puerto Rico, Guam, US Virgin Islands, American Samoa, and Northern Mariana Islands. The contract will be Firm Fixed-Price with a one-year transition-in period (base period) beginning from award through September 30, 2028, followed by seven one-year option periods for healthcare delivery (October 1, 2028 through September 30, 2036), a one-year transition-out period, and a potential six-month extension, for a total potential contract period of 8.5 years.
The solicitation requires contractors to process both electronic and paper claims with tiered pricing structures based on estimated claim volumes. Estimated quantities include approximately 63.9 million electronic claims and 1.4 million paper claims in Option Period 1, with projected growth through Option Period 7. Key performance requirements include timely and accurate claims adjudication in compliance with TRICARE Policy Manual, TRICARE Operations Manual, and TRICARE Reimbursement Manual; coordination of Medicare benefits; comprehensive customer service available 24/7 with telephone and portal access; establishment of two separate bank accounts for benefit payments; submission of TRICARE Encounter Data (TED) records; and quality management with quarterly operational reviews. The contractor must maintain experienced leadership, demonstrate cybersecurity compliance at CMMC Level 2 (Self), enter into a Data Sharing Agreement with DoD, provide transition-in activities including security certifications, and conduct transition-out operations. Pricing is solicited for electronic claims processing, paper claims processing, administrative services, data delivery, transition-in/out activities, and performance incentive payments based on beneficiary satisfaction metrics. All reports, plans, and deliverables must be submitted electronically through the E-commerce Extranet or TRICARE Encounter Data System, with multiple daily, weekly, monthly, quarterly, and annual reporting requirements specified throughout the contract period.
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TRICARE Medicare Eligible Program Second Generation (TMEP2)
Request for Proposals HT940226R0001
Part Section Title / Description
Part I – The Schedule A Solicitation/contract form
B Supplies or services and prices/costs
C Description/specifications/statement of work
D Packaging and marking
E Inspection and acceptance
F Deliveries or performance
G Contract administration data
H Special contract requirements
Part II – Contract Clauses I Contract clauses
Part III – List of Documents & Attachments
J List of attachments
Part IV – Representations and Instructions
K Representations, certifications, and other statements of offerors or respondents
L Instructions, conditions, and notices to offerors or respondents
M Evaluation factors for award
WOMEN-OWNED SMALL
BUSINESS (WOSB)
SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES
1. REQUISITION NUMBER PAGE 1 OF
2. CONTRACT NUMBER 3.AWARD/EFFECTIVE
DATE
4. ORDER NUMBER 5. SOLICITATION NUMBER 6. SOLICITATION ISSUE
DATE
7. FOR SOLICITATION
INFORMATION CALL:
a. NAME b. TELEPHONE NUMBER (No collect calls)
8. OFFER DUE DATE/
LOCAL TIME
9. ISSUED BY
13b. RATING
14. METHOD OF SOLICITATION
CODE
15. DELIVER TO 16. ADMINISTERED BY CODE
18a. PAYMENT WILL BE MADE BY CODE17a. CONTRACTOR/
OFFEROR
CODE
FACILITY
CODE
CODE
TELEPHONE NUMBER
17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN
OFFER
18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK
BELOW IS CHECKED
REQUEST
FOR QUOTE
(RFQ)
INVITATION
FOR BID
(IFB)
REQUEST
FOR
PROPOSAL
(RFP)
SEE ADDENDUM
19.
ITEM NO.
20.
SCHEDULE OF SUPPLIES/SERVICES
21.
QUANTITY
22.
UNIT
23.
UNIT PRICE
24.
AMOUNT
(Use Reverse and/or Attach Additional Sheets as Necessary)
25. ACCOUNTING AND APPROPRIATION DATA 26. TOTAL AWARD AMOUNT (For Government Use Only)
28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN 29. AWARD OF CONTRACT: REFERENCE
. YOUR OFFER ON SOLICITATION
(BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE
SET FORTH HEREIN, IS ACCEPTED AS TO ITEMS:
30a. SIGNATURE OF OFFEROR/CONTRACTOR
30b. NAME AND TITLE OF SIGNER (Type or print) 30c. DATE SIGNED
31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)
31b. NAME OF CONTRACTING OFFICER (Type or print) 31c. DATE SIGNED
AUTHORIZED FOR LOCAL REPRODUCTION
PREVIOUS EDITION IS NOT USABLE
STANDARD FORM 1449 (REV. 11/2021)
Prescribed by GSA - FAR (48 CFR) 53.212
10. THIS ACQUISITION IS UNRESTRICTED OR
NORTH AMERICAN
INDUSTRY CLASSIFICATION
STANDARD (NAICS):
SIZE STANDARD:
13a. THIS CONTRACT IS A
RATED ORDER UNDER
THE DEFENSE PRIORITIES
AND ALLOCATIONS
SYSTEM - DPAS (15 CFR 700)
SET ASIDE: % FOR:
11. DELIVERY FOR FREE ON
BOARD (FOB) DESTINATION
UNLESS BLOCK IS MARKED
SEE SCHEDULE
12. DISCOUNT TERMS
ARE ARE NOT ATTACHED
ARE ARE NOT ATTACHED
27a. SOLICITATION INCORPORATES BY REFERENCE (FEDERAL ACQUISITION REGULATION) FAR 52.212-1, 52.212-4.
FAR 52.212-3 AND 52.212-5 ARE ATTACHED.
27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED.
8(A)
ECONOMICALLY
DISADVANTAGED
WOMEN-OWNED SMALL
BUSINESS (EDWOSB)
SERVICE-DISABLED
VETERAN-OWNED
SMALL BUSINESS
(SDVOSB)
HUBZONE SMALL
BUSINESS
SMALL BUSINESS
NOTE: OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, AND 30.
COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH
AND DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND
ON ANY ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS
SPECIFIED
DATED.
OFFER
ADDENDA
ADDENDA
HT940226R0001
DEFENSE HEALTH AGENCY DEFENSE HEALTH AGENCY
DEFENSE HEALTH AGENCY
DEFENSE HEALTH AGENCY-AURORA
16401 E CENTRETECH PARKWAY
AURORA CO 80011
1200 MS
Addison Sexton 303-676-3594
HT9402
Geraldine Duran
524292
$45.5
0001 1 LOTransition-In/Phase-In: To include Security
(Physical, Personnel and NIST) Certifications.
(Fixed Price)
Continued...
STOCK RECORD (S/R)
STANDARD FORM 1449 (REV. 11/2021) BACK
19.
ITEM NO.
20.
SCHEDULE OF SUPPLIES/SERVICES
21.
QUANTITY
22.
UNIT
23.
UNIT PRICE
24.
