TDP6 RFP Performance Work Statement.pdf

SECTION C

DESCRIPTION/SPECIFICATIONS/STATEMENT OF WORK

TDP6

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Department of Defense Defense Health Agency

Performance Work Statement

TRICARE Dental Program Six Generation (TDP6)

J-10/Deputy Assistant Director, Health Care Operations Dental Program Section

Solicitation Number: HT9402-22-R-0001

Date: September 29, 2022

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PART 1

1.0 GENERAL INFORMATION

C.1.1 This is a non-personal services contract to provide the TRICARE Dental Program sixth generation (TDP6).

C.1.2 Description of services/introduction: The TDP6 contractor shall provide comprehensive dental care services worldwide to eligible TRICARE beneficiaries. The contractor shall provide all personnel, equipment, supplies, facilities, transportation, tools, materials, supervision, and other items and non-personal services necessary to fulfill the requirements of TDP6 as defined in this Performance Work Statement (PWS) except for those items specified as government furnished property and services. The contractor shall perform to the standards in this PWS.

C.1.3 Background: The TRICARE Dental contract supports the delivery of the Department of Defense (DoD) dental benefit, which is codified in 10 U.S.C. Chapter 55 § 1076a. The TRICARE Dental contract serves to integrate affordable dental health services to DoD Military Health System (MHS) beneficiaries, by private sector contractors, and driven by greater integration of dental business processes across the MHS. The Defense Health Agency (DHA) supports the MHS in its mission to provide dental health services through TRICARE dental care coverage for all eligible family members of Uniformed Service active duty, members of the Selected Reserve and Individual Ready Reserve (IRR) and their eligible family members.

C.1.4 Objectives:

• The contractor shall provide worldwide cost effective dental care services for enrollees.

• The contractor shall promote the value of utilizing diagnostic and preventive services.

• The contractor shall provide data systems in which to monitor dental health plan data and outcome measures for all dental care rendered.

C.1.5 Scope: The TDP offers worldwide dental coverage to all eligible family members of Uniformed Service active duty personnel, and to members of the Selected Reserve, the Individual Ready Reserve (IRR), the National Guard, and their eligible family members. Active duty service members, former spouses, parents, in-laws, disabled veterans, foreign personnel, and retirees and their families are not eligible for the TDP. The TDP geographic area of coverage for the Continental United States (CONUS) includes the 50 United States, the District of Columbia, Puerto Rico, Guam and the U.S. Virgin Islands. Outside the Continental United States (OCONUS) service area includes all other countries, island masses and territorial waters.

In order to fulfill DHA’s mission, TDP6 requires the contractor to establish and maintain a provider network in the 50 United States, District of Columbia, U.S. Virgin Islands, Guam, and Puerto Rico. In addition the contractor shall develop and maintain a list of Outside of the Continental United States (OCONUS) providers, referred to as TRICARE OCONUS Preferred Dentists (TOPDs).

The contractor shall be responsible for program operations and administration. TDP6 includes all associated administrative services, such as eligibility verification and enrollment, premium

HT9402-22-R-0001 C3 of C30 collection, customer service, claims processing, and beneficiary and provider education, which are at a minimum, consistent with the contractor’s commercial practices and industry standards.

C.1.6 Period of Performance (PoP):

Base Period/Transition-In: 12/01/2023 - 11/30/2024

Ordering Periods (OP) 1 through 5 will be:

OP 1: 12/01/2024 - 11/30/2025

OP 2: 12/01/2025 - 11/30/2026

OP 3: 12/01/2026 - 11/30/2027

OP 4: 12/01/2027 - 11/30/2028

OP 5: 12/01/2028 - 11/30/2029

The Residual Phase-Out CLIN (700X), will follow the last dental care delivery/transition out PoP.

Residual Phase-Out will begin after the last dental care delivery PoP (OP1, OP2, OP3, OP4, or OP5). The Government will exercise only one Residual Phase-Out CLIN (700X), which will depend on the last OP. The Residual Phase-Out CLIN’s period of performance will have a one year PoP. The Residual Phase-Out PoP is for the contractor to complete processing of all claims, grievances, and appeals from the last OP of dental care delivery.

C.1.6.1 Transition-in/transition-out periods.

C.1.6.1.1 Transition-in period: Full performance start date is, 1 December 2024 Transition-in performance is defined at C.5.4.1 and Section J, Attachment J-11, Transition-In.

C.1.6.1.1.1 The contractor shall comply with transition-in requirements of the DHA, as listed in paragraph C.1.11.1, for contractors needing to be issued Common Access Card (CAC) identification, including Department of Defense (DoD) and DHA-directed training and forms submission, prior to network access.

C.1.6.1.2 Transition-out period: Transition-out performance is defined at C.5.4.2 and Section J, Attachment J-12, Transition-Out and Residual Services.

C.1.6.1.2.1 The contractor shall comply with transition-out requirements of the DHA for contractors who have been issued a CAC or who generate “records”, as defined by C.5.5.

Records Management.

C.1.7 Administrative Specifications

C.1.7.1 Place of performance: The contractor shall perform work at at the contractor’s facility or in a remote environment as long as the required security precautions are documented and followed.

