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TRICARE Operations Manual 6010.59-M, April 1, 2015
Chapter 2
Section 2
Systems Development
Revision:  C-26, May 30, 2018
1.0  Transition
1.1  Upon reprocurement of a TRICARE contract, an incumbent contractor may succeed itself or a new contractor may be awarded the contract. The Defense Health Agency (DHA) will coordinate transition activities with the incumbent/new contractor and Defense Finance and Accounting Service (DFAS)/U.S. Coast Guard (USCG)/Public Health System (PHS), during the transition-in period. When the contract is awarded to a new contractor, the following actions will be taken by the outgoing and incoming contractors.
1.2  The outgoing contractor shall stop all allotments by sending a “stop allotment notice” to DFAS after the last payment under their contract has been received. To stop allotments, the notice has to be at DFAS by the sixth day of the preceding month, for example, to stop for May 1st, the “stop allotment notice” has to be at DFAS by April 6th.
1.3  The incoming contractor shall send an “allotment request” to DFAS no later than the sixth day of the month prior to the first payment being due. For example, to start May 1st, the “start request” must be at DFAS by April 6th.
2.0  System Interface Meetings
2.1  The incoming contractor shall schedule a systems interface meeting with the Government within 30 days of the transition start date. The purpose of the meeting is to review requirements for the establishment of connectivity with Government systems and applications.
2.2  The incoming contractor’s Facility Security Officer (FSO) shall attend a meeting with DHA Personnel Security Branch (PSB) to review Personnel Security Requirements and the procedures for requesting background checks and Common Access Cards (CACs) in accordance with the TRICARE Systems Manual (TSM), Chapter 1, Section 1.1. The FSO shall undergo the required background check and obtain the necessary trustworthiness certification (Automated Data Processing/Information Technology (ADP/IT)) prior to approving requests for the remaining staff in the incoming contractor’s organization.
2.3  User Access Requirements
The incoming contractor shall ensure personnel complete appropriate background and security checks in accordance with the TSM, Chapter 1.
2.4  Connectivity Requirements
2.4.1  The incoming contractor shall collaborate with the Government to establish the required interfaces with Government systems and applications. The contractor shall complete the submission of required forms (e.g., Business to Business Questionnaire, DD Form 2875, etc.) in accordance with the TSM, Chapter 1.
2.4.2  Data Transmission Start Up  The DHA will coordinate Business to Business (B2B) Gateway and DFAS connectivity for all contractors. DHA will also coordinate integration testing of the connectivity and data transmission. DHA and the contractor will collaborate with DFAS/USCG/PHS on the development of a test plan and schedule.  At the start-up planning meeting, each contractor on the telecommunication network shall provide DHA the name, address, and telephone number of the person who will serve as a technical POC (update when a change occurs). Contractors shall also provide a separate computer center (Help Desk) number to DHA with the DHA computer operator can use for resolution of problems related to data transmissions.
2.5  Systems Development
Approximately 60 calendar days prior to the start of health care delivery (SHCD), the non-claims processing systems and the telecommunications interconnections between these systems shall be reviewed by DHA or its designees, to include a demonstration by the contractor of the system(s) capabilities, to determine whether the systems satisfy the requirements of TRICARE as otherwise provided in the contract. This includes the telecommunications links with DHA and Defense Enrollment Eligibility Reporting System (DEERS). The contractor shall effect any modifications required by DHA prior to the initiation of services.
2.6  Claims Processing System and Operations
During the period between the date of award and the SHCD, the incoming contractor shall, pursuant to the Integrated Master Plan/Integrated Master Schedule (IMP/IMS), meet the following contractor file conversions and testing requirements:
2.6.1  Contractor File Conversions and Testing  The incoming contractor shall perform initial conversion and testing of all Automated Data Processing (ADP) files (e.g., provider files, claims history files, and beneficiary history) no later than 30 calendar days following receipt of the files from the outgoing contractor(s). Integration testing will be conducted to validate the contractor’s internal interfaces to each of the TRICARE Military Health Systems (MHS) Information Management/Information Technology (IM/IT). This testing will verify the contractor’s system integration, functionality, and implementation process. The incoming contractor shall be responsible for the preparation and completion of Integration Testing 45 days prior to the SHCD.  DHA Test Managers will work with the contractor to plan, execute and evaluate the Integration Testing efforts. The contractor shall identify a primary and a back-up Testing Coordinator to work with the DHA Test Managers. The Testing Coordinator is responsible for contractor testing preparations, coordination of tests, identification of issues and their resolution, and verification of test results. A web application will be available for use by contractor Test Coordinators to report and track issues and problems identified during integration testing.
