2.0 CONTRACT
ADMINISTRATION AND INSTRUCTIONS TO CONTRACTOR
2.1 The provisions of
Chapter 1, Section 2 are applicable to the
TOP. Additionally, the TOP contractor shall coordinate with the
Defense Health Agency (DHA) Contracting Officer (CO), the appropriate
DHA Contracting Officer Representative (COR), and the
TRICARE
Overseas Program Office (TOPO) on any TOP policy
or contractual issue that requires additional Government clarification
or assistance to resolve.
2.2 The
provisions of
Chapter 1, Section 2, paragraph 4.0 are superseded
as described in
paragraphs 2.2.1 through
2.2.6.
2.2.1 A
14 calendar day notice will be provided by the DHA Procurement Contracting
Officer (PCO) for all meetings hosted by DHA.
2.2.2 The TOP
contractor shall provide up to four contractor representatives at
the Performance Readiness Validation briefing at DHA.
2.2.3 The
TOP contractor shall provide at least two contractor representatives
for transition briefings/meetings with each overseas Military Treatment
Facility (MTF) and TAO. All briefings/meetings must be completed
no later than 60 calendar days prior to the start of health care
delivery (SHCD). These briefings/meetings shall be
targeted towards command suite/key leaders and their staff and shall
encompass all key contract areas where collaboration between the
contractor and the MTF/TRICARE Area Office (TAO) will occur.
2.2.4 The TOP
contractor shall provide annual representation at two contractor
conferences (senior management level) at DHA. The contractor shall
also provide up to four contractor representatives at up to four
additional meetings at the direction of the CO per contract year.
2.2.5 The TOP
contractor shall provide representation at semiannual TOP operational
meetings to be held at DHA Aurora with TOPO, TAO, and
service representation.
2.2.6 The
TOP contractor shall provide two contractor representatives at up
to 18 additional meetings/site visits at the direction of the CO
per option period.
8.0 TRANSITION-
IN REQUIREMENTS
8.1
Systems
DevelopmentApproximately 80 calendar
days prior to the initiation of health care delivery, the non-claims processing
systems and the telecommunications interconnections between these
systems shall be reviewed by the DHA or its designees, to include
a demonstration by the contractor of the system(s) capabilities,
to determine whether the systems satisfy the requirements of TRICARE
as otherwise provided in the contract. This includes the telecommunications
links with DHA and Defense Enrollment Eligibility Reporting System
(DEERS) and the Business-to-Business Gateway (B2B). The review will
also confirm that the hardware, software, and communications links
required for operating the automated TRICARE Duplicate Claims System
(DCS) have been installed and are ready for DHA installation of
the DCS application software (see the TRICARE Systems Manual (TSM), Chapter 4). The contractor shall implement
any modifications required by DHA prior to the initiation of services.
8.2
Execution of Agreements
with Contract Providers8.2.1 All
contract provider agreements shall be executed, and loaded to the
contractor’s system, 80 calendar days prior to the start of health
care delivery, or at such other time as is mutually agreed between
the contractor and DHA.
8.2.2 The contractor shall
report on network adequacy on a monthly basis during the transition.
8.3 See
Section 16,
for instructions regarding Statements of Responsibilities (SORs).
In addition to the SOR requirements in these referenced paragraphs,
the TOP contractor shall also execute a SOR with each TAO Director
no later than 60 calendar days prior to the SHCD
.
8.4 Enrollment
TransitionThe
contractor shall begin the enrollment process no later than (NLT)
60 calendar days prior to the scheduled SHCD, with actual enrollment
processing to begin 40 days prior to the SHCD, subject to DHA approval
of systems under the contract.
8.4.1 For
enrollments in the region with an effective date prior to the SCHD
(e.g., active duty (AD) enrollment, mid-month enrollment; transfer-in),
the incoming contractor must effect an enrollment to begin on the
SHCD once notified by the outgoing contractor of the new enrollment.
(Defense Manpower Data Center (DMDC) may run a report at the end
of the transition period that reflects new additions.)
