SECTION C

PERFORMANCE WORK STATEMENT (PWS)

C.1. Purpose:

The Department of Defense (DoD) through the Defense Health Agency (DHA) has a mission to offer worldwide dental care services to eligible Active Duty Service Members (ADSMs) through its Active Duty Dental Program’s fourth generation contract (ADDP-4). The Contractor shall provide worldwide dental coverage to ADSMs of the Uniformed Services of the U.S. Army, the U.S. Navy, the U.S. Air Force, the U.S. Marine Corps, U.S. Space Force, U.S. Coast Guard, Commissioned Corps of the National Oceanic and Atmospheric Administration (NOAA), and the Commissioned Corps of the Public Health Service (PHS). ADSMs also consist of eligible members of the Reserves and National Guard, Reserve Component members with delayed activation orders or discharged after serving more than 30 days on active duty in support of a contingency operation or a preplanned mission. PHS Reservists are not eligible. Additionally, ADSMs may consist of Foreign Forces Members (FFMs) eligible for care pursuant to an approved agreement (e.g. reciprocal health care agreement, North Atlantic Treaty Organization (NATO) Status of Forces Agreement (SOFA), Partnership for Peace (PFP)). For the purposes of this contract, reference to “ADSMs” are defined as the service members covered by ADDP-4.

C.1.1. The Contractor shall provide all personnel, equipment, supplies, facilities, transportation, tools, materials, supervision, and other item and non-personal services necessary to fulfill the requirements of ADDP-4.

C.1.2. Contract Objectives:

C.1.2.1. Objective 1 – Dental Services. The Contractor shall provide worldwide, cost-effective dental care services for enrolled ADSMs utilizing diagnostic and preventive services when ADSMs are referred for private sector care.

C.1.2.2. Objective 2 – Dental Administration. The Contractor shall establish data systems in which to monitor usage and outcome measures for all dental care rendered.

C.1.2.3. Objective 3 – Claims Processing. The Contractor shall timely and accurately process claims and reimburse providers.

C.1.2.4. Objective 4 - Customer Service. The Contractor shall provide accessible customer service in accordance with TRICARE Operations Manual (TOM).

C.1.2.5. Objective 5 – Transition. Provide evidence that all services and systems have been fully tested during the transition-in period.

C.1.3. APPLICABLE LAW, REGULATIONS, & DIRECTIVES. The following documents are hereby incorporated by reference and form an integral part of this contract and have the same force and effect as if set forth in full text.

• Title 10, United States Code (U.S.C.), Chapter 55, Section 1074(c)(1).

• 32 Code of Federal Regulations (CFR) Part 199.1, 199.3, 199.6, 199.9.

• 36 CFR Part 1222 (data created or received and maintained for the Government by

Contractors).

• 45 CFR Parts 160, 162 and 164 (the Health Insurance Portability and Accountability Act

(HIPAA) of 1996 security and privacy standards, transaction and code set standards, National Provider Identifier [NPI] requirements and implementation specifications).

• TRICARE Policy Manual (TPM) 6010.30-M, April 2021, through change 49.

• TRICARE Systems Manual (TSM) 7950.4-M, April 2021, through change 29, with the exception of the TRICARE Encounter Data (TED), as this does not apply to ADDP.

• TRICARE Operations Manual (TOM) 6010.62-M, April 2021, through change 50.

• National Institute of Standards and Technology (NIST) Special Publications (SP) 800-

171.

• Privacy Act Program Requirements (DoD 5400.11-R)

• Personnel Security Program (DoD 5200.2-R).

C.2. CONUS Dental Services. The Contractor shall supplement ADSM care provided in the DoD’s Dental Treatment Facilities (DTFs), as well as provide care to those ADSMs living in regions without access to DTFs. The Contractor shall supplement authorized care by developing and maintaining a dental provider network in the 50 United States, District of Columbia, U.S.

Virgin Islands, Guam, Puerto Rico, American Samoa, and the Northern Mariana Islands. For purposes of this contract, these regions will be referred to collectively as “CONUS.” For the purposes of this contract, the term “OCONUS” shall include all other countries, island masses, and territorial waters. The Contractor shall supplement authorized OCONUS remote care by developing and maintaining agreements with TRICARE OCONUS Preferred Dentists (TOPDs).

C.2.1. OCONUS Remote Dental Services. Under ADDP, the Contractor shall provide OCONUS routine, urgent, and emergency dental care services to ADSMs who are enrolled in remote areas (greater than 50 miles from the nearest Military Treatment Facility (MTF) capable of providing dental care services). The Kingdom of Bahrain, Honduras, Kuwait, and Souda Bay, Greece, areas are exceptions. For these locations, ADSMs do not have to be enrolled as a remote ADSM in order to receive care. Additionally, the Contractor shall provide OCONUS urgent and emergency dental care to ADSMs who are on Temporary Duty/Temporary Additional Duty (TDY/TAD), deployed, or in an authorized leave status in a remote overseas location.

