Attachment J-5b QASP Matrix TMEP2 DRAFT.xlsx
XLSX spreadsheet 29 KB Posted
- Solicitation number
- HT940226R0001
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Defense Health Agency
About this file
This is a Quality Assurance Surveillance Plan (QASP) matrix for the TRICARE Medicare Eligible Program Second Generation (TMEP2) contract. The document establishes performance standards, evaluation criteria, and monitoring requirements across multiple functional areas including claims processing, customer service, transition activities, management, and program operations.
The QASP specifies detailed performance metrics for claims processing operations, requiring 98% of retained and adjustment claims to be processed within 30 calendar days and 100% within 90 calendar days. For TED (TRICARE Encounter Data) submissions, the contractor must achieve escalating accuracy standards beginning at 80% in months 1-3, reaching 97% by month 24 through contract close. Customer service standards mandate 90% of calls transferred to agents be answered within 30 seconds, 95% of calls have total hold time not exceeding 2 minutes, blockage rates not exceed 5%, and 100% of priority written correspondence be answered within 30 days. Transition-in requirements include delivering an Integrated Master Plan and Integrated Master Schedule within 10 days of contract award, establishing bank accounts 60 days prior to service start, executing MOUs with TRICARE contractors and the Medicare BCRC 60 days before service delivery, and conducting performance readiness verification assessments. Management and operations standards require annual Data Sharing Agreements, CMMC Level 2 cybersecurity certification by contract award, quarterly operational assessments, comprehensive QM/QI programs with monthly reporting of identified problems, and six government personnel with unlimited offsite electronic access to contractor data systems. Evaluation frequency ranges from one-time assessments for transition activities to monthly, quarterly, semi-annual, and annual ongoing reviews throughout the contract performance period.
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Sheet1
| Subject Group | Subject Category | Subject Sub-Category | Reference Information | Description | Evaluation Frequency | Transition | PG/I |
| Claims Processing | Claims Processing Accuracy | Extrapolated absolute error total NTE 2% | TOM C1; S3; P6.5.1 | The extrapolated absolute error total shall not exceed 2% of the total paid amount of each universe for the first two option periods. In all remaining option periods, the extrapolated absolute error total shall not exceed 1.75%. | Quarterly | No | PG |
| Customer Service | Priority Written Correspondence | 100% Answered W/I 30 Days | CTR H.5.10; | The Contractor shall provide final responses to 100% of Priority Correspondence within 30 calendar days of receipt. | Monthly | No | PG |
| Transition-In General | Management and Administration | MOU with TRICARE Claims Review Contractor 60 days | TOM C20; S2; P1.2.1.2; | The incoming contractor shall execute an MOU with the TRICARE Claims Review Contractor for safe and secure electronic transmittal of claims processing documentation/information 60 days prior to the start of services delivery. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the contract. | One Time | Yes | |
| Transition-In General | Management and Administration | MOU with TRICARE contractors 60 days prior to SSD | TOM C20; S2; P1.2.1.1; C20; S2; P1.2.1.1.1; | The incoming contractor shall execute an MOU with the other TRICARE contractors (Managed Care Support, TRICARE Overseas, Pharmacy and Competitive Plans Demonstration (CPD) 60 days prior to the start of services delivery. The incoming contractor shall ensure the MOU includes, but is not limited to, provider file update coordination, beneficiary history transfers, customer service coordination and marketing/education coordination. | One Time | Yes | |
| Transition-Out | Management and Administration | Weekly Status Report of Inventories/Phase-Out Activities Beginning 20th Day Post TRANSPEC | TOM C2; S1; P5.5; | The outgoing contractor shall submit a weekly status report of inventories and phase-out activities to DHA beginning the 20th calendar day following the TRANSPEC Meeting as identified by DD Form 1423, CDRL, located in Section J of the applicable contract. | Weekly | No | |
