TOP2028_SECTION C_DRAFT.docx

TRICARE Overseas Program (TOP) 2028 DRAFT 2 Performance Work Statement

C.1. General

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

C.1.1.1. The TRICARE Overseas Program (TOP) supplements the direct care system in designated Military Medical Treatment Facility (MTF) locations and provides comprehensive healthcare support in remote overseas locations to Active Duty Service Members (ADSMs) and Command Sponsored Active Duty Family Members (ADFMs). Healthcare support services include private sector network development, appointment services, enrollment, medically necessary evacuations (medevacs), medical documentation collection, interpretation/translation, clinical operations (medical management, case management, population healthcare, utilization management, referral management, clinical quality management), customer service/call center, 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: Refer to 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 supplementing federal statutes and regulations, and shall not contradict them. While this contract cross-references TRICARE Manuals to aid understanding, these references are not exhaustive. The Contractor is responsible for understanding the full scope of the TRICARE program and all TOP requirements outlined in this contract, including referenced documents. DRAFT TOM Chapter 24, TRICARE Overseas Program, located in Section J, Attachment J-22 and TPM Chapter 12 provides additional guidance for TOP requirements unless specifically excluded elsewhere in the Manuals.

C.1.3.1.2. Manual Precedence. TPM > TRM > TSM > 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

C.2. High Level Objectives

C.2.1. Objective 1: Quality Overseas Healthcare System. Deliver a data driven clinical quality program utilizing quality provider networks to ensure patients receive the highest quality of care, compliant with host-nation and internationally recognized medical standards. Integrates the overseas private sector healthcare system with the direct care system and optimizes digital health solutions, including full scope telehealth services.

C.2.1. Objective 2: Flexible, Adaptable Structure. The Contractor shall implement a flexible management process capable of adapting to changes in overseas healthcare environments. This system shall efficiently deliver healthcare solutions that support the mission needs of Military Medical Treatment Facilities (MTFs), and CCMDs and enhance beneficiary health.

C.2.2. Objective 3: Optimal Beneficiary Experience. Optimize the beneficiary experience throughout all phases of healthcare delivery by meeting or exceeding access to care requirements, delivering patient-centered services, and navigating beneficiaries through the complexities of accessing healthcare overseas. Modernize the care experience using best-in-class approaches and state-of-the-art technology. Continuously improve patient care experience through data-driven initiatives and cutting-edge technology.

C.2.3. Objective 4: Combat Support Agency Role. Provide private sector healthcare solutions to support Combatant Commands (CCMDs), and Combat Support Activities.

C.3. Management

C.3.1. The Contractor shall provide and maintain qualified leadership and sufficient staffing to meet all contract requirements. At a minimum:

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 provide a monthly Responsibilities Assignment Matrix (RAM) and Staffing Report (M170) detailing current staffing levels, any vacancies, and mitigation actions for those vacancies. For reporting requirements, see DD Form 1423-1, Contract Data Requirements List (CDRL), located in Section J.

C.3.2. The Contractor shall formally designate senior-level Program Managers (PM) with the authorities to make decisions on behalf of the Contractor for matters within the scope of the contract.

C.3.2.1. The designated PMs shall be available during the host nation’s normal Government duty hours and participate in all program reviews, coordination meetings, and issue resolution discussions.

C.3.3. The Contractor shall respond to all Government requirements and requests per the stated timelines and attend all requested planning meetings (virtual or in-person).

C.3.4. Quality Management/Quality Improvement (QM/QI) program. The Contractor shall establish, operate, and maintain a comprehensive and coordinated QM/QI program that supports ongoing quality improvement across all aspects of the TOP to ensure compliance with the stated requirements.

C.3.4.1. The Contractor's QM plan shall focus on processes, program procedures, standardization, and the identification and resolution of access to care problems, fostering consistent, efficient, and effective outcomes for TOP beneficiaries.

C.3.4.2. The Contractor's QI plan shall focus on process improvements and foster innovation by incorporating strategies for achieving performance excellence in healthcare management and operations, along with healthcare industry standards (U.S., host nation, and international) to ensure quality healthcare access, delivery, and outcomes.

C.3.4.3. The Contractor shall ensure internal oversight by senior leadership, and that its QM/QI information and processes are incorporated and communicated across its entire enterprise.

C.3.4.4. The Contractor shall submit an annual QM/QI plan (P070) and a quarterly QM/QI report (Q010). For submission requirements, see DD Form 1423-1, CDRL, located in Section J.

