TMEP2 Section C Draft Performance Work Statement.pdf

SECTION C

PERFORMANCE WORK STATEMENT (PWS)

C.1. Purpose

C.1.1 The purpose of the TRICARE Medicare Eligible Program (TMEP) 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.1.1.1 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 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

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. 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. For the purposes of this contract, please see Attachment J-4, Draft 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.1.6. 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. Performance Requirements https://manuals.health.mil/pages/DownloadManualFile.ashx?Filename=Definitions.pdf https://manuals.health.mil/

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 identified TRICARE/Medicare eligible beneficiaries to the Medicare Benefits Coordination and

Recovery Center (BCRC) in accordance with TSM, Chapter 3, Section 4.2.

C.2.1.2. The Contractor shall link and cross-reference TRICARE beneficiary identifiers (as used in TRICARE claims and customer service, per 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 and DEERS.

C.2.1.3.5. Interface with and accurately determine eligibility and enrollment status based on

DEERS data in accordance with the TSM.

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.

C.2.1.3.7. Accept authorizations from the Managed Care Support Contractors (MCSC) using the

ASCX12N278 format, or any applicable format, and ensure the claims processing system can 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. The Contractor shall capture and report TRICARE Encounter Data (TED) related to claims adjudication in accordance with the TSM.

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 (TEPRV). If a provider’s status is not listed in the TEPRV, 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 a copy of the participation agreement (a copy from the

Contractor authorizing the provider or requesting one from the provider) for providers and facilities requiring them prior to reimbursing claims from those facilities as required by the

TRM.

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.

C.2.1.5. 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.2.1.6. The Contractor shall adjudicate TRICARE preauthorization/authorizations, in accordance with the quality and timeliness standards in TOM, Chapter 1, Section 3.

C.2.1.6.1. 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.2.1.7. The Contractor shall process claims consistent with TRICARE program, regulation, and policy.

C.2.1.8 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.2.1.9. Medicare Bundled Payment Initiatives

C.2.1.9.1. The Contractor shall submit TED records for institutional claims processed and reimbursed by Medicare Bundled Payment Initiatives Program with Special Processing Code

“BP-CMS Bundled care payment initiative.”

C.2.1.9.2. 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.2.1.10. 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.2.1.11. Electronic Funds Transfer (EFT)

C.2.1.11.1. 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.2.1.11.2. The Contractor shall contact providers upon claim receipt or through utilization of claims history files to set up EFT payments.

C.2.1.11.2.1. During the process of the contractor establishing the EFT payment process for a provider, the Contractor may use other means of paying the provider.

C.2.1.11.2.1.1. 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 a U.S. Bank or other U.S. financial institution.

C.2.1.12. 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 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 objective 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.2.2.2. 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 customers 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.2.2.2.2.3. The Contractor’s IVR unit shall allow callers the option of speaking to an agent in accordance with TOM, Chapter 20.

C.2.2.3. The Contractor shall comply with all beneficiary and provider service standards in the

TOM, Chapter 20, Section 11.

C.2.2.4. The Contractor shall develop and implement an education plan for conducting targeted beneficiary and provider education (Contractor Data Requirements List (CDRL) R150).

C.2.2.4.1. The Contractor’s education plan shall target beneficiary and provider education related to specific issues that surface throughout the administration of this contract.

C.2.2.4.2. The Contractor, at a minimum, shall provide education through EOB statements and letters (CDRL R150).

C.2.2.4.3. The Contractor shall work with the DHA Communications and Public Affairs

Division in identifying content for beneficiary education and shall coordinate efforts in accordance with CDRL OT050.

C.2.2.5. 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.2.2.5.1. The Contractor’s designated staff shall attend Government required training

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 to the system that would impact the Government’s ability to review and access data pertaining to the TMEP contract.

C.2.3.3. The Contractor shall participate in DHA Communication’s web partnership meetings to discuss best processes for joint endeavors.

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

C.2.3.4.1. The Contractor shall establish and operate throughout the life of the contract a QM/QI program that effectively supports ongoing quality improvement efforts.

C.2.3.4.2. 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.

C.2.3.4.3. The Contractor's QI processes shall focus on process improvements and shall foster innovation by incorporating healthcare best business practices and healthcare industry standards that lead to quality healthcare access, quality health care rendered, and quality health care outcomes.

C.2.3.4.4. 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 AP010).

C.2.3.4.5. The Contractor shall submit an annual QM/QI plan (CDRL P070). For plan submission requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the contract.

C.2.3.5. 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.2.3.6. The Contractor shall implement management controls to prevent fraud and abuse of benefit funds in accordance with 32 CFR 199.9 when 32 CFR 199.14 and TRM, Chapter 5, C.2.3.7. 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.

C.2.3.7.1. 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.2.3.8. The Contractor shall refer to DHA Program Integrity, cases that involve $500,000.00 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.2.3.9. The Contractor shall comply with management requirements in TOM, Chapter 20, C.2.3.10. The Contractor shall implement a personnel security program which meets the TSM requirements.

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.

C.2.3.11.1. 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).

C.2.3.11.1.1. The Contractor shall annually affirm their CMMC Level 2 certificate compliance in the Supplier Performance Risk System.

C.2.7.12. 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.2.3.13. Contractor Leadership

C.2.3.13.1. 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.2.3.13.2. 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.2.3.13.3. 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 (i.e., within two business days) at a 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 2 and TOM, Chapter 20, Section 2 and the TSM.

C.2.4.1.2 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.2.4.2. 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.2.4.3. 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.2.4.4. 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, paragraph 1.4.2.)

C.2.4.5. 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.2.4.6. 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.