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.