1.0 General
The contractor shall establish and
maintain sufficient staffing and management support services and
commit all other resources and facilities necessary to achieve and
maintain compliance with all quantitative and qualitative standards
for claims processing timeliness, claims inventory levels, claims
control, and claims accuracy. The requirements below outline minimum
requirements of Defense Health Agency (DHA). Contractors are encouraged
to develop and employ the most effective management techniques available
to ensure economical and effective operation.
2.0 System Additions
Or Enhancements
2.1 Implementation
of Changes in Program Requirements
The contractor
shall have the capacity, using either directly employed personnel
or contracted personnel, to maintain and operate all required systems
and to achieve timely implementation of changing program requirements.
2.2 Maintaining
Current Status of Diagnostic and Procedural Coding Systems (PCS)
Contractors are required to use the
current versions of the updated American Medical Association Physicians
Current Procedural Terminology, 4th Edition (CPT-4), and the International Classification
of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic
coding system; and any special codes that may be directed by DHA.
Beginning with dates of service on or after the mandated date, as
directed by Health and Human Services (HHS) for International Classification
of Diseases, 10th Revision (ICD-10) implementation, for outpatient
facility and all non-facility services, and for inpatient facility
charges with discharge dates on or after the mandated date, contractors
will be required to replace the use of ICD-9-CM diagnosis codes
with the current version of the ICD-10-CM and the International
Classification of Diseases, 10th Revision, Procedure Coding System
(ICD-10-PCS) for inpatient hospital procedures. The contractor is
responsible for using the most current codes correctly. That responsibility
includes making any needed revisions required by periodic CPT-4
and ICD-9-CM or ICD-10-CM and ICD-10-PCS updates issued by the publishers.
When updates occur, contractors will be notified of the date the
TRICARE Encounter Data (TED) editing system will be accepting changes
in the codes.
2.3
Zip
Code File
The contractor shall maintain and
update an electronic file of all zip codes using a Government-furnished
electronic zip code directory. The contractor shall incorporate
this electronic file in its claims processing system to determine
the validity of a beneficiary or provider zip code. This directory
will be provided by the Government no less than four and no more
than 12 times per calendar year. Updates to the electronic zip code
directory for the purposes of contract modifications, directed policy
actions, and expansion or termination of zip codes by the U.S. Postal
Service (USPS), shall be accomplished at no additional cost to the
Government.
2.4
Updating
And Maintaining TRICARE Reimbursement Systems
The contractor,
at no additional cost to the Government and as directed by DHA shall implement
all policy changes and clarifications to existing TRICARE reimbursement
systems affecting both the level of payment and the basic method
of reimbursement as they apply to current provider categories implemented
at the time of contract award. The TRICARE Reimbursement Manual
(TRM) is the source for instructions and guidance on all existing
reimbursement systems for current provider categories.
3.0 Management
Controls
The contractor shall develop and
employ management procedures necessary to ensure control, accuracy,
and timeliness of transactions associated with operation of their
call center, TRICARE Service Center (TSC) functions (TRICARE overseas
contract only), enrollment, authorizations, provider referrals,
claims processing, beneficiary services, provider services, reconsiderations,
grievances, Automatic Data Processing (ADP), and financial functions.
These procedures include such elements as:
3.1 An automated claims aging report, by status
and location, for the purpose of identifying backlogs or other problem
areas delaying claims processing. At a minimum, this report must
be sorted to enable a count of the total number of claims pending
for a specified length of time, e.g., the time periods specified
in the Monthly Cycle Time/Aging Report.
3.2 An automated returned claims report counting
the number of claims returned by the time periods specified in the
Monthly Cycle Time/Aging Report.
3.3 Procedures to ensure confidentiality of
all beneficiary and provider information, to ensure that the rights
of the individual are protected in accordance with the provisions
of the Privacy Act and the HIPAA and Health and Human Services (HHS)
Privacy Regulation and prevent unauthorized use of DHA files.
3.4 A system
to control adjustments to processed claims which will document the
actual date the need for adjustment is identified, the reason for
the adjustment and the names of both the requesting and authorizing
persons. The controls shall also ensure the accurate and timely
update of the beneficiary history files, the timely and accurate
submission of the TED data and issuance of the proper notice to
the beneficiaries and providers affected by the adjustments.
3.5 A set
of processing guidelines, desk instructions/user’s manuals and reference
materials for internal use. These materials shall be maintained,
on a current basis, for the life of the contract. Desk instructions
shall be available to each employee in the immediate work area.