C.3.5. Monthly Oversight Meetings. The Contractor shall schedule and conduct monthly oversight meetings with the Government, with meetings occurring not more than 30 calendar days apart. The Government will determine the venue and manner of presentation. For each review, the Contractor shall:

· Provide read-ahead materials (agenda, performance metrics, draft slides) at least 3 business days prior to the meeting.

· Present Contractor performance against all contract quality standards and metrics.

· Report on the status of corrective actions, emerging issues, risks, and improvement initiatives.

· Deliver meeting minutes and an action tracker within 5 business days after the review.

C.4. Transitions

C.4.1. The Contractor shall comply with all transition-in and transition-out requirements as outlined in TOM, Chapter 2, Sections 2, 6, 10 Paragraphs 1.0-5.0, 8 and TOM DRAFT Chapter 24, Section 2, located in Section J, Attachment J-22.

C.4.2. The Contractor shall execute all MOUs in C.13.1.3 no later than 90 calendar days prior to the SHCD.

C.4.3. The Contractor shall participate and provide Performance Readiness Validation (PRV) and Performance Readiness Assessment and Verification (PRAV) information to the Government as outlined in Attachment J-XX.

C.5. Enrollment

C.5.1. The Contractor shall process and verify enrollments, re-enrollments, disenrollments, and 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, DRAFT Chapter 24, Section 5, located in Section J, Attachment J-22.

C.5.2. The Contractor shall utilize industry-leading automation practices in processing billing of premiums, enrollment fees, and enrollment transactions. This includes capturing appropriate demographic contact information to include email addresses and other information necessary to conduct electronic transactions, improving efficiency, accuracy, and customer satisfaction.

C.5.3. The Contractor shall enroll the beneficiary to the region and location where the beneficiary is assigned. If the Contractor receives a TOP Prime Remote enrollment request for a city/country not included in Section J, Attachments J-2, TOP Prime Remote Locations or Attachment J-3, TOP Non-Designated Prime Remote Locations, the Contractor shall enroll the beneficiary to a new non-designated remote location.

C.5.3.1. The Contractor shall submit a listing of the new non-designated remote locations monthly to the COR.

C.5.4. The Contractor shall submit a monthly TOP Enrollment Report (M110). For report submission requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J.

C.6. Private Sector Care Networks

C.6.1. Network Development.

C.6.1.2. The Contractor shall provide a 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.

C.6.1.3. The contractor shall ensure the network is tailored to the population’s needs, accounting for medical services from the direct care system, embassy health units, or other government/military medical assets.

C.6.1.4. The Contractor shall augment the network(s) with participating non-network providers, when necessary, to ensure sufficient PSCP number, mix, and geographic distribution to provide all TRICARE reimbursable services under this contract to TOP enrollees. Participating providers are providers which do not have a signed network agreement but agree to provide cashless/claimless services and meet clinical quality standards.

C.6.1.4.1. The Contractor shall ensure that all Network and Participating providers provide cashless, claimless services for TOP beneficiaries.

C.6.1.4.2. Upon Government request, the Contractor shall augment provider network(s) and recruit additional individual or institutional providers, regardless of network adequacy status.

C.6.1.5. The Contractor’s network(s) shall support TRICARE special programs (e.g., the Extended Care Health Option (ECHO), and Autism Care Demonstration (ACD) for TOP Prime and Prime Remote enrollees.

C.6.1.6. The Contractor shall actively seek institutional and individual providers demonstrating the highest level of clinical quality.

C.6.1.6.1. The Contractor shall continuously monitor individual and institutional provider performance using parameters that address, at a minimum, cost-of-care, clinical quality of care to include population health as appropriate, patient satisfaction, access to care, English speaking/ interpretation capability, and medical documentation collection.

C.6.1.7. The Contractor shall ensure that network providers, or their interpreters can communicate in English, both orally and in writing, by demonstrating proficiency and fluency in English at 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.6.1.8. The Contractor shall provide an annual Network Implementation Plan (P040). For reporting requirements, see DD Form 1423-1, CDRL, located in Section J.

C.6.1.9. TOP Prime Locations. The Contractor shall develop and maintain a complement of network and non-network PSCPs to augment the existing capacity of the Direct Care System for ADSMs and ADFMs who are enrolled in TOP Prime locations identified in Section J, Attachment J-1, TOP Prime Locations.