| Transition-Out | Records Management | Outgoing meet with DHA Records 30 days of award | TOM C2; S1; P5.4; | The outgoing contractor shall meet with DHA Records Management within 30 calendar days following contract award to establish concurrence of the DHA Records transfer requirements and for the Outgoing Records Transfer Plan Report. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract. | One Time | Yes | |
| Transition-Out | Management and Administration | Outgoing Phase-Out Plan | TOM C2; S1; P5.2; | The outgoing contractor shall provide a proposed Phase-Out Plan at the TRANSPEC Meeting as identified by DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract. | One Time | Yes | |
| Transition-In General | Management and Administration | PRV Debriefing | TOM C2; S1; P7.0; | 7.1 The incoming contractor shall conduct PRV to assess their performance readiness in following areas in accordance with this chapter: |
• Management
• Customer Service
• Records Management
• Claims Processing
| 7.2 The incoming contractor shall provide the Government a comprehensive briefing on the processes, results, and course of actions of each PRV assessments no later than five calendar days after the assessment. | One Time | Yes | ||||||
| Transition-Out | Transition Status Meetings | Outgoing Contractor Participation in Transition Status Meetings | TOM C2; S1; P1.3.2; | The outgoing contractor shall participate in transition-out meetings to provide the Government a status or progress of all transition out activities. | Weekly | Yes | ||
| Transition-In General | Management and Administration | Interface Meetings: Records Management | TOM C2; S1; P1.2.2; | The incoming contractor shall meet with DHA Records Management (RM) and Contracting Officer (CO) within 30 calendar days following contract award to establish concurrence of the DHA records transfer requirements and the Incoming Records Transfer Plan. For reporting requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract. | One Time | Yes | ||
| Transition-In PRV & PRAV | Management and Administration | Compliance w/Gov. Approach to PRV | TOM C2; S1; P9.2.1; | The incoming contractor shall comply with the Government’s approach for assessment and verification of the contractor’s performance readiness regarding management as described above. If, after review, the Government finds the incoming contractor’s performance readiness for management to be deficient, the incoming contractor must submit a detailed mitigation plan no later than 10 calendar days following the Government’s findings. | Weekly | Yes | ||
| Transition-In PRV & PRAV | Management and Administration | Gov Access to Data Information/Repository NLT 60 Days Prior to SHCD | TOM C2; S1; P9.1.2; | The incoming contractor shall validate its ability to provide Government users with access to the data information system(s) and data repository required by the contract via a data access interface mutually agreed upon by the Government and available prior to SHCD. The validation results shall be briefed to the Government no later than 60 calendar days prior to SHCD. | Weekly | Yes | ||
| Transition-In PRV & PRAV | Management and Administration | Validation Training/Support for Gov Personnel for info system/repository 75 days prior to SHCD | TOM C2; S1; P9.1.1; | The incoming contractor shall validate its ability to provide training and ongoing customer support for Government personnel who access the contractor’s data information system(s) and data repository as required by the contract. The validation results shall be briefed to the Government no later than 75 calendar days prior to SHCD. | Weekly | Yes | ||
| Transition-In General | Management and Administration | IMS Weekly Submission | TOM C2; S1; P4.5; | The incoming contractor shall deliver a weekly IMS, as identified by DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract. | Weekly | Yes | ||
| Transition-In General | Management and Administration | Participation in Transition-in Meetings | TOM C2; S1; P1.3.1; | The incoming contractor shall participate in transition-in meetings to provide the Government a status or progress of all transition activities. | Weekly | Yes | ||
| Transition-In General | Management and Administration | IMP Weekly Submission | TOM C2; S1; P4.4; | The incoming contractor shall deliver a weekly IMP, as identified by DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract | Weekly | Yes | ||
