T-5 Draft RFP Section C.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: Definitions are included in Title 32 Code of Federal Regulations Part 199.2 and the TOM, Appendix A.

C.1.4. Documents: 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 C18 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 a network of individual and institutional providers that provides TRICARE Prime and TRICARE Select benefits in the Contractor's geographic area of responsibility.

C.2.1.2. The Contractor shall obtain health plan accreditation from a nationally recognized accrediting organization for its health networks no later than 18 months after the start of health care delivery (SHCD) and maintain accreditation 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 of the applicable contract.

C.2.1.2.1. The Contractor shall ensure the higher standard applies when this contract and the accrediting body have differing standards for the same activity.

C.2.1.3. The Contractor shall submit a plan detailing all phases of network implementation. For plan details see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.

C.2.1.3.1. 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 TRICARE Prime Service Areas (PSAs) and Non-Prime Service Areas (NPSAs) specified in the contract.

C.2.1.3.2. RESERVED

C.2.1.4. The Contractor shall offer provider networks and services to TRICARE Prime and Select beneficiaries to ensure access to care and the opportunity to choose, enroll, add additional family members, or remain enrolled in the Prime or Select programs in accordance with TRICARE access to care and enrollment standards throughout all health care delivery periods of the contract. (See TOM Chapters 6, 11 and 16 for enrollment requirements.)

C.2.1.5. The Contractor shall establish and maintain a provider network for TRICARE Prime and Select Plans that optimize Markets/Military Medical Treatment Facilities (MTFs) and deliver health care services that improve desired health outcomes for TRICARE beneficiaries.

C.2.1.6. The Contractor shall establish PSAs/nPSAs using the zip codes for those areas mandated by the Government.

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C.2.1.6.1. The Contractor shall ensure the Mandatory Government PSA and nPSA ZIP code assignment list is updated with changes from DHA and implemented within its systems each month. For reporting requirements see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.

C.2.1.7. The Contractor shall maintain an on-line directory of network providers with data elements as listed in TOM, Chapter 5, Section 1, Paragraph 2.1.6.

C.2.1.7.1. The Contractor shall maintain a minimum TBD% accuracy (to be proposed by Offerors). “Accuracy” is defined as a directory entry (record) that contains correct information for all the following data elements: provider name, provider specialty, sub-specialty, gender, work address, and work telephone number and shall be reported monthly in accordance with DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.

C.2.1.7.2. The Contractor shall ensure that the information is refreshed with any updated data in the on-line network provider directory no less than once every 24 hours.

C.2.1.7.3. The Contractor shall ensure that the on-line network provider directory accessible to users on a continual (24 hours/7 days a week) basis except for scheduled downtime for system maintenance.

C.2.1.7.4. The Contractor shall, to the maximum extent possible, schedule system maintenance windows during weekends or non-peak hours to minimize disruption of services to beneficiaries.

C.2.1.7.5. The Contractor shall refresh the data contained in the TRICARE authorized (non-network) provider directory no less than semiannually.

C.2.1.8. 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.2.1.9. The Contractor shall meet, at a minimum annually, with the Government Designated Authority (GDA) and each Market Director/MTF Director to discuss Market/MTF optimization efforts. The purpose of these meetings is to ensure the Market/MTF optimizes care in accordance with their business plan/optimization initiatives.

C.2.1.10. The Contractor shall develop and submit a Value-Based Steerage Model/Plan identifying how they will measure their effectiveness at achieving: (1) access to care, (2) high quality, (3) MTF optimization/readiness, and (4) lowering average per capita cost. For plan reporting requirements see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.

C.2.1.10.1. 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

HT940220R0005 Page C4 of C18 above four elements. For reporting requirements see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.

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).

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

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 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.

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C.2.3.4.2. The Contractor shall ensure the higher standard applies when this contract and the accrediting body have differing standards for the same activity. For reporting requirements, see Contract Data Requirements List, DD Form 1423, located in Section J of the applicable contract.

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 offer in-home CM services to beneficiaries who have a high-need for care and are at high-risk of readmission 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)

C.2.5.1. The Contractor shall develop, implement and maintain an integrated, whole person, PH Program in accordance with TOM Chapter 7, Section 3.

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

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.