C.6.1.9.1. 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.

C.6.1.9.2. The Contractor shall adjust its network and participating non-network PSCP capabilities and capacities, to include primary care, to address changes in MTF capabilities and capacities resulting from facility downsizing or closure, MTF expansion, establishment of new clinics, and provider deployment or reassignment. Adjustments shall occur within 90 calendar days after notification by the Government.

C.6.1.9.3. The Contractor shall collaborate with the applicable MTF, TAO, and DHN prior to changing the network.

C.6.1.9.4. Puerto Rico Prime Locations. The Contractor shall provide a network of PCMs to support TOP Prime enrollment of Command sponsored ADFMs, or those who are otherwise eligible for TOP Prime enrollment, in all Puerto Rico MTF locations.

C.6.1.10. TOP Prime Remote Locations. The Contractor shall develop provider networks TOP Prime Remote locations to provide primary and specialty care to TOP Prime Remote enrollees.

C.6.1.10.1. 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, demographics, and medical needs.

C.6.1.10.2. The Contractor shall collaborate with the applicable TAO when changing the network in response to changes in TOP Prime Remote population size, demographics, and medical needs.

C.6.1.10.3. The Contractor shall develop provider networks to support TOP beneficiaries in TOP Prime Remote locations that support embassies with EHUs, complementing the clinical capability and capacity of the EHU.

C.6.1.10.3.1. 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. This shall include preventive care, overflow capacity for primary and specialty care, and ancillary services.

C.6.1.10.3.2. The Contractor’s network shall include providers frequently utilized by EHUs and who demonstrate a high level of clinical quality.

C.6.1.10.4. The Contractor shall develop and maintain PSCP networks and implement the delivery of cashless, claimless services in non-network designated remote locations on a “best-effort” basis. A non-network designated remote location is a location where ADSMs/ADFMs are assigned, but the Government has not designated it as a designated TOP Prime Remote site. Non-network designated remote locations are identified in Section J, Attachment J-3.

C.6.1.10.4.1. The Contractor shall automatically add non-network designated remote locations where ADSMs/ADFMs are assigned to overseas locations in which a TOP Prime or a TOP Prime Remote/non-network designated remote location does not exist and notify the TOPO who will request the CO to modify the contract to add the location to Section J, Attachment J-3.

C.6.1.10.4.2. With respect to non-network designated remote locations, “best effort” is defined as the contractor making commercially reasonable efforts on an ongoing basis to achieve the stated outcomes for network adequacy and cashless, claimless health care.

C.6.1.10.5. The Contractor shall add a new TOP Prime Remote location for enrollment purposes within 14 days of KO notification, schedule initial site visit within 60 days, and establish a network within 120 days. Monthly status reports in writing shall be provided to COR and TAOs until completion.

C.6.1.10.5.1. The Contractor shall, in writing, notify the COR if changes cannot be made within the established timelines.

C.6.1.10.5.2. The Contractor shall communicate all TOP Prime Remote network provider changes with the TAO and appropriate Remote Points of Contact (POC(s)) before making network adjustments.

C.6.2. Access to Care. The Contractor shall ensure Access to Care (ATC) standards listed in 32 CFR 199.17(p)(5) are met for TOP Prime and TOP Prime Remote beneficiaries as follows:

C.6.2.1. 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).

C.6.2.2. The Contractor shall monitor and measure ATC performance for TOP Prime and Prime Remote enrollees and report via monthly CDRLs. The Contractor shall inform the TRICARE Overseas Program Office (TOPO) and TAO within 7 business days when ATC is impaired in terms of beneficiary travel time and/or appointment wait time and shall implement corrective actions to improve access in those areas.

C.6.2.3. For submission requirements for the Access to Care Plan (P030), Network Adequacy/Inadequacy Report (M080), and Access to Care Report (M060), see DD Form 1423, CDRLs, located in Section J.

C.6.3. Network Adequacy. The Contractor shall ensure PSCP networks are sufficient in number, mix, and geographic distribution to meet network adequacy standards outlined in 32 CFR 199.17(p)(5) and Key Performance Indicators (KPIs) in TOM Chapter 24, Section 1, and Section H, paragraph H.4.3.

C.6.3.1. The Contractor shall assess network adequacy on an ongoing basis, report any instances of network inadequacy to the Government per CDRL requirements, and submit a corrective action plan for any network inadequacy persisting more than 30 calendar days.