| Transition-In General | Management and Administration | Integrated Master Plan (IMP) Delivered 10 Days After Contract Award | TOM C2; S1; P4.1; | The incoming contractor shall deliver an Integrated Master Plan (IMP), as identified by DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract | One Time | Yes | ||
| Transition-In General | Management and Administration | Risk Mitigation Report Weekly Submission | TOM C2; S1; P4.6; | The incoming contractor shall deliver a weekly risk and mitigation report, as identified by DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract. | Weekly | Yes | ||
| Transition-In General | Management and Administration | Integrated Master Schedule (IMS) Delivered 10 Days After Contract Award | TOM C2; S1; P4.2; | The incoming contractor shall deliver an Integrated Master Schedule (IMS), as identified by DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract | One Time | Yes | ||
| Transition-In General | Management and Administration | Incoming establish bank accounts 60 days prior SSD | TOM C20; S2; P1.2.2.1; | The incoming contractor shall establish bank accounts in accordance with Section G of the contract, not later than 60 days prior to the start of services delivery. | One Time | Yes | ||
| Claims Processing | TED Processing | TED-Accuracy passing Month 24- contract close | TOM C20; S1; P3.3; | Following the start of services delivery, the contractor shall ensure 97% of TEDs (initial submissions, resubmissions and adjustment/cancellation submissions) successfully pass the DHA edit system during Month 24 through contract close. | Monthly | No | ||
| Claims Processing | TED Processing | TED-Accuracy passing Month 12-23 | TOM C20; S1; P3.3; | Following the start of services delivery, the contractor shall ensure 96% of TEDs (initial submissions, resubmissions and adjustment/cancellation submissions) successfully pass the DHA edit system during Month 12 through Month 23. | Monthly | No | ||
| Claims Processing | TED Processing | TED-Accuracy passing Month 10-11 | TOM C20; S1; P3.3; | Following the start of services delivery, the contractor shall ensure 95% of TEDs (initial submissions, resubmissions and adjustment/cancellation submissions) successfully pass the DHA edit system during Month 10 through Month 11. | Monthly | No | ||
| Claims Processing | TED Processing | TED-Accuracy passing Month 7-9 | TOM C20; S1; P3.3; | Following the start of services delivery, the contractor shall ensure 90% of TEDs (initial submissions, resubmissions and adjustment/cancellation submissions) successfully pass the DHA edit system during Month 7 through Month 9. | Monthly | No | ||
| Claims Processing | TED Processing | TED-Accuracy passing Month 4-6 | TOM C20; S1; P3.3; | Following the start of services delivery, the contractor shall ensure 85% of TEDs (initial submissions, resubmissions and adjustment/cancellation submissions) successfully pass the DHA edit system during Month 4 through Month 6. | Monthly | No | ||
| Claims Processing | TED Processing | TED-Accuracy passing Month 1-3 | TOM C20; S1; P3.3; | Following the start of services delivery, the contractor shall ensure 80% of TEDs (initial submissions, resubmissions and adjustment/cancellation submissions) successfully pass the DHA edit system during Month 1 through Month 3. | Monthly | No | ||
| Claims Processing | TED Processing | TED Submission Accuracy | TOM C20; S1; P3.3; | Three months following the start of services delivery, the contractor shall ensure that no more than 2% of vouchers or batches are unprocessable due to issues including, but not limited to, the following: Out-of-balance; Invalid header conditions; Invalid record type; Invalid contractor number; Invalid voucher/batch identifier; Invalid voucher/batch date; Invalid sequence number; Invalid resubmission number; Invalid period begin date; Invalid period end date; Invalid total number of records; and Invalid total amount paid. | Monthly | No | ||
| Claims Processing | TED Processing | 100 failing TEDs resub W/I 45 Cal Days | TOM C20; S1; P3.3; | The contractor shall correct 100% of all remaining vouchers/batches failing the TEDs edit system and resubmit to DHA within 45 days after the errors and rejected TEDs were transmitted to the contractor by DHA. Resubmissions shall include TEDs rejected on the voucher/batch in question. | Monthly | No | ||
