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TRICARE Operations Manual 6010.59-M, April 1, 2015
Transitions
Chapter 2
Section 4
Critical Processes (CPs) - Enrollment
Revision:  C-26, May 30, 2018
1.0  Enrollment
1.1  The contractor shall develop an enrollment plan to support contractor enrollment of beneficiaries and report on the implementation of the plan according to contract requirements. The contractor shall consult with the Director, TRICARE Regional Offices (TROs) and all Military Treatment Facility (MTF) Commanders/Enhanced Multi-Service Market (eMSM) Managers where Prime is offered in developing the enrollment plan.
1.2  The contractor shall have an enrollment system that supports all enrollment related activities, i.e., Defense Enrollment Eligibility Reporting System (DEERS) enrollment applications, and MTF/eMSM enrollment guidelines.
1.3  The enrollment system shall meet all the TRICARE Systems Manual (TSM) requirements, including at a minimum, the following:
•  Meet all system access requirements.
•  Ensure installation of all hardware.
•  Ensure loading of all software.
•  Ensure completion of all required forms.
•  Interface with Government systems.
1.4  The enrollment system shall be fully operational 60 days prior to the start of health care delivery (SHCD).
2.0  Enrollment Processing
At SHCD, all enrollment actions will be accomplished by the incoming contractor. If the outgoing contractor requires a retroactive change, they shall submit their request to the incoming contractor who will perform the change and notify the outgoing contractor, when it is complete.
2.1  Enrollment Processing After The SHCD
Once health care delivery begins, all enrollment actions will be accomplished by the incoming contractor.
2.2  Phase-In of TRICARE Prime Enrollment
The contractor shall begin the enrollment process for the TRICARE Prime Program no later than 60 calendar days prior to the scheduled SHCD, with new enrollment processing to begin 40 days prior to the SHCD, subject to the Defense Health Agency (DHA) approval of systems under the contract.
2.2.1  Enrollment Actions During Enrollment Dual Processing
2.2.1.1  When the Defense Manpower Data Center (DMDC) creates the Enrollment Gold File for the incoming contractor, enrollment dual processing begins (between 45-60 days prior to SHCD). This process creates a future enrollment to the incoming contractor. The following must be followed until SHCD.
2.2.1.2  For enrollments in the region with an effective date prior to the SHCD (e.g., active duty 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. DMDC may run a report at the end of the transition period that reflects new additions.)
2.2.1.2.1  The outgoing contractor has until SHCD to send updated fee information to DEERS. Beginning at the SHCD, the outgoing contractor will work with the incoming contractor to resolve any discrepancies of cumulative enrollment fees and paid-through dates on policies.
2.2.1.2.2  Beginning at the SHCD, the incoming contractor shall send the corrected fee information to DEERS using Fee/Catastrophic Cap and Deductible (CCD) Web Research application or the batch fee interface outline in the TSM, Chapter 3.
2.2.1.3  When a current enrollment in the region requires deletion with an effective date prior to the SHCD (e.g., transfers out; disenrollments for failure to pay fees; cancellations, etc.), when requested by another enrolling contractor, the incoming contractor must cancel the future enrollment segment and notify the outgoing contractor when this action has been completed.
2.2.1.4  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.), when 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 verify/reinstate the future enrollment segment.
2.2.2  In addition to other contractually required enrollment reports, the contractor, shall provide progress updates on enrollment activities in accordance with the Integrated Master Plan /Integrated Master Schedule (IMP/IMS).
2.3  Transfer Of Enrollment Files
2.3.1  The incoming contractor shall obtain enrollment policy information from DEERS through an initial enrollment load file. DMDC will provide the incoming contractor with an enrollment load file for each contract transition. The outgoing contractor shall provide: (1) the additional enrollment information required for those Active Duty Family Members (ADFMs) enrolled in TRICARE Prime residing outside of a Prime Service Area (PSA) who were granted grandfathered status and who maintained their eligibility for TRICARE Prime and (2) a list of those beneficiaries living greater than 100 miles from a Primary Care Manager (PCM) and granted re-enrollment per National Defense Authorization Act (NDAA) FY 2016, Section 701. The additional enrollment information shall include, but is not limited to, the original address of the beneficiary when they were initially grandfathered or allowed to re-enroll. (See Chapter 27 for more information on these beneficiaries.) The incoming contractor shall process each enrollment load file within 24 hours or less from receipt of the file.
2.3.2  No later than the date specified at the Transition Specifications Meeting, the outgoing South Region contractor shall provide to the incoming East Region contractor, the additional enrollment information required for Continued Health Care Benefits Program (CHCBP) enrollees.
