TMEP Draft RFP Government Responses.pdf

Government Responses to TMEP Draft RFP Questions

# Section C or H Subsection/ Citation Subject Question/Comment Government Response

1 Description Background Overseas Claims The RFI stipulates 58-59 million claims annually in the RFI. Can the government please provide the volume of oversees claims within that amount?

The TMEP contract processes claims for healthcare received in the areas identified in Section C, paragraph C.1.1. Healthcare claims pertaining to services provided/received overseas are not processed by TMEP.

2 General General Workload Volumes To ensure a level playing field, could the Government please provide estimated volumes for all workload types the TMEP contractor is responsible for in the final RFP (i.e. claims volumes, call volumes, appeals volume, medical necessity reviews, etc.)?

The Government intends to provide historical data with the final solicitation.

3 General N/A Assumptions for Pricing and Staffing

Will DHA provide a mechanism in the final RFP for offerors to document and validate key pricing and staffing assumptions when Government-provided data is not available? Yes, this may be included with the final solicitation.

4 N/A N/A Request raw historical operational data

What raw historical operational data will DHA provide to support accurate TMEP2 pricing, including historical volumes for claims, adjustments, incorrect submissions, call center traffic, TED resubmissions, and MCSC authorization mismatches?

The Government intends to provide pertinent historical data with the final solicitation. The Government does not have access to MCSC authorization mismatches. The Government will not provide TED data.

5 Section C C.2.1.3.6 Claims Processing

TOM Chapter 20, section 7.0 and TPM Chapter 1 require the contractor to issue preauthorizations/authorizations. Please provide the volume of preauthorizations and authorizations issued by the TMEP contractor for primary paid claims broken down annually over the past five option-years.

The Government will provide this information, as appropriate, with the final solicitation.

6 Section C C.1.1 Scope of services What beneficiary outreach activities beyond claims processing and customer service functions does the DHA expect the contractor to perform?

The beneficiary outreach guidelines are addressed in TOM Chapter 11. Guidelines specific to TMEP will be outlined in revised TOM, Chapter 20 included with the final solicitation.

7 Section C C.1.1.5/C.2.1 Covered Members - Overseas

This paragraph does not specificy coverage of "overseas" beneficiaries or in ex-pat status. Is there a reference that clearly defines criteria for TMEP Overseas beneficiaries. Section 2.1 (Claims) does not clearly identify whether claims are submitted to TRICARE overseas for processing or if the TMEP contractor needs to establish EFT capability with international providers.

See response to question 1.

8 Section C C.1.2 Pricing

Adjustments & Change Orders

Adaptions to TRICARE Manuals, CFR changes, Medicare initiatives

Given that the PWS and Section H require frequent adaptations to TRICARE Manuals, CFR changes, Medicare initiatives, and other regulatory modifications, how will DHA handle cost recovery for mandated updates with short implementation windows, and what is the planned timeline and process for providing historical data on the volume and frequency of rule changes so contractors can price the associated operational volatility?

Manual changes will be issued with implementation timelines. If the contractor determines there are costs associated with making the change, then it will be able to submit a cost proposal.

9 Section C C.1.2.1 Claims Processing Please provide the current and historical percentage breakdown of TMEP enrollees with traditional Medicare A and B versus Medicare Advantage enrollment. The Government does not intend to provide this information.

10 Section C C.1.2.1 Claims Processing Please provide historical TMEP enrollment trends by Medicare enrollment period, including the distribution between traditional Medicare A and B and Medicare Advantage plans.

The Government does not have trend information by Medicare enrollment period. Data regarding the number of TRICARE/Medicare dual eligible beneficiaries will be provided with the final solicitation. For TMEP/TFL eligible beneficiaries, there is no requirement to enroll.

11 Section C C.1.2.1 Claims Processing Please provide historical information for the number of TRICARE claim forms (DD 2642) received annually for the TMEP program. The Government will consider providing this information with the final solicitation.

12 Section C C.1.2.2 Beneficiary & Provider Engagement

To reduce friction and call volume, we suggest the government consider implementing background analytics layered with AI to equip the program with automated communication methodologies to beneficiaries and providers, thus promoting proactive communication and eliminating their need to interface with the Call Center.

If a potential offeror proposes use of AI, the Government may consider this in its evaluation of proposals.

13 Section C C.1.2.2 Call Center Operations

Recommend that the TMEP2 Call Center maintain an active Utilization Review Accreditation Commission (URAC) accredited Health Contact Center and Health Website to ensure commitment to quality and safety, by meeting rigorous industry standards, offering benefits like increased trust, improved operational efficiency, regulatory compliance, and a competitive advantage through independent, third-party proof of high performance and consumer protection. It serves as a recognized "gold standard" for organizations in areas like health networks, pharmacies, and case management.

The Government will review this recommendation and the requirements.

14 Section C C.1.2.2 Customer Service Please provide historical call center volumes related to coordination of benefits involving Medicare Advantage plans.

The Government does not have access to call center volumes related to coordination of benefits involving Medicare Advantage plans.

15 Section C C.1.2.2 Customer Service Please provide the historical volume of TRICARE claim forms (DD 2642) submitted without an EOB that required follow-up. The Government does not have access to this information.

