TMEP2 Section H Draft Special Contract Requirements.pdf

SECTION H

SPECIAL CONTRACT REQUIREMENTS

H.1. INTEGRATED PROCESS TEAMS

H.1.1 The Government may develop major contract and program changes through the use of

Integrated Process Teams (IPTs) staffed by Government and Contractor personnel. The

Government will not establish IPTs for all contract changes, but generally will establish them to address complex, system-wide issues. The IPT process required in this section will begin the date the CO notifies the Contractor in writing of the Government’s intent to establish an IPT.

Within 14 days after receiving such written notification, the Contractor shall identify the appropriate personnel (as agreed to by the CO and Contractor) to serve on the IPT to develop and/or improve the technical, business, and implementation approach to any proposed TRICARE program or contract change.

H.1.2 The Contractor shall participate in all required IPT meetings as determined by the

Government designated team lead, regardless of the mode of meeting (in person or via teleconference, video-teleconference, or another electronic conference mode). The frequency and scheduling of such meetings will vary depending on the topic. The Contractor shall participate with the Government team in the entire process from concept development through establishment of the final requirement. The IPT process required in this section may include developing the Government’s budgetary cost estimates, identifying requirements, developing associated rough order of magnitude cost estimates, and preparing the final specification/statement of work. The IPT process will not include post-change order activities, such as implementation/coordination meetings and definitization efforts, the costs of which will be allocable to the change order itself.

H.1.3 The Government will have sole discretion to decide to implement an IPT’s project outcome based on designed outcomes and budgetary cost estimates. The Contractor shall partner with the Government to make best efforts to pre-review any proposed contract modifications and

TRICARE manual changes to ensure that the Government’s implementation of such changes does not significantly deviate from the Government’s designed outcomes and budgetary cost estimates for the project.

H.2 FINANCIAL LIABILITY FOR SERVICES/SUPPLIES OUTSIDE SCOPE OF

CONTRACT

H.2.1. The Contractor shall assume full financial liability for civilian health care provided to eligible beneficiaries for any services and/or supplies which fall outside the scope of this contract, when such services and/or supplies have specifically been authorized by the Contractor

(e.g., the Contractor issues an authorization for a procedure/service which is specifically excluded from TRICARE coverage, and the beneficiary subsequently obtains the care based on the Contractor’s erroneous authorization). Such determinations shall be based solely on the specific services and/or supplies identified in the Contractor’s authorization letter and the

TRICARE benefit policies in effect at the time the authorization was issued. The Contractor shall not be held liable in cases where the beneficiary and/or the provider chose to engage in non-covered services that were beyond the scope of the Contractor’s authorization.

H.3 FREEDOM OF INFORMATION ACT (FOIA) RELEASABLE CONTRACT

H.3.1 The Contractor shall provide a FOIA releasable contract in accordance with 5 USC § 552 and DD Form 1423, Contract Data Requirements List (CDRL A110), located in Section J of the contract. The FOIA releasable contract shall include an explanation identifying the FOIA exemptions that prohibit disclosure and the rationale for why the exemption applies.

H.4. PERFORMANCE INCENTIVE

H.4.1. There are monetary positive incentives available under this contract. The Contractor may qualify for a positive incentive each quarter by meeting specified levels of performance during the below defined periods. The Contractor must satisfy the conditions listed in H.4.2 first in order to move on to H.4.3. When conditions have been met, positive incentives will be calculated as defined in H.4.3.1. within 30 days of receiving the results.

H.4.2. General Performance Metric. The Contractor shall not be below the acceptable quality level (AQL) for more than three metrics, monitored via the Contractor Management Report, Contract Data Requirements List (CDRL) and Government TRICARE Encounter Data (TED) and Duplicate Claims Report, in any given month of the quarter or be below the AQL for a specific metric more than three consecutive months. When these conditions are met, the

Contractor will be eligible for an incentive based on H.4.3.

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.

H.4.3.1. The positive incentive is based on the DHA survey (Section J, Attachment J-2) and will be administered quarterly during each contract option period beginning with beneficiaries who had services in the third quarter of Option period 1. If 90% or more of the beneficiaries are

“Somewhat satisfied,” “very satisfied,” and “completely satisfied” combined, the Contractor shall be awarded the following incentive:

H.4.3.1.1 Available quarterly funding by Option Period:

OPTION PERIOD AVAILABLE QUARTERLY INCENTIVE

AMOUNT

1 $285,249.00

2 $293,807.00

3 $302,621.00

4 $311,699.00

5 $321,050.00

6 $330,682.00

H.4.3.1.2. If 90% or higher but less than 97%, the Contractor will receive 50% of the available funding.

H.4.3.1.3. If 97% or higher but less than 99%, the Contractor will receive 75% of the available funding.

H.4.3.1.4. If 99%-100%, the Contractor will receive 100% of the available funding.

H.5. PERFORMANCE GUARANTEES

H.5.1. The performance guarantees described herein are the Contractor’s guarantee that the

Contractor’s performance will not be less than the contract performance standards described below. The rights of the Government and remedies described in the Performance Guarantee

Sections are in addition to all other rights and remedies of the Government allowed under the contract pertaining to the failure of a Contractor to meet contractually specified performance requirements.

