T-5 Draft RFP 3 Section C 3.9.2021 FINAL.pdf

SECTION C

DESCRIPTION/SPECIFICATIONS/WORK STATEMENT

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C.1. GENERAL

C.1.1. The purpose of this contract is to provide Managed Care Support (MCS) to the Department of Defense (DoD) TRICARE program. The MCS Contractor (MCSC) shall assist the Military Health System (MHS) in operating an integrated healthcare delivery system combining resources of the military’s direct medical care system and the Contractor’s managed care support to provide health, medical, and administrative support services to TRICARE-eligible beneficiaries.

C.1.2. Contract Objectives

C.1.2.1. Objective 1 Readiness: Support the MHS readiness mission by partnering with the Military Medical Treatment Facilities (MTFs) to optimize the delivery of healthcare services to enhance the clinical expertise of providers in the direct care system (see definition of MTF optimization in the TRICARE Operations Manual (TOM), Appendix A) for all TRICARE-eligible beneficiaries (active duty personnel, MTF enrollees, civilian network enrollees, and non-enrollees).

C.1.2.2. Objective 2 Experience of Care: Provide a care experience that is patient and family centered, compassionate, convenient, equitable, safe, and always of the highest quality.

C.1.2.3. Objective 3 Manage Per Capita Cost: Create value by focusing on quality, eliminating waste, and reducing unwarranted variation; considering the total cost of care over time, not just the cost of an individual healthcare activity.

C.1.2.4. Objective 4 Population Health: Within the constraints, boundaries, and benefits of the current program, encourage beneficiaries and providers to seek ways to improve health.

C.1.3. Definitions are included in Title 32 Code of Federal Regulations Part 199.2 and the TOM, Appendix A.

C.1.4. The following documents are hereby incorporated by reference and form an integral part of this contract. Documentation incorporated into this contract by reference has the same force and effect as if set forth in full text.

• Title 10, United States Code, Chapter 55

• 32 Code of Federal Regulations Part 199

• TRICARE Systems Manual (TSM) 7950.3-M, June 2020

• TRICARE Reimbursement Manual (TRM) 6010.61-M, June 2020

• TRICARE Policy Manual (TPM) 6010.60-M, June 2020

• TRICARE Operations Manual (TOM) 6010.59-M, June 2020

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 TRICARE Policy Manual (TPM)

HT940220R0005 Page C2 of C25 takes precedence over the other three TRICARE Manuals. The TRICARE Reimbursement Manual (TRM) takes precedence over the TRICARE Systems Manual (TSM) and the TRICARE Operations Manual (TOM). The TSM takes precedence over the TOM.

C.2. PERFORMANCE REQUIREMENTS

C.2.1. Provider Networks

C.2.1.1. The Contractor shall establish and maintain preferred provider networks (PPN) of individual and institutional providers which produce high quality clinical outcomes for TRICARE beneficiaries.

C.2.1.1.1. All network providers must be Medicare participating providers (unless they are not eligible to be participating providers under Medicare) and shall be sufficient in number, mix, and geographic distribution to provide the full scope of benefits for which all enrollees are eligible under this contract, as described in 32 CFR 199.4, 199.5, and 199.17.

C.2.1.1.2. The Contractor shall provide Prime Service Areas (PSAs) at all locations listed in the attachments applicable to its region: Attachments J-1 through J-6, Mandatory Government Required PSA Lists. J-1a through J-2a Mandatory Government required Base Relocation and Closure (BRAC) PSA Lists.

C.2.1.1.3. The Contractor shall adjust provider networks and services to compensate for changes in Market/MTF capabilities and capacities, when and where they occur over the life of the contract, including those resulting from unanticipated facility expansion, Market/MTF provider deployment, downsizing or closures.

C.2.1.1.4. The Contractor shall submit a plan detailing all phases of network development and implementation. For plan details see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J.

C.2.1.2. The Contractor’s plan shall address all components of network development (including the Contractor's network sizing model and formula(s) used to derive network specialty targets), by provider specialty in all PPNs in the Contractor’s geographic area of responsibility.

C.2.1.3. TRICARE Minimum Appointment Access Standards Reporting

C.2.1.3.1. The Contractor shall ensure that each provider type in Attachment J-7 in each meets minimum appointment access standards in each PPN.

C.2.1.3.2. If there are no providers in a geographic area, the Government will consider the drive time standards met when telehealth care is offered by the designated provider types in Attachment J-7.

C.2.1.4. TRICARE Prime Minimum Drive Time Standards

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C.2.1.4.1. The Contractor shall take into account: geographic barriers such as bridges, mountains, tunnels, average daytime traffic, roads, and other driving impediments in calculation of beneficiary drive times.

C.2.1.4.2. The Contractor shall not use telemedicine access in the calculation of minimum drive time standards.

C.2.1.5. Network Service Area Reporting

C.2.1.5.1. The Contractor shall specify areas, through zip codes, where its preferred networks are available to TRICARE beneficiaries.

C.2.1.5.2. The Contractor shall ensure the Government’s PPN ZIP code list is updated with changes from DHA and implemented within its systems each month. The Contractor shall update its PPN Service Area ZIP Code list each month. For reporting requirements see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J.

