TPA Draft Work Breakdown Structure.pdf

Third Party Administrator

Draft Work Breakdown Structure

1.0 Provide Eligibility and Enrollment The Third Party Administrator (TPA) will serve as the

“intermediary” for real time beneficiary eligibility and enrollment to the TDP7 dental carriers, providing and exchanging eligibility and enrollment-related information with the dental carriers, Defense Enrollment Eligibility Reporting System (DEERS) and related applications (Enterprise Data System, Defense Online Eligibility System, Government

Inquiry of DEERS), and any other participating entities such as service payroll centers, as appropriate. DEERS is the system of record for eligibility and enrollment)

1.1 Interface with DEERS in accordance with the TRICARE Systems Manual (TSM) to identify and accurately process eligibility queries and changes in beneficiary eligibility status

1.1.1 Provide accurate and instantaneous DEERS information to dental carriers

1.1.1.1 The TPA can expect roughly 321,000 eligibility inquiries per month from the dental carriers.

1.1.1.2 The TPA can expect roughly 528,000 Benefits Re-determinations notifications per month from DEERS which are changes in the record after Service Personnel data updates occur that requires a re-look at eligibility that needs to be reconciled.

1.2 Enroll beneficiaries based on real-time verification of individual eligibility in DEERS

1.2.1 The TPA shall obtain and validate TDP enrollment for each beneficiary and share that information with carriers via enrollment files.

1.2.2 The TPA shall transmit changes in beneficiary enrollment information to carriers in a daily file.

1.2.3 The TPA shall have processes in place to identify, research and resolve enrollment changes and errors.

2.0 Provide Premium Administration This requirement includes providing the Government confidence in the integrity of all TPA financial workflows with multiple financial stakeholders including DHA, dental carriers, service pay centers, and beneficiaries.

2.1 Process complex billing scenarios, including multiple premium streams and retroactive eligibility adjustments

2.1.1 Provide accurate monthly combined premium stream payments to dental carriers monthly.

2.1.2 Protect the integrity of program funds from receipt through reconciliation and disbursement to carriers.

2.1.3 Administer a direct billing system including automatic bank withdrawal, electronic funds transfer, credit card processing for beneficiaries.

2.2 Conduct monthly audits and reconciliations to ensure premium payments are accurately applied, and reconciliations are processed within 30 days

2.2.1 Enrollment premiums are refunded or deducted based on reconciliations monthly.

2.2.2 Develop and apply appropriate tools and procedures to “find” enrollees whose payroll provider did not remit a premium or allotment premium.

2.2.3 Calculate premium or allotment amounts due, then request, receive or remit premiums/allotments to/from payroll providers and directly to/from enrollees.

2.2.4 Take action with payroll providers to resolve instances in which requested deductions were not remitted.

2.2.5 Generate extensive reporting to include billing summaries, payment information including current balance due, paid to date and credit balance information, reconciliation reports, past-due premium reports and mid-cycle changes and terminations, at varying intervals (daily, weekly, monthly, quarterly, and annually) to DHA, dental carriers, and pay centers and provide dental carriers with a dashboard to run standard and queried reports. Examples of potential reporting capabilities include:

2.2.5.1 Daily (This includes all enrollment changes (new enrollments, disenrollments, demographic updates, plan changes, QLEs, address changes, etc.), historical changes and effective dates.

Premium Activity Reports: Detailed payment information including current balance due, paid to date, and credit balance information. This file must include all financial transactions such as applied payments, carrier initiated write-offs, refunds, and payment adjustments. Daily, with a comprehensive summary at least weekly.)

2.2.5.2 Weekly (premium detail roll-up, outstanding issues, summary of call center activity, funds transfer summary, premium reconciliation, Audit Logs and Issue Tracking: detailed logs of

TPA actions, data changes, and any open or resolved issues related to specific beneficiaries or transactions. Additionally, a separate file of all "Problem" enrollment and billing contracts, indicating contracts the TPA is actively researching or awaiting government action, Comprehensive Reconciliation Files: Detailed files allowing for full reconciliation of all enrollment and premium data. Account management reports. On-demand access.)

