1.0 Timeliness
And Quality Standards Of Performance
Contractors
are charged with providing or arranging for delivery of quality,
timely health care services and have the responsibility for providing
the timely and accurate processing of all claims received into their
custody, whether for network or non-network care. In addition, the
contractor shall provide courteous, accurate, and timely responses to
all inquiries from beneficiaries, providers, Defense Health Agency
(DHA), and other legitimately interested parties. The contractor
shall provide management reports which identify actual contractor
performance in relation to contract standards. Details for reporting
are identified in DD Form 1423, Contract Data Requirements List
(CDRL), located in Section J of the applicable contract. DHA has
established standards of performance which will be monitored by
DHA and other Government agencies to measure contractor performance.
Minimum performance standards are listed below.
1.1 Preauthorizations/Authorizations
The contractor shall issue determinations on
at least:
• Ninety percent (90%)
of all requests for preauthorization/authorization within two working days
following receipt of the request and all required information.
• One hundred percent
(100%) of such requests within five working days following receipt
of the request and all required information.
1.2
Referral
Processing and Network Adequacy
1.2.1 Following
the date of receipt of a request for a referral, the contractor
shall issue a referral authorization or denial on at least:
• Ninety
percent (90%) of all requests within two workdays.
• One hundred percent
(100%) of all requests within three workdays.
1.2.2 A minimum
of 96% of referrals for Prime enrollees who reside in TRICARE Prime
Service Areas (PSAs) and Prime enrollees who reside outside PSAs
and have waived the travel-time access standards shall be to the
Military Treatment Facility (MTF)/Enhanced Multi-Service Market
(eMSM) or a civilian network provider. All referrals, except the
following, will be included to determine compliance with the standard:
• Referrals
that are unknown to the contractor before the visit (specifically
Emergency Room (ER) visits, retroactively authorized referrals);
• Self referrals and
referrals of beneficiaries who use Other Health Insurance (OHI)
as first payor; and
• MTF/eMSM directed
referrals to non-network providers when network providers are available.
All other referrals are included without exception.
1.2.3 In addition to the referral timeliness standards
identified in
paragraph 1.2.1, the contractor shall achieve
and continuously maintain a referral processing accuracy percentage
of at least 95% during Option Period 1. Beginning with Option Period
2, this referral processing accuracy standard shall increase by
1% each Option Period until the standard reaches 99% during Option
Period 5. For purposes of evaluation, a referral shall be considered
to be processed accurately when all three of the following actions
are performed correctly:
• Consideration of Right
of First Refusal (ROFR) rules on referrals from the private sector in
CONUS;
• Verification
of beneficiary eligibility in Defense Enrollment Eligibility Reporting
System (DEERS); and
• Issuance of an authorization
to an appropriate provider/facility based on the referral.
1.2.4 Referrals which do not result
in an authorization (e.g., a referral which is returned to the MTF/eMSM
for missing information) shall not be considered in calculating
referral processing accuracy.
1.2.5 Details for reporting the timeliness standards
for preauthorization/authorization, referrals and referral accuracy
are identified in DD Form 1423, CDRL, located in Section J of the
applicable contract.
1.3
Network
Adequacy
Starting in Option Period 1, the
following percent of claims for Prime enrollees region-wide (excluding
TPR enrollees) will be for care rendered by a network provider.
This includes all claims for Prime enrollees except emergency room
claims, urgent care claims, Point of
Service (POS) claims, or claims with OHI.
• Ninety percent (90%)
Option Period 1.
• Ninety-one percent
(91%) Option Period 2.
• Ninety-two percent
(92%) Option Period 3.
• Ninety-three percent
(93%) Option Period 4.
• Ninety-four percent
(94%) Option Period 5.
1.4
Claims
Processing Timeliness
Unless otherwise specified,
the standards below apply to all claims.
1.4.1 Retained Claims
1.4.1.1 Ninety-eight
(98%) of retained claims and adjustment claims shall be processed
to completion within 30 calendar days from the date of receipt.
1.4.1.2 A “retained
claim” is defined as any claim retained (held in the contractor’s
possession) for any reason. Contractors shall retain all claims
that contain sufficient information to allow processing to completion
and all claims for which missing information may be developed from
in-house sources, including DEERS and contractor operated or maintained
electronic, paper, or film files.
Note: Nothing in this
definition prohibits a contractor from retaining a claim for external development.
1.4.2
Retained
and Excluded Claims
One hundred percent (100%)
of all claims (both retained and excluded, including adjustments),
shall be processed to completion within 90 calendar days unless
the Government specifically directs the contractor to continue pending
a claim or group of claims. “Excluded claims” are defined as:
• Claims
retained at the discretion of the contractor for the external development
of information necessary to process the claim to completion;
• Claims requiring development
for possible Third Party Liability (TPL);
• Claims requiring intervention
by another Prime contractor; and
• Claims requiring Government
intervention (i.e., claims held for CHAMPUS Maximum Allowable Charge
(CMAC) updates, claims held pending the issuance of a policy change,
etc.).