C.3. GENERAL REQUIREMENTS.

C.3.1. Contract Management and Administration. The Contractor shall establish clear organizational lines of authority and responsibility to ensure adequate, effective resources are assigned to the contract requirements. The Contractor shall have primary and alternate points of contact who are authorized to negotiate with the Government and commit to contract implementation and compliance (see Section G.2.5.). The Contractor shall notify the Government within 5 business days of personnel changes to the Contractor’s leadership (e.g.

president, vice president, etc.) and/or any changes to the primary and alternate points of contact.

C.3.1.1. The Contractor shall establish and maintain effective management strategies, staff education and training programs, lines of authority, and reporting and coordination interfaces with the Government. The Contractor shall comply with the directives cited in paragraph C.3., Applicable Directives.

C.3.2. Out of Office and Closures. The Contractor shall notify the Government when its primary and alternate points of contact will be out of the office for a full day or more. The Contractor shall notify the Government when it or its Subcontractors have scheduled or unscheduled closures of their offices.

C.3.3. Proper Identification of Contractor Personnel. Contractors, including Subcontractors at all tiers, shall provide for a clear distinction from Government personnel. Contractor employees shall not act, advertise, or presume to be Government employees, agents, or representatives. Contractor employees are required to appropriately identify themselves as Contractor employees at all times, including in telephone conversations, formal and informal written correspondence, paper and electronic, and in any other situation where their actions could be construed as acts of Government officials, unless, in the judgment of the Government, no harm can come from failing to identify themselves. Contractor employees shall be introduced as Contractor personnel and display distinguishing visible identification at all times whether in conversations, meetings, or other forms of communication with Government personnel.

C.3.3.1. Contractor personnel, while performing in a Contractor capacity, shall refrain from using their retired or reserve component military rank or title (if applicable) in written or verbal communications associated with the contracts for which they provide services.

C.3.4. Government and Contractor Visits/Meetings. Generally, the Government will provide a 14-day notice for all meetings hosted by DHA at one of its Government locations. The Government anticipates hosting approximately 4 meetings per Option Period (OP). These meetings are in addition to those stated Section J, Attachment J-13, Transition-In; and Attachment J-14, Transition-Out and Residual Services. All Contractor travel costs associated with any of these meetings shall be the responsibility of the Contractor.

C.4. PERFORMANCE REQUIREMENTS.

C.4.1. The Contractor shall provide worldwide dental care services for ADSMs.

C.4.2. The Contractor shall comply with the most current version of American Dental Association's (ADA) Current Dental Terminology (CDT) manual for covered services and update its required systems.

Performance Standards C.4.2.1. Standard: Whenever the ADA issues an updated CDT manual, the Contractor shall identify CDT codes to be added, deleted and/or revised for Section J, Attachment J-2, Benefits, Exclusions and Limitations. The Contractor shall provide the DHA Dental Program Section with its recommended changes for approval. The ADA updates CDT codes approximately once a year and the revisions are effective January 1 of the following year (see Section H.2, Current Dental Terminology).

C.4.2.1.1. Acceptable Quality Level (AQL): The Contractor shall submit its CDT recommendation within 30 calendar days of the release of the ADA’s updated CDT manual.

C.4.2.2. Standard: The Contractor shall update its systems to reflect the DHA Dental Program Section’s approved CDT code changes no later than January 1 of the following year.

C.4.2.2.1. AQL: System updates shall be completed no later than January 1 100% of the time.

C.4.3. The Contractor shall process remote ADSMs’ enrollments.

Performance Standards C.4.3.1. Standard: The Contractor shall process remote ADSMs’ enrollment actions in accordance with TSM, Chapter 3; and Section J, Attachment J-3a, Program Operations.

C.4.3.1.1. AQL: 99% of remote ADSM enrollment actions shall be accurate and complete, and within 5 business days of receipt of the updated information.

Deliverables Management Report

C.4.4. The Contractor shall provide and maintain access to general and specialty network providers for ADSMs. Network compliance shall be determined based off the network provider’s fixed structure location. “Driving miles” do not include alternative means of transportation (e.g. ferries, trains, or planes) in order for the beneficiary to access the provider’s office.

• “Rural” is defined as less than 1,000 residents per square mile.

• “Suburban” is defined as 1,000 to 3,000 residents per square mile.

• “Urban” is defined as more than 3,000 residents per square mile.