H.5.2. The Contractor guarantees that performance will meet or exceed the standards in this section. The Government will assess performance guarantees on a monthly basis and notify the

Contractor of Performance Guarantee reductions on a quarterly basis, except as stated for H.5.9., H.5.10., and H.5.12. 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 after CO notification with explanation of application of performance guarantee(s). See Section

G, Contract Administration, paragraph G.6.3.1. Performance Guarantees, for specific instruction when a performance guarantee applies.

H.5.3. Performance Guarantee 1 - Telephone Service (Blockage Rates)

H.5.3.1. Standard. Blockage rates shall not exceed 5%

H.5.3.2. Definition. The blockage rate is the percentage of calls that are not allowed into the

Contractor’s system. This includes busy rates, forced disconnects, and calls abandoned up front.

H.5.3.3. Performance Guarantee application. For each occurrence, based on the Contractor’s monthly management report, when the blockage rate standard of 5% is not met during the evaluation period, a Performance Guarantee shall be applied as follows:

Tier Blockage Rate Performance Monthly Performance Guarantee Amount

Tier 1 5.001%-7.000% $1,250.00

Tier 2 7.001%-9.000% $1,875.00

Tier 3 Over 9.001% $2,500.00

H.5.3.3.2. 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.

H.5.4. Performance Guarantee 2 - Telephone Service (Total Hold Time)

H.5.4.1. Standard. Total “on hold” time for 95% of all calls answered by an agent shall not exceed two minutes during the entire telephone call.

H.3.4.2. Definition. The total time a call is placed on hold by an agent.

H.5.4.3. Performance Guarantee application. For each occurrence, based on the Contractor’s monthly management report, when the total hold-time performance standard is not met during the evaluation period, a Performance Guarantee shall be applied as follows:

Tier Total Hold Time Performance Monthly Performance Guarantee Amount

Tier 1 Under 91.000% $2,500.00

Tier 2 91.001%-93.999% $1,875.00

Tier 3 94.000-94.999% $1,250.00

H.5.5. Performance Guarantee 3 – Telephone Service (Transfer to an Individual from

ARU)

H.5.5.1. Standard. If transferred to an individual, 90% of all call transfers shall be answered by a LIVE agent within 30 seconds.

H.5.5.2. Definition. The total time during the call in which the caller is waiting for a LIVE agent.

H.5.5.3. Performance Guarantee application: For each occurrence, based on the Contractor’s monthly management report, when the transfer to an individual from ARU performance standard is not met during the evaluation period, a Performance Guarantee shall be applied as follows:

Tier Transfer to an Individual from ARU Monthly Performance Guarantee Amount

Tier 1 Under 85.000% $2,500.00

Tier 2 85.001%-87.999% $1,875.00

Tier 3 88.000%-89.999% $1,250.00

H.5.6. Performance Guarantee 4 - Claims Processing Timeliness (Retained Claims and

Adjustment Claims)

H.5.6.1. Standard. Not less than 98% percent of retained claims and adjustment claims shall be processed within 30 calendar days from the date of receipt.

H.5.6.2. Performance Guarantee application. For each occurrence, based on submitted TED records, when the claims processing timeliness within 30 calendar days from the date of receipt performance standard is not met during the evaluation period, a Performance Guarantee shall be applied as follows:

Tier Claims Processing w/i 30 Calendar Days

Performance

Monthly Performance Guarantee

Amount

Tier 1 Under 93.000% $3,750.00

Tier 2 93.001%-95.999% $2,500.00

Tier 3 96.000%-97.999% $1,250.00

H.5.7. Performance Guarantee 5 - Claims Processing Timeliness

H.5.7.1. Standard. 100% of all claims (both retained and excluded, including adjustments) shall be processed to completion within 90 calendar days from the date of receipt.

H.5.7.2. Performance Guarantee application. For each occurrence, based on submitted TED records, when the claims processing timeliness within 90 calendar days from the date of receipt performance standard is not met during the evaluation period a Performance Guarantee shall be

Tier Claims Processing w/i 90 Calendar Days

Monthly Performance Guarantee

Amount

Tier 1 Under 95.000% $3,750.00

Tier 2 95.001%-97.999% $2,500.00

Tier 3 98.000%-99.999% $1,250.00

H.5.8. Performance Guarantee 6 - TED Edit Accuracy

H.5.8.1. Standard. Following the start of claims processing services, the Contractor shall have the following percentages of TED records (initial submissions, resubmissions and adjustment/cancellation submissions) passing the DHA edit system at the following timelines:

• 1 through 3 months - 80%

• 4 through 6 months - 85%

• 7 through 9 months - 90%

• 10 through 11 months - 95%

• 12 through 23 months - 96%

• Month 24 through contract close - 97%

H.5.8.2. Performance Guarantee application. For each occurrence when the TED edit accuracy performance standard is not met during the evaluation period a Performance Guarantee shall be applied as follows:

TED Edit Accuracy Rate Performance Monthly Performance Guarantee Amount

Months 1-3 Under 80.000%

Months 4-6 Under 85.000%

Months 7-9 Under 90.000%

Months 10-11 Under 95.000%

Months 12-23 Under 96.000%

Month 24 through contract close – Under 97.000%

$10,000.00

H.5.9. Performance Guarantee 7 - Written Correspondence Accuracy

H.5.9.1. Standard. The Contractor shall ensure the correspondence it prepares is accurate, responsive, clear and complete.