16 Section C C.1.2.2. Beneficiary and Provider Portal

Could the Government please confirm if the TMEP contractor is required to design, develop, and maintain a beneficiary and provider portal?

The Government will review this requirement and any requirements for a beneficiary and provider portal will be included in the final solicitation.

17 Section C C.1.2.4 Transition We suggest that the government consider excluding the cost of the transition from the overall price bid to eliminate unfair advantage to the incumbent and increase fair competition across all bidders. The Government will consider this approach.

Citation Subject Question/Comment Government Response

18 Section C C.1.4 Documents

Relative to requirement: C.1.4. Documents. The documents listed below hereby establish the requirements for this contract. These documents are the integral requirements 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

• TRICARE Reimbursement Manual (TRM) 6010.64-M, April 2021

• TRICARE Systems Manual (TSM) 7950.43M, April 2021

• TRICARE Operations Manual (TOM) 6010.62-M, April 2021

Question: Does DHA anticipate releasing TOM Chapter 20 with or prior to the final RFP?

A revised TOM Chapter 20 will be included with the final solicitation.

19 Section C C.1.4. Appeals and Reconsiderations

TOM Chapter 12, Section 1, paragraph 3.7 states: "The contractor shall establish unique post office boxes or addresses and email addresses to receive reconsideration requests.".

TOM Chapter 12, Section 2, paragraph 3.5.1 states: "All appeal requests must be in writing and submitted by a proper appealing party. Requests submitted via email are considered to be in writing. A signature is not required if a determination can be made that the request was submitted by a proper appealing party."

Could the Government please confirm if appeals requests and reconsideration requests are allowed to be submitted in writing through the TMEP contractor's beneficiary and provider portal?

Yes, the contractor is permitted to accept appeals through its portal.

20 Section C C.1.4. DHA-sponsored Meetings Could the Government please specify in the final RFP if DHA-sponsored meetings or conferences, noted in TOM Chapter 20, Section 1, paragraph 2.3 will be held in-person or virtual? These meetings are primarily held virtually.

21 Section C C.1.4. TOM Program Integrity Requirements

Per TOM Chapter 20, Section 13, the TMEP contractor must follow certain TOM Chapter 13 Program Integrity requirements, with explicit exclusions. Could the Government please confirm whether TMEP is expected to establish its own dedicated Program Integrity unit and whether the team is required to perform medical record reviews carried out by qualified clinical staff, or if those responsibilities are retained by DHA or regional MCSC contractors?

The contractor will be expected to have dedicated Program Integrity staff to work with DHA's PI office.

There is no requirement for PI staff to perform medical record reviews.

22 Section C C.1.4. TOM Provider Terminations

Per TOM Chapter 20, Section 13, paragraph 4.0, several requirements in TOM Chapter 13, Section 5 regarding provider exclusions/terminations are expressly excluded for TMEP. Could the Government please confirm that the DHA Program Integrity retains decision authority for provider exclusions/terminations under 32 CFR 199.9?

Under 32 CFR 199.9 DHA Program Integrity retains decision authority for provider exclusions/terminations.

23 Section C C.1.4. TOM Provider Terminations

Per TOM Chapter 20, Section 13, paragraph 4.0, several requirements in TOM Chapter 13, Section 5 regarding provider exclusions/terminations are expressly excluded for TMEP. Could the Government please confirm that the TMEP contractor’s role is limited to executing DHA-directed operational actions (e.g., suspending claims, sending TMEP‑applicable notices)?

TMEP contractor role is limited to executing DHA Directed Operational Actions.

24 Section C C.1.4. TOM Statistician Qualifications

Per TRICARE Operations Manual (TOM) Chapter 13, Section 3, paragraph 2.4, contractors are required to utilize a “qualified statistician” when developing statistical samples. Could the Government please clarify what criteria or qualifications define a “qualified statistician” for the purposes of this requirement?

A “qualified statistician” is an individual with knowledge, skills and ability to develop and design statistical samples consistent with the government requirement under TOM Chapter 13, Section 3 - Statistical Sampling and Audits. The term statistician describes a professional whom is skilled and knowledgeable in statistical techniques and methodologies.

25 Section C C.1.5 / C.2.1 Government-Furnished Data Quality

How should data quality issues in Government-furnished files, such as DEERS or TEPRV, be handled for performance measurement and processing timeliness purposes? Data quality issues should be brought to the attention of the appropriate Government POC.

26 Section C C.1.5 / C.2.1.4.2.1

TRICARE Centralized Provider File (TEPRV)

Section 2.1.4.2.1 states DHA will provide a Centralized provider file at least weekly; however this is not listed with the GFI The centralized provider file will be included in the GFI paragraph.

27 Section C C.1.5.2 DEERS Medicare Eligibility Status File

Please clarify the method of delivery for the DEERS Medicare eligibility status file. Is it transmitted directly through DEERS, requiring the TMEP contractor to have DEERS access, or via an alternative delivery mechanism? Additionally, please indicate the frequency with which the Crossover File is provided to the TMEP contractor.