C.2.1.6. The Contractor shall ensure access to care standards listed in 32 CFR 199.17(p)(5) are met for all TRICARE Prime enrollees and at least 85 percent of TRICARE Select enrollees. For reporting requirements, see Contract Data Requirements List, DD Form 1423, located in Section J.

C.2.1.6.1. The Contractor shall develop and implement a system for continuously monitoring and evaluating network adequacy and for reporting network adequacy or access issues according to contract requirements. For reporting requirements see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J.

C.2.1.6.2. The Contractor shall submit its plan for meeting and reporting on access to care standards for TRICARE beneficiaries. Access to care shall be reported at the PSA, Market and State level for the Contractor’s geographic area of responsibility. The Contractor shall report information on how it derived appointment availability standards such as provider practice and survey information. For plan reporting requirements see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J.

C.2.1.7. The contractor shall develop and implement a system for continuously monitoring network access availability for each provider and facility type identified in Attachment J-7.

Appointment availability shall be assessed for each provider type in the contractor’s network and shall not exceed access to care requirements listed in Attachment J-7. The contractor shall assess bed availability for each type of network facility to ensure beneficiaries’ access to care. For reporting requirements see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J.

C.2.1.8. The Contractor shall measure the ability of enrolled beneficiaries to access telehealth services in rural, remote and isolated areas. For reporting requirements see DD Form 1423, Contract Data Requirement List (CDRL), located in Section J.

C.2.1.9. The Contractor shall monitor and report, on a monthly basis, all complaints by beneficiaries with respect to network adequacy and the availability of health care providers. For

HT940220R0005 Page C4 of C25 reporting requirements, see Contract Data Requirements List, DD Form 1423, located in Section J.

C.2.1.10. The Contractor shall submit a Corrective Action Plan (CAP) for instances of network inadequacy. Network Inadequacy is defined as any network provider type exceeding appointment time standards in a geographic area (PSA, Market or State) without a Network Adequacy Waiver. For reporting requirements see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J.

C.2.1.11. Network Adequacy Waivers

C.2.1.11.1. The Contractor may apply for a waiver of network adequacy for a single provider type in a geographic area. Such an application must:

1. be made in writing,

2. provide the local provider saturation rate: Calculated by dividing Providers Recruited into Network divided by number of providers (of the same type) in the local community,

3. identify all good faith efforts to bring local providers into the network. If no providers of the specific provider type is available in the area, the Contractor shall submit documentation to the Government and,

4. demonstrate that the Contractor has exhausted its ability to create a locality based waiver.

C.2.1.11.2. The Contractor may remove a provider category from the network adequacy calculation in a geographic area if the Government grants a Network Adequacy Waiver for the time period specified in the waiver.

C.2.1.12. Network Quality

C.2.1.12.1. The Contractor shall maintain accreditation of its health care network by a national accrediting organization in all geographic areas of responsibility throughout the contract and all exercised options. National certification, in lieu of accreditation, is insufficient to meet this requirement. For reporting requirements, see Contract Data Requirements List, DD Form 1423, located in Section J. Network accreditation shall be from a national body that considers quality benchmarks for network management, provider credentialing, quality management and improvement, and consumer protection.

C.2.1.12.2. The Contractor shall ensure the higher standard applies when this contract and the accrediting body have differing standards for the same activity.

C.2.1.12.3. The Contractor shall establish mechanisms to evaluate network providers by quality metrics specified in TOM Chapter 7, Section 6. The Contractor shall make these quality metrics at the individual provider/facility level available in an easily understood and accessible format as part of the online network directory. See TPM, Chapter 1, Section 1.1.

C.2.1.12.4. The Contractor shall develop and submit a value-based steerage model for referrals.

A value based steerage model achieves the following elements: (1) access to care, (2) high quality, (3) MTF optimization (see DHA PI 18-001) and readiness of the force (time from the

HT940220R0005 Page C5 of C25 referral to return of medical record to the originating MTF), and (4) lowers average per capita cost. For plan reporting requirements see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J.

C.2.1.12.4.1. The Contractor shall not steer beneficiaries to the following: (1) providers on the HHS exclusion list, (2) medical facilities with a LeapFrog Hospital Safety Grade of D or F, or

(3) medical facilities where national accrediting agencies have suspended or revoked accreditation within the preceding 12 months.

C.2.1.12.4.2. The Contractor shall submit a monthly report on its Value-Based Steerage Model/ Plan performance on each element at the market level as an expression of total value. The Government will assess this requirement as a composite (steerage) value score based on the four elements listed in C.2.1.12.4. For reporting requirements see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J.

C.2.1.13. Provider Directory

C.2.1.13.1. The provider directory shall clearly communicate the following information to beneficiaries:

1. Provider Name

2. Provider Gender

3. Provider place of practice address

4. Provider appointment telephone number

5. TRICARE PCM (Y/N)

6. TRICARE network (Y/N)

7. TRICARE participating (files claims on behalf of beneficiary similar to Medicare.gov) (Y/N)

8. TRICARE Provider Readiness Designation (Y/N)

9. Provider Type

10. Provider Specialty

11. Provider Subspecialty

12. Provider quality indicator(s)

13. Provider website (if available)

14. Telehealth availability

C.2.1.13.2. The provider directory shall clearly communicate the following information to the

DHA:

1. Provider Name

2. Provider Gender

3. Provider place of practice and address

4. Provider billing address

5. Provider Type

6. Provider Specialty

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7. Provider Subspecialty

8. Provider quality indicator(s)

9. Provider website (if available)

10. Provider business phone number

11. Provider appointment phone number

12. Provider Fax number

13. Provider electronic address (Health Information Service Provider (HISP) address)

14. Participates in Health Information Exchange (Y/N)

C.2.1.13.3. The Contractor shall ensure that the on-line network provider directory is accessible to users on a continual (24 hours/7 days a week) basis except for scheduled downtime for system maintenance.