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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 system interface as described in TOM, Chapter 7, Section 5 and TSM, Chapter 1, Section 11 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.

C.2.7.6. The Contractor shall implement a process that optimizes referrals and authorizations to MTFs to enhance a medically ready force for beneficiaries enrolled in TRICARE Prime 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.2.9. Communications and Customer Service

C.2.9.1. The Contractor shall provide comprehensive readily accessible customer services for TRICARE-eligible beneficiaries and providers in accordance with TOM, Chapter 11.

C.2.9.2. The Contractor shall provide outreach and communication consistent with that offered to its commercial customers. Customer services shall include multiple, contemporary avenues of access (for example, email, World Wide Web, telephone, texting, smart phone applications, and other social media) for TRICARE-eligible beneficiaries.

C.2.9.3. The Contractor shall perform all customer service functions with knowledgeable, courteous, responsive staff that results in highly satisfied beneficiaries.

C.2.9.3.1. 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.

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C.2.9.4. 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.2.9.5. The Contractor shall provide customer service support for Markets, MTFs, Guard/Reserve Component units/commands, and the TRICARE Health Plan Customer Service Branch.

C.2.9.6. 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 5.

C.2.10. Claims Processing

C.2.10.1. The Contractor shall establish and maintain an automated claims processing system for TRICARE claims.

C.2.10.1.1. 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.2.10.1.2. 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.2.10.2. 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.2.10.3. 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.2.10.4. 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.2.10.5. 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.

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C.2.10.6. The Contractor shall capture and report TRICARE Encounter Data (TED) related to claims adjudication in accordance with the TSM.

C.2.10.7. The Contractor shall provide access to claims data for designated Defense Health Agency (DHA) and Services personnel (including Services personnel at the Market and MTF level).

C.2.10.7.1. 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.2.10.7.2. The Contractor shall provide training and ongoing customer support for its claims data system to Government users.

C.2.10.7.3. The Contractor shall provide training to its claims data system either in-person/onsite or virtually.

C.2.10.7.4. The Contractor shall ensure that its claims data system training materials are updated and current and made available to designated DHA key staff, including DHA Great Lakes, and Services personnel (including Services personnel at the Market/MTF level)

C.2.10.8. 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.2.10.8.1. Best commercial business practices shall include, but not limited to, the use of external data bases to achieve the goal of identification of accurate and complete OHI information.

C.2.10.8.2. 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.2.10.9. 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.2.11. Management

C.2.11.1. Qualified Key Personnel

C.2.11.1.1. The Contractor shall establish and maintain experienced and qualified key personnel and sufficient staffing and management support to meet the requirements of this contract. The

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Contractor shall make known to the Government who these key personnel are and regularly advise as changes in key personnel occur.

C.2.11.1.2. 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.

C.2.11.1.3. 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.2.11.2. Quality Management/Quality Improvement Program (QM/QI)

C.2.11.2.1. The Contractor shall establish and operate a QM/QI program and have in place at the start of health care delivery.

C.2.11.2.2. 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.2.11.2.3. 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.2.11.2.4. 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.2.11.2.5. 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 of the applicable contract.

C.2.11.2.6. 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.2.11.2.7. 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.

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C.2.11.2.8. 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.2.11.2.9. The Contractor shall, if problems are identified through its internal QM/QI Program, electronically submit a QM/QI report to the Government Designated Authority (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 of the applicable contract.

C.2.11.2.9.1. 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 of the applicable contract.

C.2.11.3. Coordination/Integration of Healthcare Delivery

C.2.11.3.1. The Contractor shall ensure efficient coordination of healthcare delivery between the direct care system and the Contractor's network.

C.2.11.3.2. 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.

C.2.11.3.3. 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. 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.2.11.4. Contingency Operations Program

C.2.11.4.1. 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 of the applicable contract.

C.2.11.4.1.1. 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.

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C.2.11.4.1.2. 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 capabilities.

C.2.11.4.1.3. 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.

C.2.11.4.2. The Contractor shall participate in contingency exercises including regionally coordinated table-top contingency exercises twice each calendar year per each Market and MTF.

C.2.11.4.2.1. The Contractor shall implement the contingency program at any or all locations within 48 hours of being notified by the Government Designated Authority (GDA) that a contingency exists.

