T-5 RFP.pdf

HT940220R0005

SOLICITATION, OFFER AND AWARD

4. TYPE OF SOLICITATION2. CONTRACT NUMBER 3. SOLICITATION NUMBER

7. ISSUED BY CODE 8. ADDRESS OFFER TO (If other than Item 7)

ORDER UNDER DPAS (15 CFR 700)

6. REQUISITION/PURCHASE NUMBER

NOTE: In sealed bid solicitations "offer" and "offeror" mean "bid" and "bidder".

NEGOTIATED (RFP)

SEALED BID (IFB)

5. DATE ISSUED

1. THIS CONTRACT IS A RATED RATING PAGE OF PAGES

1 199

C. E-MAIL ADDRESS

EXT.NUMBERAREA CODE

B. TELEPHONE (NO COLLECT CALLS)A. NAME

10. FOR

INFORMATION

CALL:

CAUTION: LATE Submissions, Modifications, and Withdrawals: See Section L, Provision No. 52.214-7 or 52.215-1. All offers are subject to all terms and conditions contained in this solicitation.

(Date)(Hour) local timeuntildepository located in copies for furnishing the supplies or services in the Schedule will be received at the place specified in Item 8, or if hand carried, in the

SOLICITATION

9. Sealed offers in original and

PART IV - REPRESENTATIONS AND INSTRUCTIONS

OTHER STATEMENTS OF OFFERORS

EVALUATION FACTORS FOR AWARD

INSTRS., CONDS., AND NOTICES TO OFFERORS

REPRESENTATIONS, CERTIFICATIONS AND

LIST OF ATTACHMENTS

CONTRACT CLAUSES

PART III - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACH.

I

J

K

L

M SPECIAL CONTRACT REQUIREMENTS

CONTRACT ADMINISTRATION DATA

DELIVERIES OR PERFORMANCE

INSPECTION AND ACCEPTANCE

PACKAGING AND MARKING

DESCRIPTION/SPECS./WORK STATEMENT

SUPPLIES OR SERVICES AND PRICES/COSTS

SOLICITATION/CONTRACT FORM

PART II - CONTRACT CLAUSESPART I - THE SCHEDULE

H

G

F

E

D

C

B

A

SEC. DESCRIPTION PAGE(S) (X) DESCRIPTION SEC. (X)

11. TABLE OF CONTENTS

18. OFFER DATE17. SIGNATURE

SUCH ADDRESS IN SCHEDULE.

IS DIFFERENT FROM ABOVE - ENTER

15C. CHECK IF REMITTANCE ADDRESS

EXT.NUMBERAREA CODE

15B. TELEPHONE NUMBER

(Type or print)AND

ADDRESS

OF

OFFEROR

CODE FACILITY

16. NAME AND TITLE OF PERSON AUTHORIZED TO SIGN OFFER15A. NAME

DATEAMENDMENT NO.DATEAMENDMENT NO.

and related documents numbered and dated):

amendments to the SOLICITATION for offerors

(The offeror acknowledges receipt of

14. ACKNOWLEDGEMENT OF AMENDMENTS

CALENDAR DAYS (%)30 CALENDAR DAYS (%)20 CALENDAR DAYS (%)10 CALENDAR DAYS (%)

(See Section I, Clause No. 52.232.8)

13. DISCOUNT FOR PROMPT PAYMENT

designated point(s), within the time specified in the schedule.

by the offeror) from the date for receipt of offers specified above, to furnish any or all items upon which prices are offered at the price set opposite each item, delivered at the

12. In compliance with the above, the undersigned agrees, if this offer is accepted within ______________ calendar days (60 calendar days unless a different period is inserted

NOTE: Item 12 does not apply if the solicitation includes the provisions at 52.214-16, Minimum Bid Acceptance Period.

OFFER (Must be fully completed by offeror)

IMPORTANT - Award will be made on this Form, or on Standard Form 26, or by other authorized official written notice.