| Claims Processing | TED Processing | Resubmissions Validity Edit Errors W/I 30 | TOM C20; S1; P3.3; | The contractor shall correct 99.5% of all vouchers/batches having TEDs (initial submissions, resubmissions, and adjustment/cancellation submissions) failing the edit system and resubmit to DHA within 30 days after the errors and rejected TEDs were transmitted to the contractor by DHA. Resubmissions shall include all TEDs rejected on the voucher/batch in question. | Monthly | No | ||
| Claims Processing | TED Processing | 100 unprocessable fixed W/I 30 Cal Days | TOM C20; S1; P3.3; | The contractor shall correct 100% of unprocessable vouchers/batches and return to DHA within 30 days of the date the invalid data was transmitted to the contractor by DHA. | Monthly | No | ||
| Claims Processing | TED Processing | 85 W/I 20 Cal Days of Invalid data | TOM C20; S1; P3.3; | The contractor shall correct 85% of all unprocessable vouchers/batches, including but not limited to, out-of-balance conditions and invalid header record information and return to DHA within 20 days of the date the invalid data was transmitted to the contractor by DHA. | Monthly | No | ||
| Claims Processing | TED Processing | 100 W/I 5 Cal Days of batch/vouch date | TOM C20; S1; P3.3; | The contractor shall transmit 100% of initial submission vouchers/batches to DHA within five days of the date of the batch/voucher create date. | Monthly | No | ||
| Customer Service | Quality | Telephone Response Accuracy | CTR H.5.9; | The Contractor shall ensure the telephonic responses provided are accurate, clear and complete. The Government will review a sample of 50 telephone calls at least once an option period. The review may be conducted off-site or on-site. | Semi-Annual | No | PG | |
| Correspondence | Written Correspondence | Accurate and complete correspondence review | CTR H.5.8; | The Contractor shall ensure the correspondence it prepares is accurate, responsive, clear and complete. | ||||
| The Government will review 100 pieces of written correspondence (i.e., routine, priority, web, etc.) twice an option period. The review may be conducted off-site or on-site. If off-site, the Contractor shall provide the written correspondence within 10 days of request. The review period will be included in the request. | Monthly | No | PG | |||||
| Customer Service | Telephone Services | Transfer to CSR Answered W/I 30 Sec | TOM C1; S3; P3.2.1 | 90% of all calls transferred from the Automated Response Unit (ARU) or Interactive Voice Response (IVR) unit to an agent shall be answered by a LIVE agent within 30 seconds. The answer time is the total time during the call in which the caller is waiting for a LIVE agent after having been transferred from an ARU or IVR. | Monthly | No | ||
| Transition-Out | Management | Transition-Out Data Sharing | CTR 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. | One Time | Yes | ||
| Transition In | Claims Processing | BCRC Agreement | CTR C.2.4.6; | 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). | One Time | Yes | ||
| Transition In | Mailings | Beneficiary Introductory Letter | CTR 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. | One Time | Yes | ||
| Transition In | Management | Collaboration w/Government | CTR 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. | One Time | Yes | ||
| Transition In | Operations | Adequate Resources/Fully Operational Services and Systems | CTR C.2.4.1;C.2.4.3; | The Contractor shall employ the necessary resources to complete all Transition-In requirements outlined in the TOM, Chapter 2 and TOM, Chapter 20, Section 2 and the TSM. 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. | One Time | Yes | ||
| Management | Contract Leadership | Senior-Level Team Member(s) with Resource Obligation Authority | CTR 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. | Annual | No | ||
| Management | Contract Leadership | Experienced/Qualified Leadership/Sufficient Staffing | CTR 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. | Annual | No | ||
| Management | Data Sharing | Data Sharing Agreement | CTR 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. | Annual | No | ||
| Management | Information Systems Security | Comply w/DHA Cybersecurity Requirements/CMMC Level 2 by Contract Award | CTR C.2.3.9;C.2.3.10;C.2.3.11; | The Contractor's covered information systems shall meet DHA Cybersecurity Compliance Program requirements described in the TSM, Chapter 1, Section 1.1. The Contractor shall, by contract award, have a current (i.e., not older than 3 years) Cybersecurity Maturity Model Certification (CMMC) Level 2 certificate issued by an authorized CMMC third-party assessor organization (C3PAO). The Contractor shall annually affirm their CMMC Level 2 certificate compliance in the Supplier Performance Risk System. | Annual | No | ||
