1.0 Contract
Phase-In
1.1 Start-Up
Plan
The incoming contractor shall submit
a Start-Up Plan no later than 10 calendar days following contract
award. This comprehensive plan shall be submitted electronically,
in Microsoft® (MS) Project format, to the Procuring Contracting
Officer (PCO) and Contracting Officer’s Representative (COR). The plan
shall address all events and milestones that need to occur for each
functional area described in the contract to enable the start of
service performance under this contract. Within 15 calendar days following
the Transition Specifications and Interface meetings, the incoming
contractor shall submit to the PCO and COR a revised Start-Up Plan
which incorporates the results of the Transition Specifications and
Interface meetings, as necessary. After the PCO approves the revised
Start-Up Plan, it will be incorporated into the contract at no cost
to the Government.
1.2 Transition Specifications
Meeting
1.2.1 The incoming contractor shall attend a two
to four day meeting with Department of Defense (DoD)/Defense Health
Agency (DHA) representatives at a Government-specified location, within
15 calendar days following contract award. This meeting is for the
purpose of discussing start-up requirements, and for developing
a schedule for phase-in activities. DHA will notify the incoming contractor
as to the exact date and place of the meeting. Incoming contractor
representatives attending this meeting shall have the experience,
expertise, and authority to provide approvals and establish project
commitments on behalf of their organization.
1.2.2 The transition
specifications meeting will include a meeting with the outgoing
pharmacy contractor. A Memorandum of Understanding (MOU) will be
developed (between the incoming and outgoing contractors) that addresses
coordination of phase-in/phase-out activities. Specific activities to
be addressed at the meeting include, but are not limited to:
1.2.2.1 The incoming
contractor shall coordinate with the outgoing contractor to perform
an electronic transfer of beneficiary mail order and open refill
history to the extent allowed by applicable state and federal requirements
and laws. The incoming contractor shall demonstrate its ability
to receive these files no later than 60 calendar days prior to the
start of Option Period 1.
1.2.2.2 The incoming
contractor shall make arrangements with the outgoing contractor
to ensure any Mail Order Pharmacy (MOP) prescription orders received
by the outgoing contractor after the start of Option Period 1 are
promptly forwarded to the incoming contractor. This requirement
is valid for a period of 180 days after the start of mail order
services. Overnight shipping shall be used, at the incoming contractor’s
expense, to forward the orders. The incoming contractor shall ensure
that notification of the change of contractor is sent with the dispensed
prescription to the beneficiary for those prescriptions that were
forwarded from the outgoing contractor.
1.2.2.3 The incoming
contractor shall coordinate with the outgoing contractor the transfer
of any beneficiary/claims history files, including a schedule that
addresses initial shipments and updates as necessary. The incoming
contractor shall perform initial conversion and testing of any electronic
files no later than 30 calendar days following receipt of the files
from the outgoing contractor.
1.2.2.4 The incoming
contractor shall coordinate with the outgoing contractor to establish
time frames for the transfer of any open/pending prior authorization
requests and medical necessity reviews.
1.3 Interface
Meetings
1.3.1 Within
30 calendar days from contract award, the incoming contractor shall
arrange meetings with Government and external agencies to establish
all systems interfaces necessary to meeting the requirements of
the contract. These meetings shall be scheduled with, but not limited
to, the Defense Manpower Data Center (DMDC), Pharmacy Data Transaction
Service (PDTS), and the Defense Health Agency (DHA) Communications
office. The meeting with DMDC shall be a technical specifications
meeting regarding Defense Enrollment Eligibility Reporting System
(DEERS) applications and interfaces. DHA/DoD representatives shall
be included in these meetings and all plans developed shall be submitted
to the PCO and COR within 10 calendar days after the meeting for
final approval.
1.3.2 The incoming contractor is
required to attend and participate (by telephone) in systems integration
meetings during contract start-up. The purpose of these meetings
is to address all phases of systems interface implementation and
start-up, including testing and problem resolution. The meetings,
scheduled and hosted by DHA, will be held at least weekly during
the transition period, and will continue after contract start-up
until all system integration related issues are resolved.