Note:  Each contract transition shall require a global freeze of enrollment. 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.
2.3.3  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.
2.3.4  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 the TSM, Chapter 3.
2.4  Enrollment Fees
2.4.1  The incoming contractor shall obtain the cumulative total of enrollment fees and paid- through dates for the policies from DEERS. The contractor who collects the enrollment fee shall forward the fees to the Government in accordance with Chapter 6, Section 1. The outgoing contractor shall work with the incoming contractor to resolve any discrepancies of cumulative enrollment fees and paid-through dates within 90 days of start of the SHCD on policies inherited during the transition. The incoming contractor shall send the corrected fee information to DEERS using the Fee CCD Web Research application or the batch fee interface outlined in the TSM, Chapter 3.
2.4.2  The incoming contractor shall obtain information from the outgoing contractor on fees that are being paid monthly (i.e., by allotment, recurring credit card, or Electronic Funds Transfer (EFT) and transition these monthly payment types in the least disruptive manner for the beneficiary.
2.4.3  The incoming contractor shall coordinate the transition of allotment data, through the Performance, Analysis, Transitions, and Integration Section (PAT&IS) and/or the applicable DHA Program office, with the Defense Finance and Accounting Service (DFAS), Public Health System (PHS), and U.S. Coast Guard (USCG) during the transition-in period of the contract (see the TSM, Chapter 1, Section 1.1).
2.5  Phase-Out Of Enrollment Activities
2.5.1  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.
2.5.2  The outgoing contractor shall complete all pending enrollment actions prior to the DEERS global enrollment freeze to transition enrollment. Any enrollment action not completed by the outgoing contractor prior to the freeze (and after the Gold File is created) will have to be accomplished following the above procedures.
2.5.3  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. The incoming contractor shall answer all correspondence in accordance with applicable standards (see Chapter 1, Section 3), update DEERS, as appropriate, and forward the fees to the Government in accordance with Chapter 6, Section 1.
2.5.4  No later than the date specified at the Transition Specifications Meeting, the outgoing contractor shall provide to the incoming contractor, the additional enrollment information required for those ADFMs enrolled in TRICARE Prime who reside outside of a PSA who were granted grandfathered status and maintain their eligibility for TRICARE Prime. The additional enrollment information shall include, but is not limited to, the original address of the beneficiary when they were initially grandfathered.
2.5.5  No later than the date specified at the Transition Specifications Meeting, the outgoing South Region contractor shall provide to the incoming East Region contractor, all billing and enrollment information required to administer the Continued Health Care Benefit Program (CHCBP) for its enrollees.
2.5.6  The outgoing contractor shall terminate marketing and enrollment activity 40 calendar days prior to the start of the incoming contractor’s SHCD. 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.
2.5.7  Throughout the transition 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.
3.0  Performance Readiness Validation (PRV)/Performance Readiness Assessment and Verification (PRAV)
During transition, the incoming contractor’s performance readiness status regarding enrollment activities will be subject to PRV/PRAV reviews as described below.
3.1  Enrollment PRV
3.1.1  Sixty days prior to SHCD, the contractor shall validate their enrollment system is fully operational and meets all contract requirements. The contractor shall demonstrate the ability to perform all required billing, enrollment, and collection transactions. Validation shall include demonstrating all hardware/software is operational, meets system access requirements, and correctly interfaces with Government systems including the required MTF/eMSM systems. The contractor shall validate that all enrollment rules are loaded and that accessible and sufficient staff is hired/trained to perform at historical levels of enrollment transactions.
3.1.2  Sixty days prior to SHCD, the contractor shall validate it has begun the enrollment process for the TRICARE Prime Program and demonstrate it can perform enrollment transactions with at a 97% accuracy rate (to be considered accurate, all data elements within an enrollment must be correct).
3.1.3  Forty-five days prior to SHCD, the contractor shall validate their billing system is fully operational and that it has started sending billing notices and processing renewals. The contractor will validate they have obtained information from the outgoing contractor on fees that are being paid monthly (i.e., by allotment or EFT) and they are transitioning these monthly payment types in the least disruptive manner for the beneficiary.
3.2  Enrollment PRAV
3.2.1  The contractor shall comply with the Government’s approach for assessment and verification of the contractor’s performance readiness regarding enrollment activities as described above. If, after review, the Government finds the contractor’s performance readiness for enrollment processing to be deficient, the contractor must submit a detailed mitigation plan no later than 10 days business days following the Government’s findings.
3.2.2  Specific PRAV activities, assessment techniques, and performance readiness thresholds will be identified by the Government during the Transition Specification Meeting.
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