C.2.1.13.4. The Contractor shall schedule downtime for system maintenance in accordance with the TRICARE Systems Manual.

C.2.1.13.4.1. The Contractor shall enable DHA and beneficiaries to turn on, turn off and merge non-network providers in their provider directory views.

C.2.1.13.5. Provider Directory Accuracy

C.2.1.13.5.1. The Contractor shall use electronic means for verification in addition to manual outreach efforts to continuously maintain provider directory accuracy.

C.2.1.13.5.2. If a provider has not submitted a claim within in fourteen months or if there is no response from a provider through electronic or manual outreach efforts, the Contractor shall not display the provider in the directory.

C.2.1.13.5.3. The Contractor shall maintain a minimum provider directory accuracy rate as follows:

Transition OP1 OP2 OP3 OP4 OP5 OP6 OP7 OP8 Extension 71% 72% 74% 74% 76% 76% 78% 78% 80% 80%

C.2.1.13.5.4. The Contractor shall calculate provider directory accuracy for each individual Prime Service Area and at each state/territory level.

C.2.1.13.5.5. The Contractor shall calculate the network provider directory accuracy with the following data elements: provider name, provider specialty, provider sub-specialty, provider place of practice address, provider fax number and provider appointment telephone number.

Accuracy is defined as a directory record that contains correct information for all of the above data elements listed in this paragraph. The Contractor shall calculate network provider directory accuracy by dividing the total number of directory entries (records) that contain 100% correct information (no data element errors) by the total number of records. Requirements for refreshing the data and data accuracy are not applicable to the on-line directory of TRICARE authorized

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(non-network) providers; however the Contractor shall refresh the data of TRICARE authorized (non-network) providers no less than semi-annually.

C.2.1.13.5.6. Provider directory accuracy shall be reported monthly in accordance with DD Form 1423, Contract Data Requirements List (CDRL), located in Section J.

C.2.1.14. Additional Agreements for Network Providers

C.2.1.14.1. The contractor shall include in its network provider agreements, if not connected to an MHS GENESIS-compatible Health Information Exchange, language requiring the providers to render individual consultation reports to referring MTFs within 30 days.

C.2.1.14.1.1 The contractor shall ensure that individual consultation reports meet a clear and legible standard.

C.2.1.14.1.2. The Contractor shall establish a process to routinely follow up with a network provider (no less than every 30 days) for missing consultation reports.

C.2.1.14.1.3. The Contractor shall establish roles, responsibilities and points of contact for the follow-up process for each MTF/Market.

C.2.1.15. The Contractor shall contact network providers biannually to validate information contained in the network provider directory.

C.2.2. Enrollment

C.2.2.1. The Contractor shall perform enrollments, re-enrollments, disenrollments, transfer enrollments, correct enrollment discrepancies, and assign or change the Primary Care Manager (PCM) in accordance with the provisions of the TOM Chapter 6.

C.2.2.2. The Contractor shall utilize leading industry best practice automation in processing billing and enrollment transactions and include capture of email and other information needed to conduct electronic transactions.

C.2.3. Medical Management (MM)

C.2.3.1. The Contractor shall develop, implement, and maintain a MM Program, that includes behavioral health, in accordance with the requirements in TOM Chapter 7, as well as complies with the TRICARE benefits provisions of 32 CFR 199.4, 32 CFR 199.5, and the TPM in order to provide healthcare for eligible beneficiaries to the extent authorized by law.

C.2.3.1.1. The Contractor’s MM programs shall support all services provided within each Market/MTF and shall be described in the MCSCs Memorandum of Understanding (MOU) with each Market/MTF (refer to C.2.11.9 for additional detail).

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C.2.3.2. The Contractor shall develop, implement, and maintain an electronic MM data system that complies with TOM, Chapter 7, Sections 1, 2 and 3.

C.2.3.3. The Contractor shall use predictive analytics, in the operation of its MM program, which are designed to support and manage the healthcare of individuals with high-cost conditions as described in TOM Chapter 7, Section 1.

C.2.3.3.1. The Contractor shall establish a Network Prime beneficiary-centric data warehouse and industry analytic tools/system (to include predictive analytics) and provide the Government with real-time access to view all data for a Prime beneficiary enrolled to a civilian Primary Care Manager (PCM) and to exhibit sophisticated data analysis techniques with evidence-based algorithms.

C.2.3.4. The Contractor shall obtain and maintain accreditation from a nationally recognized accrediting organization for the following MM programs: utilization management, case management, and population health.