AMOUNT
32a. QUANTITY IN COLUMN 21 HAS BEEN
RECEIVED INSPECTED ACCEPTED,
41a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT
32b. SIGNATURE OF AUTHORIZED GOVERNMENT
REPRESENTATIVE
32c. DATE
41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER 41c. DATE
42a. RECEIVED BY (Print)
42b. RECEIVED AT (Location)
42c. DATE RECEIVED (MM/DD/YYYY) 42d. TOTAL CONTAINERS
40. PAID BY
32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT
REPRESENTATIVE
32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE 32f. TELPHONE NUMBER OF AUTHORZED GOVERNMENT REPRESENTATIVE
32g. EMAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE
33. SHIP NUMBER 34. VOUCHER NUMBER 35. AMOUNT VERIFIED
CORRECT FOR
PARTIAL FINAL
37. CHECK NUMBER
38. S/R ACCOUNT NUMBER 39. S/R VOUCHER NUMBER
36. PAYMENT
COMPLETE PARTIAL FINAL
AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED:
Period of Performance: 10/01/2028 to
09/30/2029
0002 1 LOData delivered in accordance with Section J
(Not Separately Priced)
Period of Performance: 10/01/2028 to
09/30/2029
1001 63303219 EAElectronic Claims Processing - Medicare
Eligible Retiree Health Care Fund Option Period
1 (Estimated Quantity) (Fixed Price)
Period of Performance: 10/01/2029 to
09/30/2030
1002 593613 EAElectronic Claims Processing - Defense Health
Program Non-Accrual Option Period 1 (Estimated
Quantity) (Fixed Price)
Period of Performance: 10/01/2029 to
09/30/2030
1003 1313961 EAPaper Claim Rate - Medicare Eligible Retiree
Health Care Fund Option Period 1 (Estimated
Quantity) (Fixed Price)
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGES
NAME OF OFFEROR OR CONTRACTOR
SUPPLIES/SERVICES
(B)
UNIT
(D)
UNIT PRICE
(E)
AMOUNT
(F)
OPTIONAL FORM 336 (4-86)
Sponsored by GSA FAR (48 CFR) 53.110
ITEM NO.
(A)
QUANTITY
(C)
NSN 7540-01-152-8067
Period of Performance: 10/01/2029 to
09/30/2030
1004 47055 EAPaper Claim Rate - Defense Health Program
Non-Accrual Option Period 1 (Estimated
Quantity) (Fixed Price)
Period of Performance: 10/01/2029 to
09/30/2030
1005 12 MOAdmin DHP/Non-Accrual (FY30) (Fixed Price)
Period of Performance: 10/01/2029 to
09/30/2030
1006 12 MOAdmin Accrual (FY30) (Fixed Price)
Period of Performance: 10/01/2029 to
09/30/2030
1007 1 LOData delivered in accordance with Section F and
Section J (CDRL submission) Option Period 1
(Not Separately Priced)
Period of Performance: 10/01/2029 to
09/30/2030
1008 1 LOTransition-Out: Option Period 1 (Fixed Price)
Period of Performance: 10/01/2029 to
09/30/2030
1009 2 Q1Incentive - Beneficiary Satisfaction Option
Period 1 (Reference Section H.4 which outlines criteria for earning incentive monies. The total amount shown reflects the maximum incentive available) (Fixed Price)
(Option Line Item)
2001 64499830 EAElectronic Claim Processing - Medicare Eligible
Retiree Health Care Fund Option Period 2
NAME OF OFFEROR OR CONTRACTOR
SUPPLIES/SERVICES
(B)
UNIT
(D)
UNIT PRICE
(E)
AMOUNT
(F)
OPTIONAL FORM 336 (4-86)
Sponsored by GSA FAR (48 CFR) 53.110
ITEM NO.
(A)
QUANTITY
(C)
(Estimated Quantity) (Fixed Price)
Period of Performance: 10/01/2030 to
09/30/2031
2002 604834 EAElectronic Claim Processing - Defense Health
Program Non-Accrual Option Period 2 (Estimated
Quantity) (Fixed Price)
Period of Performance: 10/01/2030 to
09/30/2031
2003 1227437 EAPaper Claim Rate - Medicare Eligible Retiree
Health Care Fund Option Period 2 (Estimated
Quantity) (Fixed Price)
Period of Performance: 10/01/2030 to
09/30/2031
2004 43957 EAPaper Claim Rate - Defense Health Program
Non-Accrual Option Period 2 (Estimated
Quantity) (Fixed Price)
Period of Performance: 10/01/2030 to
09/30/2031
2005 12 MOAdmin DHP/Non-Accrual (FY31) (Fixed Price)
Period of Performance: 10/01/2029 to
09/30/2030
2006 12 MOAdmin Accrual (FY31) (Fixed Price)
Period of Performance: 10/01/2029 to
09/30/2030
2007 1 LOData delivered in accordance with Section F and
Section J (CDRL submission) Option Period 2
(Not Separately Priced)
Period of Performance: 10/01/2030 to
NAME OF OFFEROR OR CONTRACTOR
SUPPLIES/SERVICES
(B)
UNIT
(D)
UNIT PRICE
(E)
AMOUNT
(F)
OPTIONAL FORM 336 (4-86)
Sponsored by GSA FAR (48 CFR) 53.110
ITEM NO.
(A)
QUANTITY
(C)
09/30/2031
2008 1 LOTransition-Out: Option Period 2 (Fixed price)
Period of Performance: 10/01/2030 to
09/30/2031
2009 4 Q1Incentive - Beneficiary Satisfaction Option period 2 (Reference Section H.4 which outlines criteria for earning incentive monies. The total amount shown reflects the maximum incentive available.) (Fixed Price)
Period of Performance: 10/01/2030 to
09/30/2031
3001 65719060 EAElectronic Claims Processing - Medicare
Eligible Retiree Health Care Fund Option Period
3 (Estimated Quantity) (Fixed Price)
Period of Performance: 10/01/2031 to
09/30/2032
3002 616268 EAElectronic Claims Processing - Defense Health
Program Non-Accrual Option Period 3 (Estimated
Quantity) (Fixed Price)
Period of Performance: 10/01/2031 to
09/30/2032
3003 1146612 EAPaper Claim Rate - Medicare Eligible Retiree
Health Care Fund Option Period 3 (Estimated
Quantity) (Fixed Price)
Period of Performance: 10/01/2031 to
09/30/2032
3004 41062 EAPaper Claim Rate - Defense Health Program
Non-Accrual Option Period 3 (Estimated
Quantity) (Fixed Price)
Period of Performance: 10/01/2031 to
NAME OF OFFEROR OR CONTRACTOR
SUPPLIES/SERVICES
(B)
UNIT
(D)
UNIT PRICE
(E)
AMOUNT
(F)
OPTIONAL FORM 336 (4-86)
Sponsored by GSA FAR (48 CFR) 53.110
ITEM NO.
