2.0 Performance
Readiness Validation (PRV)/performance Readiness Assessment And
Verification (PRAV)
During transition, the
incoming contractor’s performance readiness status regarding referral management
will be subject to PRV/PRAV reviews as described below.
2.1 Referral
Management PRV
2.1.1 The contractor shall validate establishing
referral management system interfaces with MTF/eMSM referral management
systems. Establishing an MTF/eMSM interface must meet two criteria:
1) MTF/eMSM can send and receive referrals with no technical problems,
and (2) contractor sends ROFRs in accordance with the MTF/eMSM capability
table with 95% accuracy. Milestones for validating MTF/eMSM interfaces
are:
• Fifty
percent (50%) of MTF/eMSM interfaces are established 90 days prior
to SHCD.
• Seventy-five
percent (75%) of MTF/eMSM interfaces are established 75 days prior
to SHCD.
• Ninety-five
percent (95%) of MTF/eMSM interfaces are established 60 days prior
to SHCD.
2.1.2 Sixty days prior to SHCD,
the contractor shall validate its systems can effectively interface with
the Government’s RMS, Defense Enrollment Eligibility Reporting System
(DEERS), TRICARE Regional Offices (TROs), MTFs/eMSMs, claims, Network
Provider Directory, and Network Providers and the contractor’s portal/web
site. The contractor shall inspect, test, and produce connectivity
test results on all interfaces.
2.1.3 Fifty days prior to SHCD,
the contractor shall validate all aspects of its referral, authorization, ROFR
and command approval process by utilizing test scenarios which include
referrals to MTF/eMSM and Network providers. The validation must
encompass all necessary beneficiary categories to include processing
referrals for beneficiaries with Medicare Part A (but under age
65) and still enrolled in TRICARE Prime and referrals from United
States Coast Guard (USCG) facilities. The validation must incorporate
a review of the contractor’s ability to utilize open authorizations
that were transferred from the outgoing contractor.
2.1.3.1 The contractor
shall validate that their system can timely and accurately communicate referral,
authorization and ROFR determinations with beneficiaries, network
providers, MTFs/eMSMs, Government systems and claims systems without
technical problems. The contractor shall demonstrate beneficiary
and provider ability to view/print authorization from the contractor’s
web site/portal. The contractor shall demonstrate accurate letter
generation.
2.1.3.2 The contractor’s
validation shall demonstrate their referral management system’s
ability to accurately process 90% of referrals within two working
days and 100% within three working days. The contractor shall validate
its Referral Management beneficiary communications system--approval/denial letters,
etc. is accessible by MTFs/eMSM, TROs, and beneficiaries.
2.1.3.3 The contractor
shall validate that referrals and ROFRs processed meet Program requirements
with a 95% accuracy rate. To be considered accurate, processed referrals/ROFRs
shall include:
• Correct Beneficiary.
• Correct Beneficiary
Demographics.
• To
include sponsor’s last four Social Security Number (SSN) or Department
of Defense (DoD) ID Number.
• Date of Birth (DOB).
• Unique Identifier
Number (UIN) is present if MTF/eMSM generated request.
• Correct Servicing
Provider.
• Correct
Servicing Specialty.
• Correct Episode of
Care (EOC).
• Evaluate
and Treat.
• Evaluate
only.
• Number
of visits.
• Length
of authorization.
• Range
of Current Procedural Terminology (CPT) codes.
2.2 Referral
Management PRAV
2.2.1 The contractor shall comply with the Government’s
approach for assessment and verification of the contractor’s performance
readiness regarding referral management as described above. If,
after review, the Government finds the contractor’s performance
readiness for referral management to be deficient, the contractor
must submit a detailed mitigation plan no later than 10 business
days following the Government’s findings.
2.2.2 Specific PRAV activities,
assessment techniques, and performance readiness thresholds will be
identified by the Government during the Transition Specification
Meeting.