C.2.3.4.1. The Contractor shall obtain accreditation no later than 18 months after the Start of Health Care Delivery (SHCD) and shall be maintained in all geographic areas of responsibility, throughout the entirety of the contract performance period inclusive of all exercised option periods). National certification, in lieu of accreditation, is insufficient to meet this requirement.

C.2.3.4.2 The Contractor shall submit letters of accreditation and re-accreditation and supporting documentation to the Government within 5 business days of receipt of the documents from the accrediting organization.

C.2.4. Case Management (CM)

C.2.4.1. The Contractor shall develop, implement, and maintain a CM Program in accordance with TOM Chapter 7, Section 2.

C.2.4.2. The Contractor shall provide CM services via a dedicated point of contact for beneficiaries with sensitive, rare, high-profile, or high-visibility needs; in addition to the CM beneficiary categories identified in TOM Chapter 7, Section 2.

C.2.4.3. The Contractor shall use tools and assessments to identify beneficiaries in need of in-home CM services and offer in-home CM services to beneficiaries who have a high-need for care and are at high-risk of re-admission for 30 calendar days following discharge from an inpatient setting. The first in-home visit shall be made 48 to 72 hours post discharge.

C.2.5. Population Health (PH) Care

C.2.5.1. The Contractor shall, to the extent permitted by law and regulation develop, implement and maintain integrated, whole person, PH care in accordance with TOM Chapter 7, Section 3.

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C.2.5.2. The Contractor shall incorporate Chronic Care/Disease Management (CC/DM) conditions into their PH care.

C.2.5.3. The Contractor shall collaborate annually with the Government Designated Authority (GDA) to identify targeted diseases that will be aligned with Direct Care and based on population trends.

C.2.5.4. The Contractor shall establish the process for beneficiaries to be referred for CC/DM services from the MTF and Network providers and shall communicate this process via the MTF MOUs and network provider agreements.

C.2.6. Utilization Management (UM)

C.2.6.1. The Contractor shall develop, implement, and maintain a UM Program in accordance with TOM Chapter 7, Section 4.

C.2.6.2. The Contractor shall apply its UM practices for all TRICARE eligible beneficiaries receiving care in the private sector care system and in accordance with TOM Chapter 7, Section 4.

C.2.6.3. The Contractor shall ensure that care provided is reviewed for medical necessity (if applicable), is appropriately authorized, and complies with the TRICARE benefits contained in 32 CFR 199.4 and 199.5, and the TPM.

C.2.7. Referral Management (RM)

C.2.7.1. The Contractor shall develop, implement, and maintain a RM Program in accordance with the TOM, Chapter 7, Section 5.

C.2.7.2. The Contractor shall utilize a secure HIPAA and Government compliant computer-based method to process referrals between Market/MTFs and themselves.

C.2.7.3. Referral and authorization information provided, directed referral guidelines, and the methods of communicating referral and authorization information, will be addressed in the MOUs between the Market/MTFs and the Contractor.

C.2.7.4. The Contractor shall implement a computer-based referral management system which interfaces with the Government’s referral management interface as described in TOM, Chapter 7, Section 5 and Attachments J-13 (MHS Genesis Supplement – Interface Control Document and Performance Work Statement) that allows documents to be uploaded and associated to the referral.

C.2.7.5. The Contractor shall implement a computer-based referral management system that allows electronic transmission of referrals and authorizations initiated by the Contractor to the

MTF.

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C.2.7.6. The Contractor shall implement a process that optimizes referrals and authorizations to MTFs for beneficiaries enrolled in TRICARE Prime to enhance a medically ready force as described in TOM, Chapter 7, Section 5.

C.2.8. Clinical Quality Management (CQM)

C.2.8.1. The Contractor shall develop, implement, and maintain a CQM and Patient Safety Program in accordance with the TOM, Chapter 7, Section 6.

C.2.8.2. The Contractor’s credentialing program in TOM Chapter 4, Section 1. When this contract and the accrediting organization have differing standards for the same activity, the Contractor shall use the higher standard in performance of this contract.

C.2.8.3. The contractor shall collect and process all data to produce metrics identified in Attachment J-8, Clinical Quality Metrics. The contractor’s quality and safety for all network enrolled beneficiaries shall meet or exceed target metrics where specified. The Government reserves the right to update Attachment J-8 in accordance with FAR 52.243-1, Alternate 1.

C.2.9. Return of Clinical Information

C.2.9.1. The Contractor shall ensure an accurate record of care provided to a patient is readily available to providers involved with a TRICARE Prime beneficiary or active duty service member’s care, to ensure continuity of care and to avoid potential drug interactions due to a provider not being aware of other medications prescribed to the patient.

C.2.9.2. The Contractors shall, to enhance information sharing between direct care and private sector care, perform the following actions:

C.2.9.2.1. The Contractor shall ensure that all specialty evaluations performed by a TRICARE network provider are provided to the Government through one of the means listed in paragraph C.2.9.8.

C.2.9.3. The Contractor shall ensure the Government and the Network primary care manager (if applicable) is notified whenever a network provider changes a TRICARE Prime beneficiary or active duty service member’s primary diagnosis, adds or removes a diagnosis, adds, discontinues, or modifies a medication, or refers a patient to another provider. This information will be communicated through one of the means listed in paragraph C.2.9.8.