See paragraph 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 will be included in Section J of the final solicitation.

28 Section C C.2.1 Claims Processing Will DHA provide projected annual volumes for claims, adjustments, correspondence, and TED submissions for pricing and staffing purposes?

The Government intends to provide historical data with the final solicitation. The Government will not provide TED data.

29 Section C C.2.1 Systems and Integration Which system interfaces are expected to be Government-furnished versus contractor-developed, including DEERS, CMS BCRC, MCSCs, and other DHA systems?

TMEP-specific requirements for system interface, development and testing will be outlined in TOM, Chapter 20, Section 2, which will be released with the final solicitation. No system interfaces are furnished by the Government.

30 Section C C.2.1.11 EFT Requirements How does DHA assign responsibility for remediation when providers refuse or fail to complete EFT setup? DHA does not assign responsibility and expects the contractor to resolve these issues.

31 Section C C.2.1.11.2 EFT for providers Is there a prohibition to setting up EFT with known providers during implementation/transition in based on historical usage? The Government does not prohibit establishing EFT during transition.

Citation Subject Question/Comment Government Response

32 Section C C.2.1.3 Automation Expectations Does DHA have target expectations for automated versus manual claims processing rates, including first-pass auto-adjudication thresholds?

Yes, see performance standards in TOM, Chapter 1, Section 3 for first-pass auto-adjudication and claims reprocessing.

33 Section C C.2.1.3 System configuration What is DHA’s approach to providing a formal change management calendar for TRICARE manual updates?

Manual changes are as needed, and there is no formal change management calendar. Annual updates are made to the reimbursement systems or as otherwise required.

34 Section C C.2.1.3 TED Will historical TED data be made to offerors upon request or available to awardee during transition in? The Government will not release TED data to offerors. The data will be available to the awardee during the transition period.

35 Section C C.2.1.3. Automated claims processing system

Per TSM Chapter 1, Section 1.1, paragraph 2.5, "The contractor shall follow the cloud computing requirements as prescribed in DFARS Clause 252.204-7012. For DoD CUI constituting PHI, the contractor shall ensure the external Cloud Service Provider (CSP) is Federal Risk and Authorization Management Program (FedRAMP) authorized at the appropriate baseline/impact level and maintains compliance throughout duration of the applicable contract." Please confirm that FedRAMP Moderate is the appropriate impact level for contractor systems.

Yes, contractors that intend to use a CSP, on their behalf, are required to ensure the CSP meets the security requirements equivalent to FedRAMP Moderate IAW DFARS 252.204-7012.

36 Section C C.2.1.3.2 Claims Processing

The PWS stipulates that 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. Pursuant to this requirement, will there be defined SLAs governing transition?

No, there will not be defined SLAs governing transition; however, a modification will be issued to the contract to include implementation dates.

37 Section C C.2.1.3.2 System Change Lead Time Could the Government please identify standard or maximum lead-time expectations for required system changes after notification? For system changes, the government will identify expectations with each change.

38 Section C C.2.1.3.7 Authorization conflicts What are the adjudication steps when the MCSC and the TMEP contractor disagree on authorization validity?

If there is disagreement on the validity of an authorization, DHA would review to make a determination, as per the established Memorandum of Understanding (MOU) between TMEP and MCSC.

39 Section C C.2.1.3.7.1 Dispute Resolution What is the detailed process for resolving disagreements between the Contractor and the MCSCs? If there is disagreement, DHA would review to make a determination, as per the MOU between TMEP and

MCSC.

40 Section C C.2.1.3.8 TED capture and submission What is the frequency for TED reporting and EDI interchange mechanism for submission (is there a TSM reference specifying mode and frequency?) (H.6.2.2 references quarterly submission, but unclear if this is sampling for incentive or refers to normal submission frequency)

TED submissions are received at DHA and processed daily Monday through Friday, excluding weekends and holidays unless otherwise noted and coordinated. Daily cycle Transmission reports are returned to the sender daily, after the completion of cycle processing as well.

41 Section C C.2.1.4.1 Claims Processing Please provide historical volumes of dual-eligible claims where TRICARE was determined to be the primary payer and retrospective review was required. The Government does not have access to this information.

42 Section C C.2.1.4.1 Primary Payer Criteria Can you provide reference for conditions covered under TRICARE as primary payer when Medicare does not cover? See TRICARE Reimbursement Manual (TRM) April 2021, Chapter 4, Section 4.

43 Section C C.2.1.4.2.1 Provider credentialing What provider participation data will DHA make available (e.g., historical data versus only current-state TEPRV files)?

Historical and current data is included in the Government's centralized provider file, which the TMEP-2 contractor will have access to during the transition period.

44 Section C C.2.1.4.2.2 Participation Agreement Does the contractor have a role in approving participation agreement? Or is the role to request agreement and submit once final. Are claims denied or in pending status while participation agreement is being verified? Is the contractor required to store/retain participation agreement

The contractor does have a role in approving participation agreements. This includes obtaining the participation agreement from the contractor authorizing the provider or, if a participation agreement is not available the contractor must request one from the provider. The contractor must maintain a copy of the participation agreement. See the TRICARE Policy Manual (TPM) for required participation agreements.

