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Section J List of Attachments
The following attachments and documents form an integral part of this contract. Contractors are required to comply with the direction provided by this section. Documentation incorporated in this contract by reference has the same force and effect as if set forth in full.
| J-1 |
| DRAFT TOP Prime Locations |
| J-2 |
| DRAFT TOP Prime Remote Locations |
| J-3 |
| DRAFT TOP Non-Designated Prime Remote Locations |
| J-4 |
| DRAFT Government Furnished Space and Equipment |
| J-7 |
| DRAFT Special Healthcare Payment Conditions - Japan |
| J-8 |
| DRAFT Special Payment Conditions - Administrative Charges that are Attendant to the Delivery of Healthcare |
| J-9 |
| DRAFT Locations Authorized Private Rooms for Active Duty Service Members |
| J-10 |
| DRAFT Medical Capability Reports |
| J-11 |
| DRAFT Block Overflight Permit Locations |
| J-13 |
| DRAFT Host Nation Facility Support |
| J-14 |
| PENDING-Quality Assurance Surveillance Plan |
| J-15 |
| DRAFT MHS Genesis Internal Control Document |
| J-16 |
| DRAFT MHS Genesis HIPPA Compliant 278 Interface Connection PWS |
| J-17 |
| DRAFT Formatting CAP DME Data Files |
| J-19 |
| DRAFT Cultural Variances |
| J-20 |
| PENDING-Award Fee Plan |
| J-21 |
| DRAFT In-Person Interpretation Support |
| J-22 |
| DRAFT TRICARE Operations Manual (6010.62-M, April 2021) Chapter 24-TOP |
| J-XX |
| PENDING-Notification of Cases (NOC) Reference Table |
| J-XX |
| PENDING-Performance Readiness Validation (PRV)/Performance Readiness Assessment and Verification (PRAV) Reviews |
EXHIBITS
Exhibit A: DD Forms 1423-1, Contract Data Requirements List (CDRL)
| D010 |
| DRAFT Non-Financially Underwritten Contractor Payment/Check Issue Data |
| W010 |
| DRAFT Transition-In Status Report |
| W020 |
| DRAFT Transition-Out Status Report |
| M010 |
| DRAFT Management Report |
| M020 |
| DRAFT CQM Clinical Quality Report |
| M030 |
| DRAFT Inpatient Medical Management (IMM) Report |
| M040 |
| DRAFT Medical Management Programs Report |
| M050 |
| DRAFT Medical Documentation/ Inpatient Medical Management (IMM) Report |
| M060 |
| DRAFT Access to Care Report |
| M070 |
| DRAFT Appointing Report |
| M080 |
| DRAFT Network Adequacy/Inadequacy Report |
| M090 |
| DRAFT Provider Directory Accuracy |
| M100 |
| DRAFT Global Monthly Summary Report |
| M110 |
| DRAFT TOP Prime and Prime Remote Enrollment Report |
| M120 |
| DRAFT Medical Evacuation Report |
| M130 |
| DRAFT Preauthorizations/Authorizations and Referral Timeliness/Accuracy Report |
| M140 |
| DRAFT Cashless Claimless Care Report |
| M150 |
| DRAFT Active duty Service Member (ADSM) Claims Report – Paid Claims with No Auth or Denied Claims |
| M160 |
| DRAFT Paid Claims and Current Inventory Report (All Beneficiaries) |
| M170 |
| DRAFT Responsibilities Assignment Matrix (RAM) and Staffing Report |
| M180 |
| DRAFT Grievance Report |
| M190 |
| DRAFT Overseas Currency Report |
| M200 |
| DRAFT Non-Financially Underwritten Accounts Receivable Summary Report (Government Medicare Dual Eligible) |
| M210 |
| DRAFT Non-Financially Underwritten Accounts Receivable Summary Report (Government TRICARE Only Eligible) |
| M220 |
| DRAFT Non-Financially Underwritten Accounts Receivable Summary Report (Non- Government Medicare Dual Eligible) |
| M230 |
| DRAFT Non-Financially Underwritten Accounts Receivable Summary Report (Non- Government TRICARE Only Eligible) |
| M240 |
| DRAFT Non-Financially Underwritten Bank Account Reconciliation Report (Non- Accrual Fund Eligible) |
| M250 |
| DRAFT Non-Financially Underwritten Bank Account Reconciliation Report (MERHCF/Accrual Fund Eligible) |
| M260 |
| DRAFT Non-Financially Underwritten Bank Account Statement Report (Medicare Dual Eligible) |
| M270 |
| DRAFT Non-Financially Underwritten Bank Account Statement Report Account Statement Report (TRICARE Only Eligible) |
| M280 |
| DRAFT Non-Financially Underwritten Bank Account Statement Report Bank Cleared Payment Data |
| M290 |
| DRAFT TRS/TYA/TRR Premium Activity Report |
| M300 |
| DRAFT HIPAA Privacy Complaint Report |
| M310 |
| DRAFT Overpayment Cases Against VA Facilities |
| M320 |
| DRAFT Interpretation Services |
| Q010 |