C.2.9.4. The Contractor shall ensure that those providers who utilize an Electronic Health Record (EHR) linked to a Military Health System (MHS) GENESIS-compatible HIE include all clinical documentation (including but not limited to follow-up visits) is provided to the Government through the Health Information Exchange (HIE).

C.2.9.5. The Contractor shall ensure that laboratory results for a TRICARE Prime beneficiary or active duty service member performed by TRICARE network laboratories are provided to the

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Government and the network primary care manager (if applicable) through one of the means listed in paragraph C.2.9.8.

C.2.9.6. The Contractor shall ensure radiology study reports for a TRICARE Prime beneficiary or an active duty service member performed by TRICARE network providers are provided to the Government and the network primary care manager (if applicable). The Market Director may provide the Contractor a list of preferred radiology providers in each market/Prime Service area based on direct care providers’ satisfaction with the quality of studies and communication from the provider. The Contractor shall utilize this list in its steerage model for radiology providers.

C.2.9.7. The Contractor shall ensure results of clinical procedures, clinical pathology reports, reports of care from ancillary services including but not limited to physical therapy, occupational therapy, speech and language therapy, and audiology are provided to the referring MTF using the methods in paragraph C.2.9.8.

C.2.9.8. The Contractor will ensure records of care are provided to the Government through one of the following mechanisms:

C.2.9.8.1. HIE connection to the Government’s electronic health record. This method is preferred.

C.2.9.8.2. As an alternative to the HIE process, each Market/MTF Director has a single point-of-contact for return of the information required. The Government will provide this point-of-contact-to the Contractor through the Memorandum of Understanding (MOU) process. The Contractor shall provide this point-of-contact to network providers in the Market/Prime Service Area and require network providers use it to submit results to the Government if an HIE is not available.

C.2.9.8.3. Clinical information shall be provided to the Government within two business days of the date of service on or within 31 days from the date of discharge for inpatient admissions..

C.2.9.8.4. The Contractor shall use timely return of clinical information as part of the Contractors’ TRICARE Network provider steerage model.

C.2.10. Communications and Customer Service

C.2.10.1. The Contractor shall provide comprehensive readily accessible customer services for TRICARE-eligible beneficiaries and providers in accordance with TOM, Chapter 11.

C.2.10.2. The Contractor shall provide outreach and communication consistent with those services offered to its commercial customers. Customer services shall be formatted to TRICARE specifications and include multiple, contemporary avenues of access (for example, email, World Wide Web, telephone, texting, smart phone applications, and social media) for TRICARE-eligible beneficiaries in accordance with TOM, Chapter 11.

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C.2.10.3. The Contractor shall perform all customer service functions with knowledgeable, courteous, responsive staff that results in highly satisfied beneficiaries.

C.2.10.3.1. The Contractor shall ensure that its customer service program is delivered in a manner that achieves the objectives of this contract without charge to beneficiaries or providers.

C.2.10.4. The Contractor’s call center shall be certified by a nationally-recognized certification agency or program no later than 18 months after the SHCD and be maintained throughout the life of this contract and all exercised options.

C.2.10.5. The Contractor shall provide customer service support for Markets, MTFs, Guard/Reserve Component units/commands, and the DHA office overseeing TRICARE Customer Service.

C.2.10.6. The Contractor shall follow all requirements related to TRICARE publications, social media, beneficiary outreach, website management, TRICARE branding, and media relations as described in TOM, Chapter 11, Section 6.

2.10.7. Call Resolution

2.10.7.1. The Contractor shall provide the beneficiary with an inquiry control number with each beneficiary (or beneficiary representative) call to the Contractor’s service center.

2.10.7.2. The Contractor shall group and record all beneficiary concerns expressed on the call under the single control number.

2.10.7.3. The Contractor shall resolve all beneficiary concerns during the initial call.

2.10.7.4. The Contractor shall, if different departments/expertise is required, continue resolving the issue under the single beneficiary control number.

2.10.8. Call Backs

2.10.8.1. The Contractor’s Automated Response Unit system shall allow the beneficiary to call about an open issue from a previous call for up to 30 calendar days and direct the beneficiary into a queue for resolving previous issues.

2.10.8.2. The Contractor shall, if the beneficiary does not have the inquiry control number, research the previous control number based on the issue, date, or beneficiary ID.

2.10.8.3. The Contractor may, if the previous control number is over 30 calendar days old, open a new call inquiry.

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2.10.8.4. The Contractor shall, if a beneficiary calls back within 30 calendar days for any reason associated with an open inquiry control number, not count the issue as resolved in their first call resolution report.

C.2.11. Claims Processing

C.2.11.1. The Contractor shall establish and maintain an automated claims processing system for TRICARE claims.

C.2.11.1.1. The Contractor’s claims system shall utilize modern software development based on the ability to create clean claims, route claims for optimal processing using systems capable of intelligent decisioning that combines business rules management, decision processing, real-time event detection, decision governance and powerful advanced analytics to automate and manage decisions across the enterprise. The claims system shall also be capable of automated high volume data capture and routing focused on the Government’s requirement for continuous delivery.

C.2.11.1.2. The Contractor’s claims system shall be configured such that functionality necessary for timely and appropriate reconfiguration and adaptation for claims processing changes are quickly made at the lowest possible cost to the Government.