45 Section C C.2.1.4.2.3 Submission of Provider Information

TSM Ch 2 1.2 provides file specifications. What is mechanism for submission of data SFTP? Flat file?

Direct interface with government systems?

Per TSM Chapter 1 Section 1, Paragraph 6.7.3 TED-Specific Data Communications Technical Requirements The contractor shall communicate with the Government’s TED Data Center through the MHS B2B Gateway.

6.7.3.1 Communication Protocol Requirements

6.7.3.1.1 The contractor shall use file transfer software to support communications with the TED Data Processing center. CONNECT: Direct is the current communications software standard for TED transmissions.

46 Section C C.2.1.5 Explanation of Benefits (EOB) Compliance Details What additional information must appear on the EOB to fully comply with TOM, Chapter 20, Section 8?

TOM Chapter 8, Section 8 identifies all information that should be included in the EOB. Information specific to TMEP will be outlined in revised TOM, Chapter 20, Section 8 included with the final solicitation.

47 Section C C.2.1.6 Pre-Authorizations Provide clarification that pre-authorizations are only required when TRICARE is primary payer

Yes, preauthorizations/authorizations are only required when TRICARE is the primary payer. See paragraph 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.

48 Section C C.2.1.8 Contractor’s Scope of Authority

What specific clinical review responsibilities will the PRO function include (e.g., medical necessity, coding accuracy, DRG validation), how will clinical review guidelines be supplied or developed, and how will liability be allocated for clinical determinations that are later overturned?

Clinical review guidelines will be outlined in the revised TOM, Chapter 20, Section 7 released with the final solicitation.

49 Section C C.2.2 Customer Service Please identify the expected customer service performance metrics and targets, such as average speed of answer, abandonment rate, uptime, and first-call resolution. See performance standards in TOM, Chapter 1, Section 3.

Citation Subject Question/Comment Government Response

50 Section C C.2.2 Customer Service Will DHA provide projected call volumes by call type, including beneficiary, provider, and government inquiries?

Historical call volumes will be included in the final solicitation. The Government does not have access to call type information at this time.

51 Section C C.2.2.1.3 Call Center Requirements Given that the strict telephone metrics in Section H are a major cost driver, how does DHA view the use of virtual or contact-center-as-a-service models to meet these requirements? The Government allows virtual call centers to meet customer service requirements.

52 Section C C.2.2.1.3 Call Center Services Could the Government please confirm if the TMEP contractor is required to operate a contact center with live representatives available 24/7/365, or that the IVR must be available 24/7/365 with staff available during normal business hours?

This requirement language is being reviewed and may be refined in the final solicitation. The option to speak with a customer service representative shall be provided between the hours of 6:00 am and 11:00 pm EST (except weekends and federal holidays). The IVR may be used outside of these hours.

53 Section C C.2.2.1.3 Call Volume We suggest that in the final solicitation the Government provide the average monthly call volume received by the call center for claim-related inquiries (including claim status, payment, and adjustment issues). This will support accurate workforce management.

Historical call volume will be provided with the final solicitation.

54 Section C C.2.2.1.3 Customer Service Does the Government require live agent coverage 24 hours per day, 7 days per week, 365 days per year, or may IVR and self-service channels satisfy coverage requirements during weekends, overnights, and holidays?

See response to question 52.

55 Section C C.2.2.1.3 Customer Service 24/7/365 - Does customer service line include Nurses Advice Line as part of requirement? There is not a Nurse Advice Line requirement in TMEP.

56 Section C C.2.2.1.3. Claims Processing

Relative to requirement: C.2.2.1.3. The Contractor shall provide Call Center services 24 hours per day, 7 days per week, 365 days per year.

Question: Please clarify which Call Center services are to be available 24hours per day, 7 days per week, 365 days per year (i.e., IVR, Portal, live agent, etc.).

See response to question 52.

57 Section C C.2.2.1.3. Customer Service Please provide the total volume and volume of live agent calls received by the TMEP contractor, broken down by hour of the day (e.g., historical data by month, day and hour over life of the contract).

The Government does not have access to a breakdown of live agent calls by hour of day; however, the Government anticipates providing data regarding historical telephone inquiries to include total received and number of calls answered by the agent.

58 Section C C.2.2.3 Customer Service Standards What quality monitoring activities, beyond the metrics listed in Section H (e.g., sentiment analysis, calibration), does DHA expect the contractor to perform? See TOM, Chapter 1, Section 4 for additional requirements to conduct quality reviews.

59 Section C C.2.2.4 Beneficiary & Provider Engagement

To improve the user experience and augment beneficiary and provider education, we suggest the government consider implementing a beneficiary portal that can be accessed through multiple modalities to ensure seamless access that is secure, user-centric, and focused on a seamless and engaging experience that includes relevant content and effective notifications that is utilized for all aspects of the experience for providers and beneficiaries alike.

The Government will review this recommendation and the requirements.

60 Section C C.2.2.5 CRM Case Management What are the criteria for when the CRM system is used to document an issue? Is there any restriction on a contractor using its own CRM system for day to day operations and using the government CRM for issue management/resolution?