| DRAFT Internal Quality Management/Quality Improvement (QM/QI) Report |
| Q020 |
| DRAFT Appeals Quality Assessment Report |
| Q030 |
| DRAFT Mental Health Counselor Status Report |
| Q040 |
| PENDING-Comprehensive Autism Care Demonstration Report |
| Q050 |
| DRAFT Retrospective Review Validation Report |
| Q060 |
| DRAFT OCMR and Conus care |
| Q080 |
| PENDING Childbirth and Breastfeeding Support Demonstration |
| Q090 |
| DRAFT Fraud and Abuse Summary Report |
| Q100 |
| DRAFT Maternity Care Report |
| SA010 |
| DRAFT Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) Report |
| SA020 |
| DRAFT Population Health Outreach Report |
| P010 |
| DRAFT Clinical Quality Management Program Plan |
| P020 |
| DRAFT Medical Management (MM) Programs Plan |
| P030 |
| DRAFT Access to Care Plan |
| P040 |
| DRAFT Network Implementation Plan |
| P050 |
| PENDING Combatant Command (CCMD) Contingency Support Pan |
| P060 |
| PENDING Network Contingency Program Plan |
| P070 |
| DRAFT Internal Quality Management/Quality Improvement Program Plan |
| P080 |
| DRAFT Education Plan |
| P090 |
| DRAFT Continuity of Operations Plan (COOP) |
| P100 |
| DRAFT Contractor Owned Facilities Mitigation Plan |
| P110 |
| DRAFT Transition-In Plan |
| P120 |
| DRAFT Transition-Out Plan |
| P130 |
| DRAFT System Security Plan and Associated Plans of Action for a Contractor's internal Classified Information System |
| A010 |
| DRAFT Clinical Quality Management Program (CQMP) Report |
| A020 |
| DRAFT MOU with East Region Contractor |
| A030 |
| DRAFT MOU with West Region Contractor |
| A040 |
| DRAFT MOU with Uniformed Services Family Health Plan (USFHP) Designated Providers |
| A060 |
| DRAFT Contract Releasable under FOIA |
| A070 |
| DRAFT Service Organization Control Report (SOC1) - Statement on Standards for Attestation Engagements, SSAE No. 18 (Service Organization Report) |
| A080 |
| DRAFT Bridge Letter in Support of Service Organization Control Report (SOC1) - Statement on Standards for Attestation Engagements, SSAE No. 18 (Service Organization Bridge Letter) |
| A090 |
| DRAFT Service Organization Control Report (SOC1) - Statement on Standards for Attestation Engagements, SSAE No. 18 (Subservice Organization Report) |
| A100 |
| DRAFT Bridge Letter in Support of Service Organization Control Report (SOC1) - Statement on Standards for Attestation Engagements, SSAE No. 18 (Subservice Organization Bridge Letter) |
| A110 |
| DRAFT Third Party Recoveries for Fiscal Year Report |
| A130 |
| DRAFT Disaster Recovery Test Results Report |
| A140 |
| DRAFT IDME Ratios for Children's Hospitals Report |
| A150 |
| DRAFT Fraud Detection and Prevention Strategy and Internal Procedures |
| A160 |
| DRAFT Risk Assessment Letter of Assurance |
| A170 |
| DRAFT MOU with Competitive Plans Demonstration (CPD) Contractor |
| R020 |
| DRAFT Medical Management-Notification of Case Report |
| R030 |
| PENDING-Referral Management Matrix |
| R040 |
| DRAFT Malpractice Insurance and Licensure/Certification Requirements |
| R050 |
| DRAFT Serious Reportable Events |
| R060 |
| DRAFT MTF Notification of Active Duty Service Member (ADSM) Claims Paid with No Authorization or Denied Claims |
| R080 |
| DRAFT SOR with Military Treatment Facility (MTF) |
| R090 |
| DRAFT MOU with DHA Communications |
| R100 |
| DRAFT MOU with the Global Nurse Advice Line Contractor (GNAL) |
| R110 |
| DRAFT MOU with Active Duty Dental Program (ADDP) Contractor |
| R120 |
| DRAFT MOU with Transcom |
| R130 |
| DRAFT MOU with U.S. State Department |
| R140 |
| DRAFT Appeals Processing Guidelines, Desk Instructions and Reference Materials |
| R150 |
| DRAFT B2B Gateway Questionnaire |
| R160 |
| DRAFT System Integration Test Plans |
| R170 |
| PENDING DSMO Meeting Summary Report |
| R190 |
| DRAFT Program Integrity Standard Operating Procedures (Desk Procedures) |
| R200 |
| DRAFT Threats Reports |
| R210 |
| DRAFT Fraud/Abuse Patient Harm-Initial Notification Checklist |
| R220 |
| DRAFT Program Integrity Random Sample Audit Worksheet |
| R230 |
| DRAFT DHA/MTF Fraud & Abuse Referral Cover Sheet |
| R240 |
| DRAFT Declaration of Transfer and Destruction of Records |
(End of Section)
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Defense Health Agency