C.2.11.2. The Contractor shall process claims in accordance with the TRICARE benefit policy as delineated in 32 CFR Part 199.4 and 199.5, the TPM, TOM, and TRM.

C.2.11.3. The Contractor's claims processing system shall accurately apply deductible, co-pay, coinsurance, cost shares, catastrophic cap, referral/authorization requirements, and point-of-service (POS) provisions in accordance with the TRICARE benefit policy as delineated in 32 CFR Part 199.4 and 199.5, 199.17 and 199.18, the TPM, TOM, and TRM.

C.2.11.4. The Contractor's claims processing system shall accurately coordinate benefits with Other Health Insurance (OHI) plans to which the beneficiary is enrolled as required by 32 CFR 199.8, the TPM, and TRM.

C.2.11.5. The Contractor's claims processing system shall interface with and accurately determine eligibility and enrollment status based on the Defense Enrollment Eligibility Reporting System (DEERS) in accordance with the TSM.

C.2.11.6. The Contractor shall capture and report TRICARE Encounter Data (TED) related to claims adjudication in accordance with the TSM.

C.2.11.7. The Contractor shall provide designated DHA and military services personnel (including military services personnel at the Market and MTF level) access to real-time TRICARE claims data.

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C.2.11.7.1. The Contractor’s read-only claims data system shall be made accessible to users on a continual (24 hours per day/7 days per week) basis except for scheduled downtime for system maintenance. To the maximum extent practicable, the Contractor shall schedule system maintenance windows during weekends or non-peak hours to minimize disruption of services to Government users.

C.2.11.7.2. The Contractor shall provide training and ongoing customer support for its claims data system to Government users.

C.2.11.7.3. The Contractor shall provide training to its claims data system either in-person/onsite or virtually.

C.2.11.7.4. The Contractor shall ensure that its claims data system training materials are updated and current and made available to designated DHA and military services personnel (including military services personnel at the Market/MTF level)

C.2.11.8. The Contractor shall use commercial best business practices to identify and update Other Health Insurance (OHI) information stored in the DEERS database for non-active duty service members that have no commercial health insurance information on file.

C.2.11.8.1. Commercial best practices shall include, but are not limited to, the use of external data bases to achieve the goal of identification of accurate and complete OHI information.

C.2.11.8.2. Contractor use of its commercial data base is insufficient to meet this requirement if it only checks/verifies for OHI within its own commercial health plan.

C.2.11.9. The Contractor shall perform in compliance with all requirements regarding adjustments/recovery of underpayments, overpayments, recoupments, Third Party Liability (TPL) and collections in accordance with TOM, Chapter 10.

C.2.12. Management

C.2.12.1. Contractor Leadership

C.2.12.1.1. The Contractor shall establish and maintain experienced and qualified leadership and sufficient staffing and management support to meet the requirements of this contract.

C.2.12.1.2. The Contractor shall provide senior level team member(s) who have authority and who have the ability to make management decisions for the Contractor within the scope of the contract, to attend meeting(s) with the GDA, either via telephone conference call, video teleconference (VTC), or other agreed-upon electronic media. The Contractor shall make known to the Government who these leaders are and regularly advise as changes in leadership positions occur.

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C.2.12.1.3. The Contractor shall provide, for urgent matters, a senior level team member(s) with authority and the ability to obligate resources within the scope of the contract and to attend in-person meeting(s) with the GDA within two business days at a location identified by the GDA.

C.2.12.2. Quality Management/Quality Improvement Program (QM/QI)

C.2.12.2.1. The Contractor shall establish and operate a QM/QI program and have in place at the start of health care delivery.

C.2.12.2.2. The Contractor's Quality Management (QM) processes shall focus on clinical quality health care rendered and outcomes, program processes and procedures, standardization and access to care problems identification and resolution and shall foster a consistent, efficient, effective TRICARE program for the beneficiaries.

C.2.12.2.3. The Contractor's Quality Improvement (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 healthcare rendered, and quality healthcare outcomes.

C.2.12.2.4. The Contractor’s QM/QI programs shall be comprehensive and coordinated, covering all aspects of the TRICARE program, with oversight by Contractor senior leadership, ensuring that QM/QI information and processes are incorporated and communicated across its entire enterprise.

C.2.12.2.5. The Contractor shall submit an annual QM/QI plan. For plan reporting requirements see Contract Data Requirements List, DD Form 1423, located in Section J.

C.2.12.2.6. The Contractor shall provide visibility of QM/QI processes and reports to the Government on a routine basis. The Government will determine the reporting frequency and may adjust the frequency as it deems necessary.

C.2.12.2.7. The Contractor shall initiate and conduct monthly operational and assessment reviews with DHA where the Contractor will present their performance against all standards. The venue and manner of presentation will be determined by the Government.

C.2.12.2.8. The Contractor shall initiate Quality Improvement Projects (QIPs) for Contractor performance issues identified by the Government to be out of contract compliance for three or more consecutive reporting periods, and any other significant instances of non-conformance.

C.2.12.2.9. The Contractor shall, if problems are identified through its internal QM/QI Program, electronically submit a QM/QI report to the GDA within 10 calendar days following the end of the month when the problem was identified. The report shall include corrective actions that were initiated and those that are planned with identified target compliance/resolution achievement dates. For reporting requirements see Contract Data Requirements List, DD Form 1423, located in Section J.