(A)
QUANTITY
(C)
09/30/2032
3005 12 MOAdmin DHP/Non-Accrual (FY32) (Fixed Price)
Period of Performance: 10/01/2029 to
09/30/2030
3006 12 MOAdmin Accrual (FY32) (Fixed Price)
Period of Performance: 10/01/2029 to
09/30/2030
3007 1 LOData delivered in accordance with Section F and
Section J (CDRL submission) Option Period 3
(Not Separately Priced)
Period of Performance: 10/01/2031 to
09/30/2032
3008 1 LOTransition-Out: Option Period 1 (Fixed price)
Period of Performance: 10/01/2031 to
09/30/2032
3009 4 Q1Incentive - Beneficiary Satisfaction Option
Period 3 (Reference Section H.4 which outlines criteria for earning incentive monies. The total amount shown reflects the maximum incentive available) (Fixed Price)
Period of Performance: 10/01/2031 to
09/30/2032
4001 66227097 EAElectronic Claims Processing - Medicare
Eligible Retiree Health Care Fund Option Period
4 (Estimated Quantity) (Fixed Price)
Period of Performance: 10/01/2032 to
09/30/2033
4002 627917 EAElectronic Claims Processing - Defense Health
Program Non-Accrual Option Period 4 (Estimated
NAME OF OFFEROR OR CONTRACTOR
SUPPLIES/SERVICES
(B)
UNIT
(D)
UNIT PRICE
(E)
AMOUNT
(F)
OPTIONAL FORM 336 (4-86)
Sponsored by GSA FAR (48 CFR) 53.110
ITEM NO.
(A)
QUANTITY
(C)
Quantity) (Fixed Price)
Period of Performance: 10/01/2032 to
09/30/2033
4003 1071108 EAPaper Claim Rate - Medicare Eligible Retiree
Health Care Fund Option Period 4 (Estimated
Quantity) (Fixed Price)
Period of Performance: 10/01/2032 to
09/30/2033
4004 38358 EAPaper Claim Rate - Defense Health Program
Non-Accrual Option Period 4 (Estimated
Quantity) (Fixed Price)
Period of Performance: 10/01/2032 to
09/30/2033
4005 12 MOAdmin DHP/Non-Accrual (FY33) (Fixed Price)
Period of Performance: 10/01/2029 to
09/30/2030
4006 12 MOAdmin Accrual (FY33) (Fixed Price)
Period of Performance: 10/01/2029 to
09/30/2030
4007 1 LOData delivered in accordance with Section F and
Section J (CDRL submission) Option Period 4
(Not Separately Priced)
Period of Performance: 10/01/2032 to
09/30/2033
4008 1 LOTransition-Out: Option Period 4 (Fixed price)
Period of Performance: 10/01/2032 to
09/30/2033
NAME OF OFFEROR OR CONTRACTOR
SUPPLIES/SERVICES
(B)
UNIT
(D)
UNIT PRICE
(E)
AMOUNT
(F)
OPTIONAL FORM 336 (4-86)
Sponsored by GSA FAR (48 CFR) 53.110
ITEM NO.
(A)
QUANTITY
(C)
4009 4 Q1Incentive - Beneficiary Satisfaction Option
Period 4 (Reference Section H.4 which outlines criteria for earning incentive monies. The total amount shown reflects the maximum incentive available) (Fixed Price)
Period of Performance: 10/01/2032 to
09/30/2033
5001 68227097 EAElectronic Claims Processing - Medicare
Eligible Retiree Health Care Fund Option Period
5 (Estimated Quantity) (Fixed Price)
Period of Performance: 10/01/2033 to
09/30/2034
5002 639786 EAElectronic Claims Processing - Defense Health
Program Non-Accrual Option Period 5 (Estimated
Quantity) (Fixed Price)
Period of Performance: 10/01/2033 to
09/30/2034
5003 1000576 EAPaper Claim Rate - Medicare Eligible Retiree
Health Care Fund Option Period 5 (Estimated
Quantity) (Fixed Price)
Period of Performance: 10/01/2033 to
09/30/2034
5004 35832 EAPaper Claim Rate - Defense Health Program
Non-Accrual Option Period 5 (Estimated
Quantity) (Fixed Price)
Period of Performance: 10/01/2033 to
09/30/2034
5005 12 MOAdmin DHP/Non-Accrual (FY34) (Fixed Price)
Period of Performance: 10/01/2029 to
09/30/2030
NAME OF OFFEROR OR CONTRACTOR
SUPPLIES/SERVICES
(B)
UNIT
(D)
UNIT PRICE
(E)
AMOUNT
(F)
OPTIONAL FORM 336 (4-86)
Sponsored by GSA FAR (48 CFR) 53.110
ITEM NO.
(A)
QUANTITY
(C)
5006 12 MOAdmin Accrual (FY34) (Fixed Price)
Period of Performance: 10/01/2029 to
09/30/2030
5007 1 LOData delivered in accordance with Section F and
Section J (CDRL submission) Option Period 5
(Not Separately Priced)
Period of Performance: 10/01/2033 to
09/30/2034
5008 1 LOTransition-Out: Option Period 5 (Fixed price)
Period of Performance: 10/01/2033 to
09/30/2034
5009 4 Q1Incentive - Beneficiary Satisfaction Option
Period 5 (Reference Section H.4 which outlines criteria for earning incentive monies. The total amount shown reflects the maximum incentive available) (Fixed Price)
Period of Performance: 10/01/2033 to
09/30/2034
6001 69516783 EAElectronic Claims Processing - Medicare
Eligible Retiree Health Care Fund Option Period
6 (Estimated Quantity) (Fixed Price)
Period of Performance: 10/01/2034 to
09/30/2035
6002 651880 EAElectronic Claims Processing - Defense Health
Program Non-Accrual Option Period 6 (Estimated
Quantity) (Fixed Price)
Period of Performance: 10/01/2034 to
09/30/2035
6003 934689 EAPaper Claim Rate - Medicare Eligible Retiree
Health Care Fund Option Period 6 (Estimated
NAME OF OFFEROR OR CONTRACTOR
SUPPLIES/SERVICES
(B)
UNIT
(D)
UNIT PRICE
(E)
AMOUNT
(F)
OPTIONAL FORM 336 (4-86)
Sponsored by GSA FAR (48 CFR) 53.110
ITEM NO.
