1.0 Provider
Networks
1.1 The contractor shall establish an
adequate network of providers in accordance with access standards
outlined in
Chapter 5, Section 1 and 45 Code of Federal
Regulations (CFR) 156.230, with minimal impact to beneficiaries.
Provider network development shall be completed no later than 30 days
prior to the start of health care delivery (SHCD). The contractor
shall establish an adequate network of providers for Prime Service
Areas (PSAs)
, Base Realignment and Closure (BRAC)
sites, and non-PSAs in the Region. For the purposes
of assessing adequacy, standards shall apply to all PSAs in the region.
1.2 The contractor shall
ensure the network has the capability and capacity to permit each beneficiary
enrolled in TRICARE Prime, to enroll to a civilian Primary Care
Manager (PCM) prior to the start of Option Period 1 and residing
outside of PSAs under this contract to enroll to a PSA PCM, provided
the beneficiary resides less than 100 miles from an available network
PCM in the PSA and waives both primary and specialty care travel
time standards. Beneficiaries enrolled in Prime to a civilian PCM
prior to the beginning of Option Period 1 who reside outside of
PSAs under this contract and are 100 miles or more from an available
PCM in the PSA network, shall not be permitted to continue their
enrollment.
1.3 The
contractor shall ensure TRICARE Select access standards for appointments
for health care that meet or exceed those of high-performing health
care systems in the United States. The contractor shall utilize
sizing models to establish network contracting targets sufficient
to support the program’s access standards and network expansion
that meets or exceeds the TRICARE Select requirement by January
1, 2018. See Chapter 5, Section 1.
1.4 The contractor
shall ensure accurate and complete provider information is entered
into contractor and Government automated provider files that interface
directly with the Defense Enrollment and Eligibility Reporting System
(DEERS), contractor medical management systems, and supporting medical
management systems identified by the Government not later than 30
days prior to SHCD.
1.5 The contractor shall comply with
the Contract Data Requirements List (CDRL) requirements for providing
the contractor’s approach for meeting Access to Care requirements.
2.0
Execution
Of Agreements With Contract Providers
2.1 All contract provider agreements
shall be executed, and loaded to the incoming contractor’s system,
60 calendar days prior to the SHCD, or at such other time as is
mutually agreed between the contractor and the Defense Health Agency
(DHA).
2.2 The incoming contractor shall begin
reporting on network adequacy on a monthly basis during the transition.
4.0 Provider
Certification
4.1 The outgoing contractor shall transfer
the provider certification documentation to the incoming contractor.
The incoming contractor shall limit certification actions to new
providers and shall verify a provider’s credentials once, upon application
to become a certified provider.
4.2 The contractor shall conduct an
audit, which must include either 5% or 50, whichever is less, of all
prime contractors’ and subcontractors’ individual network provider
credentialing and privileging files to ensure that information is
appropriately verified. The audit shall be completed prior to the SHCD.
Thirty calendar days prior to the audit, the contractor shall invite
the Director, TRICARE Regional Offices (TROs), or for the TRICARE
Dual Eligible Fiscal Intermediary Contract (TDEFIC) and the Contracting
Officer’s Representative (COR) to monitor and/or participate in
the audit. Not less than 85% of the audited files shall be in full
compliance with all provider file requirements. Within five business days
of the completion of the audit’s provider file review, the contractor
shall submit to the Procuring Contracting Officer (PCO) and the
Director, TROs, or the TDEFIC COR, a written Corrective Action Plan (CAP),
which addresses all credentialing and privileging files not in full
compliance. Within 30 calendar days after completion of the audit’s
provider file review, the incomplete or incorrect files shall be corrected
to full compliance.
4.3 Provider Certification File
No later than 30 days after contract
award and on a monthly basis until the SHCD, the outgoing contractor
shall provide the incoming contractor with copies of all provider
certification files.
4.4 Phase-Out Of The Contractor’s Provider
Network, TRICARE Service Centers (TSCs) (TRICARE Overseas Contract
Only), And Military Treatment Facility (MTF)/Enhanced Multi-Service
Market (eMSM) Agreements
4.4.1 Upon notice of award to another
contractor, the outgoing contractor shall provide full cooperation
and support to the incoming contractor to allow an orderly transition,
without interruption, of all functions relating to the MTF/eMSM
interface and the establishment of a provider network by the incoming
contractor. This shall include, but is not limited to, data relating
to on-site service centers, resource sharing agreements, equipment,
telephones and all other functions having an impact on the MTFs/eMSMs.
4.4.2 Within
15 calendar days of the Transitions Specifications Meeting the outgoing
contractor shall draft and submit a revised plan for transition
of the MTF/eMSM interfaces. Resolution of differences identified
through the coordination process must be accomplished in collaboration
with the Transition Monitor appointed by DHA and according to the
guidelines in the transition schedule.
4.4.3 The outgoing contractor shall ensure
a Health Care Finder (HCF) function continues through the last date
of health care delivery under the current contract, unless otherwise
negotiated with the incoming contractor during the Transition Specifications
Meeting. The outgoing contractor shall also vacate the TSCs (TRICARE
overseas contract only) on the 40th calendar day prior to the SHCD and
establish a centralized HCF function.
4.4.4 The outgoing contractor shall continue
to issue prior authorizations for care for which it is financially
responsible. However, authorization-related information shall be
shared between the incoming and the outgoing contractors to preclude
requiring a provider or beneficiary to duplicate the paperwork and
other effort related to establishing prior authorizations. The outgoing
contractor may issue prior authorizations as late as midnight on
the day prior to the end of its health care delivery for inpatient
stays that will continue as transitional cases. The two contractors
shall interface on the clinical issues of a case where both contractors
will, or can reasonably expect to have periods of liability for
the same EOC.