The contractor must use the Government designated system for CRM inquiries/responses.

61 Section C C.2.2.5.1. Claims Processing

Relative to requirement: C.2.2.5.1. The Contractor's designated staff shall attend government required training

Question: What type of training stated in this section is the government providing to the contractor and how many hours of government required training should be expected?

The required Government training is for the Government-designated web-based customer relations management system outlined in paragraph C.2.2.5. This requirement language is being reviewed and may be refined in the final solicitation.

62 Section C C.2.3 Small Business Requirements What is the government contemplating for small business and socioeconomic requirements?

If award is made to a large business, the successful contractor will have to meet DoD's established goals for subcontracting to small business, veteran owned small business, service disabled veteran owned small business, HUBZone small business, small disadvantaged business, and women-owned small business concerns.

63 Section C C.2.3.11 CMMC Level 2 Will NIST-800-171 SPRS score be considered in lieu of CMMC level 2? No, the NIST SP 800-171 basic summary-level assessment will not be considered in lieu of CMMC level 2 requirement.

64 Section C

C.2.3.11 – Cybersecurity Compliance

Program

System security and hosting model

Can DHA describe the anticipated system hosting approach for TMEP2, including any planned use of cloud, on-premises, or hybrid environments, and outline the security authorization expectations (e.g., FedRAMP) for contractor systems that process TMEP data?

Contract type: Non-IT services based. Security requirement: DFARS clause 252.204-7012: "If the contractor intends to use an external cloud service provider to store, process, or transmit any covered defense information in performance of this contract, the contractor shall require and ensure that the cloud service provider meets security requirements equivalent to those established by the Government for the Federal Risk and Authorization Management Program (FedRAMP) Moderate baseline" So, if the contractor intends to use a cloud service offering (CSO) that has not achieved FedRAMP Moderate authorization, the contractor may pursue FedRAMP Moderate equivalency so they can use the CSO to store, process, or transmit CDI. The CMMC auditor will check whether the CSO is FedRAMP Moderate authorized or equivalent (by verifying the CSP's BoE). See DoD CIO memo for equivalency guidance:

https://dodcio.defense.gov/Portals/0/Documents/Library/FEDRAMP- EquivalencyCloudServiceProviders.pdf.

Citation Subject Question/Comment Government Response

65 Section C C.2.3.11.1 CMMC Certification Would DHA consider moving the requirement for the contractor to achieve CMMC Level 2 certification from contract award to the start of Option Period 1?

No, the requirement cannot be moved. The contractor needs to have a current CMMC status at the level specified in the contract during transition-in activities. If the offeror has obtained a conditional CMMC status from the C3PAO, then the Contracting Officer may award the contract allowing up to 180 days for the contractor to close-out identified POA&M items.

66 Section C C.2.3.11.1 CMMC Compliance What ongoing measures or audits will DHA use to ensure that the Contractor maintains CMMC Level 2 certification?

DHA will validate the contractor's current (i.e., not greater than 3 years) CMMC Level 2 results are posted in the Supplier Performance Risk System (SPRS) and the contractor's annual affirmation is performed in

SPRS.

67 Section C C.2.3.11.1 CMMC Level 2 Requirement How does DHA define “covered information systems” for the purpose of CMMC scope? "Covered contractor information system" is defined in DFARS clause 252.204-7012. See CMMC Scoping Guide, Level 2: https://dodcio.defense.gov/Portals/0/Documents/CMMC/ScopingGuideL2v2.pdf

68 Section C C.2.3.11.1 Cybersecurity Maturity Model Certification (CMMC)

For the CMMC requirement, when is compliance required (at award or by go-live), what interim controls or phased approach are acceptable prior to full compliance, and will operating in a FedRAMP Moderate environment with mapped NIST controls satisfy any portion of the intent?

CMMC compliance is a condition to contract award. Therefore, compliance verification is required at award. The OSA (Organization Seeking Assessment) will need to work with an authorized CMMC third-party assessor organization (C3PAO) for questions pertaining to CMMC scope requirements.

69 Section C C.2.3.13.1 Staffing and Leadership We suggest that in the final RFP include specifics around the minimum qualifications and experience requirements for the "experienced and qualified leadership personnel" referenced in C.2.3.13.1. The Government will consider this approach.

70 Section C C.2.3.13.3 Staffing and Leadership We suggest that the government include in the final RFP the geographic range for when senior leadership is required to attend in-person meetings "within two business days" at a GDA-identified location.

The Government will consider adding a geographic range for travel within the continental United States with the final solicitation.

71 Section C C.2.3.2 Audit access What technical specifications will DHA provide for off-site Government UI access requirements?

The contractor (as the system owner) is responsible for the technical and administrative processes to allow Government users access to their system. If the contractor system requires specific software to run on the Government User system, then that would require government approval.

72 Section C C.2.3.2 Data Currency and Latency What data latency or reconciliation tolerances does DHA consider acceptable for claims, customer service, and reporting data accessed by Government users?

The Government expects data to be current within the last 24 hours as per Section C. The Government user should have access to the same user interface as the contractor's staff.