C.6.3.2. If a frequently utilized provider refuses to join the network or become a non-network participating provider, the Contractor shall report this in the monthly Network Adequacy/Inadequacy Report (M080).

C.6.3.3. Network Waivers. The Contractor may request a Network Waiver for any location identified in Section J, Attachment J-2, or Attachment J-3, which would otherwise require the development of a PSCP network.

C.6.3.3.1. The Contractor shall submit Network Waiver requests in writing to the appropriate TAO. These requests 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 ATC for TOP Prime Remote enrollees.

C.6.4. Network Contingency Support. The Contractor shall ensure that healthcare services are continuously available to TRICARE-eligible beneficiaries in the case of contingencies, including but not limited to war, operations other than war, deployments, training, special operations, evacuation orders, and natural disasters.

C.6.4.1. 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.6.4.2. The Contractor shall respond to contingencies by taking the following actions:

· Provide TAO/MTFs with an analysis of its provider network.

· Expand the provider network (including Primary Care) to support changes in TOP Prime/TOP Prime Remote location capability.

· Recommend alternatives and courses of action if its provider network is unable to provide services.

· Provide the Government with information/status of TRICARE Prime/Prime Remote beneficiaries impacted by unforeseen circumstances.

C.6.4.3. The Contractor shall detail its approach in the Network Contingency Support Plan (P060). For plan submission requirements see DD Form 1423-1, CDRL, located in Section J.

C.6.5. Provider Directory. The Contractor shall develop and maintain a timely and accurate 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 search by provider or facility name, specialty or type of facility, subspecialty, and telehealth capability.

C.6.5.1. The provider directory shall include:

· Provider’s name,

· Provider’s sex (for individual providers),

· Provider specialty (available and credentialed),

· Provider subspecialty (including the number of subspecialists),

· Service area,

· Provider address,

· Provider appointment telephone number,

· Limitations of service (e.g., inpatient and/or outpatient, in-person/virtual),

· Languages spoken,

· The provider’s English-speaking capability and available interpretation services,

· Whether the provider is accepting new TRICARE patients,

· Country Medical Risk rating.

C.6.5.2. The Contractor shall capture any updates to the on-line provider directory at least once every 24 hours.

C.6.5.3. Provider Directory Accuracy. The Contractor shall maintain a minimum provider directory accuracy rate as follows:

C.6.5.3.1. 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 each specialty. The audit shall include TOP Prime and TOP Prime Remote locations and shall report the accuracy of the elements identified in C.6.5.1.

C.6.5.3.2. The Contractor shall successfully contact and receive a response from 100% of network and participating non-network providers at least semi-annually, or at the direction of the Government, to validate the information contained in the provider directory.

C.6.5.3.4. For audit submission requirements for Provider Directory Accuracy (M090) see DD Form 1423-1, CDRL, located in Section J.

C.6.6. Country Medical Risk Rating. The Contractor shall assign all overseas countries a Country Medical Risk rating as Very High, High, Medium, or Low Medical Risk. Risk classification shall be based on a range of factors including, but not limited to, the standard and accessibility of local medical care including availability of hospital and emergency services; disease prevalence; healthcare quality, which includes at a minimum, infant and maternal morbidity and mortality rates and blood program quality; cultural, language, or administrative barriers to accessing healthcare; and travel advisories.

C.6.6.1. The Contractor shall maintain a written methodology describing how risk ratings are determined, documented, and updated. This methodology shall be submitted to the Government for review as part of their CQMP (P010). For reporting requirements, see DD Form 1423-1, CDRL, located in Section J.

C.6.6.2. The Contractor shall review and update risk classifications at least annually or within 30 days of any significant change in a country’s healthcare environment.

C.6.7. Provider Certification/Credentialing.

C.6.7.1. The Contractor shall establish business processes to track and monitor the credentials of all network and participating non-network PSCPs working under this contract. This includes the individual provider credentials, credentialing organization, date of credentials, and date of credentials expiration.

C.6.7.2. The Contractor shall verify that individual providers working within an institution are appropriately credentialed and verified by the institution’s internal credentialing process.

C.6.7.3. 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.

C.6.7.4. 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.6.7.5. 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.6.7.6. For provider and facility credentialing, re-credentialing and certification activities reporting requirements, see the Internal Quality Management/Quality Improvement Report (Q010), Form DD 1423-1, CDRL, located in Section J.