C.2.11.4.2.2. The Contractor shall maintain contingency operations communications with the DHA, Markets and MTFs.

C.2.11.4.2.3. 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 of the applicable contract.

C.2.11.4.3. 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.2.11.4.3.1. The Contracting Officer (CO) will issue a contract modification defining the requirements for each SAT.

C.2.11.4.3.2. 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.2.11.4.3.3. The Contractor shall deploy one or more SAT teams within seven calendar days after notification from the CO.

C.2.11.4.3.4. 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.2.11.4.4. The Contractor shall, in cooperation with Markets and MTFs, coordinate the care and transfer of patients who require transfer to another location/area.

C.2.11.4.4.1. 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

HT940220R0005 Page C12 of C18 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.2.11.4.4.2. Transfers may occur as a result of medical, social, or financial reasons and include moves of non-institutionalized and institutionalized patients.

C.2.11.4.4.3. In contingency military operations, collaboration between military and civilian transport is crucial upon initial receipt of patients from Continental United States (CONUS) intermodal transportation and distribution hubs to higher echelons of care, as defined by U.S.

Transportation Command (USTRANSCOM).

C.2.11.5. Information System/Data Repository

C.2.11.5.1. 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.2.11.5.2. 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.2.11.5.2.1. 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.2.11.5.3. 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.2.11.5.3.1. The Contractor shall make available an additional 30 authorizations to be assigned at the discretion of the Government.

C.2.11.5.3.2. 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 of the applicable contract.

C.2.11.5.3.3. Data elements shall include, at a minimum, details concerning the provider network, referrals, authorizations, claims processing, program administration, beneficiary

HT940220R0005 Page C13 of C18 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.2.11.5.3.4. 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.2.11.5.3.

C.2.11.5.3.5. 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.2.11.5.3.5.1. 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 of the applicable contract.

C.2.11.5.3.6. The Contractor shall ensure that search capabilities is built into its information systems/data repository and the system shall be user-friendly.

C.2.11.5.4. 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.2.11.5.5. 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.2.11.5.6. 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.2.11.5.6.1. 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.2.11.5.6.2. 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 of the applicable contract.

C.2.11.5.7. 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.2.11.5.8. 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.

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C.2.11.6. Information Systems Security

C.2.11.6.1. The Contractor shall, upon request of the Government, provide a system security plan (or extract thereof) and any associated plans of action developed to satisfy the adequate 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” in effect at the time the solicitation is issued or as authorized by the Contracting Officer, to describe the Contractor’s unclassified information system(s)/network(s) where covered defense information associated with the execution and performance of this contract is processed, is stored, or is transmitted. For reporting requirements, see Contract Data Requirements List, DD Form 1423, located in Section J of the applicable contract.

C.2.11.6.2. 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 tier one level subcontractor(s), vendor(s), supplier(s), and the subcontractor’s tier one level subcontractor(s), vendor(s), and supplier(s), who process, store, or transmit covered defense information associated with the execution and performance of this contract.

C.2.11.6.3. The Contractor and Government will, during the post-award orientation conference, identify and affirm marking requirements for all covered defense information, as prescribed by DoDM 5200.01 Vol 4, Controlled Unclassified Information, and DoDI 5230.24, Distribution Statements on Technical Documents, to be provided to the Contractor, or to be developed by the Contractor, associated with the execution and performance of this contract.

C.2.11.6.4. The Contractor shall identify, track, and safeguard all covered defense information associated with the execution and performance of this contract.

C.2.11.6.4.1. The Contractor shall document, maintain, and provide to the Government, a record of tier 1 level subcontractors, vendors, and/or suppliers who will receive or develop covered defense information – as defined in DFARS Clause 252.204-7012 and associated with the execution and performance of this contract. For reporting requirements, see Contract Data Requirements List, DD Form 1423, located in Section J of the applicable contract.

C.2.11.6.5. The Contractor shall restrict unnecessary sharing and flow down of covered defense information, as defined in DFARS Clause 252.204-7012 and associated with the execution and performance of this contract, in accordance with marking and dissemination requirements specified in the contract and based on a ‘need-to-know’ to execute and perform the requirements of this contract. As part of the post-award Systems Integration Meeting (SIM), the Government will present an overview or briefing on protecting covered defense information and compliance with DFARS Clause 252.204-7012.

