TOP 2028 Section C Draft 1 06AUG25.pdf

TRICARE Overseas Program (TOP) 2028 DRAFT 1 Performance Work Statement

TOP 2028 Draft Requirements

Source Selection Information (See FAR 2.101 and 3.104) For Official Use Only Page 1

C.1. General

C.1.1. Scope: The Department of Defense (DoD), through the Defense Health Agency (DHA), provides TRICARE services to eligible beneficiaries in locations outside the fifty United States and the District of Columbia.

C.1.1.1. The TRICARE Overseas Program (TOP) contract will supplement the services the direct care system provides in designated Military Medical Treatment Facility (MTF) locations, as well as provide comprehensive healthcare support services in remote overseas locations to Active Duty Service Members (ADSMs) and Command Sponsored Active Duty Family Members (ADFMs). Refer to Section J, Attachment J-1 for TOP Prime Locations and J-2 for TOP Prime Remote Locations. Healthcare support services include the development of private sector care networks, enrollment, medically necessary evacuations (medevacs), medical documentation collection, interpretation/translation services, clinical operations (medical management, case management, population healthcare, utilization management, referral management, clinical quality management), customer service/call center activities, beneficiary and provider education and marketing, and claims processing/coding.

C.1.1.2. The Contractor shall provide limited services to other TRICARE eligible beneficiaries as specified in the contract.

C.1.2. Definitions: Definitions are included in 10 United States Code (USC) § 1072, Title 32 Code of Federal Regulations (CFR) Part 199.2 and the TRICARE Operations Manual (TOM) Definitions link on https://manuals.health.mil/.

C.1.3. Documents: The following documents are hereby incorporated by reference and form an integral part of this contract. Documentation incorporated into this contract by reference has the same force and effect as if set forth in full text.

C.1.3.1. TRICARE Manuals

TRICARE Policy Manual (TPM) 6010.63-M, April 2021 TRICARE Reimbursement Manual (TRM) 6010.64-M, April 2021 TRICARE Systems Manual (TSM) 7950.4-M, April 2021 TRICARE Operations Manual (TOM) 6010.62-M, April 2021

C.1.3.1.1. The TRICARE Manuals provide instruction, guidance, and responsibilities in addition to the requirements set forth in the incorporated federal statutes and regulations and may not be interpreted in contradiction thereto. Whenever practicable, the technical requirements in this contract are accompanied by one or more cross-references to the TRICARE Manuals. These cross-references are provided to facilitate the Contractor’s understanding of the contract requirements and are not all-inclusive. The Contractor is responsible for understanding the full

For Official Use Only Page 2 scope of the TRICARE program and all TOP requirements as outlined in the contract to include, but not limited to, the documents incorporated by reference in paragraph. TOM Chapter 24 provides additional guidance for TOP requirements unless specifically excluded elsewhere in the Manuals. 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. The TRICARE Manuals are located at https://manuals.health.mil/. If the Contractor believes that a conflict exists between the incorporated documents, the Contractor shall inform the Contracting Officer in writing.

C.1.3.2. Statutory and Regulatory Authority

• Title 10, United States Code (USC), Armed Forces, Chapter 55, Medical and Dental Care, (10 USC 55)

• Title 32 Code of Federal Regulations (CFR) National Defense, Part 199, Civilian Health And Medical Program Of The Uniformed Services (32 CFR 199)

C.2. Statement of Objectives

C.2.1. Objective 1: Deliver a Quality Overseas Healthcare System. Implement an overseas private sector healthcare system which delivers the highest quality of care through a data driven clinical quality program which utilizes quality provider networks to ensure patients are treated in accordance with the highest medical standards of the host-nation. Ensure the overseas private sector healthcare system integrates with the direct care system and maximizes use of industry best practice digital modalities, to include full scope telehealth services, for delivering private sector healthcare.

C.2.2. Objective 2: Optimal Beneficiary Experience of Care. Create the best possible experience for the beneficiary through all phases of healthcare delivery by improving access to care, delivering services which are patient-centered, and providing guidance through the complexities of accessing healthcare overseas. Optimize the experience of care using industry best practices and leveraging new technologies on an ongoing basis.

C.2.3. Objective 3: Combat Support Agency Role. Provide private sector healthcare solutions which support Combatant Commands (CCMD), and Combat Support Activities as outlined in C.13 Combat Support.

C.3. Management

C.3.1. Senior Level Management. The Contractor shall establish and maintain experienced and qualified leadership personnel and sufficient staffing and management support to meet the requirements of this contract.

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C.3.1.1. The Contractor shall establish and maintain effective management strategies, staff education and training programs, clear lines of authority, and reporting and coordination interfaces with the Government.

C.3.1.2. The Contractor shall identify to the Government a senior level team member or members who possess the authority and can make management decisions for the Contractor within the scope of the contract.

C.3.1.2.1. The Contractor shall promptly update the Government when there are changes in these leadership positions.

C.3.2. Flexible, Adaptable Structure. The Contractor shall establish an innovative, flexible, management system, which can quickly adapt to changes in overseas healthcare environments and advances in healthcare delivery.

C.3.2.1 The Contractor management system shall deliver healthcare solutions to MTFs/beneficiaries, and CCMDs, that meet mission needs and increase readiness in an efficient, expediated, cost effective manner.

