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.