2.0 CONTRACT
ADMINISTRATION AND INSTRUCTIONS TO CONTRACTOR
2.1 The provisions of
Chapter 1, Section 2 are applicable to the
TOP. Additionally, the TOP contractor shall coordinate with the
Defense Health Agency (DHA) Contracting Officer (CO), the appropriate
DHA Contracting Officer Representative (COR), and the
TRICARE
Overseas Program Office (TOPO) on any TOP policy
or contractual issue that requires additional Government clarification
or assistance to resolve.
2.2 The
provisions of
Chapter 1, Section 2, paragraph 4.0 are superseded
as described in
paragraphs 2.2.1 through
2.2.6.
2.2.1 A
14 calendar day notice will be provided by the DHA Procurement Contracting
Officer (PCO) for all meetings hosted by DHA.
2.2.2 The TOP
contractor shall provide up to four contractor representatives at
the Performance Readiness Validation briefing at DHA.
2.2.3 The
TOP contractor shall provide at least two contractor representatives
for transition briefings/meetings with each overseas Military Treatment
Facility (MTF) and TAO. All briefings/meetings must be completed
no later than 60 calendar days prior to the start of health care
delivery (SHCD). These briefings/meetings shall be
targeted towards command suite/key leaders and their staff and shall
encompass all key contract areas where collaboration between the
contractor and the MTF/TRICARE Area Office (TAO) will occur.
2.2.4 The TOP
contractor shall provide annual representation at two contractor
conferences (senior management level) at DHA. The contractor shall
also provide up to four contractor representatives at up to four
additional meetings at the direction of the CO per contract year.
2.2.5 The TOP
contractor shall provide representation at semiannual TOP operational
meetings to be held at DHA Aurora with TOPO, TAO, and
service representation.
2.2.6 The
TOP contractor shall provide two contractor representatives at up
to 18 additional meetings/site visits at the direction of the CO
per option period.
8.0 TRANSITION-
IN REQUIREMENTS
8.1
Systems
DevelopmentApproximately 80 calendar days
prior to the initiation of health care delivery, the non-claims processing
systems and the telecommunications interconnections between these
systems shall be reviewed by the 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) and the Business-to-Business Gateway (B2B). The review will
also confirm that the hardware, software, and communications links
required for operating the automated TRICARE Duplicate Claims System
(DCS) have been installed and are ready for DHA installation of
the DCS application software (see the TRICARE Systems Manual (TSM), Chapter 4). The contractor shall implement
any modifications required by DHA prior to the initiation of services.
8.2
Execution of
Agreements with Contract Providers8.2.1 All contract provider agreements
shall be executed, and loaded to the contractor’s system, 80 calendar
days prior to the start of health care delivery, or at such other
time as is mutually agreed between the contractor and DHA.
8.2.2 The contractor shall report on
network adequacy on a monthly basis during the transition.
8.3 See
Section 16,
for instructions regarding Statements of Responsibilities (SORs).
In addition to the SOR requirements in these referenced paragraphs,
the TOP contractor shall also execute a SOR with each TAO Director
no later than 60 calendar days prior to the SHCD
.
8.4 Enrollment TransitionThe contractor shall begin the
enrollment process no later than (NLT) 60 calendar days prior to the
scheduled SHCD, with actual enrollment processing to begin 40 days
prior to the SHCD, subject to DHA approval of systems under the
contract.
8.4.1 For
enrollments in the region with an effective date prior to the SCHD
(e.g., active duty (AD) enrollment, mid-month enrollment; transfer-in),
the incoming contractor must effect an enrollment to begin on the
SHCD once notified by the outgoing contractor of the new enrollment.
(Defense Manpower Data Center (DMDC) may run a report at the end
of the transition period that reflects new additions.)
8.4.2 When the outgoing contractor
requests deletion of current enrollments with an effective date
prior to the SHCD (e.g., transfers out; disenrollments for failure
to pay fees; cancellations, etc.), the incoming contractor must
cancel the future enrollment segment and notify the outgoing contractor when
this action has been completed.
8.4.3 For all other enrollment actions
with an effective date prior to SHCD (e.g., Primary Care Manager
(PCM) changes; Defense Medical Information System-Identification
Code (DMIS-ID) changes; enrollment begin date changes; etc.), requested
by the outgoing contractor, the incoming contractor must cancel
the future enrollment segment and notify the outgoing contractor
when this action has been completed. When notified by the outgoing
contractor that their change has been effected, the incoming contractor
must reinstate the future enrollment segment.