C.3.2.2 The Contractor’s management structure shall ensure appropriate responsiveness to Government requirements per the stated timelines.

C.3.2.3 The Contractor shall actively participate with the Government to plan and develop solutions to high priority contract changes. The Contractor’s ability to meet this requirement is a key component of the award fee determination.

C.3.3. Quality Management/Quality Improvement (QM/QI) program. The Contractor shall establish and operate a QM/QI program that effectively supports ongoing quality improvement efforts.

C.3.3.1. The Contractor's QM processes shall focus on outcomes, program processes and procedures, standardization, identifying and resolving access to care problems, and fostering a consistent, efficient, and effective TRICARE program for beneficiaries.

C.3.3.2. The Contractor's QI processes shall focus on process improvements and shall foster innovation by incorporating applicable healthcare best business practices and healthcare industry standards (e.g., U.S., host nation, and International) that lead to quality healthcare access, quality healthcare rendered, and quality healthcare outcomes.

C.3.3.3. The Contractor’s QM/QI program shall be comprehensive and coordinated, covering all aspects of the TRICARE program, to include internal oversight by Contractor senior leadership, For Official Use Only Page 4 ensuring that QM/QI information and processes are incorporated and communicated across its entire enterprise.

C.3.3.3.1. The Contractor shall submit an annual QM/QI plan (P070). For plan submission requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J.

C.3.3.4. The Contractor shall provide visibility of QM/QI processes and reports to the Government on a routine basis including the quarterly QM/QI report (Q010). For plan submission requirements, see DD Form 1423, CDRL, located in Section J.

C.3.3.5. The Contractor shall initiate and conduct monthly operational and assessment reviews for the Government during which the Contractor shall present its performance against all quality standards. The venue and manner of presentation will be determined by the Government.

C.4. Enrollment

C.4.1. The Contractor shall perform enrollments, re-enrollments, disenrollments, transfer enrollments, correct enrollment discrepancies, and assign or change the Primary Care Manager (PCM) in accordance with the provisions of TOM, Chapter 6 and TOM, Chapter 24, Section 5.

C.4.2. The Contractor shall utilize leading industry automation practices in processing billing and enrollment transactions and include capture of email and other information needed to conduct electronic transactions.

C.4.3. If the Contractor receives a TOP Prime Remote enrollment request for a city/country that is not included in Section J, Attachments J-2 or J-3, the Contractor shall enroll the beneficiary to the region and location where the beneficiary is assigned.

C.5. Private Sector Care Networks

C.5.1. Network Development. The Contractor shall provide a managed, stable, high-quality network of individual and institutional private sector care providers (PSCPs) which promotes access, clinical quality, beneficiary and provider satisfaction, and cost-efficient healthcare for TOP enrollees in the MTF locations identified in Section J, Attachment J-1, TOP Prime Locations, the network-designated remote locations identified in Attachment J-2, TOP Prime Remote Locations, and the network-designated remote locations identified in Attachment J-3, TOP Prime Remote Embassy Locations with an Embassy Health Unit (EHU).

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C.5.1.1. The Contractor shall ensure the network is tailored to meet the needs of the population and account for medical services that may be provided through the direct care system, embassy health unit or other government/military medical assets in a specific location.

C.5.1.2. When necessary, the Contractor shall augment provider network(s) with participating non-network providers to ensure that the number, mix, and geographic distribution of PSCPs are sufficient to provide all TRICARE reimbursable services under this contract to TOP enrollees in MTF locations identified in Section J, Attachment J-1, TOP Prime Locations, the network-designated remote locations identified in Attachment J-2, TOP Prime Remote Locations, and the network-designated remote locations identified in Attachment J-3, TOP Prime Remote Embassy Locations with an EHU. Participating providers are providers which do not have a signed network agreement but agree to provide cashless/claimless service and meet clinical quality standards.

C.5.1.2.1 The Contractor shall augment provider network(s) and recruit individual or institutional providers, despite network adequacy status, upon Government request.

C.5.1.3. The Contractor’s provider network(s) shall support the requirements of TRICARE special programs (e.g., the Extended Care Health Option (ECHO), and Autism Care Demonstration (ACD)) for TOP Prime and Prime Remote enrollees.

C.5.1.4. The Contractor shall actively seek institutional and individual providers who produce the highest level of clinical quality in accordance with the Contractor’s clinical quality program.

C.5.1.4.1. The Contractor shall profile and monitor provider performance in an ongoing manner using parameters that, at a minimum, address clinical quality, cost of care, English speaking/ interpretation capability, patient complaints, medical documentation collection, and access to care.

C.5.1.4.2. The Contractor shall right-size its networks to include the number of high-quality providers required to meet contract requirements.

C.5.1.5. TOP Prime Locations. In TOP Prime locations, the Contractor shall develop provider networks to support TOP Prime enrollees by complementing the clinical capability and capacity of the MTF.

C.5.1.5.1. The Contractor shall collaborate with the MTFs/Defense Health Networks (DHNs) and the TRICARE Area Offices (TAOs) to ensure the most efficient mix of healthcare delivery between the direct care system and the Contractor's network. At a minimum, collaboration shall include preventive care, overflow capacity for primary and specialty care, ancillary services, and TAO/MTF and Contractor Interfaces.

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C.5.1.5.2. The Contractor shall augment its network with Primary Care support within 90 calendar days of request by the Government.

