2.0 DHA Performance
Readiness Validation (PRV)/Performance Readiness Assessment And
Verification (PRAV)
During transition, the incoming contractor’s
performance readiness status regarding claims processing will be
subject to PRV/PRAV reviews as described below.
2.1 Claims Processing
PRV
2.1.1 The contractor shall validate its
ability to process all TRICARE claim types with a minimum of a 98%
accuracy rate no later than 90 days prior to SHCD. Claims testing
shall include multiple claim types that represent a level of complexity
involved in claims for TRICARE benefits. Validation shall include
claims processing at the operational volume and stress testing at
projected claims volumes. The contractor shall provide validation
results, to include test scenarios used, to the Government within 10
days following conclusion of the contractor’s validation.
2.1.2 The contractor
will validate its ability to provide timely and accurate responses
to beneficiary and provider claims customer service inquiries and
attest that they meet the following staffing requirements:
• Seventy-five percent (75%) of beneficiary
and provider claims customer service staffing hired and trained
on provider and beneficiary claims customer service, including internal
and external systems interfaces, no later than 90 days prior to
SHCD.
• Eighty-five
(85%) of beneficiary and provider claims customer service staffing
hired and trained on provider and beneficiary claims customer service,
including internal and external systems interfaces, no later than
60 days prior to SHCD.
• Ninety-five (95%) of beneficiary and provider
claims customer service staffing hired and trained on provider and
beneficiary claims customer service, including internal and external
systems interfaces, no later than 30 days prior to SHCD.
2.1.3 The contractor
shall validate it can receive and utilize claims history file transfers
from the outgoing contractor no later than 14 calendar days following
receipt of the files from the outgoing contractor.
2.1.3.1 The contractor
shall include in its validation process a test of a statistically
valid number of records to ensure readability and usability of information.
Tests shall include accessibility to records, accuracy of data,
and the contractor’s ability to use the data to correctly to apply
TRICARE policy, such as time or episode limited benefits.
2.1.3.2 Results
must reach a minimum of 98% accuracy no later than 45 days prior
to SHCD. The contractor shall provide test scenarios as well as
testing results to the Government no later than 45 days prior to
SHCD.
2.1.4 Reimbursement rate system applications
validation.
2.1.4.1 The contractor shall develop tests
to ensure reimbursement rate system applications are correctly loaded
and functioning properly. Areas tested shall include negotiated
network discount rates, non-network rates, and specific reimbursement
rates as required by policy (Example: Sole Community Hospitals (SCHs),
Low/High-Volume Mental Health Facilities, Partial Hospitalization facilities,
etc.). Validation shall include demonstrating a variety of claims
scenarios where reimbursement rate system applications are applied.
2.1.4.2 The contractor
shall complete its reimbursement rate system validation no later
than 90 days prior to SHCD and provide the Government with validation
results, to include test case scenarios used, within 10 days following
conclusion of the contractor’s validation. If, after review, the Government
finds the contractor’s testing or outcomes are deficient, the contractor
shall submit a detailed mitigation plan no later than 14 calendar
days following receipt of the Government’s findings.
2.1.5 Validation
that the claims processing system differentiates between beneficiary
categories.
2.1.5.1 The contractor shall validate that
its claims processing system clearly identifies and appropriately
differentiates between beneficiary categories to facilitate claims
processing accuracy by testing a multitude of scenarios with different
beneficiary categories (as specified in the TRICARE Systems Manual
(TSM)) to ensure appropriate application of cost-shares, co-pays
and rates.
2.1.5.2 The contractor shall complete its
system testing no later than 90 days prior to SHCD with a 95% accuracy
rate. The contractor shall complete its claims processing system
differentiation validation no later than 90 days prior to SHCD and
provide the Government with validation results, to include test case
scenarios used, within 10 days following conclusion of the contractor’s
validation. If, after review, the Government finds the contractor’s
testing or outcomes are deficient, the contractor shall submit a detailed
mitigation plan no later than 10 business days following receipt
of the Government’s findings.
2.1.6 Claims and TED records systems interface
validation.
2.1.6.1 The contractor’s validation shall
include developing and executing tests to validate its claims processing
system (Defense Enrollment Eligibility Reporting System (DEERS)/Defense Manpower
Data Center (DMDC), Referrals/Authorizations, etc.) can process
claims in accordance with TRICARE timeliness and accuracy standards.
The contractor’s validation methodology shall aggressively test
system connectivity of its claims processing system with both internal
and external systems in order to ensure timely and accurate processing
of claims. Testing shall include responses consistent with production
volume as well as stress testing.
2.1.6.2 The contractor
shall complete its system testing with Government interfaces and
attest to the contractor’s ability to apply information received
from DEERS/DMDC (beneficiary eligibility, catastrophic cap (CATCAP),
family association, etc.) in a timely and accurate manner, and that
they are able to successfully process TEDs prior to moving to a
production environment. The contractor shall provide its system
test plan to the Government at contract award. Initial testing shall
begin no later than three months following contract award, and the
contractor’s claims/TEDs system interfaces shall be fully operational
no later than 60 days prior to SHCD.
2.1.7 Validation
that the contractor’s claims processing system accurately and appropriately applies
referrals and authorizations.
2.1.7.1 The contractor’s
validation shall include demonstrate its ability to integrate its
referrals and claims systems with the direct care system through
CHCS and/or other Military Treatment Facility (MTF)/Enhanced Multi-Service
Market (eMSM). The contractor shall validate that its claims processing system
is able to accurately and appropriately transfer and apply information.
The contractor shall attest to its ability to achieve a minimum
of 98% accuracy in receiving and applying referrals/authorizations
information received from MTFs/eMSMs and use this information to
correctly process claims.
2.1.7.2 Communication
interface trustworthiness determinations between the contractor
and MTFs/eMSMs must be obtained and operational no later than 120
days prior to the SHCD and all validation testing shall be completed
no later than 60 days prior to SHCD.
2.2 Claims Processing
PRAV
2.2.1 The contractor shall comply with
the Government’s approach for assessment and verification of the
contractor’s performance readiness regarding claims processing 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 days 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.