1.5 Claims Processing Cycle
The contractor shall generate an initial submission
claims processing cycle and transmit related TRICARE Encounter Data
(TED) and required documents to DHA not less than three times every
seven calendar days. The contractor shall have an updated beneficiary
processed claims history and deductible file available and accessible
within one workday following each processing cycle. The contractor
shall ensure only one processed claims history and deductible file
is maintained for each beneficiary. The contractor shall provide
claims processing statistics and deferred claims reports according
to contract requirements.
1.6 Claims Processing Accuracy
1.6.1
Claim
Payment Errors
The absolute value of the
payment errors shall not exceed 2% of the total billed charges for the
first two option periods. In all remaining option periods, the absolute
value of the payment errors shall not exceed 1.75% of the total
billed charges.
1.6.2 Claim Occurrence Errors
The TED occurrence error rate shall not exceed
3% for all types of TEDs.
1.7 TEDs - Timeliness
• One
hundred percent (100%) of initial submission vouchers/batches shall
be transmitted to DHA within five calendar days of the date of the
batch/voucher create date.
• Eighty-five percent
(85%) of all unprocessable vouchers/batches, including but not limited to,
out-of-balance conditions and invalid header record information
shall be corrected by the contractor and returned for receipt at
DHA within 20 calendar days of the date the invalid data was transmitted
to the contractor by DHA.
• One hundred percent
(100%) of unprocessable vouchers/batches shall be corrected and returned
for receipt at DHA within 30 calendar days of the date the invalid
data was transmitted to the contractor by DHA.
• Ninety-nine and one-half
percent (99.5%) of all vouchers/batches having TEDs (initial submissions,
resubmissions, and adjustment/cancellation submissions) failing
the edit system shall be corrected and resubmitted to DHA within
30 calendar days after the errors and rejected TEDs were transmitted
to the contractor by DHA. The resubmission data shall contain all
TEDs rejected on the voucher/batch in question.
• One hundred percent
(100%) of all remaining vouchers/batches having TEDs failing the edit
system shall be corrected and resubmitted to DHA within 45 calendar
days after the errors and rejected TEDs were transmitted to the
contractor by DHA. The resubmission data shall contain all TEDs
rejected in the voucher/batch.
1.8 TEDs - Accuracy
1.8.1 Following
the start of health care delivery (SHCD), the contractor shall have
the following percentages of TEDs (initial submissions, resubmissions
and adjustment/cancellation submissions) passing the DHA edit system
at the following time lines:
• One through three
months - 80%.
• Four
through six months - 85%.
• Seven through nine
months - 90%.
• Ten through 11
months - 95%.
• Twelve through
23 months - 96%.
• Month 24 through
contract close - 97%.
1.8.2 Vouchers/Batches
Three months following the start of health
care delivery (SHCD), the contractor shall have no more than 2%
of the vouchers/batches being unprocessable due to, but not limited
to, such problems as:
• Out-of-balance;
• Invalid header
conditions;
• Invalid
record type;
• Invalid
contractor number;
• Invalid voucher/batch
identifier;
• Invalid
voucher/batch date;
• Invalid sequence
number;
• Invalid
resubmission number;
• Invalid period
begin date;
• Invalid
period end date;
• Invalid total number
of records; and
• Invalid total amount
paid.
3.0
Beneficiary
And Provider Services (BPS)
For all processing
standards, the actual date of receipt shall be counted as the first
day. The date the reply is mailed shall be counted as the processed
to completion date. The standards with which the contractor shall
comply include:
3.1 Routine
Written Inquiries
All routine written inquiries
shall be stamped with the actual date of receipt within three workdays
of receipt in the contractor’s custody. The contractor shall provide
final responses to routine written inquiries as follows:
• Eighty-five
percent (85%) within 15 calendar days of receipt;
• Ninety-seven percent
(97%) within 30 calendar days of receipt; and
• One hundred percent
(100%) within 45 calendar days of receipt.
3.2 Priority
Written Inquiries (Congressional, ASD(HA), And DHA)
All priority written inquiries shall be stamped
with the actual date of receipt within three workdays of receipt
in the contractor’s custody. The contractor shall provide final
responses to priority written inquiries as follows:
• Eighty-five
percent (85%) within 10 calendar days of receipt.
• One hundred percent
(100%) within 30 calendar days of receipt.
3.3 Walk-In Inquiries
(TRICARE Overseas Contract Only)
• Ninety-five percent
(95%) of walk-in inquiries shall be acknowledged and be assisted
by a service representative within 15 minutes of entering the reception
area.