| Management | Personnel Security Program | Implement a Personnel Security Program Per TSM Ch1 | CTR C.2.3.8; | The Contractor shall implement a personnel security program which meets the TSM requirements. | Annual | No | ||
| Management | Program Integrity | Case Referrals | CTR 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. | Quarterly | No | ||
| Management | Review Accomodations | Govt audits/performance evals | CTR 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 FAR. 52.246-4 Inspection of Services. | Annual | No | ||
| Management | Reimbursement | Excessive Charges-financial controls | CTR 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. | Quarterly | No | ||
| Management | Operations | TRICARE Operational Assessment | CTR 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. | Quarterly | No | ||
| Management | Quality | QM/QI Plan | CTR 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. | Annual | No | ||
| Management | QM/QI Program | Comprehensive/Coordinated QM/QI Program | CTR C.2.3.3.1;C.2.3.3.2;C.2.3.3.3;C.2.3.3.4; | The Contractor shall establish and operate throughout the life of the contract a QM/QI program that effectively supports ongoing quality improvement efforts. 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. The Contractor's QI processes shall focus on process improvements and shall foster innovation. 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). | Annual | No | ||
| Management | Govt Access | Program Office Access | CTR C.2.3.2.1;C.2.3.2.1.1;C.2.3.2.1.2; | 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. 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. The Contractor shall ensure that all data in its system is current within the last 24 hours. | Semi-Annual | No | ||
| Management | Govt Access | BCAC Access to claims data | CTR 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. | One Time | Yes | ||
| Customer Service | Beneficiary and Provider Services | Utilize Govt Designated Web Based Mgt System | CTR 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. The Contractor's designated staff shall attend Government required training. | Semi-Annual | No | ||
| Customer Service | Beneficiary & Provider Satisfaction | Targeted Education | CTR 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). The Contractor's education plan shall target beneficiary and provider education related to specific issues that surface throughout the administration of this contract. The Contractor, at a minimum, shall provide education through EOB statements and letters. | Quarterly | No | ||
| Customer Service | Interactive Voice Control (IVR) Unit | Analytic Capabilities to Manage Quality and Ensure Compliance with Standards | CTR C.2.2.2.1;C.2.2.2.2;C.2.2.2.3; | 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. 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. The Contractor's IVR unit shall allow callers the option of speaking to an agent in accordance with TOM, Chapter 20. | Annual | No | ||
| Customer Service | Customer Service Center | Agent Availability | CTR C.2.2.1.3;C.2.2.1.3.1; | The Contractor shall provide Call Center services 24 hours per day, 7 days per week, 365 days per year. Customer service representatives shall be available between the hours of 6:00 AM and 11:00 PM ET (except weekends and federal holidays). | Monthly | No | ||
| Customer Service | Customer Service Center | Avenues of access | CTR C.2.2.1;C.2.2.1.2;C.2.2.1.1; | 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. The Contractor shall perform all customer service functions with knowledgeable, courteous, and responsive staff. The Contractor shall deliver customer services in a manner that achieves the objectives of this contract without charges to beneficiaries or providers. | Annual | No | ||
| Claims Processing | Duplicate Claims Service | Utilize Duplicate Claims Service per TSM and User Guide | CTR 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. | Semi-Annual | No | ||
| Claims Processing | Reimbursement | Electronic Funds Transfer (EFT) | CTR 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. | Annual | No | ||
| Claims Processing | Claims Processing | Claims Processing Timeliness | TOM C1; S3; P6.3 | 100% of all claims (both retained and excluded, including adjustments) shall be processed to completion within 90 calendar days from the date of receipt. | Weekly | No | PG | |