See Section H.6.1., Network Provider Retention incentive, and Section J, Attachment J-3a, Program Operations for provider requirements.

Performance Standards C.4.4.1. Standard: The Contractor shall establish networks for general dental care in the 50 United States, District of Columbia, U.S. Virgin Islands, Guam, Puerto Rico, American Samoa, and the Northern Mariana Islands.

C.4.4.1.1. AQL: For Rural: 97% of ADSMs shall have access to two general dentists within 15 business days of requesting a periodic or initial (non-emergency) appointment and within 35 driving miles of ADSM DTF referred care and place of residence for remote ADSMs (annual guarantee).

C.4.4.1.2. For Suburban: 97% of ADSMs shall have access to two general dentists within 15 business days of requesting a periodic or initial (non-emergency) appointment and within 15 driving miles of ADSM DTF referred care and place of residence for remote ADSMs (annual guarantee).

C.4.4.1.3. For Urban: 97% of ADSMs shall have access to one general dentist within 15 business days of requesting a periodic or initial (non-emergency) appointment and within 5 driving miles of ADSM DTF referred care and place of residence for remote ADSMs (annual guarantee).

C.4.4.2. Standard: The Contractor shall establish networks for specialty dental care in the 50 United States, District of Columbia, U.S. Virgin Islands, Guam, Puerto Rico, American Samoa, and the Northern Mariana Islands.

C.4.4.2.1. AQL: 90% of ADSMs shall have access to an orthodontist within 15 business days of requesting an appointment and within 35 driving miles of ADSM DTF referred care and place of residence for remote ADSMs (annual guarantee).

C.4.4.2.2. 95% of ADSMs shall have access to an oral surgeon within 15 business days of requesting an appointment and within 35 driving miles of ADSM DTF referred care and place of residence for remote ADSMs (annual guarantee).

C.4.4.2.3. 85% of ADSMs shall have access to an endodontist within 15 business days of requesting an appointment and within 35 driving miles of ADSM DTF referred care and place of residence for remote ADSMs (annual guarantee).

C4.4.2.4. 85% of ADSMs shall have access to a periodontist within 15 business days of requesting an appointment and within 35 driving miles of ADSM DTF referred care and place of residence for remote ADSMs (annual guarantee).

C.4.4.2.5. 60% of ADSMs shall have access to a prosthodontist within 15 business days of requesting an appointment and within 35 driving miles of ADSM DTF referred care and place of residence for remote ADSMs.

C.4.4.3. Standard: The contractor shall maintain a network provider retention rate in accordance with Section J, Exhibit B, Contract Data Requirements List (CDRL) M050, Provider Network Access Report. For OP 1 the COR will validate the baseline 6 months after start of dental care delivery. The baseline shall be reset at the beginning of each OP, and the Contracting Officer Representative (COR) will re-validate at the end of the OP.

C.4.4.3.1. AQL: 95% of network providers shall be retained annually.

Deliverables Provider Network Access Report

C.4.5. The Contractor shall develop, maintain and make available to ADSMs, providers and Government representatives an up-to-date directory of network providers.

Performance Standard C.4.5.1. Standard: The Contractor shall post the updated directory on the Contractor’s website in accordance with Section J, Attachment J-3a, Program Operations.

C.4.5.1.1. AQL: 100% updated within 5 business days of receipt of the updated information.

C.4.5.2. Standard: The Contractor shall conduct an audit of the directory for accuracy.

Deliverables Provider Network Access Report

C.4.6. The Contractor shall develop and maintain agreements with TRICARE OCONUS Preferred Dentists (TOPDs).

Performance Standards C.4.6.1. Standard: The Contractor shall complete agreements with existing providers identified by the Government and for any new providers identified each option period in accordance with Section J, Attachments J-3b, Program Operations for OCONUS; and J-13, Transition-In.

C.4.6.1.1. AQL: The Contractor shall complete agreements with 95% of those existing providers identified by the DHA COR prior to OP 1 and any new providers identified throughout each option period.

C.4.6.2. Standard: The Contractor shall make available to ADSMs, TOPDs and Government representatives an up-to-date list of TOPDs in accordance with Section J, Attachment J-3b, Program Operations for OCONUS.

C.4.6.2.1. AQL: 100% updated within 5 business days of receipt of the updated information.

Deliverables Transition-In Status Report Management Report MOU with TRICARE Overseas Program (TOP) Contractor

C.4.7. The Contractor shall provide an annual report of each TOPD provider’s utilization rate per

OP.

C.4.8. OCONUS dental practices shall be reviewed by the Contractor. Reviews shall be conducted by either a dentist or a dental hygienist (not a nurse).

C.4.9. The Contractor shall process referrals, appointments and authorizations for ADSMs.