H.5.9.2. Administration. 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.

H.5.9.3. Assessment. The Government will assess within 30 business days of completing the review, a performance guarantee of $500.00 per written response which is incomplete or inaccurate. A response is incomplete if the response does not address all items inquired about or only partially responds to an issue. A response is considered inaccurate if incorrect information is provided, the customer is misdirected, or privacy rules are not complied with. If a response is incomplete and inaccurate, only one (1) performance guarantee of $500.00 will be assessed for that piece of correspondence. For example, if the total number of pieces of written correspondence with errors (i.e., incomplete, incorrect or both) is 20. The performance guarantee would be 20 times $500.00 equals $10,000.00.

H.5.10. Performance Guarantee 8 - Telephone Response Accuracy

H.5.10.1. Standard. The Contractor shall ensure the telephonic responses provided are accurate, clear and complete.

H.5.10.2. Administration. 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.

H.5.10.3. Assessment. The Government will assess, within 30 days of completing the review, a performance guarantee of $500.00 per telephonic response which is incomplete or inaccurate. A response is incomplete if the agent does not address all items inquired about or only partially responds to an issue. A response is considered inaccurate if incorrect information is provided, the customer is misdirected, or privacy rules are not complied with. If a response is incomplete and inaccurate, only one performance guarantee of $500.00 will be assessed. For example, if the total number of telephone calls identified as providing incorrect, inaccurate or both incorrect and inaccurate information is 20, the performance guarantee would be 20 times $500.00 equals

$10,000.00.

H.5.11. Performance Guarantee 9 - Priority Correspondence Timeliness

H.5.11.1. Standard. The Contractor shall provide final responses to 100% of Priority

Correspondence within 30 calendar days of receipt.

H.5.11.2. Performance Guarantee application. For each occurrence, based on the Contractor’s monthly management report, when the priority correspondence timeliness standard is not met during the evaluation period a Performance Guarantee shall be applied as follows:

Tier Priority Correspondence w/i 30 Calendar Days

Monthly Performance Guarantee

Amount

Tier 1 Under 95.000% $3,750.00

Tier 2 95.001%-97.999% $2,500.00

Tier 3 98.000%-99.999% $1,250.00

H.5.12. Performance Guarantee 10 – Claims Processing Accuracy

H.5.12.1. Standard. 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%.

H.5.12.2. Performance Guarantee application. For each occurrence, based on the DHA quarterly claims processing accuracy compliance reviews (see H.6) when the claims processing accuracy rate standard is not met during the evaluation period a Performance Guarantee shall be

Tier Claims Processing Accuracy Rate

Quarterly Performance Guarantee

Amount

Tier 1 Over 2.000% (OP1 & 2) $100,000.00

Tier 2 Over 1.75% $100,000.00

H.6. DHA QUARTERLY CLAIMS PROCESSING ACCURACY COMPLIANCE

REVIEWS

H.6.1. TED batch/voucher payment records are utilized to validate the accuracy of claims payment and/or denial and TED record coding for this compliance review. Results from this review will be used to measure the Contractor’s claims processing performance and assess the

Contractor’s compliance with TRICARE claims processing performance standards as stipulated in TOM, Chapter 1, Section 3, Paragraph1.6.2 - Claims Occurrence Errors and Section H.5.3, and to determine Contractor compliance with TRICARE policy regulations and contract requirements.

H.6.2. DHA Quarterly Compliance Review Sampling Methodologies, Required Contractor

Documentation, Error Determinations and Error Codes, Rebuttal Procedures, Process and

Documentation Error Codes

H.6.2.1. At the time of the quarterly compliance sample pulls, TED records in batch/vouchers that have not passed TED validity edits, or which are otherwise unprocessable as submitted by the Contractor, will be excluded from that specific review sample. TED records to be sampled will be Net records (i.e., the sum of transaction records available at the time the sample was drawn related to the initial transaction record).

H.6.2.1.1. Payment Accuracy Sampling Methodology. There will be one (1) non-denied payment sample type for this compliance review. Records to be sampled will be Net records (i.e., the sum of transaction records available at the time the sample was drawn related to the initial transaction record). Payment samples will be stratified at multiple levels, either by payment amount or by other claims-based parameters, such as, type of care and/or type of provider

(variables of the stratification will be defined prior to the data pull). Samples will be drawn from all TED records with Government payment amounts greater than zero, although the Government may choose to exclude certain TED record strata from the sampling frame (i.e., TED records with a Government Payment Amount of less than $100.00). In addition, the Government will conduct a 100% review of all TED records with Government payment amounts meeting or exceeding a high dollar threshold determined by the Government (i.e., $200,000.00).