C.5.1.5.3. TOP Prime Provider Capability and Capacity Adjustments. The Contractor shall adjust its network and participating non-network PSCP capabilities and capacities as necessary to address changes in MTF capabilities and capacities which may occur due to facility downsizing or closure, MTF expansion, establishment of new clinics, and provider deployment or reassignment.

C.5.1.5.4. The Contractor shall adjust its network capability and capacity to compensate for changes to MTF capabilities and capacities within 90 calendar days after Government notification.

C.5.1.5.5. The Contractor shall collaborate with the applicable MTF, TAO, and DHN prior to changing the network.

C.5.1.5.6. In all Puerto Rico MTF locations, the Contractor shall provide a network of PCMs to support TOP Prime enrollment of ADFMs who are Command sponsored or otherwise eligible for TOP Prime enrollment.

C.5.1.6. TOP Prime Remote Locations. In network-designated TOP Prime Remote locations, the Contractor shall develop provider networks to provide primary and specialty care to TOP Prime Remote enrollees.

C.5.1.6.1. TOP Prime Remote Provider Capability and Capacity Adjustments. The Contractor shall adjust its network and participating non-network PSCP capabilities and capacities as necessary to address changes in TOP Prime Remote population size, demographic, and medical needs.

C.5.1.6.2. The Contractor shall collaborate with the applicable TAO when changing the network in response to changes in TOP Prime Remote population size, demographic and medical needs.

C.5.1.6.3. The Contractor shall develop provider networks to support TOP Prime Remote enrollees in TOP Prime Remote locations that support embassies with EHUs, by complementing the clinical capability and capacity of the EHU.

C.5.1.6.4. The Contractor shall collaborate with the EHUs and the TAOs to ensure the most efficient mix of healthcare delivery between the EHU and the Contractor's network to include preventive care, overflow capacity for primary and specialty care, and ancillary services.

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C.5.1.6.5. The Contractor’s network shall include providers that are frequently utilized by EHUs and demonstrate a high level of clinical quality.

C.5.1.6.6. The Contractor shall add a new TOP Prime Remote location and supporting network within 90 calendar days of notification from the TOP Contract Contracting Officer (CO).

C.5.1.6.7. The Contractor shall communicate all TOP Prime Remote network provider changes with the TAO and appropriate Remote Points of Contact (POC(s)) prior to making the change.

C.5.2. English Speaking Providers. Network and participating non-network providers shall communicate in English, both orally and in writing, or provide interpretation services at the time of service.

C.5.2.1. The Contractor shall ensure network and participating non-network providers, or their interpreters, demonstrate proficiency and fluency in the English language at the Level 3– General Professional Proficiency level, for oral and written communications, as defined by the Interagency Language Roundtable guidelines (https://www.govtilr.org/Skills/ILRscale2.htm#3).

C.5.2.2. The Contractor shall ensure network and participating non-network providers support access to video and tele-interpretation support.

C.5.3. Access to Care. The Contractor shall ensure the following TRICARE standards for access, in terms of beneficiary travel time, appointment wait time, and office wait time, are met for TOP Prime and TOP Prime Remote enrollees.

C.5.3.1. Access standards include emergency care available 24 hours per day, 7 calendar days per week in the service area; acute care appointments available within 24 hours; routine care appointments within 7 calendar days; wellness care appointments within 4 weeks; specialty care appointments within 4 weeks (28 days) or per provider designation, not to exceed four weeks; no more than a 60 minute drive time from the sponsor’s duty location for specialty care, no more than 30 minutes for other types of care; office wait times shall not exceed 30 minutes for nonemergency care, except when emergency care is being provided to patients, and the normal schedule is disrupted.

C.5.3.2. The Contractor shall monitor and measure access to care performance for TOP Prime and Prime Remote enrollees and inform the TRICARE Overseas Program Office (TOPO) of locations where access to care is impaired in terms of beneficiary travel time, appointment wait time, and/or office wait time and shall implement corrective actions to improve access in those areas in the Network Adequacy/Inadequacy Report (M080) and Access to Care Report (M060).

For report submission requirements, see DD Form 1423, CDRL, located in Section J.

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C.5.4. Network Adequacy. The Contractor shall assess network adequacy on an ongoing basis and shall inform the Government of any instances of network inadequacy. Network adequacy is defined as having enough network and participating non-network providers to meet access to care standards across all specialties in a location.

C.5.4.1. The Contractor shall submit a corrective action plan for instances of network inadequacy which persist for more than 30 calendar days.

C.5.4.2. The Contractor shall ensure the PSCP networks are sufficient in number, mix, and geographic distribution to meet the network adequacy standards in 32 CFR 199.17(p)(5) and Key Performance Indicators (KPIs) in TOM Chapter 1, Section 3, paragraph 4.0.

C.5.4.3. Network Adequacy Waivers. The Contractor may request a Network Adequacy Waiver for any location identified in Section J, Attachment J-2, TOP Prime Remote Locations or Attachment J-3 TOP Prime Remote Embassy Locations, which would otherwise require the development of a PSCP network.

C.5.4.3.1. The Contractor shall submit network adequacy waiver requests to the appropriate TAO and should include the reason(s) for the waiver request (e.g., safety concerns, lack of providers, security risks), as well as a recommended strategy to ensure access to care for TOP Prime Remote enrollees.