8.4.4 Once health care delivery begins,
all enrollment actions will be accomplished by the incoming contractor.
If the outgoing contractor requires a retroactive change, they must
submit their request to the incoming contractor who will perform
the change and notify the outgoing contractor when it is complete.
8.5 Transfer of Enrollment Files8.5.1 The incoming contractor shall
obtain enrollment information from DEERS through an initial enrollment
load file. DMDC will provide the incoming contractor with an incremental
enrollment load file for each contract transition. The incoming
contractor shall process each enrollment load file within 24 hours
or less from receipt of the file.
Note: Each
contract transition shall require a three-day freeze of enrollment
and claim processing. This freeze will occur beginning the first
weekend that precedes the 60 day window prior to the SHCD. The actual
calendar dates will be determined during the transition meeting.
8.5.2 The incoming contractor shall
send enrollment renewal notices for all enrollees whose current
enrollment period expires on or after the SHCD. The incoming contractor
shall send billing statements where the enrollment fee payment would
be due on or after the SHCD. The incoming contractor shall start
sending billing notices and process renewals 45 days prior to the
SHCD.
8.5.3 Outstanding
enrollment record discrepancies and issues reported to the DEERS
Support Office (DSO) by the outgoing contractor will be transferred
to the incoming contractor for reconciliation. Records will be reconciled
in accordance with TSM, Chapter 3.
8.6 TRICARE Service Center (TSC)
Phase-In
8.6.1 8.6.1 The incoming contractor shall utilize the existing
TSCs. The outgoing contractor shall allow reasonable access to the
incoming contractor throughout the transition period to become familiar
with the communication lines, equipment and office layout.
8.6.2 The final schedule for access to and occupancy
of the TSCs will be determined at the Transition Specifications
Meeting. The approved schedule must allow the outgoing contractor
to fulfill all contract requirements through the last day of health
care delivery, and must provide the incoming contractor sufficient
access to the TSC to prepare for delivery of all required functions
on the first day of their contract.
8.6.3 All Contractor Customer Service, Education
and
Health Care Finder (HCF
) Field Representatives
and overseas TSC representatives shall be fully trained and available
for all duties no less than
80 calendar
days prior to initiation of health care services.
Note: Overseas TSCs are managed by the MTFs and are
jointly staffed by MTF and TOP contractor personnel. The TOP contractor
is responsible for providing on-site Beneficiary Service Representative (BSR)
support in all TSC locations.
8.7 Contractor File Conversions and
Testing8.7.1 The
incoming contractor shall perform initial conversion and testing
of all Automated Data Processing (ADP) files (e.g., provider files,
pricing files, and beneficiary history) NLT 30 calendar days following
receipt of the files from the outgoing contractor(s).
8.7.2 Integration testing will be conducted
to validate the contractor’s internal interfaces to each of the
TRICARE Military Health Systems (MHSs). 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.
(See the TSM, Chapter 1, Section 1.1, paragraph 2.0.)
8.7.3 Contractors shall provide certification
of compliance with the National Institute of Standards and Technology
(NIST)-based Information Assurance (IA) program identified in the
TSM, Chapter 1, Section 1.1, to fulfill
all system access requirements prior to connecting with the MHS
and/or the initiation of Integration Testing.
8.7.4 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.
8.8 Receipt of Outgoing Contractor’s
Weekly Shipment of History Updates and Dual Operations8.8.1 Beginning with the 120th calendar
day prior to the SHCD and continuing for 180 calendar days after
the SHCD, the incoming contractor shall convert the weekly shipments
of the beneficiary history updates from the outgoing contractor(s)
within two working days following receipt. These files shall be
validated by the incoming contractor before use. Tests for claims
and duplicate claims shall be performed within two workdays following
conversion. Following the SHCD, these files shall be loaded to history
and used for claims processing.