• Ninety-nine
percent (99%) of walk-in inquiries shall be acknowledged and assisted
by a service representative within 20 minutes of entering the reception
area.
3.4
Telephone
Inquiries
The following required levels of
service shall be available at all times - daily, weekly, monthly, etc.
Averages are not acceptable.
• Blockage rates shall
not exceed 5%.
• The
call abandonment rate shall be less than 5%.
• The average speed
of answer shall not exceed 45 seconds.
• If transferred to
an individual, 90% of all calls shall be answered by an individual
(not an answering machine) within 30 seconds.
• Total “on hold” time
for 95% of all calls shall not exceed 30 seconds during the entire telephone
call.
• Eighty-five
percent (85%) of all telephone caller inquiries shall achieve resolution
in one call. (Includes calls transferred to an individual.)
• Ninety-nine and one-half
percent (99.5%) of all inquiries not fully and completely resolved on
the initial call shall be fully and completely resolved to the customer’s
satisfaction within 10 business days.
4.0
Appeals
4.1 Expedited
Preadmission/Preprocedure Reconsiderations
One
hundred percent (100%) of requests for expedited preadmission/preprocedure reconsiderations
shall be processed to completion within three working days of the
date of receipt by the contractor of the reconsideration request
(unless the reconsideration is rescheduled at the written request
of the appealing party). Expedited preadmission/preprocedure requests
are those requests filed by the beneficiary within three calendar
days after the beneficiary receipt of the initial denial determination.
4.2 Nonexpedited
Medical Necessity Reconsiderations
From the
date of receipt by the contractor until processed to completion,
the contractor shall meet the following processing standards for
non-expedited medical necessity reconsiderations:
• Ninety-five
percent (95%) within 30 calendar days; and
• One hundred percent
(100%) within 60 calendar days.
4.3 Nonexpedited
Factual Reconsiderations
From the date of
receipt by the contractor until processed to completion, the contractor
shall meet the following standards for non-expedited factual reconsiderations:
• Ninety-five
percent (95%) within 30 calendar days of receipt; and
• One hundred percent
(100%) within 60 calendar days from the date of receipt of the reconsideration
request. The date of completion is considered to be the date the reconsideration
determination is mailed to the appropriate parties.
4.4 Determinations
Reversed by the Appeals Process
One hundred
percent (100%) of contractor determinations reversed by the appeals
process shall be processed to completion within 21 calendar days
of receipt.
5.0
Grievances
All written grievances shall be stamped with
the actual date of receipt within three workdays of receipt in the
contractor’s custody. The contractor shall provide interim written
response by the 30th calendar day after receipt for all grievances
not processed to completion by that date. The interim response shall
include an explanation for the delay and an estimated date of completion.
Ninety-five percent (95%) of all grievances shall be processed to
completion within 60 calendar days from the date of receipt.
6.0 Potential
Duplicate Claim Resolution
6.1 The contractor shall utilize
the automated TRICARE Duplicate Claims System (DCS) to resolve DHA
identified potential duplicate claims payments.
6.2 The contractor
shall move Open status potential duplicate claim
sets to Pending, Validate, or Closed status
on a first-in/first-out basis. To this end, contractor performance
will be measured against the percentage of claim sets in Open status
at the end of a month with load dates over 30 days old. No more
than 10% of the potential duplicate claim sets remaining in Open status
at the end of a month shall have load dates over 30 days old. Contractor
compliance with this standard shall be determined from the Performance
Standard Report generated by the DCS (see the TRICARE Systems Manual
(TSM), Chapter 4, Addendum C, Summary/Management Report entitled
“Performance Standard,” for a description and example of the Performance
Standard Report). The 10% standard becomes effective on the first
day of the seventh month following the SHCD or following system
installation whichever is later.
6.3 The contractor shall not be
responsible for meeting the performance standard during any month
in which access to the DCS is prevented for two working days due
to failure of any system component for which the Government is responsible.
6.4 All overpayment
recovery, refund, offset collection and adjustment requirements,
including timeliness standards, are applicable to the operation
of the DCS. Offsets shall be applied against any future payments
to a debtor until the debt is satisfied.
7.0 Debt
Collection Research Assistance
The contractor
shall meet required response times for problem resolution (Standard:
85% within 10 days, 100% within 30 days). Resolution is defined
as: Completely review all contractor actions on the claims, the
correction of all contractor errors including the expeditious reprocessing
of all claims with identified errors, preparing and providing a
written explanation of any beneficiary liability and the provision
of a case-specific response to the Government. If applicable, the
response to the Debt Collection Assistance Officer (DCAO) should
note that a check is being issued to the beneficiary or provider
on a priority basis and the approximate date payment is expected.