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C.2.12.2.9.1. The Contractor shall submit a monthly update/status report until all corrective actions have been achieved. For reporting requirements see Contract Data Requirements List, DD Form 1423, located in Section J.

C.2.12.3. Coordination/Integration of Healthcare Delivery

C.2.12.3.1. The Contractor shall ensure efficient coordination of healthcare delivery between the direct care system and the Contractor's network.

C.2.12.3.2. The Contractor shall collaborate with Market Directors/MTF Directors and Government staff to ensure the most efficient mix of healthcare delivery between the direct care system and the Contractor's civilian network within its geographic area of responsibility without compromising network access by non-direct care enrolled beneficiaries.

C.2.12.3.3. The Contractor shall prepare a Memorandum Of Understanding (MOU) for approval by the CO in coordination with the Market Directors/MTF Directors and GDA. See TOM, Chapter 15 for MOU details.

C.2.12.3.4. Coordination and collaboration includes, but is not limited to, preventive care, overflow capacity for primary and specialty care, ancillary services, referrals for designated specialty care, points of contact, and beneficiary enrollment.

C.2.12.4. Contingency Operations Program

C.2.12.4.1. The Contractor shall, in addition to complying with the requirements regarding continuity of essential Contractor services described in DFARS Clause 252.237-7023, submit a contingency operations plan no later than 120 calendar days prior to SHCD. For plan reporting requirements, see Contract Data Requirements List, DD Form 1423, located in Section J.

C.2.12.4.1.1. The Contractor’s contingency operations plan shall ensure continuous provision of healthcare services for TRICARE-eligible beneficiaries as Markets and MTFs respond to war, operations other than war, deployments, training, contingencies, special operations, and natural disasters.

C.2.12.4.1.2. The Contractor’s contingency operations plan shall detail how the Contractor will ensure that healthcare services are continuously available for beneficiaries in the event of such changes in Market and MTF capabilities to include bed capacity.

C.2.12.4.1.3. The Contractor’s contingency operations plan shall include processes to ensure coordination with Markets, MTFs, and THP, as well as, outside agencies including U.S.

Transportation Command (USTRANSCOM), United States Departments of Health and Human Services, Homeland Security, Defense, and Veterans Affairs, and the National Disaster Medical System (NDMS) for planning and operations.

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C.2.12.4.2. The Contractor shall participate in contingency exercises including regionally coordinated table-top contingency exercises twice each calendar year per each Market and MTF.

C.2.12.4.2.1. The Contractor shall implement the contingency program at any or all locations within 48 hours of being notified by the GDA that a contingency exists.

C.2.12.4.2.2. The Contractor shall maintain contingency operations communications with the DHA, Markets and MTFs.

C.2.12.4.2.3. The Contractor shall submit an exercise participation report at the conclusion of the exercise. For reporting requirements, see Contract Data Requirements List, DD Form 1423, located in Section J.

C.2.12.4.3. The Contractor shall deploy mobile Service Assist Team (SATs) necessary to perform customer service functions to disaster areas, Active Component and Reserve Component troop mobilization areas, Base Realignment and Closure (BRAC) areas, or to any area deemed necessary and requested by the GDA.

C.2.12.4.3.1. The Contracting Officer (CO) will issue a contract modification defining the requirements for each SAT.

C.2.12.4.3.2. The Contractor will deploy one or more SAT teams on an as needed basis for a finite period of time as defined in the modification.

C.2.12.4.3.3. The Contractor shall deploy one or more SAT teams within seven calendar days after notification from the CO.

C.2.12.4.3.4. SATs shall provide assistance with beneficiary enrollment, access to care, referrals, and include TRICARE program information to a variety of markets and community network providers.

C.2.12.4.4. The Contractor shall, in cooperation with Markets and MTFs, coordinate the care and transfer of patients who require transfer to another location/area.

C.2.12.4.4.1. Coordination of care will include coordination with the primary clinician at the losing and gaining sites, the patient’s family, and arranging medically appropriate patient transport (ground or air), ensuring all necessary supplies are available during the transport and at the receiving location; arranging for and ensuring the presence of all necessary medical equipment during transport and at the receiving location; and identifying and ensuring the availability of necessary resources to accomplish the transfer.

C.2.12.4.4.2. Transfers may occur as a result of medical, social, or financial reasons and include moves of non-institutionalized and institutionalized patients.

C.2.12.4.4.3. In contingency military operations, collaboration between military and civilian transport is crucial upon initial receipt of patients from Continental United States (CONUS)

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Transportation Command (USTRANSCOM).

C.2.12.5. Information System/Data Repository

C.2.12.5.1. The Contractor shall develop and maintain an information system/data repository which includes access to data at the beneficiary non-institutional and institutional level. The information in this information system/data repository shall be current and refreshed no less frequently than once every 24 hours.

C.2.12.5.2. The Contractor shall make its information system/data repository accessible to users on a continual (24 hours per day, 7 days per week) basis except for scheduled downtime for system maintenance.

C.2.12.5.2.1. The Contractor shall schedule system maintenance windows during weekends or non-peak hours to minimize disruption of services to Government users. This requirement is in addition to the MM/UM data access requirement and Network Prime beneficiary-centric data warehouse and analytic tools/system.

