3.1 General
3.1.1 No later than 60 days prior
to the start of services, the incoming contractor shall demonstrate
the ability of its staff and its automated systems to accurately
process all types of TRICARE Pharmacy (TPharm) claims in accordance
with current requirements. This shall be
accomplished through a comprehensive Benchmark test.
3.1.2 On a mutually agreed upon timeline
between the Government and the contractor, DoD/DHA representatives
will conduct a pre-benchmark meeting at the incoming contractor’s
site.3.1.2.1 The
incoming contractor shall provide an overview of their system(s)
and the test process, collect data for use in the benchmark, discuss
the involvement of external systems in the test (e.g., DEERS), and
discuss the dates of the test and information regarding the administration
of the test.
3.1.2.2 At
this time, DHA will provide the test scenarios to the incoming contractor
that are to be used in the development of the test claims.
3.1.2.3 Data requirements will be coordinated
at the pre- benchmark meeting to ensure that the incoming contractor
adequately prepares all files prior to the benchmark. Electronic
transaction requirements will be discussed to include timing and
logistics.
3.1.3 At this pre-benchmark meeting,
the incoming contractor shall be advised of the logistics of the
Benchmark test to include, but not limited to:3.1.3.1 The number of DoD/DHA staff who
will monitor and evaluate the results of the test;
3.1.3.2 The amount of time the incoming
contractor shall have to process test claims;
3.1.3.3 The process and point of contacts
for the incoming contractor to use for questions related to the
test scenarios provided by DHA;
3.1.3.4 Space requirements for the DHA
team including access to telephones, computer terminals, and printers;
3.1.3.5 What reference documents the
incoming contractor shall make available to the DHA team during
the test (e.g., TRICARE Manuals, Explanation of Benefits (EOB) message
codes, reject/denial codes, organizational chart, personnel directory,
etc.).
3.1.4 The incoming contractor shall
demonstrate its ability to conduct eligibility verification and claims
processing functions to include
, but not limited to:
3.1.4.1 Claims control and development;
3.1.4.2 Accessing and updating DEERS
(e.g., Other Health Insurance (OHI), personal contact information,
etc., excluding eligibility status);
3.1.4.3 Calculating cost-shares and deductibles;
3.1.4.4 Querying and updating internal and external
family and patient deductible and cost-share files on the Catastrophic
Cap and Deductible Data (CCDD) file;
3.1.4.5 Applying utilization review criteria;
3.1.4.6 Applying correct benefit design
based on the beneficiary category, plan enrollment, point of service
and other factors;
3.1.4.7 Applying overrides to rejects;
3.1.4.8 Adjusting and canceling previously processed
claims (inside and outside the 10-day window for network retail
pharmacy claims);
3.1.4.9 Producing required output for paper and electronic
transactions.
3.2 Benchmark
Procedure
s3.2.1 On the first day of the Benchmark test, the
Government will hold a brief entrance conference with
the incoming contractor personnel to discuss the schedule of events,
expectations, and administrative instructions.
3.2.2 The Benchmark test shall consist
of up to 1,000 claims, testing a multitude of claim conditions,
including TPharm covered and non-covered services, eligible and
non-eligible beneficiaries, formulary and non-formulary processing,
coordination of benefits, Department of Veterans Affairs (DVA)/Veterans
Health Administration (VHA) claims, Medicaid claims, etc. The Benchmark
test may require up to seven consecutive calendar days at the contractor’s
site(s). The test may also include adjustments and reversals, and
submission of TRICARE Encounter Data (TED) records for these actions.
3.2.3 The incoming contractor shall
conduct the Benchmark test. The test shall be comprised of both
paper and electronic (batch and Point of Service (POS)) claim transactions.
The incoming contractor shall be required to create test claims,
including prior authorizations and medical necessity reviews from
test scenarios provided to the contractor by DHA. The incoming contractor
shall supplement these test scenarios with any internal conditions
if appropriate for testing, and forward documentation to the Government.
3.2.4 The Benchmark test is comprised
of one or more cycles or batches of claims. When more than one cycle
is used, each cycle may be submitted on consecutive days. Each cycle
after the initial one shall include new test claims, as well as
claims not completed during preceding cycles. The Government will
determine what aspects of claims processing will be tested.
3.2.5 The Government will determine
which systems (internal and external) used by the incoming contractor
to process claims will be used in the Benchmark Test. The Benchmark
test shall also include generation and submission of TED records
for every test claim. Incoming contractor compliance with applicable
Health Insurance Portability and Accountability Act (HIPAA) and
security requirements shall be included in the Benchmark test, as
appropriate.
3.2.6 During the Benchmark test, the incoming contractor
shall process the claims and shall provide output for evaluation
by DHA personnel as the claims are processed to completion. The specific
schedule for claims processing and the procedures for providing
the output will be discussed with the incoming contractor at the
pre-benchmark meeting. The outcome of each test scenario
will be evaluated based on documentation provided and maintained
by the incoming contractor, including payer sheets, benefit design
document, interface control documents, etc.
3.2.7 At the conclusion of the Benchmark test, the
Government may hold an exit conference with the
incoming contractor staff to brief the incoming contractor on all
findings identified during the Benchmark test.
The Government will forward
the initial Benchmark test report to the incoming contractor within 30 calendar
days of the last day of the test. For any claims processing errors
assessed with which the incoming contractor disagrees, a written
description of the disagreement along with any specific references shall be
included with the claims. The incoming contractor shall correct
all findings identified during the Benchmark test no later than 30 days
following the date of the initial report.
3.2.8 Within seven calendar days of the last day
of the Benchmark test, the incoming contractor shall prepare and
submit the initial TED records to DHA. The Government
will notify incoming contractor of any TEDs failing
the DHA edits. The incoming contractor shall make the necessary corrections
and resubmit the TED records until 100% of the original Benchmark
test TEDs have passed the edits and are accepted by DHA.
3.2.9 The incoming contractor shall
submit the final corrected TED record to DHA 45 calendar days
from the date of the initial Benchmark test report.
New TEDs need not be generated to reflect changes created from claims
processing corrections. All
TEDs originally submitted for the Benchmark test
claims which did not pass DHA edits shall continue
to be corrected and resubmitted until all edit errors have been
resolved and 100% of the TED records have been accepted by DHA.
3.3 Operational
Aspects
3.3.1 The incoming contractor shall
conduct the Benchmark test on
the incoming contractor’s production system(s) or an identical copy
of the production system (i.e., test system). Whichever system is
used for the benchmark, it shall meet
all TRICARE requirements. If the Benchmark
is conducted on the incoming contractor’s production system, the
incoming contractor shall prevent the possibility of any data
being transmitted to other production systems, including inappropriate checks
or EOBs being actually mailed to beneficiaries or providers.
3.3.2 Certain
external test systems and files (e.g., DEERS)
are an integral component of the Benchmark test, and the incoming
contractor shall perform all necessary
verifications, queries, etc., according to TRICARE procedures and
requirements. The incoming contractor shall coordinate through DHA
to ensure that direct interface with any required external test
system is established and operational prior to the Benchmark.