(A)
QUANTITY
(C)
Quantity) (Fixed Price)
Period of Performance: 10/01/2034 to
09/30/2035
6004 33473 EAPaper Claim Rate - Defense Health Program
Non-Accrual Option Period 6 (Estimated
Quantity) (Fixed Price)
Period of Performance: 10/01/2034 to
09/30/2035
6005 12 MOAdmin DHP/Non-Accrual (FY35) (Fixed Price)
Period of Performance: 10/01/2029 to
09/30/2030
6006 12 MOAdmin Accrual (FY34) (Fixed Price)
Period of Performance: 10/01/2029 to
09/30/2030
6007 1 LOData delivered in accordance with Section F and
Section J (CDRL submission) Option Period 6
(Not Separately Priced)
Period of Performance: 10/01/2034 to
09/30/2035
6008 1 LOTransition-Out: Option Period 6 (Fixed price)
Period of Performance: 10/01/2034 to
09/30/2035
6009 4 Q1Incentive - Beneficiary Satisfaction Option
Period 6 (Reference Section H.4 which outlines criteria for earning incentive monies. The total amount shown reflects the maximum incentive available) (Fixed Price)
Period of Performance: 10/01/2034 to
NAME OF OFFEROR OR CONTRACTOR
SUPPLIES/SERVICES
(B)
UNIT
(D)
UNIT PRICE
(E)
AMOUNT
(F)
OPTIONAL FORM 336 (4-86)
Sponsored by GSA FAR (48 CFR) 53.110
ITEM NO.
(A)
QUANTITY
(C)
09/30/2035
7001 70830848 EAElectronic Claims Processing- Medicare Eligible
Retiree Health Care Fund Option Period 7
(Estimated Quantity) (Fixed Price)
Period of Performance: 10/01/2035 to
09/30/2036
7002 664202 EAElectronic Claims Processing - Defense Health
Program Non-Accrual Option Period 7 (Estimated
Quantity) (Fixed Price)
Period of Performance: 10/01/2035 to
09/30/2036
7003 873141 EAPaper Claim Rate - Medicare Eligible Retiree
Health Care Fund Option Period 7 (Estimated
Quantity) (Fixed Price)
Period of Performance: 10/01/2035 to
09/30/2036
7004 31269 EAPaper Claim Rate - Defense Health Program
Non-Accrual Option Period 7 (Estimated
Quantity) (Fixed Price)
Period of Performance: 10/01/2035 to
09/30/2036
7005 12 MOAdmin DHP/Non-Accrual (FY36) (Fixed Price)
Period of Performance: 10/01/2029 to
09/30/2030
7006 12 MOAdmin Accrual (FY36) (Fixed Price)
Period of Performance: 10/01/2029 to
09/30/2030
7007 1 LOData delivered in accordance with Section F and
Section J (CDRL submission) Option Period 7
NAME OF OFFEROR OR CONTRACTOR
SUPPLIES/SERVICES
(B)
UNIT
(D)
UNIT PRICE
(E)
AMOUNT
(F)
OPTIONAL FORM 336 (4-86)
Sponsored by GSA FAR (48 CFR) 53.110
ITEM NO.
(A)
QUANTITY
(C)
(Not Separately Priced)
Period of Performance: 10/01/2035 to
09/30/2036
7008 1 LOTransition-Out: Option Period 7 (Fixed price)
Period of Performance: 10/01/2035 to
09/30/2036
7009 4 Q1Incentive - Beneficiary Satisfaction Option
Period 7 (Reference Section H.4 which outlines criteria for earning incentive monies. The total amount shown reflects the maximum incentive available) (Fixed Price)
Period of Performance: 10/01/2035 to
09/30/2036
C - Performance Work Statement (PWS)
PERFORMANCE WORK STATEMENT (PWS)
C.1.0. Purpose. The purpose of the TRICARE Medicare Eligible Program Second Generation (TMEP2) Contract is to provide claims processing and associated customer support services for claims submitted by and on behalf of Military Health System (MHS) beneficiaries who are eligible for both Medicare and TRICARE benefits for health care received in the United States, Puerto Rico, Guam, the US Virgin Islands, American Samoa and the Northern Mariana Islands. The Contractor shall provide the expertise of health care claims processing and its support services by incorporating the best practices of the private sector in support of the TRICARE Program. The Contractor shall fulfill the objectives of the contract while complying with requirements identified herein and in the applicable chapters and sections in the TRICARE Manuals. The Contractor shall deliver all services in a manner that supports the TRICARE fully integrated health care delivery and financing system for all MHS beneficiaries.
C.1.1. The Contractor shall pay claims for the following beneficiary categories: family of active duty service members, retired members and their families, retired reservists and their families, surviving family members and eligible former spouses of the Uniformed Services who are Medicare and TRICARE eligible, and subject to the provisions of Title 10, United States Code (USC), Chapter 55. The Uniformed Services include Army, Navy, Air Force, Space Force, Marine Corps, Coast Guard, Public Health Service Commissioned Corps, and the National Oceanic and Atmospheric Administration Commissioned Officer Corps. Determination of a person's eligibility status is the responsibility of the Uniformed Services as reported in the Defense Enrollment Eligibility Reporting System (DEERS).
C.1.2. Contract Objectives
C.1.2.1. Objective 1 - Claims Processing: The Contractor shall timely and accurately process claims and comply with TRICARE benefit policies delineated in 32 Code of Federal Regulations (CFR) Parts 199.4 and 199.5, the TRICARE Policy Manual (TPM), TRICARE Operations Manual (TOM), and TRICARE Reimbursement Manual
(TRM).
C.1.2.2. Objective 2 - Customer Service: The Contractor shall provide comprehensive and accessible customer services which result in beneficiary and provider satisfaction in accordance with TOM, Chapter 20.
C.1.2.3. Objective 3 - Management Functions: The Contractor shall provide throughout the life of the contract experienced and qualified leadership personnel, sufficient staffing, and management support to meet all requirements of the contract.
C.1.2.4. Objective 4 - Transition Activities: The Contractor shall provide evidence that all services and systems have been fully tested and are operational for the start of Option Period 1, and throughout the period of performance with minimal disruption of services to beneficiaries.
C.1.3. Definitions. See 32 Code of Federal Regulations (CFR) Part 199.2 and TRICARE Manuals at:
https://manuals.health.mil/pages/DownloadManualFile.ashx?Filename=Definitions.pdf or any future designated web location.
C.1.4. Documents. The documents listed below are hereby incorporated into the contract and form an integral part of this contract. Requirements incorporated into this contract by reference have the same force and effect as if set forth in full text.
• Title 10, United States Code, Chapter 55
• 32 CFR Part 199
• TRICARE Policy Manual (TPM) 6010.63-M, April 2021 baseline, as amended
• TRICARE Reimbursement Manual (TRM) 6010.64-M, April 2021 baseline, as amended
• TRICARE Systems Manual (TSM) 7950.43M, April 2021 baseline, as amended
• TRICARE Operations Manual (TOM) 6010.62-M, April 2021 baseline, as amended
C.1.4.1. The TRICARE Manuals provide instruction, guidance and responsibilities in addition to the requirements set forth in the incorporated federal statutes and regulations and may not be interpreted in contradiction, thereto.
https://manuals.health.mil/pages/DownloadManualFile.ashx?Filename=Definitions.pdf
Among the manuals, the TPM takes precedence over the other three (3) TRICARE Manuals. The TRM takes precedence over the TSM and the TOM. The TSM takes precedence over the TOM. The manuals are located at:
https://manuals.health.mil/.