C.2.11.7. Personnel Security Program

C.2.11.7.1. The Contractor shall implement a personnel security program which meets TSM, Chapter 1, Section 1.1. requirements.

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C.2.11.8. Contractor Employee Identification

C.2.11.8.1. The Contractor’s employees shall identify themselves as Contractor employees and shall not act, or advertise as Government employees, agents, or representatives; including in telephone conversations, formal and informal written correspondence, paper and electronic; and in any other situation where their actions could be mistakenly construed as acts of Government officials.

C.2.11.9. Memorandums of Understanding (MOUs)

C.2.11.9.1. The Contractor shall develop MOUs/Memorandum of Agreements (MOAs) with DHA, Markets and MTFs that will be executed and signed as described in the TOM.

C.2.11.9.2. The Contractor shall maintain open communication and develop MOUs with the other TRICARE Contractors. Such MOUs shall delineate each Contractor’s responsibilities when beneficiaries and beneficiary information cross contract boundaries.

C.2.11.9.3. The Contractor shall ensure that the MOUs are executed no later than 90 calendar days prior to the SHCD. MOUs shall be developed for, but are not limited to, the following TRICARE Contractors.

C.2.11.9.3.1. The other MCSC, the TRICARE Dental Contractors, the TRICARE Overseas Program (TOP) Contractor, the TRICARE Medicare Eligible Program (TMEP) Contractor, the TRICARE Pharmacy Contractor (TPharm), the Nurse Advice Line (NAL) Contractor, the TRICARE Quality Monitoring (TQMC) Contractor, and the TRICARE Claims Review Services (TCRS) Contractor.

C.2.11.9.3.2. Topics addressed in these MOUs may include, but are not limited to, case management, care coordination, medication reconciliation, referrals/authorizations, beneficiary notifications, claims, OHI, disease surveillance/prevention, points of contact, and beneficiary facility transfers. The MOUs should also address any other procedures that facilitate the cooperation between Contractors, and the integration of their respective processes.

C.2.11.10. Market/MTF Optimization

C.2.11.10.1. The Contractor shall support Market/MTF business plan objectives and shall collaborate with the Government to support Market and MTF optimization.

C.2.11.10.2. The Contractor shall use commercially available web-based mapping software to calculate distance and time standards.

C.2.11.10.3. The Contractor shall provide user access to this software for up to 12 Government users at no additional cost no later than 120 calendar days prior to the SHCD to enable the Government to evaluate the Contractor’s calculations.

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C.2.11.10.4. The Contractor shall utilize the Government-provided Catchment Area Directory (CAD) file to update their processes/files as appropriate.

C.2.11.11. Systems Integration

C.2.11.11.1. The Contractor shall follow all systems integration requirements covering general automated data processing, TEDs, DEERS, and the TRICARE Duplicate Claims System (DCS) in accordance with the TSM.

C.2.11.12. Military Health System (MHS) GENESIS

C.2.11.12.1. The Contractor shall establish electronic system interface to ensure all required data needed to perform referral management and referral management messages are completely exchanged between the MHS GENESIS and Managed Care Support Contractor (MCSC) interface.

C.2.11.12.2. The Contractor shall, following completion of the MHS GENESIS to MCSC interface, maintain the interface through the remainder of the contract. Refer to the following attachments located in Section J of the contract:

J-XX: MHS GENESIS Interface Control Document (ICD) - Bi-Directional Interface from MHS GENESIS to the Managed Care Support Contractor (MCSC)

J-XX: MHS GENESIS Performance Work Statement (PWS)

C.2.11.13. Program Integrity (PI)

C.2.11.13.1. The Contractor shall have a PI unit dedicated to the TRICARE program that includes but not limited to predictive analytics, provider education, prevention, and prepayment-and post-payment reviews to ensure that necessary medical, pharmacy, and dental services are provided only to TRICARE eligible beneficiaries by authorized providers and reimbursement made to eligible beneficiaries or providers through appropriate claims adjudication and in compliance under existing law, Regulation and DHA instructions.

C.2.11.13.2. The Contractor’s PI Unit shall be focused on prevention, detection, correction, and deterrence of fraud and abuse in the TRICARE program.