8.4.2 When
the outgoing contractor requests deletion of current enrollments
with an effective date prior to the SHCD (e.g., transfers out; disenrollments
for failure to pay fees; cancellations, etc.), the incoming contractor
must cancel the future enrollment segment and notify the outgoing
contractor when this action has been completed.
8.4.3 For
all other enrollment actions with an effective date prior to SHCD
(e.g., Primary Care Manager (PCM) changes; Defense Medical Information
System-Identification Code (DMIS-ID) changes; enrollment begin date
changes; etc.), requested by the outgoing contractor, the incoming
contractor must cancel the future enrollment segment and notify
the outgoing contractor when this action has been completed. When
notified by the outgoing contractor that their change has been effected,
the incoming contractor must reinstate the future enrollment segment.
8.4.4 Once health care delivery
begins, all enrollment actions will be accomplished by the incoming
contractor. If the outgoing contractor requires a retroactive change,
they must submit their request to the incoming contractor who will
perform the change and notify the outgoing contractor when it is
complete.
8.5 Transfer
of Enrollment Files8.5.1 The
incoming contractor shall obtain enrollment information from DEERS
through an initial enrollment load file. DMDC will provide the incoming
contractor with an incremental enrollment load file for each contract
transition. The incoming contractor shall process each enrollment
load file within 24 hours or less from receipt of the file.
Note: Each
contract transition shall require a three-day freeze of enrollment
and claim processing. This freeze will occur beginning the first
weekend that precedes the 60 day window prior to the SHCD. The actual
calendar dates will be determined during the transition meeting.
8.5.2 The incoming contractor
shall send enrollment renewal notices for all enrollees whose current
enrollment period expires on or after the SHCD. The incoming contractor
shall send billing statements where the enrollment fee payment would
be due on or after the SHCD. The incoming contractor shall start
sending billing notices and process renewals 45 days prior to the
SHCD.
8.5.3 Outstanding
enrollment record discrepancies and issues reported to the DEERS
Support Office (DSO) by the outgoing contractor will be transferred
to the incoming contractor for reconciliation. Records will be reconciled
in accordance with TSM, Chapter 3.
8.6 TRICARE
Service Center (TSC) Phase-In
8.6.1 8.6.1 The incoming contractor shall utilize
the existing TSCs. The outgoing contractor shall allow reasonable
access to the incoming contractor throughout the transition period
to become familiar with the communication lines, equipment and office
layout.
8.6.2 The final
schedule for access to and occupancy of the TSCs will be determined
at the Transition Specifications Meeting. The approved schedule
must allow the outgoing contractor to fulfill all contract requirements
through the last day of health care delivery, and must provide the
incoming contractor sufficient access to the TSC to prepare for
delivery of all required functions on the first day of their contract.
8.6.3 All Contractor Customer Service,
Education and
Health Care Finder (HCF
) Field Representatives
and overseas TSC representatives shall be fully trained and available
for all duties no less than
80 calendar
days prior to initiation of health care services.
Note: Overseas
TSCs are managed by the MTFs and are jointly staffed by MTF and
TOP contractor personnel. The TOP contractor is responsible for
providing on-site Beneficiary Service Representative (BSR) support
in all TSC locations.
8.7 Contractor
File Conversions and Testing8.7.1 The incoming contractor
shall perform initial conversion and testing of all Automated Data Processing
(ADP) files (e.g., provider files, pricing files, and beneficiary
history) NLT 30 calendar days following receipt of the files from
the outgoing contractor(s).
8.7.2 Integration testing
will be conducted to validate the contractor’s internal interfaces
to each of the TRICARE Military Health Systems (MHSs). This testing
will verify the contractor’s system integration, functionality,
and implementation process. The incoming contractor shall be responsible for
the preparation and completion of Integration Testing 45 days prior
to the SHCD. (See the TSM, Chapter 1, Section 1.1, paragraph 2.0.)
8.7.3 Contractors shall
provide certification of compliance with the National Institute
of Standards and Technology (NIST)-based Information Assurance (IA)
program identified in the TSM, Chapter 1, Section 1.1, to fulfill
all system access requirements prior to connecting with the MHS
and/or the initiation of Integration Testing.