73 Section C C.2.3.4 Quality Management (QM) and Quality Improvement (QM/QI) Program

To ensure compliance with several industry models and standards (i.e., Capability Maturity Model Integration [CMMI]-Development and CMMI-Services Maturity Level 3, and ISO 9001, ISO 20000-1 and AS9100 quality management systems) we suggest the government develop a Quality Control plan that includes multiple avenues for data including customer surveys, Voice of the Customer exercises, process evaluation and improvement, call auditing, LIVE call monitoring, and regular call calibration activities in partnership with the customer.

The Government will review this recommendation and the requirements.

74 Section C C.2.3.4.2. Claims Processing

Relative to requirement: C.2.3.4.2. 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. The Contractor's QM processes shall focus on outcomes, program processes and procedures, standardization, and identifying and resolving access to care problems.

Question: Is it DHA's intention to add requirements related to "access to care" to TMEP that is beyond what a contractor can control in the current environment without a Provider Network?

These requirements are being reviewed and may be refined in the final solicitation. Paragraphs C.2.3.4.2 & C.2.3.4.3 may be removed from Section C.

75 Section C C.2.4 Transition Acceptance Criteria What criteria will DHA use to determine that transition activities are complete and that systems and operations are accepted as fully operational?

Transition requirements for incoming and outgoing contractors will be provided in TOM Chapter 20, released with the final solicitation.

76 Section C C.2.4 Transition Activities Will the Government provide historical claims, provider, and TED data for transition and testing purposes, and if so, what lookback period should be assumed? See response to question 75.

77 Section C C.2.4 Transition requirements What legacy system documentation and file format specifications from the incumbent contractor will DHA provide?

File formats and requirements for incoming and outgoing contractors will be provided in TOM Chapter 20, released with the final solicitation.

78 Section C C.2.4 Transition Requirements What transition data package (including specifications on claim history, open authorization files, and pending customer service cases) will DHA provide, and how does DHA plan to structure onboarding (e.g., phased approach versus single cutover)?

Transition data requirements for incoming and outgoing contractors will be provided in TOM Chapter 20, released with the final solicitation.

79 Section C C.2.4. Transition Meetings Could the Government please confirm if the Transition Specifications Meeting, Interface Meetings, DCS training, and initial training on deliverables during the transition period will be held in-person or virtual? Typically, Transition meetings are held in person, but the final solicitation will specify meeting format.

80 Section C C.2.4. Transition Requirements

The TOM Chapter 20, Section 2, paragraph 2.1.3 states "The outgoing contractor shall, upon receipt of written request from DHA, provide to potential offerors such items and data as required by DHA. This shall include non-proprietary information, such as record formats and specifications, field descriptions and data elements, claims and correspondence volumes, etc.". To ensure a level playing field for incoming offerors, could the Government please request that the outgoing contractor provides this information and data to be provided with the release of the final RFP?

The Government will release some data to offerors with the final solicitation. More specific data will be shared only with the contract awardee during the transition period.

81 Section C C.2.4.1 Transition Activities Other than the TRICARE Records Management requirement detailed in TOM Chapter 20 and TPM Chapter 9, are there any additional Centers for Medicare and Medicaid Services (CMS) Medicare Records Management requirements that apply to the TMEP contract?

All Records Management requirements are outlined in TOM, Chapter 9. TMEP specific requirements will be outlined in TOM, Chapter 20 issued with final solicitation.

Citation Subject Question/Comment Government Response

82 Section C C.2.4.1 / C.2.4.1.2 Transition Timing and Phasing Are the start of services and the start of Option Period 1 intended to occur on the same date, and what is the anticipated duration and phasing of transition-in activities? Yes, services will begin at the start of Option Period 1. Transition is expected to be 12 months.

83 Section C C.2.4.5 Parallel Operations with Incumbent

Does DHA anticipate a period of parallel operations with the incumbent contractor, and if so, what duration and functional scope should be assumed?

The incoming contractor is responsible for claims received at the start of Option Period 1. Transition requirements for incoming and outgoing contractors will be provided in TOM Chapter 20, released with the final solicitation.

84 Section C C.2.7.12 Data Sharing Agreement What specific elements must be included in the DSA between the Contractor and TMEP? Data sharing elements can be found at: https://www.health.mil/Military-Health-Topics/Privacy-and-Civil- Liberties/Data-Sharing-Agreements

85 Section H H 1.2 Integrated Process Teams (IPTs)

Could the Government please confirm if the Integrated Process Teams meetings will be held in-person or virtual?

Please see Section H Paragraph 1.2. The IPT meetings may be in-person or virtual. See also response to Question 86.

86 Section H H.1 Government-Directed Changes Through IPTs

What thresholds or types of changes (e.g., cost or expected hours of completion) trigger the formation of an

IPT?

IPTs are scheduled as needed, likely in response to major contractor program changes or issues. There have been no IPTs for the current contract.

87 Section H H.1 Government-Directed Changes Through IPTs

How will DHA address equitable adjustments for IPT-driven scope changes that affect cost, scope, and schedule?