28. AWARD DATE

(Signature of Contracting Officer)

27. UNITED STATES OF AMERICA

25. PAYMENT WILL BE MADE BY

26. NAME OF CONTRACTING OFFICER (Type or print)

CODE 24. ADMINISTERED BY (If other than Item 7)

ITEM

(4 copies unless otherwise specified)

23. SUBMIT INVOICES TO ADDRESS SHOWN IN

41 U.S.C. 253 (c) ( 10 U.S.C. 2304 (c) (

22. AUTHORITY FOR USING OTHER THAN FULL AND OPEN COMPETITION:

21. ACCOUNTING AND APPROPRIATION20. AMOUNT19. ACCEPTED AS TO ITEMS NUMBERED

AWARD (To be completed by government)

CODE

04/09/2021 X

HT9402

DEFENSE HEALTH AGENCY

DEFENSE HEALTH AGENCY-AURORA

16401 E CENTRETECH PARKWAY

AURORA CO 80011

1200 MDT 08/13/2021

Marcus Webb 303 marcus.r.webb.civ@mail.mil

676-3906

X

X

X

X

X

X

X

X

X

X

X

X

X

PAGE(S)

EVAN ZASLOW

AUTHORIZED FOR LOCAL REPRODUCTION

Previous edition is unusable

STANDARD FORM 33 (Rev. 9-97)

Prescribed by GSA - FAR (48 CFR) 53.214(c)

2-15 C1-C25

F1-F10 G1-G19 H1-H38

I1-I17

J1-J2

K1-K9

L1-L38 M1-M24

303-676-3646

EVAN.J.ZASLOW.CIV@MAIL.MIL

DO-C9

D1 E1

(Refer to L.4. Proposal Preparation)

(Refer to L.4.1. Electronic Proposal Submission and Proposal Due Date)

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

2 199

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940220R0005

(A) (B) (C) (D) (E) (F)

BASE YEAR; TRANSITION-IN PERIOD 1 Jan 2023 – 31

December 2023

0001 Transition-In (Firm-Fixed-Price) Planning and

Implementation of Transition-In as stated in

C.2.12.19

BASE YEAR; TRANSITION-IN PERIOD 1 Jan 2023 – 31

December 2023

0001AA Transition Readiness Milestone (5% of CLIN 0001 1 EA

Amount)

(Firm-Fixed-Price)

BASE YEAR; TRANSITION-IN PERIOD 1 Jan 2023 – 31

December 2023

0001AB Pre-Startup Validation Milestone (10% of CLIN 1 EA

0001 Amount)

(Firm-Fixed-Price)

BASE YEAR; TRANSITION-IN PERIOD 1 Jan 2023 – 31

December 2023

0001AC Pre-Open Season Milestone (40% of CLIN 0001 1 EA

Amount)

(Firm-Fixed-Price)

BASE YEAR; TRANSITION-IN PERIOD 1 Jan 2023 – 31

December 2023

0001AD Start of Health Care Delivery Milestone (45% of 1 EA

CLIN 0001 Amount)

(Firm-Fixed-Price)

0002 Contract Data Requirements List (DD Form

Continued ...

NSP

aminisini Sticky Note Completed set by aminisini aminisini Sticky Note None set by aminisini

3 199

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940220R0005

(A) (B) (C) (D) (E) (F)

1001 12 MO

1002 12 MO

1003AA IE

1003AB IE

1003AC IE

1423-1)(Not Separately Priced)

Transition-In

OPTION PERIOD 1 - 1 Jan 2024 – 31 December 2024

Underwritten Health Care Cost for Contractor

Network Prime Enrollees, Non-Prime Underwritten

Beneficiaries, and MTF Enrollees (Cost Plus Fixed

Fee)(Estimated Cost)

(Option Line Item)

Future Potential Demonstrations ($15,000,000 Government Plug-in Amount)

Anticipated Award Type: Firm-fixed-price (Option Line Item)

Managed Care Support Services

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(1st

Quarter of Calendar Year(CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(2nd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(3rd

Quarter of CY))

(Option Line Item)

Continued ...

15,000,000__________1,250,000

4 199

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(A) (B) (C) (D) (E) (F)

1003AD IE

1005 1 LO

1007 1 LO

2001 12 MO

2002 12 MO

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(4th

Quarter of CY))

(Option Line Item)

Clinical Support Agreements

(CSAs)(Firm-Fixed-Price)

(Option Line Item)

MTF/Guard/Reserve/MSO/VSO Briefings ($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

Contract Data Requirements List (DD Form

1423-1)(Not Separately Priced)

(Option Line Item)

Service Assist Teams (Mobile Disaster)($200,000 Ceiling)(Cost Reimbursable) (Option Line Item)

OPTION PERIOD 2 - 1 Jan 2025 – 31 December 2025

Underwritten Health Care Cost for Contractor

Network Prime Enrollees, Non-Prime Underwritten

Beneficiaries, and MTF Enrollees (Cost Plus Fixed

Fee)(Estimated Cost)

(Option Line Item)

Future Potential Demonstrations ($15,000,000 Government Provided Plug-in Amount)

(Option Line Item)

Continued ...