8.7.4 DHA Test Managers
will work with the contractor to plan, execute and evaluate the Integration
Testing efforts. The contractor shall identify a primary and a back-up
Testing Coordinator to work with the DHA Test Managers. The Testing
Coordinator is responsible for contractor testing preparations,
coordination of tests, identification of issues and their resolution,
and verification of test results. A web application will be available
for use by contractor Test Coordinators to report and track issues
and problems identified during integration testing.
8.8 Receipt
of Outgoing Contractor’s Weekly Shipment of History Updates and
Dual Operations8.8.1 Beginning
with the 120th calendar day prior to the SHCD and continuing for
180 calendar days after the SHCD, the incoming contractor shall
convert the weekly shipments of the beneficiary history updates
from the outgoing contractor(s) within two working days following
receipt. These files shall be validated by the incoming contractor
before use. Tests for claims and duplicate claims shall be performed
within two workdays following conversion. Following the SHCD, these
files shall be loaded to history and used for claims processing.
8.8.2 During the 180 calendar
days after the SHCD when both the incoming and outgoing contractors
are processing claims, both contractors shall maintain close interface
on history update exchanges and provider file information. During
the first 60 calendar days of dual operations, the contractors shall
exchange beneficiary history updates with each contractor’s claims
processing cycle run. Thereafter, the exchange shall not be less
than twice per week until the end of dual processing. The incoming
contractor shall assume total responsibility for the maintenance
of the TRICARE Encounter Provider Record (TEPRV) beginning with
the SHCD. The incoming contractor will coordinate and cooperate
with the outgoing contractor to ensure that the outgoing contractor
can continue to process claims accurately; conversely, the outgoing
contractor has responsibility to notify the incoming contractor
of any changes in provider status that they become aware of through
their operations.
8.9 Transition-In
Requirements Related To Transitional Cases8.9.1 In notifying beneficiaries
of the transition to another contractor, both the incoming and outgoing
contractors shall include instructions on how the beneficiary may
obtain assistance with transitional care. If the outgoing contractor
succeeds itself, costs related to each contract will be kept separate
for purposes of contract accountability.
8.9.2 Non-Network
Inpatient Transitional CasesThese
are beneficiaries who are inpatients (occupying an inpatient bed)
at 0001 hours on the first day of any health care contract period
in which the incoming contractor begins health care delivery. In
the case of Diagnosis Related Group (DRG) reimbursement, the outgoing
contractor shall pay through the first month of health care delivery
or the date of discharge, whichever occurs first. If the facility
is reimbursed on a per diem basis, the outgoing contractor is responsible
for payment of all the institutional charges accrued prior to 0001
hours on the first day of health care delivery, under the incoming
contractor. The incoming contractor thereafter is responsible for
payment.
8.9.3 Non-Network
Outpatient/Professional Transitional CasesThese are cases, such
as obstetric care, that are billed and payable under “Global” billing provisions
of Current Procedural Terminology, 4th edition (CPT-4), HCFA Common
Procedure Coding System (HCPCS), or local coding in use at the time
of contract transition, and where an Episode Of Care (EOC) shall
have commenced during the period of health care delivery of the
outgoing contractor and continues, uninterrupted, after the SHCD
by the incoming contractor. Outpatient/professional services related
to transitional cases are the responsibility of the outgoing contractor
for services delivered prior to 0001 hours on the first day of health
care delivery and of the incoming contractor thereafter.
8.9.4 Network
Inpatient Care During Contract TransitionThe status of network
provider changes (provider’s network agreement with the outgoing contractor
is terminated resulting in the provider’s loss of network status)
with the SHCD of the new contract. As a result, claims for inpatient
care shall be reimbursed in accordance with paragraph 8.9.2 for non-network
transitional cases. Beneficiary copay is based on the date of admission;
therefore, Prime beneficiaries who are inpatients as described in paragraph 8.9.2,
shall continue to be subject to Prime network copayments and shall
not be subject to Point Of Service (POS) copayments.