C.1.4.2. See Attachment J-4, TOM, Chapter 20 for TOM Chapter 20 references.
C.1.5. Government Furnished Property and Services
C.1.5.1. In support of the Defense Health Agency (DHA) educational initiatives, the DHA will furnish printed educational materials (e.g., TRICARE Handbooks and brochures) for use in informing any interested parties of the program (See TOM, Chapter 20, Section 11).
C.1.5.2. The DHA will furnish, through the Defense Manpower Data Center (DMDC), a DEERS file indicating the Medicare eligibility status, and effective dates of such status, for TRICARE beneficiaries. DMDC will send the Contractor a file which contains a header, detailed (multiple) records, and a trailer (known as the Crossover File).
C.1.5.2.1. DMDC will send the file via Secure File Transfer (SFTP) over the B2B gateway to the Contractor on a weekly basis. The file layouts are located at Section J, Attachment J-1.
C.1.5.2.2. The DHA will furnish the contractor with a copy of the TRICARE centralized provider file. See paragraph C.2.1.4.2.1.
C.1.6. Contractor Furnished Items. The Contractor shall furnish all necessary items (e.g., facilities, labor, services, supplies, etc.) not provided by the Government (as specifically identified in paragraph C.1.5. or elsewhere within the contract as Government-furnished) for the satisfactory performance of this contract.
C.2.0. Performance Requirements
C.2.1. Claims Processing
C.2.1.1. The Contractor shall utilize the DEERS file noted in paragraph C.1.5.2. to send information regarding identified TRICARE/Medicare eligible beneficiaries to the Medicare Benefits Coordination and Recovery Center (BCRC) in accordance with TSM, Chapter 3, Section 4.2, paragraph 13.
C.2.1.2. The Contractor’s system shall have the ability to link and cross-reference TRICARE beneficiary identifiers (as described in TSM, Chapter 3, Section 3.1) with the Medicare beneficiary identifier. This linkage is required to enable efficient and coordinated processing of beneficiary information between Medicare and TRICARE.
C.2.1.3. The Contractor shall establish, maintain, and monitor an automated claims processing system to ensure claims are processed in an accurate and timely manner and meet the claims processing requirements and performance standards as set forth in the TOM and TSM. The Contractor’s automated claims processing system shall:
C.2.1.3.1. Apply deductibles, copayments, coinsurance, cost shares, and catastrophic cap calculations in accordance with all applicable sections of the TRM, TPM and TRICARE benefit policy as delineated in 32 CFR 199.4, 199.5 and 199.17.
C.2.1.3.2. Have the capability to be reconfigured to adapt to changes in claims processing rules, regulations and business needs. The contractor shall ensure changes can be implemented to meet implementation dates specified by the Government or as indicated in TRICARE manual changes and ensure minimal disruption to ongoing operations during the implementation of changes.
C.2.1.3.3. Coordinate benefits with other health insurance (OHI) to which the beneficiary is entitled/enrolled as required by 32 CFR 199.8, the TPM, and TRM.
C.2.1.3.4. Meet the requirements of the TOM and TSM to ensure TRICARE catastrophic cap limits and health plan deductibles data are processed and are communicated between the Contractor’s automated claims processing system https://manuals.health.mil/ and DEERS.
C.2.1.3.5. Interface with DEERS and accurately determine eligibility and enrollment status based on DEERS data in accordance with the TSM, Chapter 3.
C.2.1.3.6. Accurately process claims in accordance with the preauthorization/authorization requirements noted in the TPM, Chapter 1, Section 6.1 and TOM, Chapter 20, when TRICARE is the primary payer, including Skilled Nursing Facilities.
C.2.1.3.7. Accept authorizations from the Managed Care Support Contractors (MCSCs) using the ASCX12N278 format, or any applicable format, and match the authorization with the claim.
C.2.1.3.7.1. The Contractor shall honor authorizations from the MCSCs unless the care authorized is not a program benefit. Differences of opinion between the MCSC and TMEP contractor regarding approved authorizations shall be resolved based on protocols established within the Memorandum of Understanding (MOU) between the Contractors and as informed by consultation with the COR.
C.2.1.3.8. Capture and report TRICARE Encounter Data (TED) related to claims adjudication in accordance with the TSM, Chapter 2.
C.2.1.4. Providers Receiving Reimbursement
C.2.1.4.1. The Contractor is not required to verify a provider's authorized status if TRICARE is not the primary payer on the claim, and if Medicare has accepted the claim from an authorized provider. If TRICARE is the primary payer on a claim, then the Contractor shall reimburse only those providers that are TRICARE authorized providers in accordance with the criteria set forth in 32 CFR Part 199.6 and the TPM.
C.2.1.4.2. When required to verify if a provider is TRICARE authorized, the Contractor shall do so by using the DHA centralized TRICARE Encounter Provider Records (TEPRVs). If a provider’s status is not listed in the TEPRVs, then the Contractor shall obtain and maintain documentary evidence to certify that the provider meets the criteria set forth in 32 CFR Part 199.6 and the TPM.
C.2.1.4.2.1. The Contractor shall utilize the DHA-supplied copy of the TRICARE centralized provider file, provided at least weekly via CONNECT:DIRECT, in its process for provider verification (See TSM, Chapter 1, Section 1.1, for data communication technical requirements). The Contractor may also submit a system access request through the Enterprise Common Access Card (CAC) Registration Service (ECRS) to obtain access to the TEPRV through the Patient Encounter Processing and Reporting (PEPR) portal.
C.2.1.4.2.2. The Contractor shall maintain copies of the participation agreements (obtained from the Contractor authorizing the provider or from the provider/facility directly) for all provider and facility types for which participation agreements are required under the TRICARE Manuals. The Contractor shall validate that such providers/facilities have participation agreements prior to reimbursing claims from them.
C.2.1.4.3. The Contractor shall submit information on all providers authorized by the Contractor to the DHA centralized TEPRVs system in accordance with the provisions of the TSM, Chapter 2, Section 1.2.
C.2.1.4.4. The Contractor shall determine allowable payment amounts for primary and secondary claims in accordance with the applicable TRICARE reimbursement methodologies and requirements contained in the TRM.
C.2.1.4.5. The Contractor shall provide to each beneficiary and each participating provider an Explanation of Benefits (EOB) that meets the requirements of TOM, Chapter 20, Section 8.
C.2.1.4.6. The Contractor shall adjudicate TRICARE pre-authorizations/authorizations, in accordance with the quality and timeliness standards in TOM, Chapter 1, Section 3.
C.2.1.4.7. When TRICARE is primary payer on a claim, before authorizing care or paying the claim, the Contractor shall ensure that the care provided is medically necessary, appropriate, and within the scope of TRICARE benefits set forth in 32 CFR Parts 199.4 and 199.5 and comply with the requirements in the TOM, TRM, and TPM.