H.6.2.1.2. Denied Payment Accuracy Sampling Methodology. The Government shall review denied claims (i.e., TED records with Type of Submission equal to ‘D - denied’, C - cancelled’ or ‘O - 100% other health insurance’) with Government paid amount equal to zero, to ensure that health care services/supplies are not being denied inappropriately; to validate the correct application of other health insurance (OHI) payments that render a claim with zero Government liability and to ensure TED record cancellations are done in accordance with TRICARE policy requirements. The Government will select for review 100% of all denied TED records with a

Government billed amount meeting or exceeding a high dollar threshold determined by the

Government (i.e., $100,000.00). TED records with billed amounts below a low dollar threshold

(i.e., $100.00) may be excluded. TED records with billed amounts between the high dollar and low dollar thresholds will be stratified and randomly selected for review.

H.6.2.1.3. Occurrence Review Sampling Methodology. There will be one (1) sample type for this compliance review. The occurrence sample will be drawn from TED records which passed

TED validity edits. The sample universe will include TED records for denied and non-denied payment types. For each compliance review cycle, the Government will randomly select up to

350 TED records for review.

H.6.2.2. Required Contractor Documentation. On a quarterly basis, the Government will transmit a list of TED records selected from each sample type (i.e., payment, denied payment and occurrence) to be reviewed by the Government’s designated compliance review Contractor.

Upon receipt of the TED record Internal Control Number (ICN) listing from DHA, the

Contractor shall retrieve and compile claims processing documentation for each selected TED record. All documentation must be received at DHA or the designated compliance review contractor within 45 calendar days from the date of the DHA letter transmitting the ICN listing.

The Contractor shall submit one (1) legible copy of each health care claim form (i.e., CMS 1500, UB 92/04, etc.)

associated with the selected TED record and the following required documents. Required documentation includes, but is not limited to, the following:

a. Claim-related correspondence, when attached to claim or related to the adjudication action, such as status inquiries, written and/or telephone, development records and other telephone conversation records

b. Other claim-related documentation, such as medical reports and medical review records, coding sheets, all authorization and referral forms and their supporting documentation, referrals for civilian medical care (e.g., Standard Form (SF) 513 or

2161), other health insurance and third-party liability documents, discounted rate agreements to include the following information:

1. Provider name and identification number

2. Effective and termination dates of agreements

c. Negotiated rate(s), per diem rate(s), state prevailing fee(s) or fee schedule(s), Diagnosis Related Group (DRG), Hospital Outpatient Prospective Payment System

(OPPS), Skilled Nursing Facility (SNF), pricing information and such other documents as are required to support the reimbursement action(s) taken on the claim

d. Copy of the Explanation of Benefits (EOB) (or EOB facsimile) for each claim selected

e. Documentation to support DHA or Contractor approved beneficiary participation in any DHA demonstration program

f. Any additional documentation that supports the adjudication of selected claim

Documentation shall be electronically transmitted in the agreed upon file format as stipulated in the Memorandum of Understanding (MOU) established between the Contractor and the designated compliance review contractor (CDRL A100).

H.6.2.2.1. In addition to the above listed claims processing documentation, the Contractor shall also send, via electronic data input, the current patient/family history (15 to 27 months) for each selected claim. This electronic data file shall be formatted and transmitted in accordance with the guidelines described in the MOU established between the contactor and the designated compliance review contractor (CDRL A100) and shall contain all agreed to and required data fields. The data file must be received by the DHA or the designated compliance review contractor within 45 calendar days from the date of the DHA ICN transmittal letter (reference

H.4.2.2 above).

H.6.2.2.2. Additional Data to Be Furnished by The Contractor - Claims Processing

Guidelines And Instructions.

a. Description of data element by field position in the patient/family history file printouts and field definitions for pricing, Other Health Insurance (OHI), authorization and/or referral screens, etc.

b. Claims adjudication guidelines used by processors; field definitions for any claims processing screen furnished (i.e., automated prepayment utilization review screens, automated duplicate screening criteria, etc.) and manual resolution instructions

c. Unique internal procedure codes with narrative and cross-reference to approved

TRICARE codes and pricing manuals used in claims processing

d. Documentation to support beneficiary approved participation in any TRICARE demonstration program(s) if applicable

Initial submission of documentation is due to the DHA by the commencement of claims processing with the submission of revisions as they occur, by not later than the fifth workday of the month following the change.

H.6.2.2.3. The Contractor shall provide, for any claim selected with adjustment transactions completed prior to the date of the TED record sample, documentation to support both the initial and adjustment processing actions, to include claims EOBs and pricing documentation.

H.6.2.3. Payment, Denied Payment and Occurrence Error Determinations

H.6.2.3.1. Payment/Denial Payment Accuracy Error Determinations. Payment errors are based on the claim information available and those processing actions taken up to the time the compliance review sample is pulled. Consideration will be given to subsequent processing actions that occur prior to the date the compliance review sample is pulled, including actions that have not passed the TED validity edits, only if supporting documentation to indicate the action taken and the date the action was completed is submitted. Actions and determinations occurring after the date the compliance review sample is pulled will not be considered in the compliance review described in this section regardless of whether resolution of a payment error exists.

H.6.2.3.1.1. There are two (2) categories of payment errors: (1) a payment error which cannot be removed by Contractor post payment processing actions and (2) a payment error which can be removed by Contractor post payment processing actions (see list of compliance review error codes defining payment error categories). Payment errors which can be removed by Contractor post payment actions will also be assessed a process error at review. If Contractor post payment actions substantiate the initial processing decision; the payment error will be removed but the process error will remain. If the initial processing action is not substantiated, both the payment and the process error will remain. Claims containing process errors will not affect payment or occurrence error rates, but will be used as a performance indicator as to the Contractor meeting compliance review documentation requirements.

