1.0 Provider
Networks
1.1 The contractor shall establish an adequate
network of providers in accordance with access standards outlined
in
Chapter 5, Section 1 and 45 Code of Federal
Regulations (CFR) 156.230, with minimal impact to beneficiaries.
Provider network development shall be completed no later than 30 days
prior to the start of health care delivery (SHCD). The contractor
shall establish an adequate network of providers for Prime Service
Areas (PSAs)
, Base Realignment and Closure (BRAC)
sites, and non-PSAs in the Region. For the purposes
of assessing adequacy, standards shall apply to all PSAs in the region.
1.2 The contractor
shall ensure the network has the capability and capacity to permit
each beneficiary enrolled in TRICARE Prime, to enroll to a civilian
Primary Care Manager (PCM) prior to the start of Option Period 1
and residing outside of PSAs under this contract to enroll to a
PSA PCM, provided the beneficiary resides less than 100 miles from
an available network PCM in the PSA and waives both primary and
specialty care travel time standards. Beneficiaries enrolled in
Prime to a civilian PCM prior to the beginning of Option Period
1 who reside outside of PSAs under this contract and are 100 miles
or more from an available PCM in the PSA network, shall not be permitted
to continue their enrollment.
1.3 The contractor shall ensure TRICARE
Select access standards for appointments for health care that meet
or exceed those of high-performing health care systems in the United
States. The contractor shall utilize sizing models to establish
network contracting targets sufficient to support the program’s access
standards and network expansion that meets or exceeds the TRICARE
Select requirement by January 1, 2018. See Chapter 5, Section 1.
1.4 The contractor
shall ensure accurate and complete provider information is entered
into contractor and Government automated provider files that interface
directly with the Defense Enrollment and Eligibility Reporting System
(DEERS), contractor medical management systems, and supporting medical
management systems identified by the Government not later than 30
days prior to SHCD.
1.5 The contractor shall comply with the Contract
Data Requirements List (CDRL) requirements for providing the contractor’s
approach for meeting Access to Care requirements.
2.0
Execution
Of Agreements With Contract Providers
2.1 All contract provider agreements
shall be executed, and loaded to the incoming contractor’s system,
60 calendar days prior to the SHCD, or at such other time as is
mutually agreed between the contractor and the Defense Health Agency
(DHA).
2.2 The incoming contractor shall begin reporting
on network adequacy on a monthly basis during the transition.
4.0 Provider
Certification
4.1 The outgoing contractor shall transfer the
provider certification documentation to the incoming contractor.
The incoming contractor shall limit certification actions to new
providers and shall verify a provider’s credentials once, upon application
to become a certified provider.
4.2 The contractor shall conduct
an audit, which must include either 5% or 50, whichever is less,
of all prime contractors’ and subcontractors’ individual network
provider credentialing and privileging files to ensure that information
is appropriately verified. The audit shall be completed prior to
the SHCD. Thirty calendar days prior to the audit, the contractor
shall invite the Director, TRICARE Regional Offices (TROs), or for
the TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC)
and the Contracting Officer’s Representative (COR) to monitor and/or
participate in the audit. Not less than 85% of the audited files
shall be in full compliance with all provider file requirements.
Within five business days of the completion of the audit’s provider
file review, the contractor shall submit to the Procuring Contracting
Officer (PCO) and the Director, TROs, or the TDEFIC COR, a written
Corrective Action Plan (CAP), which addresses all credentialing
and privileging files not in full compliance. Within 30 calendar days
after completion of the audit’s provider file review, the incomplete
or incorrect files shall be corrected to full compliance.
4.3 Provider
Certification File
No later than 30 days
after contract award and on a monthly basis until the SHCD, the
outgoing contractor shall provide the incoming contractor with copies
of all provider certification files.
4.4 Phase-Out Of The Contractor’s
Provider Network, TRICARE Service Centers (TSCs) (TRICARE Overseas
Contract Only), And Military Treatment Facility (MTF)/Enhanced Multi-Service
Market (eMSM) Agreements
4.4.1 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/eMSM
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, resource sharing agreements, equipment,
telephones and all other functions having an impact on the MTFs/eMSMs.
4.4.2 Within
15 calendar days of the Transitions Specifications Meeting the outgoing
contractor shall draft and submit a revised plan for transition
of the MTF/eMSM interfaces. Resolution of differences identified
through the coordination process must be accomplished in collaboration
with the Transition Monitor appointed by DHA and according to the
guidelines in the transition schedule.
4.4.3 The outgoing contractor shall
ensure a Health Care Finder (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 (TRICARE overseas contract only) on the 40th calendar day
prior to the SHCD and establish a centralized HCF function.
4.4.4 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.
4.4.5 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
liability. Beneficiary inquiry lines will continue to be staffed
as defined in the contract. In general, the outgoing contractor
shall maintain adequate toll-free line coverage to ensure that the
blockage rate does not exceed the blockage rate on the contractor’s
most critical private or other Government business access line.