8.8.2 During the 180 calendar days
after the SHCD when both the incoming and outgoing contractors are
processing claims, both contractors shall maintain close interface
on history update exchanges and provider file information. During
the first 60 calendar days of dual operations, the contractors shall
exchange beneficiary history updates with each contractor’s claims
processing cycle run. Thereafter, the exchange shall not be less
than twice per week until the end of dual processing. The incoming
contractor shall assume total responsibility for the maintenance
of the TRICARE Encounter Provider Record (TEPRV) beginning with
the SHCD. The incoming contractor will coordinate and cooperate
with the outgoing contractor to ensure that the outgoing contractor
can continue to process claims accurately; conversely, the outgoing
contractor has responsibility to notify the incoming contractor
of any changes in provider status that they become aware of through
their operations.
8.9 Transition-In Requirements Related
To Transitional Cases8.9.1 In
notifying beneficiaries of the transition to another contractor,
both the incoming and outgoing contractors shall include instructions
on how the beneficiary may obtain assistance with transitional care.
If the outgoing contractor succeeds itself, costs related to each
contract will be kept separate for purposes of contract accountability.
8.9.2 Non-Network
Inpatient Transitional CasesThese
are beneficiaries who are inpatients (occupying an inpatient bed)
at 0001 hours on the first day of any health care contract period
in which the incoming contractor begins health care delivery. In
the case of Diagnosis Related Group (DRG) reimbursement, the outgoing
contractor shall pay through the first month of health care delivery
or the date of discharge, whichever occurs first. If the facility
is reimbursed on a per diem basis, the outgoing contractor is responsible
for payment of all the institutional charges accrued prior to 0001
hours on the first day of health care delivery, under the incoming
contractor. The incoming contractor thereafter is responsible for
payment.
8.9.3 Non-Network
Outpatient/Professional Transitional CasesThese are cases, such as obstetric
care, that are billed and payable under “Global” billing provisions
of Current Procedural Terminology, 4th edition (CPT-4), HCFA Common
Procedure Coding System (HCPCS), or local coding in use at the time
of contract transition, and where an Episode Of Care (EOC) shall
have commenced during the period of health care delivery of the
outgoing contractor and continues, uninterrupted, after the SHCD
by the incoming contractor. Outpatient/professional services related
to transitional cases are the responsibility of the outgoing contractor
for services delivered prior to 0001 hours on the first day of health
care delivery and of the incoming contractor thereafter.
8.9.4 Network Inpatient Care During
Contract TransitionThe
status of network provider changes (provider’s network agreement
with the outgoing contractor is terminated resulting in the provider’s
loss of network status) with the SHCD of the new contract. As a
result, claims for inpatient care shall be reimbursed in accordance
with paragraph 8.9.2 for non-network transitional
cases. Beneficiary copay is based on the date of admission; therefore, Prime
beneficiaries who are inpatients as described in paragraph 8.9.2,
shall continue to be subject to Prime network copayments and shall
not be subject to Point Of Service (POS) copayments.
8.9.5 Home Health Care (HHC) During
Contract TransitionHHC,
for a 60-day EOC, initiated during the outgoing contractor’s health
care delivery period and extending, uninterrupted, into the health
care delivery period of the incoming contractor are considered to
be transitional cases. Reimbursement for both the Request for Anticipated
Payment (RAP) and the final claim shall be the responsibility of
the outgoing contractor for the entire 60-day episodes covering
the transition period from the outgoing to the incoming contractor.
8.10 Prior Authorizations and ReferralsThe incoming contractor shall
honor outstanding prior authorizations and referrals issued by the
outgoing contractor, covering care through 60 days after the SHCD
under the incoming contract, in accordance with the outgoing contractors
existing practices and protocols, within the scope of the TRICARE
program and applicable regulations or statutes. In the case of Residential
Treatment Care (RTC) care, both the incoming and outgoing contractors
are responsible for authorizing that part of the stay falling within
their areas of responsibility; however, the incoming contractor
may utilize the authorization issued by the outgoing contractor
as the basis for continued stay. This transition period for prior
authorizations and referrals is extended to one year for obstetrical
care or any other condition for which a one-year authorization has
been issued.
8.11 Case ManagementThe incoming contractor shall
receive case files and documentation regarding all beneficiaries under
case management programs. The incoming contractor shall ensure seamless
continuity of services to those beneficiaries.
8.12 Program IntegrityThe incoming contractor shall
receive case files and documentation regarding all open program
integrity cases from the outgoing contractor NLT 30 days from the
SHCD. The incoming contractor shall work with the DHA Program Integrity
Office (PI) to ensure seamless continuity of oversight of these
cases.