8.9.5 Home
Health Care (HHC) During Contract TransitionHHC, for a 60-day
EOC, initiated during the outgoing contractor’s health care delivery period
and extending, uninterrupted, into the health care delivery period
of the incoming contractor are considered to be transitional cases.
Reimbursement for both the Request for Anticipated Payment (RAP)
and the final claim shall be the responsibility of the outgoing
contractor for the entire 60-day episodes covering the transition
period from the outgoing to the incoming contractor.
8.10 Prior
Authorizations and ReferralsThe
incoming contractor shall honor outstanding prior authorizations
and referrals issued by the outgoing contractor, covering care through
60 days after the SHCD under the incoming contract, in accordance
with the outgoing contractors existing practices and protocols,
within the scope of the TRICARE program and applicable regulations
or statutes. In the case of Residential Treatment Care (RTC) care,
both the incoming and outgoing contractors are responsible for authorizing
that part of the stay falling within their areas of responsibility;
however, the incoming contractor may utilize the authorization issued
by the outgoing contractor as the basis for continued stay. This
transition period for prior authorizations and referrals is extended
to one year for obstetrical care or any other condition for which
a one-year authorization has been issued.
8.11 Case
ManagementThe
incoming contractor shall receive case files and documentation regarding
all beneficiaries under case management programs. The incoming contractor
shall ensure seamless continuity of services to those beneficiaries.
8.12 Program
IntegrityThe
incoming contractor shall receive case files and documentation regarding
all open program integrity cases from the outgoing contractor NLT
30 days from the SHCD. The incoming contractor shall work with the
DHA Program Integrity Office (PI) to ensure seamless continuity
of oversight of these cases.
8.13 Health
Insurance Portability And Accountability Act of 1996 (HIPAA)The
incoming contractor, as a covered entity under HIPAA, may honor
an authorization or other express legal document obtained from an
individual permitting the use and disclosure of protected health
information prior to the compliance date (HHS Privacy Regulation,
§164.532).
8.14 Installation
And Operation Of The DCSThe
incoming contractor shall have purchased, installed, configured,
and connected the personal computers and printers required to operate
the DCS NLT 60 days prior to the start of the health care delivery.
See the TSM, Chapter 4,
for hardware, software, printer, configuration and communications
requirements and contractor installation responsibilities. Approximately
30-45 days prior to health care delivery, DHA will provide and install
the DCS application software on the incoming contractor designated
personal computers and provide on-site training for users of the
DCS in accordance with the TSM, Chapter 4.
Following the SHCD, the DCS will begin displaying identified potential
duplicate claim sets for which the incoming contractor has responsibility
for resolving. The incoming contractor shall begin using the DCS
to resolve potential duplicate claim sets in accordance with TSM, Chapter 4 and the transition
plan requirements.
8.15 The
TOP contractor shall prepare a mailing to the Resident Commissioners
of Puerto Rico and the Northern Mariana Islands, and the Congressional
representatives for American Samoa, Guam, and the U.S. Virgin Islands
by the 45th calendar day prior to the SHCD according to the specifications
of the official transition schedule. The
proposed mailing shall be submitted to the DHA CO, DHA COR, and TOPO,
for approval no later than 90 calendar days prior to the SHCD. The
mailing shall discuss any unique processing requirements of the
contractor and any other needed information dictated by the official
transition schedule.
9.0 Transition
-OUT
9.1 Transition
Specifications MeetingThe
outgoing contractor shall attend a meeting with representatives
of the incoming contractor and DHA, within 15 calendar days following
the effective date of the contract. This meeting is for the purpose
of developing a schedule of transition-in/transition out activities.
DHA will notify the contractor(s) as to the exact date and location
of the meeting. The outgoing contractor shall provide a proposed
transition-out plan at the Transition Specifications Meeting.
9.2 DataThe outgoing contractor
shall provide to DHA (or, at the option of DHA, to a successor contractor)
such information as DHA shall require to facilitate transitions
from the contractor’s operations to operations under any successor
contract. All files shall be provided in a non-proprietary format
and the contractor shall include such file specifications and documentation
as may be necessary for interpretation of these files. Such information
may include, but is not limited to, the following:
• The
data contained in the contractor’s enrollment information system.