NSP

15,000,000__________1,250,000

5 199

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(A) (B) (C) (D) (E) (F)

2003AA IE

2003AB IE

2003AC IE

2003AD IE

2005 1 LO

Managed Care Support Services

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(1st

Quarter of Calendar Year(CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(2nd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(3rd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(4th

Quarter of CY))

(Option Line Item)

Clinical Support Agreements

(CSAs)(Firm-Fixed-Price)

(Option Line Item)

MTF/Guard/Reserve/MSO/VSO Briefings ($200,000 Ceiling) (Cost Reimbursable)

(Option Line Item)

Continued ...

6 199

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940220R0005

(A) (B) (C) (D) (E) (F)

2007 1 LO

3001 12 MO

3002 12 MO

3003AA IE

3003AB IE

3003AC IE

Contract Data Requirements List (DD Form

1423-1)(Not Separately Priced)

(Option Line Item)

Service Assist Teams (Mobile Disaster) ($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

OPTION PERIOD 3 - 1 Jan 2026 – 31 December 2026

Underwritten Health Care Cost for Contractor

Network Prime Enrollees, Non-Prime Underwritten

Beneficiaries, and MTF Enrollees (Cost Plus Fixed

Fee)(Estimated Cost)

(Option Line Item)

Future Potential Demonstrations ($15,000,000 Government Plug-in Amount) (Option Line Item)

Managed Care Support Services

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(1st

Quarter of Calendar Year(CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(2nd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

Continued ...

15,000,0001,250,000___________

7 199

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(A) (B) (C) (D) (E) (F)

3003AD IE

3005 1 LO

3007 1 LO

4001 12 MO

4002 12 MO

(Firm-Fixed-Price)(Estimated Quantity)(3rd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(4th

Quarter of CY))

(Option Line Item)

Clinical Support Agreements

(CSAs)(Firm-Fixed-Price)

(Option Line Item)

MTF/Guard/Reserve/MSO/VSO Briefings ($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

Contract Data Requirements List (DD Form

1423-1)(Not Separately Priced)

(Option Line Item)

Service Assist Teams (Mobile Disaster) ($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

OPTION PERIOD 4 - 1 Jan 2027 – 31 December 2027

Underwritten Health Care Cost for Contractor

Network Prime Enrollees, Non-Prime Underwritten

Beneficiaries, and MTF Enrollees (Cost Plus Fixed

Fee)(Estimated Cost)

(Option Line Item)

Planned Competitive Demonstrations Transition-Out ($3,000,000 Government Plug-in Amount) (Option Line Item)

Continued ...

3,000,000250,000________

8 199

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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(A) (B) (C) (D) (E) (F)

4003AA IE

4003AB IE

4003AC IE

4003AD IE

4005 1 LO

Managed Care Support Services

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(1st

Quarter of Calendar Year(CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(2nd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(3rd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(4th

Quarter of CY))

(Option Line Item)

Clinical Support Agreements

(CSAs)(Firm-Fixed-Price)

(Option Line Item)

MTF/Guard/Reserve/MSO/VSO Briefings ($200,000 Ceiling) (Cost Reimbursable)

(Option Line Item)

Contract Data Requirements List (DD Form

Continued ...

9 199

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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(A) (B) (C) (D) (E) (F)

4007 1 LO

5001 12 MO

5002 12 MO

5003AA EA

5003AB EA

5003AC EA

1423-1)(Not Separately Priced)

(Option Line Item)

Service Assist Teams (Mobile Disaster) ($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

OPTION PERIOD 5 - 1 Jan 2028 – 31 December 2028

Underwritten Health Care Cost for Contractor

Network Prime Enrollees, Non-Prime Underwritten

Beneficiaries, and MTF Enrollees (Cost Plus Fixed

Fee)(Estimated Cost)

(Option Line Item)

Future Potential Demonstrations

(Option Line Item)

Managed Care Support Services

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(1st

Quarter of Calendar Year(CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(2nd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(3rd

Quarter of CY))

(Option Line Item)

Continued ...