2.0 Start-Up
Requirements
2.1 Systems
Development
2.1.1 No later than 60 calendar days prior to the
initiation of services under the contract, the processing systems
and the telecommunications interconnections between these systems
shall be reviewed by DHA (or its designees) to include a demonstration
by the incoming contractor of the system(s) capabilities to determine
whether the systems satisfy the requirements of the contract. This includes
telecommunications links with DHA, DEERS, and PDTS. This review
is in addition to benchmark testing as outlined in
paragraph 3.0 (all
systems necessary for benchmark testing must be operational at the
start of benchmark testing). The incoming contractor shall effect
any modifications required by DHA prior to the initiation of services
under this contract. The contractor shall be notified of any such required
modifications by the PCO. The incoming contractor will attend and
participate in weekly systems integration meetings (see
paragraph 1.3.1).
2.1.2 No later
than 30 calendar days prior to the start of services, the incoming
contractor shall demonstrate to DHA successful implementation of
all web-based capabilities as required in the contract.
2.2 Execution
of Agreements with Network Pharmacies
2.2.1 Retail network pharmacy agreements
shall be executed, and loaded into the incoming contractor’s system(s)
60 calendar days prior to the start of retail pharmacy services,
or at other such time as is mutually agreed upon between the incoming
contractor and the PCO.
2.2.2 The incoming contractor shall
report on the adequacy of the network on a monthly basis during
the transition. These reports are due to the PCO and the COR within
10 calendar days following the last day of the reporting period,
and shall provide the following information:
• The number of network
pharmacies;
• The
number of network additions/deletions since the last reporting period;
• Activities undertaken
to contract with additional pharmacies in areas lacking an adequate
network; and
• A
listing of network pharmacies.
3.0
Benchmark
Testing
3.1 General
Prior to the start of services, the incoming
contractor shall demonstrate the ability of its staff and its automated
systems to accurately process all types of TRICARE Pharmacy (TPharm)
claims in accordance with current requirements. This will be accomplished
through a comprehensive Benchmark test. The Benchmark test is administered
by the incoming contractor under the oversight of DHA, and must
be completed no later than 60 days prior to the start of services
under this contract.
3.1.1 The Benchmark test shall consist
of up to 1,000 claims, testing a multitude of claim conditions,
including TPharm covered and non-covered services, eligible and
non-eligible beneficiaries, formulary and non-formulary processing,
coordination of benefits, Department of Veterans Affairs (DVA)/Veterans
Health Administration (VHA) claims, Medicaid claims,
etc. The benchmark may require up to 17 consecutive calendar days
at the contractor’s site(s). The test may also include adjustments
and reversals, and submission of TRICARE Encounter Data (TED) records
for these actions.
3.1.2 The Benchmark test is comprised
of one or more cycles or batches of claims. When more than one cycle
is used, each cycle may be submitted on consecutive days. Each cycle
after the initial one will include new test claims, as well as claims
not completed during preceding cycles. All aspects of claims processing
may be tested.
3.1.3 The incoming contractor shall
demonstrate its ability to conduct eligibility verification and claims
processing functions to include:
• Claims control and
development; accessing and updating DEERS for eligibility status;
• Calculating cost-shares
and deductibles;
• Querying
and updating internal and external family and patient deductible
and cost-share files on the Catastrophic Cap and Deductible Data
(CCDD) file;
• Accessing
and updating PDTS;
• Applying
utilization review criteria;
• Adjusting and canceling
previously processed claims (inside and outside the 10-day window
for network retail pharmacy claims); and
• Producing required
output for paper and electronic transactions.
3.1.4 The Benchmark
test may include testing of any and all systems (internal and external)
used by the incoming contractor to process claims. The Benchmark
will also test generation and submission of TED records for every
test claim. Incoming contractor compliance with applicable Health
Insurance Portability and Accountability Act (HIPAA) and security
requirements will be included in the Benchmark test, as appropriate.
3.1.5 The incoming
contractor shall conduct the benchmark test. The test will be comprised
of both paper and electronic (batch and Point of Service (POS))
claim transactions. The incoming contractor shall be required to
create test claims, including prior authorizations and medical necessity reviews
from test scenarios provided to the contractor by DHA. The incoming
contractor shall supplement these test scenarios with any internal
conditions if appropriate for testing.
3.1.6 A Benchmark test of a current
contractor’s system may be administered at any time by DHA upon
instructions by the PCO. All incoming contractor costs incurred
to comply with the performance of the Benchmark test are the responsibility
of the incoming contractor.