2.7  Data
The outgoing contractor shall provide to DHA (or, at the option of DHA, to a successor contractor) such information as DHA shall require to facilitate transitions from the contractor’s operations to operations under any successor contract. All files shall be provided in a non- proprietary format and the contractor shall include such file specifications and documentation as may be necessary for interpretation of these files. Such information may include, but is not limited to, the following:
•  The data contained in the contractor’s enrollment information system.
•  The data contained in the contractor’s claims processing systems.
•  Information about the management of the contract that is not considered, under applicable Federal law, to be proprietary to the contractor.
2.8  Transaction Testing
In the absence of the inclusion of testing requirements in updated Health Insurance Portability and Accountability Act (HIPAA) legislation, contractors shall comply with testing requirements in accordance with the Contracting Officer (CO) direction. At a minimum, testing shall include the following:
2.8.1  Contractors shall test their capability to create, send, and receive compliant transactions. Contractors shall provide written evidence (e.g., certification from a transaction testing service) of successful testing of their capabilities to create, send, and receive compliant transactions to the contracting offices no later than 60 days prior to the SHCD.
Note:  Where failures occur during testing, the contractor shall make necessary corrections and re- test until a successful outcome is achieved.
2.8.2  Contractors shall test their capability to process standard transactions. This testing shall be “cradle-to-grave” testing from receipt of the transactions, through processing, and completion of all associated functions including creating and transmitting associated response transactions. Testing involving the receipt and processing of claims transactions shall also include the submission to and acceptance by the DHA of TRICARE Encounter Data (TED) records and the creation of contract compliant electronic Explanation Of Benefits (EOB). It is expected that the contractors shall complete “cradle-to-grave” testing no later than 30 days prior to the start of services.
2.9  Phase-Out of the Contractor’s Claims Processing Operations
Upon notice of award to another contractor, the outgoing contractor shall undertake the following phase-out activities regarding services as an outgoing contractor.
2.9.1  Transfer of Electronic File Specifications
The outgoing contractor shall provide to the incoming contractor, no later than three calendar days following award announcement or upon direction of the Contracting Officer (CO), electronic copies of the record layouts with specifications, formats, and definitions of fields, and data elements, access keys and sort orders, for the following:
•  Beneficiary History Files.
•  Claims History Files.
•  The TRICARE Encounter Provider Files (TEPRVs).
•  The Enrolled Beneficiary and Primary Care Manager (PCM) Assignment Files.
•  Mental Health Provider Files: The outgoing contractor must assure that the incoming contractor has been given accurate provider payment information on all mental health providers paid under the TRICARE inpatient mental health per diem payment system. This shall include provider name; Tax Identification Number (TIN); address including zip code; high or low volume status; if high volume, provide the date the provider became high volume; and the current per diem rate along with the two prior year’s per diem amounts. The providers under the per diem payment system must be designated by Medicare, or meet exemption criteria, as exempt from the inpatient mental health unit. The unit would be identified as the provider under the TRICARE inpatient mental health per diem payment system.
2.9.2  Transfer Of ADP Files
By the 15th calendar day following the Transitions Specifications Meeting, the outgoing contractor shall prepare in non-proprietary electronic format and transfer to the incoming contractor or DHA unless otherwise negotiated by the incoming and outgoing contractors, all specified ADP files, such as the Provider and Pricing files, in accordance with specifications in the official transition schedule and will continue to participate in preparation and testing of these files until they are fully readable by the incoming contractor or DHA.
2.9.3  Outgoing Contractor Weekly Shipment Of History Updates
The outgoing contractor shall transfer to the incoming contractor, in electronic format, all beneficiary history and deductible transactions occurring from the date of preparation for shipment of the initial transfer of such history files and every week thereafter beginning the 120th calendar day prior to the SHCD until such a time that all processing is completed by the outgoing contractor in accordance with the specifications in the official transition schedule.
3.0  TED Records
3.1  The incoming contractor shall ensure the TED record complies with the TSM, Chapter 2 and the contract.
3.2  The incoming contractor shall ensure the TEPRV complies with the TSM, Chapter 2 and the contract.
3.3  The incoming contractor must demonstrate the ability to successfully create and submit all TED record types and TEPRVs prior to SHCD. This includes, but is not limited to, adjustment, denial and cancellation records.
4.1  Incoming And Outgoing Contractor Requirements
4.1.1  The incoming contractor shall access the web-based DCS via the Patient Encounter Processing and Reporting (PEPR) Portal in accordance with the TSM, Chapter 4 and ensure the connection has been tested and is accessible.
4.1.2  Contractors shall participate in Government furnished DCS training. Training will be scheduled as part of the IMP/IMS.
4.1.3  The date when an incoming contractor will assume full responsibility for resolving all existing potential duplicate claim sets from the outgoing contractor (including completing existing recoupments), and for all new potential duplicate claim sets, shall be determined during transition meetings and be established in the transition plan/schedule.