2.2.5.3 Monthly (Full Enrollment file, premium detail roll up, true-up premium reconciliations, quality assurance metrics, Billing Status and Delinquency Reports: Following the TPA’s monthly billing process, a billing status file including billing method (LES, Electronic, Paper), balance due, paid to date, and credit balance information. A separate file of all delinquent contracts, with severity of delinquency (e.g., 30, 60, 90 days), to be provided the business day following the standard invoice due date.)

3.0 Provide Customer Service This requirement includes meeting customer service standards and CONUS and OCONUS beneficiary expectations. This also includes leading a multi-channel campaign that ensures equitable promotion of all carriers and tailored communications to different enrollee segments (e.g., members of the National Guard and

Reserve, families of three or more, rural populations) to provide information that is relevant and actionable.

3.1 Provide Beneficiary Comparison Tools

3.1.1 The TPA shall offer beneficiaries a user-friendly, secure enrollment portal accessible through a mobile friendly website.

3.1.2 The TPA shall provide a tool that compares the different TDP plan benefits and premiums to assist enrollees in selecting the right plan for themselves and their families. To help those eligible understand what CDT

(Current Dental Terminology) codes are covered and the approximate enrollee share for each, the TPA shall include American Dental

Association (ADA)/CDT codes in the comparison tool. The TPA shall obtain the ADA/CDT codes from the TDP carriers to create a searchable option in the comparison tool of dental procedures along with cost shares that are offered by all carriers.

3.1.3 The TPA shall offer enrollment counseling services to guide beneficiaries through plan selection, enrollment options, and understanding their benefits.

3.1.4 Plain language explanations of plan designs and benefits, Side-by-side benefits comparison tools, AI-assisted guidance to walk users through plan selection, Dental provider look-up features, Carrier-level quality metrics to inform tradeoffs beyond price.

3.2 Beneficiary Customer Support and Call Center

3.2.1 The TPA shall offer a comprehensive range of marketing materials, including brochures, flyers, and digital content that effectively communicate program offerings and are tailored to the military community.

3.2.2 The TPA shall hire, train, and maintain a knowledgeable, courteous, and responsive call center staff resulting in highly satisfied beneficiaries.

3.3 Dental Carrier Support

3.3.1 The TPA shall have either a Memorandum of Understanding (MOU), Associate Contractor Agreement (ACA), Business Associate Agreement

(BAA), or Service Level Agreement (SLA) with each dental carrier detailing workflows and points of contact.

3.4 Service Pay Center Support

3.4.1 The TPA shall have MOUs with pay centers detailing workflows and points of contact.

4.0 Systems Connectivity This requirement includes systems interface and interoperability that is secure, reliable, and fully tested prior to start of dental care delivery, as outlined in the

TSM. Government cybersecurity standards, and HIPAA requirements, are well established and require 100% compliance by all contractors accessing Government data and Controlled

Unclassified Information (to include protected health information).

4.1 DEERS

4.1.1 The TPA will exchange information with DEERS, and numerous

Government and military pay centers using a systems architecture flexible enough to support technical, business, and mandatory Federal requirements without inhibiting or limiting functionality or user experience.

4.2 Dental Carriers

4.2.1 The TPA will test and maintain secure reliable operational interfaces with dental carriers.

5.0 Transition In and Out Capability Transition requirements are designed to mitigate performance risks and avoid failure of critical services at start of dental care delivery.

5.1 Start-Up and Transition-In

5.1.1 The TPA shall transition all systems, processes, and beneficiary information seamlessly between an outgoing or incoming contractor while ensuring no negative impact on beneficiaries’ dental health outcomes, customer service, or overall customer satisfaction.

5.1.2 Financial Management Plan/ Financial Approach (how they plan to segregate the TDP funds from other funds they handle for clients).

5.1.3 The TPA shall execute a methodical and carefully planned transition plan, with a focus on maintaining continuity of care and access to services.

5.1.4 The TPA shall provide a Communications Plan to include education and marketing.

5.1.5 The TPA shall provide weekly detailed reports on its Integrated Master

Plan/Integrated Master Schedule progress to DHA.

5.1.6 The TPA shall demonstrate testing capabilities and comply with

Government Performance Readiness Validation (PRV) and Performance

Readiness Assessment and Verification (PRAV) requirements during the transition period.

5.2 Transition-Out Plan

5.2.1 The TPA shall execute a methodical and carefully planned transition out plan, with a focus on maintaining continuity of care and access to services.