H.6.2.3.1.2. Payment errors are the amount of overpayments/underpayments on a claim, including but not limited to, misapplication of the deductible, payment of non-covered services/supplies, payment of services/supplies for which a benefit cannot be determined based on the information available at the time of processing, payment in the correct amount but sent to the wrong payee, the denial of a payable claim, an incorrect denial based on patient/sponsor ineligibility, the incorrect denial of a claim for duplicate services/procedures or services incorrectly denied as non-covered for which a benefit determination cannot be based on the information available at the time of processing. The measure of the payment error is the TED record.

H.6.2.3.1.3. Process errors (reference H.4.2.5. below) result from noncompliance with a required procedure or process, such as development required but not performed, medical emergency not substantiated, medical necessity review not evident and is cited in conjunction with a payment error (K codes listed below). Process error determinations are based on the claim information available and those processing actions which have passed the TED validity edits up to the time the review sample is pulled.

H.6.2.3.1.4. Payment errors will be assessed if a claim is selected for review and the Contractor cannot produce the claim or the claim provided is not auditable. For TED records that do not represent a legitimate condition requiring submission of a record as defined in the TRICARE

Systems Manual (TSM), a 100% error will be assessed. This condition is considered to be an unsupported TED. The payment error amount(s) will be based on either the institutional TED data field - Amount Paid by Government Contractor (TOTAL) or the non-institutional TED data field - Amount Paid by Government Contractor by Procedure Code, as submitted by the

Contractor. The Contractor has the option of submitting the original document in those cases where the copy is not legible. DHA or the designated compliance review Contractor will return the original documents upon completion of the compliance review process.

H.6.2.3.1.5. Computation Of the Total Amount Billed for Non-Denied Institutional Claims.

For treatment encounters for which no per diem, negotiated rate or DRG-based amount applies for consideration of payment, the Total Amount Billed is the actual amount billed on the claim as it appears on the TED record. This applies to treatment encounters involving services from

DRG-exempt hospitals and hospital units, those involving DRG-exempt services and those which would otherwise be subject to the DRG-based payment methodology but for which a

DRG-allowed amount cannot be computed, regardless of whether or not these claims are paid.

H.6.2.3.1.6. For treatment encounters subject to the TRICARE per diem payments, negotiated rate or the DRG reimbursement methodology, the Total Amount Billed is the correct per diem, negotiated rate or DRG-based allowable amount including any applicable outlier amounts.

H.6.2.3.1.7. Payment Error Codes. The following are payment errors that can be assessed during payment and/or denied payment compliance reviews and on which post payment actions are either not applicable or would not remove the payment errors assessed.

Error

Codes

Error Code Definition

03K Billed Amount Incorrect

04K Cost-Share/Deductible Error

07K Duplicate Services Paid

08K Eligibility Determination – Patient

09K Eligibility Determination – Provider

12K Non-Availability Statement Error

13K Other Health Insurance (OHI) / Third Party Liability (TPL) – Government Payment

Miscalculated

14K OHI Payment Omitted

15K Payee Wrong – Sponsor/Patient

16K Payee Wrong – Provider

17K Participating/Non-Participating Error

18K Pricing Incorrect

19K Procedure Code Incorrect

20K Signature Error

22K DRG Reimbursement Error

24K Incorrect Benefit Determination

25K Claim Not Provided

26K Claim Not Auditable

27K Incorrect MCS System

28K Point of Service Miscalculated/Omitted

50K Pricing Incorrect – CPT/HCPCS/CMAC/Fee Schedule Allowed Amount

Miscalculated

51K Pricing Incorrect – OPPS Reimbursement Rate Miscalculation

52K Pricing Incorrect – HHS Reimbursement Rate Miscalculation

53K Pricing Incorrect – Critical Access Hospital Reimbursement Rate Miscalculated

54K Pricing Incorrect – Residential Treatment Center (RTC) Per Diem Rate

Miscalculated

55K Pricing Incorrect – Long Term Care Facility Per Diem Rate Miscalculated

56K Pricing Incorrect – Substance Abuse Treatment Facility Per Diem Rate

Miscalculated

57K Pricing Incorrect – Skilled Nursing Facility (SNF) Per Diem Rate Miscalculated

58K Pricing Incorrect – Hospice Per Diem Rate (Inpatient) Miscalculated

59K Pricing Incorrect – Hospice Per Diem Rate (Outpatient) Miscalculated

60K Pricing Incorrect – Professional/Technical Component Rate Miscalculated

61K Pricing Incorrect – Provider Discount Rate Miscalculated/Not Applied

62K Pricing Incorrect – Blended Rate Allowed Amount Miscalculated/Not Applied

63K Pricing Incorrect – Locality Based Waiver Miscalculated/Not Applied

64K Pricing Incorrect – Claim Incorrectly Paid as Billed (PAB)