Performance Standards C.4.9.1. Standard: The Contractor shall schedule appointments as requested in accordance with Section J, Attachment J-3a, Program Operations.

C.4.9.1.1. AQL: 90% of appointments shall be scheduled within 5 business days of the request.

C.4.9.1.2. 98% of appointments shall be scheduled within 5 business days of the request.

C.4.9.1.3. 80% of all ADSMs will be able to obtain a routine appointment within 10 business days of requesting an appointment.

C.4.9.1.4. 95% of all Transition Assistance Management Program (TAMP) and Early Eligibles (EEs), who request a routine appointment, will be able to obtain an appointment within 5 business days of requesting an appointment.

C.4.9.1.5. 97% of all DRC 3 ADSMs, who request a routine appointment, will be able to obtain an appointment within 5 business days of requesting an appointment.

C.4.9.1.6. 95% of all TAMP and EEs, who request a specialty appointment, will be able to obtain an appointment within 7 business days of requesting an appointment.

C.4.9.1.7. 95% of all DRC 3 ADSMs, who request a specialty appointment, will be able to obtain an appointment within 5 business days of requesting an appointment.

C.4.9.1.8. 90% of all DTF referred endodontic procedures will be appointed with and completed by an endodontist.

C.4.9.1.9. 90% of all DTF referred oral surgery will be appointed with and completed by an oral surgeon.

C.4.9.2. Standard: The Contractor shall complete authorization requests in accordance with Section J, Attachment J-3a, Program Operations.

C.4.9.2.1. AQL: 95% of authorization requests shall be electronically sent to the Dental Service Point of Contact (DSPOC) within 5 business days of receipt of a complete authorization request (to include required documentation).

C.4.9.2.2. 100% of authorization requests shall be electronically sent to the DSPOC within 7 business days of receipt of a complete authorization request (to include required documentation).

C.4.9.2.3. 95% of authorization requests shall be completed within 5 business days of receiving all required information from the DSPOC.

C.4.9.2.4. 100% of authorization requests shall be completed within 7 business days of receiving all required information from the DSPOC.

Deliverables Management Report

C.4.10. The Contractor shall process claims to completion for ADSMs and providers. “Process to completion” is defined in the TOM, Chapter 1, Section 3, Paragraph 6.0.

Performance Standards C.4.10.1. Standard: Process claims to completion.

C.4.10.1.1. AQL: CONUS Claims

C.4.10.1.1.1. 95% within 14 calendar days of receipt.

C.4.10.1.1.2. 98% within 30 calendar days of receipt.

C.4.10.1.1.3. 100% within 60 calendar days of receipt.

C.4.10.1.2. OCONUS Claims

C.4.10.1.2.1. 95% within 21 calendar days of receipt.

C.4.10.1.2.2. 98% within 45 calendar days of receipt.

C.4.10.1.2.3.100% within 60 calendar days of receipt.

C.4.10.2. Standard: Claims shall be accurately paid in accordance with the covered benefit.

CONUS and OCONUS claims shall be separately tracked.

C.4.10.2.1. AQL: 98% are accurately paid on initial submission of the claim.

C.4.10.3. Standard: Claim errors shall be corrected. CONUS and OCONUS claims shall be separately tracked.

C.4.10.3.1. AQL: 99% are corrected within 10 calendar days after Contractor identifies the error.

Deliverables Management Report Market Basket Comparison/CDT Summary Report Market Basket Comparison/CDT Summary Report MOU with TRICARE Claims Review Services (TCRS) Contractor MOU with TRICARE Dental Program (TDP) Contractor

C.4.11. The Contractor shall process all appeals to completion.

C.4.11.1. Standard: The Contractor shall process provider, ADSM and remote ADSM appeals in accordance with Section J, Attachment J-3a, Program Operations.

C.4.11.1.1. AQL: 100% of completed appeal packages shall be forwarded to the DSPOC within 7 calendar days of receipt.

C.4.11.1.2. 100% of the time, the Contractor shall notify the appealing party within 14 calendar days of the Contractor’s receipt of the DSPOC’s decision.

Deliverables Management Report

C.4.12. The Contractor shall process all grievances to completion.

C.4.12.1. Standard: The Contractor shall process provider and ADSM and grievances to completion in accordance with Section J, Attachment J-3a, Program Operations.

C.4.12.1.1. AQL: 95% within 60 calendar days of receipt.

C.4.12.1.2. 99.9% within 90 calendar days of receipt.

Deliverables Management Report

C.4.13. The Contractor shall provide readily accessible comprehensive customer service for ADSMs and providers.

Performance Standards C.4.13.1. Standard: The Contractor shall provide customer service in accordance with Section J, Attachment J-3a, Program Operations.