C.1.7.2 Recognized Federal holidays: The contractor is not required to perform services on the following holidays:

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New Year’s Day Labor Day Martin Luther King Jr.’s Birthday Columbus Day President’s Day Veteran’s Day Memorial Day Thanksgiving Day Juneteenth Day Christmas Day Independence Day

C.1.7.3 Hours of operation: The contractor shall conduct business Monday thru Friday, with Federal holidays at the contractor’s discretion or when the Government facility is closed due to local or national emergencies, administrative closings, or similar Government directed facility closings. The contractor’s customer service center shall be available in accordance with Section J, Attachment J-5, Program Operations. The contractor shall at all times maintain an adequate workforce for the uninterrupted performance of all tasks defined within this PWS when the Government facility is not closed for the above reasons.

C.1.8 Contractor travel: The contractor shall be required to travel to meetings hosted by DHA in CONUS and OCONUS regions. The Government will provide a 14-day notice for all meetings hosted by DHA at one of its Government locations. The Government will host up to a maximum of four meetings as determined by the Government, per OP at its CONUS Government locations. In addition, the Government will host up to a maximum of two meetings as determined by the Government, per OP at each of its OCONUS regions: TRICARE Eurasia/Africa, TRICARE Latin America/Canada, and TRICARE Pacific. The Government will provide at least a 2-month notice for all OCONUS meetings that require travel. These meetings are in addition to those stated in Section J, Attachment J-11, Transition-In; and Attachment J-12, Transition-Out and Residual Services. All contractor travel costs associated with any of these meetings shall be the responsibility of the contractor.

C.1.10 Quality

C.1.10.1 Quality Control (QC): The contractor shall develop and maintain an effective QC program to ensure services are performed in accordance with this PWS. The contractor shall develop and implement procedures to identify, prevent, and ensure nonrecurrence of defective services. The contractor’s QC program is the means by which the work complies with stated requirements. See C.5.6 Quality for additional information.

C.1.10.2 Quality assurance (QA): The government will evaluate the contractor’s performance under this contract in accordance with the Quality Assurance Surveillance Plan (QASP). This plan provides a systematic method for the Government to evaluate performance and to ensure that the contractor has performed in accordance with the performance standards. It defines how the performance standards will be applied, the frequency of surveillance, and the minimum acceptable defect rate(s). See C.5.6.2 Contract Surveillance for additional information.

C.1.11 Contractor personnel

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C.1.11.1 Contractor Common Access Card (CAC) requirements: For all contractors performing work on behalf of the Goverment, the Facilities Security Officer (FSO)/Company's Security point of contact (POC) shall provide the Government all the required information per the DHA CAC request process current version 2.1, January 2018, or more recent when updated. See Section J, Attachments J-13a, DHA CAC Request Process and J-16, TRICARE Service Manual (TSM), Chapter 1, Section 1.1. A CAC is the standard identification for eligible DoD contractor personnel.

C.1.11.2 Physical Security: The contractor shall be responsible for safeguarding all government information provided for contractor use (see C.5.2 System Security and TRICARE Operations Manual (TOM) Chapter 1, Section 5).

C.1.12 Contract Management and Administration: The contractor shall establish clear organizational lines of authority and responsibility to ensure adequate, effective resources are assigned to the contract requirements. The contractor shall have primary and alternate points of contact who are authorized to negotiate with the Government and commit to contract implementation and compliance (see Section G.3, Contract Administration). The contractor shall notify the Government within 5 business days of personnel changes to the contractor’s leadership (e.g. president, vice president, etc.) and/or any changes to the primary and alternate points of contact.

C.1.12.1 The contractor shall establish and maintain effective management strategies, staff education and training programs, and coordination interfaces with the Government. The contractor shall comply with the directives cited in Part 2, paragraph C.2.3, Applicable Directives.

C.1.12.2 Out of Office and Closures: The contractor shall notify the the Contracting Officer’s Representative (COR) 24 hours in advance (unless an emergency) when its primary and alternate points of contact will be out of the office for a full day or more.

C.1.13 Data rights: The contractor shall identify its proprietary data in accordance with the TOM, Chapter 9 Records Management and Section J, Attachment J-12, Transition-Out and Residual Services.

C.1.14 Reporting

C.1.14.1 Government’s COR: The COR monitors all technical aspects of the contract and assists in contract administration. The COR is authorized to perform the following functions:

assure that the contractor performs the technical requirements of the contract; perform inspections necessary in connection with contract performance; maintain written and oral communications with the contractor concerning technical aspects of the contract; issue written interpretations of technical requirements, including Government drawings, designs, specifications; monitor contractor's performance and notifies both the CO and contractor of any deficiencies; coordinate availability of government furnished property; and provide site entry of contractor personnel. A letter of designation issued to the COR, a copy of which is sent to the contractor, states the responsibilities and limitations of the COR, especially with regard to

HT9402-22-R-0001 C6 of C30 changes in cost or price, estimates or changes in delivery dates. The COR is not authorized to change any of the terms and conditions of the resulting contract.

C.1.14.2 Post award conference/periodic progress meetings: The contractor shall attend any post award conference convened by the contracting activity or contract administration office in accordance with FAR Subpart 42.5. The Contracting Officer (CO), COR, and other Government personnel, as appropriate, may meet periodically with the contractor to review the contractor's performance (typically conducted via telephone). At these meetings the CO will apprise the contractor of how the government views the contractor's performance and the contractor will apprise the Government of problems, if any, being experienced. Appropriate action shall be taken to resolve outstanding issues. These meetings shall be at no additional cost to the government.