65K Pricing Incorrect – DMEPOS Fee Schedule – Incorrect rate/information used

66K Pricing Incorrect – Number/Units of Service Miscalculated

67K Pricing Incorrect – Multiple Surgery

68K Pricing Incorrect – Inpatient Psych Hospital Per Diem Rate Miscalculated/Not

Applied

69K Pricing Incorrect – Reimbursement Rate for SCH Miscalculated/Not Applied

70K Pricing Incorrect – AMBi Surg Miscalculated

71K Pricing Incorrect – Overseas Exchange Rate Miscalculated/Not Applied

72K Pricing Incorrect – Lesser of Reimbursement Logic Miscalculated/Not Applied

73K Pricing Incorrect – Outpatient Hospital Claim Incorrectly Processed

74K

Pricing Incorrect – Ambulance Service (Air/Ground) – Reimbursement Rate

Miscalculated

75K Pricing Incorrect – Anesthesia Pricing Miscalculated

H.6.2.3.1.8. The following are payment errors that can be assessed during payment and/or denied payment compliance reviews, in which post-payment actions may support original processing. On rebuttal, if documentation is provided that supports the processing actions, the payment errors could be removed but process errors (P codes) would remain (reference H.4.2.5.

below).

Codes

Error Code Description

01K

Authorization/Pre-Authorization needed (all except the Extended Care Health

Option (ECHO) and Adjunctive Dental Authorizations)

02K Unsupported Benefit Determination

05K Development Claim Denied Prematurely

06K Development Required

10K Medical Emergency Not Substantiated

11K Medical Necessity/Review Not Evident

21K Timely - Filing Error

23K Contract Jurisdiction Error

99K

Other - This payment error is very general, and claims would have to be reviewed on an individual basis with regard to post-payment actions.

H.6.2.3.2. Occurrence Error Determinations. Occurrence error determinations are based on only the claim information available and those processing actions taken at the time of adjudication. Actions and determinations occurring subsequent to the processed date of a reviewed claim, such as obtaining other health insurance documentation, adjusting a claim to correct financial or other data fields or developing for required information not obtained prior to processing are not a consideration of the compliance review regardless of whether a resolution of the incorrectly coded TED record results.

H.6.2.3.2.1. Occurrence Errors Result from an Incorrect Entry in Any Data Field of The

TED record. There are no exceptions. Any error, including errors in financial fields, shall be counted as occurrence errors. Some TED record error conditions are not attributed to any one specific data field but apply to the record as a whole or to certain parts of the record. In addition to erroneous data field coding, incorrect or unsupported records can result in occurrence errors being assessed as indicated.

H.6.2.3.2.2. Occurrence Error Codes. The following are occurrence error categories and codes.

All TED record occurrence errors, including errors in financial fields are counted and the error rate is expressed as a percentage of the total number of data fields in the TED record. The TED record occurrence error rate is defined as the total number of errors divided by the total number of data fields in the sample times 100.

Categories

Error Condition Specific to Data Field

A Incorrect Claim Information

B Incorrect Patient/Sponsor Information

C Incorrect Provider Information

D Incorrect Admission/Discharge Information (Institutional TED Record)

E Incorrect Diagnosis/Treatment Information (Institutional TED Record)

F Incorrect Diagnosis Information (Non-Institutional TED Records)

G Incorrect Financial Information

H Incorrect Institutional Revenue Data

I Incorrect Non-Institutional Claims/Provider/Utilization Error

Code

Error Condition Specific to Claim

Number of Errors

01J

Unlike Procedures/Providers Combined

(Non-Institutional Record)

7 errors for each additional utilization data set*

02J

Unlike Revenue Codes Combined

(Institutional Record)

5 errors for each erroneous revenue code set**

03J

Services Should be Combined

1 error for each additional revenue code/utilization

04J

Missing Non-Institutional Utilization Data

Set

7 errors for each missing data set*

05J Extra Non-Institutional Utilization Data Set 7 errors for each missing data set*

06J

Missing Institutional Revenue Code Set

5 errors for each missing revenue code set**

07J

Extra Institutional Revenue Code Set

5 errors for each missing revenue code set**

08J Incorrect Record Type 5 errors

09J Separate TED Record Required 1 error

10J

Claim Not Provided for Audit

1 error plus 1 error for each revenue code utilization data set in the TED

11J

Claim Not Auditable

12J

Unsupported TED Transaction

* Not to exceed 21 errors for combination of these error conditions

** Not to exceed 15 errors for combination of these error conditions

H.6.2.4. Quarterly Compliance Review Rebuttal Procedures. Contractor rebuttals of initial payment or occurrence error findings must be submitted electronically to DHA or designated compliance review contractor within 30 calendar days of the date of the DHA transmittal letter and in accordance with the established MOU (reference H.4.2.2). Rebuttal comments not received by DHA or the designated compliance review contractor within 30 calendar days of the transmittal letter will be excluded from further consideration. Rebuttal error determinations are considered final and will not receive further consideration except when during the rebuttal process the Contractor submits a claim not previously submitted with the initial claims compliance review process and an error is assessed on rebuttal, or when the Contractor’s rebuttal explanation of the basis on which a claim was processed results in the assessment of a new error not previously reviewed by the Contractor. Contractor rebuttal responses to new errors must be received by DHA or the designated compliance review contractor within 30 calendar days of the

DHA transmittal letter. Rebuttal comments to new errors not submitted within 30 calendar days from the date of the DHA transmittal letter will be excluded from further consideration.