DHA will handle any such requests for equitable adjustment (REAs) as it handles all other REAs. When the IPT-driven changes are made, DHA will review the impact the changes have on the contract's cost, scope, and schedule.

88 Section H H.1 Integrated Process Teams Can the government please provide a historical account or an average of the number of IPTs annually? See response to question 86.

89 Section H H.1 IPT Participation What is the expected annual volume of IPTs and the required level of contractor participation? See response to question 86.

90 Section H H.1 IPT Scope and Compensation Are Integrated Process Team participation activities considered within the scope of the base contract, or are they compensable through contract modifications when they result in new or expanded requirements? Yes, they are considered within scope of the base contract. See also response to question 87.

91 Section H H.1 – Integrated Process Teams

(IPTs) IPT participation workload For each year, how many IPTs does DHA anticipate convening, and what level of contractor participation

(e.g., roles and time commitment) is expected? See response to question 86.

92 Section H H.1.2 Integrated Process Teams

(IPT)

Please provide the total volume or average number of individual Integrated Process Teams (IPTs) active during each of the last five contract periods (e.g., broken down by contract year). See response to question 86.

93 Section H H.1.2 Integrated Process Teams

(IPT)

What was the average or required frequency of meetings for these Integrated Process Teams (IPTs) during each of the last five contract periods? See response to question 86.

94 Section H H.1.3 Government discretion in IPT outcomes

To what extent will contractors be required to implement IPT recommendations, particularly when recommendations are not aligned with contractors’ cost or operational models?

When changes arise, DHA will review with the contractor to make necessary adjustments as applicable.

See also response to question 87.

95 Section H H.2 Contractor financial liability What specific scenarios will DHA define in which the contractor is not liable for costs resulting from erroneous or incomplete provider or beneficiary information?

The contractor should ensure that complete provider or beneficiary information is available prior to issuing an authorization. If the contractor issues an accurate authorization, the contractor will not be liable.

96 Section H H.2 Financial Liability How will liability be allocated when provider billing errors occur despite the contractor having issued accurate authorizations? If the contractor issues an accurate authorization, the contractor will not be liable.

97 Section H H.2 Volume, Scale & Workload What is the anticipated size of the beneficiary population, claims volume, and customer service workload the contractor should plan to support, and how might those volumes fluctuate over time? This information will be provided with the final solicitation.

98 Section H H.3 Data Quality What is the current quality, completeness, and structure of the legacy data (eligibility, claims, provider records), and what responsibility will the contractor have for cleansing or correcting it?

The contractor is not responsible for the quality and completeness of legacy data, but will be responsible for executing all requirements in the PWS and Manuals.

99 Section H H.3 Exception Handling & Edge Cases

How are unusual or complex cases handled (for example, dual eligibility anomalies, retroactive Medicare changes, overseas beneficiaries, or disputed claims), and what level of discretion does the contractor have in resolving them?

Unusual and complex cases are handled by the contractor on a case-by-case basis in accordance with the PWS and Manual requirements, with guidance from the Government.

100 Section H H.3 FOIA releasable contract What are DHA’s expectations for redaction standards and turnaround times when preparing a FOIA-releasable version of the contract?

The first submission of the FOIA releasable contract is due 60 days after contract award. Subsequent annual submissions are due 30 days after the end of each option period.

101 Section H H.3 Operational/Technical How will coordination of benefits between Medicare and Tricare be structured operationally, and what level of responsibility will the contractor have for resolving overlapping coverage, denials, and beneficiary billing issues.

The coordination of benefits between Medicare and TRICARE is the basis for the TMEP contract. The contractor requirements and level of responsibility are detailed in TRM, Chapter 4, Section 4. The revised TOM, Chapter 20 will be issued with the final solicitation.

102 Section H H.3 Training Content What training on TRICARE, Medicare coordination, and DoD-specific policies will be provided by the government, and what training is the contractor expected to develop independently?

The Government will provide training on Government systems and records management. The contractor is expected to provide customer service training for their staff and all other training necessary to deliver the services required under the contract. The contractor shall provide the Government ongoing training and user support necessary for Government personnel to access the contractor's systems as required in Section C.2.3.2.4.

103 Section H H.4 Incentive Methodology What historical beneficiary satisfaction results or benchmarks does DHA plan to publish? Beneficiary satisfaction scores are proprietary information for the current contractor and will not be shared.

104 Section H H.4 Success Criteria Beyond formal performance metrics, how does the government define "success" for this program from an operational and beneficiary perspective?

The contractor shall provide comprehensive and accessible customer services which result in beneficiary and provider satisfaction. The revised TOM, Chapter 20 will be issued with the final solicitation.

Citation Subject Question/Comment Government Response

105 Section H H.4 –

Performance Incentives

Incentive modeling What historical beneficiary satisfaction survey scores, if any, will DHA provide to allow bidders to model the probability of earning incentives? See response to question 103.

106 Section H H.4.2 Financial And Incentive Clarifications

For H.4.2, the General Performance Metric states the contractor "shall not be below the AQL for more than three metrics...in any given month." Can the government please clarify if this means three different metrics, or three occurrences of the same metric?

The AQL shall not be below for a total of more than metrics which includes three different metrics or three concurrent metrics. The Government is reviewing this requirement and will revise for clarity.