C.5.5. Network Contingency Support. The Contractor shall ensure that healthcare services are continuously available to TRICARE eligible beneficiaries in the case of contingencies to include, but not limited to, war, operations other than war, deployments, training, special operations, and natural disasters.

C.5.5.1. The Contractor shall begin making the necessary network adjustments to support changes in TOP Prime/TOP Prime Remote location capability and/or capacity resulting from a contingency within 24 hours of notification.

C.5.5.2. The Contractor shall detail its approach in the Network Contingency Support Plan (P060). For plan submission requirements, see DD Form 1423, CDRL, located in Section J.

C.5.5.3. The Contractor shall respond to contingencies by taking the following actions:

Provide TAO/MTFs with analysis of provider network.

Expand the provider network (including Primary Care) to support changes in TOP

Prime/TOP Prime Remote location capability.

Recommend alternatives and course of action if provider network is unable to provide services.

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Provide TAO with information/status of TRICARE Prime/Prime Remote beneficiaries impacted by terrorist attack/natural disaster.

C.5.6. MTF Exercise Support. The Contractor shall participate in MTF disaster/mass casualty exercises when an MTF requests. The MTFs will request Contractor participation through the appropriate TAO at least 15 business days in advance of an exercise. The Contractor is not required to participate in more than one mass casualty exercise per MTF per Option Period

(OP).

C.5.7. Provider Directory. The Contractor shall maintain a public facing online provider directory, which includes all network and participating non-network providers. The provider directory shall be designed to be intuitive and easy to navigate with information that is easily accessible and can be quickly found through a search by provider or facility name, specialty or type of facility, subspecialty, and telehealth capability.

C.5.7.1. The provider directory shall include:

the sex (for individual providers), provider name, provider specialty (available and credentialed) provider subspecialty (include number of subspecialists), service area, provider address, provider appointment telephone number, limitations of service (e.g., inpatient and/or outpatient, in person/virtual), the English-speaking capability of the provider and available interpretation services, whether the provider is accepting new TRICARE patients, and country medical risk rating.

C.5.7.2. The Contractor shall ensure information is updated no less than once every 24 hours to capture any changes to the Provider Directory.

C.5.7.3. Provider Directory Accuracy. The Contractor shall maintain a minimum provider directory accuracy rate as follows:

OP1 OP2 OP3 OP4 OP5 OP6 OP7 OP8

85% 86% 87% 88% 89% 90% 91% 92%

C.5.7.3.1. The Contractor shall conduct a monthly audit of its provider directory. The monthly audit shall evaluate a minimum of 5% of network providers per region and 100% of authorization changes due to provider directory inaccuracy for specialty. The audit shall include TOP Prime and TOP Prime Remote locations. The audit shall report the accuracy of the

For Official Use Only Page 10 elements identified in C.5.7.1. A record will be counted as accurate only if all elements of that record are accurate. The audit shall be conducted by contacting provider offices in the same manner a beneficiary would use to make an appointment, using the phone number listed in the provider directory.

C.5.7.3.2. The Contractor shall calculate network provider directory accuracy by dividing the total number of directory entries (including participating non-network providers) that contain 100% correct information (no data element errors) by the total number of records audited. The calculation shall include all data elements specified in C.5.7.1.

C.5.7.3.3. For audit submission requirements (M090), see DD Form 1423, CDRL, located in Section J.

C.5.7.3.4. The Contractor shall contact 100% of network and participating non-network providers on a semi-annual basis, at a minimum, to validate information contained in the network provider directory.

C.5.8. Country Medical Risk Rating. The Contractor shall assign a Country Medical Risk Rating to all overseas countries. The rating shall be based on a range of factors, including, but not limited to the standard and accessibility of local medical care; the risk of infectious disease;

infant and maternal morbidity and mortality rates; blood program quality; and cultural, language, or administrative barriers to accessing healthcare.

C.5.8.1. The Contractor shall classify countries as being Very High, High, Medium, or Low Medical Risk. Country Medical Risk ratings shall be included in the provider directory.

C.5.9. Provider Certification/Credentialing.

C.5.9.1. The Contractor shall establish business processes to track and monitor the credentials of all network and participating non-network PSCPs working under this contract, including the individual provider credentials, credentialing organization, date of credentials and date of credentials expiration.

C.5.9.2. The Contractor shall verify individual providers working within an institution are appropriately credentialed through primary source verification.

C.5.9.3. The Contractor shall verify credentials for out of network PSCPs upon receipt of the first TRICARE claim and prior to payment of the claim unless the Government specifically waives this requirement in writing.

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C.5.9.4. During the certification/recertification process, the Contractor shall check the US Department of Health and Human Services (DHHS) Sanction List (https://exclusions.oig.hhs.gov/) for all providers. Providers listed on the DHHS Sanction List are excluded from providing services under all federal programs. This restriction remains in place even if a provider begins practicing in another country.

C.5.9.5. The Contractor shall complete on-site verification during provider certification in the Philippines. The Government may expand this on-site verification requirement to other locations during the life of the contract.

C.5.9.6. For provider and facility credentialing, re-credentialing and certification activities reporting requirements (Q010), see Form DD 1423, CDRL, located in Section J.