C.6.8. Network Provider Accreditation. The Contractor shall identify and ensure all network hospitals, participating non-network hospitals, and other places of institutional care meet host-nation or US commonwealth/territory accreditation standards.

C.6.8.1. The Contractor shall evaluate and monitor the quality, safety, licensure/certification, and malpractice insurance compliance of all private sector institutions before network inclusion and on an ongoing basis and provide to the Government upon request.

C.6.8.2. The Contractor shall have 100% of its network and participating non-network institutional providers actively (currently) accredited by nationally, internationally, or host nation accepted programs or validated through a Contractor proxy validation.

C.6.8.3. The Contractor shall maintain accreditation/validation documentation for each provider, updated at least every three years, and make it available for Government inspection.

C.6.9. Institutional Site Visits. The Contractor shall conduct site visits every three years to all network and participating non-network hospitals and other places of institutional care (e.g., stand-alone surgical centers, birthing centers) to assess quality, safety, and compliance with licensure/certification. The Contractor shall maintain an electronic tracker with the historical and future schedule of institutional provider site visits and provide access to TOPO and TAO staff.

C.6.10. Provider Education. The Contractor shall maintain an active provider education program that allows bi-directional interaction to ensure PSCPs are aware of applicable TRICARE requirements, policies, and procedures, enabling efficient and effective contract performance that promotes beneficiary and provider satisfaction.

C.6.10.1. The Contractor shall produce regional provider education materials. DHA Communications and Public Affairs Division (DCPAD) and the TOPO will review and approve education materials prior to dissemination.

C.6.10.2. The Contractor shall produce provider education materials in English, German, Italian, Korean, Japanese, Arabic, Spanish, French, Portuguese, Polish, and Turkish.

C.6.10.3. The Contractor shall incorporate a detailed description of their provider education program into their Education Plan and conduct ongoing provider education in accordance with the approved Education Plan. (P080). For plan submission requirements, see DD Form 1423-1, CDRL, located in Section J.

C.6.10.4. The Contractor shall produce TOP provider education material in accordance with TOM Chapter 11, Section 1, and DRAFT Chapter 24, Section 9. located in Section J, Attachment J-22. DCPAD and TOPO will review materials prior to dissemination.

C.6.11. Medical malpractice insurance. The Contractor shall determine the medical malpractice insurance requirements for each country, province, state, or commonwealth/territory, listed in Section J, Attachment J-1, and network-designated locations in Attachments J-2 and J-3.

C.6.11.1. The Contractor shall ensure that all network providers (professional and institutional) meet the medical malpractice insurance standards for their host-nation or US commonwealth/territory when applicable, as identified by C.6.11.

C.6.11.2. 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, and network-designated locations in Attachments J-2 and J-3.

C.6.11.3. The Contractor shall submit the Malpractice Insurance and License Certification Requirements Report (R050) as required. For reporting requirements, see DD Form 1423-1, CDRL, located in Section J.

C.6.12. 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 1423-1, CDRL, located in Section J.

C.6.12.1. The Contractor shall work cooperatively with the Government to develop a plan to mitigate any potential general conflicts of interest. This includes, but is not limited to, Contractor-owned clinics, hospitals, pharmacies, and medical evacuation/ambulance service companies.

C.6.12.2. Refer to Section H, paragraph H.3.4., for additional information regarding Organizational Conflict of Interest and Impaired Objectivity.

C.7. Clinical Operations (Medical Management, Case Management, Population Health, Utilization Management, Referral Management, Clinical Quality Management)

C.7.1. The Contractor shall ensure all medical management documentation and information is provided through a secure web-based portal as outlined in this contract, TOM, Ch 7, Sec. 1 and applicable J-attachments.

C.7.2. The Contractor shall provide a monthly Medical Management Programs Report (M040). For report details, see DD Form 1423-1, CDRL, located in Section J.

C.7.3. TOP Prime Medical Management.

C.7.3.1. Inpatient Medical Management (IMM). The Contractor shall provide 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.

C.7.3.2. The Contractor shall provide direct support to TOP Prime beneficiaries admitted to a private sector care facility, including:

· Outreach (e.g., telephone call, in-person visit) to the beneficiary within 12 hours of notification of 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.7.3.2.1. The Contractor shall notify TOPO/TAO when unable to conduct an in-person visit (e.g., staff not available, patient was unavailable when they attempted the visit).