4.1.4  During transition the Government will provide DCS training to the incoming contractor. Training may occur 120 days prior to the SHCD, but not later than 60 days following the SHCD. The incoming contractor shall coordinate training needs in accordance with the transition plan/schedule. All user access requirements shall be met prior to the initiation of training.
4.1.5  The incoming contractor shall begin using the DCS to resolve identified potential duplicate claim sets “owned” by the incoming contractor 120 days following the SHCD.
4.1.6  The incoming contractor shall begin processing potential duplicate claim sets transferred from the outgoing contractor 150 days following the SHCD.
4.1.7  For each regional contract for which a contractor is responsible, the contractor is required to identify at least one individual to serve as the DCS Point of Contact (POC). Contractor DCS POCs must be individuals who are, or will be, trained in the use of the DCS, and who are able to perform the required research and determine whether a particular claim is within their processing jurisdiction. Contractors shall provide the name(s), title(s), business address(es), and business telephone number(s) of their DCS POCs to the Procuring Contracting Officer (PCO), with courtesy copies to the Contracting Officer Representatives (CORs) and to the DHA DCS Program Representative. The DCS POCs shall be provided to the PCO no later than two weeks prior to implementation of the DCS.
4.1.8  DHA will provide each contractor with the list of all DCS POCs. Whenever a new contract is awarded, DHA will notify all contractors of the new contractor’s DCS POC. Once the initial listing is provided to the contractors, it is the responsibility of each contractor to maintain the listing and keep DHA and the other contractors informed of any changes.
4.1.9  In accordance with the Financial Procedures in the Transition Plan, the contract, and the TOM, the outgoing contractor shall package and forward to the incoming contractor, refund checks received and offsets taken for recoupments associated with duplicate claims payments and recoupment files associated with in progress duplicate claim recoupment 120 days following SHCD.
4.1.10  On the last day of the fourth month following the start of SHCD, or upon direction of the Government, the outgoing contractor shall cease researching Open claim sets and initiating new recoupments associated with duplicate claim payments. The outgoing contractor shall also cease entering refund data and linking adjustment data in the DCS for Pending and Validate claim sets.
4.1.11  The outgoing contractor shall move all Open DCS claim sets to a Pending, Validate, or Closed status by the last day of TED submissions (as defined by the transition plan).
4.1.12  When the outgoing contractor has ceased entering refund and adjustment data on the DCS, refunds may be received and/or TED adjustments may still be submitted for claims in Open and Pending sets. In this case, the incoming contractor may be required to resolve the set without knowing the amount of the refund received by the outgoing contractor.
4.1.13  If the actual recoupment amount was zero when the set was transferred from the outgoing contractor, the incoming contractor may apply the adjustment to the set while leaving the actual recoupment amount as zero dollars. Resolution would result in a Validate status, requiring an explanation by the incoming contractor that the outgoing contractor did not enter the actual recoupment amount.
4.1.14  Following the SHCD, the DCS will begin displaying identified potential duplicate claim sets for which the incoming contractor has responsibility for resolving. The incoming contractor shall begin using the DCS to resolve potential duplicate claim sets in accordance with the TSM, Chapter 4 and the IMP/IMS requirements.
4.1.15  The incoming contractor shall assume full responsibility for resolving all existing potential duplicate claim sets from the outgoing contractor (including completing existing recoupments) and for all new potential duplicate claims sets as agreed upon during the transition meeting.
4.2  Phase-Out of the Automated TRICARE DCS
The outgoing contractor shall phase-out the use of the automated TRICARE DCS in accordance with TSM, Chapter 4 and IMP/IMS.
5.0  Performance Assessment Reporting
5.1  Submission Requirements
Reports and plans for transition in and transition out shall be submitted as identified by the DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
5.2  Training
The incoming contractor shall schedule initial training on the submission of deliverables within 30 calendar days after award. Additional training for new users will be provided throughout the contract upon request.
5.3  Technical Support
Technical support is provided during the business week. A POC for access and deliverable submission will be provided during initial training.
6.0  Interconnectivity Between The Contractor And Defense Health Agency-Great Lakes (DHA-GL) [The Specified Authorization Staff (SAS) For Army, Air Force, Navy, Marine Corps, Coast Guard, And National Guard TRICARE Prime Remote (TPR) Enrollees]
6.1  The contractor shall provide access for entry and edit of referrals into existing systems supporting this contract. The contractor shall propose one of the following access options:
•  Government staff physically located in Great Lakes, IL, accessing the contractor’s system; or
•  Contractor staff physically located in Great Lakes, IL, accessing the contractor’s system, and Government personnel performing a backup role in the event contractor personnel are unavailable due to annual or sick leave or another reason.
6.2  The contractor shall create a standard management listing for all pending referrals requiring SAS review. The listing will be made available on-line to the SAS. The contractor shall propose the design for the listing to the SAS for approval 30 days prior to the SHCD.
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