8.13 Health
Insurance Portability And Accountability Act of 1996 (HIPAA)The incoming contractor, as a
covered entity under HIPAA, may honor an authorization or other express
legal document obtained from an individual permitting the use and
disclosure of protected health information prior to the compliance
date (HHS Privacy Regulation, §164.532).
8.14 Installation And Operation Of
The DCSThe
incoming contractor shall have purchased, installed, configured,
and connected the personal computers and printers required to operate
the DCS NLT 60 days prior to the start of the health care delivery.
See the TSM, Chapter 4,
for hardware, software, printer, configuration and communications
requirements and contractor installation responsibilities. Approximately
30-45 days prior to health care delivery, DHA will provide and install
the DCS application software on the incoming contractor designated
personal computers and provide on-site training for users of the
DCS in accordance with the TSM, Chapter 4.
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 TSM, Chapter 4 and the transition
plan requirements.
8.15 The TOP contractor
shall prepare a mailing to the Resident Commissioners of Puerto
Rico and the Northern Mariana Islands, and the Congressional representatives
for American Samoa, Guam, and the U.S. Virgin Islands by the 45th
calendar day prior to the SHCD according to the specifications of
the official transition schedule. The
proposed mailing shall be submitted to the DHA CO, DHA COR, and TOPO,
for approval no later than 90 calendar days prior to the SHCD. The
mailing shall discuss any unique processing requirements of the
contractor and any other needed information dictated by the official
transition schedule.
9.0 Transition
-OUT
9.1 Transition Specifications MeetingThe outgoing contractor shall
attend a meeting with representatives of the incoming contractor
and DHA, within 15 calendar days following the effective date of
the contract. This meeting is for the purpose of developing a schedule
of transition-in/transition out activities. DHA will notify the contractor(s)
as to the exact date and location of the meeting. The outgoing contractor
shall provide a proposed transition-out plan at the Transition Specifications
Meeting.
9.2 DataThe 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.
• An
automated indexing system that can be used independently of the
outgoing contractor’s data system. (See Chapter 9, Section 3, paragraph 2.2.2 for
Automated Indexing System requirements.)
9.3 Transition-Out Of The Contractor’s
Claims Processing OperationsUpon
notice of award to another contractor, and during the procurement
process leading to an effective date of a new contract, the contractor
shall undertake the following transition-out activities regarding
services as an outgoing contractor.
9.3.1 Transfer of Electronic File SpecificationsThe outgoing contractor shall
transfer to the incoming contractor by express mail or similar overnight
delivery service, NLT three calendar days following award announcement,
electronic copies of the record layouts with specifications, formats,
and definitions of fields, and data elements, access keys and sort
orders, for the following:
• The
TEPRVs.
• The
TRICARE Encounter Pricing Files (TEPRCs).
• The
Enrolled Beneficiary and 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 should include
provider name; tax identification number; 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.
9.3.2 Transfer Of ADP Files (Electronic)The outgoing contractor shall
prepare in non-proprietary 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, 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.
9.3.3 Outgoing Contractor Weekly Shipment
Of History UpdatesThe
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) 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.
9.3.3.1 During the 180 calendar days
after the SHCD when both the incoming and outgoing contractors are
processing claims, both contractors shall maintain close interface
on history update exchanges and provider file information. During
the first 60 calendar days of dual operations, the contractors shall
exchange beneficiary history updates with each contractor’s claims
processing cycle run. Thereafter, the exchange shall not be less
than twice per week until the end of dual processing.
9.3.3.2 The incoming contractor shall
assume total responsibility for the maintenance of the TEPRV beginning
with the SHCD. The incoming contractor will coordinate and cooperate
with the outgoing contractor to ensure that the outgoing contractor
can continue to process claims accurately; conversely, the outgoing
contractor has the responsibility to notify the incoming contractor
of any changes in provider status that they become aware of through
their operations.
9.3.4 Transfer Of Non-ADP FilesThe outgoing contractor shall
transfer to the incoming contractor all non-ADP files (e.g., authorization
files, clinic billing authorizations, and tapes/CDs, which identify
Congressional and DHA completed correspondence files, appeals files,
TRICARE medical utilization, and administration files) in accordance
with the specifications in the official transition schedule. The
hard copies of the Beneficiary History Files are to be transferred
to the incoming contractor or Federal Records Center (FRC). The contractor
shall provide samples and descriptions of these files to the incoming
contractor at the Transition Specification Meeting.