C.7.3.2.2. Newborns. The Contractor shall create a process to track, monitor, and report on all newborn birth, admission, ongoing inpatient, and discharge notes during time when not yet registered in DEERS.

C.7.3.3. 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.7.3.3.1. The Contractor shall obtain and provide medical updates through the secure web-based portal, including admission notes, clinical updates, and discharge plans and summaries.

C.7.3.3.2. The Contractor shall provide IMM on acuity basis to the MTF in alignment with the Statement of Responsibility (SOR).

C.7.3.3.3. The Contractor shall rely on available medical documents or communication only from members of the treating medical team to create admission, daily, and interim, discharge notes and shall record the source of the clinical updates (e.g., treating nurse, treating physician) on the notes.

C.7.3.3.4. 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.7.3.4. Notification of Case (NOC)/Admission Notes. The Contractor shall provide a NOC and admission notes within 24 hours of becoming aware of the admission.

C.7.3.4.1. At a minimum, the Contractor’s admission notes shall include 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 1423-1, CDRL, located in Section J.

C.7.3.5. Written Updates. The Contractor shall provide written clinical updates completed and uploaded within the specified timeframes within the MTF SOR or submitted within 8 hours when ad-hoc requested by the Government in Subjective, Objective, Assessment, and Plan (SOAP) format for TOP Prime, TOP Prime Remote, and transient beneficiaries (see C.15 for the definition of “transient beneficiaries”).

C.7.3.6. Discharge Planning Statement. The Contractor shall submit a daily discharge planning statement for each beneficiary admitted to an inpatient facility to the MTF staff in which the beneficiary is enrolled via the designated secure, web-based portal.

C.7.3.6.1. The discharge planning statement shall include:

· The estimated total length of admission.

· The estimated date of discharge, if applicable.

· The estimated date and time of transfer, and the name of the recommended receiving facility, if a transfer is planned.

C.7.3.7. 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 becomes aware of a patient's discharge. The written IDS is based on the information the Contractor obtained from the PSCP throughout the course of admission and does not depend on obtaining a written discharge summary from the PSCP. At a minimum, IDSs shall include:

· 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, and 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.7.3.7.1. The Contractor shall use a standardized IDS format that is acceptable to the Government C.7.3.8. Newborn Discharge Planning. For all newborn beneficiaries, the Contractor shall adhere to the following discharge planning requirements in addition to those in C.7.3.6.1.

C.7.3.8.1. 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:

· 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)

· Breastfeeding or bottle-feeding status, to include lactation follow-ups

· Follow-up pediatrics appointments/instructions

· For male newborns, whether circumcision was requested and the follow-up plan

· Mode of delivery (SVD, Forceps, C-Section, etc.)

C.7.3.9. Private Sector to MTF Transfers. When a beneficiary is identified for transfer from a host nation hospital to an inpatient MTF, the Contractor shall notify both the accepting MTF, and the MTF to which the beneficiary is enrolled, providing 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, and IDSs).

C.7.3.9.1. 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 the following:

· 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

· Patient condition at the end of the operation

C.7.3.10. Trauma Recapture. The Contractor shall establish a process to support Landstuhl Regional Medical Center (LRMC) recapture of trauma patients.

C.7.3.10.1. 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) less than 9 from trauma

· Gunshot wound to the neck, chest, abdomen, or extremities proximal to elbow or knee

· Patients receiving 6 or more units of blood

· Intubated patients from scene or patients with respiratory compromise

· Amputation of an 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.7.3.10.2. 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.7.4. TOP Prime Remote Medical Management.

C.7.4.1. The Contractor shall provide outpatient and inpatient medical management services for all TOP Prime Remote enrollees. This management includes case management, population health, utilization management, referral management, and clinical quality management.

C.7.4.2. TOP Prime Remote Outpatient Medical Management. In its capacity as the Medical Management Coordinator, the Contractor shall medically manage TOP Prime Remote outpatient care when that care is provided by a PSCP.

C.7.4.2.1. In its capacity as the Medical Management Coordinator, the Contractor shall have a qualified medical professional review PSCP outpatient medical documentation and determine whether the beneficiary received recommended follow-on care to include private sector care ancillary services.

C.7.4.2.2. The Contractor shall document instances of follow-on care that is not completed due to beneficiary non-adherence.

C.7.4.2.3. If the Contractor identifies that 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.7.4.3. TOP Prime Remote Inpatient Medical Management. The Contractor shall medically manage TOP Prime Remote enrollees who are admitted to a private sector care facility, regardless of location. This includes RTCs and inpatient rehabilitation facilities.