3.2 Benchmark Procedures
3.2.1 Approximately
60 calendar days following contract award, DoD/DHA representatives
will conduct a pre-benchmark meeting with the incoming contractor
to provide an overview of the test process, receive an overview
of the contractor’s system(s), collect data for use in the benchmark, discuss
the involvement of external systems in the test (e.g., DEERS and
PDTS), and discuss the dates of the test and information regarding
the administration of the test. At this time, DHA shall provide
the test scenarios to the incoming contractor that are to be used
in the development of the test claims.
Note: At DHA’s discretion, the test must be completed
no later than 60 calendar days prior to the start of services to
allow time to make any needed corrections. The pre-benchmark meeting
will be conducted at the incoming contractor’s site. Data requirements
will be coordinated at the pre-benchmark meeting to ensure that
the incoming contractor adequately prepares all files prior to the benchmark.
Electronic transaction requirements shall be discussed to include
timing and logistics.
3.2.2 At this pre-benchmark meeting,
the incoming contractor shall be advised of the logistics of the
Benchmark test including the number of DoD/DHA staff who will monitor
and evaluate the results of the test; the amount of time the incoming
contractor shall have to process test claims; the process and point
of contacts for the incoming contractor to use for questions related
to the test scenarios provided by DHA; space requirements for the
DHA team including access to telephones, computer terminals, and
printers; and what reference documents the incoming contractor shall
make available to the DHA team during the test (e.g., TRICARE Manuals,
Explanation of Benefits (EOB) message codes, reject/denial codes,
organizational chart, personnel directory, etc.).
3.2.3 On the
first day of the Benchmark test, a brief entrance conference will
be held with the incoming contractor personnel to discuss the schedule
of events, expectations, and administrative instructions.
3.2.4 During
the Benchmark test, the incoming contractor shall process the claims
and shall provide output for evaluation by DHA personnel as the
claims are processed to completion. The specific schedule for claims
processing and the procedures for providing the output will be discussed with
the incoming contractor at the pre-benchmark meeting.
3.2.5 At the
conclusion of the Benchmark test, an exit conference may be held
with the incoming contractor staff to brief the incoming contractor
on all findings identified during the benchmark. The initial Benchmark
test report will be forwarded to the incoming contractor by DHA
within 45 calendar days of the last day of the test. For any claims
processing errors assessed with which the incoming contractor disagrees,
a written description of the disagreement along with any specific
references must be included with the claims. The incoming contractor
shall correct all findings identified during the Benchmark test
no later than 45 days following the date of the initial report.
3.2.6 Within
seven calendar days of the last day of the Benchmark test, the incoming
contractor shall prepare and submit the initial TED records to DHA.
The incoming contractor shall be notified of any TEDs failing the
DHA edits. The incoming contractor shall make the necessary corrections
and resubmit the TED records until 100% of the original benchmark
test TEDs have passed the edits and are accepted by DHA.
3.2.7 The incoming
contractor has 45 calendar days from the date of the initial Benchmark
test report to submit the final corrected TED records to DHA. New
TEDs need not be generated to reflect changes created from claims
processing corrections; however, all TEDs originally submitted for
the benchmark test claims which did not pass DHA edits must continue
to be corrected and resubmitted until all edit errors have been
resolved and 100% of the TED records have been accepted by DHA.
3.3 Operational
Aspects
3.3.1 The Benchmark test may be conducted on the
incoming contractor’s production system(s) or an identical copy
of the production system (i.e., test system). Whichever system is
used for the benchmark, it must meet all TRICARE requirements. If
the benchmark is conducted on the incoming contractor’s production
system, the incoming contractor shall prevent the possibility of
any checks or EOBs being actually mailed to beneficiaries or providers
and prevent production TEDs from being sent to DHA.
3.3.2 Certain
external test systems and files (e.g., DEERS, PDTS) are an integral
component of the Benchmark test, and the incoming contractor is
expected to perform all necessary verifications, queries, etc.,
according to TRICARE procedures and requirements. The incoming contractor
shall coordinate through DHA to ensure that direct interface with
any required external test system is established and operational
prior to the benchmark.
3.4 The incoming contractor shall
also conduct high-volume stress testing for retail pharmacy transactions.
The purpose of this stress test is to ensure that proposed systems
and system interfaces are configured to allow for a high volume
of transactions in an acceptable time frame consistent with contract
performance standards.
4.0 Contract
Phase-Out
4.1 Phase-Out
Plan
The incoming contractor shall submit
a Phase-Out Plan no later than 30 calendar days following award
of a successor contract. The plan shall address all events and milestones
that need to occur during the contract transition and phase-out.