107 Section H H.4.3 Quarterly incentive amount

Is this amount fixed at time of contract award? Please clarify if the amount provided is payable each quarter. Is there any response rate factored in. (i.e. is the 99-100% required based on percentage of beneficiaries responding to the survey or percentage of overall beneficiaries?) What is the typical historical response rate for such surveys?

Yes, the quarterly incentive amount is fixed and yes, the amount provided is payable each quarter. The survey methodology will be included in the final solicitation.

108 Section H H.4.3. PERFORMANCE

INCENTIVE

Relative to requirement: H.4.3. Beneficiary Satisfaction. 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 below percentages from the applicable CLIN.

Question: Will DHA provide a copy of the beneficiary survey with the Final RFP?

The Government will consider providing this information.

109 Section H H.4.3.1 Beneficiary Satisfaction Survey For each option period, what portion of beneficiaries who utilized the contract’s services are included in the DHA survey (e.g., full population versus a sample), and how is that sample defined? Beneficiary satisfaction survey methodology will be included in the final solicitation.

110 Section H H.4.3.1 Financial And Incentive Clarifications

Section H.4.3.1 references "available quarterly funding by Option Period" for beneficiary satisfaction incentives. Are these amounts fixed, or subject to adjustment based on inflation or other factors? These amounts are fixed.

111 Section H H.5 Performance Guarantees How will PG penalty values be handled across option periods, including whether and how they will be adjusted for inflation?

The performance guarantees included in Section H are the same across all option periods. No adjustment is made by the government.

112 Section H H.5 Performance Guarantees Can multiple performance guarantees be assessed concurrently within the same evaluation period, and is there an aggregate cap on total performance guarantee reductions?

Yes, multiple performance guarantees can be assessed within the same evaluation period. There is no cap on total performance guarantees.

113 Section H H.5 Performance Guarantees Can multiple performance guarantees be assessed concurrently for the same underlying issue, and is there an aggregate cap on assessed guarantees per month or quarter? See response to question 112.

114 Section H H.5 Performance Guarantees Are the monthly performance guarantees in the tables additive to claims reimbursement or decremented from invoiced amount?

See paragraph H.5.2. The Government will assess performance guarantees on a monthly basis and notify the contractor of performance guarantee reductions on a quarterly basis. For each occurrence the contractor fails to meet a guaranteed standard, the Government will reduce the applicable amount payable to the contractor on a future invoice.

115 Section H H.5 Timeliness Standards with Financial Penalties

Given the rigidity of the performance guarantees (e.g., 98% of claims within 30 days, 100% within 90 days) with automatic monetary penalties, how does DHA plan to treat outlier claims (e.g., OHI MIA, pending medical documentation, system outages outside contractor control), and how will the Government handle delays that it causes (e.g., delayed DEERS updates, TEPRV outages, missing BCRC crossover data)?

See the TRICARE Operations Manual Chapter 8, Section 6. The government will review claims processing delays due to government system outages on a case-by-case basis.

116 Section H

H.5 – Performance Guarantees (General)

Annual penalty caps What annual or per-metric caps, if any, does DHA impose on performance guarantee penalties? There are no annual caps for performance guarantee penalties.

117 Section H

H.5 – Performance Guarantees (General)

PG enforcement methodology How does DHA define an “occurrence” for purposes of PG-related penalties (e.g., event, metric period, claim, phone call, or file)?

Paragraphs in Section H.5 refer to "each occurrence" as each monthly or quarterly performance standard that is not met.

118 Section H H.5 / H.6 Performance Guarantees Administration

Does DHA allow remediation or correction prior to the assessment of performance guarantee reductions, and how are guarantees administered when metrics rely on Government-provided or third-party data sources?

No. The contractor will be provided with an opportunity to respond to performance guarantee assessments within 10 days following notification. Metrics of any source for performance guarantees are administered in accordance with contract and policy requirements.

119 Section H H.5.2 Performance Guarentees How will DHA communicate performance guarantees to the contractor (e.g., format, frequency, and communication channels)?

Performance guarantees will be communicated to the contractor on a quarterly basis at the end of each contract quarter for performance standards measured on a monthly basis. For performance standards measured based on a Government review (e.g., quarterly claims accuracy reviews), the performance guarantees will be issued upon completion of each review. Performance guarantee results are communicated to the contractor in writing.

120 Section H H.5.2 Performance Guarentees What is the detailed appeal process for performance reductions, including steps, timelines, and decision authorities?

There is not a formal appeal process for performance guarantees. The contractor will be provided with an opportunity to respond to performance guarantee assessments within 10 days following notification.

121 Section H H.5.3 –

Telephone Blockage Rate

Blockage definition In calculating the blockage rate, how does DHA define the denominator, particularly with respect to calls abandoned by beneficiaries before system engagement? The Government will review this requirement to clarify the formula.

122 Section H H.5.4 – Total Hold Time Typographical error How should the apparent reference error in the section be corrected (currently cited as “H.3.4.2”; should this reference instead be “H.5.4.2”)?

The paragraph should be numbered H.5.4.2…