H.6.2.4.1. The due dates of the Contractor’s rebuttal comments will be calculated by adding 30 days to the Julian calendar date of the DHA rebuttal transmittal letter or by adding 30 days to the

Julian calendar date of the DHA second rebuttal transmittal letter.

H.6.2.5. Process Error Codes. Process errors result from noncompliance with a required procedure or process, such as, development required but not performed, medical emergency not substantiated, medical necessity review not evident and are cited in conjunction with a payment error. Process error determinations are based on the claim information available and those processing actions which have passed the TED validity edits up to the time the audit sample is pulled.

H.6.2.5.1. The following are process errors which will be assessed for noncompliance of a required procedure/process. These errors are neither payment errors nor occurrence errors and are not used to calculate the payment error or occurrence error rate. A process error (P code) can be assessed along with a payment error (K code). Upon rebuttal, if the process is followed to conclusion and the actions support the original decision, the payment error will be removed but the process error will remain.

Error Code Error Code Definition

01P Authorization/Pre-authorization needed (ECHO and adjunctive dental authorizations)

02P Unsupported Benefit Determinations

05P Development Claim Denied Prematurely

06P Development Required

10P Medical Emergency Not Substantiated

11P Medical Necessity/Review Not Evident

21P Timely Filing Error

23P Contract Jurisdiction Error

99P Other

H.6.2.6. Documentation Error Codes. The following are documentation errors which will be assessed to document the Contractor’s documentation problems which impact the compliance review process or indicate a situation of contractual non-compliance which is identifiable during the compliance review and requires follow-up corrective action. These errors are neither payment errors nor occurrence errors and are not used to calculate the payment error or occurrence error rates.

Error Code Error Code Definition

01L Audit documentation incomplete

02L Audit documentation illegible

03L Documentation submitted late

04L EOB incorrect

05L CA/NAS Questionable

06L Error in claims history

07L Reserved

08L Erroneous claim split

09L Erroneous TED record split

10L Adjustment – no authorizing official

11L Contract jurisdiction error

H.7. PERFORMANCE METRICS

H.7.1. Associated performance data will be reported by contractors through CDRLs and monitored with the Quality Assurance Surveillance Plan (QASP) by the Government for the purposes of incentive payments, performance guarantees and will be used as a source for

Contractor Performance Assessment Report (CPAR) ratings. Meeting the Governments acceptable quality level (AQL) is typically considered satisfactory performance.

H.7.2. Contractors may propose an ability to exceed the AQL. The higher AQL may be added, as proposed to the contract. The new AQL will be the minimally accepted rate used for the purposes of incentive payments, performance guarantees and will be used to determine a CPAR rating. Meeting the revised AQL is typically considered satisfactory performance.

H.7.3. Standards Calculation Language

H.7.3.1. For Government performance standards represented as percentages, each Contractor calculated performance standard percentage shall meet or exceed the respective Government contract performance standard to the thousandths of a percent to remain in compliance with the contract.

H.7.3.2. To ensure consistent practices for reporting of performance standards stated as percentages, all Contractor performance standard calculations and reporting shall be carried out to the thousandths decimal place and all digits following the thousandths decimal place shall be dropped.

H.7.4. Performance Standards

Monthly Standards Monitoring Method Reference (i.e., 2.1.2, 2.1.6, 2.1.10, 2.2.5)

Processed reversed appeal determinations Monthly CDRL TOM, Chapter 1, Section 3, para 7.4

Processed factual reconsiderations within 30 calendar days Monthly CDRL TOM, Chapter 1, Section 3, para 7.3

Processed factual reconsiderations within 60 calendar days Monthly CDRL TOM, Chapter 1, Section 3, para 7.3

Processed medical necessity reconsiderations within 30 calendar days

Monthly CDRL TOM, Chapter 1, Section 3, para 7.2

Processed medical necessity reconsiderations within 60 calendar days

Monthly CDRL TOM, Chapter 1, Section 3, para 7.2

Processed all claims within 90 calendar days Monthly CDRL TOM, Chapter 1, Section 3, para 6.3

Processed retained claims within 30 calendar days Monthly CDRL TOM, Chapter 1, Section 3, para 6.2

Unprocessable vouchers and/or batches: 3 months following start work

Monthly TED Reports TOM, Chapter 20, Section 1, para xxx

TED Edit Accuracy Rate Monthly TED Reports TOM, Chapter 20, Section 1, para xxx

Unprocessable vouchers corrected

& returned within 20 calendar days Monthly TED Reports TOM, Chapter 20, Section 1, para xxx

TED resubmissions returned within

30 calendar days Monthly TED Reports TOM, Chapter 20, Section 1, para xxx

TED resubmissions returned within

45 calendar days Monthly TED Reports TOM, Chapter 20, Section 1, para xxx

Initial vouchers submission Monthly TED Reports TOM, Chapter 20, Section 1, para xxx

Unprocessable vouchers corrected

& returned w/i 30 calendar days Monthly TED Reports TOM, Chapter 20, Section 1, para xxx