The Phase-Out Plan shall incorporate results of the Transition Specifications
meeting as appropriate.
4.2 Transitions Specification
Meeting
The outgoing contractor shall attend
a meeting with representatives of the incoming contractor and DoD/DHA
within 15 calendar days following contract award. The meeting is
for the purpose of discussing phase-out/phase-in activities. A MOU
will be developed between the incoming/outgoing contractors that
addresses coordination of phase-out and phase-in activities. DHA
will notify the outgoing contractor as to the exact date of the
meeting.
4.3 Data
The outgoing contractor shall provide to DHA
(or, at the option of DHA, to an incoming contractor) such information
as DHA requires to facilitate transitions from the outgoing contractor’s operations
to operations under the incoming contractor. Such information may
include, but is not limited to, the following:
• The
data contained in the outgoing contractor’s claims processing system(s).
• Information about
the management of the contract that is not considered, under applicable
Federal law, to be proprietary to the outgoing contractor.
4.4 Phase-Out
of The Contractor’s Claims Processing Operations
Upon
notice of award to another contractor, and during the procurement
process leading to a contract award, the outgoing contractor shall
undertake phase-out activities such as the following:
4.4.1 The outgoing
contractor shall, upon receipt of a written request from DHA, provide
to potential offerors such items and data as required by DHA. This
shall include non-proprietary information such as record formats
and specifications, field descriptions and data elements, claims
and correspondence volumes, etc.
4.4.2 Transfer of Automated Data
Processing (ADP) Files (Electronic)
The outgoing
contractor shall prepare, in an electronic format, and transfer
to the incoming contractor or DHA, by the 15th calendar day following
the Transition Specifications meeting, (unless otherwise negotiated
by the incoming and outgoing contractors), all specified ADP files
in accordance with the specifications in the MOU. The outgoing contractor
shall continue to participate in preparation and testing of these
files until they are fully readable by the incoming contractor.
4.4.3 Outgoing
Contractor Weekly Shipment of History Updates
The
outgoing contractor shall transfer to the incoming contractor, in
electronic format, all beneficiary history files (occurring from
the date of preparation for shipment of the initial transfer of such
history files and every week thereafter) in accordance with the
specifications in the MOU.
4.4.4 Transfer of Non-ADP Files
The outgoing contractor shall transfer to the
incoming contractor all non-ADP files in accordance with the specifications
in the MOU and
Chapter 2. The hard copies of the Beneficiary
Claims History Files are to be transferred to the incoming contractor
or Federal Records Center as required by
Chapter 2. The
contractor shall provide samples, formats, and descriptions of these
files to the incoming contractor at the Transition Specifications
meeting.
4.4.5 EOB
Record Data Retention and Transmittal
If
the outgoing contractor elects to retain EOB data on a computer
record, it must, in the event of a transition to another contractor,
provide either a full set of electronic records covering the current
and two prior years, or at the PCO’s discretion, provide the data
and necessary programs to reproduce the EOB in an acceptable format
and transfer such data and programs to the outgoing contractor or
to DHA. DHA shall be the final authority in determining the format
and/or acceptability of the data.
4.5 Final Processing
of Outgoing Contractor
The outgoing contractor
shall:
• Process to completion
all claims, including adjustments, received during its contract
period (including contract phase-out). Processing of these claims
shall be completed within 90 calendar days following the start of
the incoming contractor’s service delivery. All claims shall meet
the same standards as outlined in the current contract.
• Be liable, after the
termination of services, for any payments to subcontractors of the outgoing
contractor arising from events that took place during the period
of this contract.
• Process
all correspondence and incoming telephone inquiries which pertains
to claims or services processed or delivered under this contract
within the time frames established for response by the standards
of the contract.
• Complete
all appeal cases that pertain to claims or services processed or
delivered under this contract within the time frames established
for response by the standards of the contract.
4.5.1 Correction
of Edit Rejects
The outgoing contractor shall
retain sufficient resources to ensure correction (and reprocessing
through DHA) of all TED record edit errors no later than 120 calendar
days following the incoming contractor’s start of pharmacy services.
4.5.2 Cost Accounting
If the outgoing contractor succeeds itself,
costs related to each contract shall be kept separate for purposes
of contract accountability.
4.5.3 Records Disposition
The outgoing contractor shall comply with the
provisions of
Chapter 2, Section 10 in final disposition
of all files and documentation. The outgoing contractor shall include
a records disposition section as part of the Phase-Out Plan.