• The
data contained in the contractor’s claims processing systems.
• Information
about the management of the contract that is not considered, under applicable
Federal law, to be proprietary to the contractor.
• An
automated indexing system that can be used independently of the
outgoing contractor’s data system. (See Chapter 9, Section 3, paragraph 2.2.2 for
Automated Indexing System requirements.)
9.3 Transition-Out
Of The Contractor’s Claims Processing OperationsUpon notice of award
to another contractor, and during the procurement process leading
to an effective date of a new contract, the contractor shall undertake
the following transition-out activities regarding services as an
outgoing contractor.
9.3.1 Transfer
of Electronic File SpecificationsThe
outgoing contractor shall transfer to the incoming contractor by
express mail or similar overnight delivery service, NLT three calendar
days following award announcement, electronic copies of the record
layouts with specifications, formats, and definitions of fields,
and data elements, access keys and sort orders, for the following:
• The
TEPRVs.
• The
TRICARE Encounter Pricing Files (TEPRCs).
• The
Enrolled Beneficiary and PCM Assignment Files.
• Mental
Health Provider Files - The outgoing contractor must assure that
the incoming contractor has been given accurate provider payment
information on all mental health providers paid under the TRICARE
inpatient mental health per diem payment system. This should include
provider name; tax identification number; address including zip code;
high or low volume status; if high volume, provide the date the
provider became high volume; and the current per diem rate along
with the two prior year’s per diem amounts. The providers under
the per diem payment system must be designated by Medicare, or meet
exemption criteria, as exempt from the inpatient mental health unit, the
unit would be identified as the provider under the TRICARE inpatient
mental health per diem payment system.
9.3.2 Transfer
Of ADP Files (Electronic)The
outgoing contractor shall prepare in non-proprietary electronic
format and transfer to the incoming contractor or DHA, by the 15th
calendar day following the Transition Specifications Meeting unless
otherwise negotiated by the incoming and outgoing contractors, all
specified ADP files, such as the Provider and Pricing files, in
accordance with specifications in the official transition schedule
and will continue to participate in preparation and testing of these
files until they are fully readable by the incoming contractor or
DHA.
9.3.3 Outgoing
Contractor Weekly Shipment Of History UpdatesThe outgoing contractor
shall transfer to the incoming contractor, in electronic format,
all beneficiary history and deductible transactions (occurring from
the date of preparation for shipment of the initial transfer of
such history files) beginning the 120th calendar day prior to the
SHCD (until such a time that all processing is completed by the
outgoing contractor) in accordance with the specifications in the
official transition schedule.
9.3.3.1 During the 180 calendar
days after the SHCD when both the incoming and outgoing contractors
are processing claims, both contractors shall maintain close interface
on history update exchanges and provider file information. During
the first 60 calendar days of dual operations, the contractors shall
exchange beneficiary history updates with each contractor’s claims
processing cycle run. Thereafter, the exchange shall not be less
than twice per week until the end of dual processing.
9.3.3.2 The incoming contractor
shall assume total responsibility for the maintenance of the TEPRV beginning
with the SHCD. The incoming contractor will coordinate and cooperate
with the outgoing contractor to ensure that the outgoing contractor
can continue to process claims accurately; conversely, the outgoing
contractor has the responsibility to notify the incoming contractor
of any changes in provider status that they become aware of through
their operations.
9.3.4 Transfer
Of Non-ADP FilesThe
outgoing contractor shall transfer to the incoming contractor all
non-ADP files (e.g., authorization files, clinic billing authorizations,
and tapes/CDs, which identify Congressional and DHA completed correspondence
files, appeals files, TRICARE medical utilization, and administration
files) in accordance with the specifications in the official transition
schedule. The hard copies of the Beneficiary History Files are to
be transferred to the incoming contractor or Federal Records Center
(FRC). The contractor shall provide samples and descriptions of
these files to the incoming contractor at the Transition Specification
Meeting.