C.5.10. Network Provider Accreditation. The Contractor shall ensure all network hospitals, participating non-network hospitals in TOP Remote locations, and other places of institutional care meet the minimum accreditation standards of the specific host-nation or US commonwealth/territory.

C.5.10.1. The Contractor shall establish processes to evaluate the quality, safety, and compliance with licensure/certification and malpractice insurance requirements of private sector institutions.

C.5.10.1.1. The Contractor shall maintain such evaluations for Government inspection.

C.5.10.2. The Contractor shall identify the international and national medical accreditation program(s) for the locations in Section J, Attachments J-1, J-2, and J-3.

C.5.10.2.1. The Contractor shall have 100% of its network and participating non-network institutional providers actively (currently) accredited by nationally, internationally, or host nation accepted accreditation programs, or through a proxy validation performed by the Contractor.

C.5.10.3. The Contractor proxy validation shall include an inspection commensurate with that of the Joint Commission International.

C.5.10.3.1. The Contractor shall maintain copies of each provider's accreditation and make them available for Government inspection upon request. Accreditations/validations shall be updated every three years at a minimum.

C.5.11. Provider Clinical Site Visits. The Contractor shall conduct site visits to all network and participating non-network hospitals and other places of institutional care (e.g., stand-alone

For Official Use Only Page 12 surgical centers, birthing centers) every three years for the purpose of evaluating the provider’s quality, safety, and compliance with licensure/certification.

C.5.12. Provider Education. The Contractor shall have an active provider education program designed to enhance and maintain PSCP awareness of applicable TRICARE requirements, policies, and procedures. The provider education program shall ensure PSCPs are able to carry out the requirements of this contract in an efficient and effective manner that promotes beneficiary and provider satisfaction.

C.5.12.1. The Contractor shall produce regional provider education materials. The DHA Communications and Public Affairs Division (DCPAD) and the TOPO will review and approve education materials prior to the Contractor disseminating them.

C.5.12.2. The Contractor shall produce provider education materials in the following languages:

English, German, Italian, Korean, Japanese, Arabic, Spanish, French, Portuguese, and Turkish.

C.5.12.3. The Contractor shall incorporate a detailed description of their provider education program into their Education Plan (CDRL P080). For plan submission requirements, see DD Form 1423, CDRL, located in Section J.

C.5.12.4. The Contractor shall distribute initial provider education materials to network and participating non-network providers no earlier than 60 calendar days and no later than 30 calendar days prior to the start of healthcare delivery.

C.5.12.5. The Contractor shall conduct ongoing provider education in accordance with their approved Education Plan (CDRL P080).

C.5.12.6. The Contractor shall produce TOP provider education material in accordance with TOM Chapter 11, Section 1, and Chapter 24, Section 9. Ongoing provider education material shall be reviewed by DCPAD and the TOPO prior to dissemination.

C.5.13. Medical malpractice insurance. The Contractor shall determine the medical malpractice insurance required in each country, province, state, commonwealth/territory, listed in Section J, Attachment J-1, network-designated locations in Attachments J-2 and J-3, if applicable.

C.5.13.1. The Contractor shall ensure all network providers (professional and institutional) meet the medical malpractice insurance standards for their host-nation or US commonwealth/territory, as identified by C.5.13.

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C.5.13.2. The Contractor shall ensure each network provider agreement clearly identifies the provider has the required malpractice insurance.

C.5.13.3. The Contractor shall maintain and provide medical malpractice insurance documentation to the Government upon request.

C.5.13.4. In the absence of any country, province, state, commonwealth/territory, etc., legal requirement for medical malpractice insurance, the Contractor shall determine the local community standard for medical malpractice insurance, establish the minimum malpractice insurance which providers are required to obtain, and maintain documentation evidencing both the standard and compliance by network providers.

C.5.13.5. The TOPO reserves the authority to determine whether a network provider met the standards for medical malpractice insurance and whether the Contractor has documented the required insurance.

C.5.13.6. The Contractor shall provide the TOPO with a listing of the requirements for, and the availability of malpractice insurance and licensure/certification requirements for all countries included in Section J, Attachment J-1, network-designated locations in Attachments J-2 and J-3.

C.5.13.7. The Contractor shall refer to Malpractice Insurance and License Certification Requirements (R050), for reporting requirements, see CDRL, DD Form 1423, located in Section J.

C.5.14. Negotiated Rates. The Contractor shall negotiate reduced rates for healthcare provided by PSCPs in the countries designated in Section J, Attachment J-12, Negotiated Rate Locations.

C.5.14.1. Through negotiating rates, the Contractor shall achieve a reduction in the average cost-per-claim compared to the Contractor's pre-established baseline.

C.5.14.2. The Contractor shall demonstrate the savings generated through negotiated rates.

C.5.14.3. In the absence of any specific reimbursement rates or reimbursement methodology mandated by DHA, the Contractor may negotiate reimbursement rates with PSCPs.

C.5.14.4. The Contractor may also negotiate a rate in locations where DHA has directed a specific reimbursement rate that is lower than the DHA directed rate. The Contractor cannot negotiate a rate that exceeds the DHA-directed rate.

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C.5.14.5. The Contractor shall maintain copies of all documents used to establish reasonable and customary local reimbursement rates and shall make these documents available for Government inspection upon request.