C.2.11.13.3. The Contractor’s PI unit shall be compromised of experienced professionals that have anti-fraud experience and hold degrees, designations and/or certifications such as but not limited to: Registered Nurse/Bachelor of Science in Nursing (RN/BSN), Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Clinical Documentation Specialist (CCDS), Certification in Healthcare Compliance (CHC), Health Care Anti-Fraud Associate (HCAFA), Accredited Health Care Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), and JD (Juris Doctorate).

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C.2.11.13.4. The Contractor shall refer cases for disposition to DHA PI that involve $250,000 or greater in potential losses to the Government following procedures prescribed in 32 CFR 199.9 and TOM, Chapter 13.

C.2.11.13.5. The Contractor shall refer a minimum of TBD cases per year based on geographic area of responsibility to DHA PI that meet the minimum dollar threshold.

C.2.11.14. Privacy

C.2.11.14.1. The Contractor shall establish and maintain a privacy program which meets Federal, DoD, and DHA privacy requirements detailed in the TSM and TOM, Chapter 19.

C.2.11.15. Records Management

C.2.11.15.1. The Contractor shall operate and maintain a records management program in accordance with DoD Instruction (DoDI) 5015.02, “DoD Records Management Program,” February 24, 2015.

C.2.11.15.2. The Contractor’s records management program shall be operational no later than 120 calendar days prior to the start of SHCD.

C.2.11.15.3. The Contractor’s records management program shall adhere to the requirements outlined in TOM, Chapter 9, Records Management.

C.2.11.15.4. The Contractor shall appoint and maintain the staff necessary to meet the records management requirement including a Records Manager with the overall responsibility for the requirement and to liaise with the DHA Records Management Office.

C.2.11.15.4.1. The Contractor’s Records Manager shall have or obtain within one year of appointment the Certified Records Managers (CRM) credential issued through the Institute of Certified Records Managers.

C.2.11.15.4.2. The Contractor’s Records Manager shall have oversight of the Contractor’s records management program to ensure the planning, controlling, directing, organizing, training, promoting, and other managerial activities related to the creation, maintenance and use, and disposition of records, are carried out in such a way as to achieve adequate and proper documentation of Federal policies and transactions and effective and economical management of operations.

C.2.11.16. Financial Management

C.2.11.16.1. The Contractor shall follow all financial management requirements covering payments, claims refunds and collection procedures, invoicing, stale-dated checks, Electronic

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Funds Transfer (EFT), financial audits, and enrollment fee transfers in accordance with Section G, Section H, and TOM, Chapter 3.

C.2.11.17. Appeals and Hearings

C.2.11.17.1. The Contractor shall follow all requirements related to reconsideration procedures, appeals of medical necessity determinations, appeals of factual determinations, and DHA appeals in accordance with TOM, Chapter 12.

C.2.11.18. Telehealth

C.2.11.18.1. The Contractor shall develop a telehealth program that maximizes the availability of telehealth throughout provider networks and facilitates delivery of telehealth services in accordance with TOM, Chapter 27 and TPM, Chapter 7.

C.2.11.19. Transition

C.2.11.19.1. The Contractor shall employ the necessary resources to complete all transition-in requirements outlined in the TOM, Chapter 2 and the TSM.

C.2.11.19.2. The Contractor shall ensure fully operational services and systems at the SHCD and minimal disruption to the beneficiaries and Markets/MTFs.

C.2.11.19.3. The Contractor shall also fully comply with all necessary outgoing requirements.

C.2.11.19.4. The Contractor shall ensure that all operational areas and systems related to the seven key contract areas being evaluated during Performance Readiness Validation (PRV) and Performance Readiness Assessment and Verification (PRAV) are staffed with a sufficient number of qualified, trained personnel and that all systems and programs are functional prior to the SHCD in accordance with the timelines and performance thresholds identified in TOM, Chapter 2, Section 1.

C.2.11.19.4.1. The PRV/PRAV process will facilitate the evaluation of performance readiness in the following key contract areas: (1) provider networks, (2) enrollment, (3) customer service, (4) records management, (5) referral management, (6) claims processing, and (7) clinical operations.

See TOM, Chapter 2 for a description of the PRV/PRAV processes and specific requirements.