9.3.5 Explanation
of Benefits (EOB) Record Data Retention and TransmittalIf the contractor
elects to retain the EOB data on a computer record, it must, in
the event of a transition to another contractor, provide either
a full set of electronic records covering the current and two prior
years, or, at the PCO’s discretion, provide the data and necessary
programs to reproduce the EOB in acceptable form and transfer such
data and programs to the successor contractor or to DHA. DHA shall
be the final authority in determining the form and/or acceptability
of the data.
9.3.6 Outgoing
Contractor Weekly Status ReportingUntil
all inventories have been processed, the outgoing contractor shall
submit a weekly status report of inventories and phase-out activities
to DHA beginning the 20th calendar day following the Specifications
Meeting until otherwise notified by the PCO to discontinue. This
shall be done in accordance with specifications of the official
transition schedule.
9.3.7 Prior
Authorizations and ReferralsThe
outgoing contractor shall provide all prior authorizations and referrals
that cover care spanning the SHCD under the new contract or care
that could potentially begin in the incoming contractor’s health
care delivery period. The outgoing and incoming contractor shall
mutually agree to the date and schedule for transfer of this information.
9.3.8 Case
Management FilesNLT
60 days prior to the SHCD under the new contract, the outgoing contractor
shall provide the incoming contractor with all files pertaining
to beneficiaries covered under a Case Management program. Electronic
files shall be provided under a non- proprietary format. The outgoing contractor
shall cooperate with the incoming contractor to ensure seamless
continuity of care and services for all such beneficiaries.
9.3.9 Requirements
Related To Transitional CasesThe
outgoing contractor shall provide the incoming contractor with instructions
for beneficiaries and providers on how the beneficiary may obtain
assistance with transitional care.
9.3.10 Program
Integrity FilesNLT
30 days prior to the SHCD under the new contract, the outgoing contractor
shall provide the incoming contractor with all fraud and abuse information
it has collected during the tenure of the contract relevant to TRICARE
providers and beneficiaries. For example, (not all inclusive) high dollar
initial draft fraud cases, post payment utilization and reviews
that identified potential fraud, established provider/beneficiary
outlier watch lists, list of providers on prepayment review, copies
of educational letters, regional fraud trend/outlier reports, Fraudline
reports, and beneficiary complaints related to health care fraud.
Electronic files shall be provided under a non-proprietary format.
9.4 Final
Processing Of Outgoing ContractorThe
outgoing contractor shall:
• Process
all claims received through the last date of the outgoing contractor’s healthcare
delivery. Processing of these claims, including adjustments, shall
be completed with 180 days following the start of the incoming TOP
contractor’s healthcare delivery period.
• All
claims shall meet the same standards as outlined in the current
outgoing contract. Any residual claim received after SHCD shall
be forwarded to the incoming contractor within 24 hours of receipt.
Claims for the Philippines, that have been pended for development
of missing/required documentation or pended for provider certification, shall
be denied on the 179th day if information was not received or certification
was not complete. Any residual information related to the Philippines
claims received after SHCD shall be forwarded to the incoming contractor
with 24 hours of receipt.
• Be
liable, after the termination of services under this contract, for
any payments to subcontractors of the contractor arising from events
that took place during the period of this contract.
• Process
all correspondence, allowable charge complaints, and incoming telephonic inquiries
which pertain to claims or services processed or delivered under
this contract within the time frames established for response by
the standards of the contract.
• Complete
all appeal and grievance cases that pertain to claims or services
processed or delivered under this contract within the time frames
established for response by the standards of the contract.
9.4.1 Correction
of Edit RejectsThe
outgoing contractor shall retain sufficient resources to ensure
correction (and reprocessing through DHA) of all TED record edit
errors NLT 210 calendar days following the start of the incoming
contractor’s health care delivery.
9.4.2 Transition-Out
of the Automated TRICARE DCSThe
outgoing contractor shall phase-out the use of the automated TRICARE
DCS in accordance with the TSM, Chapter 4 and
transition plan requirements.