10 199

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(A) (B) (C) (D) (E) (F)

5003AD EA

5005 1 LO

5007 1 LO

6001 12 MO

6002 12 MO

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(4th

Quarter of CY))

(Option Line Item)

Clinical Support Agreements

(CSAs)(Firm-Fixed-Price)

(Option Line Item)

MTF/Guard/Reserve/MSO/VSO Briefings

($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

Contract Data Requirements List (DD Form

1423-1)(Not Separately Priced)

(Option Line Item)

Service Assist Teams (Mobile Disaster) ($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

OPTION PERIOD 6 - 1 Jan 2029 – 31 December 2029

Underwritten Health Care Cost for Contractor

Network Prime Enrollees, Non-Prime Underwritten

Beneficiaries, and MTF Enrollees (Cost Plus Fixed

Fee)(Estimated Cost)

(Option Line Item)

Future Potential Demonstrations

(Option Line Item)

Managed Care Support Services

(Option Line Item)

Continued ...

11 199

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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(A) (B) (C) (D) (E) (F)

6003AA IE

6003AB IE

6003AC IE

6003AD IE

6005 1 LO

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(1st

Quarter of Calendar Year(CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(2nd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(3rd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(4th

Quarter of CY))

(Option Line Item)

Clinical Support Agreements

(CSAs)(Firm-Fixed-Price)

(Option Line Item)

MTF/Guard/Reserve/MSO/VSO Briefings ($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

Contract Data Requirements List (DD Form

1423-1)(Not Separately Priced)

(Option Line Item)

Continued ...

12 199

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HT940220R0005

(A) (B) (C) (D) (E) (F)

6007 1 LO

7001 12 MO

7002 12 MO

7003AA IE

7003AB IE

7003AC IE

7003AD IE

Service Assist Teams (Mobile Disaster) ($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

OPTION PERIOD 7 - 1 Jan 2030 – 31 December 2030

Underwritten Health Care Cost for Contractor

Network Prime Enrollees, Non-Prime Underwritten

Beneficiaries, and MTF Enrollees (Cost Plus Fixed

Fee)(Estimated Cost)

(Option Line Item)

Future Potential Demonstrations

(Option Line Item)

Managed Care Support Services

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(1st

Quarter of Calendar Year(CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(2nd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(3rd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Continued ...

13 199

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HT940220R0005

(A) (B) (C) (D) (E) (F)

7005 1 LO

7007 1 LO

8001 12 MO

8002 12 MO

8003AA IE

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(4th

Quarter of CY))

(Option Line Item)

Clinical Support Agreements

(CSAs)(Firm-Fixed-Price)

(Option Line Item)

MTF/Guard/Reserve/MSO/VSO Briefings ($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

Contract Data Requirements List (DD Form

1423-1)(Not Separately Priced)

(Option Line Item)

Service Assist Teams (Mobile Disaster) ($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

OPTION PERIOD 8 - 1 Jan 2031 – 31 December 2031

Underwritten Health Care Cost for Contractor

Network Prime Enrollees, Non-Prime Underwritten

Beneficiaries, and MTF Enrollees (Cost Plus Fixed

Fee)(Estimated Cost)

(Option Line Item)

Future Potential Demonstrations

(Option Line Item)

Managed Care Support Services

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

Continued ...

14 199

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940220R0005

(A) (B) (C) (D) (E) (F)

8003AB IE

8003AC IE

8003AD IE

8005 1 LO

8007 1 LO

(Firm-Fixed-Price)(Estimated Quantity)(1st

Quarter of Calendar Year(CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(2nd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(3rd

Quarter of CY))

(Option Line Item)

Per Member Per Month (PMPM) in accordance with

Performance Requirements Section C

(Firm-Fixed-Price)(Estimated Quantity)(4th

Quarter of CY))

(Option Line Item)

Clinical Support Agreements

(CSAs)(Firm-Fixed-Price)

(Option Line Item)

MTF/Guard/Reserve/MSO/VSO Briefings ($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

Contract Data Requirements List (DD Form

1423-1)(Not Separately Priced)

(Option Line Item)

Service Assist Teams (Mobile Disaster)

($200,000 Ceiling) (Cost Reimbursable) (Option Line Item)

Continued ...