4.4.5 The outgoing contractor shall maintain
toll-free lines and web-based customer service capabilities, accessible
to the public during the first 90 calendar days of dual operations
in order to properly respond to inquiries related to claims processed
for services incurred during the period of their liability. Beneficiary
inquiry lines will continue to be staffed as defined in the contract.
In general, the outgoing contractor shall maintain adequate toll-free
line coverage to ensure that the blockage rate does not exceed the
blockage rate on the contractor’s most critical private or other
Government business access line.
5.0 Performance
Readiness Validation (PRV)/Performance Readiness Assessment And
Verification (PRAV)
During transition, the incoming contractor’s
performance readiness status regarding provider networks will be
subject to PRV/PRAV reviews as described below.
5.1 Provider
Network PRV
5.1.1 The contractor shall validate they
have established an adequate network of providers for all PSAs in
the region. The contractor will produce evidence of network adequacy
for PCMs, Behavioral Health (BH) providers, specialty care providers,
and health care facilities through comparison of the number of signed
network agreements and the contractor’s target in their Network
Implementation Plan. The contractor shall validate that signed providers
meet credentialing documentation requirements. For the purposes
of assessing adequacy, the validation shall assess all PSAs in the
region individually and not the region as whole.
5.1.1.1 Two hundred
and forty days prior to SHCD, the contractor shall finalize network
modeling and submit their Network Implementation Plan. Interim self-assessment
reports will be provided to the Government at 30 day intervals following
submission of the Network Implementation Plan.
5.1.1.2 Sixty
days prior to SHCD, the contractor shall have completed provider
network development including completion of provider agreements
and credentialing.
5.1.2 The contractor shall validate accurate
and complete provider system loads for PCMs and BH providers. The
contractor will develop “load file completion reports” which compare
the percentage of providers loaded into the requisite systems with
the number of providers required by the contractor’s Network Implementation
Plan. The reports shall include the contractor’s accuracy attestation
to the Government regarding the total number of provider system
loads by category (PCMs and BH providers) and the percentage of
records loaded that meet the scheduled accuracy threshold listed
below in all data fields. Contractor validation goals shall, at
a minimum, meet the following:
• Fifty percent (50%) of PCMs and BH providers
loaded no later than 120 days prior to SHCD at a 90% accuracy rate.
• Seventy-five percent (75%) of PCMs and
BH providers loaded no later than 90 days prior to SHCD at a 90%
accuracy rate.
• One hundred
percent (100%) of PCMs and BH providers loaded no later than 60
days prior to SHCD at a 95% accuracy rate.
The Government will consider exceptions
to the 100%/60 day requirement in medically underserved areas.
5.1.3 The contractor
shall validate accurate and complete specialty provider (other than
BH providers) and health care facility system loads. The contractor
will develop “load file completion reports” which compare the percentage
of specialty providers and facilities loaded into the requisite systems
with the number of specialty providers and facilities required by
the contractor’s Network Implementation Plan. The reports shall
include the contractor’s accuracy attestation to the Government regarding
the total number of system loads by category (specialty providers
and facilities) and the percentage of total records that meet the
scheduled accuracy threshold listed below in all data fields. Contractor
validation goals shall, at a minimum, meet the following:
• Fifty percent (50%) of specialty care providers
and health care facilities loaded no later than 120 days prior to
SHCD at a 90% accuracy rate.
• Seventy-five percent (75%) of specialty
care providers and health care facilities loaded no later than 90
days prior to SHCD at a 90% accuracy rate.
• One hundred percent (100%) of specialty
care providers and health care facilities loaded no later than 60
days prior to SHCD at a 95% accuracy rate.
The Government will consider exceptions
to the 100%/60 day requirement in medically underserved areas.
5.1.4 The contractor
shall validate the completeness and accuracy of the online directory
of network providers. The contractor shall provide a time line for
completing the online provider directory and develop validation
reports which compare the number of network providers and facilities
who have been entered in the online directory to the total number
of network providers and facilities required by the contractor’s
Network Implementation Plan Validation reports shall begin 120 days
prior to SHCD and continue at 30 day intervals according to the
time lines and scheduled accuracy thresholds listed below, until
the complete provider directory is online and operational 60 days
prior to SHCD at a 95% accuracy rate. Accuracy calculations will
be based on each data field as opposed to each record for each PSA.
Contractor validation goals shall, at a minimum, meet the following:
• Fifty percent (50%) of network providers
and health care facilities entered no later than 120 days prior
to SHCD at a 90% accuracy rate.
• Seventy-five percent (75%) of network providers
and health care facilities entered no later than 90 days prior to
SHCD at a 90% accuracy rate.
• One hundred percent (100%) of network providers
and health care facilities entered no later than 60 days prior to
SHCD at a 95% accuracy rate.
• Complete provider directory online and
operational 60 days prior to SHCD at a 95% accuracy rate.
The Government will consider exceptions
to the 100%/60 days prior to SHCD requirement in medically underserved
areas.
5.2 Provider Network PRAV
5.2.1 The contractor shall comply with
the Government’s approach for assessment and verification of the
contractor’s performance readiness regarding provider networks 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 business days following the Government’s findings.
5.2.2 Specific
PRAV activities, assessment techniques, and performance readiness
thresholds will be identified by the Government during the Transition
Specification Meeting.