C.5.14.6. The Contractor shall ensure its claims processing systems are structured such that network discounts are clearly identified provide Ad Hoc Management Reports (CDRL R010), on Government’s request, demonstrating the cost savings achieved by negotiating rates in each country identified in Section J, Attachment J-12.

C.5.15. Contractor Owned Facilities. The Contractor shall clearly identify any Contractor-owned facilities or entities providing healthcare to TOP enrollees in its Contractor Owned Facilities Mitigation Plan (P100). For plan requirements, see DD Form 1423, CDRL, located in Section J.

C.5.15.1. The Contractor shall work cooperatively with the Government to develop a plan to mitigate the appearance of a potential general conflict of interest. This includes, but is not limited to, Contractor-owned clinics, hospitals, pharmacies, medical evacuation/ambulance service companies, etc.

C.5.15.2. The Contractor shall refer to Section H, paragraph H.3.4., for additional information regarding Organizational Conflict of Interest and Impaired Objectivity.

C.5.16. Government Indemnification. The Contractor agrees to be liable for and expressly agrees to indemnify the Government from any liability resulting from services provided under the TOP contract to enrolled TRICARE beneficiaries for care provided by Contractor network providers, or, in the alternative, the Contractor agrees that all network provider agreements used by the Contractor shall contain a requirement, directly or indirectly by reference to applicable regulations or DHA policies, that the network provider agrees to indemnify the Government from any liabilities arising from any acts or omissions in the provision of medical services by the provider to enrolled beneficiaries for care provided by Contractor network providers.

C.6. Clinical Operations (Medical Management, Case Management, Population Health, Utilization Management, Referral Management, Clinical Quality Management)

C.6.1. TOP Prime Medical Management.

C.6.1.1. The Contractor shall provide inpatient medical management (IMM) of TOP Prime enrollees who are admitted to a private sector care facility regardless of location. This includes Residential Treatment Centers (RTCs) and inpatient rehabilitation facilities.

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C.6.1.1.1. The Contractor shall ensure all medical management documentation and information is provided through a secure web-based portal as outlined in TOM, Ch 7, Sec 1.

C.6.1.1.2. The Contractor shall provide a hybrid version of IMM that accommodates MTF retention of IMM responsibility for a subset of its enrollees upon MTF request.

C.6.1.2. Private Sector/Direct Care Interface. The Contractor shall interact with the MTF PCM or designee (e.g., case manager) through the duration of the inpatient stay.

C.6.1.2.1. The Contractor shall obtain and provide medical updates through the secure web-based portal, to include admission notes, clinical updates, and discharge plans and summaries.

C.6.1.2.1.1. The Contractor shall collaborate with the MTF to determine the frequency of inpatient updates and clarify in the Statement of Responsibility (SOR).

C.6.1.2.2. The Contractor shall rely on available medical documents or communication from members of the treating medical team to create admission, daily, and interim, discharge notes.

C.6.1.2.2.1 The Contractor shall record the source of the clinical updates (e.g., treating nurse, treating physician) on the notes.

C.6.1.2.3. The Contractor shall transfer all medical management responsibilities to the MTF PCM or designee, including the transfer of the discharge summary upon the patient's discharge from the inpatient facility.

C.6.1.3. Notification of Case (NOC)/Admission Notes. The Contractor shall provide a NOC and admission notes within 24 hours of the Contractor becoming aware of the admission.

C.6.1.3.1. The Contractor’s admission notes shall include, at a minimum, the admitting diagnosis, a brief history of present illness, admission physical exam findings, pertinent lab and study results, initial assessment, and plan of care (R020). For submission requirements, see DD Form 1423, CDRL, located in Section J.

C.6.1.4. Written Updates. When requested by the MTF or the TAO, the Contractor shall provide patient updates in Subjective, Objective, Assessment, and Plan (SOAP) format within 8 hours of the request for TOP Prime, TOP Prime Remote, and transient (see C.14 for definition) beneficiaries.

C.6.1.5. Discharge Planning Statement. The Contractor shall submit a daily discharge planning statement via the MTF secure, web-based portal, to the current MTF PCM that identifies whether the Contractor recommends the patient remain admitted. The discharge planning

For Official Use Only Page 16 statement shall include the estimated length of admission; or that the patient will be discharged, including an estimated date of discharge; or that the patient will be transferred to another inpatient facility, including estimated date/time of eventual transfer and identifying the recommended transfer facility.

C.6.1.5.1. Daily discharge planning statements for newborns shall include all scheduled follow-up newborn pediatric appointments.

C.6.1.6. Interim Discharge Summaries. The Contractor shall submit written interim discharge summaries (IDS) to the MTF PCM or designee (e.g. case manager) no later than 12 hours after the Contractor is aware of a patient's discharge. The written interim discharge summary is based on the information the Contractor obtained from the PSCP throughout the course of admission and is not dependent on obtaining written discharge summary from the PSCP. The interim discharge summaries shall include, at a minimum:

admission date and diagnosis discharge date and final diagnosis(es) procedures performed specialty services consulted (including pertinent findings) a summary of inpatient stay (including pertinent labs), radiology/pathology reports, immunizations findings to include why procedures were performed why specialty services were consulted discharge medications, with dosing and duration diet/activity/care instructions Durable Medical Equipment (DME), and follow-up appointments/instructions

C.6.1.6.1. Newborns shall have separate IDSs submitted to the MTF PCM or designee (e.g. case manager) no later than 12 hours after the Contractor is aware of the patient’s discharge. The written IDS is based on information the Contractor obtained from the PSCP throughout the course of the admission for both mother and the newborn and is not dependent on obtaining written discharge summary from the PSCP. The newborn IDS shall include, at a minimum:

the date and time of birth Estimated Gestational Age (EGA) at birth birth weight, length, and head circumference discharge weight Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) scores procedures performed including resuscitation course a summary of inpatient stay including pertinent maternal and newborn labs, radiology/pathology reports, immunizations and medications administered bilirubin level and follow-up time(s)

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C.6.1.6.2 The Contractor shall utilize a standardized IDS format which is acceptable to the DHA.