15 199

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(A) (B) (C) (D) (E) (F)

9001 Transition Out 6 Q1

(Option Line Item)

9002 Contract Data Requirements List (DD Form 1423-1)

Transition-Out (Not Separately Priced)

(Option Line Item)

EXTENSION PERIOD 1 JAN 2032 - 30 JUN 2032

9003 Extension of Services (FAR 52.217-8) 6-Month 6 MO

Option Period Extension, If Required

(Option Line Item)

SECTION C

DESCRIPTION/SPECIFICATIONS/STATEMENT OF WORK

HT940220R0005 Page C1 of C25

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 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 health care services to enhance the clinical expertise of providers in the direct care system (see definition of MTF optimization in the TRICARE Manual, Definitions1) for all TRICARE-eligible beneficiaries (see definition at Title 32 Code of Federal Regulations (CFR) Part 199.17(a)(6)(i)).

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 health care 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 of terms are provided in 32 CFR Part 199.2 and the TRICARE Manual, Definitions.

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 CFR Part 199

• TRICARE Policy Manual (TPM) 6010.60-M, April 2021

• TRICARE Reimbursement Manual (TRM) 6010.61-M, April 2021

• TRICARE Systems Manual (TSM) 7950.3-M, April 2021

• TRICARE Operations Manual (TOM) 6010.59-M, April 2021

C.1.4.1. The TRICARE Manuals provide instruction, guidance, and responsibilities in addition to the requirements set forth in the incorporated federal statutes and regulations and may not be

1Definitions are available at:

https://manuals.health.mil/pages/v3/DownloadManualFile.aspx?Filename=Definitions.pdf

HT940220R0005 Page C2 of C25 interpreted in contradiction thereto. Among the Manuals, the TPM takes precedence over the other three TRICARE Manuals. The TRM takes precedence over the TSM and the 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 preferred provider network of individual and institutional providers (see 32 CFR 199.17(p)) who produce high quality clinical outcomes for TRICARE beneficiaries.

C.2.1.1.1. The Contractor shall ensure that all of its network providers are Medicare participating providers (unless they are not eligible to be participating providers under Medicare) and that the providers in its network are sufficient in number, mix, and geographic distribution to provide the full scope of benefits for which all TRICARE enrollees are eligible under this contract, as described in 32 CFR 199.4, 32 CFR 199.5, and 32 CFR 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 geographic area of responsibility: Attachments J-1 through J-6, Mandatory Government Required PSA Lists; and 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 as necessary 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 expansions, Market/MTF provider deployments, facility downsizing, or facility closures.

C.2.1.1.4. The Contractor shall submit a network implementation plan detailing all phases of its network development and implementation in accordance with the TOM, Chapter 2, Section 3.

For plan details see DD Form 1423-1, Contract Data Requirements List (CDRL), located in Section J.

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

C.2.1.3. TRICARE Minimum Appointment Access Standards

C.2.1.3.1. The Contractor’s network shall meet minimum appointment access standards (see 32 CFR 199.17(p)(5)) for all provider types in the network.

C.2.1.4. TRICARE Minimum Travel Time Standards

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C.2.1.4.1. The Contractor shall, at a minimum, take into account normal traffic conditions and geographic barriers such as bridges, mountains, and tunnels in calculating beneficiary travel times.

C.2.1.4.2. The Contractor shall not use telemedicine access in the calculation of minimum travel 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 network is available to TRICARE beneficiaries.

C.2.1.5.2. The Contractor shall ensure its network ZIP code list is updated with changes from DHA and that such changes are implemented within its systems each month. For reporting requirements see DD Form 1423-1, CDRL, located in Section J.

C.2.1.6. The Contractor’s network shall meet all access to care standards listed in 32 CFR 199.17(p)(5). The Contractor’s network shall provide network coverage for at least 85 percent of TRICARE Select enrollees. For reporting requirements, see DD Form 1423-1, CDRL, 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 to the Government. For reporting requirements see DD Form 1423-1, CDRL, located in Section J.