5.0 Performance
Readiness Validation (PRV)/Performance Readiness Assessment And
Verification (PRAV)
During transition, the
incoming contractor’s performance readiness status regarding provider networks
will be subject to PRV/PRAV reviews as described below.
5.1 Provider
Network PRV
5.1.1 The contractor shall validate they have established
an adequate network of providers for all PSAs in the region. The
contractor will produce evidence of network adequacy for PCMs, Behavioral Health
(BH) providers, specialty care providers, and health care facilities
through comparison of the number of signed network agreements and
the contractor’s target in their Network Implementation Plan. The
contractor shall validate that signed providers meet credentialing
documentation requirements. For the purposes of assessing adequacy,
the validation shall assess all PSAs in the region individually
and not the region as whole.
5.1.1.1 Two hundred
and forty days prior to SHCD, the contractor shall finalize network
modeling and submit their Network Implementation Plan. Interim self-assessment
reports will be provided to the Government at 30 day intervals following
submission of the Network Implementation Plan.
5.1.1.2 Sixty days
prior to SHCD, the contractor shall have completed provider network development
including completion of provider agreements and credentialing.
5.1.2 The contractor
shall validate accurate and complete provider system loads for PCMs
and BH providers. The contractor will develop “load file completion
reports” which compare the percentage of providers loaded into the
requisite systems with the number of providers required by the contractor’s Network
Implementation Plan. The reports shall include the contractor’s
accuracy attestation to the Government regarding the total number
of provider system loads by category (PCMs and BH providers) and
the percentage of records loaded that meet the scheduled accuracy
threshold listed below in all data fields. Contractor validation
goals shall, at a minimum, meet the following:
• Fifty percent (50%)
of PCMs and BH providers loaded no later than 120 days prior to SHCD
at a 90% accuracy rate.
• Seventy-five percent
(75%) of PCMs and BH providers loaded no later than 90 days prior to
SHCD at a 90% accuracy rate.
• One hundred percent
(100%) of PCMs and BH providers loaded no later than 60 days prior
to SHCD at a 95% accuracy rate.
The Government will consider exceptions to
the 100%/60 day requirement in medically underserved areas.
5.1.3 The contractor
shall validate accurate and complete specialty provider (other than
BH providers) and health care facility system loads. The contractor
will develop “load file completion reports” which compare the percentage
of specialty providers and facilities loaded into the requisite systems
with the number of specialty providers and facilities required by
the contractor’s Network Implementation Plan. The reports shall
include the contractor’s accuracy attestation to the Government regarding
the total number of system loads by category (specialty providers
and facilities) and the percentage of total records that meet the
scheduled accuracy threshold listed below in all data fields. Contractor
validation goals shall, at a minimum, meet the following:
• Fifty
percent (50%) of specialty care providers and health care facilities
loaded no later than 120 days prior to SHCD at a 90% accuracy rate.
• Seventy-five percent
(75%) of specialty care providers and health care facilities loaded no
later than 90 days prior to SHCD at a 90% accuracy rate.
• One hundred percent
(100%) of specialty care providers and health care facilities loaded
no later than 60 days prior to SHCD at a 95% accuracy rate.
The Government will consider exceptions to
the 100%/60 day requirement in medically underserved areas.
5.1.4 The contractor
shall validate the completeness and accuracy of the online directory
of network providers. The contractor shall provide a time line for
completing the online provider directory and develop validation
reports which compare the number of network providers and facilities
who have been entered in the online directory to the total number
of network providers and facilities required by the contractor’s
Network Implementation Plan Validation reports shall begin 120 days
prior to SHCD and continue at 30 day intervals according to the
time lines and scheduled accuracy thresholds listed below, until
the complete provider directory is online and operational 60 days
prior to SHCD at a 95% accuracy rate. Accuracy calculations will
be based on each data field as opposed to each record for each PSA.
Contractor validation goals shall, at a minimum, meet the following:
• Fifty
percent (50%) of network providers and health care facilities entered
no later than 120 days prior to SHCD at a 90% accuracy rate.
• Seventy-five percent
(75%) of network providers and health care facilities entered no later
than 90 days prior to SHCD at a 90% accuracy rate.
• One hundred percent
(100%) of network providers and health care facilities entered no later
than 60 days prior to SHCD at a 95% accuracy rate.
• Complete provider
directory online and operational 60 days prior to SHCD at a 95% accuracy
rate.
The Government
will consider exceptions to the 100%/60 days prior to SHCD requirement in
medically underserved areas.
5.2 Provider Network PRAV
5.2.1 The contractor
shall comply with the Government’s approach for assessment and verification
of the contractor’s performance readiness regarding provider networks
as described above. If, after review, the Government finds the contractor’s
performance readiness for claims processing to be deficient, the
contractor must submit a detailed mitigation plan no later than
10 business days following the Government’s findings.
5.2.2 Specific
PRAV activities, assessment techniques, and performance readiness
thresholds will be identified by the Government during the Transition
Specification Meeting.