9.3.5 Explanation of Benefits (EOB)
Record Data Retention and TransmittalIf the contractor elects to retain
the 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
acceptable form and transfer such data and programs to the successor
contractor or to DHA. DHA shall be the final authority in determining
the form and/or acceptability of the data.
9.3.6 Outgoing Contractor Weekly Status
ReportingUntil
all inventories have been processed, the outgoing contractor shall
submit a weekly status report of inventories and phase-out activities
to DHA beginning the 20th calendar day following the Specifications
Meeting until otherwise notified by the PCO to discontinue. This
shall be done in accordance with specifications of the official
transition schedule.
9.3.7 Prior Authorizations and ReferralsThe outgoing contractor shall
provide all prior authorizations and referrals that cover care spanning
the SHCD under the new contract or care that could potentially begin
in the incoming contractor’s health care delivery period. The outgoing
and incoming contractor shall mutually agree to the date and schedule
for transfer of this information.
9.3.8 Case Management FilesNLT 60 days prior to the SHCD
under the new contract, the outgoing contractor shall provide the
incoming contractor with all files pertaining to beneficiaries covered
under a Case Management program. Electronic files shall be provided
under a non- proprietary format. The outgoing contractor shall cooperate
with the incoming contractor to ensure seamless continuity of care
and services for all such beneficiaries.
9.3.9 Requirements Related To Transitional
CasesThe outgoing
contractor shall provide the incoming contractor with instructions
for beneficiaries and providers on how the beneficiary may obtain
assistance with transitional care.
9.3.10 Program Integrity FilesNLT 30 days prior to the SHCD
under the new contract, the outgoing contractor shall provide the
incoming contractor with all fraud and abuse information it has
collected during the tenure of the contract relevant to TRICARE
providers and beneficiaries. For example, (not all inclusive) high dollar
initial draft fraud cases, post payment utilization and reviews
that identified potential fraud, established provider/beneficiary
outlier watch lists, list of providers on prepayment review, copies
of educational letters, regional fraud trend/outlier reports, Fraudline
reports, and beneficiary complaints related to health care fraud.
Electronic files shall be provided under a non-proprietary format.
9.4 Final Processing Of Outgoing
ContractorThe
outgoing contractor shall:
• Process
all claims received through the last date of the outgoing contractor’s healthcare
delivery. Processing of these claims, including adjustments, shall
be completed with 180 days following the start of the incoming TOP
contractor’s healthcare delivery period.
• All
claims shall meet the same standards as outlined in the current
outgoing contract. Any residual claim received after SHCD shall
be forwarded to the incoming contractor within 24 hours of receipt.
Claims for the Philippines, that have been pended for development
of missing/required documentation or pended for provider certification, shall
be denied on the 179th day if information was not received or certification
was not complete. Any residual information related to the Philippines
claims received after SHCD shall be forwarded to the incoming contractor
with 24 hours of receipt.
• Be
liable, after the termination of services under this contract, for
any payments to subcontractors of the contractor arising from events
that took place during the period of this contract.
• Process
all correspondence, allowable charge complaints, and incoming telephonic inquiries
which pertain 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 and grievance 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.
9.4.1 Correction of Edit RejectsThe outgoing contractor shall
retain sufficient resources to ensure correction (and reprocessing
through DHA) of all TED record edit errors NLT 210 calendar days
following the start of the incoming contractor’s health care delivery.
9.4.2 Transition-Out of the Automated
TRICARE DCSThe
outgoing contractor shall phase-out the use of the automated TRICARE
DCS in accordance with the TSM, Chapter 4 and
transition plan requirements.
9.4.3 Transition-Out Of The Contractor’s
Provider Network, TSCs, And MTF Agreements9.4.3.1 Upon notice of award to another
contractor, the outgoing contractor shall provide full cooperation
and support to the incoming contractor, to allow an orderly transition,
without interruption, of all functions relating to the MTF interface
and the establishment of a provider network by the incoming contractor.
This shall include, but is not limited to, data relating to on-site
service centers, equipment, telephones and all other functions having
an impact on the MTFs.
9.4.3.2 Within 15 calendar days of the
Transitions Specifications Meeting the outgoing contractor shall
draft and submit a revised plan for transition of the MTF interfaces.