C.2.1.6.2. The Contractor shall submit a plan for reporting on access to care for TRICARE beneficiaries. The Contractor’s plan shall explain how the Contractor will report access to care data at the PSA, Market, and State level for the Contractor’s geographic area of responsibility.

The Contractor shall report on how it measured appointment availability (e.g., by employing surveys). For plan reporting requirements see DD Form 1423-1, CDRL, located in Section J.

C.2.1.7. The contractor shall develop and implement a system for continuously monitoring network appointment availability for all provider and facility types. The Contractor shall assess appointment availability for each provider type in its network, at a minimum annually and otherwise as requested by the Government, to ensure beneficiary access to care. When directed by the Government, the contractor shall assess bed availability for each type of network facility.

For reporting requirements see DD Form 1423-1, CDRL, located in Section J.

C.2.1.8. The Contractor shall measure enrolled beneficiary access to telehealth services in rural, remote, and isolated areas. For reporting requirements see DD Form 1423-1, 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 or the availability of health care providers. For reporting requirements, see DD Form 1423-1, CDRL, located in Section J.

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C.2.1.10. The Contractor shall inform the Government, in a monthly report, of any instances of network inadequacy and shall submit a corresponding Corrective Action Plan (CAP).

Network inadequacy is defined as any failure to provide health care services within the network within the access standards, unless a Network Adequacy Waiver applies. The Contractor shall respond within two business days upon receipt of any inquiries from the Contracting Officer’s Representative (COR) concerning network inadequacy. For reporting requirements see DD Form 1423-1, 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. Identify the provider saturation rate for the specified geographic area: Calculated by dividing Providers Recruited into Network divided by number of providers (of the same type) in the specified area,

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

4. Demonstrate that the Contractor has exhausted its efforts to create a locality-based reimbursement rate waiver (see TRM, Chapter 5, Section 2).

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

C.2.1.12. Network Quality

C.2.1.12.1. The Contractor shall maintain accreditation by a national accrediting organization of its healthcare network in all geographic areas of responsibility throughout the life of this contract and all exercised options. National certification, in lieu of accreditation, is insufficient to meet this requirement. For reporting requirements, see DD Form 1423-1, CDRL, 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 using the quality metrics specified in the TOM Chapter 7, Section 6 and attachment J-11. The Contractor shall display meaningful quality metrics, at the individual provider and facility level, in an easily understood and accessible format as part of its online network directory.

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

The Contractor’s steerage model shall be constructed to achieve the following outcomes: (1) improved access to care, (2) utilization of high quality health care providers, (3) MTF optimization (see paragraph C.2.12.10) and readiness of the force (e.g., taking into account provider effectiveness in returning clinical information to referring MTFs (see paragraph C.2.9) (when applicable), and (4) lowering average per capita healthcare costs. For plan reporting requirements see DD Form 1423-1, CDRL, located in Section J.

C.2.1.12.4.1. The Contractor shall submit a monthly report on its Value-Based Steerage Model/Plan’s performance on each of the four elements described in C.2.1.12.4, at the Market level, as an expression of total value. For reporting requirements see DD Form 1423-1, CDRL, located in Section J.

C.2.1.13. Network Provider Directory

C.2.1.13.1. The Contractor’s network 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. Primary Care Manager (PCM) (Y/N)

6. TRICARE Provider Readiness Designation (Y/N)

7. Provider Type

8. Provider Specialty

9. Provider Subspecialty

10. Provider quality indicator(s)

11. Provider website (if available)

12. 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

7. Provider Subspecialty

8. Provider quality indicator(s)

9. Provider website (if available)

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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 its 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 of its on-line directory in accordance with the TRICARE Systems Manual.

C.2.1.13.4.1. The Contractor shall provide access on its website to a directory of TRICARE authorized, non-network providers who have submitted a claim to TRICARE over the past 14 months. The Contractor shall refresh this directory no less than semi-annually.

C.2.1.13.5. Provider Directory Accuracy

C.2.1.13.5.1. The Contractor shall use electronic means of 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 14 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 network 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 PSA and non- PSA area.

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 data accuracy are not applicable to the on-line directory of TRICARE authorized, non-network providers.

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C.2.1.13.5.6. Provider directory accuracy shall be reported monthly in accordance with DD Form 1423-1, CDRL, located in Section J.