C.1.15 Contractor Identification

C.1.15.1 Contractors, including subcontractors at all tiers, shall provide for a clear distinction from Government personnel. Contractor employees shall not act, advertise, or presume to be Government employees, agents, or representatives. Contractor employees are required to appropriately identify themselves as contractor employees at all times, including in telephone conversations, formal and informal written correspondence, paper and electronic, and in any other situation where their actions could be construed as acts of Government officials, unless, in the judgment of the Government, no harm can come from failing to identify themselves.

Contractor employees shall be introduced as contractor personnel and display distinguishing visible identification at all times whether in conversations, meetings, or other forms of communication with Government personnel.

C.1.15.2 Contractor personnel, while performing in a contractor capacity, shall refrain from using their retired or reserve component military rank or title (if applicable) in written or verbal communications associated with the contracts for which they provide services.

C.1.15.3 The contractor shall incorporate the substance of this requirement in all subcontracts awarded under this contract.

C.1.16 Contractor Access to Health Affairs (HA)/DHA Network(s)

C.1.16.1 FSO/Company's Security POC shall notify the DHA Personnel Security Office after being awarded a contract that requires access to a DoD system in accordance with Section J, Attachment J-16 TSM, Chapter 1, Section 1.1. Contractor personnel requiring access to the HA/DHA networks for performance of their tasks require a background investigation and the security awareness training. The contractor shall be prepared for this process as it could take two

(2) or more weeks. The FSO/Security POC shall submit a Standard Form (SF) 85 to DHA's Personnel Security Office for a background investigation.

C.1.16.2 Company's FSO/Security POC must notify the Personnel Security Office when the contractor has submitted the SF-85. The FSO/Security POCmust notify the DHA Personnel

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Security Office in writing of a contractor's termination from the contract, including the termination date (see Section J, Attachment J-16 TSM, Chapter 1, Section 1.1).

C.1.17 Personnel Security

C.1.17.1 The contractor shall comply with DoDI 8582.01, “Security of Non-DoD Information Systems Processing Unclassified Non-Public DoD Information”, dated December 9, 2019; DoD Manual (DoDM) 6025.18, “Implementation of the HIPAA Privacy Rule in DoD Health Care Programs” dated March 13, 2019, DoDI 8580.02 Security of Individually Identifiable Health Information in DoD Health Care Programs, August 12, 2015; and DoDI 5200.02 “DoD Personnel Security Program (PSP),”March 21, 2014 (see Section J, Attachment J-16 TSM, Chapter 1, Section 1.1). Contractor responsibilities for ensuring personnel security include, but are not limited to, meeting the following requirements:

C.1.17.1.1 Follow the DHA Personnel Security Office guidelines for submittal of security clearances. Contact the DHA Personnel Security Office for guidance on the appropriate background investigation required for personnel on the contract. The DHA Personnel Security Office can be reached at (703) 275-6038.

C.1.17.1.2 Initiate, maintain, and document personnel security investigations appropriate to the individual’s responsibilities and required access to Controlled Unclassified Information (CUI) (see C.5.2 System Security).

C.1.17.1.3 DHA Personnel Security Office does not deny any access to any automated information system (AIS), network, or Controlled Unclassified Information (CUI). If a contractor receives an unfavorable background investigation, the request for access will be sent back to the FSO for further action. Any unfavorable adjudication will result in DHA Personnel Security Office not signing off on any access request.

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PART 2

2.0 DEFINITIONS, ACRONYMS, AND APPLICABLE

PUBLICATIONS/INSTRUCTIONS

C.2.1 Definitions: See Section J, Attachment J-1, Definitions and Acronyms, 32 CFR 199.13(b) and the TRICARE Operations Manual, Appendix A (http://manuals.health.mil).

C.2.2 Acronyms: See Section J, Attachment J-1, Definitions and Acronyms, and the TRICARE Operations Manual, Acronyms (http://manuals.health.mil).

C.2.3 Applicable Directives: The following documents form an integral part of this contract and have the same force and effect as if set forth in full text. The TRICARE Manuals provide instruction, guidance and responsibilities to establish contractual requirements for implementation of federal statutes and regulations. In the event of a conflict between the manuals and either statute or regulation, which are incorporated into this contract, the statute or regulation takes precedence. If there is a conflict between the manuals, the order of precedence is (1) TRICARE Policy Manual (TPM); (2) TRICARE Systems Manual (TSM); and (3) TRICARE Operations Manual (TOM). The TRICARE Manuals are located at http://manuals.health.mil. If the contractor believes that a conflict exists between the incorporated documents, the contractor shall inform the /CO.

C.2.3.1 Title 10, United States Code (U.S.C.)., Chapter 55, Section 1076a.

C.2.3.2 32 Code of Federal Regulations (CFR) Part 199.3, 199.6, 199.9, 199.10 and 199.13.

C.2.3.3 36 CFR Part 1222 (data created or received and maintained for the Government by contractors).

C.2.3.4 45 CFR Parts 160, 162 and 164 (the Health Insurance Portability and Accountability Act of 1996 (HIPAA) security and privacy standards, transaction and code set standards, National Provider Identifier (NPI) requirements and implementation specifications).

C.2.3.5 National Institute of Standards and Technology (NIST) Special Publications (SP) 800- 171.