C.6.1.7. Private Sector to MTF Transfers. When a beneficiary is identified for transfer from a host nation hospital to an inpatient MTF, the Contractor shall provide notification to the accepting MTF, and the MTF to which the beneficiary is enrolled, with all inpatient medical management information from that episode of care (e.g. admission notes, Emergency Medical System (EMS) documentation in cases of trauma, discharge planning summaries, interim discharge summaries).

C.6.1.7.1. The Contractor shall obtain, translate, and upload all medical records to the secured web-based portal to the accepting overseas MTF within 5 calendar days from the date of transfer. Medical records, in these cases, are the final discharge summary, full copies of pertinent labs/pathology reports, pending labs/pathology reports, operation/procedure reports, and specialty services reports.

C.6.1.7.2. The Contractor shall communicate each unique instance where they are unable to obtain medical documentation to the respective MTF. Communication shall include pertinent patient information to include the referral/authorization number for MTF referred care as well the reason for not being able to obtain the medical documentation (e.g. unable to obtain release of medical information from patient).

C.6.1.7.3. Trauma/Surgical Case Transfers. For all inpatient trauma cases and any inpatient surgical cases transferred to an overseas MTF, the Contractor shall ensure that, in addition to the interim discharge summary and (EMS) documentation in cases of trauma, the provided operative/procedure reports include:

pre-and-post surgery diagnoses patient position and preparation narrative summary of the surgical techniques and approaches specimens or tissue samples removed specific type/brand/location of any implants inserted estimated blood loss unexpected findings and/or complications how the operative site was closed, and patient condition at the end of the operation

C.6.1.8. Trauma Recapture. The Contractor shall establish a process supporting the recapture of trauma patients by Landstuhl Regional Medical Center (LRMC).

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C.6.1.8.1. The Contractor shall contact the LRMC Trauma Service when TOP Prime, TOP Prime Remote, and transient beneficiaries with the following traumatically induced conditions are identified in the TAO-Eurasia-Africa (EA) Area of Operations:

Glasgow Coma Scale (GCS) < 9 from trauma Gunshot to neck, chest, abdomen or extremities proximal to elbow or knee Patients receiving 6+ units of blood Intubated patients from scene or patients with respiratory compromise Amputation of upper or lower extremity Spinal Cord injuries and all spinal column fractures All burns over 15%, or with inhalation injury Polytrauma requiring surgical intervention Other trauma cases identified in the SOR.

C.6.1.8.2. The Contractor shall coordinate with the LRMC Trauma Service to facilitate transfer of accepted patients. Details of the trauma recapture process shall be documented in the SOR with the MTF.

C.6.2. TOP Prime Remote Medical Management.

C.6.2.1. The Contractor shall provide outpatient and inpatient medical management (including case management, population health, utilization management, referral management, and clinical quality management) for all TOP Prime Remote enrollees.

C.6.2.2. TOP Prime Remote Outpatient Medical Management. In its capacity as the PCM coordinator, the Contractor shall medically manage TOP Prime Remote outpatient care when that care is provided by a PSCP.

C.6.2.2.1. In its capacity as the PCM coordinator, the Contractor shall review PSCP outpatient medical documentation and determine if the beneficiary received recommended follow-on care to include private sector care ancillary services.

C.6.2.2.2. The Contractor shall document follow-on care that is not completed due to beneficiary non-adherence.

C.6.2.2.2.1. The Contractor shall use a nurse or a physician to oversee review of PSCP outpatient medical documentation.

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C.6.2.2.3. If the Contractor identifies the PSCP provided inappropriate or non-covered care, the Contractor shall address the concern with the PSCP, report the event to the TAO via NOC processes, and complete the PQI process

C.6.2.3. TOP Prime Remote Inpatient Medical Management. The Contractor shall medically manage TOP Prime Remote enrollees who are admitted in a private sector care facility regardless of location. This includes RTCs and inpatient rehabilitation facilities.

C.6.2.3.1. Notification of Case. The Contractor shall deliver NOCs to the TAO using a secure web-based portal, required in C.6.1.1.1.

C.6.2.3.1.1. Inpatient Admissions. The Contractor shall provide a NOC to the TAO within 24 hours after the Contractor becomes aware of an inpatient admission for TOP Prime Remote, transient, and TOP Prime Beneficiaries enrolled to a private sector PCM in Puerto Rico.

C.6.2.3.1.2. Puerto Rico Medical Travel. The Contractor shall provide a NOC to the TAO within two business days of the Contractor determining that appropriate healthcare is not available in the beneficiary's local service area for TOP Prime Remote, transient, and TOP Prime Beneficiaries enrolled to a private sector PCM in Puerto Rico.