C.2.1.13.5.7. 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, dis-enrollments, transfer enrollments, correct enrollment discrepancies, and assign or change beneficiary PCMs in accordance with the requirements 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 such automation shall include the capability to capture 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 the 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 health care 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 its Memorandum of Understanding (MOU) with each Market/MTF (see paragraph C.2.12.9).

C.2.3.2. The Contractor shall develop, implement, and maintain an electronic MM data system that complies with the 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 (as described in the TOM Chapter 7, Section 1, Paragraph 5), which are designed to support and manage the health care of individuals with high-cost conditions and complex medical conditions, inpatient admissions and discharges, pharmacy (specialty drugs, multiple medications or pharmacies), and beneficiaries receiving low quality care.

C.2.3.3.1. The Contractor, in order to provide the operations described in paragraph C.2.3.3, shall establish a beneficiary-centric data warehouse (for data pertaining to TRICARE Prime and Select enrolled beneficiaries) and employ industry best practice analytic tools/systems to exhibit sophisticated data analysis techniques with evidence-based algorithms. The Contractor shall provide the Government with real-time access to view all such data.

C.2.3.4. The Contractor shall obtain and maintain throughout the life of the contract accreditation from a nationally recognized accrediting organization for the following MM programs: utilization management, case management, and disease management.

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C.2.3.4.1. The Contractor shall obtain accreditation no later than 18 months after the Start of Healthcare Delivery (SHCD) and shall maintain such accreditation in all geographic areas of responsibility throughout the life of the contract, 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 the 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, as well as beneficiaries in the categories identified in TOM Chapter 7, Section 2. If a beneficiary declines case management services, the Contractor shall offer care coordination navigation and a dedicated POC until an issue is resolved.

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. In such cases, the contractor shall ensure that a case manager makes an in-home visit 48 to 72 hours post discharge.

C.2.5. Population Health (PH) Care

C.2.5.1. The Contractor shall develop, implement, and maintain integrated, whole person PH care within the constraints, boundaries, and benefits of the Current TRICARE program and in accordance with the TOM Chapter 7, Section 3.

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

C.2.5.3. The Contractor shall collaborate annually with the Government Designated Authority (GDA) to identify targeted diseases.

C.2.5.4. The Contractor shall establish a process for MTFs and network providers to refer beneficiaries for CC/DM services and shall communicate this process to all MTFs via its MTF MOUs (see paragraph C.2.12.9) and to all network providers via its provider handbook.

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C.2.6. Utilization Management (UM)

C.2.6.1. The Contractor shall develop, implement, and maintain a UM Program in accordance with the 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 a manner consistent with the 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-compliant computer-based method, as described in the TOM Chapter 7, Section 5, paragraph 1.3, to process referrals between itself and the Markets/MTFs in its geographic area of responsibility.

C.2.7.3. The Contractor shall address referral and authorization information requirements, directed referral guidelines, and the methods of communicating referral and authorization information in its MOUs with the Markets/MTFs (see paragraph C.2.12.9) in its geographic area of responsibility.

C.2.7.4. The Contractor shall implement a computer-based referral management system to process MTF-generated and contractor-initiated referrals for the Contractor’s geographic area of responsibility through an interface with MHS GENESIS as described in paragraph C.2.12.12.1., and allows clinical and administrative documents to be uploaded and associated to referrals. The Contractor’s electronic system shall exchange referrals between the Contractor’s system and MHS GENESIS in a HIPAA compliant 278 message in accordance with paragraph C.2.12.12.1.

C.2.7.5. The Contractor’s RM Program and referral management system shall optimize referrals and authorizations to MTFs for beneficiaries enrolled in TRICARE Prime.

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 shall have a provider credentialing program that complies with the requirements in the TOM Chapter 4, Section 1. When this contract and the accrediting

HT940220R0005 Page C10 of C25 organization have differing credentialing 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 necessary to produce the metrics identified in Attachment J-8, Clinical Quality Metrics, in accordance with the requirements of the TOM, Chapter 7, Section 3. 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 (including Clear and Legible Reports (CLRs))

C.2.9.1. The Contractor shall ensure that its network providers make available or transmit to the Government (see paragraph C.2.9.2. below) accurate, complete, and legible clinical records and information pertaining to care delivered, pursuant to referrals or orders from MTF providers, to

(1) active duty service members, and (2) TRICARE Prime beneficiaries assigned to MTF PCMs.