C.2.3.6 TRICARE Policy Manual (TPM) 6010.60-M, April 1, 2015 through change 99. The following TPM Sections apply:

• Chapter 8, Section 13.1 Adjunctive Dental Care

• Chapter 8, Section 13.2 Dental Anesthesia

• Chapter 10, Section 5.1 paragraph 2.10 Dental Coverage

• Chapter 10, Section 9.1 – Early Eligibility Benefits for the Reserve Components (RCs)

• Chapter 10, Section 10.1 TRICARE Coverage for Certain Members of the National

Guard (NG)

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C.2.3.7 TRICARE Systems Manual (TSM) 7950.3-M, April 1, 2015, through change 61. The following TSM chapters apply:

• Chapter 1, General Automated Data Processing (ADP) Requirements (Section J, Attachment J-16, TSM Chapter 1, Section 1.1 will be utilized by the TDP contractor until it is published in the TSM.)

• Chapter 3, Defense Enrollment Eligibility Reporting System (DEERS) (Section5.2 does not apply to TDP)

Note: The TRICARE Encounter Data (TED) requirement as stated in the TSM does not apply to

TDP.

C.2.3.8 TRICARE Operations Manual (TOM) 6010.59-M, April 1, 2015, through change 110.

The following TOM chapters apply:

• Chapter 1, Section 1 - Organization of the Defense Health Agency (DHA) Section 2 - Contract Administration and Instructions (excluding paragraph 4.0 and 5.0) Section 4 - Management (excluding paragraphs 2.2, 2.3, 2.4, 3.1, 3.2, 3.4 and 4.0) Section 5 - Compliance with Federal Statutes Section 6 - Legal Matters

• Chapter 2, Section 10 Other Requirements (only paragraph 6.0 Appeals and Hearings applies per Contract Data Requirements List (CDRL) R130 Appeals Processing Guidelines, Desk Instructions, and Reference Materials)

• Chapter 9, Records Management ( Section 5, paragraph 3.0 Transfer to Other Contractors/Records Center, does not apply to TDP per Section J, Attachment J-12, Transition-Out and Residual Services, paragraph 3.18 Records Disposition)

• Chapter 11, Section 8 - Grievances and Grievance Processing Addendum A TRICARE Logo

• Chapter 12, Appeals and Hearings

• Chapter 13, Program Integrity

• Chapter 14, Section 1 - Contract Data Requirements Lists (CDRLs), Plans and Access

• Chapter 19, Health Insurance Portability and Accountability Act (HIPAA) of 1996

• Chapter 24, Section 12 - TRICARE Overseas Program (TOP) Point of Contact (POC)

Program

• Chapter 28 – Prescription Monitoring Program (PMP)

• Appendix A, Definitions

• Acronyms and Abbreviations may be located at http://manuals.health.mil

C.2.3.9 When a statute, regulation, or manual changes, the contract requirements shall not change until the Contracting Officer modifies the contract to incorporate the change. The contractor shall utilize the most current version of the TRICARE manuals for the requirements stated above (paragraphs C.2.3.6 through C.2.3.8). When a manual change is applicable to the contract, a contract modification will be issued to incorporate the change and update the manual references to reflect the latest manual change number. Manual change numbers may also be

HT9402-22-R-0001 C10 of C30 updated when other modifications are issued. In the event there are no applicable manual changes during an OP, an administrative modification may be issued annually to update the manual references to the most current manual change number.

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PART 3

3.0 GOVERNMENT FURNISHED PROPERTY, EQUIPMENT, AND SERVICES

The Requiring Activity Authority has assessed the need for Government Furnished Property, Equipment, and Services and determined:

C.3.1 Services: The Government will NOT provide Government Furnished Services in support of this contract/task order.

C.3.2 Facilities: The Government will NOT provide Facilities in support of this contract/task order.

C.3.3 Utilities: The Government will NOT provide Utilities in support of this contract/task order.

C.3.4 Equipment: The Government will NOT provide Equipment in support of this contract/task order.

C.3.5 Materials: The Government IS providing Materials in support of this contract/task orders.

The Government-provided Materials are described below:

C.3.5.1 The Government will provide the contractor electronic data files containing relevant information pertaining to all sponsors. The Government will provide to the contractor a list of these data files and delivery times at the transition-in meeting with DMDC (see Section J, Attachments J-11, Transition-In). These data files will assist the contractor in determining their provider network adequacy and with beneficiary educational purposes. The contractor shall comply with the security requirements stated in C.5.2 prior to receiving the data files.

Thereafter, a list of newly identified sponsors will be furnished Quarterly every OP.

C.3.5.2 The Government will provide the contractor the appropriate application software required to access the Defense Manpower Data Center's (DMDC) Defense Eligibility Enrollment Reporting System (DEERS) to perform eligibility inquiries and enrollments. The Government will grant the contractor access to DEERS only after the contractor's staff and all subcontractors' staff who will utilize systems which access and maintain TDP data, are compliant with the safeguarding methods for unclassified DoD information, personnel security and clearance requirements stated in C.5.1. The contractor and its subcontractors shall comply with C.5.1, no later than 120 days after award.

C.3.5.3 DMDC will notify all TDP enrollees that a new enrollment card is available on the milConnect.com site. Upon award of a new TDP contract, a new enrollment card will be generated for existing enrollees only if the TDP contract is awarded to a non-incumbent contractor.

C.3.5.4 The Government will print and provide to the contractor educational documents as identified in Section J, Attachment J-5, Program Operations.