C.2.1.4.8. The Contractor is a multi-function Peer Review Organization (PRO) under this contract and shall follow the standards, rules and procedures as defined in 32 CFR Part 199.15 (as applicable) to claims where TRICARE is primary payer.
C.2.1.5. Medicare Bundled Payment Initiatives
C.2.1.5.1. The Contractor shall submit TED records for institutional claims processed and reimbursed by Medicare Bundled Payment Initiatives Program using the Special Processing Code “BP-CMS Bundled care payment initiative.”
C.2.1.5.2. The Contractor shall submit a complete denial initial TED record for the non-pay professional provider claims associated with the Medicare Bundled Payment Initiatives and include (a) the denial reason code of “97- the benefit for this service is included in the payment/allowance for another services/procedure that has already been adjudicated” in accordance with TSM, Chapter 2, Addendum G and (b) the Special Processing Code BP.
C.2.1.5.3. The Contractor shall deny claims received more than 12 months after the date of service unless an exception under 32 CFR 199.7(d) applies.
C.2.1.6. Electronic Funds Transfer (EFT)
C.2.1.6.1. The Contractor shall require providers who submit claims (including Medicare crossover claims) electronically to accept an Electronic Remittance Advice (ERA) and receive payment via Electronic Funds Transfer (EFT). The Contractor shall send EFTs and ERAs in Health Insurance Portability and Accountability Act (HIPAA) standard format.
C.2.1.6.2. The Contractor shall contact providers upon claim receipt or through utilization of claims history files to set up EFT payments.
C.2.1.6.3. The contractor shall use other means of paying the provider during the establishment of EFT payment.
C.2.1.6.4. The Contractor shall, if requested, provide an option for provider(s) to opt out of EFT payments. The Contractor shall make EFT payments in U.S. dollars and only to U.S. banks or other U.S. financial institutions.
C.2.1.6.5. The Contractor shall utilize the Duplicate Claims System to facilitate identification and resolution of duplicate payments, according to the requirements of TSM, Chapter 4, and the Duplicate Claims User Guide.
C.2.2. Communication and Customer Service
C.2.2.1. The Contractor shall provide comprehensive readily accessible customer services that include multiple, contemporary avenues of access to include a beneficiary and provider portal (which result in beneficiary and provider satisfaction) in accordance with TOM, Chapter 20.
C.2.2.1.1. The Contractor shall perform all customer service functions with knowledgeable, courteous, and responsive staff.
C.2.2.1.2. The Contractor shall deliver customer services in a manner that achieves the objectives of this contract without charges to beneficiaries or providers.
C.2.2.1.3. The Contractor shall provide Call Center services 24 hours per day, 7 days per week, 365 days per year.
C.2.2.1.3.1. Customer service representatives shall be available between the hours of 6:00 AM and 11:00 PM ET (except weekends and federal holidays).
C.2.2.2. Telephone Interactive Voice Response (IVR) Unit
C.2.2.2.1. The Contractor shall operate a HIPAA compliant Interactive Voice Response (IVR) unit that includes analytic capabilities to manage the quality of its IVR set up and capture performance data to ensure compliance with customer standards in the TOM, Chapter 20, Section 1.
C.2.2.2.2. The Contractor’s IVR unit shall provide beneficiaries access to information in a user-friendly and efficient manner related to the status of claims, eligibility, and benefits in compliance with the TOM.
C.2.2.2.3. The Contractor’s IVR unit shall allow callers the option of speaking to an agent in accordance with TOM, Chapter 20.
C.2.2.2.4. The Contractor shall comply with all beneficiary and provider service standards in the TOM, Chapter 20, Section 11.
C.2.2.3. The Contractor shall develop and implement an education plan for conducting targeted beneficiary and provider education (Contractor Data Requirements List (CDRL) R150).
C.2.2.3.1. The Contractor’s education plan shall target beneficiary and provider education related to specific issues that surface throughout the administration of this contract.
C.2.2.3.2. The Contractor, at a minimum, shall provide education through EOB statements and letters (CDRL R150).
C.2.2.4. The Contractor shall utilize the Government-designated web-based customer relations management system for secure customer service case resolution in addition to the Priority Telephone and Priority Correspondence requirements. This system is used by staff at military medical treatment facilities (e.g., Beneficiary Counseling and Assistance Coordinators, Debt Collection Assistance Officers and Health Benefit Advisors), within DHA, and in service-related customer service roles (e.g., National Guard/Reserve and Recruiting Commands) to refer inquiries received from beneficiaries, providers and others across the MHS to the Contractor via this management system for resolution.
C.2.2.4.1. The Contractor’s designated staff shall attend Government required training.
C.2.2.5. The contractor shall provide a website for beneficiaries to access information (TOM, Chapter 20, Section 11).
C.2.3. Management Functions
C.2.3.1. The Contractor shall furnish the TMEP Program Office, all Beneficiary Counseling and Assistance Coordinators (BCACs), Debt Collections Assistance Officers (DCAOs), and any other approved DHA staff with read-only access to claims data. The Contractor shall post EOBs in a downloadable format that allows the Government to read and print.
C.2.3.2. Off-Site Electronic Read-Only Access
C.2.3.2.1. The Contractor shall provide up to six (6) Government personnel with unlimited offsite electronic access to all data maintained by the Contractor pertaining to the TMEP contract.
C.2.3.2.1.1. This data maintained by the Contractor and made available to the Government personnel shall include, but is not limited to, data concerning providers, authorizations, claims processing, customer service (e.g., call logs, contact notes), program administration, images and the ability to generate reports.
C.2.3.2.1.2. The Contractor shall ensure that all data in its system is current within the last 24 hours.
C.2.3.2.1.3. This shall include all data pertaining to the execution of TMEP contract.
C.2.3.2.1.4. The Contractor shall ensure that its data is searchable by the Government.
C.2.3.2.2. The Contractor shall provide the Government with access to the same user interface that it provides to its own staff.
C.2.3.2.3. The Contractor shall provide the Government with data access training and orientation as needed, within one (1) week of request by the Government.
C.2.3.2.4. The Contractor shall provide the Government ongoing training and user support for data access. Web-based training is acceptable. The Government shall be notified at least one (1) week prior to a change in the system that would impact the Government’s ability to review and access data pertaining to the TMEP contract. The Contractor shall participate in DHA Communication’s web partnership meetings to discuss best processes for joint endeavors.
C.2.3.3. Quality Management (QM) and Quality Improvement (QM/QI) Program
C.2.3.3.1. The Contractor shall establish and operate throughout the life of the contract a QM/QI program that effectively supports ongoing quality improvement efforts.
C.2.3.3.2. The Contractor’s QM processes shall focus on problem identification and resolution and shall foster a consistent, efficient TMEP program designed to achieve the objectives of the contract.
C.2.3.3.3. The Contractor's QI processes shall focus on process improvements and shall foster innovation.