C.4.13.1.1. AQL: 98% of telephone calls answered by Automated Response Unit within 30 seconds.

C.4.13.1.2. 80% of telephone calls answered by Customer Service Representative (CSR) within 30 seconds of selection by caller.

C.4.13.1.3. 5% or less telephone calls blocked at all times (measured at least hourly).

C.4.13.1.4. 80% of telephone calls resolved during the initial call; 99.9% within 7 business days.

C.4.13.1.5. Priority Written and E-mail Correspondence (final response). Priority correspondence is that which is received from Members of Congress, DoD leadership and DHA leadership.

C.4.13.1.5.1. 95% within 7 business days of receipt

C.4.13.1.5.2. 99.9% within 20 business days of receipt.

C.4.13.1.5.3. Non-priority (routine) Written and E-mail Correspondence (final response).

C.4.13.1.5.3.1. 85% within 10 business days of receipt

C.4.13.1.5.3.2. 99.9% within 30 business days of receipt.

Deliverables Management Report

C.4.14. The Contractor shall promote the value of utilizing diagnostic and preventive services.

C.4.15. The Contractor shall inform and educate ADSMs, providers, and Military Dental Treatment Facilities (DTF) staff about the program benefits with emphasis to the ADSMs about the benefit of utilizing diagnostic and preventive services.

Performance Standards C.4.15.1. Standard: The Contractor shall comply with its education plan in accordance with Section J, Attachment J-3a, Program Operations. The Contractor shall allow 30 calendar days for the DHA Dental Program Section to approve/deny any changes to the Contractor’s education plan. Timing of the publication and/or implementation shall be mutually agreed upon between the Contractor and DHA Dental Program Section.

C.4.15.1.1. AQL: 99% of planned educational activities shall be completed within the current option period.

Deliverables ADSM, Provider and DTF Education Plan MOU with DHA Communications

C.4.16. The Contractor shall provide data systems to coordinate care between the DHA Dental Program Section, Military DTF ADSM referred care, and remote ADSM dental care authorizations, and the means in which to monitor dental health plan data and outcome measures for all dental care rendered.

C.4.17. The Contractor shall provide training for the users on the Contractor’s data systems stated in Section J, Attachment J-3c, Program Operations for Data Systems.

Performance Standards C.4.17.1. Standard: The Contractor shall train (initial and refresher) and provide secure means for the users to access the systems for viewing and/or utilization. The Contractor may provide the training on-site or electronically.

C.4.17.1.1. AQL: Initial system training conducted during the Transition-In period shall be completed no later than 30 calendar days prior to OP 1.

C.4.17.1.2. After start of OP 1, new users shall receive initial training no later than 30 calendar days after identification is made to the Contractor.

C.4.17.1.3. Refresher training shall be provided monthly.

C.4.17.1.4. Provide refresher system training webinar within seven days of a request.

C.4.17.1.5. Reply to data system inquiries within one business day.

C.4.18. The Contractor shall provide Government designated users with read-only access to the Contractor’s full ADDP data set.

Performance Standard C.4.18.1. Standard: The user shall have the ability to download any of the data elements for manipulation purposes in accordance with Section J, Attachment J-3c, Program Operations for Data Systems.

C.4.18.1.1. AQL: The system shall be available 99% of the time 24 hours, 7 days a week (excluding downtime for scheduled maintenance).

Deliverables Management Report

C.4.19. The Contractor shall provide Government designated users with read-only access to an ADDP dashboard.

Performance Standard C.4.19.1. Standard: The ADDP data shall be provided in a consolidated manner in which the user shall have the ability to easily view dental health plan data and the outcome measurements without having to manipulate the data in order to retrieve the information in accordance with Section J, Attachment J-3c, Program Operations for Data Systems.

C.4.19.1.1. The system shall be available 99% of the time 24 hours, 7 days a week (excluding downtime for scheduled maintenance).

Deliverables Management Report

C.4.20. The Contractor shall establish an electronic means to track and transmit ADSM referrals and authorizations.

Performance Standard C.4.20.1. Standard: The system shall be Health Insurance Portability and Accountability Act (HIPAA) and Public Key Infrastructure (PKI) compliant, which shall allow the user the ability to search, process, and transmit referrals and authorizations in accordance with Section J, Attachment J-3c, Program Operations for Data Systems.

C.4.20.1.1. AQL: The system shall be available 99% of the time 24 hours, 7 days a week (excluding downtime for scheduled maintenance).

C.4.21. The Contractor’s system shall interface with the Military Health Services (MHS) GENESIS/Defense Health Medical Systems Modernization (DHMSM) Electronic Health Record System (EHRS), Dentrix, or other applicable DHA medical and dental computer systems.

