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.).
• Claims where
payment has been temporarily suspended at Government direction pending
the completion of fraud investigation in accordance with Chapter 13, Section 5.
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.