C.2.12.5.3. The Contractor shall provide system access to Government personnel. Minimum system access authorizations shall include two authorizations at each MTF and USCG clinic, two authorizations at each Market, two authorizations at each Intermediate Service Command, two authorizations at each Surgeons General Office, five authorizations at the Chief, TRICARE Health Plan (THP), five authorizations at DHA (various locations), two authorizations at Health Affairs, two authorizations at DHA-Falls Church, and two authorizations at DHA-Aurora.

C.2.12.5.3.1. The Contractor shall make available an additional 30 authorizations by Government personnel or contractors acting on the Government's behalf (e.g. analysts) with a need to know as determined by the Government.

C.2.12.5.3.2. The Contractor shall submit a reoccurring report to the Government with a list of all Government users provided access to its information system/data repository. For reporting requirements, see Contract Data Requirements List, DD Form 1423, located in Section J.

C.2.12.5.3.3. Data elements shall include, at a minimum, details concerning the provider network, referrals, authorizations, claims processing, program administration, beneficiary satisfaction and services, incurred healthcare costs, enrollment, geo-mapped data elements and clinical data (case management, chronic care/population health, utilization management, medical management), and all data pertaining to the execution of Prime and Select benefits both inside and outside PSAs/Markets.

C.2.12.5.3.4. The Contractor shall ensure that all data is current and refreshed no less frequently than once every 24 hours and accessible to all users identified in C.2.12.5.3. and C.2.12.5.3.1.

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C.2.12.5.3.5. The Contractor’s ad-hoc capability, standardized reports, and special report requests must satisfy the user’s requirement within mutually agreed upon timelines but within a maximum of five business days.

C.2.12.5.3.5.1. The Contractor shall submit a reoccurring report that lists all ad-hoc reports, standardized reports, and special report requests provided to the Government. For reporting requirements see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J.

C.2.12.5.3.5.2. The Contractor shall ensure that search capabilities is built into its information systems/data repository and the system shall be user-friendly.

C.2.12.5.4. The data shall be, at a minimum, available for queries on a Regional, MTF PSA, and standard geographic area (State, County, and ZIP Code) basis.

C.2.12.5.5. The data access interface will be mutually agreed upon by the GDA and Contractor no later than 150 calendar days prior to the SHCD.

C.2.12.5.6. The Contractor shall provide training and ongoing customer support for accessing the Contractor's data information system/data repository. Web-based training is acceptable.

C.2.12.5.6.1. The Contractor shall deploy this training no later than 75 calendar days prior to the SHCD and shall make additional training available on an ongoing basis.

C.2.12.5.6.2. The Contractor shall provide a reoccurring report of all Government trained personnel in its data information system/data repository. For reporting requirements see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J.

C.2.12.5.7. The Contractor shall provide customer service support to assist Government users during normal Government business hours, Monday through Friday, excluding weekends and holidays for all time zones in the geographic area of responsibility.

C.2.12.5.8. The Contractor shall provide information management and information technology support as needed to accomplish the stated functional and operational requirement of the TRICARE program and in accordance with the TSM.

C.2.12.6. Information Systems Security

C.2.12.6.1. The Contractor shall provide a completed system security plan (or extract thereof) and any associated plans of action developed to satisfy the security requirements of DFARS 252.204-7012, and in accordance with NIST Special Publication (SP) 800-171, “Protecting Controlled Unclassified Information in Nonfederal Systems and Organizations,” to describe the Contractor’s unclassified information system(s) and network(s) where DoD controlled unclassified information associated with the performance of this contract is processed, stored, or transmitted. For reporting requirements, see Contract Data Requirements List, DD Form 1423, located in Section J.

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C.2.12.6.2. The Contractor shall, upon request, provide the Government with access to the system security plan(s) (or extracts thereof) and any associated plans of action for each of the Contractor’s first-tier subcontractor(s), that processes, stores, or transmits DoD controlled unclassified information associated with the performance of this contract.

C.2.12.6.3. The Contractor shall identify and verify marking requirements for all DoD controlled unclassified information associated with the performance of this contract as prescribed by DoDM

5200.01 Vol 4, Controlled Unclassified Information, and DoDI 5230.24, Distribution Statements on Technical Documents.

C.2.12.6.4. The Contractor shall identify, track, and safeguard all DoD controlled unclassified information associated with the performance of this contract.

C.2.12.6.4.1. The Contractor shall document, maintain, and provide to the Government, a record of any first- tier subcontractor that receives or develops DoD controlled unclassified information, as defined in DFARS Clause 252.204-7012, and associated with the performance of this contract.

For reporting requirements, see Contract Data Requirements List, DD Form 1423, located in Section J.

C.2.12.6.5. The Contractor shall restrict unnecessary sharing and flow-down of DoD controlled unclassified information associated with the performance of this contract, in accordance with marking and dissemination requirements specified in the contract and based on a ‘need-to-know’ to perform the requirements of this contract.

C.2.12.6.6. The Contractor shall participate in the post-award Systems Integration Meeting (SIM), where the Government will present an overview or briefing on protecting DoD controlled unclassified information and compliance with DFARS Clause 252.204-7012.

C.2.12.7.…