C.6.2.3.1.3. Mental Health. The Contractor shall provide a NOC to the TAO within two business days of the request for services for TOP Prime Remote ADSMs for any outpatient or inpatient mental healthcare, TOP Prime Remote ADFMs who require inpatient mental healthcare, and transient beneficiaries who require urgent/emergent mental healthcare in a remote overseas location.

C.6.2.3.1.4. Care Against Medical Advice. The Contractor shall provide a NOC to the TAO within two business days of the Contractor becoming aware of a beneficiary receiving care against medical advice or if a beneficiary leaves a facility (hospital/Emergency Room/physician's office) or discontinues care or treatment against medical advice.

C.6.2.3.1.5. Aeromedical Evacuations. The Contractor shall provide a NOC to the TAO during the coordination process of aeromedical evacuations for TOP Prime, TOP Prime Remote, transient beneficiaries, and TRICARE Select ADFMs.

C.6.2.3.2. TAO Interface. The Contractor shall interface/communicate with the TAOs throughout the duration of the inpatient stay and shall provide medical updates, obtained by the Contractor, to include admission notes, clinical updates, and interim discharge plans and summaries.

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C.6.2.3.2.1. The Contractor shall rely on available medical documents or communication from members of the treating medical team to create admission, daily, and interim discharge notes and upload them to the secure web-based portal.

C.6.2.3.3. Admission Notes. The Contractor’s admission notes shall include at minimum, the admitting diagnosis, brief history of present illness, admission physical exam findings, pertinent lab/study results, initial assessment, and plan of care.

C.6.2.3.3.1. The Contractor shall upload admission notes to a secure web-based portal within 24 hours of the Contractor becoming aware of the admission.

C.6.2.3.4. Written Clinical Updates. The Contractor shall provide written clinical updates based on the acuity of the patient, with a minimum of one update every 3 calendar days, in a SOAP note format.

C.6.2.3.4.1. The Contractor shall provide written clinical updates for admissions to behavioral healthcare facilities every 7 calendar days unless there is a significant change in the patient’s status.

C.6.2.3.4.2. The Contractor shall upload all clinical updates to a secure web-based portal.

C.6.2.3.5. Interim Discharge Summaries. The Contractor shall upload written interim discharge summaries to a secure web-based portal no later than 24 hours after the Contractor is aware of the patient's discharge.

C.6.2.3.5.1. The Contractor's interim discharge summaries shall include, at minimum:

admission date and diagnosis discharge date and final diagnosis(es) procedures performed specialty services consulted with pertinent findings summary of inpatient stay including pertinent labs radiology/pathology reports, immunizations and findings, to include why procedures were performed and/or specialty services were consulted discharge medications, with dosing and duration diet/activity/care instructions/DME, and follow-up appointment(s) with instructions

C.6.3. Beneficiary Support. The Contractor shall provide direct support to TOP Prime and TOP Prime Remote beneficiaries admitted to a private sector care facility to include:

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Outreach (e.g. telephone call, in person visit) to the beneficiary within 12 hours of notification of an admission.

On call coverage, 24 hours per day, 7 days per week, 365 days per year, via a direct line to clinicians to help admitted beneficiaries and the MTF to which the beneficiary is enrolled.

A minimum of one in-person visit in TOP Prime locations. The visit shall include a beneficiary needs assessment, ensuring the beneficiary understands their care plan, determination of follow-up care, discussion with private sector clinical staff, and discharge planning. The in-person visit may be completed by a licensed or non-licensed person and is dependent on the purpose of the visit.

Additional in-person visits based on objective clinical criteria or when requested by the MTF, TAO, or beneficiary.

C.6.3.1. The Contractor shall notify TOPO/TAO when they are unable to conduct an in-person visit (e.g., staff not available, patient was unavailable when they attempted the visit).

C.6.4. Case Management (CM).

C.6.4.1. The Contractor shall establish a CM program in accordance with the TOM, Chapter 24, Section 6 and Chapter 7, Section 2.

C.6.4.2. The Contractor shall evaluate referrals from any source (e.g. MTF, PSCP, beneficiary, Government, etc.) and accept, when appropriate, for potential CM opportunities.

C.6.4.3. The MTF retains primary CM responsibility for MTF enrollees. However, the Contractor shall identify all patients who could potentially benefit from CM and provide this notification to the enrolling MTF.

C.6.4.4. The Contractor shall provide eligible beneficiaries with complex, sensitive, rare, high-profile, or high visibility needs a dedicated point of contact for CM services.

C.6.4.4.1. The Contractor shall provide a NOC to the TAO when TOP Prime Remote beneficiaries with complex, sensitive, rare, high-profile, or high-visibility needs are enrolled for CM services to inform military unit discussions regarding Exceptional Family Member Program, Early Return of Dependents, Compassionate Reassignments, etc.

C.6.4.5. The Contractor shall provide virtual CM or care coordination services to TOP Prime Remote beneficiaries who have a high need for care and are at high-risk of readmission for 30 calendar days following discharge from an inpatient setting. The first virtual visit shall be made 48 to 72 hours post discharge.

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C.6.5. Care Coordination.

C.6.5.1. The Contractor shall establish a care coordination program in accordance with the TOM Chapter 24, Section 6 and Chapter 7, Section 2.

C.6.5.2. Urgent Care Coordination.