Grievances processed Monthly CDRL TOM, Chapter 1, Section 3, para 3.2.4

Issued pre-authorizations and authorizations within 2 calendar days

Monthly CDRL TOM, Chapter 1, Section 3, para 5.1

Issued pre- authorizations and authorizations within 5 calendar days

Monthly CDRL TOM, Chapter 1, Section 3, para 5.1

Respond to priority correspondence within 10 calendar days Monthly CDRL TOM, Chapter 1, Section 3, para 3.2.3.2

Respond to priority correspondence within 30 calendar days Monthly CDRL TOM, Chapter 1, Section 3, para 3.2.3.2

Respond to routine correspondence within 15 calendar days Monthly CDRL TOM, Chapter 1, Section 3, para 3.2.2.2

Respond to routine correspondence within 30 calendar days Monthly CDRL TOM, Chapter 1, Section 3, para 3.2.2.2

Respond to routine correspondence within 45 calendar days Monthly CDRL TOM, Chapter 1, Section 3, para 3.2.2.2

Blockage rate Monthly CDRL TOM, Chapter 1, Section 3, para 3.2.1

The average time elapsed between

INITIATED telephone ringing and connection with the Automated

Response Unit (ARU)

Monthly CDRL TOM, Chapter 1, Section 3, para 3.2.1

If transferred to an individual, call transfers from ARU shall be answered by a live agent within 30 seconds

Monthly CDRL TOM, Chapter 1, Section 3, para 3.2.1

Call abandonment rate Monthly CDRL TOM, Chapter 1, Section 3, para 3.2.1

Total “on-hold” time of all calls shall not exceed two minutes during the entire telephone call

Monthly CDRL TOM, Chapter 1, Section 3, para 3.2.1

All calls answered by an agent shall achieve resolution in one call Monthly CDRL TOM, Chapter 1, Section 3, para 3.2.1

All calls not fully and completely resolved on the initial call shall be fully and completely resolved to the customer’s satisfaction within 10 business days

Monthly CDRL TOM, Chapter10, Section 3, para 3.2.1

Potential duplicate claims in open status

Monthly Government

Report TOM, Chapter 1, Section 3, para 6.4.2

First pass auto-adjudication Monthly CDRL TOM, Chapter 1, Section 3, para 6.5.2

Claims reprocessing Monthly CDRL TOM, Chapter 1, Section 3, para 6.5.3

Quarterly Standards Monitoring Method Reference

Payment error rate (first two option periods)

Quarterly Claims

Processing Accuracy

Compliance Review

(H.4)

TOM, Chapter 1, Section 3, para 6.5.1

Payment error rate (all remaining option periods)

Quarterly Claims

Processing Accuracy

Compliance Review

(H.4)

TOM, Chapter 1, Section 3, para 6.5.1

Government beneficiary satisfaction results

Quarterly - Report conducted and provided by independent contract

Section H.2.3. and Section J, Attachment

J-2

H.8 ORGANIZATIONAL CONFLICTS OF INTEREST (OCI)

H.8.1. The Contractor’s attention is directed to FAR, Subpart 9.5, “Organizational and

Consultant Conflicts of Interest.” DHA has made a determination that an actual or significant potential organizational conflict of interest exists, or the nature of the work to be performed may create an actual or significant potential organizational conflict of interest in future acquisitions.

H.8.2. For the purpose of these clauses, the term “Contractor” means the contractor, its subsidiaries, affiliates, partners, market consultants, as defined by FAR, Subpart 9.501, or any of its successors or assignees.

H.8.3. The contractor will perform all tasks contained within this contract. To avoid conflicts which may create bias ground rules, impair the Contractor’s objectivity, or give the Contractor an unfair competitive advantage, the Contractor shall notify the Government should a potential conflict arise or when the contractor plans to bid on a similar contract with DHA that could create conflict.

H.8.4. It may become necessary in the performance of this contract to review proprietary information from other contractors. The Contractor shall protect all proprietary information from unauthorized use or disclosure and refrain from using the information for any purpose other than that for which it was furnished. At the request of the Contracting Officer, the Contractor agrees to execute agreements with third party companies furnishing data in connection with work performed under this contract. Safeguards shall be implemented to restrict access to proprietary information and to avoid, neutralize, or mitigate potential conflicts of interest. Non-disclosure agreements shall be completed by the Contractor, all employees, and subcontractors who obtain access to proprietary information, and provided to the Contracting Officer.

H.8.5. The Contractor agrees that if an actual or potential organizational conflict of interest is discovered after the award of this contract, the Contractor will immediately notify the

Contracting Officer, in writing, of the nature of the conflict. The Contractor shall submit a mitigation plan to the Contracting Officer within 30 days of notification, outlining the actions the

Contractor has taken or proposes to take to avoid, neutralize, or mitigate the actual or potential organizational conflict of interest.

H.8.6. The above restrictions shall be included in all subcontracts, teaming arrangements, and other agreements calling for performance of work which is subject to the organizational conflict of interest restrictions identified in these clauses.

H.8.7. The Contractor acknowledges the full force and effect of the above clauses. The

Government reserves the right, in case of a breach, misrepresentation or nondisclosure, to terminate this contract, disqualify the Contractor from subsequent related contractual efforts, or pursues any remedy permitted by law or this contract.