1.0 General
The contractor shall establish and maintain
sufficient staffing and management support services and commit all
other resources and facilities necessary to achieve and maintain
compliance with all quantitative and qualitative standards for claims
processing timeliness, claims inventory levels, claims control,
and claims accuracy. The requirements below outline minimum requirements
of Defense Health Agency (DHA). Contractors are encouraged to develop
and employ the most effective management techniques available to
ensure economical and effective operation.
2.0 System
Additions Or Enhancements
2.1 Implementation
of Changes in Program Requirements
The contractor
shall have the capacity, using either directly employed personnel
or contracted personnel, to maintain and operate all required systems
and to achieve timely implementation of changing program requirements.
2.2 Maintaining
Current Status of Diagnostic and Procedural Coding Systems (PCS)
Contractors are required to use the current
versions of the updated American Medical Association Physicians
Current Procedural Terminology, 4th Edition (CPT-4), and the International Classification
of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic
coding system; and any special codes that may be directed by DHA.
Beginning with dates of service on or after the mandated date, as
directed by Health and Human Services (HHS) for International Classification
of Diseases, 10th Revision (ICD-10) implementation, for outpatient
facility and all non-facility services, and for inpatient facility
charges with discharge dates on or after the mandated date, contractors
will be required to replace the use of ICD-9-CM diagnosis codes
with the current version of the ICD-10-CM and the International
Classification of Diseases, 10th Revision, Procedure Coding System
(ICD-10-PCS) for inpatient hospital procedures. The contractor is
responsible for using the most current codes correctly. That responsibility
includes making any needed revisions required by periodic CPT-4
and ICD-9-CM or ICD-10-CM and ICD-10-PCS updates issued by the publishers.
When updates occur, contractors will be notified of the date the
TRICARE Encounter Data (TED) editing system will be accepting changes
in the codes.
2.3
Zip
Code File
The contractor shall maintain and
update an electronic file of all zip codes using a Government-furnished
electronic zip code directory. The contractor shall incorporate
this electronic file in its claims processing system to determine
the validity of a beneficiary or provider zip code. This directory
will be provided by the Government no less than four and no more
than 12 times per calendar year. Updates to the electronic zip code
directory for the purposes of contract modifications, directed policy
actions, and expansion or termination of zip codes by the U.S. Postal
Service (USPS), shall be accomplished at no additional cost to the
Government.
2.4
Updating
And Maintaining TRICARE Reimbursement Systems
The
contractor, at no additional cost to the Government and as directed
by DHA shall implement all policy changes and clarifications to
existing TRICARE reimbursement systems affecting both the level
of payment and the basic method of reimbursement as they apply to
current provider categories implemented at the time of contract
award. The TRICARE Reimbursement Manual (TRM) is the source for
instructions and guidance on all existing reimbursement systems
for current provider categories.
3.0 Management
Controls
The contractor shall develop and
employ management procedures necessary to ensure control, accuracy,
and timeliness of transactions associated with operation of their
call center, TRICARE Service Center (TSC) functions (TRICARE overseas
contract only), enrollment, authorizations, provider referrals,
claims processing, beneficiary services, provider services, reconsiderations,
grievances, Automatic Data Processing (ADP), and financial functions.
These procedures include such elements as:
3.1 An automated claims aging
report, by status and location, for the purpose of identifying backlogs
or other problem areas delaying claims processing. At a minimum,
this report must be sorted to enable a count of the total number
of claims pending for a specified length of time, e.g., the time periods
specified in the Monthly Cycle Time/Aging Report.
3.2 An automated
returned claims report counting the number of claims returned by
the time periods specified in the Monthly Cycle Time/Aging Report.
3.3 Procedures
to ensure confidentiality of all beneficiary and provider information,
to ensure that the rights of the individual are protected in accordance
with the provisions of the Privacy Act and the HIPAA and Health
and Human Services (HHS) Privacy Regulation and prevent unauthorized
use of DHA files.
3.4 A system to control adjustments
to processed claims which will document the actual date the need
for adjustment is identified, the reason for the adjustment and
the names of both the requesting and authorizing persons. The controls
shall also ensure the accurate and timely update of the beneficiary
history files, the timely and accurate submission of the TED data
and issuance of the proper notice to the beneficiaries and providers
affected by the adjustments.
3.5 A set of processing guidelines,
desk instructions/user’s manuals and reference materials for internal
use. These materials shall be maintained, on a current basis, for
the life of the contract. Desk instructions shall be available to
each employee in the immediate work area. Reference material such
as procedure codes, diagnostic codes, and special processing guidelines,
shall be available to each work station with a need for frequent
referral. Other reference materials shall be provided in each unit
with a reasonable need and in such quantity as to ensure the ease
of availability needed to facilitate work flow. Electronic versions
may be used.