C.2.3.3.4. The Contractor’s QM/QI program shall be comprehensive and coordinated, covering all aspects of the TMEP program, with oversight by Contractor senior leadership, ensuring that QM/QI information and processes are incorporated and communicated across its entire enterprise (See CDRL P010). If problems are identified through the contractor’s internal QM/QI Program, the contractor shall electronically submit a QM/QI report within 10 days following the end of the month when the problem was identified. The report shall include corrective actions planned/initiated. A monthly update/status report shall be submitted until all corrective actions have been achieved (See CDRL R140).
C.2.3.3.5. The Contractor shall submit an annual QM/QI plan. See CDRL P010 in Section J of the contract for plan submission requirements.
C.2.3.3.6. The Contractor shall initiate and conduct quarterly operational and assessment reviews for the Government during which the Contractor shall present its performance against all quality standards. The venue and manner of presentation will be determined by the Government.
C.2.3.3.7. The Contractor shall implement management controls to prevent fraud and abuse of benefit funds in accordance with 32 CFR 199.9, 32 CFR 199.14, and TRM, Chapter 5, Section 1.
C.2.3.4. The Contractor shall make available all personnel, facilities, and documentation required in the conduct of Government audits, investigations, and contract performance evaluations. These reviews are conducted periodically at Contractor’s and/or subcontractor’s locations and include all aspects of the Contractor's performance under the terms of the contract, in accordance with RFO FAR. 52.246-4 Inspection of Services.
C.2.3.5. The Contractor shall provide a lockable office space equipped and functionally complete with electricity, lighting, heating/air conditioning, desks, conference table and chairs, at the Contractor-operated facility for any on-site auditors.
C.2.3.6. The Contractor shall refer to DHA Program Integrity, cases that involve $75,000.00 or more in potential losses to the Government or any loss with patient harm following the procedures prescribed in the TOM, Chapter 13, Section 4.
C.2.3.7. The Contractor shall comply with management requirements in TOM, Chapter 20, Section 1.
C.2.3.8. The Contractor shall implement a personnel security program which meets the TSM requirements.
C.2.3.9. The Contractor’s covered information systems shall meet DHA Cybersecurity Compliance Program requirements described in the TSM, Chapter 1, Section 1.1.
C.2.3.10. The Contractor shall, by contract award, have and maintain for the duration of the contract a current (i.e., not older than 3 years) Cybersecurity Maturity Model Certification (CMMC) status at the CMMC Level 2 (Self) for all information systems used in performance of the contract that process, store, or transmit CUI.
C.2.3.11. The Contractor shall annually affirm their CMMC Level 2 (Self) compliance in the Supplier Performance Risk System.
C.2.3.12. The Contractor shall enter into a Data Sharing Agreement (DSA) for data obtained from DoD systems and applications and comply with DoD Health Information Privacy Regulation, HIPAA Privacy Rule and DoD Privacy Program in accordance with the TSM and TOM. The DSA shall be submitted to the DHA Privacy Office annually or until the contract is no longer valid.
C.2.3.4. Contractor Leadership
C.2.3.4.1 The Contractor shall establish and maintain experienced and qualified leadership personnel and sufficient staffing and management support to meet the requirements of this contract.
C.2.3.4.2 The Contractor shall identify to the Government a senior level team member or members who possess the authority and have the ability to make management decisions for the Contractor within the scope of the contract, and who will attend meeting(s) with the Government Designated Authority, (GDA) either via telephone conference call, video teleconference (VTC), or other agreed-upon electronic methods of communication. The Contractor shall promptly update the Government when there are changes in these leadership positions.
C.2.3.4.3 The Contractor’s leadership team shall be prepared to address urgent matters with the Government. To that end, the Contractor shall identify to the Government a senior level team member or members who possess the authority and have the ability to obligate resources within the scope of the contract, and who are able to attend in-person meeting(s) with the GDA on short notice (e.g., within two business days) at a DHA location (Falls Church, VA, Aurora, CO, San Antonio, TX and San Diego, CA) or any location identified by the GDA.
C.2.4. Transition Activities
C.2.4.1. The Contractor shall employ the necessary resources to complete all Transition-In requirements outlined in the TOM, Chapter 20, Section 2, and the TSM.
C.2.4.2. The Contractor shall submit an Integrated Master Plan (IMP) and Integrated Master Schedule (IMS) 10 days after contract award (CDRL P040 and P070).
C.2.4.3. The Contractor shall have fully operational services and systems at the start of services (Option Period 1) with no disruption of services to beneficiaries and providers.
C.2.4.4. The Contractor shall provide ongoing collaboration with the Government to ensure that the appropriate Government personnel, as identified during transition planning, are kept informed of start-up and transition progress.
The frequency, type and nature of communication shall be based on the task and involvement of the Government.
Any commonly utilized form of business communication (e.g., telephonic and email) is acceptable.
C.2.4.5. The Contractor shall mail an introductory letter to all beneficiary households who had claims activity in the previous 12 months no later than 10 days prior to the start of service delivery.
C.2.4.6. Crossover Claims. The Contractor shall establish and maintain an agreement with the Centers for Medicare and Medicaid Services (CMS) BCRC for the purpose of transferring Medicare processed claims to the Contractor for secondary processing (See TOM, Chapter 20, Section 2, and CDRL R030).
C.2.4.7. The Contractor shall meet with and provide to the successor contractor and/or the Government all information necessary to facilitate a seamless transition in accordance with TOM, Chapter 20, Section 2.
C.2.4.8. The Contractor shall fully comply with all necessary Transition-Out requirements in accordance with TOM, Chapter 20, Section 2.
C.2.5. Future Demonstrations
C.2.5.1. The Government may, during the period of this contract, conduct one or more demonstrations (under the authority of 10 U.S.C. 1092) with TRICARE Contractors in support of the TRICARE Program and health, medical, and administrative services to TRICARE Medicare eligible beneficiaries. In such cases, beneficiaries will have the option of receiving support services through the demonstration contractor or through the TMEP Contractor. The Contractor will be required to develop an MOU with any such demonstration contractor.
D - Packaging and Marking
D.1. PACKAGING
Preservation, packaging and packing, for shipment or mailing of all work delivered hereunder, by other than electronic means, shall be in accordance with good commercial practice to insure acceptance by common carrier and safe transportation at the most economical rate. The contractor shall not utilize certified or registered mail or private parcel delivery service for the distribution of reports under this contract without the advance approval of the Contracting Officer or Contracting Officer’s Representative (COR).
D.2. MARKING
D.2.1. Each package, report, or other deliverable shall be accompanied by a letter or other document which:
D.2.2. Identifies the contract by number under which the item is being delivered.
D.2.3. Identifies the deliverable item number or report requirement which requires the delivered item(s).
D.2.4. Indicates whether the contractor considers the delivered item to be partial or in full satisfaction of the requirement.