C.4.22. The Contractor shall implement the interface with MHS GENESIS/DHMSM EHRS/Dentrix, or other systems as directed by DHA. DHA will provide the systems requirements for MHS GENESIS/DHMSM EHRS/Dentrix or other applicable DHA medical and dental computer systems to be incorporated into the contract prior to implementation or as needed over the life of the contract.

C.4.23. The Contractor shall correct any data submission mistakes identified by the Government or the Contractor.

Performance Standards C.4.23.1. Standard: If the Government or the Contractor identify data submission mistakes (e.g.

the manner in which the data is submitted leads to incorrect data reporting), the Contractor shall correct the mistakes.

C.4.23.1.1. AQL: 99% within 30 calendar days of identification.

C.4.23.1.2. 100% within 60 calendar days of identification.

Deliverables Management Report

C.5. ADDITIONAL REQUIREMENTS.

C.5.1. System Security. The Contractor shall acquire, develop, and maintain processes for safeguarding unclassified DoD information, including covered defense information, commonly referred to as controlled unclassified information on all Contractor/Subcontractor systems/networks that store, process, transmit or access unclassified DoD information or controlled unclassified information in accordance with TSM, Chapter 1, Section 1.1.

C.5.1.1 The Contractor shall implement and maintain adequate security in its project, enterprise, or company-wide internal information systems or covered Contractor information systems that process, store, create, or transmit unclassified DoD information in accordance with the basic safeguarding requirements in FAR 52.204-21 (renumbered to FAR 52.240-93 in Revolutionary FAR Overhaul).

C.5.1.2. The Contractor shall implement and maintain adequate security in its project, enterprise, or company-wide internal information systems or covered Contractor information systems that process, store, create, or transmit covered defense information, commonly referred to as controlled unclassified information (e.g. PII/PHI), in accordance with safeguarding covered defense and cyber incident reporting requirements in DFARS Clause 252.204-7012.

C.5.1.3. The Contractor shall maintain a current (i.e., not greater than three years) Cybersecurity Maturity Model Certification (CMMC) Level 2 (C3PAO) status in the Supplier Performance Risk System (SPRS), in accordance with DFARS clause 252.204-7021. Covered Contractor information systems shall be subject to the security requirements in National Institute of Standards and Technology (NIST) Special Publication (SP) 800-171, "Protecting Controlled Unclassified Information in Nonfederal Information Systems and Organizations", Privacy Act Program Requirements (DoD 5400.11-R), and the Personnel Security Program (DoD 5200.2-R).

The Contractor's System Security Plan and Associated Plans of Action for Contractor’s Internal Unclassified Information System, and Contractor’s Record of Subcontractors Receiving/Developing Covered Defense Information are required prior to accessing DoD data, interfacing with Government systems, or conducting testing.

Deliverables Employee Access to DoD IS/Networks Report NIST Certification of Compliance Report Disaster Recovery Test Results Report Continuity of Operations Plan (COOP) System Security Plan and Associated Plans of Action for a Contractor’s Internal Unclassified Information System Contractor’s Record of Subcontractors Receiving/Developing Covered Defense Information.

B2B Gateway Questionnaire

C.5.2. Health Insurance Portability and Accountability Act (HIPAA). The Contractor shall comply with the HIPAA requirements of TOM, Chapter 19.

Deliverables HIPAA/Privacy Complaint Report Risk Assessment Letter of Assurance Designated Standards Maintenance Organization (DSMO) Meeting Summary Report Breach Report

C.5.3. Transition.

C.5.3.1. The transition-in of this contract shall be conducted in accordance with the requirements stated in Section J, Attachments J-13, Transition-In.

Deliverables Transition-In Status Report Transition-In Integrated Master Plan (IMP) and Integrated Master Schedule (IMS) B2B Gateway Questionnaire

C.5.3.2. The transition-out and the residual services activities shall be conducted in accordance with Section J, Attachment J-14, Transition-Out and Residual Services. Transition-Out costs shall not apply, nor shall any payment be made on CLIN X007, if an incumbent Contractor succeeds itself.

Deliverables Transition-Out and Residual Services Status Report Transition-Out and Residual Services Plan

C.5.4. Government Furnished Information.

C.5.4.1. The Contractor shall utilize the Government-provided electronic data files containing relevant information pertaining to all ADSMs in order to establish and maintain the adequacy of their provider network and to provide ADSMs with educational materials. The Contractor shall comply with the security requirements stated in C.5.1. prior to receiving the data files.