The contractor shall ensure that its network providers comply with all applicable privacy and confidentiality laws and regulations when returning such records and information to the Government.

C.2.9.1.1. The term “clinical records and information” includes but is not limited to the following:

1. Specialty evaluations (initial and follow up notes)

2. Laboratory results

3. Radiology study reports

4. Preventive services

5. Discharge summaries and emergency room reports

6. 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

7. Other clinical documents, such as documentation reflecting that a clinical diagnosis has been added, removed, or discontinued; documentation reflecting that a medication has been added, discontinued, and/or modified; documentation reflecting a referral to another provider; and documentation of provider orders.

The following documents are specifically excluded from the definition of clinical records and information: Documents associated with (1) ordering Durable Medical Equipment, (2) providing ambulance services, and (3) providing home health care services.

C.2.9.2. The Contractor shall ensure that its network providers use one of the following methods for returning clinical records and information to the Government:

C.2.9.2.1. Making the clinical records and information (including CLRs) electronically available, via connection to the eHealth Exchange, or another health information exchange (HIE) network or HIE framework (such as the CommonWell® Health Alliance or Carequality) that is connected

HT940220R0005 Page C11 of C25 to the Government’s electronic health record system, so that the Government may easily access such records and information. This is the preferred method.

C.2.9.2.2. Transmitting the clinical records and information to the designated point-of-contact (POC) at the applicable Market/MTF. The Government will provide all necessary POC information to the Contractor through the MOU process (see paragraph C.2.12.9.). The Contractor shall provide this POC information to all of its network providers in Markets/PSAs and shall require its network providers in these areas to transmit clinical records and information to the identified POC, consistent with the timeliness requirements of paragraph C.2.9.3, in cases where the providers are not connected to the eHealth Exchange or another HIE network or framework connected to the Government’s electronic health record system.

C.2.9.3. The Contractor shall ensure that its network providers make the required clinical records and information available to the Government, or transmit them to the Government, within 10 business days from the date of a patient’s visit/date of service or within 40 business days from the date of a patient’s discharge from inpatient care.

C.2.9.3.1. The Contractor shall establish a process to routinely follow up with network providers (no less than every 30 days) for missing clinical information/consultation reports.

C.2.9.3.2. The Contractor shall establish roles, responsibilities, and POCs for this follow-up process for each Market/PSA.

C.2.9.4. The Contractor shall maximize the inclusion, within its MTF referral networks, of individual and institutional providers that have and maintain access to, and comply with applicable technical standards to ensure ongoing connection with, the eHealth Exchange or another HIE network or HIE framework (such as the CommonWell® Health Alliance or Carequality) that is connect to the Government’s electronic health records system.

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 the TOM, Chapter 11.

C.2.10.2. The Contractor shall provide outreach and communication consistent with those services offered to its (or its parent or affiliate organization’s) 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 the TOM, Chapter 11.

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

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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 such certification shall 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 comply with all requirements related to TRICARE publications, social media, beneficiary outreach, website management, TRICARE branding, and media relations as described in the TOM, Chapter 11, Section 6.

C.2.10.7. Call Resolution

C.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.

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

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

C.2.10.7.4. The Contractor shall, if different departments/expertise is required to resolve a beneficiary question or concern, continue resolving the issue under the single beneficiary control number.

C.2.10.8. Call Backs

C.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 (from the time of the previous call) and direct the beneficiary into a queue for resolving previous issues.

C.2.10.8.2. The Contractor shall, if the beneficiary cannot provide an inquiry control number from a previous call, research the previous control number based on the issue, date, or beneficiary ID.

C.2.10.8.3. The Contractor may, if the beneficiary’s previous inquiry control number is over 30 calendar days old, assign the beneficiary a new inquiry control number.

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

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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 and route claims for optimal processing using systems capable of intelligent decisioning that combine business rules management, decision processing, real-time event detection, decision governance, and powerful advanced analytics to automate and manage decisions across the enterprise. The Contractor’s 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 Parts 199.4, 199.5, 199.17 and 199.18, as well as all applicable sections of 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 Part 199.8, the TPM, and TRM.

C.2.11.5. The Contractor's claims processing system shall interface with…