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PART 4

4.0 CONTRACTOR FURNISHED ITEMS AND SERVICES

C.4.1 Services: The Contractor will NOT provide Contractor Furnished Services in support of this contract/task order.

C.4.2 General: The contractor shall furnish all supplies, equipment, facilities and services required to perform work listed under Part 5 of this PWS.

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PART 5

5.0 SPECIFIC TASKS

C.5.1 PERFORMANCE REQUIREMENTS

C.5.1.1 The contractor shall provide worldwide cost effective dental care services for enrollees.

C.5.1.1.1 The contractor shall comply with the most current version of American Dental Association's (ADA) Current Dental Terminology (CDT) manual for covered services and update its required systems.

Performance Standards

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

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

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

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

C.5.1.1.2 The contractor shall offer multiple avenues of access for continuous and open enrollment. Minimum avenues of access will be telephone, paper, and on-line enrollment. The members’ enrollment must be able to transfer between active duty, Selected Reserve, IRR and National Guard status (see Section J, Attachments J-3, TDP Coverage Plans and J-5, Program Operations).

Performance Standards

a) Standard: Enrollment actions shall be processed and monitored in accordance with the TSM Chapter 3 and Section J, Attachment J-5, Program Operations.

Acceptable Quality Level (AQL): 99% of entries for telephone and paper enrollments will be accurate and complete.

b) Standard: If an enrollment application and premium payment are received after the 20th day of the month, enrollment will begin on the first day of the second month after the month in which the contractor received the application.

AQL: 95% of applications will be processed in accordance with the standard.

Deliverables M010 Management Report M070 Enrollment and Fee Reconciliation Analysis Report Q030 Enrollment Activity Summary Report

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S050 Survivor Covered Lives and Utilization Report

C.5.1.1.3 The contractor shall provide and maintain access to general and specialty network providers for enrollees.

Network compliance shall be determined based off the network provider’s fixed structure location. “Driving miles” do not include alternative means of transportation (e.g. ferries, trains, or planes) in order for the beneficiary to access the provider’s office. DHA defines:

• “Very Rural” is defined as less than 300 residents per square mile.

• “Rural” is defined as more than 300 to 1,000 residents per square mile.

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

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

The contractor may utilize the Census Bureau for determining the number of residents of the above stated areas. See Section H.3.1.3, Network Provider Retention incentive, and Section J, Attachment J-5, Program Operations for provider requirements.

Performance Standards

a) Standard: The contractor shall establish networks for general dental care in the 50 United States, District of Columbia, U.S. Virgin Islands, Guam, and Puerto Rico.

AQL: (1) For Very Rural: 95% of enrollees shall have access to one general dentist within 21 calendar days of requesting a periodic or initial (non-emergency) appointment and within 35 driving miles of their place of residence.

(2) For Rural: 95% of enrollees shall have access to two general dentists within 21 calendar days of requesting a periodic or initial (non-emergency) appointment and within 25 driving miles of their place of residence.

(3) For Suburban: 96% of enrollees shall have access to three general dentists within 21 calendar days of requesting a periodic or initial (non-emergency) appointment and within 15 driving miles of their place of residence.

(4) For Urban: 96% of enrollees shall have access to four general dentist within 21 calendar days of requesting a periodic or initial (non-emergency) appointment and within 5 driving miles of their place of residence.

b) Standard: The contractor shall establish networks for specialty dental care in the 50 United States, District of Columbia, U.S. Virgin Islands, Guam, and Puerto Rico.

AQL: (1) 90% of enrollees shall have access to an orthodontist within 28 calendar days of requesting an appointment and within 35 driving miles of their place of residence.

(2) 95% of enrollees shall have access to an oral surgeon within 28 calendar days of requesting an appointment and within 35 driving miles of their place of residence.

(3) 85% of enrollees shall have access to an endodontist within 28 calendar days of requesting an appointment and within 35 driving miles of their place of residence.

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(4) 85% of enrollees shall have access to a periodontist within 28 calendar days of

(5) 60% of enrollees shall have access to a prosthodontist within 28 calendar days of

c) Standard: The contractor shall maintain a network provider retention rate in accordance with Section J, Exhibit A, Contract Data Requirements List (CDRL) M020, Provider Network Access Report. For OP 1 the COR will validate the baseline 6 months after start of dental care delivery.

The baseline shall be reset at the beginning of each OP, and the Contracting Officer Representative (COR) will re-validate at the end of the OP.

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

d) Standard: The contractor shall deploy Mobile Dental Units (MDUs) in accordance with Section J, Attachment J-5, Program Operations for areas in which there are no practicing dentists.* AQL: MDUs shall be deployed once in each OP for up to five consecutive days to a centrally-located area within each identified county to serve those 200 or more enrollees whose closest practicing dentist is located 50 or more miles from the enrollee’s place of residence or the enrollees reside in a non-compliant area.

*The standard applies until such time a practicing dentist (network or non-network) resides in the location and access standards are met. A minimum of 30% of TDP enrollees must be scheduled for mobile care in each location per event for a mobile unit to be deployed and the standard to apply.

Deliverables M020 Provider Network Access Report

C.5.1.1.4 The contractor shall develop, maintain and make available to enrollees, providers and Government representatives an up-to-date directory of network providers.

Performance Standard

a) Standard: The contractor shall post the updated directory on the contractor’s website in accordance with Section J, Attachment J-5, Program Operations.