C.5.4.2. The Contractor shall purchase and maintain the appropriate application software required to access the DMDC Defense Eligibility Enrollment Reporting System (DEERS) to perform eligibility inquiries and remote enrollments. The Contractor will have access to DEERS only after the Contractor's staff and all Subcontractors' staff who will utilize systems which access and maintain ADDP data, are compliant with the safeguarding methods for unclassified DoD information, personnel security and clearance requirements as stated in C.5.1. The Contractor and its Subcontractors shall comply with C.5.1. no later than 120 calendar days after award.

C.5.4.3. The Contractor shall print and mail out a welcome packet to each beneficiary or household that enrolls in ADDP. Welcome packets shall include a welcome letter, wallet card, and the appropriate plan or program handbook. The Director’s Communications and Public Affairs Division at DHA (DCPAD) will develop the packet contents on behalf of the Government.

C.5.5. Quality.

C.5.5.1. Quality Control Program (QCP). The Contractor shall develop and implement a QCP in accordance with the TOM, Chapter 1, Section 4 (excluding paragraphs 2.2, 2.3, 2.4, and 4.0) and Section J, Exhibit B, CDRL AP030, QCP Plan.

C.5.5.1.1. The Contractor shall maintain a QCP that ensures that services are performed in accordance with the contract. The Contractor shall develop and implement procedures to identify, prevent, and correct problems for the duration of the contract.

C.5.5.2. Clinical Quality. The Contractor shall ensure that their QCP Plan includes written policies and procedures to identify and review all potential quality issues (PQIs) from any source, to include grievances. A quality issue (QI) is a verified deviation, as determined by a qualified reviewer, from acceptable standards of practice or care as a result of some process, individual, or institutional component of the health care/dental care system. All QIs, regardless of the source, shall be reviewed and confirmed by qualified staff to determine deviations from standards of care, assign severity levels, recommend interventions to include Corrective Action Plans (CAPs), report to licensure boards, and follow-up monitoring through resolution. All standard of care determinations shall be approved by the Contractor’s head of clinical dental care. The Contractor shall assure all identified QIs are tracked and trended and any patterns are identified; all QIs must be appropriately addressed per the terms of the contract. solution is achieved. The Contractor shall ensure that no results from a quality review (quality assurance information) are disclosed to any person or entity unless specifically provided for under 10 USC §1102.

Deliverables Monthly Management Report Quarterly Quality Control Program (QCP) Report Quality Control Program (QCP) Plan

C.5.5.3. Adverse Clinical Events The Contractor shall require all network providers to report adverse events (e.g. cross contamination, infection outbreaks, unintended injuries, wrong site surgeries, or death of an ADSM under the network provider’s care) to the Contractor.

C.5.5.3.1. The Contractor shall then report the adverse event to the TRICARE Dental Program Branch Chief and the COR. The Contractor will also be responsible for reporting all adverse events to the appropriate State Dental Board or other governing entity, when directed by the Chief of the TRICARE Dental Program Branch.

C.5.5.4. Contract Surveillance. The CO and COR will develop a Quality Assurance Surveillance Plan (QASP) to define acceptable quality levels and identify how the COR will monitor the quality of the Contractor’s performance and address Contractor performance that falls below these standards. The CO and COR will finalize the QASP after award and provide a copy to the Contractor (for purposes of the RFP see Section J, Attachment J-18, Draft QASP).

The QASP is a living document, and the Government may unilaterally update it as necessary.

The CO and COR will complete an annual Contractor’s performance evaluation in the Contractor Performance Assessment Report System (CPARS).

C.5.5.5. Records Management. All Contractor records generated under this contract shall be maintained in accordance with 36 CFR 1222; TOM, Chapter 9; Section J, Attachment J-13, Transition-In; and Attachment J-14, Transition-Out and Residual Services.

Declaration of Transfer and Destruction of Records

C.5.5.6. Fraud and Abuse.

C.5.5.6.1. The Contractor shall implement a Fraud and Abuse program in accordance with TOM, Chapter 13.

Deliverables Fraud and Abuse Summary Report Fraud Detection and Prevention Strategy and Internal Procedures Threats Report Standard Operating Procedures (Desk Procedures) Random Sample Audit Worksheet Fraud/Abuse Patient Harm-Initial Notification Checklist DHA/MTF Fraud and Abuse Referral Cover Sheet

C.5.5.6.2. Potential Fraud and Abuse Cases. The Contractor shall refer to DHA any potential case that involves more than a $10,000 loss to the Government and any potential case involving patient harm regardless of loss value (see TOM, Chapter 13, Section 3, for further requirements).