| Claims Processing | Claims Processing Timeliness | Claims Processing Timeliness W/I 30 Cal Days | TOM C1; S3; P6.2.1 | The contractor shall process 98% percent of retained and adjustment claims accurately and to completion within 30 calendar days from the date of receipt. | Monthly | No | PG | |
| Customer Service | Beneficiary Satisfaction | Satisfaction Rating | CTR H.4.3; | Beginning six months after the start of Option Period 1, if the Contractor achieves a beneficiary satisfaction rate of 90% or higher based on a DHA administered survey, the Contractor is awarded the percentages in H.4.3.2 from the applicable CLIN. | Quarterly | No | ||
| Claims Processing | Medical Management | Medically Necessary Care | CTR C.2.1.4.7;C.2.1.4.8; | 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. The Contractor shall process claims consistent with TRICARE program, regulation, and policy. 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. | Annual | No | ||
| Claims Processing | Authorizations / Preauthorizations | Adjudicate Auths and Preauths IAW TOM Standards | CTR C.2.1.4.6; | The Contractor shall adjudicate TRICARE preauthorization/authorizations, in accordance with the quality and timeliness standards in TOM, Chapter 1, Section 3. | Semi-Annual | No | ||
| Claims Processing | Explanation of Benefits | EOB Issuance | CTR 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. | Semi-Annual | No | ||
| Claims Processing | Provider Information | Submit Provider Info to DHA TEPRV System | CTR C.2.1.4.3; | The Contractor shall submit information on all providers authorized by the Contractor to the DHA centralized TEPRV system in accordance with the provisions of the TSM, Chapter 2, Section 1.2. | Semi-Annual | No | ||
| Claims Processing | Provider Information | Maintain Copy of Participation Agreement Prior to Reimbursing Claims | CTR 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. | Semi-Annual | No | ||
| Customer Service | Telephone Services | Total Hold Time for 95% of calls NTE 2 minutes | TOM C1; S3; P3.2.1 | 95% of all calls answered by an agent shall have a total "on hold" time (for the entirety of the telephone call) of two minutes or less. "On hold time" means the total time a call is placed on hold by an agent. | Monthly | No | PG | |
| Customer Service | Telephone Services | Blockage Rates NTE 5% | TOM C1; S3; P3.2.1 | Blockage rates shall not exceed 5%. The blockage rate is the percentage of calls that are not allowed into the Contractor's system. This includes busy rates and forced disconnects. All calls are defined as any call to any Contractor-operated TRICARE customer service telephone number. Customer service shall be interpreted in the broadest terms including telephone calls from beneficiaries, providers, Government representatives and interested parties about general program information, eligibility, benefits, referrals, preauthorization/authorizations, claims, complaints, processes and procedures. | Monthly | No | PG | |
| Claims Processing | Automated Claims Processing System | DEERS Interface to Determine Eligibility and Enrollment | CTR C.2.1.3;C.2.1.3.5; | The Contractor's automated claims processing system shall interface with DEERS and accurately determine eligibility and enrollment status based on DEERS data in accordance with the TSM, Chapter 3. | Annual | No | ||
| Claims Processing | Automated Claims Processing System | Coordinate Benefits with OHI Plans | CTR C.2.1.3;C.2.1.3.3; | The Contractor’s automated claims processing system shall 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. | Semi-Annual | No | ||
| Claims Processing | Automated Claims Processing System | Timely and Appropriate System Reconfiguration | CTR C.2.1.3;C.2.1.3.2; | The Contractor's automated claims processing system shall 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. | Semi-Annual | No | ||
| Claims Processing | Automated Claims Processing System | Apply Deductibles Copays and Cat Cap IAW TRICARE Manuals | CTR C.2.1.3.;C.2.1.3.1; | The Contractor’s automated claims processing system shall 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. | Semi-Annual | No | ||
| Claims Processing | Claims Crossover Eligibility File | Utilize DEERS File to Send Benes to Medicare BCRC | CTR 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. | Semi-Annual | No |
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