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

Deliverables M020 Provider Network Access Report

C.5.1.1.5 The contractor shall develop and maintain agreements with TRICARE OCONUS Preferred Dentists (TOPDs).

Performance Standards

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a) Standard: The contractor shall complete agreements with providers identified by the Government and for any new providers identified each OP in accordance with Section J, Attachments J-6a, OCONUS Program Operations, and J-11, Transition-In.

AQL: The contractor shall complete agreements with 95% of providers identified by the DHA COR prior to OP 1 and any new providers identified each OP.

b) Standard: The contractor shall make available to enrollees, TOPDs and Government representatives an up-to-date list of TOPDs in accordance with Section J, Attachment J-6a, OCONUS Program Operations.

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

Deliverables W010 Transition-In Status Report M010 Management Report

C.5.1.1.6 The contractor shall process claims to completion for enrollees and providers.

Process to completion is defined in the TOM, Appendix A.

Performance Standards

a) Standard: Process CONUS claims to completion in accordance with Section J, Attachment J-5, Program Operations.

AQL: CONUS Claims

95% within 14 business days of receipt 98% within 30 business days of receipt 100% within 60 business days of receipt

b) Standard: Process OCONUS claims to completion in accordance with Section J, Attachment J-6a, OCONUS Program Operations.

AQL: OCONUS Claims

95% within 21 business days of receipt 98% within 30 business days of receipt 100% within 60 business days of receipt

c) Standard: Claims shall be accurately paid in accordance with the covered benefit. CONUS and OCONUS claims shall be separately tracked.

AQL: 97% are accurately paid

d) Standard: Claim errors shall be corrected. CONUS and OCONUS claims shall be separately tracked.

AQL: 99% are corrected

Deliverables M010 Management Report M030 OCONUS Payment Report M050 Worldwide Incurred/Paid Claims Report

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S010 Utilization by Uniformed Services Active Duty (AD) Report S020 Utilization by Uniformed Service National Guard Reserve (NGR) Report S030 Utilization CONUS/OCONUS Frequency & Dollar Report S040 Utilization CONUS/OCONUS Denied Services Report S050 Survivor Covered Lives and Utilization Report

C.5.1.1.7 The contractor shall process appeals to completion for enrollees and providers.

Performance Standards

a) Standard: Appeals shall be processed in accordance with 32 CFR 199.13(h) and the TOM, Chapter 12 (Use Section J, Attachment J-9, Appeals Summary Log in place of Figure 12.A-2 of the TOM).

b) Standard: The contractor shall process non-expedited medical necessity and factual reconsiderations to completion.

AQL: 90% within 30 calendar days of receipt 95% within 60 calendar days of receipt 100% within 90 calendar days of receipt

c) Standard: The contractor shall process to completion determinations reversed by appeals.

AQL: 100% within 21 calendar days of receipt

Deliverables M010 Management Report R120 Appeals Processing Guidelines, Desk Instructions and Reference Materials

C.5.1.1.8 The contractor shall process grievances to completion for enrollees and providers.

Performance Standards

a) Standard: The contractor shall process grievances to completion in accordance with TOM, Chapter 11, Section 8.

AQL: 95% within 60 calendar days of receipt

Deliverables M010 Management Report

C.5.1.1.9 The contractor shall provide readily accessible comprehensive customer service for beneficiaries and providers.

Performance Standards

a) Standard: The contractor shall provide customer service in accordance with Section J, Attachment J-5, Program Operations.

AQL: (1) 98% of telephone calls answered by Automated Response Unit within 30 seconds.

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(2) 80% of telephone calls answered by Customer Service Representative (CSR) within 30 seconds of selection by caller.

(3) 5% or less telephone calls blocked at all times (measured at least hourly)

(4) 80% of telephone calls resolved during the initial call; 99.9% within 7 business days.

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

95% within 7 business days of receipt 99.9% within 20 business days of receipt.

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

85% within 10 business days 99.9% within 30 business days.

b) Standard: The contractor shall maintain overall customer satisfaction with TDP. The measurement will be based on the annual average of the quarterly customer satisfaction phone surveys conducted by DHA, Defense Health Cost Assessment and Program Evaluation (DHCAPE). The results will be provided to the contractor within 30 calendar days of completing each of the quarterly surveys.

AQL: At least 95% of those surveyed will indicate that, overall, they are at a minimum

“somewhat satisfied”.

Deliverables M010 Management Report (applies only to Standard ‘a’ above)

C.5.1.1.10 The contractor shall develop and maintain a Quality Control Program.

Performance Standard

a) Standard: The contractor shall develop and implement procedures to identify, prevent, and correct problems in accordance with Section C.5.6 Quality.

AQL: 99% of sampled claims shall indicate appropriate standard of care was rendered each

OP.

Deliverables Q010 Quality Control Program (QCP) Report

C.5.1.2 The contractor shall promote the value of utilizing diagnostic and preventive services.

C.5.1.2.1 The contractor shall inform and educate beneficiaries and providers about the program benefits with emphasis to the beneficiaries about the benefit of utilizing diagnostic and preventive services.

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Performance Standard

a) Standard: The contractor shall comply with its education plan in accordance with Section J, Attachments J-5, Program Operations and J-6a, OCONUS Program Operations. The contractor shall allow 30 calendar days for the DHA Dental Program Section to approve/deny any changes to the contractor’s education plan. Timing of the publication and/or implementation shall be mutually agreed upon between the contractor and DHA Dental Program Section.