9.4.3 Transition-Out
Of The Contractor’s Provider Network, TSCs, And MTF Agreements9.4.3.1 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 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, equipment, telephones and all other functions having
an impact on the MTFs.
9.4.3.2 Within 15 calendar
days of the Transitions Specifications Meeting the outgoing contractor shall
draft and submit a revised plan for transition of the MTF interfaces.
Resolution of differences identified through the coordination process
must be accomplished in collaboration with TOPO.
9.4.3.3 The outgoing contractor
shall ensure a 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 on the
40th calendar day prior to the start of the health care delivery
and establish a centralized HCF function.
9.4.3.4 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.
9.4.3.5 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 respective liability. Beneficiary inquiry lines
will continue to be staffed as defined in the contract.
9.5 Transition-Out
of Enrollment Activities9.5.1 Prior to the SHCD
under the successor contract, for all enrollment renewals or payments
in which the new enrollment period or period covered by the premium
payment will begin under the new contract, the outgoing contractor
shall amend renewal notices and billing statements (or include a stuffer/insert)
to advise the enrollee to direct any enrollment-related correspondence
and enrollment fee payments to the successor contractor.
9.5.2 Any enrollment-related
correspondence and/or enrollment fee payments subsequently received
by the outgoing contractor shall be forwarded to the incoming contractor
within three working days of receipt.
9.5.3 The outgoing contractor
shall terminate marketing and enrollment activity 40 calendar days
prior to the start of the incoming contractor’s health care delivery.
Any enrollment requests or applications received after the 40th
calendar day shall be transferred to the incoming contractor by overnight
delivery at the outgoing contractor’s expense.
9.5.4 Throughout the enrollment
dual processing period, the outgoing and incoming contractors shall
coordinate enrollment files no less than weekly to ensure that new
enrollments and enrollment renewals are accurately and timely reflected
in the incoming contractor’s enrollment files and in DEERS.
9.6 Cost
AccountingIf
the outgoing contractor succeeds itself, costs related to each contract
shall be kept separate for purposes of contract accountability,
according to the above guidelines.
9.7 Records
DispositionThe
contractor shall include a records disposition plan as part of the
transition-out plan submitted to DHA at the Transition Specifications
Meeting.
9.8 Provide
InformationThe
contractor shall, upon receipt of a written request from DHA, provide
to potential offerors such items and data as required by DHA. This
shall include non-proprietary information, such as record formats
and specifications, field descriptions and data elements, claims
and correspondence volumes, etc.
9.9 Recoupment9.9.1 Installment
CasesThe outgoing contractor
shall transfer all installment cases to DHA, Office of General Counsel
(OGC), Claims Collection Section (CCS). A list of all installment
cases to be transferred, shall be provided by fax or encrypted email
to CCS before the cases are transferred.
9.9.2 Cases
Less Than 12 MonthsThe
outgoing contractor shall transfer cases greater or equal to $110
($30 for pharmacy) and that are less than 12 months old to the incoming
contractor, who shall assume management of the cases. Cases received
by the incoming contractor shall be managed until the debt is collected
in full, or combined with any other under $600 active recoupment
case against the same debtor to equal $600 or more and transferred
to DHA, OGC, CCS. Cases that do not meet the criteria, shall be
written off by the contractor.
9.10 Transition
Out of TED ActivitiesTransition-out
activities related to TED shall be accomplished no later than 14
months after the start of health care delivery for the incoming
contractor. At 180 days after the end of healthcare delivery the
contractor shall not issue or reissue any checks/payments unless
authorized by DHA, CRM. The contractor is required to keep all bank
accounts associated with claims payments open until all outstanding
checks/payments have either cleared or stale date. If a payment
stale dates, the contractor is required to cancel the associated
TED data with DHA and notify the incoming contractor. The contractor
may cease TED data submissions when all TED reported checks/payments
issued under this contract have cleared or stale date. The contractor
may request (at no-cost to the government) an extension for TEDs
processing after the 14 month period ends if more time is needed
to complete stale date check processing.