4.0 Quality
Control
4.1 The
contractor shall develop and implement an end-of-processing quality
control program which assures accurate input and correct payments
for authorized services received from certified providers by eligible
beneficiaries.
4.2 The
contractor shall have a quality control program consisting of supervisory
review of appeals, grievances, correspondence, and telephone responses.
This must begin by the end of the third month after the start of
health care delivery (SHCD) and be carried out monthly thereafter.
The review shall include a statistically valid sample or 30 records,
whichever is greater, of each of the following: appeals, grievances,
correspondence processed and telephonic responses completed. The
criteria for review shall be accuracy and completeness of the written
or telephonic response, clarity of the response, and timeliness
with reference to the quantitative standards for the processing
of appeals, grievances, and correspondence. Any lack of courtesy
or respect in the response shall also be noted. All findings shall
be documented, provided to DHA Contracting Officer’s Representative
(COR) staff, or authorized auditors, and used in a documented training
program.
4.3 The quality review program will sample each
quarter, a sufficient number of processed claims and adjustments
to ensure the required quality of adjudication and processing and
provide adequate management control. Claims in the sample shall
include all claim types and be selected randomly, or by other acceptable
statistical methods, in sufficient number to yield at least a 90%
confidence level with a precision of 2%. The sample will be drawn
at or near the end of each quarter from claims completed during
the review period. The contractor may draw the sample up to 15 calendar
days prior to the close of the quarter, but must include claims
completed in the period between the date the sample is drawn and
the close of the quarter in the next quarterly sample. The contractor
shall reflect the inclusive processing dates of the claims in the
sample in the report submitted to DHA. The sampling will begin by
the end of the first quarter of processing. Documentation of the
results shall be completed within 45 calendar days of the close
of each contract quarter.
4.4 The contractor shall retain
copies of the reviewed claims, appeals, grievances, correspondence, and
related working documents, in separate files, for a period of no
less than four months following submission of audit results to the
Procuring Contracting Officer (PCO). DHA staff will review the results and
will on a regular basis audit a selected sampling of the audited/quality
review documents. The review may occur at the contractor’s site
or at a location specified by DHA. The contractor shall provide all
documentation supporting this review within 10 calendar days of
a DHA request.
5.0
Staff
Training Program
The contractor shall develop
and implement a formal initial and ongoing staff training program including
training on program updates as they occur, to ensure a high quality
of service to beneficiaries and providers. Such training shall include
mandatory, documented training in Confidentiality of Patient Records
(42 United States Code (USC) [290dd-3]) requirements (see
Section 5). The contractor shall not only
provide education on these requirements but must document the personnel
files of the staff members who receive the training. Centralized
documentation shall also be maintained of the training session agendas,
identity of attendees, actual dates and duration of training sessions,
etc. The contractor is also responsible for ensuring that subcontractor
staff is fully trained.
6.0 Internal
Audits And Management Control Programs
Using
its corporate internal review capability, the contractor is responsible
for verifying that accounting data are correct, reliable and comply
with all Government accounting standards and requirements. The contractor’s
corporate internal review staff must conduct regular, routine reviews
to ensure proper monitoring in the areas of finance, financial accounting,
internal controls, special checks issued and returned, and selected
history maintenance transactions for possible fraud or abuse.
7.0 Beneficiary
Surveys
In accordance with Department of
Defense Instruction (DoDI) 1100.13, and Health Affairs Policy Memorandum
97-012, surveys of military members, retirees and their families
must be approved and licensed through issuance of a Report Control
Symbol (RCS). Contractors shall not conduct written or telephonic
beneficiary surveys without the approval of the DHA Decision Support
Division (DSD). DHA has an ongoing survey research and analysis
program which includes periodic population-based and encounter-based
surveys of DoD beneficiaries. The surveys address beneficiary information
seeking strategies and preferences, health status, use of care,
satisfaction with military and civilian care, and attitudes toward
TRICARE. The data are collected at the Prime Service Area (PSA)
level and can be aggregated to the regional level. Regional reports
containing PSA data are available through the Director, TRICARE
Regional Offices (TROs)/Program Office. Contractors shall work with
the Director, TROs/Program Offices to define both their ongoing
and special purpose requirements for survey data. Contractors with
special needs not met by an existing instrument may submit surveys,
sampling plans, and cost estimates through the Director, TROs/Program
Office to the DHA, DSD, for approval and licensing.