AQL: 100% of planned education activities shall be completed within the current OP.

Deliverables AP010 Beneficiary and Provider Education Plan R110 MOU with DHA Communications

C.5.1.3 The contractor shall provide data systems in which to monitor dental health plan data and outcome measures for all dental care rendered.

C.5.1.3.1 The contractor shall provide training for the users on the data systems stated in Section C.5.8, Data Systems Access and Training.

Performance Standards

a) Standard: The contractor shall train (initial and refresher) and provide secure means for the users to access the systems for viewing and/or utilization. The contractor shall provide a dedicated manager responsible for training, issues, process suggestions, and provide assistance to the user when requested. The contractor may provide the training on-site or electronically.

AQL: (1) Initial system training conducted during the Transition-In period shall be completed no later than 60 calendar days prior to OP 1.

(2) After start of OP 1, new users shall receive initial training no later than 15 calendar days after identification is made to the contractor.

(3) Refresher training shall be provided quarterly.

(4) Provide refresher system training webinar within seven days of a request.

(5) Reply to data system inquiries within one business day.

Deliverables M010 Management Report

C.5.1.3.2. The contractor shall provide Government designated users with read-only access to the contractor’s full TDP data set.

Performance Standard

a) Standard: The user shall have the ability to download any of the data elements for manipulation purposes in accordance with Section C.5.8.2, TDP Full Data Set.

AQL: The system shall be available 99.9% of the time 24 hours, 7 days a week (excluding downtime for scheduled maintenance).

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Deliverables M010 Management Report

C.5.1.3.3 The contractor shall provide Government designated users with read-only access to a TDP dashboard.

Performance Standard

a) Standard: The TDP data shall be provided in a consolidated manner in which the user shall have the ability to easily view and download dental health plan data and the outcome measurements without having to manipulate the data in order to retrieve the information in accordance with Section C.5.8.3, TDP Dashboard.

AQL: The system shall be available 99.9% of the time 24 hours, 7 days a week (excluding downtime for scheduled maintenance).

Deliverables M010 Management Report

C.5.1.3.4 The contractor’s system shall interface with the Military Health Services (MHS) Genesis/Defense Health Medical Systems Modernization (DHMSM) Electronic Health Record System (EHRS).

The contractor shall implement the MHS Genesis/DHMSM EHRS at a later date as directed by DHA. DHA will provide the MHS Genesis/DHMSM EHRS requirements will be incorporated into the contract prior to implementation.

C.5.2 System Security. The contractor shall acquire, develop, and maintain processes for safeguarding unclassified DoD information, including covered defense information, commonly referred to as DoD controlled unclassified information on all contractor/subcontractor systems/networks that store, process, transmit or access unclassified DoD information or controlled unclassified information in accordance with TSM, Chapter 1, Section 1.1 (see Section J, Attachment J-16 until publication of the revised TSM, Chapter 1, Section 1.1 and also Section C, Part 6). The contractor shall implement and maintain adequate security in its project, enterprise, or company-wide internal information systems or covered contractor information systems that process, store, create, or transmit unclassified DoD information in accordance with the basic safeguarding requirements in FAR 52.204-21. The contractor shall implement and maintain adequate security in its project, enterprise, or company-wide internal information systems or covered contractor information systems that process, store, create, or transmit covered defense information, commonly referred to as controlled unclassified information (e.g. PII/PHI), in accordance with safeguarding covered defense and cyber incident reporting requirements in DFARS Clause 252.204-7012. Covered contractor information systems shall be subject to the security requirements in National Institute of Standards and Technology (NIST) Special Publication (SP) 800-171, "Protecting Controlled Unclassified Information in Nonfederal Information Systems and Organizations", Privacy Act Program Requirements (DoD 5400.11-R), and the Personnel Security Program (DoD 5200.2-R). The contractor's annual System Security

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Plan, or extract thereof, with any applicable Plans of Action is required prior to accessing DoD data, interfacing with Government systems, or conducting testing.

Deliverables M080 Employee Access to DoD IS/Networks Report A030 Disaster Recovery Test Results Report AP020 Continuity of Operations Plan (COOP) AP050 System Security Plan and Associated Plans of Action for Contractor’s Internal Unclassified Information System

C.5.3 Health Insurance Portability and Accountability Act (HIPAA). The contractor shall comply with the HIPAA requirements of TOM, Chapter 19.

Deliverables M040 HIPAA/Privacy Complaint Report A020 Risk Assessment Letter of Assurance R010 Breach Report R070 Designated Standards Maintenance Organization (DSMO) Meeting Summary Report

C.5.4 Transition.

C.5.4.1. The transition-in of this contract shall be conducted in accordance with the requirements stated in Section J, Attachment J-11, Transition-In.

Deliverables W010 Transition-In Status Report R030 Transition-In Integrated Master Plan (IMP) and Integrated Master Schedule (IMS) R170 B2B Gateway Questionnaire

C.5.4.2. The transition-out and the residual services activities shall be conducted in accordance with Section J, Attachment J-12, Transition-Out and Residual Services. Transition-Out costs shall not apply, nor shall any payment be made on CLINs X0010, if an incumbent contractor is selected as the awardee for the follow-on contract.