C.7.4.3.1. Notification of Case. The Contractor shall deliver NOCs to the TAO using a secure web-based portal (C.7.3.3.1.) in accordance with the following:

C.7.4.3.1.1. Inpatient Admissions. Within 24 hours after becoming aware of an inpatient admission for TOP Prime Remote, transient, or TOP Prime Beneficiaries enrolled to a private sector PCM in Puerto Rico.

C.7.4.3.1.2. Medical Travel. Within two business days of determining that appropriate healthcare is not available in the beneficiary's local service area for TOP Prime Remote, transient, or TOP Prime Beneficiaries enrolled to a private sector PCM in Puerto Rico.

C.7.4.3.1.3. Care Against Medical Advice. Upon becoming aware of a beneficiary receiving care against medical advice or without medical necessity.

C.7.4.3.1.4. Leaving Against Medical Advice. Upon becoming aware of a beneficiary leaving a facility (hospital/Emergency Room/physician's office) or discontinuing care or treatment against medical advice from the treating medical officer.

C.7.4.3.1.5. Complex CM Services. The Contractor shall provide a NOC to the TAO w When TOP Prime Remote or ADFM TRICARE Select beneficiaries with complex, sensitive, rare, high-profile, or high-visibility needs are enrolled for CM services. This notification will inform military unit discussions regarding Exceptional Family Member Program, Early Return of Dependents, Compassionate Reassignments, etc.

C.7.5. Case Management (CM).

C.7.5.1. The Contractor shall establish a CM program in accordance with the TOM, Chapter 7, Section 2, and DRAFT Chapter 24, Section 6 located in Section J, Attachment J-22.

C.7.5.2. The Contractor shall evaluate referrals from any source (e.g., MTF, PSCP, beneficiary, Government) and accept them, when appropriate, for potential CM opportunities.

C.7.5.3. 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.7.5.4. 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.7.5.4.1 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 re-admission for 30 calendar days following discharge from an inpatient setting. The first virtual visit shall be made 48 to 72 hours post discharge.

C.7.6. Care Coordination.

C.7.6.1. The Contractor shall establish a care coordination program in accordance with the TOM, Chapter 7, Section 2 and DRAFT Chapter 24, Section 6, located in Section J, Attachment J-22.

C.7.6.2. The Contractor shall establish a communication conduit between the MTF and the PSCP for outpatient referrals and inpatient admission that require urgent clinical care coordination and shall outline this process in the SOR.

C.7.6.2.1. The Contractor shall develop a process for identification of these cases and shall ensure the information required by the MTF is provided to make medical/operational decisions on the case and appropriately transition clinical care.

C.7.6.3. The Contractor shall develop a process for identification of TOP Remote and Transient cases that exceed host nation capabilities and shall ensure the information required by the TAO is provided to make medical/operational decisions on the case and appropriately transition clinical care to an MTF or higher level of care if required.

C.7.7. Utilization Management (UM).

C.7.7.1. The Contractor shall establish a UM program in accordance with the TOM Chapter 7, Section 4.

C.7.7.2. The Contractor shall provide UM for all TOP-eligible beneficiaries, except for TRICARE-Medicare dual-eligible beneficiaries when they receive care in the Commonwealth of Puerto Rico, Guam, American Samoa, the Northern Marianas, and the United States Virgin Islands.

C.7.8. Referrals and Authorizations

C.7.8.1. Referral Management (RM).

C.7.8.1.1. The Contractor shall operate a RM program for outpatient and inpatient services provided to TOP Prime, TOP Prime Remote, and transient beneficiaries.

C.7.8.1.2 MTFs will determine if they have the capability and capacity to provide needed specialty and inpatient care. If an MTF submits a referral, the referral signifies the referring MTF cannot provide care in the direct care system.

C.7.8.2. The Contractor shall ensure that required care is authorized and delivered by a qualified PSCP when they receive a referral request.

C.7.8.2.1. The Contractor shall provide an electronic copy of the referral/authorization to the referring MTF, the authorized provider, and the beneficiary. These requirements apply regardless of the PSCP’s location. The authorization shall include the accurate address and phone number for the specific provider or specialty clinic providing the care.