Resolution of differences identified through the coordination process
must be accomplished in collaboration with TOPO.
9.4.3.3 The outgoing contractor shall
ensure a HCF function continues through the last date of health
care delivery under the current contract, unless otherwise negotiated
with the incoming contractor during the Transition Specifications
Meeting. The outgoing contractor shall also vacate the TSCs on the
40th calendar day prior to the start of the health care delivery
and establish a centralized HCF function.
9.4.3.4 The outgoing contractor shall
continue to issue prior authorizations for care for which it is financially
responsible. However, authorization-related information shall be
shared between the incoming and the outgoing contractors to preclude
requiring a provider or beneficiary to duplicate the paperwork and
other effort related to establishing prior authorizations. The outgoing
contractor may issue prior authorizations as late as midnight on
the day prior to the end of its health care delivery for inpatient
stays that will continue as transitional cases. The two contractors
shall interface on the clinical issues of a case where both contractors
will, or can reasonably expect to have periods of liability for
the same EOC.
9.4.3.5 The
outgoing contractor shall maintain toll-free lines and web-based
customer service capabilities, accessible to the public during the
first 90 calendar days of dual operations in order to properly respond
to inquiries related to claims processed for services incurred during
the period of their respective liability. Beneficiary inquiry lines
will continue to be staffed as defined in the contract.
9.5 Transition-Out of Enrollment
Activities9.5.1 Prior
to the SHCD under the successor contract, for all enrollment renewals
or payments in which the new enrollment period or period covered
by the premium payment will begin under the new contract, the outgoing
contractor shall amend renewal notices and billing statements (or
include a stuffer/insert) to advise the enrollee to direct any enrollment-related
correspondence and enrollment fee payments to the successor contractor.
9.5.2 Any enrollment-related correspondence
and/or enrollment fee payments subsequently received by the outgoing
contractor shall be forwarded to the incoming contractor within
three working days of receipt.
9.5.3 The outgoing contractor shall
terminate marketing and enrollment activity 40 calendar days prior
to the start of the incoming contractor’s health care delivery.
Any enrollment requests or applications received after the 40th
calendar day shall be transferred to the incoming contractor by overnight
delivery at the outgoing contractor’s expense.
9.5.4 Throughout the enrollment dual
processing period, the outgoing and incoming contractors shall coordinate
enrollment files no less than weekly to ensure that new enrollments
and enrollment renewals are accurately and timely reflected in the
incoming contractor’s enrollment files and in DEERS.
9.6 Cost AccountingIf the outgoing contractor succeeds
itself, costs related to each contract shall be kept separate for
purposes of contract accountability, according to the above guidelines.
9.7 Records DispositionThe contractor shall include
a records disposition plan as part of the transition-out plan submitted
to DHA at the Transition Specifications Meeting.
9.8 Provide InformationThe 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.
9.9 Recoupment9.9.1 Installment CasesThe outgoing contractor shall
transfer all installment cases to DHA, Office of General Counsel
(OGC), Claims Collection Section (CCS). A list of all installment
cases to be transferred, shall be provided by fax or encrypted email
to CCS before the cases are transferred.
9.9.2 Cases Less Than 12 MonthsThe outgoing contractor shall
transfer cases greater or equal to $110 ($30 for pharmacy) and that
are less than 12 months old to the incoming contractor, who shall
assume management of the cases. Cases received by the incoming contractor
shall be managed until the debt is collected in full, or combined
with any other under $600 active recoupment case against the same
debtor to equal $600 or more and transferred to DHA, OGC, CCS. Cases
that do not meet the criteria, shall be written off by the contractor.
9.10 Transition Out of TED ActivitiesTransition-out activities related
to TED shall be accomplished no later than 14 months after the start
of health care delivery for the incoming contractor. At 180 days
after the end of healthcare delivery the contractor shall not issue
or reissue any checks/payments unless authorized by DHA, CRM. The
contractor is required to keep all bank accounts associated with
claims payments open until all outstanding checks/payments have
either cleared or stale date. If a payment stale dates, the contractor is
required to cancel the associated TED data with DHA and notify the
incoming contractor. The contractor may cease TED data submissions
when all TED reported checks/payments issued under this contract
have cleared or stale date. The contractor may request (at no-cost
to the government) an extension for TEDs processing after the 14
month period ends if more time is needed to complete stale date
check processing.