C.5.5.6.3. Post Payment Utilization Reviews. When performing post payment utilization reviews, the Contractor shall consider high volume ADSMs as those ADSMs whose charges exceed $25,000 during a 12-month reporting period. High volume providers are considered institutional providers whose payments exceed $750,000, individual providers whose payments exceed $100,000, and group/clinics whose payments exceed $100,000 (the threshold average is $25,000 per professional provider within the group) during a 12-month reporting period (see TOM, Chapter 13, Section 4, for further requirements).

C.6. Military Health System (MHS) Data Repository (MDR) and MHS Mart (M2).

C.6.1. MDR is DHA’s centralized data repository that captures, archives, validates, integrates and distributes DHA corporate health care data worldwide. It receives and validates data from the DoD’s worldwide network of more than 260 health care facilities and from non-DoD data sources. M2 is DHA’s management and reporting tool.

C.6.1.1. The Contractor shall program their systems to transmit and receive claims payment data to MDR and M2 in coordination with DHA.

C.6.1.2. The Contractor shall provide dental care encounter data for input into the MDR. The data, which includes both clinical and financial information, will then be available for reporting and inquiry purposes in the MDR. The data will also be available on the reports residing on the M2.

C.6.2. The Contractor shall work with the DHA Dental Program Section and DHA, Defense Health Services Systems (DHSS) in developing an ADDP Interface Control Document (ICD) describing the data exchange to the Military Health System (MHS) Data Repository (MDR).

The purpose of the ADDP ICD document is to describe the interface that provides the ADDP records from the Contractor’s automated information systems in support of the ADDP.

C.6.3. The Contractor shall submit the claims and provider data in accordance with the ICD and Section J, Attachment J-12, MDR Data Elements Layout.

C.6.4. The Contractor shall protect the data in accordance with the C2-level protection standards mandated for all "Sensitive Unclassified Systems" as required in the DoD Directive 5200.28 since the data exchanged in this interface contains protected patient level identifiable information and the aggregate data being transmitted by DHSS becomes part of a database that contains sensitive data.

C.6.5. The Contractor shall perform validation checks such as record counts, file formats, source stamps, and date-time stamps on data transferred from the Contractor to the MDR as defined in the MDR ICD. When errors are discovered in the data exchange, the Contractor will be notified immediately by DHSS operations personnel. If there are systemic problems, Interface Working Group (IWG) counterparts will be contacted by DHSS to work the issues.

Deliverables MDR Data Claims and Provider Files

C.6.6. Continuation of Essential Contractor Services. The Contractor shall develop and maintain a plan describing how it will continue to perform the essential Contractor services described in attachments J-3a Program Operations, J-3b Program Operations for OCONUS, J-3c Program Operations for Data Systems, and Section J, Exhibit B, CDRL AP040 during periods of crisis as described in Section I, DFARS 252.237-7023 Continuation of Essential Contractor Services. The Contractor shall maintain a Continuation of Essential Contractor Services Plan that ensures that services are performed in accordance with the contract. The Contractor shall develop and implement procedures to identify, prevent, and correct problems for the duration of the contract, including during government shutdowns.

Deliverables Continuation of Essential Contractor Services Plan

C.7. Deliverables.

C.7.1. The Contractor shall provide all reports and plans in accordance with Section F.5.

C.7.2. The Contractor shall work with the Government during transition-in on the report formats for the CDRLs (see Section J, Exhibit B, CDRLs).

C.7.2.1 The Contractor shall work with the Government to fully describe the format/data elements (e.g. field descriptions, field lengths, list of allowed entries for each field) to be used for each report and to build/test the reports to be forwarded to the Government. During the term of the contract, the Contracting Officer or designee may require additional changes to the makeup of these reports (e.g. add or delete data elements or change the format).

C.7.2.2. The Contractor shall implement these changes at no additional cost to the Government.

C.8. Special Reports and Plans.

C.8.1. CLIN Price Structure Report. The Contractor shall provide its price structure build-up and supporting documentation for its Section B CLIN unit prices after award.

Deliverables CLIN Price Structure

C.8.2. Ad Hoc Reports. The Government may request the Contractor to submit up to ten ad hoc reports per option period at no additional cost to the Government. The Contractor shall provide the report within 14 calendar days of the request unless a revised date is mutually agreed upon with DHA.

Deliverables Ad Hoc Management Reports

C.8.3. Consolidated Historical Data File. The Government may request the Contractor to submit a historical data file up to two times over the life of the contract at no additional cost to the Government.

Deliverables Consolidated ADDP Historical Data File

C.8.4. Disaster Action Plan. The Contractor shall develop a Disaster Action Plan to be implemented when the President of the United States declares an area of the United States or any U.S. territory with a provider network to be a "National Disaster Area" (see Section J, Attachment J-3a, Program Operations).

National Disaster Action Report

(End of Section)