C.7.8.3. Health Care Finder Services. The Contractor shall provide health care finder services for all TRICARE beneficiaries seeking care in an overseas location. In some cases, the Contractor shall perform health care finder services and authorize care to providers in the 50 United States and the District of Columbia. See TOM, Ch 24, Sections 2, 6, 8, and 9 for additional requirements. See section H for negative incentives.

C.7.8.3.1. The Contractor shall direct the beneficiary to the provider that delivers the highest level of clinical quality while ensuring ATC standards are met.

C.7.8.4. Appointment Services. The Contractor shall provide instructions on the authorization for care on how the beneficiary can contact the Contractor to request assistance with making appointments.

C.7.8.4.1. The Contractor shall offer multiple channels for beneficiary appointment support, including call centers, a secure web-based portal, and beneficiary application (see C.10.4).

C.7.8.4.2. The Contractor shall make appointments for any TRICARE ADSM or ADFM beneficiary seeking care in an overseas location upon initial contact by the beneficiary.

C.7.8.4.2.1. If the Contractor is unable to make the appointment at the initial contact, it shall document why an appointment was not made at time of initial contact and perform the necessary follow-on actions to ensure the appointment is made.

C.7.8.4.3. Once an appointment is scheduled, the Contractor shall provide the beneficiary with an electronic notification of the appointment details, including the accurate name, address, and phone number for the specific provider providing the care to the beneficiary.

C.7.8.4.4. The Contractor shall, upon request, assist with the procurement of DME and supplies.

C.7.8.4.5. Beneficiaries, or MTFs acting on behalf of beneficiaries, may choose to make appointments.

C.7.8.4.6. The Contractor shall provide a monthly Appointing Report (M070) and describe its appointing process in the Access to Care Plan (P030). For reporting requirements, DD Form 1423-1, CDRL, located in Section J.

C.7.8.5. Benefit Review. The Contractor’s RM processes shall include a provision for evaluating referrals to determine whether the requested service or supply is a covered TRICARE benefit.

C.7.8.5.1 The Contractor shall advise the beneficiary when a requested service or supply is not a TRICARE benefit.

C.7.8.5.2. The Contractor shall advise TRICARE Select beneficiaries whether a particular service or supply is a covered TRICARE benefit.

C.7.8.6. Cashless/Claimless Care. In locations where a private sector care network is required, the Contractor shall ensure all authorized care to TOP Prime, TOP Prime Remote, and transient beneficiaries are provided on a cashless, claimless basis.

C.7.8.6.1. Upon request the Contractor shall in TOP Prime locations assist TRICARE Select beneficiaries to receive Cashless/Claimless care from a network provider.

C.7.8.6.2. The Contractor shall provide a monthly Cashless/Claimless Care Report (M140). For reporting requirements, DD Form 1423-1, CDRL, located in Section J.

C.7.8.7. Retroactive Authorizations. The Contractor shall not process any MTF requests for retroactive authorizations for TOP Prime beneficiaries that are submitted more than 3 business days after the care was rendered, unless the responsible TAO has validated and approved the request. MTFs are responsible for obtaining TAO validation/approval.

C.7.8.7.1. The Contractor shall document that it received validation/approval for each MTF retroactive authorization issued.

C.7.8.7.1.1. If retroactive authorization is issued, the Contractor shall identify impacted claims and adjust them appropriately.

C.7.8.8. Referral Response. The Contractor shall provide a Health Insurance Portability and Accountability Act (HIPAA)-compliant 278 response for each approved referral to the referring MTF and receiving provider.

C.7.8.8.1. For referrals that are rejected or returned to the MTF, the Contractor shall provide text explanations in return HIPAA compliant 278 responses. The text explanations shall describe why the Contractor is returning or rejecting the referral, including the name of the data element that needs to be corrected, and what the Contractor wants the MTF to correct before the MTF resubmits the referral to the Contractor for review and authorization determination.

C.7.8.8.2. When the Contractor denies a referral because of the inability of providers in the area to provide quality care and the beneficiary declines to seek an Out-of-Country Medical Request, the Contractor shall provide the beneficiary an electronic response explaining the potential risks if the beneficiary were to pursue care on their own.

C.7.8.8.2.1 The Contractor shall document that it provided the explanation to the beneficiary.

C.7.8.9. Standards for Referrals in Japan. Due to cultural differences in the delivery of healthcare in Japan, referral processing standards for Japan are adjusted only when the Contractor makes the appointment.

C.7.8.9.1. Following the date of receipt of a valid referral, the…