Deliverables M090 Transition-Out and Residual Services Status Report R040 Transition-Out and Residual Services Plan

C.5.5 Records Management. All contractor records generated under this contract shall be maintained in accordance with 36 CFR 1222; TOM, Chapter 9; Section J, Attachment J-11, Transition-In; and Attachment J-12, Transition-Out and Residual Services.

Deliverables R130 Declaration of Transfer and Destruction of Records

C.5.6 Quality

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C.5.6.1 Quality Control Program (QCP). The contractor shall develop and implement a QCP in accordance with the TOM, Chapter 1, Section 4 (excluding paragraphs 2.2, 2.3, 2.4, 3.1, 3.2,

3.4 and 4.0) and Section J, Exhibit A, CDRL AP030, QCP Plan. The contractor shall maintain a QCP that ensures that services are performed in accordance with the contract. The contractor shall develop and implement procedures to identify, prevent, and correct problems for the duration of the contract (see Section C.5.1.1.10). The COR will review the contractor’s sampling methodology after award to determine the minimum sampling size for C.5.1.1.10.

Deliverables Q010 Quality Control Program (QCP) Report AP030 Quality Control Program (QCP) Plan

C.5.6.1.1 Clinical Quality. The contractor shall ensure that their QCP Plan includes written policies and procedures to identify and review all potential quality issues (PQIs) from any source, to include grievances. A quality issue (QI) is a verified deviation, as determined by a qualified reviewer, from acceptable standards of practice or care as a result of some process, individual, or institutional component of the health care/dental care system. All QIs, regardless of the source, shall be reviewed and confirmed by qualified staff to determine deviations from standards of care, assign severity levels, recommend interventions to include Corrective Action Plans, report to licensure boards, and follow-up monitoring through resolution. All standard of care determinations shall be approved by the contractor’s head of clinical dental care. The contractor shall assure all identified issues are tracked and trended and any patterns are identified; all issues must be appropriately addressed until complete resolution is achieved. The contractor shall ensure that no results from a quality review (quality assurance information) are disclosed to any person or entity unless specifically provided for under 10 USC §1102.

Deliverables M010 Management Report Q010 Quality Control Program (QCP) Report AP030 Quality Control Program (QCP) Plan

C.5.6.2 Contract Surveillance. The Contracting Officer (CO) and Contracting Officer’s Representative (COR) will develop a Quality Assurance Surveillance Plan (QASP) to define acceptable quality levels and identify how the COR will monitor the quality of the contractor’s performance and address contractor performance that falls below these standards. The CO and COR will finalize the QASP after award and provide a copy to the contractor (for purposes of the RFP see Section J, Attachment J-19, Draft QASP). The QASP is a living document, and the Government may unilaterally update it as necessary. The CO and COR will complete an annual contractor’s performance evaluation in the Contractor Performance Assessment Report System

(CPARS).

C.5.7 Fraud and Abuse

C.5.7.1 The contractor shall implement a Fraud and Abuse program in accordance with TOM, Chapter 13.

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Q020 Fraud and Abuse Summary Report A040 Fraud Detection and Prevention Strategy and Internal Procedures R060 Threats Report R090 Standard Operating Procedures (Desk Procedures) R140 Random Sample Audit Worksheet R150 Fraud/Abuse Patient Harm-Initial Notification Checklist R160 DHA/MTF Fraud and Abuse Referral Cover Sheet

C.5.7.2 Potential Fraud and Abuse Cases. The contractor shall refer to DHA any potential case that involves more than a $10,000 loss to the Government and any potential case involving patient harm regardless of loss value (see TOM, Chapter 13, Section 3 for further requirements).

C.5.7.3 Post Payment Utilization Reviews. When performing post payment utilization reviews, the contractor shall consider high volume beneficiaries as those beneficiaries whose charges exceed $25,000 during a 12-month reporting period. High volume providers are considered institutional providers whose payments exceed $750,000; individual providers whose payments exceed $100,000; group/clinics whose payments exceed $100,000 (the threshold average is $25,000 per professional provider within the group) during a 12-month reporting period (see TOM, Chapter 13, Section 4 for further requirements).

C.5.8 Data Systems Access and Training

C.5.8.1 The contractor shall provide access to the full TDP data set and the TDP dashboard (stated below) for the DHA Dental Program Section, Contracting Officer, Contract Specialist, Contracting Officer’s Representative, and the Tri-Service Center for Oral Health Studies (TSCOHS), for a total of 10-15 user accounts. The DHA Dental Program Section will provide the contractor a list of users during Transition-In. The contractor shall train (initial and refresher) and provide secure means for the POCs to access the system(s) for viewing and/or utilization in accordance with Section C.5.1.3.1. The contractor shall provide the Transition-In initial training at the contractor's place of business. After start of OP1, the contractor shall offer options in which to attend new user initial training and refresher training (e.g. the contractor's place of business, webinar, Teams, etc.). The contractor shall provide a dedicated manager responsible for training, issues, process suggestions, and provide assistance to the user when requested.

C.5.8.1.1 All contractor’s data systems shall be available in accordance with Section C.5.1.3.2 and C.5.1.3.3., excluding scheduled 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. To the extent practicable, the contractor shall notify the DHA, Dental Program Section 24 hours in advance of system maintenance if it will disrupt services during peak hours

C.5.8.2 TDP Full Data Set. The contractor shall provide the Government users, as…