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TRICARE Operations Manual 6010.59-M, April 1, 2015
Transitions
Chapter 2
Section 3
Critical Processes (CPs) - Provider Networks
Revision:  C-6, October 20, 2017
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.
3.0  Institutional Providers
The contractor shall ensure written agreements established with institutional providers comply with Chapter 7, Section 1, paragraph 4.0.
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.
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