Reference material such as procedure codes, diagnostic codes, and
special processing guidelines, shall be available to each work station
with a need for frequent referral. Other reference materials shall
be provided in each unit with a reasonable need and in such quantity
as to ensure the ease of availability needed to facilitate work flow.
Electronic versions may be used.
4.0 Quality Control
4.1 The
contractor shall develop and implement an end-of-processing quality
control program which assures accurate input and correct payments
for authorized services received from certified providers by eligible
beneficiaries.
4.2 The
contractor shall have a quality control program consisting of supervisory
review of appeals, grievances, correspondence, and telephone responses.
This must begin by the end of the third month after the start of
health care delivery (SHCD) and be carried out monthly thereafter.
The review shall include a statistically valid sample or 30 records,
whichever is greater, of each of the following: appeals, grievances,
correspondence processed and telephonic responses completed. The
criteria for review shall be accuracy and completeness of the written
or telephonic response, clarity of the response, and timeliness
with reference to the quantitative standards for the processing
of appeals, grievances, and correspondence. Any lack of courtesy
or respect in the response shall also be noted. All findings shall
be documented, provided to DHA Contracting Officer’s Representative
(COR) staff, or authorized auditors, and used in a documented training
program.
4.3 The quality review program will
sample each quarter, a sufficient number of processed claims and
adjustments to ensure the required quality of adjudication and processing
and provide adequate management control. Claims in the sample shall
include all claim types and be selected randomly, or by other acceptable
statistical methods, in sufficient number to yield at least a 90%
confidence level with a precision of 2%. The sample will be drawn
at or near the end of each quarter from claims completed during
the review period. The contractor may draw the sample up to 15 calendar
days prior to the close of the quarter, but must include claims
completed in the period between the date the sample is drawn and
the close of the quarter in the next quarterly sample. The contractor
shall reflect the inclusive processing dates of the claims in the
sample in the report submitted to DHA. The sampling will begin by
the end of the first quarter of processing. Documentation of the
results shall be completed within 45 calendar days of the close
of each contract quarter.
4.4 The contractor shall retain copies
of the reviewed claims, appeals, grievances, correspondence, and
related working documents, in separate files, for a period of no
less than four months following submission of audit results to the
Procuring Contracting Officer (PCO). DHA staff will review the results and
will on a regular basis audit a selected sampling of the audited/quality
review documents. The review may occur at the contractor’s site
or at a location specified by DHA. The contractor shall provide all
documentation supporting this review within 10 calendar days of
a DHA request.
5.0
Staff
Training Program
The contractor shall develop and
implement a formal initial and ongoing staff training program including
training on program updates as they occur, to ensure a high quality
of service to beneficiaries and providers. Such training shall include
mandatory, documented training in Confidentiality of Patient Records
(42 United States Code (USC) [290dd-3]) requirements (see
Section 5). The contractor shall not only
provide education on these requirements but must document the personnel
files of the staff members who receive the training. Centralized
documentation shall also be maintained of the training session agendas,
identity of attendees, actual dates and duration of training sessions,
etc. The contractor is also responsible for ensuring that subcontractor
staff is fully trained.
6.0 Internal
Audits And Management Control Programs
Using its corporate
internal review capability, the contractor is responsible for verifying
that accounting data are correct, reliable and comply with all Government
accounting standards and requirements. The contractor’s corporate
internal review staff must conduct regular, routine reviews to ensure
proper monitoring in the areas of finance, financial accounting,
internal controls, special checks issued and returned, and selected
history maintenance transactions for possible fraud or abuse.
7.0 Beneficiary
Surveys
In accordance with Department of
Defense Instruction (DoDI) 1100.13, and Health Affairs Policy Memorandum
97-012, surveys of military members, retirees and their families
must be approved and licensed through issuance of a Report Control
Symbol (RCS). Contractors shall not conduct written or telephonic
beneficiary surveys without the approval of the DHA Decision Support
Division (DSD). DHA has an ongoing survey research and analysis
program which includes periodic population-based and encounter-based
surveys of DoD beneficiaries. The surveys address beneficiary information
seeking strategies and preferences, health status, use of care,
satisfaction with military and civilian care, and attitudes toward
TRICARE. The data are collected at the Prime Service Area (PSA)
level and can be aggregated to the regional level. Regional reports
containing PSA data are available through the Director, TRICARE
Regional Offices (TROs)/Program Office. Contractors shall work with
the Director, TROs/Program Offices to define both their ongoing
and special purpose requirements for survey data. Contractors with
special needs not met by an existing instrument may submit surveys,
sampling plans, and cost estimates through the Director, TROs/Program
Office to the DHA, DSD, for approval and licensing.