E - Inspection and Acceptance
E.1. CLAUSES
52.246-4 Inspection of Services - Fixed-Price. (AUG 1996)
E.2. INSPECTION AND ACCEPTANCE
The final acceptance authority for the Government shall be:
Department of Defense Defense Health Agency Contracting Officer’s Representative (COR) TRICARE Medicare Eligible Program Second Generation (TMEP2) 16401 E. Centretech Parkway Aurora, CO 80011-9066
E.3. INSPECTION LOCATION
Inspections may be conducted electronically or by physical inspection. Inspections will be conducted either at the Defense Health Agency (DHA), the contractor’s and/or subcontractor’s facilities or other locations where work is performed as the Contracting Officer or their designee may determine. Inspections may include, but are not limited to, payment record audits, performance audits, program integrity audits and contractor/DHA quality assurance audits.
E.4. QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)
Pursuant to RFO FAR 37.604 -- Quality Assurance Surveillance Plans (QASP) and RFO FAR 46.4 -- Government Contract Quality Assurance, the Government will design, implement and conduct adequate contract surveillance and quality assurance to ensure the contract requirements and standards are performed satisfactorily. For these purposes, the Government will use a QASP, which will be provided to the contractor after award and as revisions occur.
F - Deliveries or Performance
F.1. CLAUSES
52.242-15 Stop-Work Order. (AUG 1989)
F.2. PERIOD OF PERFORMANCE
F.2.1. Transition-In. From date of award to the beginning of Option Year 1, the contractor shall begin Transition-In activities and complete specific activities by the timelines specified in TRICARE Operations Manual (TOM), Chapter 20. The contractor shall complete Transition-In by September 30, 2028, and begin option period one (1) on October 1, 2028, at 12:01 AM ET. All Transition-In activities shall be accounted for and completed by the date specified in the contractor’s Integrated Master Plan (IMP) and Integrated Master Schedule (IMS) plans (CDRL P040, IMP and CDRL P070, IMS).
F.2.2. Option Periods 1 through 7 will be:
Period Start Date End Date
Option Period One (1) 10/01/2029 09/30/2030
Option Period Two (2) 10/01/2030 09/30/2031
Option Period Three (3) 10/01/2031 09/30/2032
Option Period Four (4) 10/01/2032 09/30/2033
Option Period Five (5) 10/01/2033 09/30/2034
Option Period Six (6) 10/01/2034 09/30/2035 Option Period Seven (7) 10/01/2035 09/30/2036
F.2.3. The option periods identified herein are defined as the period in which the contractor starts providing services.
The start of service delivery is the first day of Option Period 1. In order to meet the requirements of the contract, the contractor will be performing incidental administrative tasks associated with that delivery period beyond said period.
F.2.4. Transition-Out. The Government may exercise the Transition-Out period during any one of the service delivery periods specified above. The contractor will begin Transition-Out activities when the Government exercises the Transition-Out Contract Line Item Number (CLIN) and shall complete those activities in accordance with the timelines specified in the TOM, Chapter 20. Transition-Out deliverables are due as outlined in the TOM.
F.3. GEOGRAPHIC AREA OF COVERAGE
The contract covers the United States, Puerto Rico, Guam, the US Virgin Islands, American Samoa and the Northern Mariana Islands.
F.4. PLACE OF POSTAL DELIVERY AND PROCEDURES
F.4.1. All certified and overnight mail for Defense Health Agency (DHA) is to be delivered to:
Defense Health Agency (DHA).
C/O Managed Care Contracting Division (MC-CD)/TMEP Contract 16401 E. Centretech Parkway Aurora, CO 80011-9066
DHA’s delivery hours are 7:30 AM to 4:00 PM (local time), Monday through Friday, excluding Federal holidays.
F.4.2. Notice Regarding Late Delivery In the event the contractor anticipates difficulty in complying with the delivery schedule, the contractor shall immediately notify the Contracting Officer (CO) or the Contracting Officer’s Representative (COR), in writing, giving pertinent details, including the date by which it expects to make delivery. This notification shall be informational only. The Government’s receipt of such notification shall not be construed as the Government’s waiver of any contract delivery schedule or any rights or remedies provided by law.
F.5. TIERED PRICING
F.5.1. For purposes of this section, quantities are based on total electronic or paper claims for each option period and are not further broken down by funding source (MERHCF or DHP). The expected (estimated) quantities for each option period are included below:
Option Period Claim Type Estimated Qty
1 Electronic Claims 63,896,832
1 Paper Claims 1,361,016
2 Electronic Claims 65,104,665
2 Paper Claims 1,271,394
3 Electronic Claims 66,335,327
3 Paper Claims 1,187,674
4 Electronic Claims 67,589,254
4 Paper Claims 1,109,466
5 Electronic Claims 68,866,883
5 Paper Claims 1,036,409
6 Electronic Claims 70,168,663
6 Paper Claims 968,162
7 Electronic Claims 71,495,050
7 Paper Claims 904,409
F.5.2. The following quantity tiers are established for each option period for the claim types specified below. The unit prices will be incorporated at contract award based upon proposed and accepted prices.
Electronic Claims (CLINs X001 and X002)
Low Tier Expected Tier High Tier
OP From To Unit Price From To
Unit Price From To
Unit Price
1 25,558,732 51,117,465 TBD 51,117,466 76,676,199 TBD 76,676,200 102,243,933 TBD
2 26,041,864 52,083,730 TBD 52,083,731 78,125,597 TBD 78,125,598 104,167,464 TBD
3 26,534,130 53,068,261 TBD 53,068,262 79,602,393 TBD 79,602,394 106,136,525 TBD
4 27,035,701 54,071,402 TBD 54,071,403 81,107,104 TBD 81,107,105 108,142,806 TBD
5 27,546,752 55,093,505 TBD 55,093,506 82,640,259 TBD 82,640,260 110,187,013 TBD
6 28,067,464 56,134,929 TBD 56,134,930 84,202,395 TBD 84,202,396 112,269,861 TBD
7 28,598,019 57,196,039 TBD 57,196,040 85,794,060 TBD 85,794,061 114,392,081 TBD
Paper Claims (CLINs X003 and X004)
Low Tier Expected Tier High Tier
OP From To Unit Price From To
Unit Price From To
Unit Price
1 544,406 1,088,812 TBD 1,088,813 1,633,219 TBD 1,633,220 2,177,626 TBD
2 508,556 1,017,114 TBD 1,017,115 1,525,673 TBD 1,525,674 2,034,232 TBD
3 475,069 950,138 TBD 950,139 1,425,208 TBD 1,425,209 1,990,278 TBD
4 443,785 887,572 TBD 887,573 1,331,360 TBD 1,331,361 1,775,148 TBD
5 414,562 829,126 TBD 829,127 1,243,691 TBD 1,243,692 1,658,256 TBD
6 387,264 774,529 TBD 774,530…
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